Opioid Drugs and the Risk of Hepatitis C

How the Opioid Crisis Is Driving Infection Rates

Hepatitis C is inextricably linked to opioid drug use. As the opioid epidemic continues to rage out of control in the United States, so, too, has the rate of new hepatitis C infections. According to the Centers for Disease Control and Prevention (CDC), there has been no less than a 350% increase in new hepatitis C diagnoses between 2010 and 2016, which is fueled by the prescription opioid epidemic, and the resulting increase in heroin use.

In an effort to curb the syndemic⁠—a term used to describe an epidemic driven by two interlinked conditions⁠—the CDC and other public health authorities have stepped up efforts to diagnose and treat users already infected with the hepatitis C virus (HCV). Efforts have also been made to reduce the risk of harm to injecting drug users, including the government-endorsed needle exchange programs and opioid treatment centers.

Some cities have even taken steps to create medically-supervised safe injection sites for users unable to overcome their addiction, a strategy that has proven effective in Europe, Australia, and Canada but has yet to be embraced by legislators in the United States.

Opioid Epidemic in the United States

In October 2017, the White House declared a public health state of emergency due to the rising opioid epidemic. According to the declaration, over 2 million Americans were addicted to opioid drugs resulting in over 300,000 opioid-related overdose deaths since 2000. That is more than the total number of homicides committed in the United States during the same time period.

Opioids are highly addictive and include synthetic compounds such as fentanyl and illegal drugs such as heroin. There are also natural opioids such as codeine and morphine, both of which are also subject to abuse.

Of the synthetic opioids commonly abused in the United States, fentanyl, hydrocodone, and oxycodone remain the most popular. The age group most likely to abuse these drugs are between 18 and 25, with males more likely than women to die before the age of 50 due to an opioid-related overdose.

How Opioid Addiction Occurs

Opioids work by binding to receptors in the brain that stimulate the production of the "feel-good hormone" dopamine. Although the drugs mimic brain chemicals, they aren't mediated in the same way and end up flooding the body with dopamine, relieving pain while producing a pleasurable, calming effect. When taken in higher doses, opioids can deliver an intense, euphoric high.

As the body adapts to the drug, more and more of it is needed to not only achieve the same effects but avoid the often-crushing symptoms of opioid withdrawal. For people who misuse opioids, this often results in a transition from oral to intranasal "snorting" to injecting drug use.

This is especially true with time-release formulations like OxyContin (oxycodone) and Percocet (oxycodone plus acetaminophen); crushing the tablet bypasses the slow release and delivers the full dose all at once.

The people at greatest risk of injecting opioid use are those who live in rural communities, started recreational drugs early in life, are high school dropouts, and are unemployed or homeless. It is in this setting that HCV transmission is most likely due to the shared use of needles, syringes, water, alcohol swabs, and other drug paraphernalia.

The risk of HIV is also exponentially increased in injecting drug users. According to the Centers for Disease Control and Prevention (CDC), around 75% of people with HIV who inject drugs have hepatitis C as well.

Opioids and HCV Transmission

Hepatitis C is a bloodborne disease for whom most users are infected, not surprisingly, by shared needles or other equipment used to inject drugs. The CDC reports that the recent spike in new infections is a reflection of the growing numbers of young white youth who have transitioned from oral abuse of prescription opioids to the injection of opioids and heroin.

Opioids and Heroin

Opioids and heroin are the drugs commonly abused by injecting drug users, both of which are chemically similar and produce a similar high. As such, it is not uncommon for users to abuse both drugs.

A 2014 study published in JAMA Psychiatry reported that around 80% of heroin users first misused an opioid (suggesting that prescription opioids served as the gateway drug to a "harder" and cheaper drug like heroin). On the flip side, the study said one-third of users entering an opioid treatment program reported that heroin was the first drug they abused before moving to opioids (often because drugs like oxycodone are considered more "likable" with fewer perceived negative effects).

