As America’s youth fall victim to the opioid epidemic, new evidence suggests that doctors aren’t appropriately screening teens for infectious diseases like hepatitis C and HIV.
Only about one-third of teenagers and young adults who report opioid misuse are being tested for hepatitis C by their healthcare providers, according to a new study by Boston Medical Center researchers. This is so even though about 10 percent of those who are tested are found to have been exposed to the virus.
Furthermore, only 11 percent of the teens tested for hepatitis C were also screened for HIV, notwithstanding that the two diseases tend to go hand in hand, because of similar routes of transmission.
Something’s broken regarding safeguards for this high-risk group, according to Rachel Epstein, MD, the study’s lead author and an infectious disease fellow at Boston Medical.
“In the midst of the current opioid use crisis,” she said at an infectious disease conference earlier this month, “where young people are more likely to transmit [infections], we need to be testing in order to diagnose, to find cases, and to link them to care.”
Marc Fishman, MD, an expert in teen addiction not involved in the study, says he’s chagrined, but not surprised, by the inadequate screening uncovered by the study.
“It’s typical of the disjointed nature of how we treat these things,” he says. Addiction and mental health services “have been separated from the broad house of medicine.”
Fishman is medical director of the Maryland Treatment Centers and an assistant professor at the Johns Hopkins University Department of Psychiatry.
Epstein presented her research three weeks ago at the annual meeting of the Infectious Diseases Society of America in San Francisco. It has not yet been approved for publication. (Epstein’s colleagues on the study were Jianing Wang, Kenneth Mayer, MD, Jon Puro, C. Robert Horsburgh, MD, Benjamin P. Linas, MD, and Sabrina A. Assoumou, MD.)
Hepatitis C killed 18,000 Americans in 2016. Yet modern drugs can cure the disease in most patients.
The disease killed 18,000 Americans in 2016. Yet modern drugs can cure the disease in most patients. In 2017, the FDA approved medication to treat teens with the virus.
Epstein embarked on her recent research, she tells Opioid Watch in an interview, because she noticed that while there was a dramatic uptick in opioid addiction among teenagers, there was no corresponding reported increase in hepatitis C diagnoses.
“So that brings up the question,” she continues: “Is there just not a large burden of hepatitis C in adolescents, or are we just not looking for it?”
In her study, Epstein collected and analyzed nearly 270,000 electronic medical records for teens and young adults (age 13 to 21) who had visited 57 clinics across 19 states over five years. In the end, she identified 875 young people who had been diagnosed with opioid use disorder. Of those, only about a third (315 patients) had been screened for hepatitis C.
Alarmingly, a significant number of those tested—one out of ten—had, in fact, been exposed to the virus, she found. Some patients’ immune systems had been able to kick back the virus, but most of the teens went on to develop a chronic infection.
Are the screening guidelines too narrow?
For young people, federal guidelines stress hepatitis C testing for anyone who has ever injected drugs. (HIV testing is recommended at least once for everyone, regardless of risk behaviors.)
Although the teens and young adults in Epstein’s study were known to misuse opioids, they had not necessarily reported injection drug use. The research showed, however, that many of them were being infected in fact, regardless of whether they acknowledged injecting drugs.
There are two reasons this might be so.
“It might be because people are reluctant to tell us, or are, frankly, lying” about drug injection, says Fishman.
Another possibility is that they haven’t injected drugs, but are still being exposed through other means. They might, for instance, be having sex with partners who are positive, says Nancy Reau, MD, in an interview. Reau is a professor of internal medicine and section chief of hepatology at Rush University Medical Center in Chicago.
“We have a paternalistic responsibility to be assertive about [screening],” says Fishman, because “young people tend not to think of themselves as having chronic disease.”
HCV and HIV: Why screen for one but not the other?
One of the more perplexing results of Epstein’s research was the fact that only 11 percent of the young people screened for hepatitis C were also tested for HIV. Because the two diseases are often so closely intertwined, it seems logical to screen for both.
After the notorious 2015 outbreak of HIV in Scott County, Indiana, for instance, health officials determined that 90 percent of those infected with HIV were also infected with hepatitis C.
“We were quite surprised at how low [HIV testing] was,” says Epstein.
Reau, of Rush, also found that fact disturbing.
“If I’m talking [to patients] about hepatitis C, I should be talking about HIV also,” she says. “I don’t know why there’s that disconnect.”