Concerns About Relapse to Active Drug Use and Reinfection

Clinicians and their patients have valid concerns about HCV treatment in active or recovering illicit substance users. The side effects of interferon are similar to those of opiate withdrawal, and patients have relapsed or reported cravings during HCV treatment.55,67,111,149 Clinicians have an opportunity to intervene and support such patients by providing referrals to counseling, support groups, 12-step programs, and drug treatment or by initiating therapy with methadone or buprenorphine rather than discontinuing treatment. Some clinicians increase methadone dosage during HCV treatment to ameliorate cravings and side effects of HCV treatment.67,150 One study reported that occasional drug use during HCV treatment did not have a significant effect on response to HCV treatment111; another continued HCV treatment for people who had relapsed to active drug use. No significant difference in response rates to HCV treatment was found among drug-free patients, those who relapsed before reinitiating methadone maintenance, and those who relapsed and did not reinitiate methadone maintenance during HCV treatment.149

The use of pain medication to manage the side effects of HCV treatment may be a problem for patients who want to remain drug free. One clinician has developed an innovative strategy: Patients sign a contract stipulating that they will get help in discontinuing pain medication if needed.70

Although reinfection with HCV after treatment has been a concern among clinicians who are considering treating injection drug users, few cases of HCV reinfection have been reported.151 Concern about reinfection with HCV and other blood-borne pathogens can be addressed by providing counseling to reduce exposure to blood borne pathogens, making referrals to drug treatment and other harm-reduction modalities appropriate to the patient.