Hepatitis C Treatment of Active IV Drug Users Tania Dunn, RN Isabelle Gendron, RN B.Sc.

Transcription

1 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

2 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

3 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

4 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 Épidémiologie du VHC de 2003 à 2009», (2011).

5 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 Épidémiologie du VHC de 2003 à 2009», (2011).

6 Situation of IV Drug Users in Quebec An estimated 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 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.

7 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 Épidémiologie du VHC de 2003 à 2009», (2011).

8 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 Épidémiologie du VHC de 2003 à 2009», (2011).

9 Services for addiction problem in Quebec Public Services Public Rehabilitation Center (One by region (15) exception North of Quebec) Private Services Community Services Private rehabilitation Center Support Groups Public medical care (CSSS (hospital, CLSC, clinic) Private medical care Pharmacy Community Center

10 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.)

11 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 Épidémiologie du VHC de 2003 à 2009», (2011).

12 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 Épidémiologie du VHC de 2003 à 2009», (2011).

13 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 Épidémiologie du VHC de 2003 à 2009», (2011).

14 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 Épidémiologie du VHC de 2003 à 2009», (2011).

15 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»

16 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

17 Example of a model of organization of services: Collaboration between CRD Le Virage and GMF de l UMF Charles LeMoyne

18 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

19 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)

20 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 HCV Treatment on site By professionals from the clinic Inclusion if replacement therapy for 3 months No systematic exclusion if active drug users

21 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

22 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

23 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

24 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

25 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

26 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

27 Our binder used to patient follow-up

28 Our binde used for patient follow-up

29

30

31

32

33

34 Research Results

35 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%)

36 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 %

37 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

38 HCV Treatment at GMF de l UMF Charles LeMoyne: results Hematological Complications (n=16) Hemoglobin drop < (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

39

40 Questions?