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Wolfson-Stofko B, Hirode G, Vanderhoff A, Karkada J, Capraru C, Biondi MJ, Hansen B, Shah H, Janssen HLA, Feld JJ. Real-world hepatitis C prevalence and treatment uptake at opioid agonist therapy clinics in Ontario, Canada. J Viral Hepat 2024; 31:240-247. [PMID: 38385850 DOI: 10.1111/jvh.13931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 02/02/2024] [Accepted: 02/15/2024] [Indexed: 02/23/2024]
Abstract
Widespread screening for hepatitis C virus (HCV) is necessary for Canada to meet its HCV elimination goals by 2030. People who currently or previously injected drugs are at high risk for HCV. Opioid agonist therapy (OAT, such as methadone and buprenorphine) has been shown to help stabilize the lives of people who are opioid-dependent. The distribution of OAT in North America typically requires daily, weekly, or monthly clinic visits and presents an opportunity for engagement, screening and treatment for those at high-risk of HCV. In this study, HCV screening was conducted by staff at OAT clinics in Ontario from 2016 to 2020 and those with chronic infections were treated on-site with direct-acting antivirals. Point-of-care or dried blood spot (DBS) testing was used for antibodies, DBS or serum for HCV RNA and serum for HCV RNA at SVR12 (sustained virological response). Clinics screened 1954 people (mean age 40 years ±12, 63% male). Forty-five percent were antibody positive, of whom 64% were HCV RNA+. Eighty percent of those RNA+ set an appointment in which 99% attended. Ninety-six percent started treatment with 87% completing treatment. Sixty-eight percent of people who completed treatment submitted a sample for SVR12 testing of which 97% achieved a virological cure. Results suggest that HCV screening and treatment at OAT clinics is feasible, effective and warrants expansion. Data suggest strong treatment adherence due to high rates of SVR12 comparable with other OAT-based HCV treatment programs. The lack of SVR12 sampling could be addressed by either on-site phlebotomy or incentivizing SVR12 sampling.
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Affiliation(s)
- B Wolfson-Stofko
- Viral Hepatitis Care Network (VIRCAN), Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
- Center for Drug Use and HIV/HCV Research (CDUHR), College of Global Public Health, New York University, New York, New York, USA
| | - G Hirode
- Viral Hepatitis Care Network (VIRCAN), Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
| | - A Vanderhoff
- Viral Hepatitis Care Network (VIRCAN), Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
| | - J Karkada
- Viral Hepatitis Care Network (VIRCAN), Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
| | - C Capraru
- Viral Hepatitis Care Network (VIRCAN), Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
| | - M J Biondi
- Viral Hepatitis Care Network (VIRCAN), Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
- School of Nursing, York University, Toronto, Ontario, Canada
| | - B Hansen
- Viral Hepatitis Care Network (VIRCAN), Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
- Division of Gastroenterology & Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Epidemiology, Biostatistics, Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - H Shah
- Viral Hepatitis Care Network (VIRCAN), Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
| | - H L A Janssen
- Viral Hepatitis Care Network (VIRCAN), Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
- Division of Gastroenterology & Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - J J Feld
- Viral Hepatitis Care Network (VIRCAN), Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
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Meyerson BE, Russell DM, Downer M, Alfar A, Garnett I, Lowther J, Lutz R, Mahoney A, Moore J, Nuñez G, Samorano S, Brady BR, Bentele KG, Granillo B. Opportunities and Challenges : Hepatitis C Testing and Treatment Access Experiences Among People in Methadone and Buprenorphine Treatment During COVID-19, Arizona, 2021. AJPM FOCUS 2023; 2:100047. [PMID: 37789937 PMCID: PMC10546500 DOI: 10.1016/j.focus.2022.100047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
Introduction The purpose of this study was to characterize hepatitis C virus screening and treatment access experiences among people in treatment for opioid use disorder in Arizona during COVID-19. Methods Arizonans receiving treatment for opioid use disorder from methadone clinics and buprenorphine providers during COVID-19 were interviewed about hepatitis C virus testing, curative treatment, and knowledge about screening recommendations. Interviews were conducted with 121 people from August 4, 2021 to October 10, 2021. Qualitative data were coded using the categories of hepatitis C virus testing, knowledge of screening recommendations, diagnosis, and experiences seeking curative treatment. Data were also quantitated for bivariate testing with outcome variables of last hepatitis C virus test, diagnosis, and curative treatment process. Findings were arrayed along an adapted hepatitis C virus cascade framework to inform program and policy improvements. Results Just over half of the sample reported ever having tested for hepatitis C virus (51.2%, n=62) and of this group, 58.1% were tested in the past 12 months. Among those who were ever tested, 54.8% reported a hepatitis C virus diagnosis and 16.1% reported either being in treatment or having been declared cured of the hepatitis C virus. Among those who were diagnosed with hepatitis C, 14.7% indicated that they unsuccessfully tried to access curative treatment and would not attempt to again. Reasons cited for not accessing or receiving curative treatment included beliefs about treatment safety, barriers created by access requirements, natural resolution of the infection, and issues with healthcare coverage and authorization. Conclusions Structural barriers continue to prevent curative hepatitis C virus treatment access. Given that methadone and buprenorphine treatment providers serve patients who are largely undiagnosed or treated for hepatitis C virus, opportunities exist for them to screen their patients regularly and provide support for and/or navigation to hepatitis C virus curative treatment.
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Affiliation(s)
- Beth E. Meyerson
- Family & Community Medicine, College of Medicine Tucson, The University of Arizona, Tucson, Arizona
- Southwest Institute for Research on Women, College of Social & Behavioral Sciences, The University of Arizona, Tucson, Arizona
| | | | | | - Amirah Alfar
- Drug Policy Research & Advocacy Board, The University of Arizona, Tucson, Arizona
| | - Irene Garnett
- Drug Policy Research & Advocacy Board, The University of Arizona, Tucson, Arizona
| | - John Lowther
- Drug Policy Research & Advocacy Board, The University of Arizona, Tucson, Arizona
| | | | | | - Julie Moore
- Drug Policy Research & Advocacy Board, The University of Arizona, Tucson, Arizona
| | - Greg Nuñez
- Drug Policy Research & Advocacy Board, The University of Arizona, Tucson, Arizona
| | - Savannah Samorano
- Drug Policy Research & Advocacy Board, The University of Arizona, Tucson, Arizona
| | - Benjamin R. Brady
- Comprehensive Pain and Addiction Center, The University of Arizona, Tucson, Arizona
- Mel & Enid Zuckerman College of Public Health, The University of Arizona, Tucson; Arizona
| | - Keith G. Bentele
- Southwest Institute for Research on Women, College of Social & Behavioral Sciences, The University of Arizona, Tucson, Arizona
| | - Brenda Granillo
- Southwest Institute for Research on Women, College of Social & Behavioral Sciences, The University of Arizona, Tucson, Arizona
| | - Arizona Drug Policy Research & Advocacy Board
- Family & Community Medicine, College of Medicine Tucson, The University of Arizona, Tucson, Arizona
- Southwest Institute for Research on Women, College of Social & Behavioral Sciences, The University of Arizona, Tucson, Arizona
- School of Social Transformation, Arizona State University, Tempe, Arizona
- Southwest Recovery Alliance, Phoenix, Arizona
- Drug Policy Research & Advocacy Board, The University of Arizona, Tucson, Arizona
- CAN Community Health Services, Phoenix, Arizona
- Comprehensive Pain and Addiction Center, The University of Arizona, Tucson, Arizona
- Mel & Enid Zuckerman College of Public Health, The University of Arizona, Tucson; Arizona
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Sex-specific Risk Factors and Health Disparity Among Hepatitis C Positive Patients Receiving Pharmacotherapy for Opioid Use Disorder: Findings From a Propensity Matched Analysis. J Addict Med 2021; 16:e248-e256. [PMID: 34799492 DOI: 10.1097/adm.0000000000000937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The incidence of opioid-related fatality has reached unparalleled levels across North America. Patients with comorbid hepatitis C virus (HCV) remain the most vulnerable and difficult to treat. Considering the unique challenges associated with this population, we aimed to re-examine the impact of HCV on response to medication assistant treatment for opioid use disorder and establish sex-specific risk factors affecting care. METHODS This study employs a multi-center prospective cohort design, with 1-year follow-up. Patients aged ≥18, receiving methadone for opioid use disorder were recruited from a network of out-patient opioid addiction treatment centers across Southern Ontario, Canada. Patients with ≥50% positive opioid urine screens over 1 year of follow-up were classified as poor responders. The prognostic impact of HCV on response was established using a propensity score matched analysis. Sex-specific regression models were constructed to evaluate risk factors for treatment response. RESULTS Among participants eligible for inclusion (n = 1234), HCV was prevalent in 25% (n = 307). HCV patients exhibited significantly higher rates of high-risk opioid consumption patterns 35.29% (standard deviation 0.478). Sex-specific examination revealed females with HCV incur a 2 times increased risk for high-risk opioid consumption behaviors (female odds ratio: 1.95, 95% confidence interval 1.23, 3.10; P = 0.01). CONCLUSIONS Findings from this study establish the link between HCV and poor treatment response, with differentially higher risk among female patients. In light of the high potential for overdose among this population, concerted efforts are required for distinguishing the source for sex-based disparities, in addition to establishing trauma and gender informed treatment protocols.
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Lafferty L, Rance J, Dore GJ, Lloyd AR, Treloar C. The role of social capital in facilitating hepatitis C treatment scale-up within a treatment-as-prevention trial in the male prison setting. Addiction 2021; 116:1162-1171. [PMID: 33006784 DOI: 10.1111/add.15277] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 05/20/2020] [Accepted: 09/27/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND AIMS Hepatitis C (HCV) is a global public health concern, particularly in the prison setting where prevalence is substantially higher than in the general population. Direct-acting antivirals have changed the treatment landscape, allowing for treatment scale-up efforts potentially sufficient to achieve prevention of onward transmission (treatment-as-prevention). The Surveillance and Treatment of Prisoners with hepatitis C (SToP-C) study was the first trial to examine the efficacy of HCV treatment-as-prevention in the prison setting. Social capital is a social resource which has been found to influence health outcomes. This qualitative study sought to understand the role of social capital within an HCV treatment-as-prevention trial in the prison setting. DESIGN Semi-structured in-depth interviews were undertaken with participants recruited from the SToP-C study following HCV treatment completion (with cure). SETTING Three male correctional centres in New South Wales, Australia (including two maximum-security and one minimum-security). PARTICIPANTS Twenty-three men in prison participated in semi-structured interviews. MEASUREMENTS Thematic analysis of transcripts was completed using a social capital framework, which enabled exploration of the ways in which bonding, bridging and linking social capital promoted or inhibited HCV treatment uptake within a treatment-as-prevention trial. FINDINGS Social capital fostered HCV treatment uptake within an HCV treatment-as-prevention trial in the prison setting. Bonding social capital encouraged treatment uptake and alleviated concerns of side effects, bridging social capital supported prison-wide treatment uptake, and linking social capital fostered trust in study personnel (including nurses and correctional officers), thereby enhancing treatment engagement. CONCLUSIONS Social capital, including bonding, bridging and linking, can play an important role in hepatitis C treatment-as-prevention efforts within the male prison setting.
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Affiliation(s)
- Lise Lafferty
- Centre for Social Research in Health, UNSW Sydney, Sydney, NSW, Australia
| | - Jake Rance
- Centre for Social Research in Health, UNSW Sydney, Sydney, NSW, Australia
| | - Gregory J Dore
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | - Andrew R Lloyd
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | - Carla Treloar
- Centre for Social Research in Health, UNSW Sydney, Sydney, NSW, Australia
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Heo M, Pericot-Valverde I, Rennert L, Akiyama MJ, Norton BL, Gormley M, Agyemang L, Arnsten JH, Litwin AH. Hepatitis C virus DAA treatment adherence patterns and SVR among people who inject drugs treated in opioid agonist therapy programs. Clin Infect Dis 2021; 73:2093-2100. [PMID: 33876230 DOI: 10.1093/cid/ciab334] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Adequate medication adherence is critical for achieving sustained viral response (SVR) of hepatitis C virus (HCV) among people who inject drugs (PWID). However, it is less known which patterns of direct-acting antiviral (DAA) treatment adherence are associated with SVR in this population or what factors are associated with each pattern. METHODS The randomized three-arm PREVAIL study utilized electronic blister packs to obtain daily time frame adherence data in opiate agonist therapy program settings. Exact logistic regressions were applied to test the associations between SVR and six types of treatment adherence patterns. RESULTS Of the 113 participants treated with combination DAAs, 109 (96.5%) achieved SVR. SVR was significantly associated with all pattern parameters except for number of switches between adherent and missed days: total adherent daily doses (exact AOR=1.12; 95%CI=1.04-1.22), percent total doses (1.09; 1.03-1.16), days on treatment (1.16; 1.05-1.32), maximum consecutive adherent days (1.34; 1.06-2.04), maximum consecutive non-adherent days (.85; .74-.95=.003). SVR was significantly associated with total adherent doses in the first two months of treatment, it was not in the last month. Compared to White participants (30.7±11.8(se)), Black (18.4±7.8) and Hispanic participants (19.2±6.1) had significantly shorter maximum consecutive adherent days. While alcohol intoxication was significantly associated with frequent switches, drug use was not associated with any adherence pattern. CONCLUSION Consistent maintenance of adequate total dose adherence over the entire course of HCV treatment is important in achieving SVR among PWID. Additional integrative addiction and medical care may be warranted for treating PWID experiencing alcohol intoxication.
