Commentary on Senn et al. (2009): Primary care is the place to manage hepatitis C in opiate-dependent patients
Version of Record online: 9 NOV 2009
© 2009 The Author. Journal compilation © 2009 Society for the Study of Addiction
Volume 104, Issue 12, pages 2039–2040, December 2009
How to Cite
ROBERTSON, J. R. (2009), Commentary on Senn et al. (2009): Primary care is the place to manage hepatitis C in opiate-dependent patients. Addiction, 104: 2039–2040. doi: 10.1111/j.1360-0443.2009.02822.x
- Issue online: 9 NOV 2009
- Version of Record online: 9 NOV 2009
- Hepatitis C;
- primary care
Screening for a condition which, in its early years, is largely symptomless in a population with many other priorities is always likely to be problematic. Attempts to assess the incidence and prevalence in drug injectors have used a variety of approaches, including opportunistic testing at outreach clinics, prenatal testing, case finding in primary care and in drug treatment clinics and testing of patients with symptoms suggestive of liver disease [1–3]. The population with by far the highest prevalence of hepatitis C is injecting drug users. Most are young when they become infected and upwards of 50% remain untreated . The expectation of liver cirrhosis and cancer in a percentage may seem a long way off to those infected, and have not yet achieved numbers sufficient to trigger a public heath panic, but the fuse is burning [5,6]. Dire warnings of the consequences of this pool of disease are frequent and repetitive. Senn and colleagues provide an encouraging offer of a successful model for the first stage of the process of identifying those at risk, diagnosing the presence of the disorder and starting treatment. They show clearly the value of opiate substitute treatment in engaging this risk group and the association of this therapy with a successful outcome in testing . This experience of using the attraction of this treatment to encourage a wider health care agenda is not new, and some feel that it is coercive, but as with other harm reduction measures the end undoubtedly justifies the means.
Intuitively, primary care is a good place to invoke screening programmes and additionally the expertise exists in which to prescribe opiate substitute treatment, carry out blood testing and liaise with a range of secondary care departments such as psychiatry (specialist drug, alcohol and general mental health interest), as well as community support agencies. For several reasons, including those noted by the authors, this is not always simple. General practitioners have a lot to do and often see issues such as treating drug users as a specialist responsibility. Taking appropriate blood samples from injecting drug users is not always easy, and they may well fail to see the importance. Training in hepatitis C case finding is not always adequate, and may depend upon funds being targeted. Finally, primary care organizations in different countries have varied responsibilities and capacities. However, the model is robust and the capability is there, and funding streams need to be invented if that is necessary.
The next imperative is to engage patients in treatment. Testing is all very well, but the target is treatment and elimination of the virus in order to prevent damage, further transmission or progressive disease. This, of course, gives rise to a new set of problems. Will patients attend for the next round of tests, ultrasound scans of the liver, biopsy, more bloods for alphafetoprotein, fibroscans, and will they be assessed as suitable for treatment? Many issues of suitability for treatment arise . Do they still inject? Are they heavy alcohol users? Have they psychiatric contraindications to treatment? Do they want to take an invasive treatment with miserable side effects for 6 months or longer with only a majority chance of success? Again, primary care may be the place to address these difficulties and pilot studies in the United Kingdom and elsewhere are trying to provide supportive, close-to-home treatment to a larger group of patients who have been excluded previously by virtue of lack of domestic support, irregular life-style, compliance and adherence issues and continued dependency [9,10]. As outlined in the present paper, opiate treatment facilities may provide the opportunity, or the only chance. All treatment agencies providing opiate substitute treatment for this group should have the capacity to test, as Senn et al. demonstrate, but additionally they might consider community treatment as well as testing.
Many obstructions remain but most of them are administrative, financial or based upon a misunderstanding of the appropriate methods of engaging and supporting drug users or recovered drug users. Evidence of the dangers of psychiatric comorbidity are cited frequently , but there is also increasing evidence of the exaggeration of this as an exclusion from therapy . As the present authors imply, organizational, educational and prejudicial barriers should be overcome and models of primary care treatment and testing opportunities expanded . Further advances to reduce the toxicity and improve the efficacy of hepatitis C treatment will undoubtedly help to encourage more people into treatment, but further examples of successful, easy-to-access, and linked to opiate substitute treatments are likely to drive forward this important area of management.
- 12Scottish Intercollegiate Guidelines Network. Management of hepatitis C. Guideline no. 92. December 2006. ISBN 9781905813025.