Medications for Opioid Use Disorders and Hepatitis C for Injecting Drug Users

Medications for Opioid Use Disorders and Hepatitis C for Injecting Drug Users


Hello, we are starting in a minute or two. I’m going to explain everything about CE and CME credits in a minute. I see
questions already about it, just hang tight, we’re going to talk about it. Okay, it’s noon, so hello everybody, I’m Bia Carlini, I’m the Northwest ATTC
coordinator for our webinar series and I also where two or three more hats at the
Northwest ATTC. And this first slide says that questions about the presentation
will be taken at the end but you can of course answer the questions at any time,
so we keep collecting them. And we also want to let you know, and we always
get a lot of questions on this, this webinar and PowerPoint will be made
available in 24 hours or so at our website which you can see in the link below. We also always make this version ADA- compliant, so you know that is something
to also keep in mind. Okay so today we are doing things a little different. Wwe
are very excited that we partnered with our colleagues from a AHEC Western
Washington. And working in partnership with them means that, especially and
specifically for this webinar, you’re gonna get certificates of attendance if you
are interested or CME, continuing medical education, through…
one credit through the American Academy of Family Physicians.
We really appreciate AHEC facilitating this process with us. What
you have to do: you have to do nothing if you are watching in your computer and
entered your email as registration, in four or five weeks we are going to get a
email with certificate. CME or otherwise. And this certificate won’t come from
us, it will come from email from AHEC, particularly with the term of the, the
part of the email is going to be whatcom.edu. So you’re gonna see this email
and it’s going to be your certificate that comes in the PDF. However if you are
watching in a group, there’s three or four of you that are watching, we don’t
have a way to send a CME certificate or CE certificates for each of you. So
in this case you need to email us. This is the mail there below, [email protected], telling us in this specific registration/email, these
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less than 24 hours — by the end of today, max by 9am tomorrow. So
please do that I’m going to repeat a little bit this information at the end. All this, is if you’ll notice that it’s not getting to you, this is a time where
people are in and out of town, so it’s going to take four or five weeks for you to
receive this. And you can email and with any questions. Without further ado,
and again I’m going to bring that topic at the end, again we are very pleased to
have our presenter today, Dr. Judy Tsui. Judy Tsui is a researcher focused on the
intersection of opioid use disorder, pain, and related comorbidities, meaning
hepatitis C, HIV, and other morbidities. Dr. Tsui is an internal medicine physician and
since 2013 is board-certified in addiction medicine to the American Board of
Addiction Medicine. As a clinician investigator, she focused on the complex
relationships between substance use disorders and comorbidities and how to
develop and test novel interventions to improve the lives of patients with
addictions. Without further ado, I — so now Dr. Tsui, you have to click on this web, on this slide. So as soon as you click in the slide, then you can move to the next
ones too, as you like. Thank you so much. Judy, we can’t hear you if you’re talking. Thank you for that introduction it’s a
real pleasure to be here. I hope you can hear me now. So I’m going to
be talking to you about medications for opioid use disorder and hepatitis C
access and adherence among people who inject drugs. So these are my disclosures
of research grant support and these are the objectives of the talk today. I’ll
describe the epidemiology of the opioid crisis and its overlap with hepatitis C
virus infection, review the evidence that medications for opioid use disorder,
which I’ll abbreviate as OUD, can prevent hepatitis C. I’ll highlight
research showing that medications for hepatitis C and OUD are
underutilized and describe some clinical programs that we have
implemented here at Harborview to address these gaps. And I’ll describe a
little bit of ongoing research to improve opiate use disorder and
hepatitis C medication access and adherence. So first I’d like to start
with some patient vignettes. These are based on real patients I’ve seen over
time and perhaps these might be familiar stories to you as well. So TS is a 60
year old man presenting for primary care. He has a history of experimenting with
heroin as a young adult. He had a back injury in his 40s and was thereby
introduced to prescription opioids. Subsequently he received high dose
opioids for chronic pain and he had multiple hospitalizations for “over
sedation” which I think we can now call overdose. His primary care provider
discontinued his opioids and he subsequently lapsed heroin use but he
started on buprenorphine a year ago and has been doing well and he’s been
recently diagnosed with hepatitis C. So this is another patient CL. She is a 20
year-old woman seen an emergency department for cellulitis. She has a
history of childhood physical and sexual trauma and consequent PTSD. At age 13
she experimented with alcohol, cigarettes, and marijuana. At age 15 she’s
