Part 7: Drugs and Alcohol
There is no question that alcohol should be off limits for those with HCV. Studies have shown that patients who drink have a higher incidence of cirrhosis. But not only that, patients who drink also have a faster rate of progression to cirrhosis and higher mortality rates. As well, because alcohol interferes with the effect of interferon, those with a history of drinking problems may be denied treatment.
EFFECT OF ALCOHOL ON HCV REPLICATION: A critical question is whether or not alcohol and hepatitis C infection are synergistic in a combined liver injury. In some patients, there are both histologic features of alcoholic liver injury and chronic viral hepatitis, but in most studies the predominant pattern is chronic hepatitis.
Alcohol may enhance the replication of hepatitis C and produce a more severe injury independent of the direct alcohol-induced toxic injury. There is a correlation between HCV RNA levels and amount of alcohol consumed. Alcoholic patients with HCV infection have higher hepatic iron concentrations, which may be germane to increased HCV replication. Clinical evidence of hepatic activity and viral levels is significantly greater in those consuming greater than 10g of alcohol per day.
EFFECT OF ALCOHOL ON PROGRESSION OF CHRONIC VIRAL C HEPATITIS TO CIRRHOSIS AND HEPATOCELLULAR CARCINOMA: There is a more rapid development of cirrhosis and hepatocellular carcinoma in the alcoholic with chronic HCV infection. The period from transfusion to the diagnosis of cirrhosis is shorter in the heavy drinker. As well, recent studies demonstrate that alcohol consumption in cirrhotics can lead to increased bacterial infection (American Journal of Gastroenterology, Editorial, May 2000, Volume 95, Number 5, Pages 1124-1125).
The risk for the development of hepatocellular carcinoma in alcoholic cirrhotics is 8.3 times higher in the HCV(+) patients than HCV(-) patients, and the prevalence of anti-HCV among alcoholics with HCC is 50-70 percent.
Therefore, alcohol may modify the replication of HCV as well as the oncogenicity of HCV in hepatocellular carcinoma.
INTERFERON THERAPY IN ALCOHOLIC PATIENTS WITH CHRONIC HEPATITIS C: Among alcoholic patients with chronic hepatitis C who remained abstinent during therapy with interferon, there was a significantly lower rate of HCV RNA clearance in those who consumed 70g/day of ethanol as compared to 70g/day up to the time of interferon therapy. - “Hepatitis C and Alcohol,” by E.R. Schiff, abstract submitted by the author to the National Institute of Health Conference on Hepatitis C, held March 24-26, 1997, in Bethesda, Maryland
An important cofactor of disease severity appears to be alcohol and alcohol should be avoided in those with chronic HCV infection.” - “Natural History and Clinical Aspects of HCV Infection.” H.J. Alter. Department of Transfusion Medicine, National Institutes of Health, Bethesda, Maryland. Cancer Biotechnology Weekly, 0129-1996, pp 20.
Cigarette smoking combined with the hepatitis C virus is known to be a heavy risk factor in developing primary hepatocellular carcinoma. (Int J Cancer 2000 Feb;85(4):498-502).
While many people are aware of smoking's negative effect on the lungs, less consideration is usually given to its effects on the liver. Tobacco and marijuana smoke are rich airborne stews of toxic benzpyrene, polycyclic aromatic hydrocarbons, cyanide, acetaldehyde, tars, acrolein, etc. Since these get into the bloodstream through the lungs, the liver must detoxify them. And virtually all the constituents of smoke are known to be at least mildly liver-damaging (The Liver: Master Organ for Optimal Nutrition).
A 2001 study biopsied 310 Hep C patients. 176 were current smokers (who were more often males, younger, alcohol consumers, and more often had a history of IVDU than those who had never smoked.) The results were adjusted to consider these factors. The authors concluded that “Smoking increases the severity of hepatic lesions in patients with chronic hepatitis C.” Source: Hepatology 2001;34:121-125, “Cigarette smoking and hepatic lesions in patients with chronic hepatitis C.”
A Japanese study presented at the DDW 2008 concluded that “when combined with IFN-a, nicotine disturbed the antiviral effects of IFN on HCV replication,” (www.natap.org/2008/DDW/DDW_08.htm)
There are plenty of conflicting studies on the benefits/dangers of marijuana use by the chronically ill. Recent studies show that marijuana can be beneficial for those with AIDS. The results of a study released at the XIII International AIDS Conference reports that smoking marijuana helps people with AIDS gain weight, without causing adverse virologic effects (July 2000). But HCV is not HIV. Nor is it cancer. Nor is weight gain recommended for people with HCV because of the possibility of fatty liver.
