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PROS AND CONS OF NEW HEPATITIS C TREATMENTS

4/20/2015

Everyday Health

By Anne Harding Reviewed by Matthew Vorsanger, MD

The FDA has approved several new cures for hepatitis C, but the drugs are so costly, some insurers will only cover them for the sickest patients.

Hepatitis C treatment is getting faster, simpler, and more effective. Patients on the new hepatitis C medication, Harvoni, need only pop one pill per day. Some can be cured in as little as eight weeks. And patients who take Viekira Pak, a new combination pill, for 12 to 24 weeks, don't need an added injection. This is a huge difference from just a few years ago, when hepatitis C patients had to take ribavirin pills and interferon injections for almost a year, and most weren't cured.

“Harvoni is very easy to take, it doesn't have any significant side effects,” says David Bernstein, MD, chief of hepatology for the North Shore LIJ Health System in Manhasset, N.Y. “The only thing that you see is some patients get an occasional mild headache, which is easily treatable with aspirin or Tylenol.”

Prior interferon-containing combo treatments had side effects that included anemia, depression, and flu-like symptoms among others.

Here's the problem: The newer hepatitis C drugs are super-expensive. Harvoni rings in at $1,125 per pill, or $94,500 for a 12-week course of treatment, and other new medications are nearly as pricey. Insurers are scrambling to figure out how to pay for treatment without breaking the bank. Many say they will only cover costly therapies for the sickest patients. In comparison, the cost 11 out of 12 cancer drugs the FDA approved in 2012 for cancer chemotherapy was over $100,000 for a one-year treatment course.

“Really curing hepatitis C is now within reach for a majority of the patients that we see,” says Andrew Aronsohn, MD, an assistant professor of medicine at The University of Chicago Medicine and an expert on hepatitis treatment. “The big issue revolves around cost and access to care.”

Several other new hepatitis C treatments are awaiting FDA approval. “The hope is that with lots of competition and more drugs out there, the price will go down,” says Dr. Aronsohn. “That's certainly what we're hoping for.” A potential problem with using the new drugs is how to know which will be best for an individual patient, when compared to other new treatments.

Hepatitis C TreatmentsHere's a rundown of US Food and Drug Administration-approved treatments for hepatitis C, from newest to oldest.

Viekira Pak: Approved December 2014. Viekira Pak is an interferon-free, all oral cure for hepatitis C for patients who have genotype 1 infections, including those with cirrhosis. The combination is ombitasvir, paritaprevir, and ritonavir pills, combined with dasabuvir pills. It is sometimes used with ribavirin. Patients take the drug for 12 to 24 weeks, and it cures over 95 percent.

Harvoni: Approved October 2014. Harvoni is a combination of sofosbuvir (Sovaldi) and ledipasvir. The drug cured more than 90 percent of patients with hepatitis C type 1, the most common form in the United States, after 12 weeks of treatment. Some patients who have not taken antiviral drugs before can be cured in eight weeks. “It's quite a transformative medication,” Dr. Bernstein says.

Sovaldi: Approved December 2013. Sovaldi is also a once-a-day pill, taken in combination with ribavirin or interferon. A course of treatment lasts 12 weeks, versus 24 to 48 weeks for older treatments. Some doctors have been prescribing an off-label combination (meaning not specifically FDA-approved) of Sovaldi with Olysio (simeprevir) to avoid side effects associated with the older drugs. The two-drug combo costs roughly $150,000 for a course of treatment. Patients with hepatitis C genotype 2 and genotype 3 are currently treated with a combo of Sovaldi and ribavirin, while patients with genotype 4 — who are very rare in the United States — must still be treated with interferon and ribavirin.

Olysio (simeprevir): Approved November 2013. Olysio is a once-a-day pill and, like Sovaldi, approved for use in combination with interferon and ribavirin. It is approved for treating hepatitis C genotype 1. The drug combination cured 80 percent of those with hepatitis C in 24 weeks, including patients who failed earlier drug treatments.

Telaprevir (Incivek/)/Boceprevir (Victrelis): Approved May 2011. Telaprevir and boceprevir were the first new treatments available for hepatitis C in 20 years. These drugs were also the first to directly attack the hepatitis C virus. Both are protease inhibitors, and prevent the virus from making copies of itself. Either must be taken along with ribavirin and interferon, but the course of treatment for the triple combo takes 24 weeks, versus 48 weeks for the interferon/ribavirin only regimen. Cure rates are about 80 percent with the telaprevir-based combo, while the boceprevir-based combo cures about two-thirds of patients.