introduced to prescription opioid use through a friend. By age 17 she
started snorting heroin and within a year she is injecting. She has previously
had one treatment attempt with methadone but self-discontinued. Now she’s homeless. She trades sex for money and drugs and she’s also recently been diagnosed with
hepatitis C. So I think these patient vignettes demonstrate that we are currently
witnessing concurrent epidemics of opioid use disorder and hepatitis C. So how did we arrive at this point? This
slide demonstrates the upward trend in opioid prescribing that has been
occurring from since 1999 to here. The slide goes to 2010. And the nearly
parallel trends and increased hospitalizations and overdose that have
occurred. So the good news is that since 2012, opioid prescribing rates have
peaked, however they remain high at nearly 60 prescriptions written per
hundred persons. Also rates vary tremendously by geographic region. One
alarming statistic is that in 16% of US counties, enough opioid prescriptions
were dispensed such that every person could have one. We conducted a study
prior to 2010 that showed that among patients who were presenting for
treatment for opioid addiction, 29% reported that they were introduced to
opioids through a physician’s prescription. So there’s now considerable national
attention to the origins of the opiate crisis and the role that the
pharmaceutical companies have played in promoting sales of opioids for chronic
pain as well as the role physicians have played in overprescribing. In addition,
increasing availability of heroin and diverted pharmaceutical opioids have
contributed to opioid crisis. So although opiate prescribing rates have peaked
since 2012, the bad news is that deaths related to opioids are unfortunately
still increasing. So this slide shows overdose-related mortality by gender, and
as you can see there is no slowing of deaths in recent years. If anything there
is an increase in the rate around 2015 which is believed to be related to an
increase in fentanyl availability. So the other major consequence of the
opioid epidemic that has emerged over time is increase in infectious
disease related to injecting drugs. The first instance of this that caught
the attention of the public eye occurred in 2015 when, in a small rural county in
Indiana, they reported a cluster of eleven new cases of HIV. So an
investigation eventually found 181 cases total, nearly all who were also infected
with hepatitis C, that were related to injecting a prescription opioid named
Opana. So since that initial outbreak in
Indiana there have been subsequent HIV outbreaks associated with injecting
drugs reported in northeastern Massachusetts and just recently here in
Seattle as a consequence of the opioid crisis. There’s actually been a shift in the epidemiology of hepatitis C, with an
increase in cases among young adults and in rural areas. And so this was first
reported in this paper in CID [Clinical Infectious Diseases] in 2014. So the authors examined national
surveillance data of acute hepatitis C cases between 2006 and 2012. They found
that nearly half the cases occurred among young adults, and the majority of
states reported an increase in 2012 compared to 2006. Of note, most cases were
white and nearly half were women, which represents a shift in demographics as
historically there’s been a predominance of hepatitis C among non-whites and men. So in Massachusetts, the state where I
practiced prior to moving to Seattle five years ago, they have been very hard
hit by the opioid epidemic and as a result they have seen a shift in age
distribution of cases with hepatitis C, as witnessed in this figure. In 2002 most
of the cases were concentrated among older adults, which we call the “Baby Boomer” generation, but by 2009 as you can see there’s a bimodal distribution of
prevalence with cases nearly equally distributed between young adults and
Baby Boomers in Washington State. We have recently witnessed an increase in cases
of hepatitis C as well, believed to be driven by both these new infections and
young adults as well as increased diagnosis among the Baby Boomer
generation as a result of enhanced screening efforts. So these are data that
were recently presented in a story in The Seattle Times. So we’re really at a crossroads in time
now, where the magnitude of the current opioid crisis and its infectious
disease consequences have become abundantly clear, and yet we have the
tools to overcome this crisis. So next I’ll talk about medications for opioid
use disorder and hepatitis C. So the good news is that we have a number of
different medications that are efficacious for treating opioid use
disorder. So those medications include methadone, which is obviously not new and
has been available since the 1950s. It’s a full opioid agonist and is therefore
highly efficacious but it has greater risks for side effects such as sedation
and overdose compared to the other two medications. And its other limitation
is that it cannot be prescribed in office based setting, but must be dispensed
in federally regulated OTPs. So the fact that it’s dispensed as daily observed
therapy in the OTPs can be viewed both as a therapeutic advantage but an
inconvenience to patients. Buprenorphine is a partial agonist approved in 2003. It
binds tightly to opioid receptors that have ceiling effects such that