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Affiliation(s)
- Moonseong Heo
- Department of Public Health Sciences, Clemson University, Clemson, SC, USA
| | | | - Lior Rennert
- Department of Public Health Sciences, Clemson University, Clemson, SC, USA
| | - Matthew J Akiyama
- Department of Medicine, Division of General Internal Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Brianna L Norton
- Department of Medicine, Division of General Internal Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Mirinda Gormley
- Department of Public Health Sciences, Clemson University, Clemson, SC, USA
| | - Linda Agyemang
- Department of Medicine, Division of General Internal Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Julia H Arnsten
- Department of Medicine, Division of General Internal Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Alain H Litwin
- Clemson University School of Health Research, Clemson University, Clemson, SC, USA.,Department of Medicine, University of South Carolina School of Medicine, Greenville, SC, USA Department of Internal Medicine, Prisma Health, Greenville, SC, USA
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Norton BL, Akiyama MJ, Arnsten JH, Agyemang L, Heo M, Litwin AH. High HCV cure rates among people who inject drugs and have suboptimal adherence: A patient-centered approach to HCV models of care. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 93:103135. [PMID: 33667826 DOI: 10.1016/j.drugpo.2021.103135] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 12/23/2020] [Accepted: 01/20/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND Though people who inject drugs (PWID) make up the majority of the hepatitis C virus (HCV) epidemic, concerns about adherence often exclude PWID from receiving direct-acting antiviral (DAA) medication. The most effective models of HCV care to promote sustained virologic response (SVR) and high adherence need to be evaluated. METHODS We conducted a prospective cohort study in three opioid treatment programs (OTPs) in the Bronx, NY. Participants, in collaboration with providers, chose one of three models of onsite care: directly observed therapy (mDOT), group treatment (GT), or self-administered individual treatment (SIT). SVR12, daily adherence, and participant characteristics were compared between groups. RESULTS Of 61 participants, the majority were male (62%) and Latino (67%), with a mean age of 53 (SD 9). Participants received DAAs via one of three models of care: mDOT (21%), GT (25%), or SIT (54%). The majority (59%) used illicit drugs during treatment. Overall, SVR12 was 98% with no differences between models of care: mDOT (100%), GT (100%), and SIT (97%) (p = 1.0). Overall, daily adherence was 73% (SD 16); 86% among those who chose mDOT compared to 71% among those who chose GT (p<0.01) and 73% among those who chose SIT (p<0.01). CONCLUSION Despite ongoing illicit drug use and suboptimal adherence, SVR12 was high among PWID treated onsite at an OTP using any one of three models of care. Shared decision making in real world settings may be key to choosing the appropriate model of care for PWID.
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Affiliation(s)
- Brianna L Norton
- Department of Medicine, Division of General Internal Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, United States; Department of Medicine, Division of Infectious Diseases, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, United States.
| | - Matthew J Akiyama
- Department of Medicine, Division of General Internal Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, United States; Department of Medicine, Division of Infectious Diseases, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, United States
| | - Julia H Arnsten
- Department of Medicine, Division of General Internal Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, United States; Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, United States; Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, United States
| | - Linda Agyemang
- Department of Medicine, Division of General Internal Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, United States
| | - Moonseong Heo
- Department of Public Health Sciences, Clemson University, Clemson, SC, United States; School of Mathematical Science, Clemson University, Clemson, SC, United States
| | - Alain H Litwin
- Department of Medicine, University of South Carolina School of Medicine - Greenville, Greenville, SC, United States; Department of Medicine, Prisma Health-Upstate, Greenville, SC, United States; Clemson University School of Health Research, Clemson, SC, United States
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Story A, Garber E, Aldridge RW, Smith CM, Hall J, Ferenando G, Possas L, Hemming S, Wurie F, Luchenski S, Abubakar I, McHugh TD, White PJ, Watson JM, Lipman M, Garfein R, Hayward AC. Management and control of tuberculosis control in socially complex groups: a research programme including three RCTs. PROGRAMME GRANTS FOR APPLIED RESEARCH 2020. [DOI: 10.3310/pgfar08090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Background
Socially complex groups, including people experiencing homelessness, prisoners and drug users, have very high levels of tuberculosis, often complicated by late diagnosis and difficulty in adhering to treatment.
Objective
To assess a series of interventions to improve tuberculosis control in socially complex groups.
Design
A series of observational surveys, evaluations and trials of interventions.
Setting
The pan-London Find&Treat service, which supports tuberculosis screening and case management in socially complex groups across London.
Participants
Socially complex groups with tuberculosis or at risk of tuberculosis, including people experiencing homelessness, prisoners, drug users and those at high risk of poor adherence to tuberculosis treatment.
Interventions and main outcome measures
We screened 491 people in homeless hostels and 511 people in prison for latent tuberculosis infection, human immunodeficiency virus, hepatitis B and hepatitis C. We evaluated an NHS-led prison radiographic screening programme. We conducted a cluster randomised controlled trial (2348 eligible people experiencing homelessness in 46 hostels) of the effectiveness of peer educators (22 hostels) compared with NHS staff (24 hostels) at encouraging the uptake of mobile radiographic screening. We initiated a trial of the use of point-of-care polymerase chain reaction diagnostics to rapidly confirm tuberculosis alongside mobile radiographic screening. We undertook a randomised controlled trial to improve treatment adherence, comparing face-to-face, directly observed treatment with video-observed treatment using a smartphone application. The primary outcome was completion of ≥ 80% of scheduled treatment observations over the first 2 months following enrolment. We assessed the cost-effectiveness of latent tuberculosis screening alongside radiographic screening of people experiencing homelessness. The costs of video-observed treatment and directly observed treatment were compared.
Results
In the homeless hostels, 16.5% of people experiencing homelessness had latent tuberculosis infection, 1.4% had current hepatitis B infection, 10.4% had hepatitis C infection and 1.0% had human immunodeficiency virus infection. When a quality-adjusted life-year is valued at £30,000, the latent tuberculosis screening of people experiencing homelessness was cost-effective provided treatment uptake was ≥ 25% (for a £20,000 quality-adjusted life-year threshold, treatment uptake would need to be > 50%). In prison, 12.6% of prisoners had latent tuberculosis infection, 1.9% had current hepatitis B infection, 4.2% had hepatitis C infection and 0.0% had human immunodeficiency virus infection. In both settings, levels of latent tuberculosis infection and blood-borne viruses were higher among injecting drug users. A total of 1484 prisoners were screened using chest radiography over a total of 112 screening days (new prisoner screening coverage was 43%). Twenty-nine radiographs were reported as potentially indicating tuberculosis. One prisoner began, and completed, antituberculosis treatment in prison. In the cluster randomised controlled trial of peer educators to increase screening uptake, the median uptake was 45% in the control arm and 40% in the intervention arm (adjusted risk ratio 0.98, 95% confidence interval 0.80 to 1.20). A rapid diagnostic service was established on the mobile radiographic unit but the trial of rapid diagnostics was abandoned because of recruitment and follow-up difficulties. We randomly assigned 112 patients to video-observed treatment and 114 patients to directly observed treatment. Fifty-eight per cent of those recruited had a history of homelessness, addiction, imprisonment or severe mental health problems. Seventy-eight (70%) of 112 patients on video-observed treatment achieved the primary outcome, compared with 35 (31%) of 114 patients on directly observed treatment (adjusted odds ratio 5.48, 95% confidence interval 3.10 to 9.68; p < 0.0001). Video-observed treatment was superior to directly observed treatment in all demographic and social risk factor subgroups. The cost for 6 months of treatment observation was £1645 for daily video-observed treatment, £3420 for directly observed treatment three times per week and £5700 for directly observed treatment five times per week.
Limitations
Recruitment was lower than anticipated for most of the studies. The peer advocate study may have been contaminated by the fact that the service was already using peer educators to support its work.
Conclusions
There are very high levels of latent tuberculosis infection among prisoners, people experiencing homelessness and drug users. Screening for latent infection in people experiencing homelessness alongside mobile radiographic screening would be cost-effective, providing the uptake of treatment was 25–50%. Despite ring-fenced funding, the NHS was unable to establish static radiographic screening programmes. Although we found no evidence that peer educators were more effective than health-care workers in encouraging the uptake of mobile radiographic screening, there may be wider benefits of including peer educators as part of the Find&Treat team. Utilising polymerase chain reaction-based rapid diagnostic testing on a mobile radiographic unit is feasible. Smartphone-enabled video-observed treatment is more effective and cheaper than directly observed treatment for ensuring that treatment is observed.
Future work
Trials of video-observed treatment in high-incidence settings are needed.
Trial registration
Current Controlled Trials ISRCTN17270334 and ISRCTN26184967.
Funding
This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 8, No. 9. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Alistair Story
- Institute of Health Informatics, University College London, London, UK
- Find&Treat, University College Hospitals NHS Foundation Trust, London, UK
| | - Elizabeth Garber
- Institute of Health Informatics, University College London, London, UK
- Royal Free London NHS Foundation Trust, London, UK
| | - Robert W Aldridge
- Institute of Health Informatics, University College London, London, UK
| | - Catherine M Smith
- Institute of Health Informatics, University College London, London, UK
| | - Joe Hall
- Institute of Health Informatics, University College London, London, UK
- Royal Free London NHS Foundation Trust, London, UK
| | - Gloria Ferenando
- Institute of Health Informatics, University College London, London, UK
- Royal Free London NHS Foundation Trust, London, UK
| | - Lucia Possas
- Institute of Health Informatics, University College London, London, UK
- Royal Free London NHS Foundation Trust, London, UK
| | - Sara Hemming
- Institute of Health Informatics, University College London, London, UK
- Royal Free London NHS Foundation Trust, London, UK
| | - Fatima Wurie
- Institute of Health Informatics, University College London, London, UK
| | - Serena Luchenski
- Institute of Health Informatics, University College London, London, UK
| | - Ibrahim Abubakar
- Institute for Global Health, University College London, London, UK
| | - Timothy D McHugh
- Centre for Clinical Microbiology, University College London, London, UK
| | - Peter J White
- Medical Research Council Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, UK
- National Institute for Health Research Health Protection Research Unit in Modelling Methodology, Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, UK
- Modelling and Economics Unit, National Infection Service, Public Health England, London, UK
| | - John M Watson
- Research Department of Infection and Population Health, University College London, London, UK
| | - Marc Lipman
- Royal Free London NHS Foundation Trust, London, UK
- Respiratory Medicine, Division of Medicine, University College London, London, UK
| | - Richard Garfein
- Division of Global Public Health, School of Medicine, University of California, San Diego, CA, USA
| | - Andrew C Hayward
- Institute of Epidemiology and Health Care, University College London, London, UK
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8
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Marks M, Scheibe A, Shelly S. High retention in an opioid agonist therapy project in Durban, South Africa: the role of best practice and social cohesion. Harm Reduct J 2020; 17:25. [PMID: 32295595 PMCID: PMC7161298 DOI: 10.1186/s12954-020-00368-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 03/26/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Moral conservatism within government and communities has resulted in a reluctance to support the provision of opioid agonist therapy for people with opioid use disorders in South Africa. In April 2017, South Africa's first low-threshold opioid agonist therapy demonstration project was launched in Durban. The project provided 54 low-income people with heroin use disorders methadone and voluntary access to psychosocial services for 18 months. At 12 months, retention was 74%, notably higher than the global average. In this paper, we aim to make sense of this outcome. METHODS Thirty semi-structured interviews, two focus groups, ten oral histories and ethnographic observations were done at various project time points. These activities explored participants' pathways into drug use and the project, their meaning attributed to methadone, the factors contributing to project success and changes they experienced. Recordings, transcripts, notes and feedback were reviewed and triangulated. Key factors contributing to retention were identified and analysed in light of the existing literature. RESULTS The philosophy and architecture of the project, and social cohesion were identified as the main factors contributing to retention. The use of a harm reduction approach enabled participants to set and be supported to achieve their treatment goals, and was shown to be important for the development of trusting therapeutic relationships. The employment of a restorative justice paradigm provided a sense of acceptance of humanity and flaws as well as an imperative to act responsibly towards others, fostering a culture of respect. Social cohesion was fostered through the facilitation of group sessions, a peace committee and group sport (soccer). In concert, these activities provided opportunities for participants to demonstrate care and interest in one another's life, leading to interdependence and care, contributing to them remaining in the project. CONCLUSIONS We believe that the high retention was achieved through attraction. We argue that opioid agonist therapy programmes should take the principles of harm reduction and restorative justice into consideration when designing low-threshold opioid agonist therapy services. Additionally, ways to support cohesion amongst people receiving agonist therapy should be explored to support their effective scale-up, both in low-middle income countries and in high-income countries.
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Affiliation(s)
- Monique Marks
- Urban Futures Centre, Steve Biko Campus, Durban University of Technology, Durban, South Africa
| | - Andrew Scheibe
- Urban Futures Centre, Steve Biko Campus, Durban University of Technology, Durban, South Africa
- TB HIV Care, 7th Floor, 11 Adderley Street, Cape Town, South Africa
| | - Shaun Shelly
- Urban Futures Centre, Steve Biko Campus, Durban University of Technology, Durban, South Africa
- Department of Family Medicine, University of Pretoria, Pretoria, South Africa
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Dennis BB, Akhtar D, Cholankeril G, Kim D, Sanger N, Hillmer A, Chawar C, D'Elia A, Panesar B, Worster A, Marsh DC, Thabane L, Samaan Z, Ahmed A. The impact of chronic liver disease in patients receiving active pharmacological therapy for opioid use disorder: One-year findings from a prospective cohort study. Drug Alcohol Depend 2020; 209:107917. [PMID: 32088589 DOI: 10.1016/j.drugalcdep.2020.107917] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 02/08/2020] [Accepted: 02/11/2020] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Despite the demonstrated benefit of methadone, the incidence opioid-related overdose, and its associated mortality continues to rise at an alarming rate. The impact of high prevalence comorbid features such as chronic liver disease (CLD) on methadone treatment response remain unclear. AIM To determine whether CLD is associated with poor response to methadone treatment. METHODS Using a well-established multi-center cohort from the Genetics of Opioid Addiction Study (GENOA), we evaluated if presence of CLD among 1234 eligible patients with opioid use disorder receiving methadone treatment impacted health and behavioural responses to treatment. CLD was classified as any liver disorder/dysfunction present for a minimum period of six months. Serial urine toxicology assessments were used to determine treatment response. The effect of CLD was determined using a multi-variable logistic regression model. RESULTS CLD was present in 25 % (n = 314) of the population. On average, patients with CLD were found to be older (mean age 44 vs 36 years, p < 0.0001), unemployed (81.8 % vs 61 %, p < 0.0001), and receiving government disability benefits at significantly higher rates (21.9 % vs 11 %, p < 0.0001). Increased levels of physical craving, emotional stress, as well as health risk behaviors were noted in CLD patients. Findings from the multi-variable model demonstrate a 68 % increased risk for dangerous opioid consumption behaviors (Odds Ration [OR]: 1.68, 95 % Confidence Interval [CI] 1.22, 2.31, p = 0.001) among patients with CLD. Methadone dose (OR: 0.76, 95 % CI 0.70, 0.81, p < 0.0001) was shown to be protective with a significant risk reduction of 24 % per 20 mg increase in methadone. Duration in treatment was also found to be protective (OR: 0.99, 95 % CI 0.97, 0.99, p < 0.0001). CONCLUSION CLD poses a distinct risk for patients with opioid addiction. Closer drug monitoring, and substance use contingency management should be considered to reduce mortality risk in these patients.
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Affiliation(s)
- Brittany B Dennis
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton ON L8S4L8, Canada; Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94305, USA.
| | - Daud Akhtar
- Department of Medicine, University of British Columbia, Vancouver Costal Health, Vancouver Canada.
| | - George Cholankeril
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94305, USA.
| | - Donghee Kim
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94305, USA.
| | - Nitika Sanger
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton ON L8S4L8, Canada; McMaser Neuroscience Graduate Program, McMaster University, Hamilton ON, L8S4L8, Canada.
| | - Alannah Hillmer
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton ON L8S4L8, Canada; McMaser Neuroscience Graduate Program, McMaster University, Hamilton ON, L8S4L8, Canada.
| | - Caroul Chawar
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton ON L8S4L8, Canada; McMaser Neuroscience Graduate Program, McMaster University, Hamilton ON, L8S4L8, Canada.
| | - Alessia D'Elia
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton ON L8S4L8, Canada; McMaser Neuroscience Graduate Program, McMaster University, Hamilton ON, L8S4L8, Canada.
| | - Balpreet Panesar
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton ON L8S4L8, Canada; McMaser Neuroscience Graduate Program, McMaster University, Hamilton ON, L8S4L8, Canada.
| | - Andrew Worster
- Department of Health Research Evaluation and Impact (Formerly Department of Clinical Epidemiology and Biostatistics), McMaster University, Hamilton ON L8S4L8, Canada.
| | - David C Marsh
- Northern Ontario School of Medicine, Sudbury ON P3E2C6, Canada; Canadian Addiction Treatment Centres, Markham ON L3T 7P6, Canada.
| | - Lehana Thabane
- Department of Health Research Evaluation and Impact (Formerly Department of Clinical Epidemiology and Biostatistics), McMaster University, Hamilton ON L8S4L8, Canada; Centre for Evaluation of Medicine, Hamilton ON L8S4L8, Canada.
| | - Zainab Samaan
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton ON L8S4L8, Canada; McMaser Neuroscience Graduate Program, McMaster University, Hamilton ON, L8S4L8, Canada; Department of Health Research Evaluation and Impact (Formerly Department of Clinical Epidemiology and Biostatistics), McMaster University, Hamilton ON L8S4L8, Canada; Population Genomics Program, Chanchlani Research Centre, McMaster University, Hamilton ON L8S4L8, Canada.
| | - Aijaz Ahmed
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94305, USA.
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Jessop AB, Bass SB, Brajuha J, Alhajji M, Burke M, Gashat MT, Wellington C, Ventriglia N, Coleman J, D'Avanzo P. "Take Charge, Get Cured": Pilot testing a targeted mHealth treatment decision support tool for methadone patients with hepatitis C virus for acceptability and promise of efficacy. J Subst Abuse Treat 2019; 109:23-33. [PMID: 31856947 DOI: 10.1016/j.jsat.2019.11.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Revised: 10/25/2019] [Accepted: 11/04/2019] [Indexed: 12/27/2022]
Abstract
Hepatitis C (HCV) is a highly prevalent infection in current and former IV drug users. Current estimates indicate that over 70% of those in methadone maintenance treatment programs (MMTs) have HCV, but only 11% have initiated treatments despite availability of new treatments that are easily tolerated and can cure infection in about 8 weeks. We conducted a pilot randomized trial at four Philadelphia, PA MMTs to test acceptability, feasibility and promise of efficacy of our "Take Charge, Get Cured" mobile health (mHealth) treatment decision tool, developed through extensive formative work that included methadone patients' input and targeted directly to concerns of methadone patients with Hepatitis C (HCV). We compared its impact on perceptions and knowledge about HCV and HCV treatment, decisional conflict, intention to and actual initiation of HCV care to a web-based Cochrane-reviewed, non-targeted HCV decision tool. Subjects (n = 122) were randomized, administered baseline questionnaires, interacted with the targeted or non-targeted decision tool on an electronic tablet, and answered post-test questions. After 3-months subjects (n = 93; 76%) were surveyed for follow up. "Take Charge, Get Cured" users were more likely to report the tool helped with decision making and demonstrated greater improvement in knowledge, decisional conflict, and intention to be treated for their HCV infections than users of the non-targeted decision tool. They were significantly more likely to say the targeted tool was helpful and that they would recommend it to others. At three month follow up, targeted group participants were more likely to say the tool helped them make a better decision about treatment and prepared them to talk to their doctor about what matters most to them about treatment. No differences were seen in actions to initiate HCV care, but more targeted group participants reported talking to their doctors about HCV treatment. Results indicate a highly targeted mHealth decision tool is an important strategy to affect perceptions and knowledge of HCV treatment that lowers decisional conflict about initiating treatment, key components in decision making. We believe this highly acceptable and feasible intervention could be utilized in clinical settings to address the important barriers to initiating HCV treatment in a vulnerable population.
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Affiliation(s)
- Amy B Jessop
- Western Michigan University, Public health Program, 200 Ionia Ave, NW, 4th Floor, Grand Rapids, MI 49503, USA; HepTREC, 141 Whitemarsh Rd, Ardmore, PA 19003, USA.
| | - Sarah Bauerle Bass
- Temple University, Department of Social and Behavioral Sciences, Risk Communication Laboratory, College of Public Health, Ritter Annex, Philadelphia, PA 19122, USA
| | - Jesse Brajuha
- Temple University, Department of Social and Behavioral Sciences, Risk Communication Laboratory, College of Public Health, Ritter Annex, Philadelphia, PA 19122, USA
| | - Mohammed Alhajji
- Temple University, Department of Social and Behavioral Sciences, Risk Communication Laboratory, College of Public Health, Ritter Annex, Philadelphia, PA 19122, USA
| | - Monika Burke
- HepTREC, 141 Whitemarsh Rd, Ardmore, PA 19003, USA
| | | | - Carine Wellington
- Temple University, Department of Social and Behavioral Sciences, Risk Communication Laboratory, College of Public Health, Ritter Annex, Philadelphia, PA 19122, USA
| | - Nicole Ventriglia
- Temple University, Department of Social and Behavioral Sciences, Risk Communication Laboratory, College of Public Health, Ritter Annex, Philadelphia, PA 19122, USA
| | - Jennie Coleman
- Temple University, Department of Social and Behavioral Sciences, Risk Communication Laboratory, College of Public Health, Ritter Annex, Philadelphia, PA 19122, USA
| | - Paul D'Avanzo
- Temple University, Department of Social and Behavioral Sciences, Risk Communication Laboratory, College of Public Health, Ritter Annex, Philadelphia, PA 19122, USA
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11
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Farnia V, Alikhani M, Ebrahimi A, Golshani S, Sadeghi Bahmani D, Brand S. Ginseng treatment improves the sexual side effects of methadone maintenance treatment. Psychiatry Res 2019; 276:142-150. [PMID: 31082749 DOI: 10.1016/j.psychres.2019.05.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 04/29/2019] [Accepted: 05/01/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND While methadone maintenance therapy (MMT) in patients with opioid use disorder (OUD) decreases the risk of substance use relapses and criminal and risky sexual behavior, a major disadvantage is its negative impact on sexual function. In the present study we tested whether, compared to placebo, ginseng extract ameliorates methadone-related sexual dysfunction among female and male patients with OUD and receiving MMT. METHOD A total of 74 patients (26 females: mean age: M = 39.0 years; 48 males; mean age: 40.64 years) took part in a double-blind, randomized and placebo-controlled study. Female and male patients were separately randomly assigned either to the ginseng or to a placebo condition. At the beginning of the study and four weeks later, patients completed questionnaires on sexual function. RESULTS Irrespective of gender, sexual function improved over time, but more so in the ginseng condition than in the placebo condition. CONCLUSIONS Ginseng appears to counteract the sexual dysfunction resulting from methadone use in both female and male patients with OUD and undergoing MMT.
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Affiliation(s)
- Vahid Farnia
- Psychiatry Department, Substance Abuse Prevention Research Center, Health institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Mostafa Alikhani
- Psychiatry Department, Substance Abuse Prevention Research Center, Health institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Alireza Ebrahimi
- Psychiatry Department, Substance Abuse Prevention Research Center, Health institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Sanobar Golshani
- Psychiatry Department, Substance Abuse Prevention Research Center, Health institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Dena Sadeghi Bahmani
- Psychiatry Department, Substance Abuse Prevention Research Center, Health institute, Kermanshah University of Medical Sciences, Kermanshah, Iran; Isfahan Neurosciences Research Center, Alzahra Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran; Sleep Disorders Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran; University of Basel, Psychiatric Clinics (UPK), Center of Affective, Stress and Sleep Disorders (ZASS), Basel, Switzerland
| | - Serge Brand
- Psychiatry Department, Substance Abuse Prevention Research Center, Health institute, Kermanshah University of Medical Sciences, Kermanshah, Iran; Sleep Disorders Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran; University of Basel, Psychiatric Clinics (UPK), Center of Affective, Stress and Sleep Disorders (ZASS), Basel, Switzerland; University of Basel, Department of Sport, Exercise, and Health, Division of Sport Science and Psychosocial Health, Basel, Switzerland.
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12
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Akiyama MJ, Norton BL, Arnsten JH, Agyemang L, Heo M, Litwin AH. Intensive Models of Hepatitis C Care for People Who Inject Drugs Receiving Opioid Agonist Therapy: A Randomized Controlled Trial. Ann Intern Med 2019; 170:594-603. [PMID: 30959528 PMCID: PMC6868527 DOI: 10.7326/m18-1715] [Citation(s) in RCA: 91] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Many people who inject drugs (PWID) are denied treatment for hepatitis C virus (HCV) infection, even if they are receiving opioid agonist therapy (OAT). Research suggests that HCV in PWID may be treated effectively, but optimal models of care for promoting adherence and sustained virologic response (SVR) have not been evaluated in the direct-acting antiviral (DAA) era. OBJECTIVE To determine whether directly observed therapy (DOT) and group treatment (GT) are more effective than self-administered individual treatment (SIT) in promoting adherence and achieving SVR among PWID receiving OAT. DESIGN Three-group, randomized controlled trial conducted from October 2013 to April 2017. (ClinicalTrials.gov: NCT01857245). SETTING Three OAT programs in Bronx, New York. PARTICIPANTS Persons aged 18 years and older with genotype 1 HCV infection who were willing to receive HCV therapy on site in the OAT program. Of 190 persons screened, 158 were randomly assigned to a study group and 150 initiated treatment: DOT (n = 51), GT (n = 48), and SIT (n = 51). INTERVENTION 2 intensive interventions (DOT and GT) and 1 control condition (SIT). MEASUREMENTS Primary: adherence, measured by using electronic blister packs. Secondary: HCV treatment completion and SVR 12 weeks after treatment completion. RESULTS Mean age was 51 years; 65% of participants had positive results on urine drug testing during the 6 months before treatment, and 75% reported ever injecting drugs. Overall adherence, estimated from mixed-effects models using the daily timeframe, was 78% (95% CI, 75% to 81%) and was greater among participants randomly assigned to DOT (86% [CI, 80% to 92%]) than those assigned to SIT (75% [CI, 70% to 81%]; difference, 11% [CI, 5% to 18%]; Bonferroni-corrected P = 0.001). No significant difference in adherence was observed between participants randomly assigned to GT (80% [CI, 74% to 86%]) and those assigned to SIT (difference, 4.7% [CI, -2% to 11%]; Bonferroni-corrected P = 0.29). The HCV treatment completion rate was 97%, with no differences among groups (P = 0.53). Overall SVR was 94% (CI, 89% to 97%); the SVR rate was 98% in the DOT group, 94% in the GT group, and 90% in the SIT group (P = 0.152). LIMITATION These findings may not be generalizable to PWID not enrolled in OAT programs. CONCLUSION All models of onsite HCV care delivered to PWID in OAT programs resulted in high SVR, despite ongoing drug use. Directly observed therapy was associated with greater adherence than SIT. PRIMARY FUNDING SOURCE National Institute on Drug Abuse and Gilead Sciences.
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Affiliation(s)
- Matthew J Akiyama
- Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York (M.J.A., B.L.N., J.H.A., L.A.)
| | - Brianna L Norton
- Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York (M.J.A., B.L.N., J.H.A., L.A.)
| | - Julia H Arnsten
- Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York (M.J.A., B.L.N., J.H.A., L.A.)
| | - Linda Agyemang
- Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York (M.J.A., B.L.N., J.H.A., L.A.)
| | | | - Alain H Litwin
- University of South Carolina School of Medicine-Greenville and Greenville Health System, Greenville, South Carolina, and Clemson University School of Health Research, Clemson, South Carolina (A.H.L.)
