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  Conference on Retroviruses
and Opportunistic Infections
Boston USA
March 8-11, 2020
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HCV, Opioid Use, Psych Illness Cluster in Veterans Group--Treatment of Opioid Use Very Low
  CROI 2020, March 8-11, 2020, Boston


Mark Mascolini
Analysis of a large US veterans cohort confirmed frequent cooccurrence of HCV infection, psychiatric illness, and prescription opioid use [1]. While veterans usually received treatment for HCV and psychiatric illness, only 5% got treated for opioid misuse alone. Fewer than 18% with all three conditions got treated for all three.
A syndemic--or "synergistic epidemic"—denotes clustering of two or more diseases in a single population. Medical anthropologists describe three core features of a syndemic: (1) clustering of two or more conditions in a specific population, (2) synergism of the clustered conditions in producing adverse outcomes, and (3) resulting large-scale social, cultural, and economic forces.
ERCHIVES researchers proposed that a syndemic of HCV infection, psychiatric illness, and prescription opioid use occurs in US veterans. To test that hypothesis, they analyzed members of the ERCHIVES cohort, which includes all US veterans diagnosed with HCV since 2001 and HCV-negative veterans matched by 5-year age group, race, and sex.
The researchers used medical records to identify veterans with each of the three diseases of interest, alone or in combination with one or two of the others. They defined HCV infection as a positive HCV antibody test and at least one positive HCV RNA. Prescription opioid use meant prescription of any approved opioid for more than 31 continuous days (to exclude short-term use for surgical or dental procedures). Psychiatric illness meant more than one inpatient or more than two outpatient ICD-9/10 codes for major or minor depression, bipolar disorder, schizophrenia, or posttraumatic stress disorder. Treatment meant prescription of any licensed medication for the condition.
The study group included 781,271 veterans in ERCHIVES in 2001-2018. The following list shows the numbers with only one disease, two diseases, or all three diseases--and the percentage in each group treated for the diagnosed disease or diseases:
HCV alone: 238,506, 51.6% treated
Psych illness alone: 99,681; 64.5% treated
Opioid use alone: 28,226; 4.9% treated
HCV plus psych illness: 136,974; 45.6% treated
HCV plus opioid use: 81,400; 16.5% treated
Psych illness plus opioid use: 133,344: 26.9% treated
HCV, psych illness, opioid use: 55,521; 17.8% treated
These findings underline substantially lower pharmacologic treatment of prescription opioid use than the other two diseases. Only about 5% with long-term use of prescription opioids alone got treated for the condition (top rows), compared with 52% with HCV alone and 65% with psychiatric illness alone. In veterans with both prescription opioid use and one of the other diseases (middle rows), much lower proportions got treated than veterans with combined HCV and psychiatric illness. Only 18% of veterans with all three diseases got treated for all three (bottom row).
The ERCHIVES researchers concluded that these veterans satisfy at least one component of the syndemic definition, cooccurrence of HCV, psychiatric illness, and prescription opioid use. "While there is considerable uptake of pharmacologic treatment for HCV and psychiatric illness," they pointed out, "such treatment for opioid use disorders is very low." And medication-based treatment of two and especially three cooccurring diseases proved less frequent than treatment of individual diseases.
1. Butt AA, on behalf of the ERCHIVES study team. Syndemic of HCV, prescription opioid use, and psychiatric illness: a novel framework. Conference on Retroviruses and Opportunistic Infections (CROI). March 8-11, 2020. Boston. Abstract 600.