Issues in curing hepatitis C today are cost and access to care.

Ribavirin: Approved in 1998. Patients take this oral medication twice a daily, and it must be used in combination with interferon. Side effects include a serious form of anemia that can make heart disease worse and lead to a heart attack. A course of interferon/ribavirin therapy lasts 48 weeks, and will cure about 40 percent to 45 percent of patients.

Interferon: Approved in 1991. Interferon is a human-made copy of an infection-fighting substance produced by immune-system cells. Patients must take it by once-weekly injection. Side effects can be severe, and include depression, irritability, flu-like symptoms, and blood abnormalities. When the drug was used on its own to treat hepatitis C, patients had to take it for 12 to 18 months. This lengthy treatment cleared the virus in just 20 percent of patients.

patients.http://www.everydayhealth.com/news/pros-cons-new-hepatitis-treatments-patients/

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PSYCHOLOGICAL EFFECT OF LIVER IMPAIRMENT REDUCES QUALITY OF LIFE IN PATIENTS WITH CHRONIC HEPATITIS C

4/15/2015

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Results from a research study titled “Depression rather than liver impairment reduces quality of life in patients with hepatitis C,” show that in patients with chronic hepatitis C (CHC), the psychological effects of the disease deserve more attention and that the implementation of integrated medical, psychiatric, and psychological care may be helpful. The study is published in the current issue of the Revista Brasileira de Psiquiatria.

Approximately 170 million individuals are infected with the hepatitis C virus (HCV) worldwide. The condition causes chronic liver disease, cirrhosis, and hepatocellular carcinoma (HCC), and is responsible for more than 475,000 deaths per year.

Health-Related Quality of Life (HRQOL) is one measurable dimension of a broader quality of life score that is more directly related to health, and it focuses on the patient’s subjective evaluation of well-being, individual experiences, and values regarding the process of being sick.

Although HRQOL is variably impaired in cirrhotic patients, the results of studies evaluating the impact of the degree of liver fibrosis on HRQOL are still controversial.

Eliane D. Gontijo and her colleagues investigated the impact of CHC on HRQOL by conducting clinical, psychiatric, and sociodemographic evaluations. The researchers assessed psychological impairments in a total of 124 patients that attended a referral center for hepatitis. All patients were assessed for neuropsychiatric disturbances, depression, anxiety and quality of life using four different testing methods.

Using multiple linear regressions, the results revealed a reduction in the HRQOL score that was related to major depressive disorder and increased levels of alanine aminotransferase. However, it was not associated with hepatic cirrhosis.

Based on the results, the researchers suggest that major depressive disorder rather than the grade of liver fibrosis is related to impairments in HRQOL in patients with chronic hepatitis C. According to the researchers, these new findings emphasize the fact that for patients with CHC, there is a need for clinicians to pay more attention to associated psychological impairments.
http://hepatitisnewstoday.com/2015/03/27/psychological-effect-of-liver-impairment-reduces-quality-of-life-in-patients-with-chronic-hepatitis-c/

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C U L8ter: HEPATATIS C ERADICATION

4/10/2015

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TAGline Spring 2015

Hepatitis C is now curable. Now all we need is surveillance to monitor it, global funding to fight it, and targets set to address it

By Tracy Swan

The first global targets for eliminating hepatitis C virus (HCV) will be set by the World Health Organization later this year. It’s about time: although HCV is preventable and curable, it kills 700,000 people annually and continues to spread among millions more. At least 185 million people worldwide have been infected with HCV, although data on the epidemic’s scope and spread are sketchy. This inadequate surveillance has made it easy to ignore hepatitis C, and difficult to secure and allocate sufficient resources to save lives.

The best and worst of the situation—dramatic improvements in treatment in the face of a rapidly rising death toll—have ignited a global movement to address hepatitis C. The treatment revolution officially began in 2011, when proof-of-concept for an interferon-free cure was established. Since then, hepatitis C drug development has moved at breakneck speed.

Oral combinations of direct-acting antivirals (DAAs) have cured over 90 percent of people in clinical trials, including people with cirrhosis or HIV/HCV coinfection. These DAAs offer great promise for a global public health approach to hepatitis C: using the same drugs for everyone, for the same length of time.