Women at Risk

While men are more likely in general to abuse drugs than women, the opioid epidemic is unique. According to the National Institute on Drug Abuse, women are far more likely to misuse prescription opioids to self-treat medical conditions such as anxiety or tension.

This has translated to increased rates of hepatitis C in women of childbearing age as well as the increased rates of HCV transmission from mother to child during pregnancy.

A 2016 study from the CDC reported that, between 2011 and 2014, the rate of HCV infections in women of childbearing age spiked by 22% due to injecting drug use, while the number of infants born to HCV-infected mothers increased by 68%.

Changing Face of the Epidemic

Prior to the 1990s, hepatitis C was seen mostly in Baby Boomers who were likely to have been infected due to poor medical practices at the time. The hepatitis C virus was only officially identified in 1989, while the routine screening of HCV in the U.S. blood supply only started in 1992.

Today, people who inject drugs account for over 69% of new HCV infections and 78% of the total HCV infections in the United States.

Arguably, the greatest challenge in reducing the risk of HCV in injecting drug users are the high rates of reinfection. While study results vary, there are some that suggest that up to 11% will get reinfected following a drug relapse, while no less than 26% of men who have sex with men who inject drugs will also get reinfected.

Unless current drug-taking behaviors are curbed, the effectiveness of HCV therapy and harm reduction efforts may be gravely compromised.

How to Know If You Have Hepatitis C

People who inject drugs are at greatest risk of hepatitis C and should without seek testing to determine if they have been infected. This is true for both current injecting drug users or those who have injected drugs in the past.

Chronic hepatitis C infection often has no symptoms but can silently damage the liver over the course of years and decades, leading to liver scarring, cirrhosis, and an increased risk of liver failure and cancer. You cannot "tell" that someone has hepatitis C by looking at them or checking for symptoms; only an HCV test can diagnose the disease.

As of March 2020, the U.S. Preventive Services Task Force (USPSTF) recommends HCV screening for all adults ages 18 to 79. The CDC also updated their guidelines in April 2020, recommending screening for all adults and pregnant women.

Formerly, the USPSTF recommended HCV screening for persons at high risk of infection and endorsed a one-time screening for adults born between 1945 and 1965. The task force updated their recommendations in part given the introduction of newer, highly effective hepatitis C drugs.

There is a rapid test available that screens for HCV antibodies in the blood. (Antibodies are proteins produced by the immune system in response to a disease that pathologists use to identify a virus.) The test can be performed on-site without the need for a lab technician and can return results in around 20 minutes.

A negative test result means that you have not been infected, while a positive result means that HCV antibodies have been detected. Although rapid tests are highly sensitive, there is a risk of false-positive results. To ensure a correct diagnosis, a confirmatory test—either an enzyme-linked immune assay (EIA) test or a polymerase chain reaction (PCR) test—would be performed if a rapid test result is positive. The chance of a false positive following this two-step approach is highly unlikely.

In addition to HCV screening, injecting drug users would be advised to undergo screening for HIV and the hepatitis B virus (HBV) due to the increased risk of infection in injecting drug users.

Treatment of Injecting Drug Users

If a positive test result is confirmed, you would be forwarded to the appropriate clinic or health practitioner for further testing and treatment. The testing would include liver function tests and an ultrasound to evaluate the status of your liver. The doctor would also determine the genetic type (genotype) of your virus so that the correct drug treatment can be delivered.

In recent years, a slew of highly effective drugs—called direct-acting antivirals (DAAs)—have been approved for the treatment of chronic hepatitis C infection, offering cure rates of up to 99% in as little as 12 to 24 weeks of treatment.

All patients with virologic evidence of a chronic HCV infection should be considered for treatment. That means patients with a detectable HCV viral level over a six-month time period. Those with a limited life expectancy of less than 12 months may not be considered for treatment.

