Addressing the Intersection of Substance Abuse and Viral Hepatitis CDC’s National Hepatitis Coordinators Conference San Antonio, TX January 28, 2003 H. Westley Clark, M.D., J.D., M.P.H. Director, Center for Substance Abuse Treatment (CSAT) Substance Abuse and Mental Health Services Administration (SAMHSA)

and Hepatitis C

Background: Hepatitis C in the United States The leading cause of chronic liver disease 4 million are estimated to be infected in the United States with 25,000 deaths annually Alter, M.J., Kruszpn-Moran, D., Nainan, O.V. et al, 1999

Background Estimates from various studies indicate that as many as 80% of injecting drug users (IDUs) are HCV+ within first year of injecting drug use and 90% of all users are chronically infected.

Background Liver Transplantation 17,300 patients were on the OPTN national patient waiting list as of October 11, 2002 Only 30% of the patients on the waiting list were transplanted in 2001 Hep C liver failure is leading cause of transplantation in the U.S. The expected demand for transplantation will no doubt increase in 2003 given current trends. OPTN: Organ Procurement and Transplantation Network

SAMHSA/CSAT Hepatitis C Activities Educate Opiate Treatment Program (OTP) (Methadone) staff Working with HRSA on Liver Transplantation and Methadone Issues CSAT/CDC/HRSA Training Projects HCV/SA Treatment Improvement Protocol (TIP) and related publications HRSA= Health Resources and Services Administration

Education of OTP staff on Hepatitis C Pilot Project with AATOD Onsite training sessions at Opioid Treatment Programs 60-70 treatment programs in 6-10 communities in several states AATOD= American Association for the Treatment of Opioid Addiction

SAMHSA/CSAT/CDC/HRSA Cross Training Initiative 2 day workshops on HIV, TB, STDs, SA & Hepatitis issues integration Technical Assistance for public health, substance abuse and other providers Funded contract to identify best model and funding practices for integrating HIV, hepatitis, mental health and substance abuse services.

CSAT HCV Conferences National Conferences: Regional Conferences “Drug Use, HIV, Hepatitis: Bring it all Together” co-sponsored by CSAT, NIDA and CDC Regional Conferences “Keeping it Real” in Atlanta, Georgia, May, 2001 and in Baltimore, Maryland, October, 2002 NIDA= National Institute of Drug Abuse

CSAT-CDC Collaborations CDC’s Hepatitis State Partners Conferences Presentations Website links Buprenorphine and Methadone presentation National HIV Prevention Conference, July 27-30, 2003 in Atlanta, Georgia (proposed) CDC/HRSA/CSAT joint workshop on integrated care models, Washington, DC, April 03, AATOD Conference

CSAT-HRSA Collaborations Presentation on HRSA’s HIV/AIDS Bureau Grantees meeting Aug 02 Buprenorphine physician training HIV/AIDS Providers Conference Jun 03, Orlando Working with HRSA on liver transplantation on methadone patients

Best Practice Clinical Guidelines CSAT Treatment Improvement Protocol (TIP) for Managing Hepatitis C in Addicted Patients being planned to begin in FY 2003 Classifying Skin Lesions of Injecting Drug Users A Method for Corroborating Disease (just published)

Major Themes/Issues Surveillance of incidence and prevalence of HCV among injecting and non-injecting drug users Reducing the incidence of HCV among new IDUs (especially among adolescents). Early identification and combination treatment of never treated IDUs with chronic infections and re-treatment of those failing to achieve a Sustained Viral Response (SVR), especially among African American IDUs.

Major Themes/Issues Increase HCV/HIV testing in drug treatment programs Expand present efforts to vaccinate IDUs with Hepatitis B vaccine.

Major Themes/Issues HCV treatment HIV/HCV co-infection issues Side effects of combination treatment Neuropsychiatric effects (depression with suicidal ideation) “Trigger” effects of Peg-Interferon

Major Themes/Issues Clinical guidelines on prophylactic SSRIs Stigma as a barrier to treatment and transplantation SSRIs= Selective Serotonin Reuptake Inhibitors

TIP 24: A Guide to Substance Abuse Services for Primary Care Clinicians http://hstat.nlm.nih.gov/hq/Hquest/db/local.tip.tip24/screen/TocDisplay/s/43156/action/Toc

TIP 6: Screening for Infectious Diseases among Substance Abusers http://hstat.nlm.nih.gov/hq/Hquest/db/local.tip.tip6/screen/TocDisplay/s/43971/action/Toc

Buprenorphine Information Info Center Toll-free: 866-BUP-CSAT (287-2728) Mon-Fri 8:30 AM- 5:00 PM ET Voice message off hours, reply next working day Info@buprenorphine.samhsa.gov Se habla español.

SAMHSA’s National Helpline For information on substance abuse treatment and referral: 1 800 662-HELP (4357) 24 hours/7 days a week Se habla español www.samhsa.gov

National Clearinghouse on Alcohol and Drug Abuse (NCADI) To obtain Treatment Improvement Protocols (TIPS) and other educational materials: http://www.health.org 1- 800- 729-6686 24/7 Se habla español