The response to HCV among women and children has been pitiful. Globally, 1.5 million to 12 million pregnant women have hepatitis C, and the vertical transmission rate ranges from three percent to 10 percent—possibly higher if the mother is also HIV-positive, especially if she is untreated. At present, there is no way to prevent vertical transmission.

As for the safety and efficacy of HCV treatment in children, trials are lagging. However, the first interferon-free pediatric HCV treatment trials are now opening in the United States, the United Kingdom, Australia, New Zealand, Germany, Italy, and the Russian Federation.

Target DAA Regimen Profile Will Be:

safe and tolerable; preferably ribavirin-free (Ribavirin cannot be used in people with unstable heart disease or during pregnancy; it causes birth defects and can be fatal to unborn babies. It also has many side effects, including anemia.);
effective and potent: must cure ≥90 percent;
universal: can be used for all HCV genotypes; for people with HIV/HCV, cirrhosis, and kidney disease; during pregnancy and nursing; and in pediatrics and the elderly;
simple and easily delivered/administered: minimal pre-treatment testing and on-treatment monitoring needed; fixed-duration (preferably ≤12 weeks); once-daily (fixed-dose combination preferred); no food requirement;
affordable; and
stable at different temperatures.

Access, Access, Access
There are several barriers to HCV treatment scale-up—the most significant being high drug prices. In low- and middle-income countries, patent protection allows pharmaceutical companies to control where generic versions of their drugs are sold, through voluntary licensing (VL) agreements.

Many middle-income countries—including China, home to at least 30 million people with hepatitis C—have not been offered VLs, although they bear the brunt of the HCV epidemic. These countries are left to use legal challenges, such as blocking patents, issuing licenses themselves (called compulsory licensing), or purchasing drugs from another country, where affordable generics are available (called parallel importing).

Scaling up HCV treatment is only one piece of the elimination puzzle. Diagnostics must also be simplified. Currently, diagnosing HCV is a complex, expensive, and inconvenient multi-step process. However, it may be possible to streamline HCV diagnostics and pre-treatment assessments in resource-limited settings.

Evidence to inform and support simplification of HCV diagnostics and monitoring—before, during, and after treatment—continues to evolve, including a handful of important studies featured at the 2015 Conference on Retroviruses and Opportunistic Infections (CROI) in Seattle.

Unlike the interferon treatment days of yore, it may now be possible to treat hepatitis C without measuring pre-treatment viral load, or monitoring viral load responses during treatment—or at the end of it. Eliminating these tests will simplify treatment in resource-limited settings, ultimately saving time and money for patients and providers.

David Wyles from the University of California at San Diego and colleagues analyzed treatment outcomes among more than 2,000 participants in AbbVie’s PEARL, SAPPHIRE, and TURQUOISE trials (of ombitasvir/paritaprevir/ritonavir and dasabuvir, with or without ribavirin), including people with HIV/HCV or cirrhosis. They found that people were just as likely to be cured, whether it took two, four, six, or eight weeks of treatment to suppress HCV—and regardless of their pre-treatment hepatitis C viral load.

Viral-load test results at week four and at end of treatment (EOT)—a mainstay of HCV treatment monitoring—do not always predict the outcome of HCV treatment. Nearly everyone becomes undetectable within weeks of starting DAAs, but some people relapse within weeks of finishing treatment. In effect, early responses do not predict treatment success, nor do they predict treatment failure with DAA regimens.

Most people with detectable virus at week four will be cured, according to Sreetha Sidarthan from the Institute of Human Virology in Baltimore and colleagues, who analyzed results from the ERADICATE and SYNERGY trials of sofosbuvir-based regimens. Of the 17 people with detectable RNA at week 4 in SYNERGY, 100 percent were cured. In ERADICATE, 32 of 50 people had detectable HCV RNA at week 4; ultimately, 31 of the 32 were cured. EOT testing did not reliably predict cure either.

Researchers have speculated about why HCV may be detectable at the end of treatment in people who are actually cured. One such theory developed by Thi Huyen Tram Nguyen of the French Institute of Health and Medical Research and colleagues suggests that some defective virus lingers after HCV treatment has stopped production of new virus. This virus cannot infect liver cells or reproduce, but persists after treatment is finished, only to die off a few weeks later.

