Back in 1992, a friend and colleague of mine by the name of Bill M. became ill. He began feeling tired and run down, unable to make it through a full day at the treatment facility where he was working.

He was constantly nauseous, had little or no appetite, and was losing weight. Bill was never a small man, but his weight dropped from 290 to 210 in less than 6 months. He was also having difficulty walking — his knee and ankle joints were constantly stiff and achy.

Being in recovery for almost 15 years, Bill was surprisingly reluctant to see his family physician. He later told me, “I was always fearful that something from my drug-using past would creep up on me — I didn’t really want to know if my shooting heroin would haunt me for the rest of my life.” He finally made an appointment, primarily because of the insistence of his wife and family.

Testing revealed that Bill had Hepatitis C. All who knew him were baffled. He was in long-term recovery. He hadn’t relapsed and wasn’t currently involved in high-risk behaviors. In spite of his size and weight he had been in pretty good health. Plus, none of us — family, friends, and treatment colleagues — had ever heard of this illness. By the time Bill was diagnosed, his illness was in an advanced stage. No treatment was helping and there was some talk of a liver transplant.

Unfortunately, Bill’s health failed rapidly after this and he succumbed to his illness before a transplant could even be considered.

This was my first exposure to Hepatitis C. The illness impacts a higher percentage of the population with which drug and alcohol counselors work, more than any other group. It is because of this reality that drug and alcohol counselors need to have basic information about this deadly disease and understand our responsibility of identifying high-risk behaviors that warrant testing and treatment interventions.

The history of Hepatitis C
During the early 1970s, doctors became aware of the spread of an aggressive new virus that attacked the liver. The disease attacked the body in a similar fashion to Hepatitis A and B. This new virus caused liver inflammation, but unlike patients who contracted Hepatitis A and B, those who were diagnosed with this new virus couldn’t be cured by existing treatment methods (Alter, 1996).

Hepatitis C stayed in the patient’s body and continued to damage the liver, eventually causing death. Because test results would indicate that these patients had neither Hepatitis A nor B, doctors referred to the condition as “non-A, non-B Hepatitis.” Then, in 1989, doctors finally identified the cause of this mysterious liver disease. It was a virulent strain of Hepatitis they called Hepatitis C virus, or “HCV” (AMA, 1995).

The hepatitis C virus
HCV is one of the most significant causes of chronic liver disease in the U.S. It accounts for about 20 percent of acute viral Hepatitis, 60 to 70 percent of chronic Hepatitis, and 30 percent of cirrhosis, end-stage liver disease, and liver cancer. Approximately 4 million Americans, or 1.8 percent of the U.S. population, have the antibody to HCV (anti-HCV), indicating ongoing or previous infection with the virus. Hepatitis C causes an estimated 8,000 to 10,000 deaths annually in the U.S. (CDC, 2003).

Chronic Hepatitis C varies greatly in its course and outcome. At one end of the spectrum are patients who have no signs or symptoms of liver disease and completely normal levels of serum liver enzymes. Liver biopsy usually shows some degree of chronic Hepatitis, but the degree of injury is usually mild, and the overall prognosis may be good.

At the other end of the spectrum are patients with severe Hepatitis C who have symptoms, HCV RNA in serum, and elevated serum liver enzymes, and who ultimately develop cirrhosis and end-stage liver disease.

In the middle of the spectrum are many patients who have few or no symptoms, mild to moderate elevations in liver enzymes, and an uncertain prognosis. Researchers estimate that
at least 20 percent of patients with chronic Hepatitis C develop cirrhosis, a process that takes 10 to 20 years. After 20 to 40 years, a smaller percentage of patients with chronic disease develop liver cancer (CDC, 2003).

Chronic Hepatitis C can cause cirrhosis, liver failure, and liver cancer. Approx-imately 20 percent of patients develop cirrhosis within 10 to 20 years of the onset of infection.
Liver failure from chronic Hepatitis C is one of the most common reasons for liver transplants in the U.S. Hepatitis C might be the most common cause of primary liver cancer in the developed world. In Italy, Spain, and Japan, at least half of liver cancers could be related to HCV. Males, alcoholics, patients with cirrhosis, people over age 40, and those infected for 20 to 40 years are more likely to develop HCV-related liver cancer (Worman, 2002).