patients experience less adverse side effects. Naltrexone is an opioid
antagonist and it fully blocks opiate receptors with no opiate effects. It is
available as an injectable called vivitrol which was FDA approved in 2010
I should note that the buprenorphine is mainly prescribed these days as
a sublingual medication, however injectable formulations just became
approved this year but they’re not really widely used as of yet. So these
medications have been shown in numerous studies, including our randomized control
trials, to decrease opioid craving and use, overdose and mortality, HIV risk
behaviors, and HIV and hepatitis C incidence. So next I’ll review evidence to demonstrate that opioid antagonist therapy can prevent
hepatitis C. So this is a paper that I wrote with colleagues at UCSF while I
was a fellow there and it was looking at the association between opioid agonist
therapy and incidence of hepatitis C virus infection among young adult
persons who inject drugs. So the study used data from the UFO study, which was
an observational cohort study of young adult injectors in the San Francisco
area, and they were enrolled and followed between 2000 and 2013 so participants
were hepatitis C uninfected and they were followed quarterly with surveys and
hepatitis C viral load testing. So the sample included 552 participants and the
median age was 23 and most participants were white males who injected heroin. The
majority reported no substance use treatment in a prior year which does
speak to care delivery gaps. So there were a hundred 71 new cases of hepatitis
C that occurred over 680 person years of observation. So we compared the incidence
of new hepatitis C infections among persons in four groups: those who
reported no drug treatment in the past four months, those who reported OA
drug treatment, so that could be counseling or 12-step groups, those who
reported detoxification, and those who reported treatment with opioid agonist
therapy either methadone or buprenorphine. And as you can see, the
incidence was markedly lower among the opioid agonist therapy group compared to
the others. So adjusted Cox proportional hazards models demonstrated that
maintenance OAT was independently and significantly associated with lower
relative hazards for becoming infected with hepatitis C over time. So about
a 60% reduction in incidence. In 2017 Cochrane published a systematic review
of studies that looked at the effects of opioid agonist therapy on hepatitis C
incidence that included our study with 11 other studies from North America,
Europe, and Australia. And as you can see all the studies had strikingly similar
findings demonstrating benefits in reducing incidence of hepatitis C over
time. So that review concluded that OAT reduces the risk of hepatitis C
acquisition by 50%. However this was based on 12 observational studies, not
randomized controlled trials, therefore they did say that the quality of the
evidence was still low. We published a subsequent study that suggested there
might actually be an attenuated effect in females compared to males. So in
considering the economic implications, I would like to point out that the cost of
treating opioid use disorder is relatively inexpensive compared to the
cost of treating hepatitis C. So both methadone and buprenorphine are priced
and around six thousand dollars per year of treatment and contrast the sticker
costs for treating hepatitis C with a sofosbuvir-based regimen is
about eighty four thousand dollars, although admittedly the price of
hepatitis C meds has come down now that there are multiple regimens on the
market. But it’s also worth keeping in mind the additional cost savings that
occur with opiate use disorder treatment and preventing overdose, injury, other
infectious complications such as osteomyelitis, endocarditis, etc. So I
think when framing it as such it becomes obvious that’ll be a used to certain
treatment is a worthwhile investment. But I don’t want to downplay the importance
of new medications for hepatitis C. So now we’ll shift gears to talk about
the recent revolution in hepatitis C treatment. So the emergence of
direct-acting antivirals, or DAAs, has radically changed the Hep C
treatment paradigm. Sofosbuvir was the first DAA to come on in the scene in 2013
but now there exist multiple regimens including medications that will treat
all genotypes or pan genotypic. So we’ve really reached a new era where nearly
all patients can be cured of hepatitis C with just 8 to 12 weeks of oral
medications with few side effects. So this slide shows how radically different
treatment today looks like compared to treatment during the interferon era
where patients had to take weekly shots in addition to daily pills and most
patients had side effects and at the end of the day there was only a 50/50 chance
of being cured. So you might or might not be aware that in the fall of 2018, Governor Jay Inslee announced a statewide initiative to eliminate
hepatitis C. So this is a photo of him in the Harborview liver clinic
with a patient. So the name of that initiative is Hep-C-Free Washington. So this is not just a statewide goal as
WHO has also announced the same ambitious goal to achieve hepatitis C
elimination globally by 2030. And there’s overwhelming consensus that treating
active persons who inject drugs is essential for achieving that goal. So
treating the baby boomer generation is the most effective strategy for reducing