Picking a single HCV regimen that suits all, including people living with HIV, has become easier. In clinical trials, cure rates are just as high for people coinfected with HIV and HCV as for people with HCV alone. An important consideration, however, is drug-drug interactions. Since most HIV-positive people will be using DAAs with HIV treatment, interactions with antiretrovirals (ARVs) need to be managed—or avoided.

The once-daily combination of sofosbuvir and daclatasvir—expected to be approved in the United States later this year—is ARV-friendly. Sofosbuvir can be used with all ARVs except tipranavir/ritonavir. Although daclatasvir dose adjustments are needed with certain ARVs (atazanavir and efavirenz), no change in dosing is needed with other boosted HIV protease inhibitors (darunavir and lopinavir), all nucleoside reverse transcriptase inhibitors, certain non-nucleoside reverse transcriptase inhibitors (nevirapine and rilpivirine), and the integrase inhibitors raltegravir and dolutegravir.

Sofosbuvir and daclatasvir also boast very high cure rates in HIV/HCV-coinfected individuals. In ALLY-2, a phase III evaluation of this regimen, 203 coinfected participants were treated for eight or 12 weeks, according to genotype and treatment history. At CROI, David Wyles and colleagues reported that 97 percent of the 12-week group were cured. In the 8-week group, 76 percent of treatment-naive study participants with HCV genotype 1 were cured.

Daclatasvir and sofosbuvir were safe and effective for HCV genotypes 1, 2, 3, and 4, regardless of treatment experience or liver damage (although cure rates were slightly lower in people with cirrhosis) (see table 1). But more information is needed in non-1 genotypes, especially in people with genotypes 5 and 6, and in people with genotype 3 and cirrhosis—for whom cure rates have reached only 60 percent. Unfortunately, there were only 26 people with non-1 genotypes in ALLY-2; none had G5 or G6. Data on other pangenotypic combinations are expected later this year.

More good news for people with HIV/HCV coinfection came from ION-4, a 335-person trial of co-formulated sofosbuvir and ledipasvir in people with HCV genotypes 1 and 4. Susanna Naggie from Duke University and colleagues reported that 96 percent of study participants were cured after 12 weeks of treatment. Study participants’ ARV regimen options were limited to those containing efavirenz, rilpivirine, or raltegravir, plus tenofovir and emtricitabine (because of a known drug interaction between sofosbuvir/ledipasvir and tenofovir, renal function was carefully monitored during this trial).

Treatment history or cirrhosis did not lower cure rates, but race did—unlike trials of sofosbuvir/ledipasvir in HCV monoinfection. Naggie and colleagues noted that all 10 relapses occurred in black participants, and the cure rate was lower (90% vs. 96%). There were no differences in HCV drug levels by race or ARV regimen, or in people who relapsed versus people who were cured. More research will help to explain and, we hope, override the difference in response rate.

On the treatment front, progress against HCV has been astounding. But even the best DAAs—once they are universally affordable—and the simplest diagnostic and monitoring tools aren’t enough. Political will and resources will be essential to achieving global hepatitis C elimination targets once they are finally established. The infrastructure to make good on these goals must be created—or expanded. The structural barriers that have allowed this epidemic to flourish—such as criminalization of gay people, people who use drugs, and sex workers—must also be eliminated.•
http://www.treatmentactiongroup.org/tagline/2015/spring/c-u-l8ter-hepatitis-c-eradication

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Peace, Love and Heroin in Upstate New York

4/8/2015

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By Dawn Roberts 04/07/15Heroin use has gotten rural, and whiter after authorities leaned hard to cut down on prescription opiates making their way to the streets. In no place has this rung more true than Ulster County.

Image: Shutterstock Woodstock, NY has a history it can’t escape. Forty-seven years after the last tab of brown acid was consumed in Bethel, this sleepy upstate town (and its neighbors) have a different drug casting a shadow on the mountains: heroin is here. It never really left, but in the last four years a perfect storm created a radical increase in the number of users, addicts, ODs and deaths from the drug. The problem is not centered or worse in Woodstock, it just happens to be the town with a legendary name. It’s also where I live.

There are 20 towns in Ulster County extending from New Paltz to Marbletown, Kingston, Ulster and Saugerties. In total, less than 200,000 people live here. Many are part-timers who come up from New York City on weekends to enjoy the unspoiled mountains, recreation and laid-back atmosphere.

To the casual visitor the area looks like most hamlets on the Hudson River between Manhattan and Albany. Land stretches out far and wide. The businesses tend to be small sole proprietorships. Antique shops, art galleries, restaurants and tourist-friendly destinations abound. Once, these communities thrived when corporations like IBM employed white-collar professionals. That changed in the 1990s when IBM left, and no significant employer came in to take its place.

The economy of Ulster County is precarious. The main businesses—colleges, ski areas, hotels, restaurants and bars—have strong seasonal fluctuations. During snowy winters, some mountain towns thrive. In the summer, the population swells with tourists. But by this time in March every year, everyone who can, leaves for warmer shores. The rest of us tough it out one grim, grey day at a time, keeping our fires burning and praying the pipes don’t freeze. These are normal day-to-day issues of life in the rural northeast.

The opportunities for young people are different in areas like this than they are in an urban environment. There are few companies offering jobs that pay a living wage. Most people are working at more than one occupation, and tend to have a small business of their own as well. This is not the cause of addiction. The stress of financial insecurity on families and individuals is another story. There is a sense of scarcity in these parts, more palpable than any other place I have lived. Particularly in winter months, it gets bleak. Restaurants close down until spring, and many stores are not open on the slower days of the week. While the national story of economic growth blares on a monthly basis, evidence of such growth is not visible in these communities.

The ProblemHeroin has become a significant problem in all of New York’s upstate counties. Statistics from NIDA show heroin use has gotten rural, and whiter. The stereotype of heroin as an inner city problem for people of color has been flipped on its head. The average American heroin addict is 25-years-old, white and living in a suburban or rural locale. Further evidence of this phenomenon comes from hospitals, treatment centers and morgues in Ulster County. The incidence of overdose, hospitalization or death from heroin use has increased 12-fold from 2011. Data on heroin overdoses and deaths lag behind the current year. With this in mind, I interviewed doctors, treatment centers, law enforcement, the district attorney’s office, the fire department and the county medical examiner. I spoke to some people who requested anonymity, and others who did not. The goal was an attempt to understand the rapid spread of heroin addiction in this county and what is being done to address the problem.

Ulster County District Attorney Holley Carnright said, “You can be a 50-year-old accountant or 14 and in the 10th grade...” Heroin addiction knows no socioeconomic or demographic borders. Then there are recent sobering statistics: in Ulster County, 70% of drug arrests were for heroin or opiates, up from 30% in 2012.

Nationally, heroin use has about doubled since 2007, going from 373,000 to 669,000 users in 2012, according to SAMHSA. Heroin overdose deaths have spiked in the northeast, increasing 211% from 2010 to 2012, according to the Centers for Disease Control and Prevention.

There’s a sad irony noted by police, addiction specialists and users. Authorities leaned hard to cut down on prescription opiates making their way to the streets. Interconnected databases allowed pharmacies to see any controlled substance scripts written in the state of New York. Pharmacists partnered with local police, and violators with forged scripts were arrested. Physicians were informed if their patients were obtaining medication from multiple sources. The tactics worked so well that drugs like OxyContin and Vicodin became harder to source and their prices skyrocketed. At the same time, a flood of cheap heroin hit the same streets. Some addicts made the jump from prescription drugs to heroin, based on cost and availability. It’s a scene that’s played out in the war against drugs time and time again.

While that explanation makes some rational sense, it doesn’t address the “why” that surrounds addiction. Heroin has always been available in these parts according to sources in law enforcement. It became more available when criminal entrepreneurs from other cities realized they could increase their profits significantly by making a day-trip north. Mere availability doesn’t explain the large number of addicts who are on the streets first thing in the morning in order to get their doses sorted for the day.

Asking questions about heroin addiction provides no neat answers. Statistics that measure death and overdose come from public institutions, and only tell a small part of the story. No one I spoke with attempted to minimize or deny the scope and effect of heroin addiction in the county. Everyone is aware of the problem, coming to actionable conclusions about fixing it is a different proposition.

The individuals spoken to for this story all have a slightly different perspective on the problem. Law enforcement has a job, which includes arresting drug dealers. But even the most senior undercover narcotics detective I spoke with understands that it’s impossible to police addiction out of existence. First responders in this county are armed with Narcan, and the drug is credited for saving two lives the very first day it went into use. Even so, someone who overdoses and is revived by Narcan cannot be forced to go to treatment. Some who are brought back from the brink, come to angry that their high was ruined, the last thing the user recalls is that he/she was okay.