Other studies (May 2000) speak of the synthetic marijuana derivative CT-3 as an anti-inflammatory and analgesic therapy intended as a safer alternative to nonsteroidal anti-inflammatory drugs (NSAIDs), the most commonly prescribed analgesic and anti-inflammatory therapy for long-term treatment of arthritis. One study states that marijuana use increases tumor growth. Another links it to emphysema.
A report from the New South Wales Users and AIDS Association “Hepatitis C and Drug Use” states that marijuana presents no problems for the liver; another report warns that marijuana may interact adversely with antidepressants.
It has been shown that marijuana interferes with the effectiveness of interferon alpha-2a in the treatment of genital warts due to drug-induced impairment of cellular immunity. (“Genital Warts do not respond to systemic recombinant interferon alpha-2a treatment during cannabis consumption,” Gross G; Roussaki A; Ikenberg H; Drees N., Dermatologica, 1991, 183(3):203-7) Whether this is also true for marijuana use during interferon alpha-2b treatment for hepatitis is unknown.
A presentation made in the Fall of 2004 at the 55th Annual Meeting of the American Association of Liver Diseases showed that HCV + people who smoke marijuana daily have a rapid rate of liver scarring (fibrosis). In this study, 66% of those who smoked daily for an average of 16 years progressed rapidly, compared to 40% of those who smoked about once every 2 weeks, and 41% of those who never smoked marijuana. "Patients with ongoing chronic hepatitis C should be advised against daily cannabis use, since regular use over the span of the disease is an aggravating factor regarding fibrosis progression."
Another researcher commented that Hep C patients have many CB1 receptors in their livers, so that smoking marijuana is a cofactor, and not directly responsible for the fibrosis. (Source: Mark L. Fuerst, AASLD: Smoking Marijuana Raises Fibrosis Risk in Patients With Chronic Hepatitis C Infection Nov. 2, 2004 Abstract 67]
A recent study (Oct 2006) showed that use of cannabis might help some Hep C patients stay on treatment, but some experts voiced their worries, basing their concern on a French study of untreated Hep C patients showing those who used cannabis daily had more liver scarring and were more likely to have their fibrosis progress than those who used marijuana little or not at all.
At the EASL meeting in Barcelona, that team reported that cannabis sativa binds to two receptors, one of which activates the accumulation of fat, according to a study of 311 treatment-naïve patients, 59% of whom were non-users, 15% smoked fewer than 1 joint daily, and 26% daily users.
Fatty liver was found in 16.3% in non-users, 10.9% in occasional users, and 30.9% in daily users. Steatosis was also linked to body mass index of 27 kg/m2, use of maintenance treatment, alcohol consumption of 30 g/day, genotype 3, hyperglycemia, fibrosis stage 2 or more. Still, the authors report “a strong link between daily cannabis use and steatosis severity in patients with chronic hepatitis C,” and state, “Patients with untreated chronic hepatitis C should be advised to refrain from daily cannabis use.” (www.hivandhepatitis.com/aboutus2.html#liz)
A study of blood donors who showed traces of past infection with the liver-damaging disease hepatitis C has uncovered a possible link between the infection and snorting cocaine. Snorting “could be an unrecognized route” for the hepatitis C virus to get into the body, said a team of medical researchers led by Dr. Cathy Conry-Cantilena of the National Institute of Allergy and Infectious Diseases. But the researchers noted that cocaine abuse may not be the actual cause of the hepatitis.
Cocaine users may simply be more prone to other behaviors that make them vulnerable to the infection. Hepatitis C is usually passed via contaminated blood. The researchers said it was possible the straws used to snort the drug could be tainted with blood and the virus could get into a user’s body through the wall of the nose, which is often damaged in cocaine snorters.
7.4.0 What are the effects of recreational drugs?
If you are HCV+, alcohol and other drugs are likely to put added strain on your already stressed liver. And even if you already have HCV, you are still open to re-infection if you expose yourself to the virus through unsafe drug use. There are several different types and variations of HCV, and every time you catch a different type, it is like you have been infected for the first time. People with multiple infections of HCV are often the ones who become sicker. It is advisable to avoid alcohol and all street drugs.