immediate complications related to hepatitis C,
such as cirrhosis and liver cancer, and there’s related costs but for reducing
incidence and prevalence over time we must focus on treating the individuals
who are responsible for transmission. So this concept of
treating infected individuals to reduce incidence of new infections over time, ie
treatment as prevention, is something we saw proven for HIV. This slide
shows data from colleagues in Vancouver Canada. The red line depicts the number
of patients with HIV who are on ART, while the blue line shows the number of
new HIV diagnoses. And as you can see the new infection rate is inversely
proportional to increased numbers of persons who are placed on ART. So there’s belief that treatment is prevention should also apply for hepatitis C, the rationale being that DAA cure rates among people who inject drugs appeared
to be nearly equivalent to non- PWID. And as well reinfection is thought to be
a relatively rare occurrence, and in theory theory can be prevented with
OAT and syringe service programs. However admittedly more real-world data is
needed on reinfection rates and to demonstrate treatment as prevention for
hepatitis C. So the current guidelines from the American
Association of the Study of Liver Diseases and the Infectious Disease Society
of America are very clear that all persons with chronic hepatitis C should
be treated and they even state that the scale of hepatitis C treatment in
persons who inject drugs is necessary to positively impact the hepatitis C
epidemic in the US and globally. So how much scale-up is needed? This slide shows
data from a modeling study that looked at how differing rates of treatment
among PWID would impact future prevalence. So what I’d like you to
appreciate is that even relatively small differences in the
numbers treated, say going from 20 to 40 persons per thousand, has a fairly large
impact on future prevalence. So extending treatment to even small numbers of PWID
can apparently make a big difference. So I hope I’ve convinced you that there are
highly efficacious medications that can impact these concurrent epidemics of
opiate use disorder and hepatitis C. But the question is are patients who are
eligible for these medications able to receive them? So next we’ll review the
evidence on treatment delivery gaps and some programs that we have implemented
at Harborview to address. So my colleague Sara Glick and I conducted a study to
examine the prevalence of reporting treatment with opioid agonist therapy, ie
either methadone or buprenorphine, among people who inject drugs in the Seattle
metropolitan area. So the study used 2015 data from NHBS which is a
survey of HIV prevalence and behavioral risks that’s conducted annually, with
every three years being focused on adult PWID. Because the national survey asked
only about any treatment for addiction in the past year we added questions to
our local survey that focused specifically on use of either buprenorphine or or methadone. So the sample was comprised of 487 persons who injected
drugs who reported opioid use. Of those the vast majority, 70%, reported no past
year treatment with either methadone or buprenorphine, speaking to major
treatment gaps. The treatment that was more frequently reported was methadone:
27 reported past year treatment. At this time in 2015, only five percent reported
past year buprenorphine treatment and twice as many reported that they tried
buprenorphine treatment but were unable, speaking to barriers. So we
used the same 2015 data set to explore access to treatment for hepatitis C
among persons who inject drugs. This is what we found the cascade of care for
hepatitis C looks among the Seattle area PWID. Starting with a sample of 338
persons who inject drugs who were hepatitis C antibody positive, we found
that the majority of them reported having previously been screened and
being aware of their diagnosis, which is good news. The bad news is that only 7%
reported ever having completed treatment, speaking to major gaps. Iit is of course
important to note that the data from the study were collected in 2015, so this was
only two years after the arrival of the first DAA, sofosbuvir. Data from 2018
are currently being analyzed and it will be interesting to see how this has changed. So those results I showed you work for
active PWID, the majority who are probably not engaged in care. You might
wonder if the cascade would look different for persons who are actively
engaged in addiction treatment in primary care, so we did a study to map
out the Hep C care cascade among patients who are receiving buprenorphine
treatment in a primary care clinic at Boston Medical Center, and sadly the care
cascade did not look dramatically different. We found that similarly many of those patients had received testing, but very
few were treated: only 2% of those with chronic infection had initiated
treatment, even though nearly 50% of those diagnosed had seen a specialist. Again admittedly this is pre DAA era data, so it will be important to see
how this changes in the DAA era. So next I’ll turn to describe some
current programs that we have implemented to address opiate use
disorder treatment gaps, but first we need to understand the reasons for such
treatment gaps. We know that there are substantial barriers to treatment, both
on the provider and patient side. To prescribe buprenorphine requires
