Addiction Medicine & Psychiatry
First Judicial District Court/Adult Drug Court
Santa Fe, New Mexico
Debra Newman, PA-C, MPAS, MPH, has no relevant conflicts of interest to report.
In northern New Mexico, an area with one of the highest HCV rates in the nation, strategies to curb disease transmission in incarcerated populations and in persons who inject drugs are paramount to protecting public health. Harm reduction strategies such as needle exchange programs, exemplified by the one successfully implemented in New Mexico, and providing medication assisted treatment (MAT) help motivated patients who are struggling with concomitant HCV and opioid use disorders.
My Experience: HCV and Opioid Use Disorder
Where I serve as a treatment provider for Adult Drug and Treatment Court in New Mexico’s Santa Fe and Rio Arriba counties, laboratory testing for HCV is performed within the first month of entrance into drug treatment. With rare exceptions, drug court clients do not enter the system aware of their HCV status. Clients with chronic HCV infection who are in stable health are referred to specialty care for HCV treatment, and they can receive these services through one of several clinics in the community, including one that also serves the homeless population.
If clients present with opioid use disorder, they continue to receive MAT and ancillary services, including counseling, contingency management, and urine drug screens, through Adult Drug and Treatment Court. In my experience, the clients who are receiving HCV treatment or those who have successfully completed HCV treatment are more motivated to be drug free in an effort to remain successful with their HCV treatment and MAT long term. Many have lacked access to HCV treatment for months or years prior, so they often view this as a chance to be cured of HCV infection, re-engage with family, and improve their overall health. For these clients, engagement with a health system that cares makes a big difference─ providers who take the time to listen, go the extra mile when the going gets tough, and are willing to do what it takes to make life work for them. Most of these clients will also admit that they are exhausted with the burdens of an untreated chronic disease and are happy to be re-engaging with their families, obtaining steady work, securing housing and transportation, and becoming free of the ever-present stress and risks of seeking drugs on the street.
Treating Opioid Use Disorder During Incarceration
Many clients I provide care for were aware of and received antibody testing for HCV while incarcerated; some were informed of their results, but others were not. However, most do not understand the meaning of HCV antibody testing, and none was offered MAT while incarcerated, prompting continued opioid use. Many also sought illicit buprenorphine, which studies have shown is used to avoid withdrawal symptoms in many cases. However, in some jails in New Mexico, the fear of illicit trading and use of buprenorphine has driven staff to instead provide long-acting naltrexone to incarcerated individuals with opioid use disorders. Other states, such as Rhode Island and Massachusetts, have embraced a more thoughtful approach, affording clients the option of all 3 FDA-approved therapies: buprenorphine, methadone, and naltrexone. Some studies have demonstrated that individuals are at a higher risk of overdose death after discontinuation of naltrexone, suggesting that buprenorphine and methadone may be safer options.
A significant lack of understanding exists among jail and prison system employees, from frontline correctional officers to wardens, regarding substance use and HCV. Educational programs on research findings and best practices regarding substance use disorders, MAT, and HCV treatment need to be implemented to reduce stigma of these disorders and improve the quality of care.
More than 50% of people who use illicit buprenorphine with a documented opioid use disorders had never been prescribed buprenorphine as determined by review of the New Mexico Prescription Monitoring Program. As a large, mostly rural state, access to care is an ongoing challenge; the need for access to all MAT options in New Mexico jails and prisons cannot be overstated. Would we deny hypertension or diabetes medications to incarcerated clients? By withholding MAT, we are asking our clients to do their best to manage an untreated chronic disease on their own—in my opinion, this is reprehensible, shameful, and not in line with best practices.
The Way Forward
Clients with documented chronic HCV infection should be informed of the treatments available today for HCV that require only 8-12 weeks of medication, with cure rates of more than 95%. HCV practitioners can also participate in the effort to expand MAT services. Through networks such as the Providers Clinical Support System, HCV providers with new X waivers can get the assistance they need to coprescribe buprenorphine with HCV therapy. There is also the Clinical Consultation Service from the STD Clinical Consultation Network that provides a range of expert advice on substance use disorders, HCV, and more. Finally, through Project ECHO in New Mexico, practitioners can gain valuable assistance on addiction, psychiatry, and HCV, as well as other chronic diseases.
In my experience, clients seen through Adult Drug and Treatment Court who are treated for their HCV remain more motivated to adhere to MAT, with fewer relapses in drug and alcohol use, are less depressed and anxious, have improved sleep, and have fewer symptoms of posttraumatic stress disorder. Looking toward the future, eradication of HCV in motivated patients with a concomitant substance use disorder will protect public health and lead to brighter futures for patients, families, and communities.
What is your approach to managing substance use disorder in patients with HCV? Answer the polling question and enter your thoughts in the comments section below. For more in-depth discussion on HCV elimination among individuals who are incarcerated, watch this CME/CE-certified interactive video featuring my colleagues Matthew J. Akiyama, MD, MSc; Anne Spaulding, MD, MPH; and me discussing this important issue.