Common Medical Problems in Opioid-Addicted Patients

Diana L. Sylvestre, MDAssistant Clinical Professor of Medicine

University of CA, San FranciscoExecutive Director

Organization to Achieve Solutions in Substance-Abuse (O.A.S.I.S.)

Oakland, CA

Case Discussion R.B., 53 y.o A.A. male, 26 yr. history of IDU,

regular use 2 yr. Sober for 2 weeks after a recent 21-day methadone detox but now using small amounts of heroin again. Requesting buprenorphine therapy.

Only medical problem: sometimes his BP is high, but never took medications.

Only medication INH: 4 mo.? Brings records. Heavy drinker for about 5-10 years in his 30’s

but none for 7 years, heroin is only drug currently used.

Case Discussion, cont.

A review of his records is notable for:

Platelets 126,000 (150-450)WBC 2,400 (3,500-10,000)Alkaline Phosphatase 128 (65-110)AST 46 (20-45)ALT 67 (30-50) 6 mo ago, 39 1 yr ago

Case Discussion, cont.

Summary: healthy 53 yo IDU on INH with mild thrombocytopenia, leukopenia, and hepatic inflammation who would like to start buprenorphine.

What are the most likely diagnoses?

Differential Diagnosis

Hepatitis C Often asymptomatic 60-94% of IDU’s have been exposed 70-85% have chronic, active infection 10% cirrhosis after 2 decades Mild transaminitis is common, although LFTs

are often normal Thrombocytopenia, neutropenia related to

portal hypertension

Differential Diagnosis

2. INH: TB Mild LFT abnormalities in 10-20% Increased with HCV? Alcoholism exacerbates

1. Hepatitis C

Differential Diagnosis

3. HIV 15-20% of long-term IDU’s are infected The majority of HIV-infected IDU’s are

coinfected with HCV Abnormal LFT’s, leukopenia Thrombocytopenia not uncommon

1. Hepatitis C2. INH

Differential Diagnosis

4. Hepatitis B Serologic evidence of HBV infection is

found in 72-89% of IDU’s Chronic infection develops in 5% 65% of HBV infections are subclinical Transmission by parenteral, sexual, or

perinatal routes

1. Hepatitis C2. INH3. HIV

Differential Diagnosis

5. Alcoholic Hepatitis High rates of comorbid alcoholism in

opioid-dependent patients Liver toxicity exacerbated by HCV AST>ALT

1. Hepatitis C2. INH3. HIV4. Hepatitis B

The Need for Vigilance

As this case indicates, the majority of long-term IDUs presenting for buprenorphine therapy will have a number of potential comorbid medical conditions that need to be addressed.

What are the screening recommendations?

Hepatitis C Hepatitis C antibody indicates exposure, not

active disease: ~25% remit spontaneously LFT’s persistently normal in 1/4 PCR testing to diagnose active disease (>$100) Genotype: best predictor of treatment response

(genotype 1=40%, genotype 2,3 =80%) (>$250) Vaccinate for HBV, HAV

SCREEN: HCV Ab, LFT’s, CBC

Hepatitis B Infection-related immunity: surface antibody and

core antibody (HBSAb+ and HBcAb+) Immunization leads to HBSAb+ alone Lone HBcAb +: loss of SAb or low-level infection HBV surface antigen is positive with active

infection. Confirm with HBV DNA. Treatment: high-dose IFN, lamivudine Vaccinate non-immune IDUs for HBV (3 shots) SCREEN (at least): HBSAb, HBSAg

HIV

HIV antibody positivity confirmed with Western Blot analysis

AIDS= CD4 <200 or AIDS-defining diagnosis Follow infection with CD4 and HIV viral load HAART therapy standard: 3 drugs

RT’s, NNRTI’s, PI’s HCV an opportunistic infection in HIV SCREEN: HIV Ab

Tuberculosis More common in patients with IDU, ethnic

minorities, homeless, HIV, and alcoholism Multi-drug resistance problematic PPD+: 1 cm (HIV-), .5 cm (HIV+) CXR if +, hospitalize if active pulmonary TB PPD+ treatment is 6 mo INH/B6 (12 mo HIV+),

watch for hepatotoxicity Initial therapy for active TB is 4 drugs

SCREEN: Annual PPD

Other Considerations

STD’s: higher rates of syphilis, HPV, chlamydia, GC

Bacterial infections: soft tissue, endocarditis COPD: cigarettes, pneumonia Hepatitis A: offer vax if HCV+

SCREEN: annual RPR, physical exam, refer for preventive health care

Case Discussion, cont.

Based on screening recommendations, R.B. has the following testing performed: CBC, Chem panel with LFT’s HBV Surface Ab, Ag HCV Ab HIV Ab RPR No PPD needed in previous reactor

Results

Hct and WBC wnl, platelets 137,000 (>150,000)

Chem panel and LFT’s normal RPR + at 1:4, FTA negative HBV SAb and SAg negative HIV negative HCV Ab: repeatably positive

Case Discussion, cont.

You tell R.B. that his testing indicates that he has been exposed to hepatitis C, but that he will need further testing in order to determine whether he is actively infected.

You counsel him about the importance of alcohol abstinence, indicating that the low platelet count suggests liver damage.

Because of your concerns about the extent of liver damage, you refer R.B. for additional evaluation prior to starting buprenorphine.

Results

HCV RNA PCR 749,000 IU/ml Genotype 1a HAV IgG negative Abdominal ultrasound: enlarged

heterogeneous liver, mild splenomegaly

Outcome

R.B.’s regular physician is willing to consider hepatitis C treatment, but only if he is sober. On the basis of a normal albumin, bilirubin, and PT, she believes that his liver function appears adequate, and agrees that buprenorphine therapy is indicated.

She vaccinates him for HAV and HBV.

Follow-up

After a 3 month stabilization on buprenorphine, RB was referred for liver biopsy, which showed grade 3 inflammation and stage 3 fibrosis.

Based on these results, R.B. is undergoing a 48-week course of pegylated interferon and ribavirin. Aside from interferon-related depression that has required treatment with an SSRI, he is tolerating the therapy nicely, and a 12-week viral load showed undetectable virus.

He remains drug-free on buprenorphine.

Summary

Chronic medical conditions, especially infectious diseases, are common in IDUs.

The office-based buprenorphine practitioner may be the IDU’s only contact with the medical system

Summary (cont.)

Therefore, all office-based buprenorphine patients need:

1. A full annual physical examination

2. Screening for:• HCV• HBV• HIV• TB• Syphilis

Summary (cont.)

*** IDU’s can be difficult patients and are complicated to manage medically. If you will be referring your patients for medical treatment, develop your physician referrals with great care, and interact liberally with them.