Hepatitis C Treatment of Active IV Drug Users

Hepatitis C Treatment of
Active IV Drug Users
Tania Dunn, RN
Isabelle Gendron, RN B.Sc.
CRD Le Virage
Équipe TDO
GMF de l’UMF Charles LeMoyne
St-Lambert, Quebec
February 2012
Potential Conflicts of Interest
• Tania Dunn (Vertex)
• Isabelle Gendron (Merck, Reckitt Benckiser)
• Both of us have collaborated to a research
sponsored by Hoffman La Roche
Program
• Situation of IV Drug Users in Quebec
• Glance through drug users services in Quebec
• Glance through hepatitis C and treatement in
Quebec
• Example of a model of organization of
services: Collaboration between CRD Le Virage
and GMF de l’UMF Charles LeMoyne
Situation of IV Drug Users in Quebec
Source: Parent et al. « Surveillance des maladies infectieuses chez les utilisateurs de drogues par injection. Épidémiologie
du VIH DE 1995 à 2009. Épidémiologie du VHC de 2003 à 2009 », (2011).
Situation of IV Drug Users in Quebec
Source: Parent et al. « Surveillance des maladies infectieuses chez les utilisateurs de drogues par injection. Épidémiologie
du VIH DE 1995 à 2009. Épidémiologie du VHC de 2003 à 2009 », (2011).
Situation of IV Drug Users in Quebec
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An estimated 100 000 cocaine users
15% to 20% of these users are IDU
Cocaine is the most common used drug by injection
Possibility of 15 to 50 injections per day
Cocaine is the substance most frequently injected in
users aged 25 and over
• Crack/Freebase is the non injected drug the most
commonly used
Sources: -Parent et al. « Surveillance des maladies infectieuses chez les utilisateurs de drogues par injection. Épidémiologie
du VIH DE 1995 à 2009. Épidémiologie du VHC de 2003 à 2009 », (2011).
-INSPQ « Usage de drogues et prévention des infections transmissibles sexuellement et par le sang (ITSS). Cahier du
participant. » Novembre 2011.
Situation of IV Drug Users in Quebec
Source: Parent et al. « Surveillance des maladies infectieuses chez les utilisateurs de drogues par injection. Épidémiologie
du VIH DE 1995 à 2009. Épidémiologie du VHC de 2003 à 2009 », (2011).
Situation of IV Drug Users in Quebec
Source: Parent et al. « Surveillance des maladies infectieuses chez les utilisateurs de drogues par injection. Épidémiologie
du VIH DE 1995 à 2009. Épidémiologie du VHC de 2003 à 2009 », (2011).
Services for addiction problem in
Quebec
Public Services
Private Services Community Services
Public
Rehabilitation
Center
Private
rehabilitation
Center
Support Groups
Private medical
care
Community Center
(One by region (15)
exception North of
Quebec)
Public medical care
(CSSS (hospital,
CLSC, clinic)
Pharmacy
Services in Monteregie
• CRD Le Virage
– Public services
– Rehabilitation treatment
– Approches used (biopsychosocial, systemic approach,
motivationnal approach and harm reduction)
– Outpatient services (8 locations throughout the territory)
– Residential services (detoxification center for adults
(integrated program (21 days))
– Various programs (youth and adult substance abuse
programs, program in adult pathological gambling, etc.)
Hepatitis C in Canada
Source: Parent et al. « Surveillance des maladies infectieuses chez les utilisateurs de drogues par injection. Épidémiologie
du VIH DE 1995 à 2009. Épidémiologie du VHC de 2003 à 2009 », (2011).
Hepatitis C in Quebec
Source: Parent et al. « Surveillance des maladies infectieuses chez les utilisateurs de drogues par injection. Épidémiologie
du VIH DE 1995 à 2009. Épidémiologie du VHC de 2003 à 2009 », (2011).
Hepatitis C in Quebec
Source: Parent et al. « Surveillance des maladies infectieuses chez les utilisateurs de drogues par injection. Épidémiologie
du VIH DE 1995 à 2009. Épidémiologie du VHC de 2003 à 2009 », (2011).
Hepatitis C in Quebec
Source: Parent et al. « Surveillance des maladies infectieuses chez les utilisateurs de drogues par injection. Épidémiologie
du VIH DE 1995 à 2009. Épidémiologie du VHC de 2003 à 2009 », (2011).
