Download Medical Examinations at Entry to Treatment for Drug Abuse as an

SUPPLEMENT ARTICLE
Medical Examinations at Entry to Treatment
for Drug Abuse as an Opportunity to Initiate
Care for Hepatitis C Virus Infection
Holly Hagan,1 Shiela M. Strauss,1 Janetta M. Astone,1 and Don C. Des Jarlais1,2
1
Center for Drug Use and HIV Research, National Development and Research Institutes, and 2Baron Edmund de Rothschild Chemical Dependency
Institute, Beth Israel Medical Center, New York, New York.
Over the course of addiction, a substantial proportion of drug users enter drug abuse treatment programs.
Data from a cross-sectional survey of drug abuse treatment programs in the United States were analyzed to
describe the scope of the medical examination performed at admission to such programs. All of the methadone
programs (n p 95) and 50% of drug-free programs (80 of 161) required a medical examination at entry. Most
examinations included screening for signs and symptoms of liver disease and liver function testing. Nearly
all methadone programs (97%) provided referral to medical care or support for patients with test results
positive for antibody to hepatitis C virus (HCV), compared with 75% of drug-free programs (P ! .01 ). Drugfree programs requiring medical examinations provided education about HCV and testing for HCV to a larger
proportion of their patients (P ! .05 ). With high dropout rates in the early stages of treatment for drug
addiction, these medical visits may be an important opportunity for further monitoring and care for HCV
infection and other conditions.
An excess incidence of hepatitis C virus (HCV) infection occurs among injection drug users and persons
who administer illicit drugs by other routes, such as
smoking or inhaling [1–5]. HCV infection results in a
chronic carrier state in 80%–85% of patients; treatment
of persistent infection with pegylated IFN-a and ribavirin may result in sustained viral response in 40%–
50% of patients [6, 7]. Drug use is associated with
several other acute and chronic medical conditions, including HIV infection and coinfection with HIV and
HCV [8, 9]. However, despite drug users’ relatively poor
health, studies have shown that access to medical care
among drug users is low, compared with persons who
do not use illicit drugs [10]. Of particular concern with
respect to treatment of chronic illness, the use of health
care may be crisis oriented, with little continuity in
medical care [11]. Recent research has reported that
Reprints or correspondence: Dr. Holly Hagan, Center for Drug Use and HIV
Research, National Development and Research Institutes, 71 West 23rd St., New
York NY 10010 ([email protected]).
Clinical Infectious Diseases 2005; 40:S297–303
2005 by the Infectious Diseases Society of America. All rights reserved.
1058-4838/2005/4009S5-0007$15.00
treatment for HCV infection is offered to only a small
proportion of medically eligible patients with a recent
history of drug use [12].
Over the course of chronic dependence on narcotics
and other hard drugs, many drug users in the United
States will have contact with programs for treatment of
drug abuse [13]. These treatment programs have been
shown to be an important setting for increasing access
to care and treatment for infectious diseases [14–16].
Although many drug abuse treatment programs are
providing HCV-related services to some of their patients, important gaps remain. For example, surveys of
drug abuse treatment programs in the United States
and the United Kingdom have shown that a minority
of programs offer screening for HCV to all of their
patients [15, 17]. Methadone programs in the United
States provide more HCV-related services to their patients than do drug-free treatment programs, including
offering HCV screening and education to a higher proportion of patients and providing more-comprehensive
HCV-related information to patients [18, 19]. Managers of both treatment modalities have reported that,
if they were given the resources to do so, they would
Medical Examinations in Drug Treatment Programs • CID 2005:40 (Suppl 5) • S297
Table 1.
Characteristics of medical examination in relation to drug abuse treatment offered.