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13
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Bauerle Bass S, Jessop A, Gashat M, Maurer L, Alhajji M, Forry J. Take Charge, Get Cured: The development and user testing of a culturally targeted mHealth decision tool on HCV treatment initiation for methadone patients. PATIENT EDUCATION AND COUNSELING 2018; 101:1995-2004. [PMID: 30055893 DOI: 10.1016/j.pec.2018.07.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 06/09/2018] [Accepted: 07/07/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE This paper describes the development of a mobile health tool to facilitate Hepatitis C (HCV) treatment decision making in methadone patients. METHODS Using an iterative, formative evaluation framework, we used commercial marketing techniques to create 3D maps of survey data to develop culturally relevant messaging that was concept tested. The resulting tool was then user tested and results were used to modify the tool. RESULTS The "Take Charge, Get Cured" tool was developed with surveys (n = 100), perceptual mapping analysis, concept testing (n = 5), and user testing (n = 10). "Think aloud" sessions were audio recorded and surveys given. Patients thought the goal of the tool was to encourage treatment and it was aimed to the needs of methadone patients. Means of 6.7-7 (on a 7 point scale) were observed for survey items related to ease of use, content, and satisfaction. CONCLUSION The iterative development was essential to ensuring a culturally targeted tool, specific to the needs of HCV + methadone patients. There was a high level of acceptance for the tool. PRACTICE IMPLICATIONS Our study indicates that using a formative evaluation strategy is essential for development of highly targeted patient communication, especially in hard-to-reach populations.
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Affiliation(s)
- Sarah Bauerle Bass
- Risk Communication Laboratory, Department of Social and Behavioral Sciences, Temple University College of Public Health, Phiadelphia, PA, 19122, USA.
| | | | | | - Laurie Maurer
- Risk Communication Laboratory, Department of Social and Behavioral Sciences, Temple University College of Public Health, Phiadelphia, PA, 19122, USA
| | - Mohammed Alhajji
- Risk Communication Laboratory, Department of Social and Behavioral Sciences, Temple University College of Public Health, Phiadelphia, PA, 19122, USA
| | - Jon Forry
- Risk Communication Laboratory, Department of Social and Behavioral Sciences, Temple University College of Public Health, Phiadelphia, PA, 19122, USA
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14
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Bass SB, Jessop A, Maurer L, Gashat M, Al Hajji M, Gutierrez M. Mapping the Barriers and Facilitators of HCV Treatment Initiation in Methadone Maintenance Therapy Patients: Implications for Intervention Development. JOURNAL OF HEALTH COMMUNICATION 2017; 23:117-127. [PMID: 29252118 DOI: 10.1080/10810730.2017.1414902] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
An estimated 70-90% of current methadone users have Hepatitis C (HCV). Current treatments have few side effects and can cure infection in 8-12 weeks, but less than 10% of methadone patients initiate treatment. Engaging this group in treatment is an important strategy to lower both morbidity and mortality from liver disease and eliminate a significant reservoir of HCV in communities. To understand how to address this treatment gap we used commercial marketing techniques called perceptual mapping and vector message modeling to analyze survey data from 100 HCV+ methadone patients from four centers in Philadelphia. Results were used to understand barriers and facilitators to treatment initiation and to devise targeted message strategies to adapt to a mobile health communication intervention. Results indicate that focusing on how treatment can make one feel "in charge", positive interactions with healthcare providers, the positive attributes of the new vs. old HCV treatments, and providing strategies to address tangible barriers to getting treatment, would be important to address in a communication intervention. These marketing methods allow for focusing on specific variables to "move" the group toward a treatment decision, making them an innovative technique to use in developing highly targeted health communication messages.
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Affiliation(s)
- Sarah Bauerle Bass
- a Risk Communication Laboratory, Department of Social and Behavioral Sciences , Temple University College of Public Health , Philadelphia , PA , USA
| | | | - Laurie Maurer
- a Risk Communication Laboratory, Department of Social and Behavioral Sciences , Temple University College of Public Health , Philadelphia , PA , USA
| | | | - Mohammed Al Hajji
- a Risk Communication Laboratory, Department of Social and Behavioral Sciences , Temple University College of Public Health , Philadelphia , PA , USA
| | - Mercedes Gutierrez
- a Risk Communication Laboratory, Department of Social and Behavioral Sciences , Temple University College of Public Health , Philadelphia , PA , USA
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15
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Farnia V, Tatari F, Alikhani M, Yazdchi K, Taghizadeh M, Sadeghi Bahmani D, Karbasizadeh H, Holsboer-Trachsler E, Brand S. Rosa Damascena oil improved methadone-related sexual dysfunction in females with opioid use disorder under methadone maintenance therapy - results from a double-blind, randomized, and placebo-controlled trial. J Psychiatr Res 2017; 95:260-268. [PMID: 28923720 DOI: 10.1016/j.jpsychires.2017.08.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 08/13/2017] [Accepted: 08/14/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Methadone maintenance therapy (MMT) is provided to patients with opioid use disorder (OUD). However, as with all opioids, methadone impacts negatively on sexual function. To counter this, Rosa Damascena oil (RDO) has been used successfully for opioid-dependent male patients under MMT and with methadone-related sexual dysfunction (MRSD). In the present study, we tested the possible influence of RDO on sexual function and sex hormones of opioid-dependent female patients undergoing MMT and with MRSD. METHODS Fifty female patients (mean age: 38.8 years) diagnosed with OUD, undergoing MMT and with MRSD were randomly assigned either to the RDO or the placebo condition. At baseline, patients completed questionnaires covering socio-demographic and OUD-related information. At baseline, and four and eight weeks later they additionally completed questionnaires on sexual function and happiness. Blood samples to assess thyroid hormones, prolactin, progesterone, and estradiol levels were taken at baseline and eight weeks later (end of the study). RESULTS Over time sexual function and happiness increased, but more so in the RDO condition than in the placebo condition. Over time, prolactin decreased, and progesterone, and estradiol increased, but again more so in the RDO condition. Sex hormone levels and sexual function were statistically unrelated. CONCLUSIONS Results from this double-blind, randomized, and placebo-controlled clinical trial showed that opioid-dependent females undergoing MMT and with MRDS did benefit from RDO administration, as sexual function and happiness increased, and female sexual hormone levels changed in positive directions.
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Affiliation(s)
- Vahid Farnia
- Substance Abuse Prevention Research Center, Psychiatry Department, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Faeze Tatari
- Substance Abuse Prevention Research Center, Psychiatry Department, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Mostafa Alikhani
- Substance Abuse Prevention Research Center, Psychiatry Department, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Katayoun Yazdchi
- Kermanshah University of Medical Sciences, Gynecology and Obstetrics Department, Kermanshah, Iran
| | - Moshen Taghizadeh
- Research Center for Biochemistry & Nutrition in Metabolic Diseases, Kashan University of Medical Sciences, Kashan, Iran
| | - Dena Sadeghi Bahmani
- University of Basel, Psychiatric Clinic (UPK), Center for Affective, Stress and Sleep Disorders (ZASS), Basel, Switzerland
| | | | - Edith Holsboer-Trachsler
- University of Basel, Psychiatric Clinic (UPK), Center for Affective, Stress and Sleep Disorders (ZASS), Basel, Switzerland
| | - Serge Brand
- Substance Abuse Prevention Research Center, Psychiatry Department, Kermanshah University of Medical Sciences, Kermanshah, Iran; University of Basel, Psychiatric Clinic (UPK), Center for Affective, Stress and Sleep Disorders (ZASS), Basel, Switzerland; University of Basel, Department of Sport, Exercise and Health, Division of Sport and Psychosocial Health, Basel, Switzerland.
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16
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Lafferty L, Treloar C, Guthrie J, Chambers GM, Butler T. Social capital strategies to enhance hepatitis C treatment awareness and uptake among men in prison. J Viral Hepat 2017; 24:111-116. [PMID: 27778436 DOI: 10.1111/jvh.12627] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 08/30/2016] [Indexed: 12/22/2022]
Abstract
Prisoner populations are characterized by high rates of hepatitis C (HCV), up to thirty times that of the general population in Australia. Within Australian prisons, less than 1% of eligible inmates access treatment. Public health strategies informed by social capital could be important in addressing this inequality in access to HCV treatment. Twenty-eight male inmates participated in qualitative interviews across three correctional centres in New South Wales, Australia. All participants had recently tested as HCV RNA positive or were receiving HCV treatment. Analysis was conducted with participants including men with experiences of HCV treatment (n=10) (including those currently accessing treatment and those with a history of treatment) and those who were treatment naïve (n=18). Social capital was a resourceful commodity for inmates considering and undergoing treatment while in custody. Inmates were a valuable resource for information regarding HCV treatment, including personal accounts and reassurance (bonding social capital), while nurses a resource for the provision of information and care (linking social capital). Although linking social capital between inmates and nurses appeared influential in HCV treatment access, there remained opportunities for increasing linking social capital within the prison setting (such as nurse-led engagement within the prisons). Bonding and linking social capital can be valuable resources in promoting HCV treatment awareness, uptake and adherence. Peer-based programmes are likely to be influential in promoting HCV outcomes in the prison setting. Engagement in prisons, outside of the clinics, would enhance opportunities for linking social capital to influence HCV treatment outcomes.
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Affiliation(s)
- L Lafferty
- The Kirby Institute, UNSW Australia, Sydney, NSW, Australia
| | - C Treloar
- Centre for Social Research in Health, UNSW Australia, Sydney, NSW, Australia
| | - J Guthrie
- The Australian National University, Canberra, ACT, Australia
| | - G M Chambers
- National Perinatal Epidemiology and Statistics Unit, UNSW Australia, Sydney, NSW, Australia
| | - T Butler
- The Kirby Institute, UNSW Australia, Sydney, NSW, Australia
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17
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Nolan S, Klimas J, Wood E. Alcohol use in opioid agonist treatment. Addict Sci Clin Pract 2016; 11:17. [PMID: 27931253 PMCID: PMC5146864 DOI: 10.1186/s13722-016-0065-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 11/29/2016] [Indexed: 12/22/2022] Open
Abstract
Alcohol misuse among individuals receiving agonist treatment for an opioid use disorder is common and is associated with significant morbidity and mortality. At present, though substantial research highlights effective strategies for the screening, diagnosis and management of an alcohol or opioid use disorder individually, less is known about how best to care for those with a dual diagnosis especially since common treatments for opioid addiction may be contraindicated in a setting of alcohol use. This review summarizes existing research and characterizes the prevalence, clinical implications and management of alcohol misuse among individuals with opioid addiction. Furthermore, it highlights clinically relevant management strategies in need of future research to advance care for this unique, but important, patient population.
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Affiliation(s)
- Seonaid Nolan
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada. .,Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
| | - Jan Klimas
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.,School of Medicine and Medical Science, University College Dublin, Coombe Healthcare Centre, Dolphins Barn, Dublin, Ireland
| | - Evan Wood
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.,Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
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Chirikov VV, Shaya FT, Mullins CD, dosReis S, Onukwugha E, Howell CD. Determinants of quality of care and treatment initiation in Medicare disabled patients with chronic hepatitis C. Expert Rev Gastroenterol Hepatol 2016; 9:1447-62. [PMID: 26524244 DOI: 10.1586/17474124.2015.1095087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Aligning with a national priority to bridge health disparities in disadvantaged populations, we explored contextual determinants of pretreatment quality of care and treatment receipt of Medicare disabled patients with hepatitis C virus (HCV) infection. METHODS We used Medicare claims (2006-2009) linked to the Area Health Resource Files. Ordinal partial proportional odds and weighted modified Poisson regressions were used to model the determinants of quality care receipt and interferon-based treatment, respectively. RESULTS We identified 1936 Medicare disabled HCV patients, of whom 10.4% were treated with peg-interferon. Despite the high comorbidity burden among HCV disabled patients, greater engagement in care correlated with greater likelihood of quality care and treatment receipt. CONCLUSION Our study highlights the need for process and linkage to care in Medicare disabled HCV patients, but future research relevant to novel interferon-free agents is needed to assess patterns of quality of care and treatment receipt in this vulnerable population.
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Affiliation(s)
- Viktor V Chirikov
- a 1 Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, 220 Arch Street, Saratoga Offices 12th Floor, Baltimore, MD 21201, USA
| | - Fadia T Shaya
- a 1 Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, 220 Arch Street, Saratoga Offices 12th Floor, Baltimore, MD 21201, USA.,b 2 University of Maryland School of Medicine, Baltimore, MD, USA
| | - C Daniel Mullins
- a 1 Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, 220 Arch Street, Saratoga Offices 12th Floor, Baltimore, MD 21201, USA
| | - Susan dosReis
- a 1 Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, 220 Arch Street, Saratoga Offices 12th Floor, Baltimore, MD 21201, USA
| | - Ebere Onukwugha
- a 1 Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, 220 Arch Street, Saratoga Offices 12th Floor, Baltimore, MD 21201, USA
| | - Charles D Howell
- c 3 Department of Medicine, Howard University College of Medicine, 2041 Georgia Ave. Suite 5C02, Washington, DC 20060, USA
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Schulte M, Hser Y, Saxon A, Evans E, Li L, Huang D, Hillhouse M, Thomas C, Ling W. Risk Factors Associated with HCV Among Opioid-Dependent Patients in a Multisite Study. J Community Health 2016; 40:940-7. [PMID: 25814381 DOI: 10.1007/s10900-015-0016-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
We examined risk factors associated with hepatitis C virus (HCV) infection among opioid-dependent patients enrolled into medication-assisted therapy (buprenorphine or methadone) to determine factors affecting chronic infection. Patients (N = 1039) were randomized as part of a larger, multisite clinical trial sponsored by the National Drug Abuse Treatment Clinical Trials Network assessing liver function. HCV status was first assessed with an antibody screen; if positive, then current infection was determined with an antigen screen testing for detectable virus. Patients were classified as HCV negative, HCV positive but have cleared the virus, or as having chronic HCV. Logistic regression analysis was used to examine demographic and behavioral correlates of the three groups. Thirty-four percent of patients were classified with chronic infection and 14% had evidence of prior infection with apparent clearing of the virus. Chronic infection was associated with recent injection drug use and cocaine use. Chronic HCV infection was also associated with being older and Hispanic. Age, ethnicity, and current drug use increase the likelihood of being chronically infected with HCV. Strategies targeting high risk subgroups can aid in preventing further disease escalation.