Hepatitis C Treatment in Quebec
Models of care teams
• Hospital model
– The most common
– Usually offered by specialists
• Model frontline proximity
– Provides care in the home environment
– Very low treshold
• Model frontline family medicine
– Additional services for patients in substitution treatment
– Interdisciplinary team in one place
• Health care in prisons
– Distinction between federal and provincial in providing treatment
– Collaboration CSSS, prison and hospital
Source: INSPQ « Virus de l’hépatite C: pour une prise en charge en réseaux des personnes infectées. Module 3:
Équipe de soins pour le traitement de l’hépatite C. Cahier du participant. Novembre 2009 »
Collaboration
• Since 2001, CRD Le Virage and GMF de l’UMF Charles
LeMoyne have worked together to offer services for
the treatment of opiate addiction
– Nurses and social wokers from the CRD Le Virage
support the medical team in the care offered
– The Virage staff involved in the substition
treatment program work on the premises of the
medical clinic. On a daily basis we are the
frontline in answering to the various needs of the
patients in the program
Example of a model of organization
of services: Collaboration between
CRD Le Virage and GMF de l’UMF
Charles LeMoyne
HCV Treatment at GMF de l’UMF
Charles LeMoyne: some background
• About a third of patients followed in substitution
treatment are infected with HCV
• Very little success with the traditional organization in
hospital
– Mutual reluctance patients/specialists
– Many stops along the treatment
• Practice guidelines that do not promote treatment in
IDU
HCV Treatment at GMF de l’UMF
Charles LeMoyne: some background
• Patients under replacement therapy→time
and place ideal for treating hepatitis C?
– Often more stable period
– Existing regular medical follow-up
– Trust already established with the team
• Experience of treating some patients but not
in an organized manner (No involvment of
Virage staff but use of nursing resources made
available by pharmaceutical industry)
HCV Treatment at GMF de l’UMF
Charles LeMoyne: Research Project
• Based on the OASIS model
San francisco Organization to Achieve Solutions in Subtance-Abuse
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HCV Treatment on site
By professionals from the clinic
Inclusion if replacement therapy for 3 months
No systematic exclusion if active drug users
HCV Treatment in GMF de l’UMF
Charles LeMoyne: Research Project
• Quebec: no example like OASIS model
• Structure at UMF is in favor of this type of support
• Interest of professionals
• Little evidence: research project sponsored by
Hoffman-Laroche
HCV Treatment at GMF de l’UMF
Charles LeMoyne: Research Project
Projet goal
Assess the acceptability, feasibility and
efficacy of a systematic procedure for
handling cases of HCV in patients followed at
the methadone clinic of GMF de l’UMF
Charles LeMoyne
HCV Treatment at GMF de l’UMF
Charles LeMoyne: Research Project
•Team involved:
•5 general practitionners
•1 nurse (CRD Le Virage)
•1 social worker (CRD Le Virage)
•1 health physician community
•Project started in 2007
HCV Treatment at GMF de l’UMF
Charles LeMoyne: recruitment
• All patients were invited to an information
meeting
• Each treatment cohorte was invited to a
second information meeting
– Sharing of experiences
HCV Treatment at GMF de l’UMF
Charles LeMoyne: progress
• 2 preparatory meetings with the nurse
– General education about HCV and treatment
– First injection under direct supervision
• Self-administered medication
• Frequency of appointments according to
guidelines and side effects
HCV Treatment at GMF de l’UMF
Charles LeMoyne: progress
• Visit for replacement therapy and hepatitis C treatment =
same day
• Binder used for monitoring each patient
• At each visit:
– Self-administered questionnaire for depression (CES-D)
– Meeting with the nurse to discuss side effects and drug use, blood
tests, administrative support, case discussion with the doctor
– Meeting with the doctor : physical exam, management of side effects
and renewal of prescriptions
• Beck depression questionnaire every 12 weeks with the social
worker
• Support to the patient’s family if needed
Our binder used to
patient follow-up
Our binde used for patient follow-up
Research Results…
HCV Treatment at GMF de l’UMF
Charles LeMoyne: results
Description of participants (n = 16)
Average age (year)
43,8
Gender
Men
15 (94%)
Women
1 (6%)
Employment
7 (44%)
Mean follow-up at l’UMF (months)
66 (min.9, max. 145)
Genotype
1a
7 (44%)
1b
5 (31%)
2a
1 (6%)
3a
3 (19%)
HCV Treatment at GMF de l’UMF
Charles LeMoyne: results
• Initial acceptance: +/- 70%
– Reason for refusal (fear of side effects, no
perceived need, pregnancy)
– Younger, women
• Presence at appointments: 96%
• Adherence to treatment: >99 %
HCV Treatment at GMF de l’UMF
Charles LeMoyne: results
Treatment completed
Yes
13 (80%)
No
3 discontinued (20%) (all genotype 1+ 2 was
retreatment)
-2 no-responder
-1 suicidal ideations
Rapid virologic response (RVR) (n=16)
3 (19%)
Response at the end of treatement (n=15)
13 (87%)
Sustained virologic response (SVR) (n=15)
11 (73%) – one lost to follow-up
HCV Treatment at GMF de l’UMF
Charles LeMoyne: results
Hematological Complications (n=16)
Hemoglobin drop < 110
8 (50%)
Erythropoietine (Eprex) prescription
7 (44%)
Neutrophils drop < 0,6
6 (38%)
Filgrastim (Neupogen) prescrition
6 (38%)
Other side effects:
Prescription of antidepressants for 3 patients
No significant increase in dose of methadone or
suboxone
Questions?