Drug abuse treatment
programs, no. (%)
Characteristic
Requires a medical examination at treatment enrollment
Yes
No
Of those requiring a medical examination
Provided on-site
Yes
No
Examination performed by a physician or physician assistant
Yes
No
Examination asks about history of
Liver disease
Yes
No
Hepatitis
Yes
No
Jaundice
Yes
No
Loss of appetite
Yes
No
Enlargement of the abdomen
Yes
No
Tendency toward bleeding or bruising
Yes
No
Swelling of lower extremities
Yes
Methadone
(n p 95)
Drug-free
(n p 161)
P
95 (100)
80 (50)
!.01
0 (0)
81 (50)
85 (89)
32 (40)
10 (11)
48 (60)
78 (84)
48 (62)
15 (16)
29 (38)
92 (97)
3 (3)
65 (87)
10 (13)
.01
92 (97)
3 (3)
69 (90)
8 (10)
.05
71 (75)
24 (25)
51 (68)
24 (32)
NS
85 (89)
10 (11)
65 (86)
11 (14)
NS
79 (83)
16 (17)
52 (68)
24 (32)
.02
76 (80)
19 (20)
53 (71)
22 (29)
NS
!.01
!.01
!.01
83 (87)
49 (65)
No
Patient is asked about alcohol use
12 (13)
26 (35)
Yes
No
Patient is asked about HIV seropositivity
94 (99)
1 (1)
73 (95)
4 (5)
NS
Yes
No
Examination includes
76 (80)
19 (20)
56 (74)
20 (26)
NS
.01
Inspection of the skin for spider angiomas or other signs
of liver disease
Yes
82 (86)
51 (71)
No
Palpation or percussion for enlarged liver
Yes
13 (14)
21 (29)
78 (82)
56 (78)
No
Palpation or percussion for enlarged spleen
Yes
17 (18)
16 (22)
81 (86)
47 (66)
13 (14)
24 (34)
No
NS
!.01
(continued)
Table 1.
(Continued.)
Drug abuse treatment
programs, no. (%)
Methadone
(n p 95)
Characteristic
Examination includes blood testing
Yes
No
Drug-free
(n p 161)
P
94 (99)
55 (72)
!.01
1 (1)
21 (28)
92 (97)
3 (3)
103 (75)
34 (25)
!.01
95 (100)
87 (54)
!.01
0 (0)
74 (46)
67 (71)
27 (29)
43 (88)
6 (12)
.03
67 (100)
35 (81)
!.01
0 (0)
8 (19)
61 (91)
6 (9)
42 (100)
0 (0)
.05
9 (17)
43 (83)
10 (33)
20 (67)
NS
Program provides referral to medical care or other support
for anti-HCV–positive patientsa
Yes
No
Program provides any medical care to patients
Yes
No
Of those performing blood testing
Blood tests typically include a liver panel
Yes
No
Treatment staff review liver panel test results
Yes
No
Patients are informed of their liver panel test results
Yes
No
Follow-up testing of abnormal liver panel tests is done
Only for patients with HCV risk factors
All patients with abnormal results
NOTE. Totals may not equal n because of missing data. All P values were calculated by x2 tests. anti-HCV,
antibody to hepatitis C virus (HCV); NS, not significant.
a
For programs that have HCV-positive patients.
be interested in providing more HCV-related services [20].
Many programs, especially methadone and residential drug
abuse treatment programs, require that all of their patients
undergo a medical examination before admission. The time of
entry to treatment for drug abuse may be a period when drug
users are motivated to make substantial lifestyle changes and
improve their health. The staff of drug abuse treatment programs, including medical personnel, may have relatively longterm contact with some patients, although retention in drug
abuse treatment programs overall is relatively low, with ∼50%
of patients in drug-free programs leaving within the first 3
months and 25%–30% of patients in methadone programs leaving within the first year [21]. Nonetheless, the entry medical
examination may detect HCV infection or symptoms indicating
progression of chronic hepatitis and may serve as a point of
referral to additional monitoring of HCV infection and care.
Here, we analyzed data from a national survey of US drug
abuse treatment programs to describe the extent to which drug
abuse treatment programs are currently conducting medical
examinations and what the examinations include, to under-
stand the potential contribution of this relatively routine service
to screening for and care of HCV infection.
