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Continuum of Care: HCV and the Addiction Specialist

Editor’s Note: Part 4 of 4

A natural consequence of expanded screening protocols and the advent of the direct-acting antiviral era is that a flood of patients with HCV is entering the health care system. Accordingly, the number of non-HCV specialists required to treat the disease also is on the rise. HCV Next has published a four-part series on the successes achieved and obstacles faced by clinicians in four different fields — infectious diseases, gastroenterology, primary care and addiction medicine — as they grapple with everything from screening and diagnosis to resistance variants and liver compensation. This is the fourth in the series and features input from clinicians who deal with addiction.

HCV Next reached out to five experts for opinions on the role of addiction in treating the disease. Each clinician was asked the same series of questions. The experts include Phillip O. Coffin, MD, director of substance use research at the San Francisco Department of Public Health and assistant professor in the division of HIV/AIDS at the University of California, San Francisco; Adrian Dunlop, PhD, area director and senior staff specialist, Drug & Alcohol Clinical Services, Hunter New England Local Health District in New South Wales, Australia, and conjoint associate professor in the School of Medicine and Public Health, Faculty of Health at the University of Newcastle, and chief addiction medicine specialist at the Mental Health, Drug and Alcohol Office, NSW Ministry of Health; Anthony Martinez, MD, associate professor of medicine and medical director of Hepatology at the University at Buffalo, Buffalo General Medical Center, Erie County Medical Center Division of Gastroenterology, Hepatology and Nutrition; Rae Jean Proeschold-Bell, PhD, associate professor at the Duke Global Health Institute, the Duke Center for Health Policy and Inequalities Research, and director of the DGHI Evidence Lab; and Terra Hodge, MSW, LCAS, clinical social worker and addiction therapist at Duke University Medical Center.

A whole host of clinical activities fall under the large umbrella that is addiction medicine, according to the experts in practice. Addiction specialists can have a hand in everything from psychiatric care to helping patients find and secure employment. As a result, HCV may be just one of the many priorities to be accounted for with any given patient or group. But the versatility built into addiction medicine can also make these specialists an asset in the battle against HCV. Patients frequently see their addiction specialist more than they see any other doctor, which confers a level of trust. In the midst of dealing with pain management and referrals to other specialists, addiction experts can use this trust to encourage patients to adhere to their medications and remain on the pathway to cure.

Q: What are addiction specialists doing right in terms of treating HCV? And, similarly, what positives do they bring to the table in terms of experience and background?

Martinez: Addiction medicine is a wide-ranging spectrum that is not as standardized as primary care or internal medicine. Provision of services varies in terms of providers, treatment modalities and settings. On the simple end, you have methadone clinics with no ancillary services or even primary care. Then you have some academic medical centers, for example, with more funding and services available. These facilities offer one-stop shopping for psychiatry, behavioral medicine and other special needs services, including hepatology. At Cornell, we had a methadone clinic that offered a full spectrum of services.

There is also variety in provider type in addiction medicine. Historically, addiction specialists were from psychiatry, but that has changed a lot in the last 10 or 15 years. As it stands right now, addiction medicine practitioners might come from the disciplines of psychiatry, pain management, primary care, or other specialties. There is a huge upside to these practitioners being involved in HCV management. Addiction practitioners understand this population. If we want to have an impact on the global epidemic, these are the patients that we need to engage in treatment. Addiction specialists can help us target them.

Dunlop: There is a spectrum of activity regarding HCV assessment and management by addiction specialists. Addiction specialists are generally aware of HCV prevalence in people who use drugs, that treatment exists and that it is quite resource intensive to provide in terms of patient education and medical monitoring. They also know that patients may be reluctant to pursue treatment. At the most active end of the scale, addiction specialists screen, assess and treat HCV-positive people, but this is still a minority of specialists.

Coffin: HCV is increasingly seen as an issue that addiction specialists can address. Initially, this means incorporating HCV screening into the routine testing done for clients at entry to services and, in some cases, running HCV support groups. In some settings, such as agonist maintenance programs (eg, buprenorphine or methadone maintenance), treating HCV onsite is gaining favor as providers have frequent contact with patients. There are multiple reasons to believe that HCV care should be incorporated into therapy for substance use disorders. First, the acute issue for patients seeking substance use disorder treatment is substance use, and thus the addiction specialist is central to their care. Second, substance use disorder treatment requires frequent, even daily, contact with providers, raising the possibility of closely monitored care and treatment. Third, as HCV is often a sequelae of substance use, it makes sense to address that infection along with the other medical complications. In fact, HCV treatment and cure can be a powerful motivator for patients with substance use disorders to avoid future drug use and get their other medical issues managed. Finally, providers who care for large numbers of substance users tend to better understand the issues of stigma and judgment often faced by patients with substance use disorders, and may be better equipped to aid patients in navigating care.

Q:What areas need improvement?

Coffin: Most substance use disorder treatment programs do not yet address HCV. Many do not screen for HCV and only a limited pool provide additional HCV care services such as treatment. For greater numbers of patients with substance use disorders to be treated, there needs to be substantial changes within the medical model of substance use disorder treatment. Many of these treatment programs have no medical staff and many lack on-site phlebotomy. Even some sites with such services may not be able to bill for medical care because they are not the primary care medical home for a given patient. For those with an outside primary care provider, communication between the substance use treatment program and primary care providers is limited or even entirely absent, due in part to confidentiality restrictions surrounding substance use treatment. These are difficult issues to resolve, but there is hope that parity in care through the Affordable Care Act will inspire changes that will reduce some of these barriers.

Hodge and Proeschold-Bell: Training for addiction therapists should include more about how they can help patients get screened and/or treated for HCV. The Licensed Clinical Addiction Specialist licensure program in North Carolina only minimally covers HCV despite the fact that a route of contracting HCV is through the addictions behavior of sharing needles. Addiction specialists need more training to understand fully the connection between HCV and liver cirrhosis, including things such as what the effect of alcohol use is on the absorption rate of HCV antiviral medication.

We also need more addictions treatment that is integrated with medically based HCV care. For example, if addiction therapists are co-located in a liver clinic, they need to be able to share electronic notes with HCV medical providers. On the other hand, if they are not in the same clinic, there could be processes in place for patients to sign a release of information to allow the HCV medical providers and addiction specialists to communicate to jointly support the health of the patient, including reaching their substance use goals.

Dunlop: The new era of the direct-acting antivirals should change all this. Treatment is going to be so much easier. I think we’ll see a big turnaround and many more of our patients will start asking for it. With this in mind, it is important that we respond as a field. The need to scale up screening, assessment and DAA therapy is on our doorstep.

There certainly are training needs for addiction specialists in this area, but I do not think this is the biggest challenge. The biggest challenge is the logistics of treating large numbers of patients as rapidly as we can with the goal of eventually eradicating HCV. That’s a big ask, but it is possible. This will now be possible in Australia from March this year with no restrictions on fibrosis stage or current injecting status. Current injectors are actually the target group we need to try the hardest to treat. Attracting those not in addiction treatment is an even bigger challenge, but these are the issues we have to face. We could be leaders or followers here. I think we can be leaders.

Martinez: The number one thing that needs improvement is screening. This is the only disease where we have gone from discovery to cure in such a rapid period of time but still don’t screen properly. However, there are no universal screening guidelines in the addiction setting. What one methadone clinic is doing in one state is completely different from what they’re doing in another state. Another thing we can do is educate providers about changes in HCV management. We need to disseminate that treatment now is relatively free of side effects, extremely effective and interferon-free. There is still the mindset that interferon is the mainstay of treatment and that patients won’t do well on it. This population has become very treatable, and practitioners of addiction medicine will benefit from education regarding new treatment options. Finally, we need to overcome the stigma associated with patients with substance use disorders, especially active drug use. We were very fortunate at the University at Buffalo to participate in a recent study evaluating treatment of active drug users with the newly FDA-approved regimen of grazoprevir and elbasvir (Zepatier, Merck) which demonstrated outstanding SVR rates in this population. There are also good historical data to demonstrate that these patients are as compliant as the general population and that reinfection is relatively low. Newer data also suggest that treatment as prevention is going to be a major way of having an impact on disease prevalence.

Q: What can the professional societies do to improve and ensure quality of care for patients with HCV?

Martinez: AASLD has evolved their recommendations for treating this cohort. Back in the days of peg-riba, the recommendation was for abstinence for 6 months. We now assess patients on a case-by-case basis.

