This article is more than 5 years old. Information may no longer be current.

Millennials, Drugs and HCV

Issue: July/August 2014

Add topic to email alerts

Receive an email when new articles are posted on

Please provide your email address to receive an email when new articles are posted on .

Subscribe

Added to email alerts

You've successfully added to your alerts. You will receive an email when new content is published.

Click Here to Manage Email Alerts

You've successfully added to your alerts. You will receive an email when new content is published.

Click Here to Manage Email Alerts

Back to Healio

We were unable to process your request. Please try again later. If you continue to have this issue please contact customerservice@slackinc.com.

Back to Healio

A surge in injection drug use is shifting the epidemiology of HCV. In recent years, the number of new cases of hepatitis C virus among people younger than 30 years has increased at an alarming rate. A shift in patterns of injection drug use appears to be driving the changes in HCV epidemiology.

The upsurge in new cases has been observed in US states including Alabama, Colorado, Connecticut, Georgia, Indiana, Massachusetts, New York and West Virginia, among others. HCV infection among injection drug users is increasingly reported in suburban and rural settings, whereas, traditionally, infection has largely been concentrated in urban areas, according to data from Morbidity & Mortality Weekly Report.

Over the last 15 years, we saw a resurgence in injection drug use, which is the predominant way people become infected with HCV in the United States. In particular, this resurgence has resulted in many cases of HCV among young people, Arthur Y. Kim, MD, director of the Viral Hepatitis Clinic at Massachusetts General Hospital, told HCV Next.

Arthur Y. Kim

The numbers are sobering. In terms of newly reported cases of HCV, of course we see a lot of baby boomers, but there is almost an equal number of people younger than 30, Kim said. The vast majority inject heroin.

The difficulty in reaching young people with HCV who inject drugs is just one part of the problem. Untangling the myriad cause-and-effect relationships of injection drug use and infection that plagued the HIV community has raised ongoing concerns in the HCV community. The question arises of whether to target the drug addiction first or reduce the pool of infected individuals first, or a combination of both. The line between treatment as prevention and prevention as treatment also is blurred. Increased screening is necessary, but keeping new patients in the system, often emotionally unstable patients with psychiatric disorders that fuel the addiction, will create a whole new set of difficulties.

An Emerging Trend

Surveillance data from Massachusetts put the spotlight on the growing number of young people who inject drugs newly infected with HCV (see Figure).From 2002 to 2009, the rate of newly reported HCV infection among Massachusetts residents aged 15 to 24 years increased from 65 to 113 cases per 100,000 people, with more cases reported in the latter years of the study period. From 2007 to 2009, the Massachusetts Department of Public Health reported receiving 1,925 reports of new HCV infection in residents aged 15 to 24 years. The young people were from all over the state, nearly all outside of major metropolitan areas; primarily non-Hispanic white; and equally men and women, according to data published in MMWR in 2011.

Figure. Rates of newly reported cases of HCV by age in Massachusetts (2002-2009).

Source:CDC

Injection drug use was identified as the most common risk factor for HCV transmission in those aged 15 to 24 years. During the same period, state-level data indicated an increase in heroin use by adolescents and young adults in Massachusetts.

The increase in case reports appears to represent an epidemic of HCV infection related to injection drug use among new populations of adolescents and young adults in Massachusetts, Shauna Onofrey, MPH, and colleagues at the CDC wrote in the MMWR report.

In Massachusetts, where he works, Kim estimates that 1,000 to 2,000 new cases of HCV are reported each year in individuals younger than 30 years. This is a significant number, given that the population of Massachusetts is 6.5 million,said Kim, a member of the HCV Next Editorial Board. Extrapolated to nationwide numbers, Kim estimated that 178,000 people tried heroin for the first time in 2011. The sheer magnitude of this is substantial.

After the Massachusetts data were published, similar data emerged soon after from other states. Recent findings in MMWR in April indicated that reports of HCV increased from 15 to 54 cases per 100,000 people among individuals younger than 30 years in Wisconsin from 2003 to 2012. Fifty-eight percent of people with HCV in this age group reported injection drug use.

Julie Bruneau

The body of evidence is clear. The vast majority of new infections in developed and many developing countries occur among young or new injectors of drugs, said Julie Bruneau, MD, professor in the department of family medicine and from the research center at the University of Montreal. It is estimated that within the first 5 years of injection practices, about half of the people who inject drugs will become infected by HCV.

Patterns in the Young

The drug problem in the United States is huge. An analysis of data from the National Household Survey on Drug Abuse (1979-2002) indicated that 590,000 young adults aged 18 to 29 years reported injection drug use. The rate of HCV in this cohort of young injectors is estimated at 45%.

Growing heroin use has played a large role in increasing rates of drug use and HCV infection.A May JAMA study published by Theodore J. Cicero, PhD, and colleagues concluded that the demographic composition of heroin users entering treatment has shifted over the last 50 years such that heroin use has changed from an inner-city, minority-centered problem to one that has a more widespread geographic distribution, involving primarily white men and women in their late 20s living outside of large urban areas.

Cicero, a professor of neuropharmacology and vice chairman for research in the department of psychiatry at Washington University School of Medicine in St. Louis, has been monitoring prescription drug abuse. We are starting to see that people who were previously using prescription drugs like Percocet and Oxycontin have used heroin in the last 30 days. They are turning to heroin because their prescription drug of choice is too expensive. Heroin, the alternative, is cheaper and more accessible, he told HCV Next.

