Integrated Internist – Addiction Medicine – Hepatology Model for Hepatitis C Management for Individuals on Methadone Maintenance

D. Martinez; R. Dimova; K. M. Marks; A. B. Beeder; M. Zeremski; M. J. Kreek; A. H. Talal

Disclosures

J Viral Hepat. 2012;19(1):47-54. 

In This Article

Abstract and Introduction

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.

Introduction

Five million individuals in the United States are infected with hepatitis C virus (HCV), a virus that can result in cirrhosis, end-stage liver disease and hepatocellular carcinoma. Conventional therapy, consisting of pegylated interferon (PEG-IFN) and ribavirin (RBV), results in viral eradication in roughly one-half of infected individuals.[1,2] Currently, injection drug use is the strongest risk factor for HCV acquisition with HCV seroprevalence >70% among injection drug users (DUs) older than 40 years. However, DUs have been systematically excluded from treatment for HCV owing to stigmatization, physicians' concerns regarding adherence and patients' misinformation concerning the importance of a diagnosis of HCV.[3,4] Between 2010 and 2030, the prevalence of cirrhosis is estimated to increase from 25% to 45% among chronic hepatitis C patients.[5] Simultaneously, the number of treated patients is projected to decline,[6] unless new strategies are developed to enable DUs to obtain antiviral treatment.

Despite the potential benefits of treatment, surprisingly few HCV-infected DUs are offered anti-HCV therapy, even though expert panels have endorsed HCV treatment in this population.[7,8] Active engagement in therapy for addiction has been shown to increase treatment access for various infectious diseases, such as HIV and tuberculosis, among illicit substance users.[9,10] It has also been demonstrated that the longer a patient is engaged in substance abuse treatment the greater the stability and retention in treatment for medical conditions.[11]

Traditional HCV management via referral of DUs to outpatient specialty clinics has resulted in the appearance in the clinic of less than one-third of referred patients.[12] Among DUs, therapeutic effectiveness is an issue of treatment access, acceptance and adherence rather than drug efficacy.[13] Consequently, an approach that integrates the expertise of a variety of disciplines, including specialists in addiction medicine, hepatology, infectious diseases, primary care and psychiatry, has been advocated for the treatment of HCV among DUs.[14] Adherence is likely to be further enhanced if a program offers familiarity, continuity among providers and ready access to health care professionals, as a strong relationship with medical personnel has been shown to be an important determinant of patients receiving preventative care as well as HCV and HIV treatment services.[15–17]

To address these concerns, we devised the 'internist-addiction medicine-hepatology colocalization model', an integrated, co-located program in which an internist-addiction medicine specialist (ADM) evaluated methadone-maintained patients for HCV infection in the hepatology clinic under the direction of a hepatologist (AHT). We applied our model to patients from our institution's two methadone maintenance clinics located in close proximity to our viral hepatitis clinic. A primary premise of our model was that methadone-maintained patients would be more likely to accept an HCV evaluation if continuity of care was maintained between the methadone maintenance treatment program (MMTP) and the viral hepatitis clinic by the same physician caring for patients in both venues.

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