HCV is a small (40 to 60 nm in diameter), enveloped, single-stranded RNA virus of the family Flaviviridae. Because the virus mutates rapidly, changes in the envelope protein may help it evade the immune system.

There are at least 6 major genotypes and more than 50 subtypes of HCV. The different genotypes have different geographic distributions. The most common in the U.S. are genotypes 1a and 1b. Genotypes 2 and 3 are present in only 10 to 20 percent of patients. There is little difference in the severity of disease or outcome of patients infected with different genotypes.

However, patients with genotypes 2 and 3 are more likely to respond to alpha interferon treatment (Strader & Seeff, 1996).

Clinical symptoms and signs
Many people with chronic Hepatitis C have no symptoms of liver disease. If symptoms are present, they are usually mild, nonspecific, and intermittent. They may include:

• fatigue
• mild discomfort or tenderness in the right upper quadrant
• nausea
• poor appetite
• muscle and joint pains

Similarly, the physical exam is likely to be normal or show only mild hepatomegaly or tenderness. Some patients have vascular spiders or palmar erythema (CDC, 2003).

Clinical features of cirrhosis
Once a patient develops cirrhosis, or if the patient has severe disease, symptoms and signs are more prominent. In addition to fatigue, the patient may complain of muscle weakness, poor appetite, nausea, weight loss, itching, dark urine, fluid retention, and abdominal swelling. Physical findings of cirrhosis may include (CDC, 2003):

• enlarged liver
• enlarged spleen
• jaundice
• muscle wasting
• excoriations
• ascites
• ankle swelling

Extrahepatic manifestations
Complications that do not involve the liver develop in one to two percent of people with Hepatitis C. The most common is cryoglobulinemia, which is marked by (CDC, 2003):

• skin rashes, such as purpura, vasculitis, or urticaria
• joint and muscle aches
• kidney disease
• neuropathy
• cryoglobulins, rheumatoid factor, and low complement levels in serum

Other complications of chronic Hepatitis C are:

• glomerulonephritis
• porphyria cutanea tarda

Diseases that are less well documented to be related to Hepatitis C are:

• seronegative arthritis
• keratoconjunctivitis sicca (Sjôgren’s syndrome)
• non-Hodgkin’s type, an B-cell
• lymphomas
• fibromyalgia
• lichen planus

Serologic tests
The various tests used to detect the presence of Hepatitis C will be the responsibility of the medical staff of any treatment facility. Counseling personnel may be involved from the standpoint of identifying high-risk activities that may put a client at risk and require investigation. Also, counselors will need to be able to understand the tests used, know how to read the results, and may be involved in helping the medical staff present findings to a client. Please be certain that you discuss these tests with your medical staff and understand what information they provide.

Enzyme immunoassay
Anti-HCV is detected by enzyme immunoassay (EIA). The third-generation test (EIA-3) used today is more sensitive and specific than previous ones. However, as with all enzyme immunoassays, false-positive results are occasionally a problem with the EIA-3. Additional or confirmatory testing is often helpful (CDC, 2003).

The best approach to confirm the diagnosis of Hepatitis C is to test for HCV RNA using a sensitive polymerase chain reaction (PCR) assay. The presence of HCV RNA in serum indicates an active infection. Testing for HCV RNA is also helpful in patients for whom EIA tests for anti-HCV are unreliable. For instance, immunocompromised patients may test negative for anti-HCV despite having HCV infection because they may not produce enough antibodies for detection with EIA. Likewise, patients with acute hepatitis may test negative for anti-HCV when the physician first tests. Antibody is present in almost all patients by one month after onset of acute illness; thus, patients with acute Hepatitis who initially test negative may need follow-up testing. In these situations, HCV RNA is usually present and confirms the diagnosis (CDC, 2003).

Recombinant immunoblot assay
Immunoblot assays are used to confirm anti-HCV reactivity, too. These tests are also called “Western blots” — serum is incubated on nitrocellulose strips on which four recombinant viral proteins are blotted. Color changes indicate that antibodies are adhering to the proteins. An immunoblot is considered positive if two or more proteins react and is considered indeterminate if only one positive band is detected. In some clinical situations, confirmatory testing by immunoblotting is helpful, such as for the person with anti-HCV detected by EIA who tests negative for HCV RNA.