Theodore J. Cicero

The result is a change in demographics, according to Cicero. He cited the prescription drug users who transition to heroin. Prescription drug users are traditionally white and from the middle class with the means to buy some drugs, he said. Heroin was traditionally an inner-city drug, but that has changed. Heroin users are now white, with college education and high-paying jobs.

This transition is of particular concern because there is a population of people taking heroin and using needles with no such history. These new users have very little understanding of the dangers associated with needles Cicero said. Moreover, their families react to the news of their addiction or acquisition of HCV with shock. The support systems are not in place. I predict that we will see a larger jump in HCV and HIV transmission in these groups, in addition to a lot of overdoses.

Larry D. Keen II, PhD, a postdoctoral fellow in the department of clinical and health psychology at University of Florida College of Public Health and Health Professions, said the day-to-day habits of injection drug users are important to monitor. If you give them unlimited drugs, they will often do them in the same room with the same people. But with an influx of new users, those tight circles are being broken. If one new person comes into the group, and that person has used needles inappropriately and is infected with HCV, this can have a big impact.

Also of particular concern, Keen said, is that the stigma surrounding injection drug use has diminished. It is becoming more accepted, he said. Needles used to be the one level where users were shamed. Now we are seeing a growth in people who are sharing and using needles. This is leading to a number of systemic diseases, not just those in the liver.

A Unique Patient Population

Experts said they believe that there is a narrow window for HCV prevention interventions that target adolescents and young adults. Risk factors other than drug-use behaviors that influence risk for acquiring or transmitting HCV may include homelessness, inadequate medical care and a lack of understanding about risk.Traditionally, young drug users have also been difficult to engage in interventions.

This presents unique challenges for education, outreach and other interventions.

HCV is oftentimes spreading among young drug injectors at the beginning of their drug trajectory, calling for innovative ways to reach them, Bruneau said.

The Wisconsin Division of Public Health conducted a pilot program from October 2012 to October 2013 that offered rapid HCV testing to clients at four agencies that provide outreach testing for HCV and HIV, syringe exchanges, counseling and other harm-reduction services to individuals with drug dependence. During the 1-year study, 1,255 people (median age, 28 years, 59% men, 78% non-Hispanic white) received a rapid HCV test; of those, 20% were positive for HCV. Fifty-three percent reported no previous HCV testing, and 10% could not remember if they were tested. Sixty-nine percent reported injecting drugs within 6 months of the test; on average, they reported injecting drugs with 5.4 people. Sixty-six percent reported sharing drug equipment, and 42% reporting sharing equipment within 6 months of testing, according to results published in MMWR in April.

Sharing drug equipment is the most important behavior associated with HCV infection and transmission.

People need to understand that other parts of the works can be infected, not just the needle, Kim said.

The risk for HCV transmission among users who share drug preparation equipment, including cotton and rinse water, is high. Moreover, adolescents and young adults appear more likely to share equipment, as their social networks are based on trust and sharing.

Need for Age-Appropriate Interventions

The basics of treating HCV begin with screening, regardless of injection drug use status, and identifying drug users of any age with HCV remains a mainstay approach, according to Jason Grebely, BSc, PhD, senior lecturer at the Kirby Institute at UNSW Australia. Interventions to expand HCV testing and assessment should be evaluated to better understand strategies that are best suited to improve HCV screening in young individuals, he said.

Jason Grebely

In February 2013, the US Department of Health and Human Services convened a 2-day meeting of federal agencies to address the emerging epidemic of HCV in young injection drug users. There, John Zibbell, PhD, from the CDC Division of Viral Hepatitis, suggested that a focus on injection processes in young people could lead to a reduction in HCV transmission. Education about safer injection practices and further understanding that all parts of the drug use process and equipment can be contaminated may lead to safer practices among new or young injectors. The HHS panel also suggested developing culturally competent messages and delivering them in age-appropriate multimedia formats to target younger populations. Jag Khalsa, PhD, MS, from the NIH, also discussed the importance of reaching young opiate users before they reach the injecting stage.

Kimberly Page, MD, MPH, professor in the department of epidemiology and biostatistics, and colleagues at the University of California, San Francisco, recommended a combination of six comprehensive measures that have not been widely researched or implemented to date, with the goal to prevent HCV transmission in young people who may be infected with HCV due to injection drug use. The measures stem from the 16-year U Find Out, or UFO Study, of injection drug users. The recommendations include: reducing sharing of drug preparation equipment; HCV screening, testing and counseling; risk reduction within injecting relationships; injection cessation and breaks; scaled-up needle/syringe distribution, HCV treatment and vaccines; and combination prevention.

Programs and interventions targeted for adults may not be successful when applied to youth. Innovative strategies that use social media outreach, for example, should be considered to engage young people, according to the National Alliance of State and Territorial AIDS Directors report, Hepatitis C and Young People Who Inject Drugs.

Additionally, the involvement of current and former injection drug users in the design of such intervention and education programs may also be beneficial, Timothy McFarlane, MLS (ASCP), from the department of family medicine at Indiana University School of Medicine, wrote in a 2011 hepatitis C cluster investigation report. Because outreach workers and treatment programs have an established rapport with persons who inject drugs, collaboration between health departments and such health care professionals may facilitate intervention efforts, he wrote.

The NIH and other groups are working to educate people in the community, according to Keen. We are talking to various participants, not just injection drug users, he said. The goal is to teach people about all of the risks involved.

The Treatment as Prevention Conundrum