Tag Archives: Injection Drug Use

Hepatitis C in Native American Populations

HEAL Blog is the recipient of the ADAP Advocacy Association’s 2015-2016 ADAP Social Media Campaign of the Year Award
By: Marcus J. Hopkins, Blogger

In August 2017, HEAL Blog covered efforts by the Cherokee Nation to proactively combat Hepatitis C (HCV) within the tribe’s boundaries in Northeastern Oklahoma (Hopkins, 2017). The program, started three years ago, comprised several steps, including compulsory screening of all tribe members aged 20-69, expanding screening locations to include dental clinics, establishing a Syringe Services Program (SSP) within the tribe’s borders, and using Direct-Acting Antivirals (DAAs) to treat those infected with HCV. The tribe, itself, is absorbing the costs of treating its citizens (Juozapavicius, 2018).

Photo Source: HHS

Map of Cherokee Nation

According to the most recent report released by the Centers for Disease Control and Prevention (CDC), deaths related to HCV have been decreasing in every demographic since 2013, including in Native American (NA) populations. That said, NAs still had the highest rate of HCV-related death in 2016, with a rate of 10.75 (per 100,000), down from a staggering 12.95 in 2015 (CDC, 2018). These data indicate that, while the effort by the Cherokee Nation are certainly proving to be effective, there is still a lot of ground to cover.

As with other race demographics, the leading risk for HCV infection is Injection Drug Use (IDU). Doctor Jorge Mira, Director of Infectious Diseases for the Cherokee Nation, indicates in the Juozapavicius article that, over the past two years, he began hearing the word “heroin” more and more, every day. This trend of IDU is in line with other race demographics. The common factors across race demographics are high levels poverty and unemployment. In areas where these factors are present (particularly in rural settings), heroin use and IDU are almost a given.

The efforts to combat the disease within the Cherokee Nation need to be replicated at the state and Federal levels. The reality is that these problems are not going to go away, and in the areas where they’re most prevalent, they are going to get exponentially worse in the coming years. In the meantime, we can look to the Cherokee Nation for their leadership on the issue, and begin implementing them in small scale at the local level.

References:

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Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.

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San Francisco: A Case Study in Multi-Pronged Approaches

HEAL Blog is the recipient of the ADAP Advocacy Association’s 2015-2016 ADAP Social Media Campaign of the Year Award
By: Marcus J. Hopkins, Blogger

One of the most frequent drums HEAL Blog likes to bang is that epidemics do not occur in siloes. As we learned in Scott County, Indiana, an uptick in new HIV and Hepatitis C (HCV) cases was largely the result of the Injection Drug Use (IDU) of the now-removed-from-the-market prescription opioid drug, Opana. The HIV community has been banging this drum since the 1980s; unfortunately, the politics around IDU were such that Syringe Services Programs (SSPs, or needle exchanges) simply weren’t a politically feasible reality in most of the United States. In other parts of the country, like San Francisco, underground exchanges began in the late-80s, and legalization was relatively quick to follow.

Needle exchange program with volunteers working with injection drug users

Photo Source: 5KPIX CBS

San Francisco’s first underground needle exchange – Prevention Point –  began in 1988 when a group of friends realized that something needed to be done to stop the spread of HIV among People Who Inject Drugs (PWIDs). Against California law, the organizers and volunteers went to great lengths to provide sterile syringes to PWIDs and also partnered with researchers, collecting data to document the positive health benefits programs like theirs could achieve (San Francisco AIDS Foundation, n.d.). Prevention Point operated for four years underground until 1992, when then-mayor Frank Jordan declared a public health emergency in the city of San Francisco and committed $138,000 to Prevention Point. This bold step went a long way to ensuring that SSPs were legalized within the state of California.

Fast-forward to 2018, and again, IDU is again a serious issue in San Francisco. This time, however, the San Francisco Department of Public Health is leading the charge using a variety of integrated initiatives involving:

opioid overdose prevention, education, and the distribution of Naloxone [an opioid overdose reversal drug]; access to and distribution of [sterile] syringes; prevention, screening, and treatment of HIV and HCV; alcohol prevention; and the creation of a Harm Reduction training institute (Chaverneff, 2018).

