Relapse to Opioid Use After Treatment of Chronic Hepatitis C With Pegylated Interferon and Ribavirin

Abstract

Hepatitis C virus is the most common blood-borne pathogen in the United States. An estimated 1.8% of the U.S. population is chronically infected (1). Currently, intravenous drug use is the most common route of infection; each year, 30,000 people are newly diagnosed with the hepatitis C virus (2). Chronic infection with the hepatitis C virus is associated with cirrhosis and hepatocellular carcinoma and is the most common reason for liver transplants in the United States. The current optimal treatment for hepatitis C virus consists of pegylated interferon (IFN), given via injection once per week, and daily doses of ribavirin (3). Antiviral treatment for hepatitis C virus is either for 24 or 48 weeks, depending on the genotype of the virus. Response to treatment is measured by determining viral titers of hepatitis C viral RNA. An end-of-treatment response is defined as the absence of hepatitis C virus viral RNA immediately after the course of treatment is completed. A sustained viral response is the absence of hepatitis C viral RNA 6 months after treatment is completed. Patients with a sustained viral response have a more than 95% chance of remaining virus free indefinitely. Treatment for hepatitis C virus can pose mental health challenges because antiviral therapy can induce depressive symptoms and has occasionally been known to trigger mania or psychoses (4, 5). Antiviral therapy may also exacerbate preexisting mental health conditions, including depression, posttraumatic stress disorder, and mania. Antiviral therapy has also been associated with the relapse of substance use (6). It is generally recommended that patients with preexisting mental health or substance dependence conditions be stable at least 6 months before initiation of antiviral therapy (7). In 2002, the National Institutes of Health Consensus Development Conference on the Management of Hepatitis C recommended that treatments for hepatitis C virus be extended to groups previously thought to be at high risk for receiving IFN treatment. These high-risk groups include those with a current or past history of substance disorder (8). It is estimated that 70%–90% of intravenous drug users are chronically infected with the hepatitis C virus but that only about 50% are ever offered treatment (9). The Portland Veterans Affairs Medical Center Hepatitis C Resource Center includes a multidisciplinary clinic specializing in the evaluation and treatment of patients considered high risk for IFN treatment, in particular, patients with comorbid mental health and substance use disorder diagnoses. Our clinic performs mental health screening before patients receive IFN treatment and ongoing evaluation and treatment of mental health problems, including those that emerge during antiviral therapy. Our multidisciplinary team includes professionals from the areas of hepatology, mental health, and chemical dependency (10). One high-risk group in our clinic is patients with a history of opioid dependence (11). In this report, we present the case of “Mr. O,” a particularly complex and high-risk patient with schizophrenia and a history of intravenous opioid and cocaine dependence who was receiving opioidsubstitution treatment (methadone maintenance) at the time of antiviral treatment for hepatitis C virus. We describe our treatment plan for his complex clinical situation and his successful completion of antiviral therapy. We also describe an unintended consequence of successful hepatitis C virus treatment. Having been “cured” of hepatitis C virus, the patient decided to see if he was “cured” of the need for methadone and ultimately relapsed to heroin use.