There is no impediment to the treatment of hepatitis C in people who inject drugs. Although a high degree of drug adherence is needed to achieve a cure, having an opiate addiction neither excludes one from treatment nor suggests that a user cannot adhere to treatment.

In fact, compared to older hepatitis C drugs, newer-generation DAAs are ideal for use in opioid drug users. They can be prescribed in tandem with buprenorphine or methadone (two drugs commonly used to treat opiate addiction), neither causing interactions nor requiring dose adjustments.

Even so, many doctors remain reluctant to start treatment, due not only to adherence concerns but also the high rates of psychiatric illness in active drug users (especially younger users).

To this end, a multidisciplinary team of clinicians, psychologists, and addiction specialists may be needed to assess an individual’s readiness to start treatment. The current body of evidence suggests that the outcomes are generally good even among current drug users.

According to a 2017 review published in the World Journal of Gastroenterology, injecting drug use is not associated with reduced HCV cure rates, and the decision to treat should be made on a case-by-case basis.

Prevention and Harm Reduction

Receiving a negative HCV diagnosis does not mean that you are in the clear. While it is true that you have not been infected, you remain at high risk of hepatitis C, HIV, hepatitis B, and other bloodborne diseases. Injecting drugs also places you at risk of severe bacterial infections from unsterile needles as well as drug overdose and death.

To mitigate these risks, your health provider will counsel you on harm reduction strategies, ranging from the managed use of opioid drugs to opioid treatment and abstinence. Harm reduction is a non-judgmental, non-coercive approach that helps reduce risk whether a person is actively seeking treatment or not.

Opioid Treatment

Clearly the best way to avoid getting or transmitting hepatitis C by stopping drug use. Even though this is not always easy, opioid treatment should always be considered as an option. There are different approaches to treatment, many of which are offered at low cost or no cost through Medicaid, Medicare, or private health insurance under provisions of the Affordable Care Act.

To find a treatment center near you, speak with your health provider or use the online locator offered by the Substance Abuse and Mental Health Services Administration (SAMHSA).

Other Harm Reduction Strategies

Health experts recognize that it is unrealistic to endorse abstinence as the only approach to drug addiction. Under the principles of harm reduction, it is important to accept that drug use is a part of our world and to minimize its harm rather than ignoring or condemning it.

To this end, there are several strategies known to reduce the harm of injecting drug use:

  • Seek syringe services programs. Syringe services programs (SSPs), also known as needle exchanges, are state and local programs where people can get free sterile needles and syringes and safely dispose of used ones. The North American Syringe Exchange Network (NASEN) offers an online locator to find an SSP near you.
  • Avoid sharing needles. Less ideally, if an SSP is not available and you cannot access sterile needles, you should make every effort to avoid sharing needles.
  • Learn how to sterilize injecting equipment. Needles, syringes, cookers, and other drug paraphernalia can be cleaned with full-strength bleach (no water) and rinsed with clean water. This won't entirely erase the risk of HCV or HIV, but it can significantly reduce it. (Bleach cannot be used to clean water or cotton and should never be reused.)
  • Get vaccinated for HBV. Hepatitis B can be avoided with an HBV vaccine, delivered in a series of three shots. Sadly, there is no vaccine for hepatitis C.
  • Take HIV post-exposure prophylaxis (PEP) to prevent HIV. While no vaccine exists to prevent HIV, there is a tablet you can take, called HIV post-exposure prophylaxis (PEP), that may reduce the risk of infection.

Future Strategies

In January 2018, the first legal safe injection site (SIS) in the United States was opened in Philadelphia, offering a medically supervised facility in which to inject drugs safely. Despite its proven effectiveness in reducing HCV infections in other countries, the concept is still considered radical in the United States with little support from federal or state legislators.

A federal court ruled in 2019 that the Philadelphia program did not contravene the Controlled Substances Act of 1970, paving the way for more than a dozen proposed sites in cities like New York City, Boston, San Francisco, Seattle, and Denver as well as Vermont and Delaware.

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