This multi-pronged approach to dealing with these intertwined epidemics using community-based methods, including peer education and testing models that have proven effective in other settings around the world.

More importantly, their model also includes taking HCV treatment outside of traditional healthcare settings, and helps to provide treatment at an Opiate Treatment Outpatient Program (at University of California San Francisco), at the San Francisco County Jail, at the SF AIDS Foundation Syringe Exchange program, at Magnet (a gay men’s sexual health clinic), at shelters, and in street settings (mobile setups). Of these, the most notable success was that the 10 patients who began HCV therapy in shelters all completed treatment; conversely, less than half of the 100 inmates who began HCV therapy completed treatment (Burk, 2018).

This model has been working for San Francisco, and it has the potential to work around the country, as well.

References:

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Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.

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We Have a Cure for HCV; Few People Can Get It

HEAL Blog is the recipient of the ADAP Advocacy Association’s 2015-2016 ADAP Social Media Campaign of the Year Award
By: Marcus J. Hopkins, Blogger

Numerous films and novels have predicted this fate: there’s a fatal disease and someone invents a cure, but nobody can get it, and people die because of it. It’s a metaphor about the dangers of unchecked capitalism – the greedy owner of the cure who holds the rest of the world hostage until his demands are met.

And here it is – 2018, and we’ve had a cure for Hepatitis C (HCV) that’s easily tolerated since 2013, but it’s so prohibitively expensive that private and public payors, alike, have strictly limited access to it. They make patients, physicians, and pharmacists jump through as many hoops as possible to get the cure, from the strictest prerequisite abstinence guidelines, to allowing the disease to progress until it’s “bad enough” to cover it.

Medical Benefits Claim Form with the word, "REJECTED"

Photo Source: NPR

Sure, the cost of the newest drugs to cure HCV have dropped to ¼ of the introductory price of Sovaldi (Gilead), but, still – $30k for eight weeks of treatment? That’s still prohibitively expensive, even with the deep discounts and rebates given to many payors by manufacturers during the negotiation process. Those expenditures are only going to increase.

Now, there is evidence suggesting that undiagnosed HCV is more prevalent than undiagnosed HIV (Torian et al, 2018). Since the 1990s, hospitals and emergency departments have actively touted “routine HIV” screening, but have failed to deliver on those promises:

Lessons from HIV are both instructive and sobering: routine HIV screening is not truly routine; linkage continues to challenge even experienced providers; and linkage and treatment initiation vary widely across sites (Torian et al, 2018).

The findings from this study indicate not only a need to increase screening and linkages to care for HIV, but that this increase needs to be spread to HCV, as well. The latter argument, while correct, is unlikely to occur, in no small part because states and patients simply don’t have the resources to successfully implement this type of public health initiative.

Beyond just testing, minorities and Medicaid recipients – a significant portion of those infected with HCV – enjoy some of the lowest treatment rates in the nation (Wong et al, 2018). Hispanic patients were siginifantly less likely to receive treatment for HCV than white patients, and those on Medicaid, state insurance, or indigent care or no insurance were significantly less like to receive treatment than those with commercial insurance.

That last part comes to a head in rural America, where patients are far likelier to rely upon Medicaid as their primary payor for medical services, and where Injection Drug Use (IDU) of prescription opioids and/or heroin is high. In states like Ohio, Indiana, West Virginia, and Kentucky, IDU and rates of overdose go hand in hand with increased rates of both Hepatitis B and HCV.

The sad reality is that, given the existing political makeup of both state and Federal legislatures, it’s highly unlikely that the significant resources needed to effectively combat the spread of HCV will be allocated. At a time when budgets are being slashed in order to accommodate tax cuts for corporation and the wealthy, to suggest that conservative lawmakers are suddenly going to provide an exponential (or even incremental) increase in funding is unrealistic.