Addiction societies should be involved in the development of HCV treatment guidelines related to this population. They can offer a lot to the societies like AASLD in terms of really understanding this patient cohort and overcoming stigma. The addiction and hepatology disciplines each have a lot to offer each other. If the addiction community can educate the GI/hep community in terms of dealing with psychiatric and addiction comorbidities, then AASLD can help addiction societies in terms of screening, linkage and recognition of more advanced liver disease, for example.

In a perfect world, I’d like to see AASLD-sponsored workshops for addiction specialists that train them to become hepatitis C champions. Societies such as ASAM could also offer training to hep C providers related to better understanding of substance use disorders.

Coffin: Patients with substance use disorders seeking treatment for HCV are frequently told they need to be abstinent from substances prior to being treated for HCV. This is no longer an element of the IDSA or AASLD guidelines, particularly when interferon-free regimens are utilized. Data are rapidly emerging that support broad access to DAA-based HCV treatment for substance users and even many payers are eliminating restrictions related to alcohol or other substances. Professional societies should emphasize that substance use is no longer even a relative contraindication for HCV treatment, and use of drugs by injection may be a positive indication for early treatment because reducing incidence will be impossible without decreasing prevalence among those most at risk of transmitting the virus.

Dunlop: Providing flexible training packages for professionals, patient education and information are important. But the critical issue is promoting the need for treatment by addiction specialists in addition to other groups. Gastroenterology, internal medicine, infectious diseases as well as family physicians all need to play a part. But addiction specialists, addiction medicine and addiction psychiatry are critical. The societies are in a great place to assist here.

We need to think of the resources required to do all this. It will require discussion and debate to determine the resources required. Then we need actual resources dedicated to the cause. We can’t afford to see this as the problem of another specialty. It’s ours as well.

Q: Addiction specialists will have their own busy practices and challenges; which aspect of the continuum of HCV care should they be most focused on?

Hodge and Proeschold-Bell: Addiction specialists can help patients reach the alcohol and substance use goals that their HCV medical providers have for them in order for them to be prescribed HCV antiviral medication. For example, some medical providers may only feel comfortable prescribing HCV antiviral medication if a patient is consuming a small amount of alcohol. In that case, the addiction specialist can work with the patient to develop individualized behavioral strategies to reach that drinking goal, and can enhance the patient’s motivation and feelings of efficacy toward decreasing alcohol use.

Also, addiction specialists often learn detailed information about what substances patients are using and how they are using them. This gives addiction specialists the opportunity to educate patients about specific ways to avoid transmitting HCV to others or re-infecting themselves, like not sharing straws or rolled bills to snort substances. Addiction specialists can encourage high-risk patients to be tested for HCV and to seek care from a hepatologist if they have been told in the past they were HCV positive.

Dunlop: Think of it like a cascade. If you don’t screen, you don’t know. Many patients don’t actually know their HCV RNA status, so antibody and RNA testing for all at risk is the first step. Even if you’ve got resources, at each stage — evaluation, treatment, post-treatment follow-up — there are going to be demands beyond your own resources. There is an advantage to partnerships with other specialists who can treat, physician assistants or nurse practitioners who can further assess and treat. Dianne Sylvestre, MD, assistant clinical professor of medicine at University of California at San Francisco, showed me about a decade ago how possible it is to do a lot with minimal resources. Just having a commitment to address HCV remains the key first step for our profession.

Keeping up with changing medication regimens takes time, but we are all required to engage in continuing medical education. This area is certainly relevant. The EASL and AASLD guidelines are both great, and I’m sure they will keep being updated. The special edition of the International Journal of Drug Policy has free downloads of treatment recommendations and some great up-to-date articles on this area. Self-education is very possible.

Martinez: Again, screening and linkage are huge. Once we get these patients evaluated by a specialist and started on the road to treatment, they are in there anywhere between 5 and 7 days a week. Once the clinic knows they’re on therapy, they can be very helpful in monitoring compliance.

Coffin: There are many elements of medicine that should be addressed by addiction specialists, including screening for HIV, HCV, sexually-transmitted infections, and tuberculosis; providing vaccinations for viral hepatidites, influenza, pneumococcus, and tetanus; and ensuring access to sterile injection equipment and the opioid overdose reversal agent naloxone. While not all of these are standard elements of addiction medicine today, they are increasingly common and will be even more so as we come to increasingly rely on pharmacotherapies to treat substance use disorders. Screening and confirmatory RNA testing for HCV should be a routine element of substance abuse care where appropriate laboratory services are available.

