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Hillsborough doctor sees Hepatitis C link to heroin use

HILLSBOROUGH - The use of heroin and heroin overdoses has grabbed headlines in Central Jersey all year.

For Dr. Ronald Nahass, president of ID Care, a Hillsborough-based practice specializing in infectious diseases, those headlines also should include Hepatitis C, a curable disease caused by a virus that infects the liver. Left untreated the virus can cause lifelong infection, liver scarring, liver cancer, liver failure and death.

The virus is spread through blood and body fluids, often through sharing drugs and needles.

Nahass recently presented the conclusions of a study on the incident of Hepatitis C in suburban drug users in New Jersey at the national meeting of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology, the Pediatric Infectious Diseases Society and the HIV Medicine Association.

"We recognize and think the heroin problem is really getting appropriate recognition for the problem it is. I've been concerned that folks aren't linking or recognizing that not only is the heroin a tragedy but the problem with the Hepatitis C within the state is as big a tragedy associated with it," said Nahass who sees young suburban heroin users as the next wave of Hepatitis C patients.

The Centers for Disease Control and Prevention estimates there are at least 3.2 million people in the U.S. with chronic Hepatitis C. infection and about 150 million people are living with the virus worldwide.

According to Nahass, about a year ago a colleague Dr. Mark Schwartz, an addiction medicine specialist, became concerned as he was seeing patients at Princeton House, a behavioral health unit of the University Medical Center at Princeton, being admitted for detoxification also having Hepatitis C.

Nahass said Schwatz started randomly testing and was noticing there seemed to be a lot of patients with positive Hepatitis C tests.

"They had a general practitioner physician who was seeing those patients and he suggested that maybe they engage me because he knew of my interest in Hepatitis C to help them in developing a program of evaluation," he said.

As a result, Nahass, working with Schwartz and Dr. Neal Shofield at Princeton House, put into place a program of screening every patient for Hepatitis C who was admitted for acute detox.

Study results

In the 10-month study the doctors found 44 percent of the patients 376 of 861, who were admitted for treatment tested positive for Hepatitis C, with 63 percent, 237 of 376 patients under age 35.

"That's really a problem," Nahass said. "I would guess if we did it in Atlantic City, Camden, Paterson, Morristown or Flemington you would see the same thing, and that's the concern."

"It's a real tragedy. I'm an adult doctor, but to sit across from a 17, 18 and a 19-year-old and 20-year-old and talk to them about having Hepatitis C there is usually tears on my side and their side. The only saving grace in our epidemic is that the HIV virus is not in this population," said Nahass, adding the possible introduction of HIV is a concern.

Kathleen Seneca, an ID Care nurse practitioner, and Nahass started evaluating each patient who tested positive for Hepatitis C. He said the patients were provided with information, counseling, and an understanding of what the test means and the importance of getting evaluated and treatment because with treatment they will no longer be infected and the disease can't be further transmitted.

Nahass saw his involvement as a way to provide information, get patients treated and limit the spread of the virus in the state.

"Probably only about 50 percent of them really had any inkling they were infected, maybe even less," Nahass said.

"One of the other things that's pretty tragic about this whole problem is that the recidivism rate as you might expect with intravenous drug use is pretty high. So even if you acutely detox off heroin it's not all that uncommon to see someone come back and be readmitted for another episode of detoxification," he said. "And you'll see that they go from being negative for Hepatitis C to positive for Hepatitis C in that relatively short time period so that they get re-exposed because of their habit and got infected in the time period between the first evaluation and the second evaluation. We call that an acute infection."

He said most patients were devastated because they realized Hepatitis C was something they didn't need to get and they are scared.

Kathleen H. Seneca, left, and Dr. Ronald Nahass, president of ID Care, an infectious disease practice in Hillsborough, talk about Dr. Nahass' recently presented conclusions drawn in a study on the incidence of Hepatitis C in suburban drug users in New Jersey.

A virus with no initial symptoms

Without testing, Nahass said there is no way for someone to know they have Hepatitis C.

"And one of the problems with this particular infection, is that it is silent. There really are no clinical symptoms. There's no real way to know unless you get tested. You just don't generally feel sick," he said.

Nahass said the Centers for Disease Control and the United States Public Health Service Task Force have come out with recommendations that all baby boomers be tested for Hepatitis C once because it's an asymptomatic disease and because the majority of people in the United States who have Hepatitis C are baby boomers.

"Except now, this is the so-called second wave. The second wave are the young suburban heroin using population under 35 that have it as well," Nahass said. "Anybody at a heroin detox center is at risk, and they should all be tested."

Because the study was limited to one facility in the state, Nahass would like to see it expanded and has had some discussions with other facilities.