References:

  • Torian, L.V., Felsen, U.R., Qiang, X., Laraque, F., Rude, E.J., Rose, H., Cole, A., et al. (2018, April 04). Undiagnosed HIV and HCV Infection in a New York City Emergency Department, 2015. American Journal of Public Health 108, no. 5 (May 1, 2018): pp. 652-658. DOI: 10.2105/AJPH.2018.304321 Retrieved from: https://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2018.304321
  • Wong, R.J., Jain, M.K., Therapondos, G., Shiffman, M.L., Kshirsagar, O., Clark, C., & Thamer, M. (2018, March 09). Race/ethnicity and insurance status disparities in access to direct acting antivirals for hepatitis C virus treatment. The American Journal of Gastroenterology. DOI: 10.1038/s41395-018-0033-8. Retrieved from: https://www.nature.com/articles/s41395-018-0033-8

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Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.

 

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Prescription Opioid Diversion and Its Role in HCV Transmission

HEAL Blog is the recipient of the ADAP Advocacy Association’s 2015-2016 ADAP Social Media Campaign of the Year Award
By: Marcus J. Hopkins, Blogger

In last week’s post, we discussed efforts to force pharmaceutical companies to report payments made to nonprofit organizations and patient advocacy groups in an effort to track which groups are funded primarily (or wholly) by pharmaceutical companies to promote their own business interests. Essentially, by funding certain organizations (such as Pain Advocacy groups), these companies can wage war against legislative attempts to restrict access to and/or prescribing of their highly addictive products (thus losing them money). This week, we’re going to take a look at the diversion of prescription opioid drugs, and how this can lead to both an increase in the likelihood of opioid addiction, and how it contributes to an increase in disease transmission via Injection Drug Use (IDU).

Each day, more than 1,000 people are treated in emergency departments for not using prescription opioids as directed

Photo Source: CDC

When I moved back to Kingsport, Tennessee as an adult in my late-20s, I began to notice a pattern: my co-workers and high school friends would tell me about their exploits with illicitly obtained “pills” – mostly OxyContin, as this was the late-00s. While working in a casual dining restaurant, I frequently heard about and witnessed efforts by my co-workers to obtain these drugs from other restaurant employees. Money would change hands, furtive glances were made around the restaurant to ensure no one was watching, and a few pills would be received, either loose or in a plastic bag. This activity was, of course, both illegal and against company policy, but it’s just SO easy to do, and I never reported the activity.

These drugs were often obtained by the seller either through a legitimate prescription for their own pain, or through getting them off of a third party. This type of drug dealing is called “diversion” – when legitimately prescribed opioid drugs are used outside of their prescribed purpose. It’s also the way that most prescription opioid addicts begin their path to addiction.

In 2015, HEAL Blog talked about the havoc prescription opioids wreaked upon my state (Hopkins, 2015). Teenagers would gain access to their parents’, grandparents’, or friends’ legitimately prescribed opioid drugs and use them recreationally. Unbeknownst to them, Purdue Pharma failed to mention that they knew their product was highly addictive, and before long, entire towns were in the throes of addiction. Fast forward to the ‘10s, and many of those prescription opioid addicts have moved away from the now-difficult-to-obtain prescription drugs to the much easier and cheaper to obtain heroin. Unfortunately for them, a good percentage of those heroin batches contain Fentanyl or Carfentanil – highly potent synthetic opioids that often lead to overdoses.

At the end of 2014, Scott County, Indiana, saw an huge spike in new HIV infections, caught because healthcare workers noticed a spike in new Hepatitis C infections. These new infections were driven almost entirely by IDU of Opana – a highly addictive prescription opioid that was removed from the market in 2017 (Kean, 2017). By the end of 2016, the county had 216 new HIV infections in the span of just two years, and of those, 95% were co-infected with HCV (May, 2016). So severe was the problem that Indiana and several surrounding states took the unprecedented approach of legalizing Syringe Services Programs – a move that was nigh unthinkable, since the early days of its proposal in the 1980s.