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Affiliation(s)
- M Schulte
- UCLA Integrated Substance Abuse Programs, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, 11075 Santa Monica Blvd., Suite 200, Los Angeles, CA, 90025, USA,
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Novick DM, Salsitz EA, Joseph H, Kreek MJ. Methadone Medical Maintenance: An Early 21st-Century Perspective. J Addict Dis 2016; 34:226-37. [PMID: 26110221 DOI: 10.1080/10550887.2015.1059225] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Methadone medical maintenance is the treatment of stable methadone-maintained patients in primary care physicians' offices under an exemption from federal methadone regulations. Reports from seven such programs in six states show high retention and low frequencies of illicit drug use. Patients and physicians indicate high levels of satisfaction. Although methadone maintenance has a long history of safety and efficacy, most methadone medical maintenance programs are no longer operating or accepting new patients. Federal regulations for standard methadone clinics allow some features of methadone medical maintenance, and advocacy for state approval of these changes is strongly recommended.
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Affiliation(s)
- David M Novick
- a Laboratory of the Biology of Addictive Diseases, The Rockefeller University , New York , New York , USA
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Behan J, Geier M. Intolerance of sublingual buprenorphine-naloxone during induction in a patient with end-stage liver disease: A case report. Ment Health Clin 2016; 6:131-133. [PMID: 29955460 PMCID: PMC6007647 DOI: 10.9740/mhc.2016.05.131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Introduction Sublingual buprenorphine is indicated for opioid dependence. It comes in 2 formulations: a mono buprenorphine product (BUP) and a combination product containing naloxone (BUP-NAL), which functions as an abuse deterrent. Sublingual naloxone does not reach clinically significant levels except in cases of hepatic impairment, where its metabolism can be impaired. Substantial naloxone accumulation could block the therapeutic effects of buprenorphine. The risk of hepatic impairment is elevated in the opioid dependence population, and our case highlights the need for careful evaluation of hepatic function and consideration of BUP. Case/Results We report a patient with end-stage liver disease who began BUP-NAL induction with modest improvement on treatment day 1 followed by sustained withdrawal after receiving an observed dose on day 2. He returned to the clinic 2 days after his second successive day of BUP-NAL, vomiting and complaining of persistent withdrawal. To avoid potential accumulation of naloxone, the patient was eventually switched to and stabilized on BUP with good response. Discussion/Conclusion The clinical course this patient experienced during induction makes a case that naloxone can accumulate and interfere with the effectiveness of buprenorphine in the presence of liver dysfunction. Our case highlights the need for consideration of BUP in circumstances where patient safety and effective treatment outweigh the risks of prescribing a product with abuse deterrent properties.
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Affiliation(s)
- Jennifer Behan
- City and County Department of Public Health Pharmacist, Behavioral Health Services, San Francisco Health Network, San Francisco, California,
| | - Michelle Geier
- City and County Department of Public Health Pharmacist, Behavioral Health Services, San Francisco Health Network, San Francisco, California
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Hepatitis C Virus Testing and Treatment Among Persons Receiving Buprenorphine in an Office-Based Program for Opioid Use Disorders. J Subst Abuse Treat 2016; 66:54-9. [PMID: 26988423 DOI: 10.1016/j.jsat.2016.01.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2015] [Revised: 01/11/2016] [Accepted: 01/18/2016] [Indexed: 12/12/2022]
Abstract
AIMS In the United States, hepatitis C virus (HCV) infection is primarily spread through injection drug use. There is an urgent need to improve access to care for HCV among persons with opioid use disorders who inject drugs. The purpose of our study was to determine the prevalence of HCV, patient characteristics, and receipt of appropriate care in a sample of patients treated with buprenorphine for their opioid use disorders in a primary care setting. METHODS This study used retrospective clinical data from the electronic medical record. The study population included patients receiving buprenorphine in the Office Based Opioid Treatment (OBOT) clinic within the adult primary medicine clinic at Boston Medical Center between October 2003 and August 2013 who received a conclusive HCV antibody (Ab) test within a year of clinic entry. We compared characteristics by HCV serostatus using Pearson's chi-square and provided numbers/percentages receiving appropriate care. RESULTS The sample comprised 700 patients. Slightly less than half of all patients (n=334, 47.7%) were HCV Ab positive, and were significantly more likely to be older, Hispanic or African American, have diagnoses of post-traumatic stress disorder (PTSD) or bipolar disorder, have prior heroin or cocaine use, and be HIV-infected. Among the 334 HCV Ab positive patients, 226 (67.7%) had detectable HCV ribonucleic acid (RNA) indicating chronic HCV infection; only 5 patients (2.21%) with chronic HCV infection ever initiated treatment. CONCLUSIONS Nearly half of patients (47.7%) receiving office-based treatment with buprenorphine for their opioid use disorder had a positive hepatitis C virus antibody screening test although initiation of HCV treatment was nearly non-existent (2.21%).
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Tsui JI, Lira MC, Cheng DM, Winter MR, Alford DP, Liebschutz JM, Mao J, Edwards RR, Samet JH. Hepatitis C virus infection and pain sensitivity in patients on methadone or buprenorphine maintenance therapy for opioid use disorders. Drug Alcohol Depend 2015; 153:286-92. [PMID: 26048638 PMCID: PMC4509826 DOI: 10.1016/j.drugalcdep.2015.05.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2015] [Revised: 05/02/2015] [Accepted: 05/04/2015] [Indexed: 01/17/2023]
Abstract
BACKGROUND Patients with opioid use disorders on opioid agonist therapy (OAT) have lower pain tolerance compared to controls. While chronic viral infections such as HCV and HIV have been associated with chronic pain in this population, no studies have examined their impact on pain sensitivity. METHODS We recruited 106 adults (41 uninfected controls; 40 HCV mono-infected; and 25 HCV/HIV co-infected) on buprenorphine or methadone to assess whether HCV infection (with or without HIV) was associated with increased experimental pain sensitivity and self-reported pain. The primary outcome was cold pain tolerance assessed by cold-pressor test. Secondary outcomes were cold pain thresholds, wind-up ratios to repetitive mechanical stimulation (i.e., temporal summation) and acute and chronic pain. Multivariable regression models evaluated associations between viral infection status and outcomes, adjusting for other factors. RESULTS No significant differences were detected across groups for primary or secondary outcomes. Adjusted mean cold pain tolerance was 25.7 (uninfected controls) vs. 26.8 (HCV mono-infection) vs. 25.3 (HCV/HIV co-infection) seconds (global p-value=0.93). Current pain appeared more prevalent among HCV mono-infected (93%) compared to HCV/HIV co-infected participants (76%) and uninfected controls (80%), as did chronic pain (77% vs. 64% vs. 61%, respectively). However, differences were not statistically significant in multivariable models. CONCLUSION This study did not detect an association between HCV infection and increased sensitivity to pain among adults with and without HIV who were treated with buprenorphine or methadone for opioid use disorders. Results reinforce that pain and hyperalgesia are common problems in this population.
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Affiliation(s)
- Judith I. Tsui
- Section of General Internal Medicine, Department of Medicine, University of Washington School of Medicine, 325 9 Avenue Seattle, WA 98104
| | - Marlene C. Lira
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, 801 Massachusetts Ave., Second Floor, Boston, MA 02118
| | - Debbie M. Cheng
- Department of Biostatistics, Boston University School of Public Health, 801 Massachusetts Ave., Third Floor, Boston, MA 02118
| | - Michael R. Winter
- Data Coordinating Center, Boston University School of Public Health, 801 Massachusetts Ave., Third Floor, Boston, MA 02118
| | - Daniel P. Alford
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, 801 Massachusetts Ave., Second Floor, Boston, MA 02118,Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, 801 Massachusetts Ave., Second Floor, Boston, MA 02118
| | - Jane M. Liebschutz
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, 801 Massachusetts Ave., Second Floor, Boston, MA 02118,Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, 801 Massachusetts Ave., Second Floor, Boston, MA 02118
| | - Jianren Mao
- Department of Anesthesia, Massachusetts General Hospital, 101 Merrimac Street, Boston, MA 02110
| | - Robert R. Edwards
- Department of Anesthesia, Brigham and Women’s Hospital, Pain Management Center, 850 Boylston Street, Chestnut Hill, MA 02467
| | - Jeffrey H. Samet
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, 801 Massachusetts Ave., Second Floor, Boston, MA 02118,Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, 801 Massachusetts Ave., Second Floor, Boston, MA 02118,Department of Community Health Sciences, Boston University School of Public Health, 801 Massachusetts Ave., Second Floor, Boston, MA 02118
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Haley SJ, Kreek MJ. A window of opportunity: maximizing the effectiveness of new HCV regimens in the United States with the expansion of the Affordable Care Act. Am J Public Health 2015; 105:457-63. [PMID: 25602859 PMCID: PMC4330831 DOI: 10.2105/ajph.2014.302327] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2014] [Indexed: 12/18/2022]
Abstract
Patients with chronic HCV have predictable overlapping comorbidities that reduce access to care. The Affordable Care Act (ACA) presents an opportunity to focus on the benefits of the medical home model for integrated chronic disease management. New, highly effective HCV treatment regimens in combination with the medical home model could reduce disease prevalence. We sought to address challenges posed by comorbidities in patients with chronic HCV infection and limitations within our health care system, and recommend solutions to maximize the public benefit from ACA and the new drug regimen.
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Affiliation(s)
- Sean J Haley
- Sean J. Haley is with the Department of Health and Nutrition Sciences, Brooklyn College and the City University of New York, School of Public Health, New York. Mary Jeanne Kreek is with the Laboratory of the Biology of Addictive Diseases, The Rockefeller University, New York
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25
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Soyka M. Alcohol use disorders in opioid maintenance therapy: prevalence, clinical correlates and treatment. Eur Addict Res 2015; 21:78-87. [PMID: 25413371 DOI: 10.1159/000363232] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Maintenance therapy with methadone or buprenorphine is an established and first-line treatment for opioid dependence. Clinical studies indicate that about a third of patients in opioid maintenance therapy show increased alcohol consumption and alcohol use disorders. Comorbid alcohol use disorders have been identified as a risk factor for clinical outcome and can cause poor physical and mental health, including liver disorders, noncompliance, social deterioration and increased mortality risk. The effects of opioid maintenance therapy on alcohol consumption are controversial and no clear pattern has emerged. Most studies have not found a change in alcohol use after initiation of maintenance therapy. Methadone and buprenorphine appear to carry little risk of liver toxicity, but further research on this topic is required. Recent data indicate that brief intervention strategies may help reduce alcohol intake, but the existing evidence is still limited. This review discusses further clinical implications of alcohol use disorders in opioid dependence.
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Affiliation(s)
- Michael Soyka
- Department of Psychiatry and Psychotherapy, Ludwig Maximilian University, Munich, Germany; Private Hospital Meiringen, Willigen, Meiringen, Switzerland
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Schackman BR, Leff JA, Barter DM, DiLorenzo MA, Feaster DJ, Metsch LR, Freedberg KA, Linas BP. Cost-effectiveness of rapid hepatitis C virus (HCV) testing and simultaneous rapid HCV and HIV testing in substance abuse treatment programs. Addiction 2015; 110:129-43. [PMID: 25291977 PMCID: PMC4270906 DOI: 10.1111/add.12754] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Revised: 07/11/2014] [Accepted: 09/29/2014] [Indexed: 12/13/2022]
Abstract
AIMS To evaluate the cost-effectiveness of rapid hepatitis C virus (HCV) and simultaneous HCV/HIV antibody testing in substance abuse treatment programs. DESIGN We used a decision analytic model to compare the cost-effectiveness of no HCV testing referral or offer, off-site HCV testing referral, on-site rapid HCV testing offer and on-site rapid HCV and HIV testing offer. Base case inputs included 11% undetected chronic HCV, 0.4% undetected HIV, 35% HCV co-infection among HIV-infected, 53% linked to HCV care after testing antibody-positive and 67% linked to HIV care. Disease outcomes were estimated from established computer simulation models of HCV [Hepatitis C Cost-Effectiveness (HEP-CE)] and HIV [Cost-Effectiveness of Preventing AIDS Complications (CEPAC)]. SETTING AND PARTICIPANTS Data on test acceptance and costs were from a national randomized trial of HIV testing strategies conducted at 12 substance abuse treatment programs in the United States. MEASUREMENTS Lifetime costs (2011 US$) and quality-adjusted life years (QALYs) discounted at 3% annually; incremental cost-effectiveness ratios (ICERs). FINDINGS On-site rapid HCV testing had an ICER of $18,300/QALY compared with no testing, and was more efficient than (dominated) off-site HCV testing referral. On-site rapid HCV and HIV testing had an ICER of $64,500/QALY compared with on-site rapid HCV testing alone. In one- and two-way sensitivity analyses, the ICER of on-site rapid HCV and HIV testing remained <$100,000/QALY, except when undetected HIV prevalence was <0.1% or when we assumed frequent HIV testing elsewhere. The ICER remained <$100,000/QALY in 91% of probabilistic sensitivity analyses. CONCLUSIONS On-site rapid hepatitis C virus and HIV testing in substance abuse treatment programs is cost-effective at a <$100,000/quality-adjusted life year threshold.
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Affiliation(s)
- Bruce R. Schackman
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, USA
| | - Jared A. Leff
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, USA
| | - Devra M. Barter
- HIV Epidemiology and Outcomes Research Unit, Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Boston, MA, USA
| | - Madeline A. DiLorenzo
- Division of General Medicine, Massachusetts General Hospital, Boston, MA, USA
- The Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
| | - Daniel J. Feaster
- Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Lisa R. Metsch
- Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami, FL, USA
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Kenneth A. Freedberg
- Division of General Medicine, Massachusetts General Hospital, Boston, MA, USA
- The Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
- Department of Health Policy and Management, Harvard School of Public Health, Boston MA, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Benjamin P. Linas
- HIV Epidemiology and Outcomes Research Unit, Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Boston, MA, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
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Effect of steady-state faldaprevir on the pharmacokinetics of steady-state methadone and buprenorphine-naloxone in subjects receiving stable addiction management therapy. Antimicrob Agents Chemother 2014; 59:498-504. [PMID: 25385094 DOI: 10.1128/aac.04046-14] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
The effects of steady-state faldaprevir on the safety, pharmacokinetics, and pharmacodynamics of steady-state methadone and buprenorphine-naloxone were assessed in 34 healthy male and female subjects receiving stable addiction management therapy. Subjects continued receiving a stable oral dose of either methadone (up to a maximum dose of 180 mg per day) or buprenorphine-naloxone (up to a maximum dose of 24 mg-6 mg per day) and also received oral faldaprevir (240 mg) once daily (QD) for 8 days following a 480-mg loading dose. Serial blood samples were taken for pharmacokinetic analysis. The pharmacodynamics of the opioid maintenance regimens were evaluated by the objective and subjective opioid withdrawal scales. Coadministration of faldaprevir with methadone or buprenorphine-naloxone resulted in geometric mean ratios for the steady-state area under the concentration-time curve from 0 to 24 h (AUC(0-24,ss)), the steady-state maximum concentration of the drug in plasma (C(max,ss)), and the steady-state concentration of the drug in plasma at 24 h (C(24,ss)) of 0.92 to 1.18 for (R)-methadone, (S)-methadone, buprenorphine, norbuprenorphine, and naloxone, with 90% confidence intervals including, or very close to including, 1.00 (no effect), suggesting a limited overall effect of faldaprevir. Although individual data showed moderate variability in the exposures between subjects and treatments, there was no evidence of symptoms of opiate overdose or withdrawal either during the coadministration of faldaprevir with methadone or buprenorphine-naloxone or after faldaprevir dosing was stopped. Similar faldaprevir exposures were observed in the methadone- and buprenorphine-naloxone-treated subjects. In conclusion, faldaprevir at 240 mg QD can be coadministered with methadone or buprenorphine-naloxone without dose adjustment, although given the relatively narrow therapeutic windows of these agents, monitoring for opiate overdose and withdrawal may still be appropriate. (This study has been registered at ClinicalTrials.gov under registration no. NCT01637922.).
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Soyka M, Backmund M, Schmidt P, Apelt S. Buprenorphine-naloxone treatment in opioid dependence and risk of liver enzyme elevation: results from a 12-month observational study. Am J Addict 2014; 23:563-9. [PMID: 25251050 DOI: 10.1111/j.1521-0391.2014.12131.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Revised: 09/22/2013] [Accepted: 11/10/2013] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Some case series mention possible liver toxicity in opioid-dependent patients under buprenorphine treatment. METHODS This 12-month prospective observational follow-up study in opioid-dependent patients under buprenorphine-naloxone treatment assessed outcome and safety issues. At baseline, 337 eligible datasets were available; 181 patients completed the 12-month study. Liver enzymes were tested at baseline and after 12, 24, and 52 weeks' treatment. RESULTS One to two percent of patients showed mostly discrete elevations of liver enzymes, but no patient met the criteria for drug-induced liver injury. No serious liver-related adverse events occurred, but two non-serious cases of liver enzyme increase were recorded. No patient dropped out of treatment for liver-related disorders. CONCLUSION This study is in line with some recent studies and provides further evidence that buprenorphine-naloxone is relatively safe with respect to liver injury.
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Affiliation(s)
- Michael Soyka
- Department of Psychiatry, Ludwig Maximilian University, Munich, Germany; Private Hospital Meiringen, Meiringen, Switzerland
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Bachhuber MA, Southern WN, Cunningham CO. Profiting and providing less care: comprehensive services at for-profit, nonprofit, and public opioid treatment programs in the United States. Med Care 2014; 52:428-34. [PMID: 24638120 PMCID: PMC4277871 DOI: 10.1097/mlr.0000000000000121] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Opioid use disorders are frequently associated with medical and psychiatric comorbidities (eg, HIV infection and depression), as well as social problems (eg, lack of health insurance). Comprehensive services addressing these conditions improve outcomes. OBJECTIVE To compare the proportion of for-profit, nonprofit, and public opioid treatment programs offering comprehensive services, which are not mandated by government regulations. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional analysis of opioid treatment programs offering outpatient care in the United States (n=1036). MAIN OUTCOME MEASURE Self-reported offering of communicable disease (HIV, sexually transmitted infections, and viral hepatitis) testing, psychiatric services (screening, assessment and diagnostic evaluation, and pharmacotherapy), and social services support (assistance in applying for programs such as Medicaid). Mixed-effects logistic regression models were developed to adjust for several county-level factors. RESULTS Of opioid treatment programs, 58.0% were for profit, 33.5% were nonprofit, and 8.5% were public. Nonprofit programs were more likely than for-profit programs to offer testing for all communicable diseases [adjusted odds ratios (AOR), 1.7; 95% confidence interval (CI), 1.2, 2.5], all psychiatric services (AOR, 8.0; 95% CI, 4.9, 13.1), and social services support (AOR, 3.3; 95% CI, 2.3, 4.8). Public programs were also more likely than for-profit programs to offer communicable disease testing (AOR, 6.4; 95% CI, 3.5, 11.7), all psychiatric services (AOR, 25.8; 95% CI, 12.6, 52.5), and social services support (AOR, 2.4; 95% CI, 1.4, 4.3). CONCLUSIONS For-profit programs were significantly less likely than nonprofit and public programs to offer comprehensive services. Interventions to increase the offering of comprehensive services are needed, particularly among for-profit programs.
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Affiliation(s)
- Marcus A. Bachhuber
- Center for Health Equity Research and Promotion, Philadelphia Veterans Affairs Medical Center, Philadelphia, PA, USA
- Robert Wood Johnson Foundation Clinical Scholars Program at the University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - William N. Southern
- Division of Hospital Medicine, Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Chinazo O. Cunningham
- Division of General Internal Medicine, Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA
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How to build trustworthy hepatitis C services in an opioid treatment clinic? A qualitative study of clients and health workers in a co-located setting. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2014; 25:865-70. [PMID: 24559604 DOI: 10.1016/j.drugpo.2014.01.011] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Accepted: 01/14/2014] [Indexed: 11/21/2022]
Abstract
BACKGROUND Given the increasing burden of hepatitis C (HCV) related liver disease, innovative health care models are required to extend the reach of HCV care and treatment. Opioid substitution treatment (OST) clinics are places of high HCV prevalence. The OST clinic is a complex environment, quite distinct to other health care settings, with punitive regulations and practices, and a client population likely to be mistrustful of systems of authority. Nonetheless, trust is widely documented as essential to effective therapeutic encounters. This paper examines what is required to develop a trustworthy service in a place, the OST clinic, described by some critics as a site of "social control". METHODS In-depth interviews were conducted with 57 clients and 19 staff from four NSW pilot clinics participating in the Australian ETHOS study. RESULTS Interview data were examined using Hall's framework of trust, involving five principle domains: fidelity, competence, honest, confidentiality and global trust. 'Honesty' was found to be key to participants' establishing trust in the co-located service and its staff. However, the clinic site was also found to be a place of rationed trust, in which the themes of OST as "ruling peoples' lives" and the fear of repercussions resulting from perceived transgressions against clinic rules, threatened to over-ride or undermine the development of trust in HCV services. Client participants described trusting health workers "to a point". They expressed concerns about the fidelity of co-located HCV and OST services and described fears of "institutionalised lies" and breaches of confidentiality. Anxieties around the latter revealed a sense of "us and them" held by some clients, one in which health workers were perceived to "stick together" by putting their own interests before those of the clients. DISCUSSION Although the co-location of HCV and opioid treatments makes intuitive policy sense, HCV health workers in the OST space may be seen as representatives of a deeply mistrusted system. For the effective development of a trustworthy HCV care service, policy and practice activities are required to engender trust through clearly articulated explanations of service boundaries and the promotion of "success stories" through trusted peer networks.
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Russell M, Pauly MP, Moore CD, Chia C, Dorrell JM, Cunanan RJ, Witt G. The impact of lifetime drug use on hepatitis C treatment outcomes in insured members of an integrated health care plan. Drug Alcohol Depend 2014; 134:222-227. [PMID: 24262649 PMCID: PMC3888084 DOI: 10.1016/j.drugalcdep.2013.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Revised: 09/07/2013] [Accepted: 10/01/2013] [Indexed: 11/15/2022]
Abstract
BACKGROUND The relation of drug use to HCV treatment outcome in an insured household population has not been previously reported. METHODS Lifetime frequencies of marijuana use and non-medical use of stimulants, sedatives, and opioids; hallucinogens; and inhalants were retrospectively assessed in 259 privately insured members of an integrated health care plan treated for chronic hepatitis C virus infection (HCV+) with pegylated interferon alpha and ribavirin and examined with respect to rates of sustained virological response (SVR). RESULTS The majority of patients reported chronic use of multiple illegal drugs; 61.6% reported injection drug use (IDU); 79.5% abstained from drug use during the six months prior to HCV treatment. Total frequency of individual drugs, multiple drugs, and length of abstention from drugs prior to HCV treatment were not related to impaired SVR rates. Sustained viral responses were obtained in 80.2% of patients with HCV genotype 2/3 and 45.1% of patients with genotype 1/4/6. Marijuana use during HCV treatment, reported by 8.5% of patients, was associated with higher treatment adherence (95.5% compared with 78.9%, p=0.045), but lower SVR rates (40.9% compared with 62.5%, p=0.041). In addition, drug use during HCV treatment was associated with significantly higher relapse rates, 18.8% compared with 7.7% (p=0.053). CONCLUSION A history of chronic illegal drug use should not be considered a deterrent to HCV treatment in members of an integrated health care plan who are motivated to seek treatment and closely monitored, but drug use during HCV treatment, including marijuana use, should be discouraged.
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Affiliation(s)
- Marcia Russell
- Prevention Research Center, 1995 University Avenue, Suite 450, Berkeley, CA 94704, United States.
| | - Mary Patricia Pauly
- Department of Gastroenterology and Hepatology, Kaiser Permanente North Valley Medical Center, 2025 Morse Avenue, Sacramento, CA 95825
| | - Charles Denton Moore
- Kaiser Permanente Health Plan, Chemical Dependency Recovery Program, 2829 Watt Avenue, Suite 150, Sacramento, CA 95821
| | - Constance Chia
- Kaiser Permanente Health Plan, Chemical Dependency Recovery Program, 2829 Watt Avenue, Suite 150, Sacramento, CA 95821
| | - Jennifer Mary Dorrell
- Kaiser Permanente Health Plan, Chemical Dependency Recovery Program, 2829 Watt Avenue, Suite 150, Sacramento, CA 95821
| | - Renee Junko Cunanan
- Department of Gastroenterology and Hepatology, Kaiser Permanente North Valley Medical Center, 2025 Morse Avenue, Sacramento, CA 95825
| | - Gayle Witt
- Department of Gastroenterology and Hepatology, Kaiser Permanente North Valley Medical Center, 2025 Morse Avenue, Sacramento, CA 95825
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Turner SJ, Brown J, Paladino JA. Protease inhibitors for hepatitis C: economic implications. PHARMACOECONOMICS 2013; 31:739-751. [PMID: 23839698 DOI: 10.1007/s40273-013-0073-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Chronic hepatitis C virus (HCV) infection, a blood-borne virus, is the leading cause of chronic liver disease and liver transplantation worldwide. Chronic HCV infection is usually asymptomatic in the early stages of the disease, making an estimation of the total population affected difficult to elicit. The gold standard treatment option to date has been a combination of pegylated interferon and ribavirin. Recent developments have led to the introduction of two protease inhibitors for use in chronic HCV-boceprevir and telaprevir. Phase III studies have shown both agents have the potential to significantly increase the probability of attaining a sustained virologic response (the primary outcome of interest in chronic HCV) in genotype 1 infections. However, the added cost of these agents also presents the need for decision makers to determine their place on drug formularies. The protease inhibitors are to be administered as triple therapy with the existing gold standard. However, significant variation exists as to the proposed duration of triple therapy, use of lead-in pegylated interferon and ribavirin and subsequent pegylated interferon therapy after finishing the course of triple therapy. Treatment algorithms also exist for the use of stopping rules in the case of early non-responders.The aim of this review is to highlight the current understanding of the economic impact protease inhibitors may have on health care systems and considerations required in the treatment of HCV. Economic and health-related quality of life issues are addressed from multiple viewpoints. The major aspects of the economic evaluations, to date, that included triple therapy as an alternative in the treatment of chronic HCV are brought to light. Future economic evaluations in alternative settings would be useful. The review also emphasizes the challenges for future research. This includes the potential for new therapies to no longer require inclusion of pegylated interferon and/or ribavirin, as well as the use of protease inhibitors in non-genotype 1 patients or those with significant co-morbidities such as HIV/AIDS.
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Affiliation(s)
- Stuart J Turner
- School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, 205 Kapoor Hall, Buffalo, NY 14214, USA
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Moreira SA, Morcos PN, Navarro MT, Bech N, Smith PF, Brennan BJ. Effect of ritonavir-boosted danoprevir, a potent hepatitis C virus protease inhibitor, on the pharmacokinetics of methadone in healthy subjects undergoing methadone maintenance therapy. Pharmacotherapy 2013; 34:220-6. [PMID: 23946152 DOI: 10.1002/phar.1341] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
STUDY OBJECTIVE To investigate the steady-state pharmacokinetics of methadone when coadministered with ritonavir-boosted danoprevir (DNVr). DESIGN Open-label, two-period, single-sequence pharmacokinetic study. SETTING Two U.S. research centers. PATIENTS Eighteen methadone-maintained healthy adults. MEASUREMENTS AND MAIN RESULTS In Period 1 (Day -1), subjects received their daily methadone maintenance therapy (MMT). In Period 2 (Days 1-10), subjects received MMT plus DNVr 100/100 mg twice/day. Pharmacokinetic parameters for the total concentrations of (R)- and (S)-methadone on Days -1 and 10 were determined using noncompartmental methods. Unbound (R)- and (S)-methadone concentrations at 3 hours postdose were also assessed on Days -1 and 10. Geometric mean ratios (GMRs) and 90% confidence intervals (CIs) were used to compare steady-state (R)- and (S)-methadone pharmacokinetics when MMT was administered with or without DNVr. Methadone withdrawal was assessed using the Subjective Opiate Withdrawal Scale. Compared with MMT alone, methadone AUCtau and Cmax GMR (90% CI) following coadministration with DNVr were 1.02 (0.91-1.15) and 1.01 (0.90-1.13) for (R)-methadone, and 1.01 (0.90-1.13) and 0.99 (0.89-1.10) for (S)-methadone, respectively. Unbound (R- and (S)-methadone concentrations were comparable with or without DNVr. No instances of methadone withdrawal were reported. MMT in combination with DNVr was well tolerated. CONCLUSION Coadministration of DNVr with MMT resulted in no significant pharmacokinetic interactions or signs of methadone withdrawal. No dosage adjustment is needed for MMT when coadministered with DNVr.