completing an 8-hour training and applying to the DEA for special license,
and this in itself is unfortunately a barrier. Currently there’s some federal
legislation pending that removes requirement, but for now it exists. Historically of course only physicians can prescribe buprenorphine, although
recently that has changed to allow nurse practitioners and PAs to prescribe. There
has been a lack of training of medical students and residents to prescribe in the
past and also the stigma of opioid use disorder makes some physicians
disinclined to take on caring for this patient population. We also know that
even well-intentioned providers who do get waivers often don’t prescribe and
studies cite lack of time and clinic infrastructure support as as well
as fear of medication diversion as barriers. In January 2016,
prior to fully implementing our office based buprenorphine program, we conducted
a survey to assess interest in prescribing buprenorphine among
providers in our adult medicine clinic at Harborview. So we surveyed 27
residents and 17 attendings and found that at that time the majority,
eighty-nine percent, did not have waivers to prescribe but that many, 67 percent,
had high interest in prescribing. So younger age and belief in buprenorphine
effectiveness were significantly associated with high interest in
prescribing, speaking to the need to target younger resident providers. So responding to younger physicians’
desires to become buprenorphine waivered, we implemented a program for training
medical students to prescribe buprenorphine with support from SAMHSA. So
we just completed the trainings for medical students and are very pleased to
say that we surpassed their goals with 16 medical students, who as you can see
are bound for many different residency programs after graduation. Through
surveys that we did pre and post-training, we found that student
confidence increased from 21 to 90 percent with the training and nearly all
these students plan to obtain their waiver, although we’ll continue to track
them to see how many actually follow through and prescribed in their
residency. So we have residency trainings that are planned for this summer and
have trained most of our residents at Harborview today. So next I’d like to
tell you a bit about our buprenorphine program that we implemented around
January 2016 at Harborview and also share some outcome data from our program. So we partnered with the state and Evergreen Treatment Services, receiving a
grant from SAMHSA to implement a collaborative care model for office
based buprenorphine treatment, at the adult medicine clinic. And as you recall,
a major barrier for primary care providers to prescribe buprenorphine is
cited as a lack of time and clinic support. So we adopted this collaborative
care model that uses a nurse care manager as the center of clinical
activities that was originally pioneered at Boston Medical Center. So we’ve had
some great success with that model and have subsequently acquired new funding
to expand this program beyond the adult medicine clinic. So those of you
who might be interested in more description of the Massachusetts collaborative
care model and other models of delivery of care, I’ll refer you to this excellent
review article that was published in the Annals of Internal Medicine in 2016. So this slide shows substance use outcomes
of 422 patients who were treated with buprenorphine through our MAT-PDOA,
our buprenorphine program, from 2015 to 2017. The slide compares past 30 days
substance use at baseline versus six months among patients and as you can see
there are impressive declines in the use of opioids and even other non opioid
drugs in the treated sample. So any opioid use went down by 73% and even
methamphetamine use went down by 56%. So furthermore there were significant
differences in acute healthcare utilization at six months. The percentage
of patients reporting an emergency department visit or hospitalization in
the past 30 days went down, and differences between baseline and six
months were significant. Unsurprisingly outpatient treatment went up, since this
care is offered in an outpatient setting, and also we hope that by engaging
patients in opioid use disorder treatment they’ll address other health
issues such as their hepatitis C. So in addition to provider-related barriers we
must acknowledge patient-level barriers. So one such barrier is that most
patients with substance use disorder do not perceive a use disorder and do not
seek treatment. As a result it becomes critical to offer opioid use disorder
medications in medical contexts where patients with opioid use disorder
being seen but where treatment has not historically been offered. So two such
examples of that are the emergency department and the hospital inpatient
setting. So studies have shown the benefits of offering buprenorphine in
both these settings and currently we have
efforts underway at Harborview to provide buprenorphine in both the
emergency department and also for hospitalized patients. So I’m going to
tell you a little bit more about that paper that looked at the impact of
offering buprenorphine among hospitalized patients, since that’s
was a study I was also involved with in Boston. So that study recruited
hospitalized patients with opioid use disorders, so either heroin or
prescription opioids, who were not already in addiction treatment. And it randomized