If users are opiate dependent methadone may be an alternative in this phase of infection, simply because it is available in pure form.
Hepatitis generally increases the chances of overdosing (especially on alcohol, and benzodiazepine tranquilizers such as Serepax, Rohypnol, Valium, Mogadon and Temazepam) because the liver cannot handle the doses of drugs to which the user was formerly accustomed.
Serepax is better than other benzodiazepines but it still presents problems.
Heroin is relatively harmless during hepatitis infection but all drugs present problems, whether in pure or impure forms. Amphetamines and benzodiazepines are medium destructive and alcohol is the worst.
In as far as drug use is concerned, purer forms of drugs are advisable in all cases (for instance methadone is better than street heroin, pharmaceutical amphetamines are better than street amphetamines) but this is only a minor improvement, for it is the liver’s function of removing drugs from the body which is affected by the hepatitis C virus. It is best to be aware of any possible problem in this area and the specific relationship between specific drugs and the liver.
It is best to be entirely drug free during the acute phase of hepatitis infection so that the liver can repair itself. Drug-taking presents fewer problems if you have a healthy liver. (New South Wales Users and AIDS Association “Hepatitis C and Drug Use”)
7.4.1 Intravenous drug use precautions
When injecting drugs, the best protection is to never re-use injection equipment. Cleaning injection equipment is not guaranteed to kill the hepatitis C virus.
To avoid hepatitis C when injecting:
- Have a syringe, spoon, water, filter, swab and tourniquet.
- Wash your hands with warm soapy water before and after injecting.
- Clean the spoon with a fresh swab.
- Keep all your utensils separate from your friend’s utensils.
- Inject yourself - but if someone else does inject you, make sure he/she has washed his/her hands.
- If you get blood on your hands, go and wash them before you touch anything on the table. If someone asks you to pass them something, tell them to wait.
- If you do touch something before you’re able to wash your hands, treat it as contaminated.
- Dispose of your used syringes, filters, swabs, etc, properly by putting them into a sharps container, or use an empty plastic drink bottle or detergent container. (Look for the letters PET on the bottom of the plastic bottles, as these are especially strong.) Be careful not to dispose of your fits in aluminum cans or glass bottles. Kids collect cans for recycling and could get needle sticks, and glass bottles can easily break.
- Remember - use new equipment every time. Cleaning equipment doesn’t always kill the hepatitis C virus.
- Remember - wash your hands with soap and water before and after injecting. You can’t always see minute amounts of blood.
- Remember - make the bench or table where you’re injecting as clean as possible.
7.4.2 Cleaning syringes
We don’t know that disinfection or cleaning really works so be safe and use all new equipment every time you hit up. Reusing fits
should be a last option only. If you’re cleaning syirnges, remember the following guidelines:
Ιmmediately after use, rinse the syringe in cold water until signs of blood are gone. Squirt water down sink or into an old drink bottle.
Do this as soon as you’ve used the syringe since dried or clotted blood is hard to wash out and can block the syringe. Always use cold water as hot water will clot blood in the syringe and block it.
Fill the syringe with fresh high-strength bleach. Use the strongest bleach available (which is usually the most expensive). With the syringe full of bleach, replace the cap over the needle and shake it for 30 seconds or more. Time this on a watch or count it out slowly. Then squirt the bleach out into the sink or an old drink bottle. Now repeat the bleach process, again shaking for thirty seconds.
With another container of fresh clean water, rinse out the syringe at least two times. Again, squirt the water down the sink or into an old drink bottle, not into your containers of bleach or clean water. Empty all your containers down the sink when you are finished.
this way of cleaning syringes can’t be guaranteed to kill the hepatitis C virus. - Hepatitis C
Council of NSW
7.4.3 Methadone and hepatitis C
The effects of methadone can alleviate possible painful symptoms of hepatitis C. Although this may be helpful, it can camouflage early signs of liver damage (if it develops). Flu-like hepatitis C symptoms may give the impression that you are on prescription pills. If this causes problems at the clinic where you receive your methadone, it may be useful to remind them of the complicating effect of hepatitis C symptoms.
If you experience flu-like symptoms of hepatitis C, these symptoms should not be misinterpreted as withdrawal symptoms from opiates.
People should be careful with methadone dosages and aware of their real tolerance for drugs. This is especially important if liver damage is severe. - Hepatitis C Council of NSW
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