Drug court has been active here since the late 1990s. Nonviolent drug offenders, who are addicts, are offered comprehensive treatment and a structured program of accountability. Drug court offers an option to incarceration, but also requires a serious level of commitment. Those who fail will go to jail. It’s a strong incentive, but some addicts prefer prison to random drug tests, participation in treatment and following the rules required to stay in the program. These tend to be addicts who do not believe they can ever stop using. Clearly drug courts are moving in the right direction, treating addicts as human beings who are capable of making better choices when they are supported and encouraged. It is also far less costly to treat addicts rather than locking them in jail cells.

The Waiting GameThere are several treatment facilities in Ulster County. The one thing they have in common is that they all have waiting lists. The same goes for physicians who prescribe Suboxone for outpatient detoxification. It’s clear that a large number of people who need and want help to end their addictions are not able to access care. I spoke with one young woman who described a close friend who is an active addict and goes to work every day. He is desperate for help, but can’t afford private treatment and is on a waitlist for a publicly funded option.

Funding Additional Education and TreatmentIn talking with law enforcement, I inquired about the endgame for the cash and property confiscated in the many drug raids that occur here. I wondered if those funds could be put towards education and additional treatment centers. While some of the money eventually returns to the county and, in theory, goes to treatment and education, the timeframe is lengthy. On top of that, every entity involved, from local to regional and federal gets a piece of the revenue.

Another interesting fact was mentioned by the DA’s office—some school boards and parents resist drug education programs. While that may sound counterintuitive, one must remember that the county is extremely liberal. Some parents associate these programs with the failed War on Drugs. Additionally, drug awareness seminars were traditionally delivered by law enforcement. A police presence sends a far different message than one coming from a recovering addict. While it may sound like an ideal plan to bring in such individuals, the continued stigma of drug addiction and the reaction of certain parents and board members makes this too difficult a task to accomplish.

Inside a Treatment CenterThe Bridge Back To Life Center is a key recovery hub in Kingston. Its director, Al Nace, agrees that opiate addiction is an equal opportunist without geographic or economic boundaries. The age range of clients at his center runs the gamut, from adolescents to 65-year-olds. There’s a mix of people from all walks of life. There are lawyers, health-care professionals and teachers side-by-side with young mothers, people struggling with dual diagnosis (mental health and addiction) and those currently unemployed. They’re all at BBTLC to put their lives back together. The treatment facility has several campus locations, including a hospital for detox, day programs, and after-work evening programs for those fortunate enough to have kept their day jobs.

While BBTLC assists those struggling with heroin, it treats other addictions as well. Alcohol, tranquilizers, sleeping pills—it doesn’t matter what a person used, only that he/she wants to get better and resume a life of purpose. Nace knows that you can’t take an addictive substance out of a client’s life, and leave the empty space there. It has to be filled, or the client will inevitably return to using their drug of choice.

To that end, he created an art program (which in the beginning, he supplied the brushes, paint and canvases for). Last year, a show of client’s work attracted hundreds of interested citizens. There is a boxing gym about a mile away that clients are encouraged to participate in and an annual bike race/fundraiser that is open to all. Nace is genuinely dedicated to his clients. Right now, Bridge Back has a waiting list of approximately 30 people who desperately want help. In order to allow one of those individuals in, someone has to leave the program, either by graduating, dropping out or being administratively discharged. Bridge Back is a rigorous program. If a client is not participating in group, or tests positive for an illicit substance, they will be counseled. Nace has a deep understanding of the arc of recovery from addiction. Although he has to make hard choices every day, he knows that setbacks are part of the course. This is kept top-of-mind when a client who is struggling is confronted and potentially given another chance to succeed.

Compared to the gourmet meals and equine therapy available in Southern California treatment centers, Bridge Back is bare bones. The low, unassuming brick building is clean but sparse. There are large white boards in group-therapy rooms for teaching and sharing purposes, and plenty of space for seating. The facility accepts clients with private insurance as well as those on Medicaid. As I left our meeting, I noticed a young girl trudging through the snow. I offered her a ride, knowing it would be a several mile walk in any direction to town. She looked like a teenager, but let me know she had three children who had been removed by Child Protective Services as a result of her drug use. She was on her way to meet with her probation officer. Even so, she was clear eyed and upbeat. She intends to regain custody of her children. Bridge Back To Life offers the kind of intensive structure, therapy and education that are helping her to navigate the journey.