patients to receive either linkage, which was induction with buprenorphine followed by a
prescription to urge them to an outpatient appointment, or detox, which
was induction with buprenorphine to manage just the acute withdrawal
followed by a taper over five days. So that study enrolled 139 subjects and had
a six-month follow-up period and the study found that patients in the linkage
compared to detox were more likely to enter outpatient treatment and they
were more likely to be retained in outpatient treatment at six months, although as you can see, the retention rates were quite low even in the linkage
arm, and they were significantly less likely to be using illicit opioids at
six months by self-report. So another important reason for the medication
treatment gap that I’ve already alluded to are the suboptimal rates of adherence
and retention. So this is particularly a problem for buprenorphine compared to methadone. Methadone has been shown to have better retention in studies. And in
fact we saw this in the earlier study that I presented to you that showed, that
looked at self-report of treatment with methadone or buprenorphine in the past
year among people who inject drugs. So in that study we asked participants who had reported treatment how long they had been treated in the past
year, and we found that among those who reported methadone treatment, the
majority had been on medication for more than six months, which is good, which is
maintenance treatment. But for buprenorphine it was the opposite: most
individuals who had been treated reported that they received medications
for three months or less. So studies suggests that about 50% of patients who
initiate buprenorphine will drop out within six to 12 months and this is data
from our program showing that we’re just average in this respect. So clearly
there’s a lot of room for improvement in this area. So next I’ll talk a little bit
about research studies that test novel healthcare interventions to improve
adherence and outcomes for patients with opiate use disorder and hepatitis C. So this is a recently published study
that’s looking at intensive models of hepatitis C care for people who inject
drugs who are also receiving opioid agonist therapy that was conducted by
colleagues out in New York City. So the study recruited Hep C positive adults in
three OAT programs in the Bronx and it randomized patients to receive either
directly observed therapy, so these were actually methadone clinics, group therapy,
or self administered individual treatment, which was just treatment as
usual, patients taking their medications on their own. And so the study measured
adherence to medications through the use of electronic blister packs. So this
figure shows the adherence rates to hepatitis C medications over time and as
you can see the treatment as usual, the self direct self administer treatment,
had the lowest rate of adherence and it appeared to diminish over time so that
towards the end of the study or the end of treatment only about 75% of their
doses were being taken. But the study did show that there were very high cure
rates in this population. So SVR stands for “sustained virologic
response” and as the measure of hepatitis C cure, that’s being undetectable all 12
weeks after the completion of treatment. And as you can see the SVR rates in the
three arms range from 90% to 98% so nearly everyone is getting cured. So the
study concluded that DOT was associated with slightly better rates of adherence
and actually adherence was found to be significantly associated with likelihood
of care, however all models of care, even the treatment as usual, resulted in very
high rates of cure 90 to 98 percent and the overall appearance rate in the state
was 78 percent. And given that 94 percent of that the sample was cured
it suggests that lower adherence might be tolerated with hepatitis C treatment. So what about opioid use disorder
medication adherence? I told you that retention is poor. There are also some studies to show that non adherence to medications is quite
common with buprenorphine. One study suggested that 30% of doses were not
taken, and that study did show also that non-adherence correlated with illicit
opioid use. So we have a study that was funded by NIDA to pilot and test an
adherence app for buprenorphine treatment. So this app allows patients the
chance to upload videos of themselves taking their medication which can be
reviewed later in a provider portal. So we just completed phase one which was
a qualitative study and a pilot feasibility study, and I’ll tell you a
little bit about those results. So we first just did a qualitative study to
look at provider and patient perspectives on barriers to buprenorphine
adherence and also the acceptability of video directly observed therapy to
enhance adherence. So these are some quotes from patients, what they said
about adherence. “Sometimes I’ve forgotten in the afternoon when you’re busy not
really thinking about it. There’s been times that I’ve just said throughout the
day, hey I forgot my to take my suboxone.” So there did seem to be some
unintentional forgetting however another patient said this and these are his
words not mine: “It’s just because us addicts, whether everyone else wants to
admit it or not, we like to get high and taking the medicine we can’t get high
if we’re taking it like we should. That’s why I wouldn’t want to take it