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Harris M, Rhodes T. Hepatitis C treatment access and uptake for people who inject drugs: a review mapping the role of social factors. Harm Reduct J 2013; 10:7. [PMID: 23651646 PMCID: PMC3686576 DOI: 10.1186/1477-7517-10-7] [Citation(s) in RCA: 187] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2012] [Accepted: 04/13/2013] [Indexed: 02/06/2023] Open
Abstract
Background Evidence documents successful hepatitis C virus (HCV) treatment outcomes for people who inject drugs (PWID) and interest in HCV treatment among this population. Maximising HCV treatment for PWID can be an effective HCV preventative measure. Yet HCV treatment among PWID remains suboptimal. This review seeks to map social factors mediating HCV treatment access. Method We undertook a review of the social science and public health literature pertaining to HCV treatment for PWID, with a focus on barriers to treatment access, uptake and completion. Medline and Scopus databases were searched, supplemented by manual and grey literature searches. A two step search was taken, with the first step pertaining to literature on HCV treatment for PWID and the second focusing on social structural factors. In total, 596 references were screened, with 165 articles and reports selected to inform the review. Results Clinical and individual level barriers to HCV treatment among PWID are well evidenced. These include patient and provider concerns regarding co-morbidities, adherence, and side effect management. Social factors affecting treatment access are less well evidenced. In attempting to map these, key barriers fall into the following domains: social stigma, housing, criminalisation, health care systems, and gender. Key facilitating factors to treatment access include: combination intervention approaches encompassing social as well as biomedical interventions, low threshold access to opiate substitution therapy, and integrated delivery of multidisciplinary care. Conclusion Combination intervention approaches need to encompass social interventions in relation to housing, stigma reduction and systemic changes in policy and health care delivery. Future research needs to better delineate social factors affecting treatment access.
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Affiliation(s)
- Magdalena Harris
- Centre for Research on Drugs and Health Behaviour, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H9SH, UK.
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Abstract
OBJECTIVES To explore attitudes toward hepatitis C antiviral therapy in a real-world setting, we asked patients in opioid agonist treatment who were offered antiviral therapy about perceived barriers to initiating therapy. METHODS We recruited patients in opioid agonist treatment who had previously been offered cost-free hepatitis C antiviral therapy in a clinical trial. We collected demographic and open-ended interview data. The semistructured interview guide included questions about attitudes toward hepatitis C therapy and barriers to initiating treatment. Each interview was audio recorded and transcribed verbatim. We used the qualitative editing method to analyze the interview transcripts. RESULTS We enrolled 19 patients who had been approached to initiate hepatitis C therapy in a clinical trial. All participants were low-income men, with one third self-identifying as racial minorities. When asked about possible barriers to treatment, multiple problems emerged, including the fear of treatment side effects, difficulties with health care providers, limited access to medical care and health information, and misperceptions about antiviral therapy. CONCLUSIONS Despite intense educational efforts, concerns over antiviral therapy, relations with providers, and access to the health care system remain critical barriers. These factors should be addressed to improve antiviral therapy rates for patients receiving opioid agonist treatment.
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Abstract
Hepatitis C virus (HCV) antibody is present in most patients enrolled in methadone maintenance programs. Therefore, interactions between the HCV protease inhibitor telaprevir and methadone were investigated. The pharmacokinetics of R- and S-methadone were measured after administration of methadone alone and after 7 days of telaprevir (750 mg every 8 h [q8h]) coadministration in HCV-negative subjects on stable, individualized methadone therapy. Unbound R-methadone was measured in predose plasma samples before and during telaprevir coadministration. Safety and symptoms of opioid withdrawal were evaluated throughout the study. In total, 18 subjects were enrolled; 2 discontinued prior to receiving telaprevir. The minimum plasma concentration in the dosing interval (C(min)), the maximum plasma concentration (Cmax), and the area under the plasma concentration-time curve from h 0 (time of administration) to 24 h postdose (AUC(0-24)) for R-methadone were reduced by 31%, 29%, and 29%, respectively, in the presence of telaprevir. The AUC0-24 ratio of S-methadone/R-methadone was not altered. The median unbound percentage of R-methadone increased by 26% in the presence of telaprevir. The R-methadone median (absolute) unbound C(min) values in the absence (10.63 ng/ml) and presence (10.45 ng/ml) of telaprevir were similar. There were no symptoms of opioid withdrawal and no discontinuations due to adverse events. In summary, exposure to total R-methadone was reduced by approximately 30% in the presence of telaprevir, while the exposure to unbound R-methadone was unchanged. No symptoms of opioid withdrawal were observed. These results suggest that dose adjustment of methadone is not required when initiating telaprevir treatment. (This study has been registered at ClinicalTrials.gov under registration no. NCT00933283.).
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Bosilkovska M, Walder B, Besson M, Daali Y, Desmeules J. Analgesics in patients with hepatic impairment: pharmacology and clinical implications. Drugs 2012; 72:1645-69. [PMID: 22867045 DOI: 10.2165/11635500-000000000-00000] [Citation(s) in RCA: 103] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The physiological changes that accompany hepatic impairment alter drug disposition. Porto-systemic shunting might decrease the first-pass metabolism of a drug and lead to increased oral bioavailability of highly extracted drugs. Distribution can also be altered as a result of impaired production of drug-binding proteins or changes in body composition. Furthermore, the activity and capacity of hepatic drug metabolizing enzymes might be affected to various degrees in patients with chronic liver disease. These changes would result in increased concentrations and reduced plasma clearance of drugs, which is often difficult to predict. The pharmacology of analgesics is also altered in liver disease. Pain management in hepatically impaired patients is challenging owing to a lack of evidence-based guidelines for the use of analgesics in this population. Complications such as bleeding due to antiplatelet activity, gastrointestinal irritation, and renal failure are more likely to occur with nonsteroidal anti-inflammatory drugs in patients with severe hepatic impairment. Thus, this analgesic class should be avoided in this population. The pharmacokinetic parameters of paracetamol (acetaminophen) are altered in patients with severe liver disease, but the short-term use of this drug at reduced doses (2 grams daily) appears to be safe in patients with non-alcoholic liver disease. The disposition of a large number of opioid drugs is affected in the presence of hepatic impairment. Certain opioids such as codeine or tramadol, for instance, rely on hepatic biotransformation to active metabolites. A possible reduction of their analgesic effect would be the expected pharmacodynamic consequence of hepatic impairment. Some opioids, such as pethidine (meperidine), have toxic metabolites. The slower elimination of these metabolites can result in an increased risk of toxicity in patients with liver disease, and these drugs should be avoided in this population. The drug clearance of a number of opioids, such as morphine, oxycodone, tramadol and alfentanil, might be decreased in moderate or severe hepatic impairment. For the highly excreted morphine, hydromorphone and oxycodone, an important increase in bioavailability occurs after oral administration in patients with hepatic impairment. Lower doses and/or longer administration intervals should be used when these opioids are administered to patients with liver disease to avoid the risk of accumulation and the potential increase of adverse effects. Finally, the pharmacokinetics of phenylpiperidine opioids such as fentanyl, sufentanil and remifentanil appear to be unaffected in hepatic disease. All opioid drugs can precipitate or aggravate hepatic encephalopathy in patients with severe liver disease, thus requiring cautious use and careful monitoring.
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Affiliation(s)
- Marija Bosilkovska
- Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals, Geneva, Switzerland
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Evaluation of an integrated care service facility for people living with hepatitis C in New Zealand. Int J Integr Care 2012; 12:e229. [PMID: 23593067 PMCID: PMC3602958 DOI: 10.5334/ijic.819] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2011] [Revised: 06/03/2012] [Accepted: 06/21/2012] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION People living with hepatitis C are a highly marginalised population who may not readily access health care. Existing models of hepatitis C care may not meet the needs of these patients. This research evaluates the experiences of patients attending an innovative hepatitis C clinic that offers integrated care and service delivery. METHOD Surveys were completed by 120 clients and comprised of questions relating to changes in lifestyle habits since attending the clinic, hepatitis C knowledge, hepatitis C treatment and experiences with health care staff at the clinic. RESULTS The majority of respondents indicated that attendance at the clinic has provided them with the information to better manage their hepatitis C and had given them confidence to make lifestyle changes. Participants demonstrated a very high knowledge of hepatitis C and reported experiencing a less discriminatory environment at the clinic compared to other health care settings. Respondents who had been attending the clinic for more than 6 months were significantly more likely to indicate a desire to commence hepatitis C treatment over the next 5 years. DISCUSSION The findings point to the importance of integrated care in the community setting in providing clients with a positive experience of health care, which appears to increase their skills and desire to better manage their hepatitis C.
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Together … to take care: multidisciplinary management of hepatitis C virus treatment in randomly selected drug users with chronic hepatitis. J Addict Med 2012; 4:223-32. [PMID: 21769040 DOI: 10.1097/adm.0b013e3181cae4d0] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Hepatitis C Virus (HCV) infection is treated with peg-interferon α2a or α2b and ribavirin. International studies show that drug user adherence to treatment is 40% to 60% and increases if the patient is in addiction treatment. The aim of the Together To Take Care (TTTC) study was to achieve better adherence to HCV therapy in randomly selected drug users, who are considered "difficult to treat." The secondary aim of the TTTC Study Group was to standardize a method for a multidisciplinary management of the liver disease in drug users. The TTTC group data were matched with a control group. Adherence: The 93.7% of patients followed therapy prescribed; of the patients infected by HCV genotype (gt) 3, all completed therapy as scheduled. For the 48-week treatment group, 66.7% of patients completed therapy (2 of 9 patients stopped treatment for breakthrough). Toxicological results: 10 (62.5%) patients were negative in the toxicological tests (opiates, cocaine, and alcohol). Virological results: 8 of 16 patients were infected by HCV gt 1, and 8 were infected by gt 3; 2 of 16 (12.5%) patients were human immunodeficiency virus (HIV) coinfected (1 HCV gt 1a and 1 HCV gt 3). All patients: 11 of 16 (68.75%) patients were HCV ribonucleic acid undetectable 24 weeks after completing therapy (sustained virological response, SVR). Gt 1: 4 of 8 (50.0%) showed SVR. Gt 3: 7 of 8 (87.5%) showed SVR. Overall, the HCV gt 3 patients had 87.5% probability of SVR, whereas gt 1 patients had 50% probability of SVR (gt 3/gt 1 patients odds ratio = 7). The results were analyzed by Fisher exact test. Our results show that good healthcare management plays an important role in increasing patients' adherence to therapy. In the project "TTTC," the patients work with the physicians to take responsibility for their health and acquire self-efficacy and self-awareness, thanks to the special care.
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TRELOAR CARLA, HULL PETER, DORE GREGORYJ, GREBELY JASON. Knowledge and barriers associated with assessment and treatment for hepatitis C virus infection among people who inject drugs. Drug Alcohol Rev 2012; 31:918-24. [DOI: 10.1111/j.1465-3362.2012.00468.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Swart A, Burns L, Mao L, Grulich AE, Amin J, O'Connell DL, Meagher NS, Randall DA, Degenhardt L, Vajdic CM. The importance of blood-borne viruses in elevated cancer risk among opioid-dependent people: a population-based cohort study. BMJ Open 2012; 2:bmjopen-2012-001755. [PMID: 23045358 PMCID: PMC3488729 DOI: 10.1136/bmjopen-2012-001755] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE To quantify cancer risk in opioid dependence and the association with infection by the oncogenic blood-borne viruses (BBVs) hepatitis C (HCV), hepatitis B (HBV) and HIV. DESIGN Cohort study. SETTING New South Wales, Australia. PARTICIPANTS All 45 412 adults aged 16 years or over registered for opioid substitution therapy (OST) between 1985 and 2007. Notifications of cancer, death and infection with HCV, HBV and HIV were ascertained by record linkage with registries. MAIN OUTCOME MEASURES The ratios of observed to expected number of cancers, standardised incidence ratios (SIRs), and the average annual per cent change (AAPC) in overall age and sex-standardised cancer incidence. RESULTS Overall cancer risk was modestly increased compared to the general population (SIR 1.15, 95% CI 1.07 to 1.23). Excess risk was observed for 11 cancers, particularly lung (4.02, 95% CI 3.32 to 4.82), non-Hodgkin's lymphoma (1.51, 95% CI 1.20 to 1.88) and liver (8.04, 95% CI 6.18 to 10.3). Reduced risk was observed for six cancers, including prostate (0.16, 95% CI 0.06 to 0.32) and breast (0.48, 95% CI 0.35 to 0.62). Individuals notified with HCV or HBV had a markedly increased risk of liver cancer; lung cancer risk was also increased in those with HCV. HIV was associated with an elevated risk of liver, anus and kidney cancer, non-Hodgkin lymphoma and Kaposi sarcoma. Cancer risk was not increased in individuals without a BBV notification, apart from pancreatic cancer (3.92, 95% CI 1.07 to 10.0). Cancer incidence increased significantly over time (AAPC 9.4%, 4.2% to 15%, p=0.001). CONCLUSIONS BBVs play a major role in the cancer risk profile of opioid-dependent individuals registered for OST. To address the dramatic increasing trend in cancer incidence, the OST setting could be utilised for cancer prevention strategies.