Here, in West Virginia, the rate of new HCV infections more than doubled from 2015 to 2016, from 3.4 to 7.2 (per 100,000), 68% of which were likely the result of IDU (WVDHHR, 2018). Despite this, Danny Jones, the mayor of Charleston, WV – the state capital – is on the warpath against the Kanawha County Harm Reduction Clinic because of an increase in used needles left throughout the city (Jenkins, 2018). Never mind that much of this refuse could be eliminated would the city spring for the Biohazard Disposal Kiosks requested by the health department, who instead had to fund them using funds from Emergency Medical Services programs.

Prescription drug diversion has led to tragic repercussions for many living in Appalachia who are now struggling with both addiction and comorbid infectious diseases. But, this problem doesn’t just exist in rural Appalachia, the Midwest, and New England – these issues are manifesting all around the U.S., and if we don’t take drastic measures to deal with drastic consequences, we’ll find ourselves faced with expensive outcomes.

References:

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Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.

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The Kids Aren’t Alright

HEAL Blog is the recipient of the ADAP Advocacy Association’s 2015-2016 ADAP Social Media Campaign of the Year Award
By: Marcus J. Hopkins, Blogger

For nearly three years, healthcare officials and epidemiologists have been sounding the alarm: the face of the Hepatitis C (HCV) epidemic is changing – it’s getting younger by the minute. We, here at HEAL Blog, have been beating that drum alongside them, and yet, the U.S. Centers for Disease Control and Prevention (CDC) has yet to formally change the screening recommendations to reflect the new reality. As more evidence piles up that new Acute HCV infections are largely being driven by prescription opioid and heroin Injection Drug Use (IDU) among Americans aged 15-45.

A piece written by the Digestive Health Team out of the Cleveland Clinic – Why Is Hepatitis C on the Rise in 20- to 29-Year-Olds? – explicitly says as much. In addition, while African-Americans share a disproportionate burden in the epidemic (as a percentage of the population), these issues are particularly pronounced in white, non-urban (suburban and rural) populations living primarily in Appalachia, the Midwest, and New England.

So, what is it about these areas that drives people to abuse prescription opioids, heroin, and/or other illicit drugs? There isn’t just one answer. A lot of the areas where these outbreaks and epidemics are so pronounced share several similarities – struggling economic circumstances; higher-than-average unemployment; less access to and utilization of healthcare services; high rates of Social Security Disability Insurance utilization; economies driven by high-intensity labor industries (mining, for example). Any combination of these factors can lead people to develop substance addictions; that these areas are more remote with fewer outlets and opportunities for employment, entertainment, or social engagement essentially creates enclaves where people can all but disappear into a considerably isolated world of addiction.

Where the kids come in often has to do with the friends, relatives, and other adults whose legitimate opioid prescriptions get unknowingly diverted by experimenting teens who inadvertently become addicted to the highly addictive substances. As a young adult living in a small city in Tennessee in the 2000s, virtually all any of my friends and co-workers wanted to do was find “pills” (primarily OxyContin). Whereas I grew up in the cocaine-fueled 80s and ecstasy-addled 90s, parties in the 2000s were, for my generation, comparatively somber affairs, with everyone pilled out on opioids and barely able to function. Once the U.S. Food & Drug Administration (FDA) started to catch on and legislators began tightening prescribing guidelines, they turned to cheaper and more readily available heroin.

With IDU comes a whole host of risks that, for much of the 80s and 90s – particularly as it related to HIV/AIDS – were made explicitly known. Every health and D.A.R.E. (Drug Abuse Resistance Education) I was made to attend as a child, pre-teen, and teenager included a very graphic section on the dangers of injecting drugs. Almost every school in the 90s had a rumor going around about some random person who was dancing at a nearby club and got stabbed with a used needle and got AIDS. While a lot of hyperbole was involved in these stories, the sense of horror we were expected to evince – “WHAT?!?! A DIRTY NEEDLE?!?!” – led a lot of us to become more risk averse, particularly in our younger years.

Twenty years later? A lot of those fears have been forgotten. We no longer see horrific images of people dying from AIDS – the treatments are amazing, tolerable, and don’t kill you. We aren’t afraid of diseases like HIV or viral hepatitis, anymore, because…well, HIV isn’t a death sentence, and HCV is curable. Hepatitis B is still a huge problem, as it has no cure. But, the reality is that neither the fear of becoming addicted, nor the fear of becoming infected are presently palpable enough to prevent people from even starting. What starts out as a way to kick back with your friends and loosen up can quickly turn into a daily habit and morph into a physical dependency. Once you’re dependent and addicted, the risks become less frightening.