all the time.” So the response to the idea of video directly observed therapy
was generally favorable. Here’s one patient, quote, “The suboxone program in
general relies a lot on trust and communication between the patient and
provider or providers, you know, so I think that would be good. Everybody could be on the same page. They feel good about it, especially when
you’re changing doses or have had maybe problems in the past staying on the
program. I think it would help hold people accountable.” So given that generally positive
response, we conducted a small pilot feasibility study that enrolled 14
subjects to use the app for four weeks. And from that study we found that all
participants but one were able to successfully upload videos. Most, 10 out
of 14 of the participants, reported that they were satisfied or very satisfied
with using the app. 2 out of 14 were more neutral but none were dissatisfied. And
for those who were able to use the app, daily buprenorphine treatment was
confirmed through videos 73% of the time. So the results of these this study
suggested that use of a smartphone app to allow at home video directly observed
therapy of buprenorphine treatment is both feasible and acceptable. So now
we’ve moved on to phase 2 which is a two site
randomized control trial of using the app versus treatment as usual. That’s
being conducted at Harborview and at Boston Medical Center. So we’re in the midst of enrolling subjects for that study right now, and we’re
having the participants use the app for 12 weeks and looking at our primary
outcome of illicit opiate use measured by percentage of weekly urine drug tests
that are positive for opioids. We’ll also be looking at retention in treatment as
well, as another important outcome. So summary, conclusions, the epidemics of
opioid use disorder and hepatitis C virus infection are closely intertwined,
elimination of hepatitis C is a state national and global priority and it
requires treating persons who inject drugs. Efficacious medications exists for
both opioid use disorder and hepatitis C and yet are underutilized by patients
who might benefit. Numerous programs have been developed at University of
Washington and Harborview to address opiate use disorder and housing
treatment gaps and at other other places as well, and we have ongoing research that’s
testing whether an m-health intervention for video DOT can improve outcomes. So I’d
like to acknowledge my community partners and the research that I’ve
shown you and in particular I want to thank all the patient participants; we
could not conduct this research without their support. I also want to acknowledge
our office based opioid treatment team at Harborview and we’ve grown quite a
bit so this slide is not nearly as complete as it should be. And then I guess I’ll take
any questions now. Yeah so before questions let me say thank you so much
Dr. Tsui, that was very very good and before we take questions, we always like
to remind the participants today that we can offer this services like this
wonderful webinar if we report to our funders your input. so we get better
and we keep being able to provide this service. So, please we’re going to send two short
surveys, one now and one in a month, for you guys to respond. We really appreciate
your honest feedback and mostly your feedback anyhow! You are
going to receive a small compensation for five dollars when you respond to these surveys. Reminding again we are lucky this time to be partnered
with AHEC Western Washington. This webinar is eligible for CME credit. People that do not use CME credit can use it as
a certificate of attendance to get continuing education credits in the way
that works for them. You don’t have to do anything they will be emailed to you in
few weeks. However if you are watching this as three people watching the front
of the same computer with one email on registration, the only way we are gonna
know you’re more than one person is if you email to us the email address
attached to your registration and the people attending to the address in this slide. We’ll ask you to do this by 9:00 a.m. tomorrow Pacific time. Okay so we are now open for questions, you can type at any time. I gonna have a
first question here. So, Dr. Tsui, are there are any interactions between
hepatitis C medications and medications for opioid use disorders that we should
be concerned about? No there are not. As I showed you there are studies that have
demonstrated that people who are on methadone and buprenorphine can have
excellent treatment outcomes and it’s safe to use the Hep C meds with those
medications. There are some interactions with other drugs such as PPIs, seizure
medications, statins, so I think if you have a patient who’s on other
medications it’s always a good idea to check in with the pharmacist, either
where you’re you know getting the prescriptions from or a pharmacist in
your clinic just to make sure that there aren’t any interactions that you need to
know about. Okay thanks there’s a question here, saying very nice research, I
know this is not directly relevant to your presentation but what observations
incidental or otherwise have you had regarding kratom, which many people who
misuse opioids attribute to their recovery. Oh my goodness you know I think that’s
actually out of the scope of my expertise, so I think I will refrain from
commenting. Not a problem whatsoever and the question is really