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Affiliation(s)
- Alexander Swart
- Prince of Wales Clinical School, Adult Cancer Program, Lowy Cancer Research Centre, University of New South Wales, Sydney, New South Wales, Australia
| | - Lucinda Burns
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, New South Wales, Australia
| | - Limin Mao
- National Centre in HIV Social Research, University of New South Wales, Sydney, New South Wales, Australia
| | - Andrew E Grulich
- Kirby Institute, University of New South Wales, New South Wales, Australia
| | - Janaki Amin
- Kirby Institute, University of New South Wales, New South Wales, Australia
| | | | - Nicola S Meagher
- Prince of Wales Clinical School, Adult Cancer Program, Lowy Cancer Research Centre, University of New South Wales, Sydney, New South Wales, Australia
| | - Deborah A Randall
- School of Medicine, University of Western Sydney, Penrith, New South Wales, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, New South Wales, Australia
- Centre for Health Policy, Programs and Economics, School of Population Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Claire M Vajdic
- Prince of Wales Clinical School, Adult Cancer Program, Lowy Cancer Research Centre, University of New South Wales, Sydney, New South Wales, Australia
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Martinez AD, Dimova R, Marks KM, Beeder AB, Zeremski M, Kreek MJ, Talal AH. Integrated internist - addiction medicine - hepatology model for hepatitis C management for individuals on methadone maintenance. J Viral Hepat 2012; 19:47-54. [PMID: 21129131 PMCID: PMC3708453 DOI: 10.1111/j.1365-2893.2010.01411.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Despite a high prevalence of hepatitis C virus (HCV) among drug users, HCV evaluation and treatment acceptance are extremely low among these patients when referred from drug treatment facilities for HCV management. We sought to increase HCV treatment effectiveness among patients from a methadone maintenance treatment program (MMTP) by maintaining continuity of care. We developed, instituted and retrospectively assessed the effectiveness of an integrated, co-localized care model in which an internist-addiction medicine specialist from MMTP was embedded in the hepatitis clinic. Methadone maintenance treatment program patients were referred, evaluated by the internist and hepatologist in hepatitis clinic and provided HCV treatment with integration between both sites. Of 401 evaluated patients, anti-HCV antibody was detected in 257, 86% of whom were older than 40 years. Hepatitis C virus RNA levels were measured in 222 patients, 65 of whom were aviremic. Of 157 patients with detectable HCV RNA, 125 were eligible for referral to the hepatitis clinic, 76 (61%) of whom accepted and adhered with the referral. Men engaged in MMTP <36 months were significantly less likely to be seen in hepatitis clinic than men in MMTP more than 36 months (odds ratio = 7.7; 95% confidence interval 2.6-22.9) or women. We evaluated liver histology in 63 patients, and 83% had moderate to advanced liver disease. Twenty-four patients initiated treatment with 19 completing and 13 (54%) achieving sustained response. In conclusion, integrated care between the MMTP and the hepatitis clinic improves adherence with HCV evaluation and treatment compared to standard referral practices.
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Affiliation(s)
- A. D. Martinez
- Division of General Internal Medicine and Hepatology, Department of Medicine, University of California San Diego, San Diego, CA
| | - R. Dimova
- Division of Gastroenterology and Hepatology, Center for the Study of Hepatitis C, Rockefeller University, New York, NY, USA
| | - K. M. Marks
- Division of Infectious Diseases, Department of Medicine, Rockefeller University, New York, NY, USA
| | - A. B. Beeder
- Department of Public Health, Weill Cornell Medical College, Rockefeller University, New York, NY, USA
| | - M. Zeremski
- Division of Gastroenterology and Hepatology, Center for the Study of Hepatitis C, Rockefeller University, New York, NY, USA
| | - M. J. Kreek
- The Laboratory of the Biology of Addictive Diseases, Rockefeller University, New York, NY, USA
| | - A. H. Talal
- Division of Gastroenterology and Hepatology, Center for the Study of Hepatitis C, Rockefeller University, New York, NY, USA
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Rance J, Newland J, Hopwood M, Treloar C. The politics of place(ment): problematising the provision of hepatitis C treatment within opiate substitution clinics. Soc Sci Med 2011; 74:245-53. [PMID: 22133583 DOI: 10.1016/j.socscimed.2011.10.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2010] [Revised: 10/07/2011] [Accepted: 10/10/2011] [Indexed: 02/06/2023]
Abstract
The hepatitis C virus (HCV) epidemic is a significant public health challenge in Australia. Current initiatives to expand access to HCV treatment focus on opiate substitution therapy (OST) settings where the prevalence of hepatitis C among clients is high. In Australia, the provision of OST for many clients is via large clinics, with an estimated median of 150 clients per service. Conceptually informed by the work of Michel Foucault, our analysis of the proposed integrated treatment model focuses on the critical but overlooked question of organisational culture and power operating within OST. We argue that the specific context of OST not merely reflects but actively participates in the political economy of social exclusion via which the socio-spatial segregation and stigmatisation of the service user as 'drug user' is enacted. This paper analyses data collected from two samples during 2008/9: OST clients living in New South Wales, Australia and a range of OST health professionals working in Australian settings. In total, 27 interviews were conducted with current OST clients; 19 by phone and 8 face-to-face. One focus group and 16 telephone interviews were conducted with OST health professionals. Our analysis of key themes emerging from the interview data suggests that the successful introduction of HCV treatment within the OST clinic is not a given. We are concerned that particular areas of tension, if not explicit contradiction, have been overlooked in current research and debates informing the proposed combination treatment model. We question the appropriateness of co-locating a notoriously arduous, exacting treatment (HCV) within the highly surveillant and regulatory environment of OST. While applauding the intention to improve access to HCV care and treatment for people who inject drugs we caution against a treatment model that risks further entrenching (socio-spatial) stigmatisation amongst those already experiencing significant marginalisation.
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Affiliation(s)
- Jake Rance
- The National Centre in HIV Social Research, The University of New South Wales, Randwick, Sydney, NSW 2052, Australia.
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Efficacy of chronic hepatitis C therapy with pegylated interferon and ribavirin in patients on methadone maintenance treatment. Eur J Clin Microbiol Infect Dis 2011; 31:1225-32. [DOI: 10.1007/s10096-011-1433-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2011] [Accepted: 09/15/2011] [Indexed: 12/21/2022]
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Treloar C, Hull P, Bryant J, Hopwood M, Grebely J, Lavis Y. Factors associated with hepatitis C knowledge among a sample of treatment naive people who inject drugs. Drug Alcohol Depend 2011; 116:52-6. [PMID: 21194852 DOI: 10.1016/j.drugalcdep.2010.11.018] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2010] [Revised: 11/18/2010] [Accepted: 11/20/2010] [Indexed: 02/06/2023]
Abstract
BACKGROUND Assessment and uptake of treatment for hepatitis C among people who inject drugs (PWID) is low and strategies to enhance hepatitis C care in this group are needed. Knowledge of hepatitis C and its treatment is one precursor to decisions about treatment. METHODS We conducted a cross-section study designed to evaluate treatment considerations in participants with self-reported hepatitis C infection in New South Wales, Australia. Participants were recruited from needle and syringe programs, opiate substitution clinics, pharmacies that dispensed opiate substitution treatment and from the mailing list of a community-based hepatitis C organisation and completed a self-administered survey. Knowledge of hepatitis C was assessed by a 48-item scale addressing the natural history and treatment of hepatitis C. Factors associated with knowledge were assessed by ordinal regression. RESULTS Among the 997 participants recruited, 407 self-reported acquiring hepatitis C through injecting drug use and had never received hepatitis C treatment. Knowledge about hepatitis C was overall poor and the effects of the long term consequences of hepatitis C were over-estimated. Higher knowledge scores were associated with recruitment site, higher education levels and recent contact with a general practitioner. One-third of participants indicated that they did not intend to have treatment and one-fifth did not answer this question. CONCLUSION Knowledge is a precursor to informed decisions about hepatitis C treatment. These results indicate that efforts to support those less engaged with hepatitis C care (and specifically those on opiate substitution treatment) and those with lower literacy are required.
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Affiliation(s)
- Carla Treloar
- National Centre in HIV Social Research, University of New South Wales, NSW 2052, Australia.
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Taylor LE, Bowman SE, Chapman S, Zaller N, Stein MD, Cioe PA, Maynard MA, McGovern BH. Treatment for hepatitis C virus genotype 1 infection in HIV-infected individuals on methadone maintenance therapy. Drug Alcohol Depend 2011; 116:233-7. [PMID: 21177046 PMCID: PMC4212315 DOI: 10.1016/j.drugalcdep.2010.11.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2010] [Revised: 10/05/2010] [Accepted: 11/11/2010] [Indexed: 01/28/2023]
Abstract
BACKGROUND A minority of HIV/HCV coinfected patients with opiate addiction undergo HCV treatment. HCV therapy for HCV-monoinfected methadone maintenance (MM) recipients is safe and effective. We evaluated treatment efficacy and adherence to pegylated interferon (pegIFN) among HIV/HCV coinfected MM recipients. METHODS HCV treatment-naïve, HIV-infected persons 18-65 years with chronic HCV genotype 1 on MM were prospectively enrolled in an HCV treatment study at two HIV clinics. At weekly visits pegIFN alfa-2a injections were directly administered. Daily MM recipients had morning ribavirin delivered with methadone at off-site methadone clinics. Weekly take-home MM recipients took ribavirin unsupervised. Target enrollment was 30 participants. RESULTS During 18 recruitment months, 11 participants were enrolled, 6 of whom received daily methadone. Mean age was 46, 64% were female, 5 were Caucasian, 4 Black and 2 Hispanic. At baseline, 82% had high HCV RNA and 55% had stage 2 fibrosis or greater. The majority (91%) were on HAART, and 82% had undetectable HIV RNA with a median CD4(+) of 508cells/μL. All had polysubstance use history, non-substance-based psychiatric diagnoses and were on psychotropic medications pre-enrollment. Two (18%) participants achieved a Sustained Virologic Response (SVR). Two completed 48 treatment weeks, 5 were withdrawn due to adverse events, 2 dropped out prematurely and 2 had treatment discontinued for virologic non-response. Of on-treatment weeks, adherence to pegIFN was >99%. CONCLUSIONS SVR rate was comparable to historic controls for coinfected genotype 1 patients, with optimal pegIFN adherence. Adverse effects often prevented therapy completion in this population.
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Affiliation(s)
- Lynn E. Taylor
- The Warren Alpert Medical School of Brown University, United States,The Miriam Hospital, United States,Corresponding author at: The Warren Alpert Medical School of Brown University, The Miriam Hospital, Center for AIDS Research, Building 156, 164 Summit Avenue, Providence, RI 02906, United States. Tel.: +1 401 793 4705; fax: +1 401 793 4709. (L.E. Taylor)
| | | | | | | | - Michael D. Stein
- The Warren Alpert Medical School of Brown University, United States,Butler Hospital, United States
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Batki SL, Canfield KM, Ploutz-Snyder R. Psychiatric and substance use disorders among methadone maintenance patients with chronic hepatitis C infection: effects on eligibility for hepatitis C treatment. Am J Addict 2011; 20:312-8. [PMID: 21679262 DOI: 10.1111/j.1521-0391.2011.00139.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
We set out to describe the prevalence and severity of psychiatric and substance use disorders (SUDs) in methadone maintenance treatment (MMT) patients with chronic hepatitis C virus (HCV) infection and to measure the impact on HCV-treatment eligibility. Psychiatric disorders, SUDs, and HCV-treatment eligibility were assessed in 111 MMT patients prior to a controlled trial of HCV treatment. Lifetime and current diagnosis rates, respectively, were: any non-SUD Axis I disorder: 82% and 57%, any mood disorder: 67% and 35%, any anxiety disorder: 63% and 22%, any psychotic disorder: 11% and 9%. Antisocial personality disorder was present in 40%. A total of 56% met criteria for current SUDs. A total of 66% received psychiatric medications prior to HCV treatment; over half were receiving antidepressants. Despite psychiatric and substance use comorbidity, only 15% of patients were ineligible for HCV treatment: 10% due to failure to complete the evaluation, and 5% due to psychiatric severity. Substance use did not lead to ineligibility in any participant. Multiple logistic regression showed the Beck Depression Inventory contributed significantly to predicting HCV treatment eligibility. Most MMT patients were eligible [corrected] for HCV treatment despite current SUD and non-SUD diagnoses. Depression severity may be a more significant predictor of HCV treatment eligibility than is substance use.
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Affiliation(s)
- Steven L Batki
- Department of Psychiatry, University of California, San Francisco, USA.
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Randall D, Degenhardt L, Vajdic CM, Burns L, Hall WD, Law M, Butler T. Increasing cancer mortality among opioid-dependent persons in Australia: a new public health challenge for a disadvantaged population. Aust N Z J Public Health 2011; 35:220-5. [DOI: 10.1111/j.1753-6405.2011.00682.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
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Buxton JA, Kuo ME, Ramji S, Yu A, Krajden M. Methadone use in relation to hepatitis C virus testing in British Columbia. Canadian Journal of Public Health 2011. [PMID: 21370787 DOI: 10.1007/bf03403970] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE We examined methadone use among a large cohort of individuals undergoing serologic testing for hepatitis C virus (HCV) infection. METHODS In British Columbia, community pharmacy methadone dispensations are recorded in the PharmaNet database and HCV antibody (anti-HCV) test results are recorded by the Provincial Public Reference Laboratory. Provincial HCV laboratory testing records from 1992 to 2004 were linked to methadone dispensation records from 1995-2006. We describe methadone maintenance treatment (MMT) among individuals undergoing anti-HCV testing between 1992 and 2004. RESULTS Between 1992 and 2004, 404,941 individuals were tested for anti-HCV in BC; 32,918 (8%) were positive. Overall, methadone was dispensed to 10,314 (2.5%) of individuals tested for anti-HCV; 1% of negative testers and 21% of positive testers. Of 10,314 individuals receiving methadone, 6732 (65%) had a positive anti-HCV test during the study period. Laboratory anti-HCV serostatus was known at MMT initiation in 70%; of these, 2596 (36%) were anti-HCV negative and 4638 (64%) were anti-HCV positive at first methadone dispensation. Seroconversion from anti-HCV negative to positive following MMT initiation was confirmed in 288 persons. CONCLUSION Methadone used in conjunction with other harm reduction initiatives can reduce the transmission of blood-borne infections among individuals who inject opiates, however many who enter the BC Methadone Program are already anti-HCV positive and others seroconvert after MMT initiation. Our data suggest there are missed prevention opportunities for MMT and other harm reduction services. Linkage of laboratory and health service data can provide a population lens to identify and evaluate potential prevention strategies.
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