Prescribers of opioid substitutes lack funding, facilities and guidelines to treat hepatitis C, global survey reveals

Keith Alcorn
24 June 2019

Only 30% of physicians who prescribe opioid substitution therapy to people who inject drugs have also prescribed direct-acting antivirals, despite being ideally placed to offer testing and treatment for hepatitis C, an international survey has found.

Opioid substitution therapy consists of prescribing medical opioids to reduce dependence on injected heroin. People who use drugs are enabled to avoid the harms associated with injecting illicit drugs, such as bacterial infections, arrest and imprisonment, and may stabilise their daily routines.

Opioid substitution therapy can be prescribed by physicians in drug dependence clinics or some community-based drugs services. The type of opioid agonist prescribed varies by country and access to opioid substitution therapy depends on national policy. In most countries in eastern Europe and central Asia, for example, opioid substitution therapy is not available due to long-standing professional disapproval of its use.

Prescribers have an important opportunity to promote hepatitis C testing and treatment among people who inject drugs, but little is known about the attitudes of opioid agonist prescribers offering hepatitis C testing and treatment, how many are already doing it and what barriers exist to hepatitis C testing and treatment in the drug dependence clinic.

The C-SCOPE study was designed to investigate these questions among prescribers in Australia, Canada, Europe and the United States through a structured questionnaire. The study recruited 203 physicians who worked as part of a team providing care to people who inject drugs. The majority worked alongside addiction medicine specialists and psychiatrists but only 27% worked in a clinic where a hepatitis C specialist was part of the team.

On-site testing for hepatitis C antibodies was available at only 40% of clinics and only 35% of clinics were able to carry out venepuncture on-site. Only 25% were able to conduct assessment of liver disease on-site and the study showed that for a majority of actions, from antibody testing to staging of liver disease, service users needed to be referred to another clinic with the risk that they would fail to engage with another service. Diagnosis and pre-treatment work may require up to five visits, the study authors point out.

These findings reflect the low priority given to testing for hepatitis C in drug dependence clinics. Although a majority of respondents said that they followed national guidelines, only 56% of physicians tested all patients attending the clinic for opioid substitution therapy on their first visit. Electronic health record systems that alerted physicians to the need to test or re-test patients were available in 40% of clinics.

Once diagnosed with hepatitis C, most patients had to be referred to another site for pre-treatment blood tests and liver fibrosis assessment. Only 30% of physicians had prescribed direct-acting antivirals in their drug dependence clinic.

Asked about the barriers to screening and treatment, physicians frequently cited long delays in referring patients to other clinics and long travelling distances to sites providing hepatitis C care. Within the clinic, the lack of staff qualified to draw blood (venepuncture) was a common barrier (38%), as were the need for imaging to stage fibrosis to take place outside the clinic (39%) and the lack of case managers or linkage to care coordinators (37%). The lack of peer support programmes that encouraged testing within the clinic was also cited as a frequent barrier (42%).

Lack of funding for treatment, restrictions on access to treatment for drug users and lack of protocols for testing and treatment in drug dependence clinics were also frequently cited as barriers.


Litwin A et al. Perceived barriers related to testing, management and treatment of HCV infection among physicians prescribing opioid agonist therapy: the C-SCOPE study. J Viral Hepat, 2019.