The EIA anti-HCV reactivity could represent a false-positive reaction, recovery from Hepatitis C, or continued virus infection with levels of virus too low to be detected (the last occurs only rarely when sensitive PCR assays are used). If the immunoblot test for anti-HCV is positive, the patient has most likely recovered from Hepatitis C and has persistent antibody without virus. If the immunoblot test is negative, the EIA result was probably a false positive (CDC, 2003).

Immunoblot tests are routine in blood banks when an anti-HCV-positive sample is found by EIA. Immunoblot assays are highly specific and valuable in verifying anti-HCV reactivity. Indeterminate tests require further follow-up testing, including attempts to confirm the specificity by repeat testing for HCV RNA (CDC, 2003).

PCR amplification
PCR amplification can detect low levels of HCV RNA in serum. Testing for HCV RNA is a reliable way of demonstrating that Hepatitis C infection is present and is the most specific test for infection. Testing for HCV RNA by PCR is particularly useful when aminotransferases are normal or only slightly elevated, when anti-HCV is not present, or when several causes of liver disease are possible. This method also helps diagnose Hepatitis C in people who are immunosuppressed, have recently had an organ transplant, or have chronic renal failure. At present, however, there are no PCR assays approved by the Food and Drug Administration for general use, although commercial test systems are available.

Many commercial laboratories offer their own PCR assays, which are not subject to strict independent quality controls. Thus, the reliability and specificity of the PCR technique are not standardized. In addition, it is expensive and prone to technical or laboratory error. When ordering HCV RNA testing by PCR, the physician should use a high-quality laboratory willing to document standardization of the test (CDC, 2003).

Risk factors and transmission
HCV is spread primarily by contact with blood and blood products. Blood transfusions and the use of shared, unsterilized, or poorly sterilized needles and syringes have been the main causes of the spread of HCV in the U.S. (see Table 1, page 28). With the introduction in 1991 of routine blood screening for HCV antibody and improvements in the test in mid-1992, transfusion-related hepatitis C has virtually disappeared (CDC, 1998).

The major high-risk groups for Hepatitis C are (CDC Slide Set, 2003):

• People who had blood transfusions before June 1992, when sensitive tests for anti-HCV were introduced for blood screening.
• People who have frequent exposure to blood products. These include patients with hemophilia, solid-organ transplants, chronic renal failure, or cancer requiring chemotherapy.
• Healthcare workers who have suffered needle-stick accidents.
• Injection drug users, including those who used drugs briefly many years ago.
  At present, injection drug use is the most common risk factor for contracting the
  disease.
• Infants born to HCV-infected mothers.

Medical treatment
While some antiviral treatment now is available for HCV, it has not been highly effective. It has been shown to have toxic effects and often is poorly tolerated. Research efforts to develop more effective treatment approaches that are appropriate for broader patient populations are ongoing. At present, the antiviral drug interferon, used alone or in combination with ribavirin, is approved for treatment of HCV (NIH, 1997). When interferon is combined with ribavirin, the effectiveness of treatment improves.

Studies indicate that the combination is effective in 30 to 40 percent of those treated, but that many patients relapse when therapy is stopped. Currently, treatment is recommended only for patients at greatest risk for progression to cirrhosis. Individuals found to be infected with HCV need to be assessed and monitored by a specialist for the presence and severity of chronic liver disease and for treatment eligibility (NIH, 1997).

Screening and prevention: The role of the addiction professional
Unlike Hepatitis A and B, there is no vaccine to prevent Hepatitis C infection. Thus, prevention efforts must rely on behavioral techniques. That puts drug and alcohol counseling professionals on the front and center stage in an effort to help combat this illness.

During the screening and evaluation process, questions about IV drug use are already routinely asked. In addition, it is recommended that drug and alcohol treatment professionals include the following questions as part of their routine screening/evaluation (CDC, 2003):

Medical history

• Have you had a blood transfusion prior to 1992?
• Have you experienced chronic fatigue or tiredness for which there was no explanation?
• Have you had surgery, including oral surgery?
• Have you hadd a Cesarean section or other obstetric or gynecological surgery?
• Have you been diagnosed as HIV-positive?
• Have you had kidney dialysis?
• Have you had an elevated liver enzyme test (ALT)?

Lifestyle

• Have you had a tattoo?
• Have you had body piercing?
• Have you changed sex partners frequently?
• Have you inhaled cocaine?
• Have you been in prison?
• Have you injected drugs, even once?
• Have you had a problem with alcoholism?
• Have you had unprotected sex with anybody who would fit the above descriptions?