Not all addiction specialists will be comfortable or have the bandwidth to manage or treat HCV, but some will with appropriate education and support. Those providers able to treat HCV can make a major contribution to the goal of HCV elimination. For those who are not comfortable, they should have easy access to providers who are comfortable providing this treatment. Given that funding for HCV prevention, care and treatment is remarkably limited, addiction specialists lacking the bandwidth to manage HCV will need to develop innovative partnerships with providers or services that are able to assist.

Q: Could you comment on when it might be necessary for an addiction specialist treating a patient with HCV to hand that patient off to someone more qualified?

Martinez: Assessment of liver disease for evidence of advanced fibrosis is very important. It is probably better if individuals with advanced fibrosis or cirrhosis are managed by a gastroenterologist. This staging assessment, however, can be made by the addiction medicine specialists very easily. Non-invasive methods to evaluate staging such as a FibroTest, which is a widely available blood test, can be ordered with baseline lab work in the addiction setting. Other non-invasive modalities such as FibroScan (Echosens) or MR elastography are also options for non-invasive staging evaluation, if available. The key is to teach the addiction community how to recognize these things. There should be a free blood test. The specialist can order an ultrasound and hand the patient off. This is a pretty easy thing that can be outlined. We talk a lot in the addiction community about this. It’s a big message we need to convey.

Dunlop: Like any other part of medicine, when things get complicated, we need advice. This includes patients who have HIV co-infection, unstable mental health problems (unless you are an addiction psychiatrist), experience significant side effects from DAA treatment (we think this won’t be anywhere near as common as with interferon-based treatment) or are viral nonresponders. But as addiction specialists, we’re used to people not responding to treatment; this is just a cognitive shift for us.

Hodge and Proeschold-Bell: HCV medical providers and addiction specialists each have their own expertise. Both are needed to treat a patient who has both HCV and substance or alcohol use. The ideal goal is for HCV medical providers and addiction specialists to work together. Integrated medical-addictions care can take many forms, including release of information for providers in different settings to talk to each other about a shared patient. Alternatively, in co-located care, HCV medical and addictions services are offered in the same location, where the ideal is for all staff to be aware of the expertise each offers, to be charting in the same electronic medical record, and to create joint patient treatment plans informed by both HCV medical and addictions providers.

Coffin: Handing off a patient depends on a given provider’s level of comfort with and bandwidth for providing HCV treatment. Some addiction specialists may refer patients with confirmed HCV for management, whereas others may be able to manage the entire treatment process. Some may feel stymied by the selection of the optimal regimen and by barriers erected by payers, although many of these problems can be addressed by accessing HCV specialist colleagues, online resources, or telemedicine services. In the unlikely event that an interferon-based regimen is considered necessary, a hand-off to an HCV specialist is more likely, but the mental health and medical complications of interferon-based treatments are simply not relevant to therapy with DAAs. There is no reason to hold back on our efforts to expand the medical providers that can care for HCV and every reason to include addiction specialists.

• For more information:
• Phillip O. Coffin, MD, MIA, can be reached at 25 Van Ness Ave., Suite 500, San Francisco, CA 94102; email: phillip.coffin@ucsf.edu.
• Adrian K. Dunlop, MD, can be reached at Newcastle Community Health Centre, Suite 8, Level 3, 670 Hunter St., Newcastle 2300, New South Wales, Australia; email: Adrian.Dunlop@hnehealth.nsw.gov.au.
• Terra Hodge, MSW, and Rae Jean Proeschold-Bell, PhD, can be reached at Duke University Medical Center, Box 90392, Durham, NC 27708; email: terra.hodge@dm.duke.edu; rae.jean@duke.edu.
• Anthony Martinez, MD, can be reached at 100 High St., Room 617F, B Building, Buffalo, NY 14203; email: adm35@buffalo.edu.

Disclosures: Coffin, Dunlop, Hodge and Proeschold-Bell report no relevant financial disclosures. Martinez reports speaking for Abbvie, Bayer, Bristol-Myers Squibb, Gilead and Salix; consulting for Gilead and Intercept; and receiving research grants from Abbvie, Gilead, Merck and Tobira.