"But as you might expect one of the problems in doing it, and I give Princeton House some credit for this, is that there is a cost to it," he said. "Those blood tests are not all that inexpensive and if a facility is being marginally reimbursed for these detoxification services those tests can eat into their ability to run the program for detoxification."

As a result, he said most facilities are choosing not to test for Hepatitis C because they can't afford to and because there is no reimbursement.

Nahass, however, said there are some opportunities for grant funding.

But perhaps an even bigger challenge is the linkage to care -- getting patients to the care they need after they have been tested and counseled.

He said out of 270 patients only six actually came in for treatment.

"Which is tragic in and of itself because you have these opportunities to slow the epidemic by curing them, getting them treated, and we can't get them in and that's called linkage to care," said Nahass who has received some funding to hire a case manager to contact patients, and help them navigate patient's communication, transportation, and family issues to get them the treatment they need.

"We've been really successful with HIV because the Ryan White Care Act provided funding for case management. Insurance payments generally don't, but to fund case management, which worked very well with HIV in linking people to care, even intravenous drug users are successfully treated because of that. We don't have that same funding mechanism in Hepatitis C. And so in the absence of case management, I think it will be very difficult to get many of them in for treatment," Nahass said. "That's a challenge and we're trying to figure it out."

Change through legislation

Toward that goal, Becky Lucas, ID Care director of clinical services, helped write a bill that aims to require narcotic and drug abuse treatment centers to offer Hepatitis C counseling and testing to clients.

"It's also kind of the same bill as the baby boomers," said Lucas, adding the bill is still waiting for a number. She said the bill is sponsored by state Sen. Anthony Bucco, R-25th District who represents Morris and Somerset counties. Lucas believes she will be able to speak at a committee meeting about the bill.

Bucco said the bill 3149 is very simple in that it wants narcotic and drug abuse treatment centers to offer Hepatitis C. pre-screening and counseling. He said the bill is currently in the health committee waiting to be heard, and hopefully go to the floor for a vote. He does not expect it to be heard until after the election, or it may need to be reintroduced in the next session, he said.

Bucco said he chose to sponsor the bill based on what his constituents want.

"Hepatitis C is a problem with drug users," he said, adding if the virus can be curbed, every step counts.

State Sen. Joseph Vitale, D-19th, chair of the senate Health, Human Services and Senior Citizens Committee, sees the important of the bill.

Vitale, who represents Carteret, Perth Amboy, Sayreville, South Amboy and Woodbridge in Middlesex County, said he's already written a bill passed by the state Senate requiring all health care providers and hospitals to offer Hepatitis C screening. Vitale said Bucco bill could be incorporated into his, or it could remain separate.

"I think we do do need universal testing. It's a simple test," said Vitale, noting like Nahass that the Centers for Disease Control and Prevention recommend all baby boomers born between 1946 and 1965 be tested for Hepatitis C because of the initial lack of symptoms.

Vitale said he has a package of about 21 bills aimed as addressing the heroin crisis focusing on prevention, education, treatment and recovery. He said 16 of the bills have been signed into law.

"We're working on this from four or five different angles," said Vitale, adding he recognizes with intravenous heroin drug users there also is a chance for sharing needles and getting Hepatitis C or HIV.

"We have a lot of people passionate about this issue," Nahass said.

Though none of the patients in the study were also infected with HIV, Nahass is concerned about the possibility of the spread of HIV within this group.

He said in southern Indiana there is a suburban heroin using populations that quickly went from no cases of HIV in December 2014 to a couple of cases in January and February and now there are about 170 HIV cases, all from a single strain of the virus.

"I find that just amazing as an example of how quickly and how serious this problem is,"said Nahass, who is hoping to keep HIV out of the network of transmission so patients aren't battling both ailments.

The Three H diseases

Heroin, HIV and Hepatitis C are called the three H diseases.

"They are all linked," he said. "The root of the problem is the heroin. And the heroin is so cheap and so available that theoretically, if you could potentially address that maybe you solve the concern for the HIV and solve the Hep C problem."

While solving the heroin problem could solve the HIV and Hepatitis C problem, solving the Hepatitis C problem might be easier.

And making people aware of the danger of Hepatitis C may be key. He's looking at the possibility of using social media to reach the the target age group through Twitter, Facebook and Instagram.

He's also considered doing an ice bucket-type challenge he calls the Whip C Challenge.

"It is about raising the awareness and it is about the three H's. Even though we don't have HIV," said Nahass. "The three H's go together. It's heroin, HIV and Hep C. It is a tragedy what we're dealing with."

Additional information about services offered by ID CARE are available at www.idcare.com or by calling 908-281-0221.

Staff Writer Suzanne Russell: 732-565-7335; srussell@mycentraljersey.com

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