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Young Suburban Drug Users Drive 'Second Wave' of HCV Epidemic
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A recent study at an opioid detoxification program in suburban New Jersey found that 41% of young heroin users were infected with hepatitis C virus.
“When you look at the HCV epidemic, there are two parts of it: one is the baby boomer part, which affects people born between 1945 and 1965,” Ronald G. Nahass, MD, president and staff physician at ID Care and professor at Rutgers University School of Medicine, told Infectious Disease News. “And now we’re now seeing a boomlet of young suburban heroin users who are being affected in large numbers and really represent a new hepatitis C epidemic.”
The study, conducted by Nahass and colleagues, was the first to estimate HCV prevalence among young people who inject drugs (PWID) in New Jersey, but its findings are consistent with nationwide estimates showing that approximately 45% of young PWID are infected with HCV.
As rates of injection drug use increase nationwide, especially among people aged 18 to 25 years, experts fear that a “second wave” of HCV is upon us.
Changing face of HCV and injection drug use
Injection drug users represent the clear majority of people with new HCV infections.
According to 2009 surveillance data, 56% of patients with acute HCV reported using injection drugs in the previous 6 months. However, researchers suggest the actual rate of injection drug use among patients with HCV is even higher. Among patients aged 30 years and younger with acute HCV infections interviewed in 2011 through 2012, 77% reported ever injecting drugs.
The high rate of HCV infection among PWID is now being compounded by an overall increase in heroin use, especially among young people. In 2013, an estimated 517,000 persons reported using heroin within the previous year. This represents a nearly 150% increase since 2007. Persons aged 18 to 25 years reported the largest increase (108.6%) in injection drug use from 2002-2004 to 2011-2013.
Furthermore, according to Theodore J. Cicero, PhD, professor of psychiatry at the Washington University School of Medicine, and colleagues, the problem of heroin use “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 geographical distribution, involving primarily white men and women in their late 20s living outside of large urban areas.”
Abuse of prescription opioids, such as OxyContin (oxycodone hydrochloride, Purdue Pharma), is closely correlated to the increase in heroin abuse among young, nonurban populations. Cicero and colleagues wrote that, for many of these users, heroin is “a cheaper and more accessible alternative to their preferred prescription opioid.” Interviews with young PWID have shown that they typically initiate substance abuse at a mean age of 13 years, transition to oral opioid use by 17 years and start using heroin by age 18 years.
Given the correspondence between HCV and injection drug use, it is, perhaps, unsurprising that the changing face of injection drug use is mirrored by the changing face of HCV. After two decades of declining rates of HCV, the number of infections nationwide began to increase in 2010, and it is an increase that is largely attributable to a rise in cases among young people. In 2006, people aged 30 years and younger accounted for 36% of acute HCV cases reported to the CDC; by 2012, that percentage had risen to 49%. Additionally, rates of HCV are increasing more rapidly among young people in suburban and rural environments than in cities. In other words, as injection drug use increases among young, nonurban populations, a new HCV epidemic is following close behind.
Princeton House findings
From Oct. 1, 2014 to June 9, 2015, 573 patients aged 17 to 35 years were tested for HCV while admitted to an opioid detoxification program at Princeton House, a psychiatric facility in suburban New Jersey. Of those, 237 (41.4%) were HCV antibody-positive.
The largest concentration of users was between the ages 22 and 29 years, and there were a handful as young as 17 years.
“It’s similar to what’s being seen across the country,” Nahass said. Nevertheless, Nahass said he was “taken aback at the sheer number.” Having worked on HIV treatment and prevention efforts starting in the 1980s, Nahass remembers the “bad days” of the HIV epidemic, and he fears for how HCV will impact a younger generation of disenfranchised injection drug users.
Among the patients tested at Princeton House, researchers found a rate of HCV genotype-3 that was more than twice the national average — suggesting a closed network of injection drug users who engage in risky behavior leading to HCV transmission, according to Nahass and colleagues.
Within a closed network of users sharing needles and other supplies, as well as potentially forming sexual relationships, disease can spread quickly. Nahass and colleagues noted that there were no cases of HIV found among the HCV–positive patients, but it is a finding that Nahass was reluctant to celebrate. He said that the introduction of HIV in the network “feels like an inevitability.”
The speed with which an infection can spread within a closed network such as this one is particularly disconcerting given the recent HIV/HCV outbreak in Scott County, Indiana, in which almost 200 HIV infections were recorded in a rural, white community of 4,200. According to Bruce R. Schackman, PhD, professor of health care policy and research at Weill Cornell Medical College, previous HCV outbreaks might have signaled what was to come.
Challenges in linking to care
The good news about HCV is that it is now easily treatable. “If you could treat the population, you could really stem the tide of the epidemic, because it’s an easy infection to treat,” Nahass said. “HIV can’t be cured and you have to take lifelong medicine for it. With hepatitis C, as little as 8 weeks of a pill a day can cure a lot of these people.”
The problem, however, is that very few people who are infected by HCV are aware of their infection, as it can be asymptomatic for many years. Of an estimated 3.2 million individuals in the United States with chronic HCV infection, only half have had an HCV antibody test, and less than a quarter have had a confirmatory HCV RNA test.
And for those people who do learn of their infection, there are barriers to treating it, especially among young populations simultaneously struggling with addiction. One of the most disappointing results of the Princeton House study was the extremely low rates of linkage to care among patients who learned they were HCV–positive. Of 187 HCV–positive patients who were further evaluated, 16 (8.6%) returned for outpatient follow-up visits and only three (1.6%) started treatment — two of whom failed to adhere to their regimen.
The study did not formally assess the reasons for failing to link to care, but Nahass believes that the lack of aftercare was a main contributor. “You can detox them,” he said, “but if you don’t have a real intense program for aftercare, which is a challenge for a lot of the detox programs,” success will be limited. “Detoxing off heroin is not a solution to the reasons they got on heroin.”
Challenges addressed by aftercare include recidivism, access to transportation, maintaining communication, psychosocial problems, and access to health care, according to Nahass and Schackman. Young people in particular may have little experience navigating the health care system. Additionally, Schackman noted that patients with evidence of recent substance use may have difficulty getting approval for treatment in some places.
“Testing alone is not enough,” he said. “If you don’t have effective linkage to care, you have in some sense wasted the effort. If you lose people in follow-up, you’re going to have to go out and find and test them all over again.”
Both Schackman and Nahass suspect that, if testing programs were complemented by care coordination programs, they would see far more success in linking patients to care. In a study of HCV testing at a methadone treatment facility, researchers found that care coordination led to 70% linkage to at least one follow-up visit. Schackman is currently evaluating the economic value of these findings.
“Clearly, there is a real opportunity to identify people who need treatment and who are unaware of their infection in some of these treatment settings,” he said. “We need to take advantage of that by better integration between the medical setting and the substance abuse treatment program setting to reach out to these younger people who are not so connected to health care settings.” – by Sarah Kennedy
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- CDC. Surveillance for Viral Hepatitis-United States, 2013. Commentary. http://www.cdc.gov/hepatitis/statistics/2013surveillance/commentary.htm. Accessed November 11, 2016.
- Cicero TJ, et al. JAMA Psychiatry. 2014;doi:10.1001/jamapsychiatry.2014.366.
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Disclosures: Nahass is a clinical investigator for AbbVie, Bristol-Myers Squibb, Janssen, Gilead Sciences and Merck. Schackman reports no relevant financial disclosures.