Hard Times In Ulster CountyBBTLC assists average citizens of these upstate communities. The struggle of Ulster County residents reflects hard economic times. While total employment here grew 1.7% in 2012, it lags behind national numbers. According to a study by SUNY New Paltz, in Ulster County, approximately 13% of all residents, 15% of families with young children, and 47% of single-mother families with young children fell below the poverty line. In the village of Ellenville, 70.6% of all single mother families live in poverty. These figures provide a vivid picture of strife, and illustrate why a portion of the population might feel helpless and hopeless. That said, if poverty in itself was the root of addiction, the Depression of the 1930s should have produced a generation of addicts, but it didn’t.

To describe Ulster County residents as salt-of-the-earth types is an accurate assessment. The American ideal of rugged individualism is alive, well and tested regularly in these cities. A large number of the self-employed work with their hands and on the land. There are carpenters, excavators, tree surgeons, farmers, loggers and handymen. That is in addition to the many artists, writers, musicians and craftspeople who have historically been attracted to the area. Local critics say that elected officials haven’t done enough to bring corporate investment to the area. At the same time, the demands for resources corporations require can be contrary to the needs of the people. A recent proposal to bring a Nestle water bottling facility to the region was nixed, based on the million gallons of water per day required to run the plant. Such are the tensions of a county in transition.

How does city development relate to heroin addiction? There are high correlations between poverty, trauma, stress and addiction. All of these factors collide in an area where 14% of residents receive federal aid and the unemployment rate languishes at 9% compared to federal figures of 5.6%. In the face of few employment opportunities, some can’t imagine a brighter future for themselves. A bleak outlook lends itself to the desire to self soothe. According to the National Council on Drug Abuse, lack of money is not a singular cause of drug use. The relationship is complicated. Poverty comes with a litany of factors; low-status, low-skilled jobs, unstable family and personal relationships, low educational achievements, high arrest rates, high incidence of undiagnosed mental illness, poor health, and high death rates. These are remarkably similar to the factors surrounding drug abuse.

Unemployment has been strongly correlated to drug use. According to the Substance Abuse and Mental Health Services Administration (SAMHSA) 18.2% of unemployed adults in 2013 were current drug users compared to the 9.1% of those who were employed full time and 13.7% of those who were employed part time. A person in an impoverished situation may abuse drugs or alcohol as a way to cope with a dangerous environment, to deal with financial stress or cope with physical or emotional abuse.

Opiate addiction has raised its black flag across New York State. From larger cities like Albany and Buffalo to the tiny towns in Ulster County. There is no safe haven. “It's no longer the back alley bum,” says Renee Hustins, a school bus driver who knows four people who've lost children to heroin. ”It's your neighbors' kids. It's the grocery-store worker. It's crazy.”

According to Vancouver Professor Bruce Alexander, the phenomenon of addiction is neither a disease of the brain nor a moral failing. He posits that addiction is, in fact, an adaptation to the environment. It may not be the sole factor, but one that has been largely overlooked. Alexander’s writing in The Globalization of Addictionpoints to some key issues; that humans have been separated from their ties to family, culture and spirituality. Further, he notes that the unending pressure and competition of modern life have disassociated us in a manner that leaves a void demanding to be filled.

Addiction, obsessive consumption of food, worldly goods, and power are all evidence of this adaptive behavior. He points to history, where addiction in certain societies was rare for centuries. Dramatic changes in circumstance, such as the collapse of a civilization or tribal unity is when the symptoms of addiction arise.

In Alexander’s view, the deep need for “social, cultural, and spiritual wholeness” is the space that addiction fills. His premise that addiction is more a social ill than an individual disorder is controversial. However, after studying statistics, economic trends and poverty levels in Ulster County, Professor Alexander’s theories might just be the missing link.

Dawn Roberts is a writer and media consultant in New York. Follow her on Twitter @SilverHolloMuzo
http://www.thefix.com/content/peace-love-and-heroin-upstate-new-york

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ADVANCING AWARENESS AND ACTION AGAINST HEPATITIS C AMONG AFRICAN AMERICANS

4/1/2015

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blog*AIDS*gov
March 25, 2015 • 0 comments • By Ronald Valdiserri, M.D., M.P.H., Deputy Assistant Secretary for Health, Infectious Diseases, and Director, Office of HIV/AIDS and Infectious Disease Policy, U.S. Department of Health and Human Services
A recent forum convened by HHS focused on strengthening the response to hepatitis C in African American communities, gathering representatives of more than three dozen organizations from across the nation to discuss ideas, opportunities, and strategies to address this significant health disparity.

