• Rates of steroid use in Australia are unclear but use appears to be increasing;
• Some policy, legal and regulatory responses to steroid use in Australia have been implemented too hastily, without sufficient evidence and in ways that may be counterproductive to harm reduction.
• There is a lack of fit between research, policymaking and service provision in relation to steroid use in Australia;
• Much more research is needed to better understand this emerging phenomenon, including the harms and risks associated with it.

Via the prolific Dr Andrew Byrne:

High rates of sustained virological response in hepatitis C virus-infected injection drug users receiving directly observed therapy with peginterferon alpha-2a (40KD) (PEGASYS) and once-daily ribavirin. Waizmann M, Ackermann G. Journal of Substance Abuse Treatment 2010 38:338-345

Dear Colleagues,

This report is very good news for those considering anti-viral treatment for hepatitis C from an opioid pharmacotherapy setting. Out of 49 patients 48 obtained a sustained viral response according to this group from Leipzig, Germany. Side effects were modest and none required cessation or alteration of treatment schedules. Uniquely they give all treatment under supervision in the clinic on a daily basis with ribavirin given as single daily dose of 800mg (1200mg for genotypes 1/4) rather than the more usual split dose regimen, given for 26 weeks (48 weeks for genotype 1/4). Furthermore, all patients were given antidepressant citalopram (Cipramil) 20mg daily starting 2 weeks before commencement of anti-viral drugs as a prophylactic regardless of whether they had clinical depression or not at the outset.

Study patients’ mean age was 30 years, 50% male; genotypes 1 (41%), 2 (4%), 3 (53%), 4 (2%). Subjects had to have been ‘stable’ for at least 3 of 6 months in opiate treatment. They were taking buprenorphine 0.6mg – 7.4mg or levo-methadone 10 – 50mg (equivalent to 20 – 100mg of the regular racemic product). They had been taking opiates for an average of 6 years and had HCV for an estimated 3.5 years. This is in contrast to other reports where opiate use/HCV were of substantially longer duration.

The authors did a retrospective analysis of 49 such patients over 3 year period, including LFTs, Hb, WBC, platelets and viral loads. It is not quite clear how these were chosen for inclusion – random, time period or consecutive?

The clinic typically treated a population of 125 addicts on a daily basis including weekends. Doctors and counsellors were available on-site every day and a hotline was available to patients.

While the results seem extremely favourable, the authors cite another study with compliance rate of 100% and SVR rate of 94% from 17 HCV genotype 3-infected MMT patients treated with IF plus RBV, the former under observation and using psychosocial supports (Krook et al. Norway 2007). This is also consistent with numerous studies showing improved results from directly observed treatment (DOT) in HIV infection (see Sharkey 2011). Others have reported improved HCV rates with increased psychosocial supports and less illicit drug/alcohol use.

We should all be encouraging our patients with HCV to consider assessment and treatment where appropriate. If these outcomes can be corroborated we should also probably consider the benefits of additional supervision of medication for better adherence as well as possibly once daily antivirals and antidepressants.

Comments by Andrew Byrne ..

Opinion blog: http://methadone-research.blogspot.com/
New York spring stories: http://andrewbyrneinnewyork.blogspot.com/
Dr Strain on the new bupe “film” or ‘wafer’. http://methadone-research.blogspot.com/2011/04/eric-strain-talks-about-buprenorphine.html

Krook AL, Stokka D, Heger B, Nygaard E. Hepatitis C treatment of opioid dependants receiving maintenance treatment: Results of a Norwegian pilot study. 2007 European Addiction Research 13:216-221

Sharkey KM, Kurth ME, Anderson BJ, Corso RP, Millman RP, Stein MD. Directly observed antiretroviral therapy improves adherence and viral load in drug users attending methadone maintenance clinics: A randomized controlled trial. Drug Alc Depend 2011 114;2-3:245-248

Waizmann M, Ackermann G. High rates of sustained virological response in hepatitis C virus-infected injection drug users receiving directly observed therapy with peginterferon alpha-2a (40KD) (PEGASYS) and once-daily ribavirin. Journal of Substance Abuse Treatment 2010 38:338-345

From Prof Louisa Degenhardt – Chair, Illicit Drug Use Expert Group:

We are looking for data from around the world on hepatitis B and C (HBV and HCV) prevalence among injecting drug users (IDUs). Do you have data from your country?

As part of work we are conducting for the 2010 Global Burden of Disease Study, we are undertaking a systematic review of existing data on the prevalence of HBV and HCV among injecting drug users. This work is being overseen by the Illicit Drug Use Expert Group and a team of researchers with expertise in undertaking systematic reviews (see www.gbd.unsw.edu.au). This is one of the first attempts to quantify the extent to which viral hepatitis is an issue faced by people who inject drugs on a global scale. Such estimates are crucial building blocks to inform responses to viral hepatitis at country, regional and global levels.

We are in the process of making estimates for every country around the world on:
– the prevalence of HCV among IDUs
– the prevalence of HBV among IDUs, with separate estimates for
o hepatitis B surface antigen (HBsAg)
o antibody to hepatitis B core antigen (anti-HBc)

Many of you may be familiar with the estimates that were released by the Reference Group to the UN on HIV and injecting drug use (see www.idurefgroup.com). We hope to produce a similar set of estimates for HBV and HCV. This is challenging because in many countries, data may not be widely available. We have conducted a large search of the peer-reviewed literature, and are gathering as much grey literature (such as NGO and government reports) as possible. However, there will be some material that our search would have missed.

Do you have any information that may be of use to us? Any assistance will be acknowledged in the reports we are writing on this subject. Due to the tight timelines of this project we can only consider material received by Monday 17 January 2011. Many thanks in anticipation of any information you can provide, and for circulating to other colleagues who may be able to assist.

Have a happy and safe holiday.
Paul Nelson,
on behalf of Prof Louisa Degenhardt
Chair, Illicit Drug Use Expert Group
2010 Global Burden of Disease Study
Please direct all correspondence to gbd@med.unsw.edu.au