METHODS
A cross-sectional telephone survey of drug abuse treatment
programs in the United States was performed to study a broad
set of research questions regarding HCV-related education, services, and medical care provided. Drug abuse treatment programs were selected at random from the October 2000 Inventory of Substance Abuse Treatment Services list of drug abuse
treatment units compiled by the Substance Abuse and Mental
Health Services Administration. To be included in the initial
screening, programs must have provided treatment for drug
abuse, dependence, or addiction; those that treated alcohol use
only were excluded. Drug abuse treatment programs that provide methadone to their patients were oversampled in the survey, because patients with risk factors for HCV infection would
be more likely to receive methadone treatment than other types
of treatment. Randomly ordered lists of drug abuse treatment
programs were created, one including those licensed to dispense
Medical Examinations in Drug Treatment Programs • CID 2005:40 (Suppl 5) • S299
methadone and the other including all other types of drug abuse
treatment.
By use of these lists, managers of programs were contacted
and asked questions to determine eligibility for the survey, including whether drug abuse treatment services were provided
on-site and to ⭓50% of all patients; programs that offered only
detoxification or short-term treatment of !7 days’ duration
were excluded. At the time of the screening, managers were
also asked a few questions about services related to HCV provided at the program, to judge whether there were systematic
differences between programs that volunteered versus those that
refused to join the study. Attempts were made to screen a total
of 1286 programs; 42% did not meet inclusion criteria for the
study or could not be contacted after repeated attempts, and
10% refused to participate in the screening. Thus, a total of
614 programs were eligible and willing to enroll in the study
and completed the screening questionnaire. According to protocols approved by the institutional review board at National
Development and Research Institutes, participants provided informed verbal consent prior to completion of the interview.
Data were collected via a 3-h computer-assisted telephone
survey by use of Questionnaire Development System software
(version 2.0; NOVA Research Company). The questionnaire
was divided into 3 sections, and, typically, each section was
completed by the director, the staff supervisor, and the program
nurse or the person most knowledgeable about the subjects
covered in that section of the questionnaire. Items in the survey
included characteristics of the program, such as organizational
structure, source of financing, licensing, and ideology of the
director; patient demographics; and staffing. A large set of questions focused on HCV- and HIV-related education, screening,
and support provided by the program. The methods and instrument used in the present study were modified from a national study of outpatient substance abuse treatment programs
by D’Aunno et al. [14]. The instrument and protocols were
pilot tested with 25 treatment programs, and modifications
were made on the basis of the pilot study. Data collection was
performed from October 2001 to June 2003.
Eligible programs were contacted by phone and mail to prepare them for participation in the survey; worksheets were sent
to the program so that participants could collect some quantitative information before completing the interview (e.g., the
number of women in the program and the estimated proportion of patients who were positive for antibody to HCV [antiHCV]). During the interval between initial screening for eligibility and recontacting them, 45 programs became ineligible,
and 90 could not be reached despite many attempts. This reduced the number of eligible programs to 479; among the 479,
a total of 291 programs participated in the survey (61%). The
primary reason for not participating in the survey was a lack
of staff time and resources to complete the survey worksheets
S300 • CID 2005:40 (Suppl 5) • Hagan et al.
and interview. Among the 291 participating programs, 256
(88%) completed the section of the survey that asked about
medical examination at enrollment. Univariate analysis was
done with x2 and t tests to evaluate the statistical significance
of differences in medical examinations between programs, by
modality, availability of other services, and other program-level
characteristics. Because our intent was to describe service availability as it exists in programs (rather than evaluating a causal
relation), no multivariate models were created.
RESULTS
There were 95 methadone programs and 161 drug-free treatment programs in the sample. The methadone clinics were
larger in terms of number of patients enrolled in the past year,
with a mean of 457 patients (median, 362 patients), compared
with a mean of 397 patients (median, 210 patients) enrolled
in the drug-free programs. As expected, a greater proportion
of patients in methadone programs had ever injected an illicit
drug, with a mean of 78% (median, 89%), compared with a
mean of 20% (median, 13%) in drug-free programs (P ! .01).
Most methadone programs (94%) offered testing for anti-HCV
to at least some of their patients, compared with 68% of drugfree programs (P ! .01).
