Post-its from Practice:
Misinformation about hepatitis C treatment (Sep 2011)
Yesterday Gill came into my room with a long face and said; "You're going to say I told you so". Two years ago, she found out she was HCV and PCR positive, and genotype 3. That hadn't been the right time for her to start treatment as she was working full-time, drinking above safe limits and not settled on OST. Last week she had just been for her first appointment in over 2 years, at the local hepatology clinic.
Over that period we have worked hard together. These efforts had meant Gill had completely stopped drinking and is stable on a methadone mixture. She has informed her work that she needs treatment and they have been completely supportive. We have also undertaken all the base-line tests - which were good and completed a mental health assessment, as she had experienced a bout of depression five years ago. She understood the evidence and had decided not to restart antidepressants at this time, but said she would choose to if her mood worsened on treatment.
Before referral we had discussed treatment options and the choice of hospitals. Gill was very optimistic about her chances of clearing as she has genotype 3 and decided to go back to the hospital she had previously attended, which was also closest to where she lived. I encouraged her to go to a different hospital given that we have had a much better response there, especially to active drug users. One patient in a very similar situation to Gill had started treatment at the latter hospital two weeks after my referral and was doing really well, now being in her third month.
Soon the reason for her opening comment above became clear! On arrival the consultant insisted that she would need to cease using methadone before hepatitis C treatment could commence. He added that they would not even consider treatment without a formal mental health assessment by a psychiatrist. When Gill replied that her GP had said almost the opposite about the methadone, he implied that I knew nothing. I won't print what Gill replied in my defense!
It worries me that a consultant working in hepatology believes that methadone affects hepatitis C treatment, and does not know that it is quite safe for the liver. It is true that treatment side effects can mimic opioid withdrawal, so the patient may feel like he/she needs more methadone to be stable and comfortable. As such, clinical monitoring for methadone withdrawal symptoms is recommended as maintenance therapy may need to be adjusted in some patients.
We know that active drug users and patients on substitution maintenance treatment do not differ from past users in terms of SVR and compliance to hepatitis C treatment. Patients currently using drugs or on OST with chronic hepatitis C infection should therefore not be excluded from treatment. This is supported by NICE guidelines.
I cannot help but wonder how much of this consultant's comments relate to a certain prejudice towards people who use drugs, and bias his views. It worries me that perhaps he hasn't heard that we try to practice evidence-based, rather than opinion-based, medicine!
Gill has gone away to reflect on how to move forward. As she does this I am writing this post-it, before I challenge the hospital again. Misinformation and/or prejudice are not acceptable.
The GMC states: "...you must not refuse or delay treatment because you believe that a patient's actions have contributed to their condition. You must treat your patients with respect whatever their life choices and beliefs. You must not unfairly discriminate against them by allowing your personal views [including your views about a patient's lifestyle] to adversely affect your professional relationship with them or the treatment you provide or arrange".
Perhaps I will recommend he completes our excellent new "RCGP Certificate in the detection, diagnosis and management of hepatitis B and C in Primary Care". I would also recommend this to you all because it is a great way to increase knowledge about this important subject.
Will he change? I remain optimistic that he might, especially once he hears from me again (and perhaps reads this article!).