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Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.

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Is it Time for a Rethink on Hepatitis C Care?

HEAL Blog is the recipient of the ADAP Advocacy Association’s 2015-2016 ADAP Social Media Campaign of the Year Award
By: Marcus J. Hopkins, Blogger

In the state of West Virginia, any Medicaid beneficiary who is diagnosed with Hepatitis C must personally or through their prescribing doctor consult with either an Infectious Disease specialist or a doctor whose specialty includes Hepatitis C (e.g. – a Hepatologist) in order to have their prescription for Hepatitis C (HCV) Direct-Acting Antivirals (DAAs) approved. In addition, the patient must have a Metavir fibrosis score of F2 or higher as a prerequisite, as well as abstain from illicit drug and alcohol use for a period of 3 months.

These additional barriers to treatment are not only time consuming, but potentially costly. The consultation requirement, alone, exponentially increases the amount of money Medicaid must reimburse just in order to fill a prescription that can now be obtained for potentially $10k per patient (this, according to hearsay, since actual prices paid are forbidden from being made public by existing Trade Secrets laws). Beyond that, even current screening practices tend to require patients to see a specialist, just to get screened for the disease. This is both problematic, and relatively easily remedied.

Barriers to seeing out health care. About 1 in 2 Americans admit they have put off needed health care and have avoided going to a doctor when necessary.

Photo Source: VeraQuest

With the introduction of HCV DAAs in 2013, HCV patients gained access to what was once thought improbable – a relatively easily tolerated “cure” with a high level of efficacy and considerably fewer and less serious side effects. Since that time, an additional nine HCV DAAs have been brought to the market, with newer drugs coming down the pike. The most recent release, AbbVie’s Mavyret, is a potential game changer, offering curative treatment in 8-to-12 weeks for roughly 1/3 to 1/2 the price of the most popular drugs on the market, while sharing essentially identical cure rates. In fact, Mavyret has become the Preferred Drug for several Medicaid Fee-for-Service and Managed Care Organization (MCO) plans since its approval in August of last year.

But, still, issues remain. In West Virginia, the rate of HCV more than doubled from 3.4 (per 100,000 persons) in 2015 (CDC, 2017) to a staggering 7.2 in 2016 (West Virginia Department of Health and Human Resources, 2018). While increased screening may account for this considerable increase, 68% of new Acute HCV infections listed Injection Drug Use (IDU) as the primary risk factor (WV DHHR, 2018), which indicates that increased screening of this community needs to be a priority.

Some of the ways that this can be accomplished is at the regulatory level – requiring screening of all adults in virtually every healthcare setting (e.g. – emergency rooms, primary care, community health centers, urgent care clinics, and correctional settings). In fact, in a simulation model, researchers from Boston Medical Center, Mass. General Hospital, and Stanford University found that this expanded screening protocol would increase life expectancy and quality of life, while also remaining cost effective (Legasse, 2018).

The strategy would also identify an estimated 250,000 more HCV cases than the current U.S. Centers for Disease Control & Prevention (CDC)-recommended strategy of focusing screening efforts on the Birth Cohort – individuals born between 1945-1965 (Green, 2018). This would have a projected benefit of increasing cure rates from 41% to 61%, while also reducing the risk of death from HCV-linked conditions by more than 20% compared to the current CDC guidelines (Toich, 2018).

It is clear that expanding screening to include all adults, rather than focusing efforts on the Birth Cohort and those whose doctors are aware of any other risk factors (because, let’s be honest – few people who inject drugs are open about that with most doctors, unless they’re there for an IDU-related condition or because of an overdose, at which point, it’s pretty obvious). Once we achieve THAT measure, we can move on to allowing Primary Care Physicians and Registered Nurses begin to administer and monitor HCV DAA therapy, because, it’s just not that difficult to do.

References:

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Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.

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