All of the methadone programs and 50% of the drug-free
treatment programs required a medical examination at the time
of enrollment into treatment (table 1). Among methadone programs, 89% provided those examinations on-site, and most
examinations were done by a physician or physician assistant
(84%). Drug-free programs were more likely to offer medical
examinations off-site. In both treatment settings, the medical
history obtained from patients typically included asking about
past liver disease, hepatitis, and jaundice. In most of these examinations, drug users were asked whether they had experienced symptoms associated with hepatitis or liver disease, such
as loss of appetite, enlargement of the abdomen, tendency toward bruising or bleeding, and swelling of lower extremities.
Medical histories obtained at methadone programs tended to
include asking a greater number of questions related to liver
disease. A small proportion of programs of either type omitted
asking about alcohol use (1%–5%) or HIV seropositivity (20%–
26%), conditions that may affect the clinical course of chronic
hepatitis C disease.
Medical examinations for methadone patients were more
likely to include palpation for enlarged spleen and inspection
of the skin for signs of liver disease. Nearly all examinations
performed in methadone programs (99%) included collection
of a blood specimen, compared with 72% of drug-free programs. Among programs that did perform blood testing as part
of the enrollment examination, liver function tests were performed in more drug-free programs (88%) than methadone
programs (71%). In drug-free programs, all patients given liver
Table 2. Characteristics of medical examination in relation to other services related to hepatitis C virus (HCV) provided to patients
undergoing treatment for drug abuse.
Patients were actually screened for anti-HCV
!50% of patients
⭓50% of patients
(n p 36)
(n p 48)
Yes
36 (100)
48 (100)
No
0 (0)
0 (0)
Yes
19 (53)
42 (88)
No
17 (47)
6 (13)
Program, characteristic
Methadone programs
P
HCV education was provided to:
!50% of patients
⭓50% of patients
(n p 30)
(n p 65)
30 (100)
65 (100)
0 (0)
0 (0)
22 (73)
45 (69)
8 (12)
20 (31)
P
Medical examination required at enrollment
…
Examination includes liver panel
!.01
NS
Protocol for follow-up testing of abnormal LFT results
Only for patients with HCV risk factors
3 (20)
4 (11)
12 (80)
31 (89)
Yes
36 (100)
48 (100)
No
0 (0)
0 (0)
(n p 61)
(n p 34)
Yes
34 (56)
26 (76)
No
27 (44)
8 (24)
Yes
19 (63)
15 (68)
No
11 (37)
7 (32)
All patients with abnormal results
NS
2 (12)
7 (19)
15 (88)
30 (81)
30 (100)
65 (100)
0 (0)
0 (0)
(n p 77)
(n p 84)
32 (42)
48 (57)
45 (58)
36 (43)
16 (57)
27 (64)
12 (43)
15 (36)
NS
Program helps HCV-positive patients obtain medical
care or support
Drug-free programs
…
NS
Medical examination required at enrollment
.04
.05
Examination includes liver panel
NS
NS
Protocol for follow-up testing of abnormal LFT results
Only for patients with HCV risk factors
2 (14)
6 (35)
12 (86)
11 (65)
Yes
37 (61)
27 (79)
No
24 (39)
7 (21)
All patients with abnormal results
NS
2 (18)
8 (32)
9 (82)
17 (68)
36 (47)
51 (61)
41 (53)
33 (39)
NS
Program helps HCV-positive patients obtain medical
care or support
.06
.08
NOTE. Data are no. (%) of programs, except where noted. Totals may not equal n because of missing data. All P values were calculated by x2 tests. LFT,
liver function testing; NS, not significant.
function tests were informed of the results, compared with 91%
of patients in methadone programs. However, taking into account the fact that fewer drug-free programs required medical
examinations or did any blood testing, a larger proportion of
methadone patients received liver test results (61/95 [64%])
than did patients in drug-free programs (42/161 [26%]). Follow-up testing (including anti-HCV, serologic testing for hepatitis B virus, and other tests) was usually performed for all
patients with abnormal liver function test results; in some cases,
further testing was performed only when patients had risk factors for HCV infection, such as history of drug injection.
Nearly all methadone programs (97%) provided referral to
medical care for anti-HCV–positive patients, as did a large majority of drug-free programs (75%; P ! .01). All methadone programs provided some form of medical care to their patients,
compared with 54% of drug-free programs (P ! .01).
