With U.S. hepatitis C virus (HCV) cases heavily concentrated among current and former injection drug users (IDUs), addiction specialists are in a unique position to at least steer HCV-positive individuals toward treatment for the virus. However, according to a new study based on surveys of addiction specialists, the respondents may have been well aware of the importance of treating hep C, but they tended to report subpar competency in actually guiding their patients through direct-acting antiviral therapy.
Given the vast breadth of the hep C epidemic in the United States and the limited number of specialists available to treat a considerable glut of cases, there is a movement afoot to encourage other types of clinicians, including general practitioners and nurse practitioners, to help handle the case load.
The virus is particularly prevalent among those with a history of injection drug use. Considering this fact, the authors of a study known as C-SCOPE surveyed clinicians practicing at clinics providing opiate agonist therapy (OAT) such as methadone, looking to determine how competent these health care providers believed they were in the testing, management and treatment of hep C.
“With both the opioid epidemic and the hep C epidemic, we have to get out of our traditional silos and all become public-health physicians and deliver population-health strategies,” says the study’s senior author, Alain H. Litwin, MD, a professor of medicine and psychiatry at the Albert Einstein College of Medicine in New York City. “People are just not getting treated.”
Litwin, who has been working in OAT programs for 17 years, presented the study’s findings at the 6th International Symposium on Hepatitis Care in Substance Users in Jersey City, New Jersey, in September.
Between April and May 2017, Litwin and his coauthors gave an online survey to 203 clinicians practicing at OAT clinics in various Western nations, including 82 in the United States, 16 in Canada, 92 in Europe and 13 in Australia.
Twenty-one percent of the respondents were addiction specialists, 20 percent were addiction psychiatrists, 29 percent were psychiatrists and 26 percent were primary care physicians or internal medicine clinicians. Seventy percent of them practiced in an urban setting. They managed an average of 51 IDUs and had an average of 11 years of experience in the field.
Asked whether it was reasonable to expect a psychiatrist, even one specializing in addiction treatment, to treat hep C, Litwin replied that such clinicians are in a good position to provide nonjudgmental care that will not alienate a population subject to high levels of stigma and bias. “I do think psychiatrists need to be knowledgeable about the treatments and motivate their patients, whether or not they’re going to take it on themselves,” he said. “Desperate times call for desperate measures in terms of what we’re seeing with the opioid epidemic in the United States.”
Clearly, the respondents were no strangers to the hep C epidemic and the imperative of combatting the epidemic among IDUs in particular. A respective 82 percent and 84 percent of the clinicians said testing and treatment of hep C among this population was important (these survey responses included “somewhat important,” “very important” and “extremely important”).
However, when asked for a self-assessment of their competency in this field, the clinicians revealed they were in many cases unprepared to actually engage in effective testing and treatment of HCV among their IDU patients. Twelve percent expressed below-average competence in the regular HCV screening of this population. The proportions expressing subpar competence about other related measures were as follows: interpretation of hep C test results, 14 percent; advising patients about new HCV treatments, 28 percent; knowledge of new treatments, 37 percent; and the treatment and management of HCV, 40 percent.
After adjusting the data for various factors, the researchers found that, compared with being a general practitioner or internist, being a psychiatrist was associated with a 4.3-fold increased likelihood of below-average competence in advising patients about new hep C treatments. Half of psychiatrists fell into the underconfident group on this measure, compared with just 13 percent to 18 percent of the other main category of clinicians.
For every lesser year of experience in the field, the survey respondents had a 7 percent increased likelihood of such subpar competence in advising about new HCV treatments. The average years of experience among those expressing such below-average competence was 9.4 years, compared with 12 years among those with above-average competence.
Compared with general practitioners and internists, psychiatrists and addiction medicine physicians were a respective 5.8-fold and 2.8-fold more likely to have below-average competence in treating and managing hep C. Psychiatrists and addiction specialists reported a respective 44 percent and 20 percent rate of below-average competence on this point, compared with 15 percent among general practitioners and internists.
“Given this self-professed lack of competence and lack of knowledge,” Litwin says, “I think there’s a lot of room for interventions, educational interventions that can improve these things. Every psychiatrist or addiction medicine specialist needs to be knowledgeable about the treatment to motivate their patients and activate them even if they’re not treating them. That’s our call to arms.”
The study is limited by the fact that it is based on self-report, and therefore subject to the biases of the respondents and their ability to accurately assess their own competence. Additionally, the population surveyed is not necessarily a representative sample of clinicians at addiction clinics, although the study authors did endeavor to increase the odds that they would draw a representative sample.