Hepatitis C virus (HCV) infection disproportionately affects African Americans, with some estimates indicating that African Americans have rates of chronic HCV approximately double that of whites. Additionally, HCV is a major cause of liver cancer and African Americans have the highest mortality rates from liver and bile duct cancer. (Read more about HCV [PDF 535KB] and HCV and African Americans [PDF 107KB].)

Given these stark disparities, African Americans are among the populations prioritized by the Action Plan for the Prevention, Care and Treatment of Viral Hepatitis (Action Plan), which outlines steps to educate communities about the benefits of viral hepatitis prevention, care, and treatment as well as actions to enhance healthcare provider knowledge about populations most disproportionately impacted. The Action Plan is a national plan that requires the participation and engagement of many partners in order to achieve its goals, especially those related to addressing health disparities like improving outcomes for African Americans living with hepatitis C.

The HHS Office of HIV/AIDS and Infectious Disease Policy and theHHS Office of Minority Healthorganized the two-day Forum on Hepatitis C in African American Communities with input from other partners. Participants included leaders from national and community-based organizations representing healthcare providers, the faith community, the business community, and health advocates, as well as representatives from state and local health departments, Black sororities and fraternities, and federal partners in the Action Plan including the Centers for Disease Control and Prevention (CDC), the Substance Abuse and Mental Health Services Administration (SAMHSA), the HHS Office on Women’s Health, the Department of Veterans Affairs., and others (View the list of participants [PDF 155KB].)

Held earlier this month, the forum began with presentations on hepatitis C in the African American community by Dr. John Ward, Director of CDC’s Division of Viral Hepatitis, as well as presentations about advances in HCV screening, care and treatment, and the Action Plan. These presentations provided all participants with a common foundation of knowledge that informed the participant-driven dialogues that followed about how to best empower providers and communities to address hepatitis C .

Some of the ideas and strategies generated by the participants included:

When educating African American communities about hepatitis C
Lead with personal stories to capture attention before offering expert opinion
Focus on that fact that with the availability of a cure, this is a “winnable battle”
Leverage the power of social media
Highlight that the Affordable Care Act provides opportunities for HCV prevention, diagnosis and treatment
Build strength in numbers by spreading awareness throughout networks and engaging in partnerships, foster development or expansion of information pipelines through coalitions, webinars, and sharing resources among interested organizations
Highlight successful community-based efforts to diagnose and treat hepatitis C
Invest in systems and processes that promote routine HCV testing and quality care

At the conclusion of the forum, participants indicated they or their organizations would undertake a range of activities in the coming weeks and months to educate their colleagues, networks, and communities, including:

Disseminating emails/letters to their constituents describing the forum and educating them about HCV among African Americans;
Evaluating existing strategies and programming to include hepatitis C;
Planning hepatitis C training/education sessions for healthcare providers;
Developing strategies to increase hepatitis C awareness and/or testing specifically among African American “Baby Boomers,” given the high prevalence of infection among that age cohort;
Ensuring that community education events include information about HCV and sponsoring hepatitis C screening community events;
Adding hepatitis C information, resources, and/or widgets, buttons, or badges to organizational web pages, including links to CDC’s online viral hepatitis risk assessment tool;
Joining the online conversation about hepatitis C by beginning to follow viral hepatitis-related social media accounts (#ViralHepAction, #HepC) and sharing blog posts about HCV and the Action Plan;
Planning to make use of materials from CDC’s Know More Hepatitis campaign in various activities;
Joining in the observance of Hepatitis Awareness Month in May and/or Hepatitis Testing Day on May 19; and
Considering implementation of a community-wide HCV test and cure program.

Each of these activities complements the steps detailed in the Action Plan and will make important contributions to growing efforts to improve HCV testing, care, and treatment among African Americans. We are grateful to these leaders for their thoughtful contributions to the dialogue begun during the forum and we look forward to continuing to collaborate with them over the coming months and years to create additional opportunities to address hepatitis C among African Americans.
https://blog.aids.gov/2015/03/advancing-awareness-and-action-against-hepatitis-c-among-african-americans.html

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