Only thirty percent of physicians who prescribe opioid
substitution therapy to people who inject drugs have also prescribed
direct-acting antivirals, despite being ideally placed to offer testing and
treatment for hepatitis C, an international survey has found.
Opioid substitution therapy consists of prescribing medical opioids to
reduce dependence on injected heroin. People who use drugs are enabled to avoid
the harms associated with injecting illicit drugs, such as bacterial
infections, arrest and imprisonment, and may stabilise their daily routines.
Opioid substitution therapy can be prescribed by physicians
in drug dependence clinics or some community-based drugs services. The type of
opioid agonist prescribed varies by country and access to opioid substitution
treatment depends on national policy. In most countries in Eastern Europe and
Central Asia, for example, opioid substitution treatment is not available due
to long-standing professional disapproval of its use.
Prescribers have an important opportunity to promote
hepatitis C testing and treatment among people who inject drugs, but little is
known about the attitudes of opioid agonist prescribers offering hepatitis C
testing and treatment, how many are already doing it and what barriers exist to
hepatitis C testing and treatment in the drug dependence clinic.
The C-SCOPE study was designed to investigate these
questions among prescribers in Australia, Canada, Europe and the United States
through a structured questionnaire. The study recruited 203 physicians who worked
as part of a team providing care to people who inject drugs. The majority
worked alongside addiction medicine specialists and psychiatrists but only 27%
worked in a clinic where an HCV specialist was part of the team.
On-site testing for hepatitis C antibodies was available at
only 40% of clinics and only 35% of clinics were able to carry out venepuncture
on-site. Only 25% were able to conduct assessment of liver disease on-site and
the study showed that for a majority of actions, from antibody testing to
staging of liver disease, service users needed to be referred to another clinic
with the risk that they would fail to engage with another service. Diagnosis
and pre-treatment work up may require up to five visits, the study authors
These findings reflect the low priority given to testing for
hepatitis C in drug dependence clinics. Although a majority of respondents said
that they followed national guidelines, only 56% of physicians tested all
patients attending the clinic for opioid substitution treatment on their first
visit. Electronic health record systems that alerted physicians to the need to
test or re-test patients were available in 40% of clinics.
Once diagnosed with HCV, most patients had to be referred to
another site for pre-treatment blood tests and liver fibrosis assessment. Only
30% of physicians had prescribed direct-acting antivirals in their drug
Asked about the barriers to screening and treatment,
physicians frequently cited long delays in referring patients to other clinics
and long travelling distances to sites providing hepatitis C care. Within the
clinic, the lack of staff qualified to draw blood (venepuncture) was a common
barrier (38%), as were the need for imaging to stage fibrosis to take place outside
the clinic (39%) and the lack of case managers or linkage to care coordinators
(37%). The lack of peer support programmes that encouraged testing within the
clinic was also cited as a frequent barrier (42%).
Lack of funding for treatment, restrictions on access to
treatment for drug users and lack of protocols for testing and treatment in
drug dependence clinics were also frequently cited as barriers.