Family history

• Do any of the previous categories apply to a member of your immediate family?
• Has a member of your immediate family been diagnosed with Hepatitis B or C?

Work history

• Does your work ever put you into contact with blood, blood products, or needles?

Getting tested
Because of the high risk factors that exist, any person who responds positively to any of these questions, including those who injected only once or perhaps occasionally many years ago and who may not consider themselves to be injection drug users, should be tested for Hepatitis C infection (CDC, 2003). The Center for Disease Control also recommends that those at risk should also receive immunization for Hepatitis A and B. Persons with known HIV infection should be screened for HCV as well (AMA, 1995).

During the course of substance abuse treatment, counselors need to include basic information on the disease as part of the educational offerings now included in virtually all types of treatment programming. Risk factors should be reviewed and clients should be counseled to reduce their risk for acquiring infection or of potentially transmitting infection to others. Treatment professionals also need to educate themselves on the problems, needs, and issues related to this illness.

Clients who test positive for HCV should be given information regarding the need for preventing further harm to the liver, reducing risks for transmitting HCV to others, and obtaining medical evaluation and follow-up for chronic liver disease and possible treatment. It is important that physicians know if a person is infected with HCV so that medications that may have side effects involving the liver can be avoided. To protect the liver from further harm, HCV-infected clients should also be vaccinated against Hepatitis A and B.

The recovering counselor
There is one additional group that bears our attention. Recently I was presenting at a workshop for a group of about 60 counselors-in-training. As part of the discussion, we were talking about the screening process and certain risk factors that required referral to other services. I related the story about my friend Bill and his death due to Hepatitis C. I asked for a show of hands from those in training to see how many were also in personal recovery — almost 75 percent of the group raised their hands. I then asked to see how many were aware of the problems of Hepatitis C and if any had already gone through testing. Approximately thirty-six had already been tested and of that group fifteen were diagnosed with Hepatitis C and currently undergoing treatment for the disease.

With a field that still is dominated by counselors who are in personal recovery, it is imperative that any counselor who has had IV drug use as part of their past undergo testing. When my friend Bill died, his family lost a kind and loving husband and father, his friends lost his jovial spirit and nature, and the treatment field lost a valuable asset. With a disease that can lay in wait for 10, 20, or even 30 years — the cost of waiting for symptoms to appear is too great.

Kevin Scheel, MS, LADC, MAC, is a Masters prepared chemical dependency counselor with more than 28 years of experience in the field. He has served as an instructor at McLellan Community College in Waco, Texas, as a trainer and educational consultant with the Hazelden Foundation’s Addiction Counselor Training program in Dallas, Texas, and is currently the Director of Educational Services for the Distance Learning Center for Addiction Studies (DLCAS.com).

References
Alter, M. J. (1996). Epidemiology of Hepatitis C. European Journal of Gastroenterology & Hepatology, 8(4), 319-323.
American Medical Association (AMA). (1995). Prevention, diagnosis, and management of viral hepatitis: A guide for primary care physicians [Fact sheet]. Chicago, IL.
Centers for Disease Control and Prevention. (2003). Hepatitis A to E. Available at: http://www.cdc.gov/ ncidod/diseases/hepatitis/slideset/index.htm.
Centers for Disease Control and Prevention (CDC). (2003). Hepatitis C. Available at: http://www.cdc.gov/ ncidod/diseases/hepatitis/c/
Centers for Disease Control and Prevention (CDC). (1998). Recommendations for prevention and control of hepatitis C virus (HCV) infection and HCV-related chronic disease. Morbidity and Mortality Weekly Report, 47,1-39.
National Institute of Health (NIH). (1997). Management of hepatitis C. March 24-26; 15(3): 1-41. Hepatology, 26(Supplement 1).http://odp.od.nih.gov/consensus/
cons/105/105_statement.htm
Strader, D. B., & Seeff, L. B. (1996). The natural history of chronic hepatitis C infection. European Journal of Gastroenterology & Hepatology, 8(4), 324-328.
Worman, Howard J. (2002). The Hepatitis C Sourcebook. McGraw-Hill/Contemporary Books.

This article is published in Counselor, The Magazine for Addiction Professionals, June 2003, v.4, n.3, pp. 22-28.

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