In table 2, provision of specific components of the medical
examination is shown in relation to the availability of other
services related to hepatitis C disease in treatment program by
modality. Medical examinations were more likely to be required
in drug-free programs, in which more than half of patients
actually received anti-HCV screening and education. Among
methadone programs, liver function tests were more likely to
be done in programs in which the majority of patients were
tested for anti-HCV. Among drug-free programs that provided
education and screening for HCV to more than half of their
patients, a slightly higher proportion also helped HCV-positive
patients obtain medical care and treatment.
DISCUSSION
In the present study, a large proportion of patients enrolled in
drug abuse treatment programs in the United States received
a medical examination at time of enrollment. In most cases,
this examination included screening for signs and symptoms
of liver disease. Because many drug-free programs include a
high proportion of patients with a history of alcohol abuse, the
examination may also be intended to detect alcohol-related
cirrhosis. Nearly all programs inform patients of the results of
blood tests for liver abnormalities and do follow-up testing to
Medical Examinations in Drug Treatment Programs • CID 2005:40 (Suppl 5) • S301
discover underlying causes for abnormal tests results. Patients
are also usually asked about HIV infection and alcohol use.
Thus, in the majority of drug abuse treatment programs, the
entry physical examination may be an excellent starting point
for addressing a number of issues related to HCV, HIV, coinfection, liver disease, and alcohol use.
Several differences between methadone and drug-free treatment programs were also noted. The data showed that enrollment into methadone treatment programs includes a somewhat
more extensive examination for signs and symptoms of hepatitis and that blood testing for liver abnormalities was more
likely to be performed. Level and type of medical screening and
examination at the time of enrollment would be expected to
vary between programs that provide a highly regulated medication, such as methadone, versus those that primarily provide
counseling. Methadone programs were more likely to help antiHCV–positive patients obtain medical care or other support
and were more likely to have provided any medical care to
their patients. This may be related to the fact that methadone
programs are a more medically oriented environment, with
medically trained staff and facilities.
The present study has several limitations, including that the
sample may not be fully representative of all drug abuse treatment programs in the United States. It is conceivable that programs that offered more HCV-related services would be more
likely to participate in a study of this type, although comparison
of those programs that agreed to participate and those that did
not showed no systematic differences in terms of factors that
may be related to the provision of medical examinations (such
as hospital affiliation, ownership of the unit, membership in a
network of units, number of patients treated each month, and
number of staff members who have direct contact with patients). Because the data were obtained by self-report from staff
of the programs, it is also possible that there was misclassification of programs with respect to the characteristics we studied. This potential bias was addressed in the design of the study,
by having programs complete worksheets in advance of the
interview to allow program staff to examine records and collect
quantitative data with more accuracy.
Because they are done in such a large proportion of drug
abuse treatment settings, these medical examinations can be an
important point of entry to additional medical care for HCV
and other infectious diseases. Examinations that establish a
clinician-patient relationship can also set the stage for followup HCV-related education and counseling. To a limited extent,
some coordination already occurs, because programs that required medical examinations were also more likely to provide
anti-HCV screening and education to all patients. Blood testing
for liver abnormalities also tended to occur in settings in which
a majority of patients were likely to receive screening for antiHCV. In our survey, methadone treatment programs provided
S302 • CID 2005:40 (Suppl 5) • Hagan et al.
a more comprehensive examination than did drug-free programs, and only half of drug-free programs required any medical examinations at entry. These differences are attributable
somewhat to regulations governing methadone programs but
also indicate that too few drug-free programs are using an
opportunity to address important medical issues with their patients. Clearly, underutilized capacity exists in a large proportion of drug abuse treatment programs in the United States to
serve as sites for medical care and support for their patients
who are at risk of acquiring HCV and other infections.
Acknowledgments
We wish to acknowledge the contribution of project interviewers to the
quality of the study and the generosity of drug abuse treatment program
providers who participated in the surveys.
Financial support. National Institutes of Health (grant DA-13409).
Potential conflicts of interest. All authors: no conflicts.
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