already framed that this might be really different from what kind of expertise
and research you do. Okay let’s try another question, thanks so much,
can individuals who fail treatment or get reinfected with HCV get treated
again? Yes we do have medications for patients if they fail initial
first-line regimens and you know patients who fail because they had
interruptions or discontinued their medications they can also be treated
again with the same medication. So yes failure does not mean that a patient
cannot eventually get cured. Very good, thank you. Is this question here. Meg, in the middle or I think a question got cut off in the middle? We’re going to go to another question I have, but there’s a
Paul Costello, I think it cut in the middle. So, another question: how do you approach treatment for HCV
for someone who is actively using drugs? Some important things to counsel
them about? Yeah so I think it’s important to counsel them on of course
safe injecting behaviors, so to make sure that they’re not sharing any
injecting equipment, syringes, needles cottons, everything while they’re
going through treatment so they don’t get reinfected. It’s also important to
counsel them that they don’t reuse their own equipment, if they’re using
while during treatment because potentially you know the virus can live
in syringes for up to three weeks and they could sort of reexpose themselves
during treatment. Of course you know we want to offer as much support as we can
and encourage patients to receive treatment for their use disorder if
they’re willing to do that, so offering the buprenorphine or methadone or other
medications is important even if it’s just during treatment, if they are
feeling ambivalent about long term treatment. It’s of course important to
address all the psychosocial factors as well. For patients who are homeless this
might be challenging and you know efforts should be made to house them. At
Harborview we have a respite program and actually understand that they have just
made arrangements so that patients who are homeless who they need, they think
will have strong likelihood of not being cured otherwise, can be admitted to
that program for their treatment . So it’s really all about trying to support the
patient so that they can successfully adhere to their many medications and get
cured and that they don’t get reinfected. Great, thanks, okay. So the question that I
thought was a question was a comment.I’m going to read a comment and then move to
a second request here. So thanks for sharing your thoughts and work. As a
hospice doctor and a CHC doctor I love seeing suboxone patients
stabilized and HepC patients get [unsure]. That was the comment. Then we
have another one, request would you mind putting a plug, which I’m doing right now,
for the the the draft Hep C Free Washington plan. It is open for public
comment for one more week. And there is a link here that
of everybody has access to see to the question to the chat. It’s at doh.wa.gov.
I’ll put an even more of a plug I’m on the Hepatitis C, the elimination committee,
that helped to put this draft together so a lot of work went into this plan and
at the same time we want to make sure that we get everybody’s opinions on and
so would definitely encourage everybody listening to take a look at it and to
provide comments as they see fit. Perfect a lot of serendipity that’s
wonderful. So we we want to remind you for that our webinar continues during the summer as well. You can join us on the next webinar on methamphetamine. And we have one more question here before we wrap up. Thank you. So
do you know if they are creating a HepC vaccine? Yeah so there is a Hep C
vaccine trial that’s going on, in fact I think that they are, they’ve completed it
and so they should be coming out with results soon. Some of the investigators
that I work with on other studies and so I think the idea is that would be another
piece that would be another component in addition to treatment and treatment
elimination that would allow us to get the incidence down to the point of
elimination, That you know like that would just be another thing that would
then hopefully prevent new infections and possibly reinfection. So yeah I would
look out for that study I think results should be fairly soon forthcoming. Great
okay so the wrapping up, I’m gonna read a comment that we want to join the comment as well as a wrap-up, thank you so much for your participation,
and the comment says great work I’m so appreciative that you took the chance on
treating this population while they are not fully into recovery because
so often this population is denied treatment for the other conditions such
as you know surgery skin grafts etc so they get so discouraged about
addressing their medical conditions. I hope we can change the culture of how
providers do is this population but more work like yours. Thank you very much.
Thank YOU, Jackie, for all your hard work and I will say you
know it is so gratifying to treat and cure patients of hepatitis C. They are so
grateful to receive this medication to get cured, you know. They know that it’s a
lot of money and a lot of investment and it really I think means a lot to this
population and then it does a lot towards you know facilitating a better
health outcomes all together. Okay thank you so much again and I hope, you attendees, to see you next month. bye bye

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