Hepatitis C and Stimulant Use Disorder: Challenges and Opportunities

To the Editor—The recently published ANCHOR study by Dr Elana Rosenthal and colleagues [1] describes the effectiveness of offering buprenorphine for the treatment of opioid use disorder along with direct-acting antiviral therapy (DAA) for chronic hepatitis C together at a single center. In this observational trial, sustained virologic response was obtained in 82% of participants, and 68% remained on opioid agonist therapy at the end of 24 weeks. This is an important example of a simple, adaptable, patient-centered intervention that improves outcomes for 2, often co-occurring, diseases.

This trial builds on previous work highlighting the potential benefits of integrating treatment for substance use disorders into different healthcare settings [2]. Unfortunately, while effective for patients with opioid use disorder, this approach is not currently applicable to patients who have contracted hepatitis C due to a primary stimulant use disorder.

Stimulant use is on the rise in North America, leading to escalating healthcare costs and contributing significantly to the current overdose crisis [3, 4]. Among the many harms associated with stimulant use is an increase in the risk of contracting hepatitis C, with models from multiple illustrative scenarios suggesting that stimulant injection could be associated with as many as 9–24% of new hepatitis C cases in people who inject drugs [5]. Unfortunately, unlike with opioid use disorder, there remains no widely effective pharmacotherapy for the treatment of stimulant use disorder. Current options are limited to psychosocial supports, with contingency management programs (a behavioral approach involving the provision of rewards in exchange for urine drug screens negative for stimulants) being the best-evidenced strategy [6].

Given the relationship between stimulant use and hepatitis C, the results of the ANCHOR study suggest a number of actions that might help this high-risk population. First, while there remains no strong evidence supporting the use of pharmacotherapy for stimulant use disorder, there remains signals of potential benefit within the treatment literature [7]. Increased support for research in this area is paramount and could allow for a comparable integrated treatment approach to the one described. Second, these results ask whether the provision of DAAs might be feasible in other substance use treatment settings. For example, the Veterans Health Administration runs outpatient contingency management programs for the treatment of stimulant use disorder in 94 stations across the United States [8]. Whether the treatment of hepatitis C could be accommodated in this type of environment is worth exploring. Finally, the lack of effective treatment options to integrate with hepatitis C treatment underscores the importance of prevention. Ongoing advocacy for access to harm-reduction strategies with a proven track record of reducing risky injecting practices (such as access to sterile drug use paraphernalia and supervised consumption sites) is crucial [9].

An intervention such as the one described in the ANCHOR trial is a laudable example of a scalable strategy to simultaneously treat opioid use disorders and their related health consequences. Given the growing potential for stimulants to contribute to the burden of hepatitis C in North America, it is also a reminder of how badly new approaches to the treatment of stimulant use disorder are needed.

Notes

Financial support. P. B. is supported by a Michael Smith Foundation for Health Research Trainee Award. L. T. is supported by a Michael Smith Foundation for Health Research Scholar Award.

Potential conflicts of interest. The authors: No reported conflicts of interest. Both authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest.