A TREATMENT IMPROVEMENT PROTOCOL

Addressing Viral 

Hepatitis in People With 

Substance Use Disorders

TIP 53
A TREATMENT IMPROVEMENT PROTOCOL

Addressing Viral 

Hepatitis in People With 

Substance Use Disorders

TIP 53

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

Center for Substance Abuse Treatment

1 Choke Cherry Road

Rockville, MD 20857
ii

Addressing Viral Hepatitis in People With Substance Use Disorders

Acknowledgments

This publication was prepared for the Substance Abuse and Mental Health Services 

Administration (SAMHSA) by the Knowledge Application Program (KAP), a Joint Venture 

of The CDM Group, Inc., and JBS International, Inc., under contract numbers 270-04-7049 

and 270-09-0307, with SAMHSA, U.S. Department of Health and Human Services (HHS). 

Christina Currier served as the Government Project Officer. 

Disclaimer

The views, opinions, and content of this publication are those of the authors and do not 

necessarily reflect the views, opinions, or policies of SAMHSA or HHS. 

Public Domain Notice

All materials appearing in this volume except those taken directly from copyrighted sources are 

in the public domain and may be reproduced or copied without permission from SAMHSA 

or the authors. Citation of the source is appreciated. However, this publication may not be 

reproduced or distributed for a fee without the specific, written authorization of the Office of 

Communications, SAMHSA, HHS.

Electronic Access and Copies of Publication

This publication may be ordered from SAMHSA’s Publications Ordering Web page at http://

www.store.samhsa.gov. Or, please call SAMHSA at 1-877-SAMHSA-7 (1-877-726-4727) 

(English and Español). The document can be downloaded from the KAP Web site at http://

www.kap.samhsa.gov.

Recommended Citation

Substance Abuse and Mental Health Services Administration. Addressing Viral Hepatitis in 

People With Substance Use Disorders. Treatment Improvement Protocol (TIP) Series 53. HHS 

Publication No. (SMA) 11-4656. Rockville, MD: Substance Abuse and Mental Health Services 

Administration, 2011.

Originating Office

Quality Improvement and Workforce Development Branch, Division of Services Improvement, 

Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services 

Administration, 1 Choke Cherry Road, Rockville, MD 20857.

HHS Publication No. (SMA) 11-4656

Printed 2011
iii

Contents

What Is a TIP? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

TIP Format . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

TIP Development Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii

Consensus Panel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi

1—Overview of Viral Hepatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Purpose of and Audience for the TIP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Terminology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

The Liver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

What Is Viral Hepatitis? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Hepatitis A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Hepatitis B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Hepatitis C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Other Types of Viral Hepatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Co-Infection with Different Types of Viral Hepatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Co-Infection with Viral Hepatitis and HIV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Chapter Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

2—Screening for Viral Hepatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

The Treatment Program’s Role in the Screening Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Antigens and Antibodies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Hepatitis A Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Hepatitis B Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Hepatitis C Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Counseling Practices That Educate, Support, and Motivate 

 Clients Undergoing Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Chapter Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

3—Evaluation of Chronic Hepatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

The Medical Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Liver Panel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Viral Load Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Genotype Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Liver Biopsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Chapter Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
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Addressing Viral Hepatitis in People With Substance Use Disorders

4—Helping Clients Make Medical Decisions About Hepatitis Treatment . . . . . . . . . . . . . . 31

The Counselor’s Role . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Factors to Consider About Hepatitis Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Counseling Clients Diagnosed With Chronic Hepatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Supporting the Decision to Treat Hepatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Special Populations: Barriers to Hepatitis Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Chapter Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

5—Hepatitis Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Overall Treatment Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Treatment for Hepatitis A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Treatment for Hepatitis B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Treatment for Hepatitis C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

People Receiving Medication-Assisted Treatment for Opioid Dependence . . . . . . . . . . . . . . . 46

People Who Relapse to Substance Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

People Who Have HCV/HIV Co-Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

People Who Have Co-Occurring Behavioral Health Disorders . . . . . . . . . . . . . . . . . . . . . . . . . 49

Chapter Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

6—Counseling Approaches for People Who Have Viral Hepatitis . . . . . . . . . . . . . . . . . . . . 51

The Need for Counseling Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Ensuring Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

Providing Reliable Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

Building the Therapeutic Relationship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

Helping Clients Understand Their Diagnoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Incorporating Client Needs in Substance Abuse Treatment Planning . . . . . . . . . . . . . . . . . . . 53

Developing a Prevention Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

Using Motivational Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

Confronting the Social Factors of Hepatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

Addressing Relapse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Building Support Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

Providing Effective Case Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

Chapter Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

7—Adding or Improving Hepatitis Services: A Guide for Administrators . . . . . . . . . . . . . . 61

Program Assessment and Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

Screening for Viral Hepatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

Medical Evaluation and Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

Treatment for Chronic Hepatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
v

Prevention and Vaccination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Support Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

Outreach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

Integrating Hepatitis Interventions With Existing HIV Services . . . . . . . . . . . . . . . . . . . . . . . 68

Developing Policies and Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Successful Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Legal and Ethical Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

Chapter Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

Appendix A—Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

Appendix B—Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

Appendix C—Hepatitis Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

Appendix D—Managing Side Effects of Hepatitis C Antiviral Treatment . . . . . . . . . . . . . . . . 95

Appendix E—Medicinal Plants/Alternative Treatments 

 Potentially Harmful to People Who Have Hepatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99

Appendix F—Mental Health Treatment Considerations 

 for People Who Have Chronic Viral Hepatitis C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101

Appendix G—Motivational Interviewing and Counseling Resources . . . . . . . . . . . . . . . . . . . 109

Appendix H—Sources for Financial Assistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111

Appendix I—Hepatitis C Training Programs for 

 Substance Abuse Treatment Program Staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113

Appendix J—Stakeholders Meeting Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115

Appendix K—Field Reviewers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119

Appendix L—Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123

Contents
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Addressing Viral Hepatitis in People With Substance Use Disorders

Exhibits

Exhibit 1-1 The Liver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Exhibit 1-2 Overview of the Most Common Types of Viral Hepatitis . . . . . . . . . . . . . . . . . . . . 4

Exhibit 1-3 Disease Course of Hepatitis B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Exhibit 1-4 Disease Course of Hepatitis C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Exhibit 2-1 HCV Screening Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Exhibit 3-1 The Liver Panel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Exhibit 3-2 Comparison of HIV and HBV/HCV Viral Load Tests . . . . . . . . . . . . . . . . . . . . . 25

Exhibit 3-3 Comparison of the Most Common HCV Genotypes in the United States . . . . . . 26

Exhibit 4-1 Pregnancy and Antiviral Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Exhibit 4-2 Statements and Recommendations on Hepatitis Treatment . . . . . . . . . . . . . . . . . . 33

Exhibit 4-3 Hepatitis C Treatment Response Classifications . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Exhibit 4-4 Counseling Approaches Based on HCV Status . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Exhibit 5-1 Medications for Chronic Hepatitis B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Exhibit 5-2 Counseling Tips for Addressing Concerns About Chronic Hepatitis B . . . . . . . . . 42

Exhibit 5-3 Medications Approved for Treating Chronic Hepatitis C . . . . . . . . . . . . . . . . . . . 43

Exhibit 5-4 Adhering to Antiviral Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Exhibit 5-5 SUD Treatment Modifications for Clients

 Receiving MAT for Opioid Dependence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Exhibit 7-1 Hepatitis Treatment Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

Exhibit 7-2 Staff Training for Hepatitis in Substance Abuse Treatment Programs . . . . . . . . . . 67

Exhibit 7-3 Sample Policy: Screening for Hepatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Exhibit F-1 Potential Interactions Among Medications Used 

 to Treat Chronic Hepatitis and Behavioral Health Conditions . . . . . . . . . . . . . . . . . . . . . . 107
vii

What Is a TIP?

Treatment Improvement Protocols (TIPs) are developed by the Center for Substance Abuse 

Treatment (CSAT), part of the Substance Abuse and Mental Health Services Administration 

(SAMHSA) within the U.S. Department of Health and Human Services (HHS). Each TIP 

involves the development of topic-specific best-practice guidelines for the prevention and treatment of substance use and mental disorders. TIPs draw on the experience and knowledge of 

clinical, research, and administrative experts of various forms of treatment and prevention. TIPs 

are distributed to facilities and individuals across the country. Published TIPs can be accessed 

via the Internet at http://www.kap.samhsa.gov.

Although each consensus-based TIP strives to include an evidence base for the practices it 

recommends, SAMHSA recognizes that behavioral health is continually evolving, and research 

frequently lags behind the innovations pioneered in the field. A major goal of each TIP is 

to convey “front-line” information quickly but responsibly. If research supports a particular 

approach, citations are provided.

TIP Format

This TIP is organized into two parts:

•	 Part 1 is for counselors and administrators of behavioral health programs providing substance 

abuse treatment. It comprises seven chapters and emphasizes steps substance abuse treatment 

counselors and administrators can take to educate clients, prevent new hepatitis infections, 

and help clients who have viral hepatitis recover from their substance use disorders (SUDs). 

Information is provided at a basic level so that it can be understood by readers without 

medical training. Chapter 1 presents an overview of the most common types of viral hepatitis. Chapters 2 and 3 provide detailed information on screening for hepatitis and evaluation, 

respectively. Factors to consider when helping a client decide whether to undergo hepatitis 

treatment are addressed in Chapter 4; the treatment process is explained in Chapter 5. 

Chapter 6 describes counseling approaches for treating clients who have SUDs and viral 

hepatitis. Chapter 7 offers recommendations for administrators on how to add or improve 

hepatitis services, showcasing programs with proven track records. Note: Many people 

in treatment for SUDs are affected by mental disorders prior to the start of hepatitis 

treatment; mental disorders also may arise through the course of hepatitis treatment. 

Guidance for addressing co-occurring mental disorders is included throughout the TIP. 

Hepatitis-related issues specific to the treatment of mental disorders, not in the context of 

co-occurring SUDs, are covered in Appendix F. 
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Addressing Viral Hepatitis in People With Substance Use Disorders

•	 Part 2 is an online literature review for clinical supervisors, program administrators, and 

counselors interested in reviewing the medical literature on which this TIP is based. The 

literature review, available at http://www.kap.samhsa.gov, will be updated every 6 months 

for 5 years following publication of this TIP. 

TIP Development Process

TIP topics are based on the current needs of behavioral health professionals and other healthcare 

providers for information and guidance. After selecting a topic, SAMHSA invites staff members 

from Federal agencies and national organizations to be members of a resource panel that reviews 

an initial draft prospectus and outline and recommends specific areas of focus, as well as resources 

that should be considered in developing the content for the TIP. These recommendations are 

communicated to a consensus panel composed of experts on the topic who have been nominated 

by their peers. In partnership with Knowledge Application Program writers, consensus panel 

members participate in creating a draft document and then meet to review and discuss the draft. 

The information and recommendations on which they reach consensus form the foundation of 

the TIP. A panel chair ensures that the guidelines mirror the results of the group’s collaboration.

A diverse group of experts closely reviews the draft document. Once the changes recommended 

by these field reviewers have been incorporated, the TIP is prepared for publication, in print and 

online. TIPs can be accessed via the Internet at http://www.kap.samhsa.gov.
ix

Consensus Panel

Chair

David A. Fiellin, M.D.

Professor of Medicine and of Public Health 

and Associate Professor of Investigative 

Medicine

Yale University School of Medicine

New Haven, Connecticut 

Panelists

Valentin Bonilla, Jr., RPA

Chief Physician Assistant

Methadone Maintenance Medical Center

Beth Israel Medical Center

New York, New York 

Danielle Brown, M.P.H.

Clinical Research Supervisor

Mt. Sinai Medical Center

Mount Vernon, New York

Bruce Burkett

Executive Director

Missouri Hepatitis C Alliance

Columbia, Missouri 

Eugenia Curet, M.S.W., Ph.D.

Clinical Instructor in Public Health

Administrative Director 

Adult and Adolescent Services Clinics

Cornell Weill Medical College

New York, New York 

Brian R. Edlin, M.D.

Associate Professor of Medicine and Public 

Health

Center for the Study of Hepatitis C 

Cornell Weill Medical College

New York, New York 

William James Harrison III, M.H.S., CADC

Site Director

Brandywine Counseling, Inc.

Wilmington, Delaware 

Alain Litwin, M.D., M.P.H.

Division of Internal Medicine

Montefiore Medical Center

Bronx, New York

Susan Simon

President and Founder

Hepatitis C Association

Scotch Plains, New Jersey

Shiela M. Strauss, Ph.D.

Associate Professor 

Director

Muriel and Virginia Pless Center for Nursing 

Research

New York University College of Nursing

New York, New York 

Theodore Paul Ziegler

Chief Executive Officer

Community Health Center

Akron, Ohio 

xi

Foreword

The Treatment Improvement Protocol (TIP) series fulfills the Substance Abuse and Mental 

Health Services Administration’s (SAMHSA’s) mission to improve prevention and treatment 

of substance use and mental disorders by providing best practices guidance to clinicians, program 

administrators, and payers. TIPs are the result of careful consideration of all relevant clinical and 

health services research findings, demonstration experience, and implementation requirements. 

A panel of non-Federal clinical researchers, clinicians, program administrators, and patient advocates debates and discusses their particular area of expertise until they reach a consensus on best 

practices. This panel’s work is then reviewed and critiqued by field reviewers.

The talent, dedication, and hard work that TIPs panelists and reviewers bring to this highly 

participatory process have helped bridge the gap between the promise of research and the needs 

of practicing clinicians and administrators to serve, in the most scientifically sound and effective 

ways, people in need of behavioral health services. We are grateful to all who have joined with us 

to contribute to advances in the behavioral health field.

Pamela S. Hyde, J.D.

Administrator

Substance Abuse and Mental Health Services Administration

Dr. H. Westley Clark, M.D., 

J.D., M.P.H., CAS, FASAM

Director

Center for Substance Abuse 

Treatment 

Substance Abuse and 

Mental Health Services 

Administration

Francis M. Harding

Director

Center for Substance Abuse 

Prevention 

Substance Abuse and 

Mental Health Services 

Administration

A. Kathryn Power, M.Ed.

Director

Center for Mental Health 

Services 

Substance Abuse and 

Mental Health Services 

Administration

1

Overview of 1 Viral Hepatitis

IN THIS CHAPTER

•	Introduction

•	Purpose of and Audience 

for the TIP

•	Terminology

•	The Liver

•	What Is Viral Hepatitis?

•	Hepatitis A

•	Hepatitis B

•	Hepatitis C

•	Other Types of Viral 

Hepatitis

•	Co-Infection With 

Different Types of Viral 

Hepatitis

•	Co-Infection With Viral 

Hepatitis and HIV

•	Chapter Summary

You come in here to stop drinking and using drugs; I don’t 

want to die no more. I don’t want to go, to live in a box. 

I don’t want to eat out of the garbage. I don’t want to go 

to jail. I want to change. And 2 weeks, 3 weeks into this 

thing, I’m just starting to feel right, and I get news that I 

got hepatitis C.

— A Client’s Perspective (Strauss, Astone, MunozPlaza, Hagan, & Des Jarlais, 2005, pp. 1821–1822) 

Introduction

An estimated 3.5–5.3 million people in the United States live with 

chronic viral hepatitis (Institute of Medicine [IOM], 2010). Viral 

hepatitis is often a silent disease whose symptoms and signs become 

evident only after the disease has caused severe liver damage. The 

symptoms of hepatitis can take decades to manifest, so many people 

who are infected with hepatitis are unaware that they have the disease and therefore do not seek treatment. As a result, between 2010 

and 2020, an estimated 150,000 people in the United States could 

die of liver cancer or other hepatitis-related liver disease (IOM, 

2010). For many of these people, substance use will be a major factor 

that contributes to or worsens their hepatitis-related outcomes. 

All people who use or have used illicit substances are at risk of 

contracting viral hepatitis. Injection drug use (IDU) is the primary 

way of contracting hepatitis C, and people who use substances are at 

risk for contracting other forms of viral hepatitis. Substance use disorders (SUDs) do not cause viral hepatitis, but people can contract 

or spread some types of viral hepatitis by sharing needles and other 

drug paraphernalia. In people who have chronic hepatitis, continued 

use of alcohol contributes to and frequently accelerates liver damage 

(Bhattacharya & Shuhart, 2003), increasing the likelihood that the 

individuals will develop cirrhosis or liver cancer. 

In 2010, the U.S. Department of Health and Human Services (HHS) 

convened an interagency working group on viral hepatitis, comprised 
2

Addressing Viral Hepatitis in People With Substance Use Disorders

of experts throughout HHS to develop a 

comprehensive strategy for addressing the 

prevention, screening, and treatment of viral 

hepatitis, and for improving the coordination 

of care and treatment of individuals infected 

with viral hepatitis. The working group broadened the scope of expertise even further by 

soliciting information from other government 

agencies, professional organizations, community organizations, and members of the general 

public. As a result of many months of work by 

this diverse group of experts, HHS recently 

released Combating the Silent Epidemic of 

Viral Hepatitis: U.S. Department of Health and 

Human Services Action Plan for the Prevention, 

Care and Treatment of Viral Hepatitis (also 

called the Viral Hepatitis Action Plan) (HHS, 

2011). This TIP supports the goals and objectives of the Viral Hepatitis Action Plan by 

providing information on the prevention and 

treatment of viral hepatitis and by encouraging 

behavioral health professionals to recommend 

hepatitis screening for their clients who might 

be at risk for hepatitis infection. 

Viral hepatitis can be prevented and treated. 

Counselors, health professionals, and administrators in SUD treatment settings play an 

important role in promoting the prevention 

and treatment of viral hepatitis among their 

clients. 

Purpose of and Audience 

for the TIP

The main objective of this Treatment 

Improvement Protocol (TIP) is to improve 

care for clients with SUDs by increasing 

knowledge of viral hepatitis among staff in 

behavioral health programs that provide substance abuse treatment. Some surveys have 

shown that substance abuse treatment providers are not well informed about viral hepatitis 

(Strauss et al., 2006). Clients often perceive 

that counselors do not have the information 

they need (Munoz-Plaza, Strauss, Astone, 

Des Jarlais, & Hagan, 2004). With up-to-date 

information, counselors, health professionals, 

and administrators in SUD treatment settings 

can encourage clients to understand the serious nature of hepatitis, risk factors, the importance of liver wellness, screening, treatment 

options, and ways to avoid spreading—

or contracting—hepatitis. 

Other behavioral health treatment providers 

(e.g., counselors in mental health treatment 

settings, nurses, mid-level providers) will 

also find useful information in this TIP. 

Information is provided in lay terms so that 

it can be understood by readers who do not 

have medical training.

Terminology

Terminology in the medical field may differ 

from that used in the substance abuse treatment field. This TIP uses terms from both 

disciplines. Appendix B contains a glossary 

of terms used in this TIP. 

Because the TIP is primarily focused on care 

for clients with SUDs, counselor refers to 

substance abuse treatment counselor. Client refers 

to people seeking services at behavioral health 

programs providing substance abuse treatment. 

Occasionally, the TIP refers to people seeking 

services at a medical facility; in these instances, 

the term patient is used. People refers to adults, 

unless otherwise indicated.

Treatment program refers to a behavioral 

health program providing treatment for 

SUDs. Medical care refers to care for the body 

(e.g., treatment for hepatitis) as distinct from 

behavioral health care, which is the subset of 

medical care that addresses mental, emotional, 

and behavioral issues. Co-occurring is used to 

refer to health conditions (e.g., SUDs, mental 
3

1—Overview of Viral Hepatitis

disorders, hepatitis) that appear together in 

sequence or simultaneously; wherever this term 

is used, the pertaining conditions are indicated. 

Hepatitis refers to viral hepatitis infection.

Relapse, when used alone, refers to relapse 

to substance use. Virologists sometimes use 

relapse to refer to the return of hepatitis after 

antiviral treatment, which here is referred to 

as virologic relapse.

Exhibit 1-1 The Liver

The Liver

To appreciate the impact of hepatitis, it is 

essential to understand the liver—the organ 

predominantly affected in people with hepatitis. The liver, located on the upper right side 

of the abdomen just beneath the rib cage 

(Exhibit 1-1), performs numerous functions 

essential to human life.

Blood passes from the intestines to the liver. 

Blood from the intestines contains nearly 

everything absorbed by the intestines, including nutrients and harmful or toxic substances 

(toxins). The liver breaks down toxins found 

in the blood and excretes them as harmless 

byproducts into the bile (a greenish yellow, 

thick, sticky fluid that aids in digestion) or 

back into the blood. Bile enters the intestine 

and leaves the body in stool. Byproducts 

excreted by the liver into blood are filtered out 

by the kidneys, then leave the body in urine. 

The liver also metabolizes drugs, alcohol, and 

prescription and over-the-counter medications, often making them inactive or easier 

to excrete from the body. If a person has a 

severely damaged liver, these substances build 

up in the body. 

The liver manufactures several physiological 

products necessary for the body to function: 

cholesterol, bile, and other substances (e.g., 

clotting factors that are needed to stop 

bleeding). The liver also stores sugar, fats, and 

vitamins for later use. Sugar is stored in the 

liver as glycogen, transformed into glucose, 

and released into the bloodstream when 

needed. 

What Is Viral Hepatitis?

Hepatitis is inflammation of the liver. It can 

be caused by viruses, alcohol or substance use, 

exposure to toxins, and certain diseases. Viral 

hepatitis refers to liver inflammation caused by 

one of several types of viruses that attack the 

liver. In the United States, these are primarily hepatitis A virus (HAV), hepatitis B virus 

(HBV), and hepatitis C virus (HCV) (Exhibit 

1-2), but other types of hepatitis viruses do 

exist. The body can rid itself of infection in 

some cases. In others, the body cannot get 

rid of the infection by itself and the infection 

becomes chronic (continues indefinitely). 
4

Addressing Viral Hepatitis in People With Substance Use Disorders

Exhibit 1-2 Overview of the Most Common Types of Viral Hepatitis

Category Hepatitis A Hepatitis B Hepatitis C

Transmission route Fecal–oral route Blood and body 

fluids

Blood

Percentage of adults 

infected who develop 

chronic infection

0% 6%–10% 75%–85%

Immunity after infection Yes Yes No

Vaccine available Yes Yes No

Hepatitis can be acute, which means that the 

infection does not last longer than 6 months. 

If the body’s immune system cannot fight off 

the virus within 6 months, the disease is considered chronic. In the United States, three to 

five times more people are living with chronic 

hepatitis B or C than with human immunodeficiency virus (HIV). Chronic hepatitis can 

lead to very serious health consequences—

even death—because of liver failure or related 

medical conditions. 

Most people who have chronic hepatitis do 

not know it (IOM, 2010). In most cases, 

people with infection have no symptoms of 

the disease, or their symptoms are so mild they 

do not see a medical care provider about them. 

Symptoms of hepatitis include the following: 

•	 Fatigue (tiredness)

•	 General feeling of being unwell (malaise)

•	 Flu-like symptoms (e.g., headaches, 

muscle aches, low-grade fever)

•	 Lack of appetite, weight loss

•	 Nausea and vomiting, abdominal pain

•	 Jaundice (new or uncharacteristic yellow 

tinge to skin and mucus membranes)

•	 Diarrhea

•	 Itching of the skin

•	 Tea- or dark-colored urine

•	 Pale bowel movements

A person with chronic hepatitis can remain 

symptom free for decades while the liver is 

silently damaged. As hepatitis progresses 

and causes more liver damage, the liver 

may become scarred, referred to as fibrosis. 

Fibrosis sometimes leads to cirrhosis, which 

is profuse scarring of liver tissue. When cirrhosis develops, changes in the liver’s structure 

compromise its ability to function. The spleen

(an organ that fights infections and regulates 

the flow of blood in the body) may also be 

affected. Muscle wasting can occur, resulting 

from lack of appetite and the liver’s inability 

to produce crucial proteins that build muscles. 

Sometimes the abdomen and ankles swell 

because of the body’s increased difficulty with 

sodium handling and removing fluids and toxins. The person may develop jaundice. When 

liver damage is this extensive, serious complications are likely, including bleeding from the 

esophagus (varices) or stomach, abdominal 

swelling (ascites), and difficulty thinking and 

making decisions (encephalopathy). By the 

time these symptoms occur, liver damage is 

extensive, and the individual is at risk of liver 

failure or liver cancer—a condition that almost 

always has a poor prognosis. 

Hepatitis A

Hepatitis A never becomes chronic, and most 

individuals recover within 6 months. Once 

recovered, a person is no longer contagious 

and is immune to reinfection with HAV. 
5

1—Overview of Viral Hepatitis

Modes of Transmission

HAV is spread by the oral transmission of 

fecal matter (stool) of a person who is infected 

with HAV and it is extremely contagious. 

Minute amounts of fecal matter containing 

the virus left on a person’s hands can contaminate water, food, or utensils, and a person who 

ingests this material can develop hepatitis A. 

HAV can survive outside the body for several 

days and in water for several months. People 

are most infectious during the 2 weeks before 

the onset of symptoms. HAV is not spread 

through casual contact. The virus is not present in semen. 

Disease Burden 

An estimated one-third of U.S. residents have 

had HAV infection (Bell et al., 2005). The 

number of new HAV cases has declined by 

92 percent since a vaccine became available 

in 1995. Nevertheless, approximately 3,000 

new infections were investigated and reported 

in 2007, representing an estimated 25,000 

infections during that year (Daniels, Grytdal, 

& Wasley, 2009). The primary risk factor in 

the United States for contracting hepatitis A 

is traveling to areas where HAV is endemic, 

followed by contact with someone who is 

infected with HAV, or having anal intercourse 

with an infected person. However, many 

people who contract hepatitis A do not report 

any risk factors (Klevens et al., 2010; Daniels 

et al., 2009). 

Disease Course

HAV infection is rarely life threatening, 

although severity and mortality may increase 

with age and underlying chronic liver disease. 

Signs and symptoms include fatigue, fever, loss 

of appetite, dark urine, and jaundice. When 

symptoms occur, they usually appear suddenly and generally disappear within a month. 

Hepatitis A can be serious when coupled with 

other forms of hepatitis or HIV. 

Hepatitis A and Substance Use

People who use drugs are at risk for acquiring 

hepatitis A. Outbreaks occur among people 

who inject drugs (Daniels et al., 2009; Wells, 

Fenaughty, Cagle, & Jaffe, 2006) and are 

associated with poor hygiene and low socioeconomic status (Crowcroft, 2003; Quaglio, 

Lugoboni, Messelani, Des Jarlais, & Lechi, 

2006). 

Prevention 

Hepatitis A is preventable. The most effective 

way to prevent HAV infection is through vaccination. The vaccine is given in two doses, 6 

months apart. A combined HAV and HBV 

vaccine is also available. 

The Centers for Disease Control and 

Prevention (CDC, 2010a) recommends 

hepatitis A vaccination for the following 

adults: 

•	 People who use injection drugs

•	 Men who have sex with men (MSM)

•	 People with chronic liver disease 

•	 People who receive blood clotting-factor 

concentrates

•	 People who travel to countries that have 

high rates of hepatitis A

•	 People with occupational risks of infection 

(e.g., workers in daycare centers, laboratories)

Despite recommendations for vaccination, 

many people are not vaccinated. Vaccination 

rates in high-risk groups range from 8 percent 

to 13 percent (Carey & Perlman, 2005; Chen 

& Cantrell, 2006). Moreover, half of those 

who had been vaccinated received only one 

dose instead of the two doses required for full 

protection. However, hepatitis A vaccination 

in the United States among children has been 

increasing since May 2006, when the universal 

vaccination of children (aged 12–23 months) 

was recommended. By 2008, coverage was 

estimated to be 40 percent in young children 

(CDC, 2010b). 
6

Addressing Viral Hepatitis in People With Substance Use Disorders

Contraindications to receiving the hepatitis 

A vaccine include having a severe allergy to 

vaccine components and being moderately 

or severely ill at the time the vaccination is 

offered. All clients, especially pregnant women, 

should consult their medical care provider to 

determine whether they should get vaccinated 

against hepatitis A. 

Washing hands frequently—especially after 

using the bathroom, changing a diaper, and 

before preparing food—helps prevent the 

spread of HAV. 

Hepatitis B 

Hepatitis B can be acute or chronic. More 

than 90 percent of infants and 30 percent 

of children ages 1–5 years who have been 

exposed to HBV will remain chronically 

infected with HBV. By contrast, approximately 90 percent of adults with HBV infection alone (i.e., without co-infection) recover 

completely from HBV infection and do not 

become chronically infected (CDC, 2010c). 

For those with chronic infection, compromise 

of the immune system (e.g., by chemotherapy 

or HIV co-infection) places the person at risk 

for reactivation (Luetkemeyer, 2010; CDC, 

2009). 

Modes of Transmission

HBV is very contagious; it is much more 

infectious than HIV (World Health 

Organization, 2009). HBV is spread through 

infected blood and other body fluids (e.g., 

semen) and can live outside the body for more 

than 7 days. Modes of transmission include:

•	 Sharing IDU equipment (e.g., needles, 

syringes, cookers, filters). 

•	 Accidental needle sticks or other breaches 

of the skin, especially among those whose 

occupations expose them to blood (e.g., 

medical care workers, dentists). 

•	 Unprotected sex with a partner who is 

infected with HBV. 

•	 An infected mother passing the virus 

to her infant during delivery.

•	 Receipt of a blood transfusion or transplantation surgery from an infectious 

donor. (This is rare in the United States 

since mandatory screening was implemented in 1972.) 

Disease Burden

Hepatitis B is a major cause of liver disease 

worldwide. In 2007, there were approximately 

43,000 new infections in the United States. 

Between 800,000 and 1.4 million people in 

the United States live with chronic hepatitis B 

(Wasley et al., 2010; Daniels et al., 2009). In 

the United States, Asian and Pacific Islanders 

and MSM are disproportionately infected 

with HBV. 

Disease Course

Approximately 35 percent of those infected 

exhibit symptoms. Usually, acute HBV 

infection alone is not life threatening. 

Up to 10 percent of people with acute hepatitis 

B will develop chronic hepatitis after 6 months

(Exhibit 1-3). Most of those with chronic 

infection remain symptom free, although they 

can infect other people. Some experience serious illness. HBV infections become chronic 

more frequently in people with compromised 

immune systems (e.g., people with HIV infection). Worldwide, hepatitis B is the most 

likely form of hepatitis to cause liver cancer, 

particularly hepatocellular carcinoma. Chronic 

hepatitis B can also result in cirrhosis of 

the liver, liver failure, and death. Daniels et 

al. (2009) estimate 3,000 people die in the 

United States per year from chronic HBV 

infection. 
7

1—Overview of Viral Hepatitis

Exhibit 1-3 Disease Course of Hepatitis B 

100 people develop acute hepatitis B

90–94 will no longer be 

infected in 6 months

6–10 will still have the 

virus in 6 months

Hepatitis B and Substance Use 

Three percent to 11 percent of people 

who inject drugs have chronic hepatitis B 

(Weinbaum et al., 2008). One study suggests 

that rates of asymptomatic HBV infection 

among clients on methadone maintenance 

may be as high as 25 percent (Bart et al., 

2008). Alcohol use by people with hepatitis B 

damages the liver, which is already compromised with the hepatitis infection. 

Prevention 

Vaccination is the most effective way to prevent

HBV infection. The consensus panel recommends HBV vaccination for the following 

adults: 

•	 People who are infected with HCV

•	 People who are sexually active with or 

who share a household with a person 

with infectious HBV

•	 Men who have sex with men (MSM)

•	 People who inject drugs

•	 People with occupational exposure to 

blood (e.g., medical care workers, dentists)

•	 People who attend or work at institutions 

for people with developmental disabilities

•	 Hemodialysis patients or those with endstage renal disease

•	 People who are infected with HIV

•	 Anyone with liver disease

•	 Anyone who lives in or travels to 

countries with high rates of HBV

•	 Adults in correctional settings 

The HBV vaccine is given in three doses 

within a 6-month period. However, the most 

convenient way to provide immunization is 

with the combined hepatitis A/hepatitis B 

vaccine (sold under the brand name, Twinrix). 

It is administered in three intramuscular injections on a 0-, 1-, and 6-month schedule, or 

may be given on an accelerated schedule of 

four doses, given on days 0, 7, and 21–30 with 

a booster dose at 12 months (FDA, 2010a). 

Despite the availability of the HBV vaccine, 

many at-risk individuals have not been vaccinated. A study of people age 30 and younger 

who inject drugs found that only 22 percent 

had been vaccinated against HBV (Lum et 

al., 2008). Contraindications to getting the 

hepatitis B vaccine include having had a 

severe allergic reaction to a previous dose or 

to a component of the vaccine. Clients should 

discuss the vaccination with a medical care 

provider. 

Hepatitis C

Hepatitis C can be acute or chronic, but 

it starts as an acute infection (that may go 

unrecognized). Unlike people with hepatitis 
8

Addressing Viral Hepatitis in People With Substance Use Disorders

A and B, people who have hepatitis C and 

clear the virus do not develop immunity; they 

can become reinfected with the virus at a later 

date. 

Modes of Transmission

Hepatitis C is a blood-borne disease. IDU is 

the most common risk factor for acquiring

hepatitis C. The virus can enter the body 

through any puncture in the skin (e.g., cuts, 

burns, sores), and travels, via the blood, to the 

liver. Risks of sexual transmission are unclear 

but appear to be low, especially compared with 

sexual transmission rates of HIV or HBV. 

Nonetheless, HCV infection rates are higher 

in people who have multiple sex partners. 

Infections have been reported in individuals 

with no known risk factors. 

Disease Burden 

HCV infection is the most prevalent chronic, 

blood-borne infection in the United States 

(Alter et al., 1999). Approximately 3.2 million

U.S. residents have chronic HCV infection 

(CDC, 2010c). Forty percent of chronic liver 

disease—the 10th leading cause of death 

in the United States—is caused by HCV. 

Hepatitis C is most prevalent among people 

born between 1945 and 1965, the majority of 

whom were likely infected during the 1970s 

and 1980s, when infection rates were the 

highest. CDC (2010c) estimated 17,000 new 

infections in 2007, and people who inject 

drugs account for more than half of the new 

cases. 

Disease Course

HCV can be detected in the blood within 1–3 

weeks of transmission. However, the majority 

of people with hepatitis C are asymptomatic. 

Of people who contract hepatitis C, 15 percent

to 25 percent clear the infection, but 75 percent

to 85 percent do not and the infection becomes 

chronic (CDC, 2010c) (Exhibit 1-4). Chronic 

HCV is insidious, usually progressing very 

slowly and with few or no symptoms for the 

first 20–30 years after infection. Symptoms 

often do not occur until the liver damage has 

advanced. As the disease progresses, the liver 

may develop fibrosis, which can progress to 

cirrhosis. Approximately 12,000 people die 

each year from HCV-related liver disease 

(IOM, 2010). 

Exhibit 1-4 Disease Course of Hepatitis C

100 people develop acute hepatitis C

15–25 will no longer be 

infected in 6 months

75–85 will still have the virus 

in 6 months (chronic)

8–17 will develop cirrhosis 

over 20 years
9

1—Overview of Viral Hepatitis

HCV infection appears to progress more 

quickly in men, people older than 50 at the 

time of infection, and people with concurrent HBV or HIV (Hézode et al., 2005). 

Mortality is high in people with HCV/HIV 

co-infection.

Hepatitis C and Substance Use

HCV is highly contagious; people who inject 

drugs are more likely to contract hepatitis C 

than HIV (Garfein, Vlahov, Galai, Doherty, 

& Nelson, 1996). People who inject drugs are 

at high risk for becoming infected with HCV 

from sharing needles and drug use paraphernalia. Up to 91 percent of people who inject 

drugs and share needles or other paraphernalia 

over a prolonged period will eventually acquire 

HCV infection (Abou-Saleh & Foley, 2008; 

Macias et al., 2008; Maxwell, Shinderman, 

Miner, & Bennet, 2002; Tseng et al., 2007). 

Liver disease progresses more quickly in 

people who have HCV and abuse alcohol 

than in people with only one of the conditions (Bhattacharya & Shuhart, 2003; Felsen, 

Fishbein, & Litwin, 2010).

Prevention

There is no vaccine against hepatitis C. It can 

be prevented only by avoiding contact with 

contaminated blood. 

HCV—True or False?

You can get HCV infection by using the razor of a person who is infected with HCV.

True. HCV is spread through contact with infected blood, such as may be found on a razor or 

toothbrush.

You’ll probably get HCV infection if you eat food from a plate that wasn’t cleaned well.

False. You can only get HCV infection through contact with infected blood.

Hepatitis C is mostly spread through unprotected sex. 

False. The greatest risk factor is IDU. Sexual transmission of HCV is rare, except in people who are 

infected with HIV. However, some evidence suggests that HCV might be passed through sex, if the 

sex includes the possibility of blood exposure (Tohme & Holmberg, 2010).

A vaccine has been developed to protect against HCV.

False. There is no vaccine against HCV.

Hepatitis C can be spread when people who inject drugs share their rinse water.

True. When people who are infected with HCV use needles, drops of their blood are mixed with 

the rinse water. Anyone who uses the same rinse water could contract HCV.

Most people who have HCV infection will become seriously ill and die from liver disease.

False. One to five percent of people who have HCV will die from HCV-related diseases. People 

who have additional medical or substance use problems are at increased risk of developing serious 

liver disease, which can be fatal. People who have other types of viral hepatitis or HIV infection are 

also more likely to get serious liver disease. However, people who adhere to hepatitis C treatment 

and abstain from alcohol and drugs improve their chances for a healthy life.

Adapted from Strauss et al., 2006.
10

Addressing Viral Hepatitis in People With Substance Use Disorders

Other Types of Viral Hepatitis 

Hepatitis D virus (HDV) infects only people 

who are already infected with hepatitis B. 

HDV is transmitted the same way as HBV—

through blood and other body fluids. Because 

hepatitis D can occur only in people with 

hepatitis B, vaccination against HBV infection 

also prevents HDV infection. When people 

who have hepatitis B contract hepatitis D, the 

result can be a superinfection, which has a poor 

prognosis.

Hepatitis E virus (HEV) was first identified 

in 1980, and little is known about it. Hepatitis 

E manifests only as an acute infection. It is 

most often transmitted through the fecal–

oral route, with the highest rates in countries 

with poor sanitation. While vaccines are not 

available at this time, they are in development. 

Hepatitis F virus (HFV) was identified in 

1991, and researchers disagree on whether it is 

a discrete type of viral hepatitis. No diagnostic 

tests exist for HFV infection. 

Little is known about Hepatitis G virus 

(HGV) infection, which was identified 

in 1995, but it does not appear to cause 

significant liver damage. 

Co-Infection with Different Types 

of Viral Hepatitis 

Some people are infected with more than one 

type of hepatitis. Several studies (Cacopardo, 

Nunnari, & Nigro, 2008; Crockett & Keeffe, 

2005; Wietzke-Braun, Manhardt, Rosenberger, 

Ramadori, & Mihm, 2007) indicate that when 

co-infection occurs, one of four scenarios is 

possible:

•	 No effect. In some cases, there is no 

known effect from the concurrent 

infections. 

•	 More severe disease. In most cases, coinfection worsens the severity of one type 

of hepatitis. 

Clinical Scenario

Sarah: “I don’t see what the big deal is about hepatitis. I feel fine.”

Counselor: “Hepatitis is a silent disease. You could go for years feeling fine while hepatitis 

damages your liver.” 

Sarah: “So, I get a little liver damage. I know lots of people with hep who just live with 

it.” 

Counselor: “Let’s work together during our sessions to better understand what hepatitis is 

really all about. It’s true that some people can live with degrees of liver damage, 

depending on their overall health, but if your liver gets damaged enough, it 

won’t work anymore. When your liver doesn’t work, you become very ill. Your 

liver performs hundreds of functions that keep you alive. Right now, your liver is 

removing toxins, storing the nutrients your body needs, producing the materials 

you need to digest food, and doing many other things. If your liver stops working 

properly, your quality of life can be seriously lowered. What kind of life do you 

want for yourself?”

Sarah: “I want to feel good and to be able to do all the things I like to do. I didn’t realize 

that when a disease is ‘silent,’ it can actually be doing a lot of damage. I guess I 

can’t just ignore my hepatitis and hope that it will go away.” 
11

1—Overview of Viral Hepatitis

•	 Activation of disease. To become an 

active disease, HDV infection depends 

on co-infection with HBV. 

•	 Deactivation of disease. In rare cases, 

co-infection may suppress previously 

active disease.

Co-Infection with Viral Hepatitis 

and HIV

HAV/HIV Co-Infection

HIV treatment may need to be temporarily 

suspended if HAV infection is acquired. Most 

studies suggest that this delay does not affect 

HIV progression. However, hepatitis A may 

be more severe and last longer in people who 

have both infections than in people who do 

not have HIV (Ida et al., 2002). 

HBV/HIV Co-Infection 

As many as 90 percent of people who have 

HIV infection have been infected with HBV 

(i.e., with prior resolved infections; RodriguezMendez, Gonzalez-Quintela, Aguilera, & 

Barrio, 2000; Scharschmidt et al., 1992), and 

10 percent to 15 percent of these people will 

become chronic carriers. Most studies suggest 

that this co-infection does not significantly 

change the likelihood that the HIV infection 

will progress to AIDS. However, the coinfection increases the likelihood that HBV 

infection will become chronic and progress 

quickly and that liver damage might be more 

severe (Alberti, Vario, Ferrari, & Pistis, 2005; 

Sulkowski, 2008).

HCV/HIV Co-Infection 

HIV infection may increase a person’s risk 

of contracting HCV through sexual contact 

(Delwaide, Bourgeois, Colle, & Robaeys, 

2002). Approximately 25 percent to 33 percent 

of people who are infected with HIV are 

co-infected with HCV (Alberti et al., 2005; 

Rockstroh & Spengler, 2004). Some studies 

(Eyster et al., 1993; Garcia-Samaniego et al., 

2001; Lesens, Deschenes, Steben, Belanger, & 

Tsoukas, 1999; Pol et al., 1998) suggest that 

people who have HCV/HIV co-infection are 

more likely to develop cirrhosis, liver cancer, 

and liver failure than those with hepatitis 

only. The presence of both infections increases 

the risk of liver toxicity from HIV medications. However, liver damage slows when 

HIV medications are taken by preserving 

or restoring immune function and reducing 

HIV-related immune activation and inflammation. Therefore, the benefits of HIV 

medications may outweigh the risks (Panel 

on Antiretroviral Guidelines for Adults and 

Adolescents, 2011; Hammer et al., 2008; 

Sherman, 2007). If untreated, HCV infection 

progresses more quickly in people who are 

co-infected with HIV than in those who are 

infected with HCV alone. 
12

Addressing Viral Hepatitis in People With Substance Use Disorders

Chapter Summary

Viral hepatitis is an inflammation of the liver caused by a virus. Over time, inflammation can lead to 

scarring, which, in turn can lead to cirrhosis and eventually to liver failure. 

The most common types of hepatitis in the United States are hepatitis A, B, and C.

Hepatitis A:

•	Is spread through contaminated fecal matter.

•	Is never chronic and rarely serious (severity and mortality may increase with age and underlying 

chronic liver disease).

•	Leads to immunity to subsequent HAV infection for individuals who have been infected and 

cleared the virus.

•	Can be prevented through vaccination, abstinence, and safe injection practices.

Hepatitis B:

•	Is spread through blood and other body fluids.

•	Can be acute or chronic.

•	Is usually spread through IDU or sexual contact.

•	Can be prevented through vaccination, abstinence, and safe injection practices.

Hepatitis C:

•	Is the most prevalent blood-borne illness in the United States.

•	Is most commonly spread in the United States through IDU.

•	Becomes chronic in 75 percent to 85 percent of people who are infected.

•	Can take decades to develop symptoms.

•	No vaccine is available, but abstinence and safe injection practices can prevent transmission. 
13

2 Screening for Viral 

Hepatitis

IN THIS CHAPTER

•	The Treatment Program’s 

Role in the Screening 

Process

•	Antigens and Antibodies

•	Hepatitis A Screening

•	Hepatitis B Screening

•	Hepatitis C Screening

•	Counseling Practices 

That Educate, Support, 

and Motivate Clients 

Undergoing Screening 

•	Chapter Summary

I didn’t know anything about [hepatitis C] so didn’t know 

what to think except feeling like my life was over. I was 

only 27 years old, and thought I would not reach 30.

—Kathleen (Hepatitis C Support Project, 2007)

The Treatment Program’s Role in the Screening 

Process

Medical staff members at substance abuse treatment programs might 

assume the primary role for screening individuals for hepatitis and 

explaining the screening process and test results. Opioid treatment 

programs with medical staff members should screen for hepatitis B 

and C at intake and periodically as indicated. In programs without 

onsite medical staff, clients may be referred elsewhere for screening 

with minimal (if any) involvement of the substance abuse treatment 

program. 

Regardless of the type of program, counselors should have a basic 

understanding of the importance of screening, the screening process, 

and the meaning of the results. Counselors can encourage clients 

referred for hepatitis screening to follow through and complete the 

screening and evaluation process (evaluation is addressed in Chapter 

3). Clients might feel anxious about being diagnosed with hepatitis, 

and they might delay or avoid getting screened. 

Antigens and Antibodies

Hepatitis screening involves testing a small sample of blood for 

antigens and antibodies to determine whether the individual has 

been infected with viral hepatitis. Antigens are foreign substances, 

such as microorganisms (e.g., bacteria, fungi, parasites, viruses) or 

chemicals, which invade the body. When the body is exposed to 

antigens, it produces antibodies as a part of its immune response. 

Antibodies are proteins that bind to the antigens to try to clear them 

from the body. Hepatitis blood tests look for antigens or antibodies 

specific to each type of hepatitis virus. 
14

Addressing Viral Hepatitis in People With Substance Use Disorders

Hepatitis A Screening

Screening for hepatitis A involves testing the 

blood for antibodies to the hepatitis A virus 

(HAV). HAV screens sometimes are referred 

to as hepatitis A antibody tests or hepatitis A 

total antibody tests.

A positive antibody test result indicates that a 

person has or had HAV infection or has been 

vaccinated against hepatitis A. This person is 

immune to future HAV infection. A negative 

test result indicates that antibodies were not 

detected in a person’s blood. A person without 

antibodies has never been infected with HAV, 

has never been vaccinated against HAV, and is 

still susceptible to HAV infection. 

Hepatitis B Screening

Hepatitis B virus (HBV) antigens are proteins 

that appear in different areas of the virus. HBV

has three antigens (surface, core, and e), some 

of which can be detected in the blood. The 

body’simmune response produces antibodies 

tailored to each type of antigen (surface antibody, core antibody, and e antibody), which 

can also be detected from a blood test. The 

basic blood test for hepatitis B consists of 

three screening tests: a hepatitis B surface 

antigen test, which determines whether a 

person currently has the infection; a hepatitis

B core antibody test, which determines whether

a person has ever been infected; and a hepatitis

B surface antibody test, which determines 

whether a person has cleared the virus after 

infection, or has been vaccinated and is now 

immune to future infections. These are 

described below. 

Is the person currently infected with HBV? The 

screening test for hepatitis B surface antigens 

detects the presence of HBV in the blood. The 

antigens are detectable 4–10 weeks after exposure to HBV. A positive test result means the 

person is currently infected and can pass the 

infection to others. Most adults who acquire 

HBV clear the virus within a few months, and 

their hepatitis B surface antigen test result 

will be negative after that time. Some people 

remain infected and continue to test positive for hepatitis B surface antigen. If, after 

6 months, the person still tests positive, his 

or her HBV infection is considered chronic. 

People diagnosed with chronic hepatitis B 

should have an evaluation (see Chapter 3). 

Has the person ever been infected with HBV?

The hepatitis B core antibody screening test 

detects the presence of antibodies to the HBV 

core antigen. The antibody appears in the 

blood within a few weeks of HBV infection. 

A positive result means the person has been 

infected with HBV, but it does not specify 

whether the person has cleared the virus, still 

has the infection, or is immune to reinfection. 

Is the person immune to HBV? The hepatitis 

B surface antibody screening test detects the 

presence of antibodies the immune system 

produces to attack the virus. These antibodies 

appear in people who have been vaccinated 

against HBV, or who had been infected and 

cleared the virus from their bodies. A positive 

hepatitis B surface antibody screening test 

means the person has lifetime immunity 

from hepatitis B (the Centers for Disease 

Control and Prevention [CDC], 2009). In 

some situations, hepatitis B screening may 

be unavailable, but the hepatitis B vaccine 

is available. People can be safely vaccinated 

against hepatitis B if they have been previously 

infected or vaccinated. 

Hepatitis C Screening

The most common test for hepatitis C virus 

(HCV) detects antibodies to HCV in the 

blood, but the results are not clear cut and 

should be interpreted carefully. A “positive” 

HCV antibody test could mean the person 

is a chronic carrier of HCV (75 percent to 
15

2—Screening for Viral Hepatitis

85 percent), has been infected but has resolved 

infection (15 percent to 25 percent), or is one 

of the few recently (acutely) infected (CDC, 

2010c). Following HCV infection, it usually 

takes at least 6–8 weeks for the body to 

develop enough antibodies to be measured 

in a screening test, but it can take longer. For 

example, people who have suppressed immune 

systems (e.g., people who have HIV infection) 

may not test positive for 15 weeks–6 months 

after exposure to the virus. An infection 

that has been present for less than 6 months 

may not be detected with an antibody test. 

However, an infection that has been present 

for 6 months is almost always detectable with 

an antibody test. 

A positive HCV antibody test means the 

person was infected with the virus; it does not 

always mean the person is still infected. Up 

to 25 percent of people infected with HCV 

successfully clear the virus from their systems 

within 6 months after being infected, but the 

antibody remains present in the screening test. 

Most antibody testing requires a blood sample 

that is sent to a laboratory for processing. 

However, in 2010, the U.S. Food and Drug 

Administration (FDA) approved a rapid 

antibody blood test for HCV (the first in the 

United States) that is available in some medical offices. The rapid test is for individuals 

15 years and older who are at risk for HCV 

infection or who have hepatitis symptoms. 

The test still requires a blood sample, but it 

involves the use of a “test strip” that provides 

results in approximately 20 minutes. However, 

the rapid test is not sufficient to make a final 

diagnosis of HCV infection. If the rapid test 

is positive, more traditional and sophisticated 

tests will be necessary to confirm the diagnosis 

(FDA, 2010b).

People who have a positive result on an HCV 

antibody screening test should receive additional tests to get more information (Exhibit 

2-1). The most common followup test is a 

qualitative HCV RNA (ribonucleic acid) test. 

RNA is the genetic material of the virus, and 

the qualitative test determines whether the 

virus is present. A quantitative RNA test—or 

quantitative viral load test—measures how 

much of the virus is present (see Chapter 3). 

Because of the difficulty in interpreting an 

HCV antibody screening test, some medical 

care providers ask for a followup test before 

reporting the results of the antibody test to 

their patients. If HCV RNA is present for at 

least 6 months, the HCV infection is considered 

chronic.

Clients might need help deciding 

whether to get screened, 

understanding the test results, and 

determining their next steps.

In people who are at risk of HCV infection, 

false positive antibody test results are rare. 

Therefore, a positive result in a person with a 

history of drug use, particularly injection drug 

use (IDU), is a true positive more than 99 percent of the time—meaning that the person has 

been infected with HCV.

The accuracy of a negative HCV antibody test 

result is very high. However, to account for the 

6-month window period, people who inject 

drugs or engage in other high-risk behaviors 

should be retested every year (Backmund, 

Reimer, Meyer, Gerlach, & Zachoval, 2005).

Counseling Practices That 

Educate, Support, and Motivate 

Clients Undergoing Screening 

Clients might need help deciding whether to 

get screened, understanding the test results, 

and determining their next steps. Even when 

services offered through the substance abuse 

treatment program are limited, discussing 
16

Addressing Viral Hepatitis in People With Substance Use Disorders

Exhibit 2-1 HCV Screening Process

HCV screening (antibodies) test

Positive Results

Person has been infected with HCV Negative Results

No detectable infection at this time. Retest!

•	If the person has engaged in risky 

behavior within 6 months

•	If the person relapses to IDU

Is this person still infected?

HCV RNA test

Positive

Person is infected with HCV

Complete Medical Evaluation

(See Chapter 3)

Negative

No sign of infection

Retest in 6 months

Positive after 6 months

Person is infected with HCV

Negative test after 6 months

Person not currently infected 

with HCV; infection was likely 

cleared by the person’s immune 

system; person is susceptible 

to reinfection

hepatitis testing with clients presents an 

opportunity for counselors to motivate clients 

for change by confronting substance use and 

by making choices that improve their overall 

health. However, this may also be true when 

services are offered on-site through substance 

abuse treatment programs. A study at one 

methadone clinic that offered hepatitis screening and vaccination revealed that although the 

majority of clients completed screening (for 

hepatitis A, B, and C), only 54.7 percent of 

clients who lacked immunity for hepatitis A 

received vaccinations and only 2.9 percent of 

clients who lacked immunity for hepatitis B 

received vaccinations (Felsen et al., 2010). 

The Consensus Panel makes the following 

general recommendations while recognizing 

that, in some programs, the counselor’s role 

may be limited:

•	 Consider screening to be more than just a 

blood test. It is an opportunity to educate 

the client about hepatitis, its effects on 

health, and prevention strategies. It is an 

opportunity for clients to identify their 

risk factors and learn how they can reduce 

the risk of contracting or transmitting 

viruses. 

•	 Be aware that many clients may not 

know whether they have been screened 

for hepatitis in the past or they might 

not know the results. They might confuse 
17

2—Screening for Viral Hepatitis

HIV screening or any blood test with 

hepatitis screening, and they might 

erroneously believe that they are—or 

are not—infected. 

•	 Clearly explain that the hepatitis test is 

optional. Clients may not understand 

what disease the test will detect or that 

they have the option not to give consent 

(Munoz-Plaza et al., 2005). 

•	 Follow up with clients regardless of the 

results. Failure to follow up is a missed 

opportunity to deliver or reinforce prevention messages (Munoz-Plaza et al., 

2005). 

Discussing Screening for Viral 

Hepatitis

Many clients entering substance abuse 

treatment do not know their hepatitis status. 

In two urban studies, as many as 68 percent 

of clients who did not know whether they 

had been infected with HCV tested positive 

(Kwiatkowski, Fortuin, Corsi, & Booth, 2002; 

Felsen et al., 2010). In a five-city sample, 72 

percent of those who tested positive for HCV 

were unaware of their infection (Hagan et al., 

2006). 

Clinical Scenario

Counselor: “Hi, Jim. I’m glad you came in today. We’ve focused a lot on your drug use and 

you’ve described a lot of consequences in terms of your relationships, job, and 

finances. Today, I wondered if it would be okay to talk about how your use has 

generally affected your health.”

Jim: “Sure, I guess so.”

Counselor: “Great! First I’d like to know how much you know about your risks of getting 

hepatitis due to your injection drug use.”

Jim: “Well, I know some folks who have gotten sick and died from it, but I also know 

some who got treated and seem to be okay. I’m worried that I may have this 

infection and will end up like the ones who died—I’m not very lucky.” 

Counselor: “It is true that hepatitis can lead to death in some people, but there have been 

some important improvements in hepatitis treatment over the past few years. But 

before we talk about hepatitis treatment, I’d like to talk a bit about how the virus 

is spread, tests for hepatitis, and some factors, such as alcohol use, that can affect 

how the virus damages the liver. Is that okay?”

Jim: “It’s something that I’d rather not think about, but I know I should. I’ve avoided 

getting tested because I’m worried that I’ll test positive. I don’t have any health 

insurance and can’t afford treatment.” 

Counselor: “That’s a lot to worry about, so I do understand why you’re unsure about the next 

steps, if any, to take. So let’s talk a bit more about what you think your next step 

should be. I can tell you that we’ll do everything we can to help you. And please 

remember that not everyone who tests positive for hepatitis needs treatment. 

So, what do you think?”
18

Addressing Viral Hepatitis in People With Substance Use Disorders

For many clients, a discussion with the counselor 

might be the first conversation they have 

about hepatitis. Clients might be uninformed 

about hepatitis or reluctant to discuss the 

disease. By using motivational strategies, 

counselors can improve clients’ chances for 

engagement in a discussion about hepatitis. 

It is crucial that a treatment counselor

or health professional use a nonjudgmental and compassionate tone.

Addressing Hepatitis for the First 

Time

It is crucial that a treatment counselor or 

health professional use a nonjudgmental and 

compassionate tone. Clients need to feel comfortable disclosing information about their 

health and risky behaviors. The following 

strategies can help initiate the conversation:

•	 Display posters, literature, or other 

hepatitis-related items that could help 

prompt the client to ask questions about 

hepatitis. (See Appendix C for hepatitis 

resources). 

•	 Assess clients’ ability to discuss hepatitis, 

based on their degree of openness in the 

counseling session, the amount of detail 

they provide in their responses, and the 

length of the therapeutic relationship. 

•	 Raise the subject in a way that avoids 

making clients feel defensive or afraid. 

Consider introducing the subject by 

making parallels with other conditions 

that have been discussed. Say, for example, 

“You said you were tested for HIV several 

times. Were you ever tested for viral 

hepatitis?” or “You mentioned that your 

friend is sick with HIV. Have you been 

tested for HCV or HIV? Tell me about 

those tests.”

•	 Be patient and allow time for multiple, 

short conversations about the subject. 

This might ease feelings of fear, anxiety, 

or shame. 

Educating Clients About Viral 

Hepatitis 

Clients may believe they know about viral 

hepatitis, but their understanding of the 

disease may not be accurate. It is easy to 

confuse the three main types of viral hepatitis 

A, B, and C. Clients may have formed 

impressions based on limited or incorrect 

information. Counselors should briefly 

describe hepatitis A, B, and C, including their 

prevalence, transmission, and relationship to 

drug use, as well as to other infections, such 

as HIV and sexually transmitted diseases. 

(Chapter 1 provides an overview of hepatitis. 

Resources for online materials are in Appendix 

C.) Specific strategies for speaking with 

clients include:

•	 Speak clearly and keep the message 

simple, focused, and brief. 

•	 Use language, examples, and concepts 

that the client understands.

•	 Use appropriate visual aids.

•	 Frame numerical statements in terms 

that are easy to visualize. Say “5 out of 

100 people” rather than “5 percent of the 

population”; say “more than half” instead 

of “the majority.”

•	 Repeat the information at different times 

in different ways. The average client retains 

only approximately one-third of what he 

or she is told. Summarize essential points. 

•	 Pay attention to a client’s response to the 

information. For example, if a client stiffens his or her posture, consider saying, “I 

notice that this topic seems to make you 

uncomfortable. It does for a lot of people. 

Please tell me what you’re feeling right 

now. I’d really like to help you with this.” 
19

2—Screening for Viral Hepatitis

•	 Use the opportunity to describe the 

potential detrimental effects of alcohol 

and other substance use on the liver of a 

person who is infected with HCV.

Identifying Patterns of Risky 

Behavior

Screening is an opportunity to draw attention 

to the client’s behaviors that put him or her at 

risk for contracting hepatitis: 

•	 Ask for the client’s perception of his or 

her risk for having contracted hepatitis: 

“How likely do you think it is that the 

test will be positive?”

•	 Listen for and identify behaviors that put 

the client at risk for contracting hepatitis 

A, B, and C and HIV, especially unprotected sex and sharing injection drug 

paraphernalia. 

•	 Assess the client’s alcohol consumption. 

Preparing Clients for Screening

Once clients are comfortable talking about 

viral hepatitis, they might be more willing to 

undergo screening. However, clients might be 

anxious about the test itself; a reassurance that 

testing is a simple procedure can help allay 

these concerns. Many substance use treatment 

facilities do not offer screening, and clients 

might need to be referred elsewhere. The following strategies can enhance the discussion 

of the hepatitis screening process and hepatitis 

prevention: 

•	 Ask the client whether he or she has ever 

had a hepatitis test: “Have you ever been 

tested before?” or “What did you do when 

you found out that you were positive [or 

negative] for hepatitis?” 

•	 Remember that information about screening 

might need to be repeated, depending on 

the rapport between client and counselor, 

the client’s cognitive abilities and interest, 

and other issues that come up during a 

session.

•	 Discuss the benefits of screening, such 

as the possibility for early diagnosis and 

treatment (e.g., prevention of transmission to others, reduced risk of long-term 

complications). Clearly state that screening 

is voluntary.

•	 Describe the screening procedure and 

explain that blood samples are needed. 

Be sensitive to potential relapse triggers. 

For a person who injects drugs, the use 

of a needle in the blood draw might 

prompt cravings. 

•	 Advise a client with a history of IDU that 

the blood draw might be difficult if his or 

her veins are damaged. 

•	 Tell the client how long it generally takes 

to receive results (the timeframe varies by 

testing venue and the laboratory). A delay 

does not indicate a positive result.

•	 Make a plan with the client to get to 

and from the appointment.

•	 Ensure that the client has emotional 

support or referrals during the waiting 

period. If a support group is available, 

encourage the client to attend to learn 

more about viral hepatitis and about 

others’ responses to it. 

•	 Clarify the meaning of possible results. 

Say, for example, “A positive HCV antibody test result means that you have been 

infected with HCV. It does not necessarily 

mean that you are sick or that you are still 

infected. A negative result means that you 

have not been infected with hepatitis C 

or your infection occurred within the last 

6 months.” 

•	 Make a plan with the client for receiving 

the screening results; for example, call a 

member of a mutual support group or 

schedule an additional appointment with 

the counselor. 
20

Addressing Viral Hepatitis in People With Substance Use Disorders

Discussing Screening Results With 

Clients 

The medical personnel who ordered or 

arranged the screening test, not counselors, 

usually explain the results. Hepatitis screening should be part of the intake physical 

examination in an opioid treatment program, 

and medical personnel may report the results. 

However, the client may want to discuss the 

results with the counselor or ask the counselor 

questions. 

Anxiety might interfere with some 

clients’ ability to comprehend or 

retain information, which might need 

to be repeated.

Suggestions for conversations with clients 

when the test results are negative include the 

following:

•	 Explain results clearly and simply: “So the 

HCV antibody screening result was negative? This means that, as of 6 months ago, 

you did not have hepatitis C.” 

•	 Emphasize that a negative result to an 

HCV test does not indicate immunity 

to hepatitis C and that the client should 

take precautions to avoid infection. If a 

relapse to drug use occurs, advise clients 

to avoid sharing any drug paraphernalia 

or equipment. Specify that this includes 

cookers, cotton, water, needles, syringes, 

pipes, and straws. 

•	 Emphasize the importance of getting 

HAV and HBV vaccinations. Provide 

information about the availability of 

low- or no-cost vaccinations.

Clients whose screening test results are positive 

for chronic hepatitis will need additional tests 

and examinations—usually with doctors who 

specialize in diseases of the liver (i.e., gastroenterologists)—to get accurate diagnoses and 

to determine their health status and the extent 

of liver damage. These tests are described in 

Chapter 3. 

The following guidelines can help prepare 

clients for the next steps in evaluating their 

chronic hepatitis:

•	 Ask clients whether they were referred 

to a medical care provider for additional 

tests. Encourage them to make and keep 

appointments. 

•	 Explain that the screening test indicates 

only that clients have been infected with 

hepatitis and additional testing is necessary to determine their health status. 

•	 Prepare clients to consider getting further 

evaluation. Say, for example, “Depending 

on the results of the additional medical 

tests, you might be asked to make some 

important decisions about whether to 

undergo antiviral treatment.” 

•	 Identify barriers to further testing (e.g., 

transportation to medical appointments, 

insurance coverage) and ways to overcome 

them. 

Clients will react in a variety of ways to news 

of a positive result. Anxiety might interfere 

with some clients’ ability to comprehend or 

retain information, which might need to be 

repeated. Some clients might be worried 

about spreading the virus to others or about 

the reaction of family, friends, and others. 

Impediments to clients’ coping with a positive 

screening test for HCV include their concern 

about any disclosure of the positive test result 

and fear of inappropriate or disrespectful 

treatment by medical staff members or other 

clients (Strauss et al., 2008). For others, a 

positive test might be of little concern because 

they are more concerned with treatment for 

a substance use disorder (SUD) and stressors 

in their life other than an asymptomatic viral 

infection. 
21

2—Screening for Viral Hepatitis

To help clients come to terms with their 

positive test results:

•	 Explain results clearly and simply: “Let’s 

look at your test result, and then we’ll 

talk about how best to understand it. The 

HCV test result is positive, which means 

you have been infected with the hepatitis 

C virus.” 

•	 Assess reactions to the results: “How do 

you feel about knowing that you have 

been infected with hepatitis C? What 

does this result mean to you?” 

•	 Address immediate fears and concerns 

before providing further information.

•	 Provide information on liver health in 

the client’s language of choice and at the 

client’s reading and comprehension levels. 

•	 Provide reassurance and hope: “For some 

people, hepatitis is very serious, but for 

most people it never causes life-threatening disease. You can do many things to 

protect your liver.” 

•	 Stress the importance of getting vaccinated against hepatitis A and B. “If you 

get hepatitis A or B, it can make your 

hepatitis C worse. There are vaccinations 

against hepatitis A and B. We can help 

arrange for you to get vaccinated.” 

•	 Reiterate the importance of not drinking 

alcohol: “Alcohol damages the liver faster 

in people who have hepatitis. It’s really 

important to stick with treatment.” 

•	 Caution against taking medications 

without first consulting a medical care 

provider. “Some medications—even ones 

you buy over the counter or those that 

are available by prescription—can harm 

your liver. Even some vitamins and herbal 

medications can be dangerous. Check 

with your medical care provider before 

you take anything.” 

•	 Encourage clients to learn their HIV 

status. HBV and HCV infections cause 

liver damage more quickly in people who 

also have HIV infection. Chronic hepatitis 

can complicate the treatment of HIV. If 

clients are not HIV positive, urge them to 

take measures to avoid infection. 

•	 Explain hepatitis transmission to promote 

prevention: 

− HCV is easily spread through exposure 

to infected blood by sharing drug use 

paraphernalia or equipment or any 

item that can have minute bits of 

blood on it, including toothbrushes 

and razors.

− HCV is not spread by sneezing, 

coughing, hugging, or sharing eating 

utensils or drinking glasses; it is not 

spread through casual contact.

− The risk of spreading HCV by sexual 

contact is very low, but HBV can be 

spread by sexual contact (and any 

close personal contact).

− Open sores or wounds should be 

treated and covered with a bandage. 

Having hepatitis C does not exclude 

clients from work, school, or other 

settings.

− Clients who are infected with HCV 

cannot donate blood, body organs, 

or semen.

− In the event of a relapse, clients 

should not share any drug paraphernalia or equipment and should return 

to treatment. 
22

Addressing Viral Hepatitis in People With Substance Use Disorders

Chapter Summary

Screening for hepatitis A involves a blood test that detects antibodies produced by a person’s 

immune system to fight the virus.

•	A positive test result means the person is currently infected, had been infected, or has been 

vaccinated against infection and is immune to infection. 

•	A negative test result means the person has never been infected or vaccinated. This person 

should probably be vaccinated against HAV.

Screening for hepatitis B involves blood tests that measure HBV antigens and antibodies. 

•	The test for hepatitis B surface antigen detects the presence of HBV. A positive result means the 

person is currently infected and can pass the infection to others. If, after 6 months, the person 

still tests positive, his or her HBV infection is considered chronic.

•	The test for hepatitis B core antibody detects the presence of the core protein of the virus. A 

positive result means the person has been infected with HBV, but it does not specify whether the 

person has cleared the virus, still has the infection, or is immune to reinfection. A negative result 

means the person has never been infected with HBV. This test does not tell whether a person is 

immune to infection or reinfection. 

•	The test for hepatitis B surface antibody detects the presence of the surface protein (or the 

surface antigen) of the virus that appears after the virus has been cleared (or the person has 

been successfully vaccinated). People who have surface antibodies have lifetime protection from 

future HBV infection. In people who do not clear the virus but develop chronic infection, these 

antibodies never appear.

Screening for hepatitis C involves a blood test to detect antibodies, but the results are not clear 

cut and should be interpreted carefully.

•	A positive test result means the person has been infected with HCV and might be chronically 

infected; it does not always mean the person is still infected. Diagnostic tests are needed.

•	A negative test result means either the person has not been infected or the person was infected 

recently and antibodies have not yet appeared. Another test might be needed in 6 months.

Counselors can use the screening as an opportunity to:

•	Educate clients about hepatitis.

•	Identify patterns of risky behavior.

•	Urge clients to get vaccinated against HAV and HBV.

•	Educate clients to prevent hepatitis transmission.
23

3 Evaluation of Chronic 

Hepatitis

IN THIS CHAPTER

•	The Medical Evaluation

•	Liver Panel 

•	Viral Load Tests

•	Genotype Test

•	Liver Biopsy 

•	Chapter Summary

After my f irst liver biopsy (and, yes, I was scared of the 

biopsy needle, but it was all over pretty fast), it was discovered that I had stage 2 f ibrosis and inflammation. It 

was time for action.

—Brian (Hepatitis C Support Project, 2006)

The Medical Evaluation

Clients diagnosed with chronic hepatitis require a full medical 

evaluation to gather information about the nature of their infection, 

the severity of the disease, and factors that might affect the course 

of the disease and its treatment. At some point, clients will probably 

be referred to a specialist. This chapter focuses on the evaluation 

of chronic hepatitis, which is caused by the hepatitis B or C virus. 

The evaluation of chronic hepatitis can involve several tests:

•	 Liver panel and other blood tests 

•	 Viral load tests 

•	 Genotype test

•	 Liver biopsy 

Taken together, the results of these tests help a physician assess 

the disease progression, its prognosis, and the risks and benefits 

of hepatitis treatment. 

Liver Panel 

A liver panel, also referred to as liver function tests (LFTs), is a series 

of blood tests to measure the extent of liver injury. It is among the 

first tests for people who are diagnosed with chronic hepatitis. A 

liver panel measures levels of enzymes and proteins that, if not 

within the normal range, might indicate liver damage. However, 

normal levels on a liver panel do not always mean that the liver is 
24

Addressing Viral Hepatitis in People With Substance Use Disorders

not damaged. People who have cirrhosis, for 

example, can have normal LFTs. Exhibit 3-1 

identifies the tests in a standard liver panel 

and what each test measures. Other tests 

might include complete blood counts and 

other measures to help round out the overall 

assessment of liver health.

Viral Load Tests

Nucleic acid tests, which measure nucleic acid, 

can indicate the quantity of virus present in 

the bloodstream; hence, they are referred to as 

quantitative viral load tests. These are the best 

and most specific tests to indicate the presence of viral hepatitis B or C. Nucleic acid is 

composed of molecules that carry the genetic 

information used in the development and 

functioning of organs, such as the liver. The 

nucleic acid test for hepatitis B is hepatitis B 

virus (HBV) DNA (deoxyribonucleic acid), 

and the test for hepatitis C is hepatitis C virus 

(HCV) RNA (ribonucleic acid). Qualitative 

HCV RNA tests, which determine whether 

the virus is present, are used to screen for 

hepatitis C (see Chapter 2).

The extent of liver damage does not correlate 

with measures of HBV DNA or HCV RNA. 

A low viral load does not mean a person has 

little liver damage, nor does a high viral load 

necessarily indicate more severe infection 

or more advanced disease. Clients who are 

familiar with HIV testing often assume that 

viral load results for HBV and HCV mean 

the same as they do for HIV viral load results. 

Exhibit 3-2 highlights the similarities and 

differences between the HIV and HBV/HCV 

viral load tests. 

Exhibit 3-1 The Liver Panel

Test Significance

Alanine aminotransferase (ALT) Elevated levels of this enzyme indicate liver damage. 

Normal levels do not necessarily indicate healthy liver.

Albumin Decreased levels of this protein indicate liver disease, 

such as cirrhosis (or other health conditions). Levels 

are often normal until liver disease is extensive.

Alkaline phosphatase High levels of this enzyme indicate an obstruction in 

the liver (or bile ducts).

Aspartate aminotransferase (AST) Elevated levels of this enzyme might mean liver 

damage. The enzyme is not specific to the liver, so 

high levels could mark problems elsewhere in the 

body.

Total bilirubin Elevated levels of this blood byproduct cause 

jaundice.

Gamma-glutamyl transpeptidase (GGT) Elevated levels of this enzyme indicate liver damaged 

by alcohol use or viral hepatitis.

Prothrombin time (PT) This test measures the time it takes blood to clot. 

Longer than normal clotting time might indicate 

severe liver damage.
25

3—Evaluation of Chronic Hepatitis

Exhibit 3-2 Comparison of HIV and HBV/HCV Viral Load Tests

Component HIV Viral Load Test HBV/HCV Viral Load Test

What does the test measure? The presence or amount of 

HIV in the blood.

The presence or amount of HBV 

or HCV in the blood.

What does a negative result 

mean?

In a person who is HIV 

positive, the person still has 

HIV infection but the virus’s 

replication is under control.

In a person with HCV antibodies, 

the person has no evidence of 

chronic hepatitis.

What does a positive result 

mean?

The person is infected with 

HIV.

The person is infected with the 

hepatitis virus.

What do the levels mean? High levels correlate with 

disease severity and indicate 

a high likelihood of disease 

progression.

High levels before hepatitis 

treatment might suggest a low 

likelihood of clearing the virus 

once antiviral treatment begins. 

People who have high levels 

might be more infectious to 

others. During treatment for 

hepatitis B or C, viral load tests 

can determine whether antiviral 

treatment is working. After 

treatment, increased viral load 

might indicate virologic relapse.

Genotype Test 

This test identifies the type or strain of the 

hepatitis virus. HBV has eight genotypes, 

labeled A–H; genotypes A–D constitute the 

most prevalent genotypes in the United States. 

Knowing the genotype of HBV might predict 

how successful antiviral treatment will be, but 

more studies are needed.

At least six genotypes (and some subtypes) of 

HCV exist, but genotypes 1, 2, and 3 are most 

common in the United States. The genotype 

of the virus does not change. Once the HCV 

genotype is determined, another genotype 

blood test is not needed unless the person 

clears the HCV infection and then acquires 

a new HCV infection. 

No genotype causes more severe disease than 

any other, but the genotype has implications 

for response to antiviral treatment and the 

duration of treatment. Historically, genotype 

1 has been characterized as less treatable, or 

more difficult to cure, than genotypes 2 and 3. 

People who had genotypes 2 or 3 were more 

likely to respond to hepatitis treatment than 

are people who had genotype 1. However, 

people who have genotype 1 hepatitis have 

reason to be treated. Boceprevir and telaprevir 

were approved by the U.S. Food and Drug 

Administration (FDA, 2011a; FDA, 2011b) 

in 2011 to be used in combination with 

interferon and ribavirin for the treatment of 

adults with chronic hepatitis C, genotype 1. 

These medications have demonstrated higher 

success rates and shorter treatment times for 

genotype 1, and other new medications are 

currently in development. Chapter 4 provides 

information on how genotype factors into 

hepatitis treatment decisions. Exhibit 3-3 

compares genotypes 1 with genotype 2 and 3.
26

Addressing Viral Hepatitis in People With Substance Use Disorders

Counselors can help clients understand the 

significance of their genotypes in the following 

ways: 

•	 Ask clients what they have been told 

about genotypes.

•	 Respond accordingly. Although genotype 

1 has historically been less responsive to 

antiviral treatment than other genotypes, 

as many as 68 percent of clients who have 

genotype 1 respond to newer treatments. 

Types 2 and 3 are more responsive to 

antiviral treatment than type 1.

•	 Assure clients that having genotype 1 does 

not mean that the disease will progress 

more quickly or that the symptoms will be 

more severe. 

•	 Tell clients that the most important 

thing is to follow up with their physician, 

because all genotypes have possible treatments that are rapidly improving.

Ask clients, “What does this information 

mean to you? Does it make sense? How might 

this information help you decide your next 

step?”

Exhibit 3-3 Comparison of the Most Common HCV Genotypes in the United 

States

Component Genotype 1 Genotypes 2 and 3

Frequency The most common genotype 

in the United States; accounts 

for approximately 75% of HCV 

cases.

Combined, they account for 

approximately 25% of HCV 

cases in the United States.

Response to antiviral 

treatment*

Nearly 50% of people respond 

successfully to hepatitis 

treatment with interferon 

and ribavirin. The addition of 

telaprevir or boceprevir can 

increase this to as much as 

67%–68% (McHutchison, 2009; 

Poordad et al., 2011).

Approximately 80% of people 

respond successfully to 

treatment and clear the virus.

Length and dose of antiviral 

treatment*

Antiviral treatment with 

interferon and ribavirin lasts 12 

months and involves a higher 

dose of medication compared 

with genotypes 2 or 3. The 

addition of boceprevir or 

telaprevir can reduce treatment 

time to 24 weeks (FDA, 2011a; 

FDA, 2011b).

Antiviral treatment lasts 6 

months and involves a lower 

dose of medication compared 

with genotype 1.

*Applies only to people who have HCV alone, not to people who have co-infections with other forms of viral hepatitis or HIV.
27

3—Evaluation of Chronic Hepatitis

Liver Biopsy

A liver biopsy involves removing and examining 

a small number of liver cells that can reveal: 

•	 The extent of liver inflammation. 

•	 The amount of scarring (fibrosis) present.

•	 Presence or absence of cirrhosis.

•	 Lesions in the liver.

•	 Other conditions (e.g., alcoholic liver 

disease) that might be damaging the liver 

and the severity of the conditions.

•	 Possible effects of hepatitis treatment.

Reasons to have a liver biopsy include the 

following:

•	 It is the best way to evaluate the health 

of the liver and the only way to reveal the 

extent of scarring (if any). 

•	 It can help the physician decide whether 

antiviral treatment is advisable or needed. 

Treatment might not be necessary if the 

liver is healthy, or it might be inadvisable 

if the patient has other issues that might 

contraindicate treatment. 

•	 The results can be used when deciding 

whether to continue antiviral treatment if 

side effects are severe. Chapter 4 addresses 

factors to consider in making medical 

decisions about hepatitis treatment. 

As with any surgical procedure, liver biopsies 

have risks, including pain and internal bleeding. Some clients might feel the risks of 

biopsy are not worth the potential information gleaned from the procedure. Increasingly, 

people who have genotype 2 or 3 HCV start 

antiviral treatment without having a liver 

biopsy. People who have these genotypes 

might decide that, because treatment is likely 

to succeed, they will try treatment regardless 

of their biopsy results. People for whom antiviral treatment is not as likely to be successful 

might decide not to go through treatment 

unless their liver disease is progressing. Thus, 

the most important factor in determining 

whether individuals should have a biopsy is 

how essential the results are to them and to 

their medical care provider. 

Helping Clients Decide Whether to 

Have a Liver Biopsy

Following are suggestions to help clients 

decide whether to have a liver biopsy:

•	 Help clients weigh the potential risks 

and benefits. Counselors cannot provide 

medical advice, but they can, with the 

clients’ medical care providers, help clients 

understand their choices. 

•	 Listen to clients’ fears, and respond with 

accurate information. 

•	 Help clients plan how they will cope 

with pain after the procedure. Some will 

require medications to treat pain. Taking 

any medication may be a relapse trigger 

for someone with a history of drug use. 

Counselors can explain that taking medications under a medical care provider’s 

supervision is appropriate to relieve pain; 

these medications do not necessarily lead 

to relapse. Untreated pain might be as 

likely to trigger craving for opioids as the 

appropriate use of pain medications. 

•	 Help clients find someone to accompany 

them to the procedure. Patients are required

to have someone take them home 

afterward. A substance abuse treatment 

program can offer to find a peer or staff 

person who could take a patient to and 

from the procedure (Litwin, Soloway, & 

Gourevitch, 2005).

•	 Address the positive aspects of a biopsy 

(e.g., it provides important information 

that can help clients move forward). 

•	 Help clients work out logistical issues. 

For some clients, arranging for child care 

or taking care of other logistical issues 

present problems. 
28

Addressing Viral Hepatitis in People With Substance Use Disorders

Clinical Scenario

Counselor: “Hi, Susan. Tell me about your recent doctor’s visit for your HCV evaluation.”

Susan: “Yeah, I went. I found out that my liver is fine and I don’t have to worry.”

Counselor: “That’s great news! What else did the doctor say?”

Susan: “She said that the liver tests—the enzymes—are real good and low.”

Counselor: “Terrific news! You must be very relieved.”

Susan: “Yeah, I am. I was really worried after the last relapse. The discussions that we had 

really helped me to see how my drug use might be causing more problems with 

my liver and in other areas of my health. My doctor said she’d like me to get a 

biopsy, but if my liver enzymes are okay, I’m not sure why I should do that.”

Counselor: “It sounds confusing that your health seems to have improved and yet your doctor 

wants more information. So what are you thinking at this point?”

Susan: “Well, I’m not sure. I mean, how is this possible, you know, how could my liver be 

improved and yet I still have HCV?”

Counselor: “Well, let’s talk about that for a few minutes, if that’s okay.”

Susan: “Sure, can you make sense of this? I really don’t want to have a biopsy.”

Counselor: “You know, this happens quite often. People who have HCV will see improvements 

in their enzyme numbers, but those tests are only one piece. It’s really important to 

get more testing to get the whole picture of what’s going on in there. What do you 

think?”

Susan: “Well, I guess that makes sense. Would I really have to get a biopsy?”

Counselor: “Well, that’s really up to you to decide, with information from your doctor. But it 

sounds as if you might be willing if she could tell you more about why it’s really 

important.”

Susan: “Yeah, maybe I should. Could you help me with that?”

Counselor: “Sure. Let’s see how you might start that conversation with her, and you could 

make another appointment right now from my office if that would help.”

•	 Help clients explore ways to pay for the 

biopsy. Be familiar with medical assistance 

programs for uninsured clients, and keep 

a list of physicians who are willing to 

perform biopsies on people who have a 

history of drug use. Insured clients need 

to make sure that their insurance covers 

the procedure. 

•	 Help clients identify support from family 

and peers. The additional burden of an 

illness can make people who are already 

marginalized feel more isolated. Supportive 

people can help clients cope with the 

disease and antiviral treatment side effects 

and identify potentially dangerous side 

effects. 
29

3—Evaluation of Chronic Hepatitis

Liver Biopsy Procedure

The physician should thoroughly inform 

the patient about the procedure, including 

alternatives, risks, benefits, and limitations. 

The procedure typically takes place at an 

outpatient surgical center or in a hospital. The 

patient will need to sign an informed consent 

form before the procedure. The physician 

determines preprocedure orders (e.g., when 

the patient needs to stop eating and drinking; 

special diet, if necessary; which medications, 

including over-the-counter, to stop taking 

(Rockey, Caldwell, Goodman, Nelson, & 

Smith, 2009). 

The biopsy procedure involves the following:

•	 Patients receive a local anesthetic on 

the right side of the abdomen to numb 

the area. The degree of pain anticipated 

during and after the procedure should be 

taken into account.

•	 The surgeon inserts a needle into the liver 

and extracts a small piece of liver tissue. 

•	 Laboratory personnel examine the liver 

tissue and provide the physician with the 

results within a few days.

•	 Nurses observe the patients for a few 

hours before they are discharged. 

Following the procedure, it usually is 

necessary for patients to lie on their right 

sides for 3–4 hours to prevent bleeding.

Precautions to take after the biopsy include 

the following:

•	 For at least 24 hours, patients should not 

lift objects heavier than 15 pounds. 

•	 Some patients might be sore where the 

needle was inserted, or they might experience pain in their right shoulders. These 

symptoms are temporary and usually go 

away in a few days.

•	 With the physician’s approval, patients 

might take acetaminophen for pain. As 

is the case for most medical procedures, 

patients should not take aspirin or ibuprofen for 7 days before or after the biopsy.

Resources for information about liver biopsy 

are in Appendix C.

Chapter Summary

A hepatitis evaluation provides information for making informed decisions about antiviral 

treatment.

HCV evaluation can include the following:

•	Liver panel 

•	Viral load tests

•	Genotype test

•	Liver biopsy

Counselors can help clients cope with an evaluation of chronic hepatitis by:

•	Helping them identify and weigh the risks and benefits of evaluation.

•	Exploring the client’s feelings. 

•	Helping clients plan how they will cope with waiting for and receiving evaluation results.

31

4 Helping Clients Make 

Medical Decisions About 

Hepatitis Treatment

IN THIS CHAPTER

•	The Counselor’s Role

•	Factors to Consider 

About Hepatitis 

Treatment

•	Counseling Clients 

Diagnosed With Chronic 

Hepatitis

•	Supporting the Decision 

to Treat Hepatitis

•	Special Populations: 

Barriers to Hepatitis 

Treatment

•	Chapter Summary

When I was trying to decide whether I should get on the 

interferon or not, I was hammered until I made a decision. 

Some medical staff and some clinical staff think because 

you use drugs that you’re totally stupid, or you’re playing to 

get time off. There’s got to be a little more compassion and 

a little more education. They definitely need to let the residents be part of the decision. I mean, it’s their lives.

—Counselor and Former Client in “Program C” 

(Strauss et al., 2005, p. 1821)

The Counselor’s Role

Medical care providers that once would have denied hepatitis 

treatment to people with substance use disorders (SUDs) now 

routinely screen and evaluate such people and often recommend 

antiviral treatment. Pharmacotherapy for an opioid addiction, for 

example, is no longer considered a contraindication to evaluation, 

care, or treatment of chronic hepatitis (Kresina et al., 2008). 

Informed counselors can help their clients make decisions about 

medical care for hepatitis and can support the clients in managing 

the risks and benefits that come with any decision. 

Factors to Consider About Hepatitis Treatment

People who have chronic viral hepatitis have three options: 

1. They can be treated with potent antiviral medications.

2. They can defer antiviral treatment.

3. They can decide not to be treated. 

Although antiviral treatment holds the best promise of eliminating 

chronic hepatitis, the treatment is long, could be difficult, and could 

be expensive without insurance. (Sources for financial assistance are 

listed in Appendix H.) Undergoing treatment might not be the best 

choice for everyone. 
32

Addressing Viral Hepatitis in People With Substance Use Disorders

The decision to start antiviral treatment 

should be made by the patient and the medical 

treatment team, based on the patient’s characteristics, circumstances, and an overall assessment of the treatment risks and benefits. Many 

times, a patient needs to consult a specialist, 

such as a hepatologist, to get all the information needed to make a sound decision. Before 

developing the hepatitis treatment plan, the 

physician and patient need to consider several 

factors:

•	 Timing of hepatitis treatment

•	 Treatment contraindications

•	 Presence of more urgent problems

•	 Likelihood of adhering to hepatitis 

treatment

•	 Likelihood of treatment success 

Timing of Hepatitis Treatment

Timing is primarily a factor of how much 

damage the hepatitis has done to the liver. 

Patients with mild liver disease (mild scarring), 

detected by biopsy, might be able to defer 

hepatitis treatment. Some people, however, 

might want to do what they can to get rid 

of their hepatitis C virus (HCV) infection 

regardless of the state of their liver disease. 

In this situation, a patient’s feelings about 

being infected and his or her level of interest 

in undergoing treatment can be the deciding 

factors. 

Those with intermediate liver disease (intermediate 

scarring) should seriously consider hepatitis 

treatment, weighing all relevant factors. For 

example, people who have HIV co-infection 

who face the likelihood of an accelerated 

progression of liver disease have an increased 

incentive to treat their hepatitis C. 

For people who have cirrhosis (severe scarring), 

timely treatment of hepatitis treatment might 

be warranted, unless the liver disease has 

advanced beyond the point that it will respond 

to antiviral treatment, or the risks of treatment 

outweigh possible benefits. 

Patients with end-stage liver disease (decompensated cirrhosis) might not be appropriate 

for treatment, unless they are on a transplant 

waiting list and/or being cared for by experts. 

Information on hepatitis treatment options, 

including transplantation, is included in 

Chapter 5.

Hepatitis Treatment 

Contraindications

Some co-occurring medical or behavioral 

health conditions, certain lifestyle choices, 

or pregnancy can contraindicate treatment 

for chronic hepatitis (Ghany, Strader, Thomas, 

& Seeff, 2009). Contraindications include: 

•	 Major uncontrolled psychiatric disorders 

(e.g., depression, bipolar, schizophrenia). 

•	 Prior solid organ (i.e., renal, heart, lung) 

transplantation.

•	 Pregnancy or unwillingness to use 

adequate contraception (see Exhibit 4-1).

Exhibit 4-1 Pregnancy and Antiviral Treatment 

•	Interferon and ribavirin can cause birth defects, so pregnant women (or their sexual partners) 

should not be administered these medications. Women who are breastfeeding should not 

undergo antiviral treatment for hepatitis. 

•	A man receiving antiviral treatment for HCV should not impregnate a woman during his 

treatment and for 6 months thereafter because of the possible risk of birth defects. 

•	Women with HCV have to decide whether to complete antiviral treatment before trying to 

become pregnant or to delay treatment until after delivery. 
33

•	 A condition that would make hepatitis 

treatment dangerous (e.g., severe uncontrolled hypertension, untreated heart failure, significant and uncontrolled coronary 

heart disease, poorly controlled diabetes, 

chronic pulmonary disease).

•	 An allergy or hypersensitivity to medications (e.g., interferon, ribavirin).

Use of drugs and alcohol is no longer an 

absolute contraindication to antiviral treatment 

(see Exhibit 4-2). Many people who actively 

inject drugs are not willing to undergo antiviral treatment or might have difficulty adhering 

to treatment. However, some people who use 

drugs, including people who inject drugs, are 

willing and able to undergo and adhere to 

antiviral treatment (Ghany et al., 2009).

Presence of More Urgent Problems

Some health issues might take precedence 

over beginning treatment for hepatitis, particularly if the extent of liver damage is mild 

or intermediate:

•	 Treatments for HIV infection or other 

life-threatening conditions might need 

to begin first. 

•	 Stabilization of a mental or substance use 

disorder might be necessary. 

•	 The priority of some clients might be to 

meet basic needs (e.g., finding housing; 

getting regular, nutritious meals). 

•	 Clients in crisis might need to stabilize 

before antiviral treatment can begin, 

depending on the number and severity of 

stressors in their lives.

Likelihood of Adhering to Hepatitis 

Treatment 

It is difficult to predict which individuals can 

or will adhere to hepatitis treatment. Until 

recently, the standard practice was to recommend against treating chronic hepatitis in 

people whose circumstances or conditions 

might interfere with their ability to adhere to 

treatment (e.g., continued substance abuse, 

mental illness). But this is no longer the case. 

The following points summarize the current 

thinking on treating people who have conditions previously considered contraindications 

to antiviral treatment: 

•	 Hepatitis C treatment is associated 

with exacerbation of existing psychiatric 

Exhibit 4-2 Statements and Recommendations on Hepatitis Treatment

Agency Treatment Guideline

National Institutes of Health 

Consensus Statement on the 

Management of Hepatitis C

Decisions about treatment of hepatitis C in people who 

inject drugs should be made on a case-by-case basis; drug 

use itself is not an absolute contraindication to antiviral 

treatment for hepatitis C (National Institutes of Health [NIH], 

2002).

New York State Department of 

Health Guidelines for the Medical 

Management of Hepatitis C

“Patients actively using injection drugs should be offered 

drug counseling and psychiatric support services.... [T]

reatment of the actively injecting drug using person should 

be based upon the willingness of the client to undergo 

therapy, ability to regularly attend appointments for close 

monitoring, and agreement to use of contraception to 

prevent pregnancy” (New York State Department of Health, 

2005a, p. 11).

American Association for the 

Study of Liver Diseases Guidelines 

on Diagnosis, Management, and 

Treatment of Hepatitis C

Therapy should be individualized for people who currently 

use alcohol and who are willing to participate in a substance 

abuse or alcohol treatment support program (Ghany et al., 

2009).
34

Addressing Viral Hepatitis in People With Substance Use Disorders

symptoms, new symptoms, and thoughts 

of suicide. Depression is a common side 

effect of antiviral treatment and a main 

reason people stop treatment. However, 

with psychiatric treatment and monitoring, people who have psychiatric disorders 

have rates of adherence and successful 

outcome comparable with rates of those 

who do not have psychiatric disorders 

(Martin-Santos et al., 2008). 

•	 People in opioid treatment programs 

sometimes have structured support, which 

helps them adhere to antiviral treatment 

and have successful outcomes. 

•	 People who relapse to alcohol or injection drug use can sometimes successfully 

complete antiviral treatment at rates that 

do not significantly differ from those 

of people who do not abuse substances 

(Anand et al., 2006; Backmund, Meyer, 

& Edlin, 2004; Dalgard, 2005; Robaeys, 

Van Vlierberghe, Mathei, Van Ranst, & 

Buntinx, 2006; Van Thiel, Anantharaju, 

& Creech, 2003). 

Likelihood of Hepatitis Treatment 

Success

Hepatitis C treatment success is defined as 

achieving a sustained virologic response (SVR) 

(see Exhibit 4-3)—when the virus cannot be 

detected for up to 24 weeks (and usually many 

years) after therapy. If the virus cannot be 

eradicated, treatment is generally considered 

unsuccessful, even though the progression of 

liver disease might have slowed during treatment. For individuals with mild liver disease, 

a higher predicted likelihood of achieving an 

SVR might make them more interested in 

antiviral treatment than individuals whose 

expected likelihood of responding is lower. 

Historically, success rates for those who 

received hepatitis treatment were between 

40 percent and 50 percent (Heathcote & 

Main, 2005), but new therapies promise higher 

success rates and shorter treatment times.

Several factors affect the likelihood of treatment 

success: 

•	 Genotypes. Clients who are infected with 

HCV genotype 2 or 3 have approximately 

an 80 percent chance of success, as 

opposed to as much as a 67 percent to 68 

percent chance for those who are infected 

with genotype 1 (see Chapter 3). 

•	 Viral load. Treatment response rates tend 

to be low for those with genotype 1 HCV 

infection and high pretreatment viral load 

(see Chapter 3).

Exhibit 4-3 Hepatitis C Treatment Response Classifications

Treatment Outcome Description

Sustained virologic response (SVR) The virus is absent from the blood at the end of treatment 

and 6 months later. SVR is considered a successful 

treatment response.

Non-response Antiviral treatment does not work, meaning the virus 

can be detected in viral load tests. If the level of virus 

does not decrease by one hundredfold after 12 weeks of 

treatment, or if it does not go away completely after 24 

weeks, treatment is unsuccessful and can be stopped.

Virologic relapse The virus disappears from the blood during antiviral 

treatment but returns when treatment is stopped.
35

•	 Ethnicity. For reasons that are not understood but might be related to genetic 

factors (Balagopal, Thomas, & Thio, 

2010), hepatitis treatment response rates 

are low among Blacks and Hispanics, 

compared with rates among Whites 

and Asians (Conjeevaram et al., 2006; 

Rodriguez-Torres et al., 2009). 

•	 HIV co-infection. Response rates are lower 

in individuals with HIV co-infection.

•	 Liver damage. People who have extensive 

liver damage are less likely to respond 

to hepatitis treatment than those with 

moderate or low liver damage, although 

treatment is more urgent for people who 

have severe liver damage. 

Counseling Clients Diagnosed 

With Chronic Hepatitis

Exhibit 4-4 lists potential counseling approaches

to various HCV evaluation results. Individual 

circumstances vary, and treatment decisions 

will ultimately reflect advice from a medical 

professional working in concert with the client. 

For clients who are considering antiviral treatment, counselors can:

•	 Encourage clients to ask their medical 

care provider for the information needed 

to make informed decisions about 

treatment.

•	 Encourage thorough, informed consideration of treatment. 

Exhibit 4-4 Counseling Approaches Based on HCV Status

Evaluation Result Hepatitis Treatment 

Approach

Counseling Approach

•	No evidence of liver 

damage 

•	No HCV found in blood 

(negative antibody test); 

might need to retest in 6 

months

•	No HCV antiviral treatment 

needed

•	Educate client about liver 

health

•	Create risk-reduction plan

•	Encourage vaccination 

against hepatitis A virus (HAV) 

and hepatitis B virus (HBV) 

•	Evidence of mild liver 

damage

•	HCV ribonucleic acid (RNA)

found in blood

•	Stable mental/physical 

health or life circumstances

•	Defer antiviral treatment

•	Stabilize health and life 

circumstances

•	Monitor liver health

•	Educate client about liver 

health

•	Create risk-reduction plan

•	Encourage vaccination 

against HAV and HBV 

•	Encourage action toward 

improved health and/or life 

circumstances

•	Evidence of severe liver 

damage

•	HCV RNA found in blood

•	Stable or unstable mental/

physical health and life 

circumstances

•	Consider antiviral treatment

•	Monitor and stabilize health 

or life circumstances 

•	Encourage treatment 

adherence

•	Educate client about liver 

health

•	Create risk-reduction plan

•	Encourage vaccination 

against HAV and HBV 

•	Encourage action toward 

improved health and/or life 

circumstances
36

Addressing Viral Hepatitis in People With Substance Use Disorders

Exhibit 4-4 Counseling Approaches Based on HCV Status (continued)

Evaluation Result Hepatitis Treatment 

Approach

Counseling Approach

•	HCV RNA found in blood

•	Genotype 2 or 3

•	Stable or unstable mental/

physical health or life 

circumstances

•	Urge antiviral treatment 

•	Stabilize health and life 

circumstances as necessary

•	Encourage treatment 

adherence

•	Educate client about liver 

health

•	Create risk-reduction plan

•	Encourage vaccination 

against HAV and HBV 

•	Encourage action toward 

improved health and/or life 

circumstances

•	End-stage liver disease, 

regardless of other factors

•	Consider liver 

transplantation

•	Encourage vaccination 

against HAV and HBV 

•	Encourage action toward 

meeting requirements for 

transplantation 

•	 Encourage clients to take action toward 

improved health or life circumstances.

•	 Assess mental health and SUD recovery 

statuses.

•	 Emphasize the importance of alcohol 

abstinence. 

•	 Help clients strengthen their support 

systems. 

Counselors can explain the following information to clients:

•	 If hepatitis treatment does not completely 

clear the virus, some benefit might still 

occur (e.g., lower viral levels, less inflammation or fibrosis) (NIH, 2002). Also, 

many people who have hepatitis C do not 

develop cirrhosis, end-stage liver disease, 

or liver cancer.

•	 The length of antiviral treatment varies.

•	 Clients will need to get frequent lab 

tests to ensure medication tolerance and 

effectiveness.

•	 If side effects are too severe or if the 

medication is not working, the medical 

care provider might reduce the dose or 

stop treatment altogether. This does not 

mean the client failed; it means that 

the treatment failed. It should be noted, 

however, that the client might still receive 

some benefit from treatment even though 

treatment was not completed (NIH, 

2002). Nonresponse to treatment does 

not mean that liver damage is more 

severe. 

Supporting the Decision to Treat 

Hepatitis

For many clients who have chronic hepatitis, 

the decision to initiate hepatitis treatment is 

difficult. Some clients might feel an urgent 

need to undergo aggressive antiviral treatment. Others might feel that treatment, even 

if strongly recommended by their medical care 

provider, is not right for them, or they want to 

wait until they are further along in their recovery from substance use. Questions to help 

clients weigh their hepatitis treatment options 

include the following:
37

4—Helping Clients Make Medical Decisions About Hepatitis Treatment

•	 “What are the possible gains and losses of 

your decision to get or not to get antiviral 

treatment?”

•	 “Which of these are most important to 

you?”

•	 “If you’re not ready to begin hepatitis 

treatment now, what would have to happen 

to get you ready or make you decide to 

begin treatment?” 

•	 “What would you be interested in doing 

now?”

Only the client, in conjunction with his or 

her medical care provider, can decide whether 

antiviral treatment is the right choice. After 

discussing the benefits and risks of treatment 

in the context of the client’s life, the counselor 

should respect and support the client’s decision. 

Counselors can help clients who undertake 

antiviral treatment adhere to the regimen, as 

well as help those who defer treatment understand how to promote and maintain liver 

health.

Special Populations: Barriers to 

Hepatitis Treatment

Many people might have to overcome barriers 

to screening and treatment of chronic hepatitis, 

including people who are homeless or incarcerated; people who have mental illness; members of ethnic, racial, or gender minorities; 

people whose first language is not English; 

and others. Although conditions differ among 

populations and individuals, the needs of marginalized people are often similar. Counselors 

can assist these clients by:

•	 Helping them obtain basic information 

about all types of hepatitis in a format or 

language they can understand. 

•	 Encouraging them to get vaccinated 

against hepatitis A and B.

•	 Advocating screening and treatment 

when the medical care provider’s reluctance to treat is based solely on the SUD 

diagnosis. 

Clinical Scenario

Selena is a 36-year-old Hispanic woman who has been in outpatient treatment for opioid 

dependence for 2 months after completing detoxification and a residential treatment program. 

Her HCV treatment has caused side effects that feel like opioid withdrawal, which has triggered 

cravings for oxycodone. She stated in her last meeting with her counselor that she is going to stop 

taking her hepatitis medications to avoid relapsing. What should the substance abuse treatment 

team do in response to this situation?

Primary Concerns

•	Selena wants to stop taking her hepatitis medications.

•	Selena might not be ready to tolerate the side effects of antiviral treatment. 

•	Selena needs stronger coping skills for managing her cravings. 

Intervention Options

•	In consultation with her medical care provider, help her weigh the risks and benefits of stopping 

antiviral treatment and how it can be done safely.

•	Discuss ways to help Selena manage her current cravings (e.g., ongoing counseling, support 

groups, referral to an intensive outpatient program or a residential treatment program, increased 

or random urine drug testing and other monitoring, waiting until she is further along in her 

recovery from using opioids to resume hepatitis medications). 

•	Help Selena understand that she can restart antiviral treatment at a later date. 

•	Discuss the possibility of starting opioid maintenance treatment if she is not already on 

medication-assisted treatment.
38

Addressing Viral Hepatitis in People With Substance Use Disorders

•	 Helping clients find medical care providers who are familiar with and understanding of their culture or subculture.

•	 Making referrals to specialized case 

management services for shelter services, 

housing, food, and other basic needs.

•	 Understanding marginalized clients’ distrust of medical care systems and public 

health surveillance requirements.

•	 Helping clients understand and navigate 

complex medical care requirements.

•	 Monitoring for the co-occurrence of 

mental and substance use disorders, 

especially for the worsening of psychiatric 

symptoms when HCV treatment begins, 

and managing care or referring for specialized care, as indicated.

Appendix C includes resources available for 

people facing particular barriers to treatment. 

Chapter Summary

In determining eligibility for treatment of viral hepatitis, medical care providers consider:

•	Timing of hepatitis treatment.

•	Treatment contraindications.

•	The presence of more urgent problems.

•	The likelihood of patients’ adhering to hepatitis treatment.

•	The likelihood of treatment success.

Medical care providers, clients, and counselors should work together to consider the advisability of 

antiviral treatment.

There is growing consensus that people who have injected or still inject drugs can be successfully 

treated for hepatitis. 

Steps to help clients decide whether to begin antiviral treatment include:

•	Helping clients understand the meaning of evaluation results for hepatitis treatment.

•	Assessing clients’ SUD recovery, mental health issues, support systems, and life circumstances.

•	Educating clients about their choices.

•	Helping clients reframe goals of recovery to include a meaningful, healthy life.

Once a client makes a decision about hepatitis treatment, the counselor should support that 

decision and offer to reconsider in the future if circumstances change.

Clients from special populations might require additional education or advocacy. Their unique 

needs must be considered in antiviral treatment planning. 
39

5 Hepatitis Treatment

IN THIS CHAPTER

•	Overall Treatment 

Recommendations

•	Treatment for Hepatitis A

•	Treatment for Hepatitis B

•	Treatment for Hepatitis C

•	People Receiving 

Medication-Assisted 

Treatment for Opioid 

Dependence

•	People Who Relapse to 

Substance Use

•	People Who Have HCV/

HIV Co-Infection

•	People Who Have 

Co-Occurring Behavioral 

Health Disorders

•	Chapter Summary

It was late July 2006 and I was ready to commit to getting 

myself better. I remember taking my f irst ribavirin pill 

and knowing that this is the start of a new life for me. 

I had help with my f irst pegylated interferon shot. I 

scheduled my shots for Friday nights just in case I got sick 

afterwards. I was nervous and scared. That f irst night 

I had a fever and just felt very tired and weak. But the 

end of the next day I was ok.... The f irst doctor’s appointment after starting treatment went very well. My liver 

enzymes were already back to normal. I felt so happy. 

Twelve weeks into treatment they checked my viral count 

and it was undetectable. I knew I was going to make it 

through this.

—Kathleen (Hepatitis C Support Project, 2006)

Overall Treatment Recommendations

Clients who become infected with hepatitis and seek antiviral 

treatment—especially for hepatitis C—face long and in some 

cases difficult treatment regimens that, in the end, might not clear 

the virus from their bodies. Clients in treatment for chronic viral 

hepatitis might have to manage serious side effects of the treatment 

while striving to manage their behavioral health issues. People who 

decide to delay or forgo hepatitis treatment must learn new skills to 

live with their disease. 

Facing these difficult decisions, some clients will feel overwhelmed, 

fearful, and hopeless. Counselors who understand hepatitis treatment 

options and their side effects can better support their clients in 

recovery from substance use disorders (SUDs). 

Clients who have any form of viral hepatitis will benefit from: 

•	 Resting.

•	 Avoiding alcohol and discontinuing drug use.
40

Addressing Viral Hepatitis in People With Substance Use Disorders

•	 Avoiding other substances that can 

harm the liver, including acetaminophen 

(Tylenol) in large doses.

•	 Eating nutritious, well-balanced meals. 

•	 Getting vaccinated against hepatitis A 

and hepatitis B.

Treatment for Hepatitis A

Because hepatitis A is always acute, its treatment is generally limited to addressing symptoms, monitoring liver health, and letting the 

virus run its course. Clients recently exposed 

to hepatitis A virus (HAV) might be advised 

by their medical care providers to receive the 

HAV vaccination or immunoglobulin injection to reduce the likelihood of becoming ill 

(Franciscus, Highleyman, & Kukka, 2007; 

Victor et al., 2007).

In rare cases, hepatitis A leads to severe liver 

problems that require medication, hospitalization, or transplantation. If left untreated, liver 

problems can lead to life-threatening conditions. Therefore, a client who might have been 

infected with HAV should seek the care of a 

medical care provider. 

Suggestions for counseling clients who have 

hepatitis A include the following:

•	 Assure clients that their symptoms are 

temporary. 

•	 Reinforce prevention with messages such 

as, “You will recover from hepatitis A; 

let’s talk about what you can do to make 

sure you never get the more serious types. 

A vaccine against hepatitis B can protect 

you, and there are ways to reduce the risk 

of getting hepatitis C.”

•	 Encourage clients to take care of themselves. Say, for example, “Your body is 

working hard to fight off the hepatitis 

infection. It is very important that you 

take care of yourself now.” 

•	 Reinforce the importance of maintaining 

SUD recovery activities. Say, “Your liver 

is injured. If you drink or use drugs, you 

could make it worse. Let’s talk about 

everything you’re doing to stay free of 

alcohol and other substances.” 

Treatment for Hepatitis B

All cases of hepatitis B begin as an acute 

infection and most cases resolve without 

treatment. However, if the person does not 

recover completely within 6 months, the 

infection is considered chronic. Clients diagnosed with chronic hepatitis B should get 

regular monitoring by a medical care provider, 

and some might undertake treatment. Several 

medications are used for chronic hepatitis B. 

Treatment might be started with any of the 

U.S. Food and Drug Administration (FDA)-

approved antiviral medications, but interferon, 

tenofovir, or entecavir are preferred (Lok & 

McMahon, 2009). These medications might 

be prescribed individually or in combination 

(see Exhibit 5-1). 

Any treatment for hepatitis B has benefits 

and risks. Antiviral treatment generally lasts 6 

months–1 year and can extend for years longer 

(possibly for life). Managing side effects can 

be difficult. The decision to undertake treatment should not be made in haste because 

ending some antiviral medications early can 

reactivate the HBV infection. Many people 

elect to delay hepatitis B treatment until they 

are better able to adhere to it. Exhibit 5-2 

provides counseling tips for addressing clients’ 

concerns about hepatitis B. 

Treatment for Hepatitis C

Because most people who have hepatitis C 

have mild symptoms or no symptoms, clients 

often do not know they are infected and, 

therefore, do not seek hepatitis treatment 

until severe hepatitis C virus (HCV)-related 
41

5—Hepatitis Treatment

Exhibit 5-1 Medications for Chronic Hepatitis B

Medication Administration Side Effect

Short-acting 

interferon

Injected several times a 

week for 6 months–1 year, 

sometimes longer

Depression, suicidal behavior, aggression, 

homicidal behavior, flu-like symptoms, 

diarrhea, nausea, taste alteration, anorexia, 

weight gain, liver and biliary system 

disorders, bone pain, arthritis, leg cramps, 

blood disorders

Long-acting 

(pegylated) 

interferon

Injected once per week for 

6 months–1 year

Dry mouth, flushing, headache, fatigue, 

malaise, dizziness, hypothyroidism, nausea, 

anorexia, diarrhea, blood disorders, liver 

and biliary system disorders, musculoskeletal 

system disorders, insomnia, depression, 

anxiety, emotional lability, impaired 

concentration, menstrual disorders, 

coughing, sinusitis, rash, dry skin, taste 

alteration, blurred vision, conjunctivitis

Lamivudine Tablet taken once per day 

for 1 year or longer

Headache, fever, nausea and vomiting, 

malaise, fatigue, cough, diarrhea, insomnia, 

rash, shortness of breath; hepatitis B virus 

(HBV) infection might worsen if medication is 

stopped

Adefovir dipivoxil Tablet taken once per day 

for 1 year or longer

Lactic acidosis, fluid retention, nausea and 

vomiting, pain in abdomen or stomach, 

jaundice, drowsiness, kidney problems, 

liver problems; hepatitis might worsen if 

medication is stopped

Entecavir Tablet taken once per day 

for 1 year or longer

Lactic acidosis, liver problems, headache, 

fatigue, dizziness, nausea; hepatitis might 

worsen if medication is stopped

Telbivudine Tablet taken once per day 

for 1 year or longer

Fatigue, cough, diarrhea, headache, 

abdominal pain, rash, fever, back pain, 

muscle pain, sore throat, joint pain, nausea, 

lactic acidosis, liver problems; hepatitis 

worsens if medication is stopped

Tenofovir Tablet taken once per day 

for 1 year or longer

Lactic acidosis, liver problems, serious 

psychiatric symptoms, depression, diarrhea, 

dizziness, fatigue, headache, kidney 

problems, nausea, vomiting, stomach pain, 

rash, insomnia, weakness, bone problems 

(pain, softening of bones, decreased bone 

density); hepatitis worsens if medication is 

stopped

Source: Physicians’ Desk Reference 2010 (64th ed.), 2009.
42

Addressing Viral Hepatitis in People With Substance Use Disorders

Exhibit 5-2 Counseling Tips for Addressing Concerns About Chronic Hepatitis B

•	Help clients understand that although their symptoms might have diminished, they remain 

infected. Explain, “I know you feel better now, but remember that you still have the infection and 

could spread it to others. Have other members of your household been tested or vaccinated?”

•	Help clients understand the importance of seeing a medical care provider for regular monitoring. 

Ask, “Have you talked to your doctor lately about your chronic hepatitis B? What decisions have 

you made about hepatitis treatment?” 

•	If clients are treating their hepatitis B, ask, “What are you doing to help yourself adhere to 

treatment?”

•	For clients who do not have hepatitis A, hepatitis C, or HIV co-infection, stress the importance of 

prevention. Say, “It’s great that you are addressing your HBV infection. It is very important that 

you make sure you don’t get other forms of hepatitis or HIV. These can make your HBV infection 

worse. Let’s make a plan to make sure you don’t contract another infection and that you get 

vaccinated.”

•	Reinforce the importance of maintaining substance abuse recovery activities. 

diseases have produced other symptoms or 

their infections are found in a screening test. 

Approximately one in five people clears HCV 

infection without treatment. In rare cases, 

acute HCV infection quickly leads to liver 

failure (for example, following reinfection 

after a liver transplant). Therefore, any client 

diagnosed with hepatitis C is a potential 

candidate for antiviral treatment. 

Acute Hepatitis C

Treating hepatitis C early might greatly increase 

a patient’s chances of sustained virologic 

response (SVR) and prevent long-term liver 

damage (Kresina et al., 2008). Response rates 

in acute HCV infection are radically better 

than in chronic infection, but to maximize 

the likelihood of viral clearance, treatment 

should be initiated within the first 20 weeks. 

Therefore, counselors should encourage clients 

who have hepatitis C to seek specialized care 

immediately. No clear regimen exists for treating acute hepatitis C. Currently, treatment is 

a shortened form (approximately 12 weeks) of 

the antiviral treatment for chronic hepatitis C. 

Chronic Hepatitis C

Treatment options for people who have chronic 

hepatitis C include:

•	 Antiviral treatment. A course of potent 

medications might slow disease progression or eliminate the disease. 

•	 Deferring treatment. Not all patients 

want treatment, even if it is advised. 

•	 Liver transplantation. For people who 

have end-stage liver disease, transplantation surgery might be the only option. 

However, the waiting list for such surgery 

can be long. 

Antiviral Treatment

Antiviral treatment helps the body fight off 

HCV infection (i.e., weakens the virus). When 

the virus is not detected in the blood of a 

patient who is receiving antiviral treatment, 

and when it remains undetected for 6 months 

after treatment is completed, the patient is 

said to have an SVR. The virus does not return 

in 95 percent to 99 percent of patients who 

achieve an SVR, and it does not appear to 

cause further damage (McHutchison et al., 

2006; Swain et al., 2007). 
43

However, an SVR does not make a person 

immune to reinfection. If reexposed to HCV, 

a person could be reinfected. Clearing HCV 

does not make a person immune to other 

forms of hepatitis or to liver disease. For 

instance, drinking heavily can still cause liver 

damage, even after successful treatment of 

hepatitis C. 

The standard recommended treatment for 

hepatitis C is a combination of pegylated 

interferon injections and ribavirin (Exhibit 

5-3). However, in 2011, the FDA approved 

two new oral medications, boceprevir and telaprevir. They represent a new type of medication for HCV infection that works differently 

than interferon and ribavirin and works in 

combination with those traditional medications 

(FDA, 2011a; FDA, 2011b). 

Hepatitis C treatment works well for most 

people, whereas for a minority it produces 

little or no improvement. Counselors can help 

their clients improve their chances for successful 

hepatitis treatment by encouraging them to:

•	 Take all medications as prescribed, keep 

all medical appointments, and reschedule 

missed appointments as soon as possible. 

•	 Maintain a healthful lifestyle.

•	 Learn about HCV medications, including special risks and warnings even after 

antiviral treatment has finished. 

•	 Always carry a list that includes the 

prescribing medical care provider’s name 

and phone number and the names and 

dosages of the medications.

•	 Check with their medical care provider 

before starting new medicines, including 

vitamins, supplements, herbal remedies, 

prescription medications, and over-thecounter medications.

•	 Avoid drinking alcohol or taking drugs 

with no known medical use.

•	 Maintain as many recovery activities as 

possible.

•	 Report side effects to their medical care 

provider.

Side effects of antiviral medication differ 

from person to person. Some side effects are 

mild to moderate and remain so. But in some 

people, side effects become more severe with 

continued hepatitis treatment. HCV treatment 

is long, and having to manage side effects for 

the duration of treatment can strain individuals and those they turn to for support. Side 

effects—particularly flu-like symptoms and 

Exhibit 5-3 Medications Approved for Treating Chronic Hepatitis C

Medication Administration

Long-acting (pegylated) interferon Injected weekly for 6 months–1 year

Ribavirin Tablet or capsule taken orally, usually twice per day for 6 

months or longer

Boceprevir Capsule taken orally, three times per day (with food). 

The length of dosing time varies based on viral response 

and the extent of liver disease. It must be taken in 

combination with interferon and ribavirin.

Telaprevir Tablet taken orally, three times per day (with food) for 12 

weeks (another 12–36 weeks may be required, depending 

on viral response). It must be taken in combination with 

interferon and ribavirin.
44

Addressing Viral Hepatitis in People With Substance Use Disorders

depression, which are common side effects 

of interferon—are the primary reason people 

stop hepatitis C treatment. Because people are 

more likely to clear the virus if they complete 

their antiviral treatment, it is crucial that they 

get the support they need to manage side 

effects so the side effects do not cause them 

to discontinue treatment (Exhibit 5-4). 

Although most side effects are manageable by 

the patient, others require medical intervention. Conditions requiring medical attention 

include the following: 

•	 Depression or mania. Counselors need 

to be particularly attuned to the development of these neuropsychiatric symptoms, 

routinely assess for them, and refer 

clients for mental health treatment as 

appropriate. 

•	 Anemia (reduced red blood cell count). 

Ribavirin often leads to anemia that can 

cause fatigue and increase the risk of 

chest pain, shortness of breath, or heart 

attack. 

•	 Neutropenia (reduced white blood cell 

count resulting in an increased risk of 

infections). Neutropenia is rarely severe 

enough to terminate antiviral treatment. 

•	 Pulmonary conditions. Shortness of 

breath or cough might develop during 

hepatitis treatment. People who develop 

these symptoms should consult their 

medical care provider to rule out other 

causes.

•	 Eye problems. Antiviral treatment 

can induce or aggravate eye problems, 

especially in people who have diabetes or 

hypertension. Clients who complain of 

blurry vision, any obstruction to vision, or 

loss of vision should receive an immediate 

medical examination.

Appendix D provides practical approaches to 

managing common side effects of hepatitis 

C antiviral treatment. The U.S. Department 

of Veterans Affairs, National Hepatitis C 

Program, offers information on managing side 

effects on its Web site (http://www.hepatitis.

va.gov/pdf/treatment-side-effects.pdf ).

Deferring Treatment 

Some clients might choose to postpone 

antiviral treatment. They might have more 

urgent health problems to tend to, or they 

might feel they are not strong enough in their 

SUD recovery to undergo hepatitis treatment. 

Exhibit 5-4 Adhering to Antiviral Treatment

Substance abuse treatment counselors can help clients adhere to antiviral treatment by:

•	Explaining intended effects and side effects of medication.

•	Paying attention to side effects and advising clients to report them to their medical care 

providers.

•	Being respectful and nurturing. 

•	Providing reminder services (e.g., cell phone reminders, pill organizer boxes).

•	Addressing depression, when appropriate. 

•	Striving for multidisciplinary collaboration among all professionals caring for the client. 

Where possible, observed dosing might also encourage treatment adherence. 

Source: Robaeys & Buntinx, 2005
45

Medical care for clients who choose to defer 

treatment generally involves:

•	 Getting regular medical evaluations.

•	 Having liver enzyme and cancer screening 

tests once or twice every year.

•	 Getting a liver biopsy every 3–5 years.

•	 Adopting a lifestyle that promotes liver 

health. 

It is critical for clients with compromised 

liver functions to take precautions against 

contracting HIV and to get vaccinated against 

HAV and HBV. Clients who are co-infected 

with HCV and HIV should be encouraged 

to get treated for their HIV. Clients who are 

HIV negative should be retested for HIV 

at the advice of their medical care provider. 

Counseling tips for working with clients who 

have chronic hepatitis include: 

•	 Help clients understand that they should 

see a medical care provider regularly. 

“When was the last time you saw your 

doctor about your hepatitis?”

•	 Encourage patients to adopt habits that 

support liver health, such as avoiding 

alcohol and eating a healthful diet. 

•	 Help clients think about how to create 

or improve their support networks so 

that no matter what hepatitis treatment 

choices they eventually face, they have 

help from others. “Would you like to 

create a list of people you know and list 

the help they could provide you as you 

cope with hepatitis?”

Liver Transplantation

Although many people who have hepatitis 

C respond to antiviral treatment or can live 

indefinitely with their illness, in some people, 

liver damage will be extensive and a liver 

transplantation is needed. Counselors should 

be prepared to support clients who have 

been told that liver transplantation surgery 

is necessary. They might also need to educate 

the transplantation team about the value of 

medication-assisted treatment (MAT) for 

opioid dependence. The following factors 

influence a patient’s acceptance to a transplant 

waiting list:

•	 Urgency of need

•	 Willingness and ability to endure the 

extensive preoperative and postoperative 

tests and procedures

•	 Willingness and ability to follow physician’s instructions

•	 Willingness to adjust to the postoperative 

lifestyle

•	 Access to caregivers who can provide 

support during the lengthy transplantation process 

•	 Ability to stop all alcohol use

Patients obtaining a liver transplant generally 

go through the following phases:

1. Contacting a transplant center. People 

who have been told that a liver transplant 

is their only hope should obtain a physician’s referral to a transplant center as 

soon as possible. Each transplant center 

has its own criteria for placing patients 

on its waiting list. Clients who are not 

accepted for a waiting list might be 

deferred until the conditions that prevented the client from being accepted 

are resolved. 

2. Waiting for the transplant. The time 

between being put on a waiting list and 

receiving the transplant can be as short 

as a few days or as long as several years. 

While waiting, patients must keep their 

records updated at the transplant center 

and stay as healthy as possible to be ready 

for surgery when a liver becomes available. 

They must avoid consuming alcohol or 

drugs and continue to take medications as 

prescribed.
46

Addressing Viral Hepatitis in People With Substance Use Disorders

Complementary or Alternative Medicine

Clients might turn to complementary or alternative medicine (CAM), believing it will bolster 

nutrition, attack the hepatitis, protect or strengthen the liver, or mitigate side effects of viral 

hepatitis treatment. As many as 20 percent of people who have liver disease use herbal remedies. 

No conclusive scientific evidence supports the use of CAM for hepatitis C; herbal treatments, 

dietary supplements, alternative medicines, and acupuncture have not been proven to cure or 

relieve symptoms of hepatitis C (Dieticians of Canada, 2003; National Center for Complementary 

and Alternative Medicine, 2008). In addition, some herbal treatments might harm the liver, further 

damaging an already compromised organ. Plants and alternative treatments that can harm the liver 

are provided in Appendix E. 

3. Getting the transplant. The surgery itself 

takes up to 12 hours. Recovery can take 

months. 

4. Living with the transplant. Following 

a transplantation procedure, patients 

must take medication for the rest of 

their lives to reduce the chance of their 

bodies rejecting the donated liver. This 

medication weakens the immune system. 

Patients might experience an array of 

intense emotions following the surgery. 

Counselors can help clients explore their 

emotions while developing realistic expectations for their futures. Liver transplants 

buy some time, but not necessarily a lot 

of it. Within 5–10 years, many patients 

contract hepatitis C again and, because 

medications suppress their immune 

response, the disease progresses much 

more rapidly (Berenguer et al., 2006; 

National Institutes of Health [NIH], 

2002). In fact, the recurrence of HCV 

after a transplant is universal unless viral 

eradication occurs before the transplant. 

In such cases, progression of the disease 

might be rapid, sometimes resulting in 

cirrhosis within 1 year of transplant.

Counselors can play a critical role with clients 

who have end-stage liver disease or liver cancer 

and are not likely to obtain a liver transplant 

in time, who have been rejected from waiting 

lists, or who cannot go through the procedure. 

Specifically, counselors can help clients with 

end-of-life decisions, help ensure that those 

decisions are respected, and obtain palliative 

care. This work might be enhanced by 

collaboration with medical care providers, 

social workers, ethicists, family, hospice care, 

spiritual advisors, and therapists. Resources for 

liver transplantation are provided in Appendix C. 

People Receiving MedicationAssisted Treatment for Opioid 

Dependence 

Some medical care providers and clients 

believe that people on methadone or 

buprenorphine are ineligible for, or will not 

benefit from, antiviral treatment. However, 

research suggests that treatment for hepatitis 

C can be effective for people receiving MAT 

for opioid dependence (Kresina, Bruce, Cargill, 

& Cheever, 2005; Mauss, Berger, Goelz, Jacob, 

& Schmutz, 2004; Sylvestre, Litwin, Clements, 

& Gourevitch, 2005). NIH (2002) hepatitis 

C treatment guidelines state that MAT has 

been shown to reduce risky behaviors that can 

spread HCV infection, and it is not a contraindication to HCV treatment. 

Many clients receiving methadone, buprenorphine, or naltrexone might want antiviral 

treatment, but it is not offered to them by 

their medical care providers. Counselors can 

provide a crucial service by informing clients 
47

that their receipt of MAT for opioid dependence does not exclude them from hepatitis 

treatment. Counselors can help clients search 

for medical care providers who are open to 

assessing them for hepatitis treatment, and 

counselors can advocate treatment if they 

perceive that clients are being discriminated 

against because of their past or current substance use status. 

Adherence to antiviral treatment is an 

important factor in treatment success, and 

studies show that individuals receiving methadone treatment can adhere to treatment for 

hepatitis C (Schaefer et al., 2007; Sylvestre 

& Clements, 2007). Modifying treatment for 

clients receiving MAT for opioid dependence 

might help them adhere to antiviral treatment 

(Exhibit 5-5). Chapter 7 provides more information on program-level modifications.

People Who Relapse to 

Substance Use

People who relapse, continue to use, or have 

only recently quit using drugs or alcohol are 

often denied treatment for viral hepatitis. 

One study found that more than one-third 

of substance abuse treatment programs listed 

recent drug use as a reason their clients had 

not been treated for HCV infection (AstoneTwerell, Strauss, Hagan, & Des Jarlais, 2006). 

Several factors determine whether a person 

is a good candidate for antiviral treatment, 

and recovery status is just one factor. Clients 

should not be denied hepatitis treatment 

for this reason alone. Other misperceptions 

abound. NIH (2002) indicates that treatment 

of chronic hepatitis C can be successful even 

when patients have not abstained from active 

drug use. 

Exhibit 5-5 SUD Treatment Modifications for Clients Receiving MAT for Opioid 

Dependence

Type of Interaction Recommendation

Support meetings, peer 

support, and counseling 

sessions

These activities might help clients cope with side effects and 

urges to relapse that result from injecting medication (Litwin 

et al., 2005). If an opioid treatment program (OTP) is the only 

source of counseling, additional referrals for more intensive 

individual or family counseling might help clients with the 

multiple psychosocial issues that might arise.

Flexible counseling schedules 

while maintaining medication 

schedules

If licensure standards allow, 15-minute sessions four times 

monthly instead of monthly 1-hour sessions might be more 

realistic for clients with fatigue from chronic hepatitis or antiviral 

treatment. Programs could allow one outside support group 

meeting to substitute for a monthly group session.

Flexible individual dosing 

regimens

Clients in OTPs who undergo treatment for HCV infection 

often report increased opioid cravings and request increased 

methadone doses. It is unclear why hepatitis treatment is 

associated with increased cravings, but for some clients the 

side effects of antiviral medications might mimic withdrawal. 

Increasing methadone doses might help relieve the flu-like 

side effects caused by hepatitis treatment. Research has not 

confirmed that interferon lessens the effects of methadone.

Observed dosing by staff Some people might better adhere to antiviral treatment if they 

take their oral medication or interferon in the presence of SUD 

treatment staff. Residential programs and OTPs might be better 

able to offer medication observation than non-OTP outpatient 

programs.
48

Addressing Viral Hepatitis in People With Substance Use Disorders

Misperception 1. Antiviral Treatment Is Ineffective in People Who Continue to Abuse 

Substances

People who have recently used injection drugs or who relapsed to drug use during hepatitis 

treatment have SVRs comparable with SVRs in other groups (Robaeys & Buntinx, 2005; Van Thiel et 

al., 2003). However, SVR is more likely in people who have at least 6 months of abstinence than in 

people who continue to abuse substances regularly (Robaeys & Buntinx, 2005).

Misperception 2. People Who Abuse Substances Do Not Adhere to Antiviral Treatment

Research suggests that, with support, people who use substances can adhere to antiviral 

treatment. Clients who are not in OTPs are more likely to discontinue treatment early, particularly 

in the first 8 weeks of therapy (Schaefer, Heinz, & Backmund, 2004). Sylvestre et al. (2005) found 

that individuals with occasional drug use had adherence rates that were comparable with rates of 

those who were abstinent. However, people who relapsed to regular heavy drug use showed a 

significantly lower level of adherence.

Misperception 3. People Who Continue to Abuse Substances Will Be Reinfected With HCV 

Even if SVR Is Achieved 

Although data are limited, evidence suggests that the risk of reinfection with HCV is low, even 

among people who relapse to injection drug use (Backmund et al., 2004; Dalgard et al., 2002; 

Robaeys & Buntinx, 2005; Schaefer et al., 2004). 

Strategies for helping clients who relapse to 

substance use include:

•	 Developing an SUD treatment plan that 

includes a range of effective treatment 

options; additional testing to evaluate 

HAV, HBV, and HCV status; and a 

hepatitis treatment referral.

•	 Using motivational interviewing to 

engage clients in treatment to improve 

their quality of life. 

•	 Providing education on HCV transmission and treatment and helping with 

psychosocial difficulties. 

•	 Recognizing clients’ ambivalence, efforts 

in SUD treatment, and attempts to 

reduce substance use. 

•	 Referral to mental health treatment, if 

warranted.

People Who Have HCV/HIV 

Co-Infection 

People who are co-infected with HCV and 

HIV must adjust to two major diagnoses that 

can have difficult treatment regimens. In clients with HIV, hepatitis C treatment is generally advised when the likely benefits outweigh 

the risks of serious side effects (Ghany et al., 

2009). Approximately 35 percent of people 

who have HCV/HIV co-infection achieve an 

SVR (Sherman, 2007), and this success rate 

might be improved with new medications. 

Counselors can help clients understand the 

implications of HCV/HIV co-infection and 

provide support. Strategies to address the 

issues include the following:

•	 Educate clients about HCV/HIV coinfection. Many people who have HIV 

might be aware of the health consequences of HIV but be unaware that HIV 

infection greatly increases the progression 

of HCV, increasing the likelihood of 
49

cirrhosis, end-stage liver disease, and liver 

cancer. In fact, liver disease—from underlying hepatitis B, C, or alcohol abuse—is 

the major non-AIDS cause of death in 

HIV-infected persons.

•	 Stress the importance of being tested for 

hepatitis and receiving antiviral treatment 

as soon as possible. All individuals who 

are infected with HIV should be screened 

annually for HCV. 

•	 Screen for and address cognitive deficits. 

People who are co-infected are more 

likely to suffer cognitive deficits in multiple areas, including learning, abstraction, 

motor abilities, memory, and information processing (Cherner et al., 2005). 

Counselors should be attentive to signs 

of these problems, conduct assessments, 

help clients cope with these issues, and 

advocate on behalf of their clients with 

HCV treatment providers. 

•	 Help clients manage side effects. 

Individuals who have HIV often receive 

medications that can have significant side 

effects. People who are co-infected with 

HCV and HIV might experience many 

side effects with antiviral treatment (Gish, 

Afdhal, Dieterich, & Reddy, 2005). 

•	 Encourage clients to seek and receive 

compassionate medical care. Medical care 

providers who have not received training 

in managing HCV/HIV co-infection 

can present barriers to effective hepatitis 

treatment. Clients might also be negatively 

influenced by judgmental approaches, 

frustration, and unrealistic expectations 

for treatment (Kresina et al., 2005). 

These attitudes can result in distrust 

and poor communication between client 

and provider, as well as in frustration 

and lack of adherence by the client. 

Counselors can help clients find medical 

care providers who are familiar with and 

able to treat this population. 

•	 Help coordinate care. People who have 

HCV/HIV have multiple needs requiring 

an array of medication and treatment. 

Counselors can coordinate with medical 

care providers to address these needs. 

A multidisciplinary approach can help 

clients access the treatment that they 

need and increase treatment retention. 

•	 Emphasize adherence to treatment. 

Effective results depend on close 

adherence to all treatment regimens. 

Counselors should explain the importance 

of taking medications exactly as directed. 

People Who Have Co-Occurring 

Behavioral Health Disorders

Studies have demonstrated that completion 

and outcome of antiviral treatment can be 

similar for clients who have co-occurring 

substance use and mental disorders compared with clients who do not have these 

co-occurring conditions (Chainuvati et al., 

2006; Guadagnino, Trotta, Carioti, Caroleo, & 

Antinori, 2006; Sylvestre & Clements, 2007). 

People who have and do not have psychiatric 

histories had similar rates of HCV treatment 

adherence. In people who have depressive 

symptoms, medications to treat depression 

should be given early in HCV treatment to 

improve treatment adherence. Freedman and 

Nathanson (2009) suggest that optimal results 

are obtained when coordinated substance 

abuse and psychiatric treatment occurs before 

and during treatment for hepatitis C.

Counselors can help their clients with cooccurring substance use and mental disorders 

cope with hepatitis. Suggestions for initiating 

conversations follow: 

•	 “Your doctor expressed some concern 

about your candidacy for treatment 

because of your depression. How do you 

see things?”
50

Addressing Viral Hepatitis in People With Substance Use Disorders

•	 “What would be helpful for your 

depression?”

•	 “Your doctor says you can go ahead with 

hepatitis treatment. What do you think 

you need to do for this to be successful?”

Information specific to supporting clients 

who have co-occurring substance use and 

mental disorders and hepatitis is provided in 

Appendix F. 

Chapter Summary 

•	Hepatitis A rarely requires treatment. 

•	Chronic HBV can be treated with several oral antivirals; currently, tenofovir or entecavir are the 

recommended first-line options for initial oral treatment options. 

•	Hepatitis C can be treated effectively if discovered early (i.e., in its acute phase), but it is rarely 

discovered early. 

•	Treatment for chronic hepatitis C is lengthy, can cause side effects that are difficult to manage in 

some people, and requires good adherence. It is not appropriate for everyone. 

•	Some clients might elect (or be advised) to defer antiviral treatment. 

•	For some people, a liver transplant is the only option. Counselors can help clients through the 

process.

•	Clients in OTPs are eligible for antiviral treatment.

•	Clients who use substances or relapse can achieve SVR comparable with that of other groups if 

they adhere to hepatitis treatment.

•	HCV/HIV co-infection can be very serious. 

•	Clients with co-occurring behavioral health disorders can adhere to—and respond to—antiviral 

treatment.
51

6 Counseling Approaches 

for People Who Have 

Viral Hepatitis

IN THIS CHAPTER

•	The Need for Counseling 

Strategies

•	Ensuring Safety

•	Providing Reliable 

Information

•	Building the Therapeutic 

Relationship

•	Helping Clients 

Understand Their 

Diagnoses

•	Incorporating Client 

Needs in Substance 

Abuse Treatment 

Planning

•	Developing a Prevention 

Plan

•	Using Motivational 

Approaches

•	Confronting the Social 

Factors of Hepatitis

•	Addressing Relapse 

•	Building Support 

Systems

•	Providing Effective Case 

Management

•	Chapter Summary

When I found out that I had hepatitis C, I was really 

angry. I worked so hard to get off drugs and was just 

starting to get my life together. Then they told me I had 

this disease. I couldn’t believe it. I didn’t go back to the doctor for a while—I didn’t want to deal with it.

—Carlos (New York State Department of Health, 

2005b)

The Need for Counseling Strategies

Counselors are in a unique position to provide education, emotional 

support, and other types of assistance for clients who have hepatitis 

and substance use disorders (SUDs). However, most treatment programs do not have components in place to address viral hepatitis. 

According to the 2007 National Survey of Substance Abuse 

Treatment Services, only 22 percent of treatment facilities offer 

onsite screening tests for hepatitis B; 23 percent offer onsite screening for hepatitis C (Office of Applied Studies, 2007). Other studies 

have shown that only 54 percent of treatment programs provide 

education about hepatitis, and many counselors are uninformed 

or misinformed about the disease (Astone, Strauss, Vassilev, & Des 

Jarlais, 2003). 

Depending on the resources available, counselors might be able 

to implement only some of the strategies presented for supporting 

clients who have hepatitis. Readers are encouraged to accomplish 

what they can to improve SUD treatment practices for their clients 

and to advocate for client access to services that cannot be implemented immediately. Information specific to supporting clients 

who have co-occurring mental disorders and hepatitis, absent a 

co-occurring SUD, is provided in Appendix F.
52

Addressing Viral Hepatitis in People With Substance Use Disorders

Ensuring Safety

If a client with infectious hepatitis becomes 

injured and bleeds, staff members are at risk 

of contracting the infection. Counselors should 

use universal precautions, such as wearing 

gloves and other protective gear when exposure 

to infected blood or other body fluids is possible. Counselors should take care to avoid 

accidental needle sticks, which can transmit 

hepatitis and HIV. Counselors should also 

know their hepatitis status and take cautions 

to protect clients and coworkers, if necessary.

Counselors can discuss hepatitis 

in ways that build the therapeutic 

relationship.

Providing Reliable Information

Providing current, accurate information is an 

important counseling service. Misinformation 

obtained by word of mouth or on the Internet 

can increase clients’ fears and feelings of hopelessness. Counselors can dispel misinformation 

about hepatitis by providing educational sessions incorporated into treatment programming. Chapter 1 gives an overview of viral 

hepatitis, and Appendix C provides a list of 

resources that are available on the Internet. 

Building the Therapeutic 

Relationship

Counselors can discuss hepatitis in ways that 

build the therapeutic relationship. Clients are 

more likely to ask questions and express concerns and fears about screening, a diagnosis 

of chronic hepatitis, and its treatment if the 

counselor and client have a good working relationship. There are a number of ways in which 

a counselor can help clients (Astone, Strauss, 

Munoz-Plaza, Hagan, & Des Jarlais, 2005). 

These include:

•	 Being well informed about hepatitis, 

especially chronic hepatitis C.

•	 Talking to clients about their diagnoses 

and medical treatment with empathy.

•	 Assuring clients that the counselor will 

help them negotiate necessary services, 

either within or outside the treatment 

program.

•	 Helping clients overcome possible barriers 

to hepatitis treatment.

•	 Interpreting information clients receive 

from medical care providers, the Internet, 

family, friends, and other clients.

•	 Repeating information in different ways 

until clients understand it.

•	 Asking about clients’ families’ responses 

to their diagnoses and helping clients 

cope with those responses.

•	 Educating clients about the liver and how 

to stay healthy with hepatitis and stating 

that the majority of people who have 

chronic hepatitis C and who do not use 

alcohol will not develop life-threatening 

complications.

•	 Offering messages of hope about living 

with hepatitis.

•	 Emphasizing consistently the importance 

of clients’ addressing their health-related 

issues.

•	 Explaining complex hepatitis treatment 

and test results or collaborating with 

medical professionals who can provide 

necessary explanations to clients.

•	 Helping to make medical appointments 

and advocating for clients with medical 

care providers.

•	 Helping clients devise strategies for 

remembering medical and other scheduled 

appointments.
53

6—Counseling Approaches for People Who Have Viral Hepatitis

Helping Clients Understand Their 

Diagnoses

Clients’ reactions to a diagnosis of viral hepatitis 

vary. For some clients, the possibility that they 

might become ill in 20–30 years might be the 

least of their concerns as they face the immediacy of their potentially life-threatening SUD 

and other life stressors. For others, a diagnosis 

might present a crisis. Those who have been in 

substance abuse treatment for many years, for 

example, might view a diagnosis as a threat to 

their hard-won sense of stability (Litwin et al., 

2005). New clients might feel overwhelmed by 

the extra complications placed on the already 

daunting prospect of recovery. Some might 

use their diagnoses of hepatitis as an excuse 

to start using substances again. 

Counselors need to be prepared for a range 

of reactions. Some clients might need to talk 

through fears and anger many times before 

moving forward with medical treatment. In 

these situations, counselors might need to 

schedule more individual sessions with clients 

to discuss these issues. Other clients might 

need prodding to understand their diagnoses 

and take appropriate steps to reduce their 

risks of spreading the illness or worsening 

their prognosis. Clients might be concerned 

about how to tell loved ones about their diagnoses and worried about transmitting the virus 

to others. Women might be concerned about 

pregnancy and hepatitis treatment or viral 

transmission. 

Incorporating Client Needs in 

Substance Abuse Treatment 

Planning 

Substance abuse treatment planning might be 

complicated by both hepatitis symptoms and 

potential side effects of the antiviral treatment. 

Counselors might need to adjust substance 

abuse treatment for clients who have hepatitisrelated symptoms or antiviral treatment side 

effects. 

Facets of substance abuse treatment might 

need to be flexible for clients who have hepatitis 

(within accreditation and licensing guidelines) 

and allow for the following:

•	 Individualized, flexible substance abuse 

treatment planning to permit missed 

sessions resulting from hepatitis symptoms, antiviral treatment, or medical 

appointments

•	 Time for clients to rest 

•	 Time for hepatitis-specific support 

groups for clients in residential treatment 

(individual sessions could be scheduled to 

replace missed group sessions) 

•	 More frequent sessions or more intensive 

programs 

•	 Longer duration of substance abuse treatment to make up for missed sessions and 

to provide ongoing support during the 

hepatitis treatment regimen

Ongoing screening and assessment for 

depression and other mental disorders are 

necessary for all clients but are particularly 

important for clients with hepatitis who are 

receiving interferon. Depression is a major 

side effect of interferon treatment, and clients 

with a history of depression are at particular 

risk for worsening of symptoms. Treatment 

plans for clients who have co-occurring 

substance use and mental disorders should 

include:

•	 Periodic screening for depression, referral 

for evaluation by a mental health professional, and consideration of initiating 

antidepressant treatment, if warranted.

•	 Regular medication adherence checks 

for clients who are taking antidepressant 

medication.

•	 Frequent communication among substance 

abuse, mental health, and medical care 

providers, with permission of the client.
54

Addressing Viral Hepatitis in People With Substance Use Disorders

Developing a Prevention Plan

Clients might continue to put themselves or 

others at risk for contracting viral hepatitis, 

especially early in recovery. By identifying 

a client’s risky past or current behavior, the 

counselor can help the client create a plan 

to reduce the chances of contracting or spreading viral hepatitis. The following steps are 

suggested:

•	 Identify a specific high-risk incident. 

Focusing on past behavior might be difficult for a client who feels shame or regret. 

Discussing one specific incident might 

be less onerous for the client. Ask the 

client to describe the “who, what, where, 

when, and how” of the most recent risky 

experience. Ask whether the client talked 

about hepatitis risks with partners. Try to 

determine whether the client’s patterns 

of risky behavior are chronic, episodic, or 

a single incident. Ask, for example, “Was 

that the first time you let someone inject 

you?”

•	 Start where the client is. Keep in mind 

that some clients will not know how 

they became infected. Developing a 

risk-reduction plan for this type of client might require a gradual, supportive 

approach to identifying risk factors.

•	 Identify a situation when the client minimized his or her risk. Ask the client to 

describe what precautions he or she took 

and why. Offer positive reinforcement, 

such as “So you refused to share a needle. 

That must have been hard to do. Good 

for you.”

•	 Synthesize patterns of behavior. Identify 

the client’s pattern of risky behavior and 

the specific circumstances that lead to the 

behavior.

•	 Negotiate a prevention plan. Clients might 

feel besieged by the many changes they 

are asked to make. Develop incremental 

and achievable steps to minimize risk 

for transmitting viral hepatitis. Put the 

behavioral change plan in writing, and 

give a copy to the client. 

•	 Revisit the plan periodically, and assess 

progress. Check with the client periodically to determine whether new behaviors, 

stressors, or circumstances need to be 

addressed in the plan. Renegotiate the 

plan if necessary. 

•	 Include vaccinations against hepatitis A 

or hepatitis B and prevention strategies 

for other infections, such as HIV, that are 

spread in the same way as different types 

of hepatitis.

Using Motivational Approaches

Using motivational approaches, the counselor 

can help clients understand the relationship 

between good health and recovery (Litwin 

et al., 2005). Counselors can identify the 

strengths clients have demonstrated in 

counseling sessions and encourage clients 

to develop ways to use those strengths to 

cope with current health challenges. Appendix 

G provides sources of information about 

motivational interviewing and counseling. 

Confronting the Social Factors of 

Hepatitis 

Many people who have viral hepatitis report 

that the social ramifications of a hepatitis C 

diagnosis are severe (Astone-Twerell, Strauss, 

& Munoz-Plaza, et al., 2006). Many people 

who have SUDs and chronic hepatitis feel 

they are judged as immoral and blameworthy 

because the infection results primarily from 

the sharing of contaminated injection drug 

use equipment (Astone-Twerell, Strauss, 

Munoz-Plaza et al., 2006). People who have 

hepatitis C virus (HCV) infection might be 

viewed by some as having made poor choices 

because they engaged in dangerous and illegal 
55

behaviors that resulted in their illnesses. 

Negative attitudes about people who have 

chronic hepatitis remain, even among some 

medical professionals (Brener, Von Hippel, & 

Kippax, 2007; Paterson, Backmund, Hirsch, 

& Yim, 2007; Von Hippel, Brener, & Von 

Hippel, 2008). Counselors can advocate nondiscriminatory treatment for clients who have 

hepatitis.

For some clients, a diagnosis of hepatitis can 

generate feelings of low self-worth. Some 

clients who have viral hepatitis report that 

their diagnoses caused them to develop a 

negative sense of self (Astone-Twerell, Strauss, 

Munoz-Plaza, et al., 2006). The majority of 

clients reported experiencing fear, shame, and 

social rejection (Brener et al., 2007; Conrad, 

Garrett, Cooksley, Dunne, & MacDonald, 

2006; Zickmund, Ho, Masuda, Ippolito, & 

LaBrecque, 2003). 

Clients might need to use discretion in revealing 

their diagnoses. Counselors can help clients 

decide whom they can tell by encouraging 

clients to ask themselves the following 

questions:

•	 Does this person need to know? 

− Household members need to know, 

particularly if they are sex partners 

or likely to share things like razors 

or hair clippers. Extended family 

members might not need to know.

− Under some circumstances employers 

might need to know. For example, if a 

client’s work is affected by the illness 

or if he or she frequently misses work 

because of illness or medical appointments, a supervisor might need to be 

told. 

•	 What is the person likely to do with the 

information? Is this person trustworthy?

•	 Is this the right time to tell this person? 

•	 What are the risks in telling the person? 

Is a negative reaction likely?

•	 What questions might the person have 

about the client’s diagnosis? Can the client answer those questions?

A diagnosis of viral hepatitis might 

increase a client’s potential for 

relapse to alcohol or drug use.

Clients might need help with talking to their 

families, employers, and friends about their 

hepatitis. Counselors can help by:

•	 Role playing with clients, allowing them 

to practice how they tell various people.

•	 Offering to be present when clients talk 

to family members.

•	 Providing family members and friends 

with information about the symptoms, 

treatment, and transmission of the 

disease. 

Addressing Relapse 

A diagnosis of viral hepatitis might increase 

a client’s potential for relapse to alcohol or 

drug use. The diagnosis might also exacerbate 

depression and anxiety, which are known triggers for an SUD relapse. Treatment for HCV 

infection itself also can trigger relapse. The 

reasons for this are unknown, although the 

act of injecting medication might trigger cravings in clients who injected drugs. Side effects 

from antiviral treatment might also mimic 

withdrawal. Increases in methadone doses 

might be appropriate (Sylvestre & Clements, 

2007). 
56

Addressing Viral Hepatitis in People With Substance Use Disorders

The counselor can start conversations about 

relapse by asking the client the following 

questions:

•	 “What kinds of things make you think 

about using again?”

•	 “Do you consider getting injections during 

treatment a possible trigger to drug use?”

•	 “What kinds of things could help you 

avoid substance use?”

•	 “Who could support you in these efforts?”

•	 “How worried are you about the possibility of a relapse?”

Clients might need the counselor’s 

help in telling family members 

about a hepatitis diagnosis.

Counselors can give clients the following tips 

(U.S. Department of Veterans Affairs, 2004):

•	 “Remind yourself that interferon is working to heal your liver from the damage 

caused by HCV infection.”

•	 “Try not to isolate yourself while injecting 

interferon. It might be helpful to inject 

interferon around people you trust, such 

as family members.”

•	 “Talk openly about your feelings of injecting interferon with members of your support group and other people you trust.” 

•	 “Remind yourself that being abstinent is 

the best thing you can do to keep yourself 

healthy when you have HCV infection.” 

•	 “Get help managing side effects. 

Remember to talk with your doctor if you 

are experiencing side effects from your 

HCV treatment.”

•	 “Do not skip or change doses of interferon. 

Try to make the injections part of your 

routine.”

Building Support Systems

Support Groups

Hepatitis groups are a widely used source of 

ongoing support for clients living with hepatitis and might help demystify treatment for 

participants. In these groups, clients educate 

and support one another about the infection, 

the treatment process, and managing medication side effects. Support groups help clients 

“believe that good outcomes are attainable” 

(Litwin et al., 2005, p. S342). 

Support groups in substance abuse treatment 

settings can be facilitated by a counselor, 

nurse, or peer. The choice of facilitator should 

be based on a program’s resources and the 

needs of its clients. Support groups can also 

be found at hospitals and clinics. Appendix C 

lists national organizations that help people 

find local resources or that offer online support communities. Counselors can help clients 

get the support they need by asking clients the 

following questions:

•	 “How can you get professional help if you 

need it?”

•	 “It takes courage to take on this challenge. Would you be interested in the 

names and numbers of people you could 

talk to?”

•	 “Talking to others in drug recovery who 

have successfully been through hepatitis 

treatment can be really helpful. Do you 

see this as being part of your hepatitis 

recovery?” 

Peer Counseling and Support

In a study at a residential treatment program 

(Munoz-Plaza et al., 2004), clients most 

frequently recommended the use of peer 

counselors as a way to enhance hepatitis treatment services. These clients found that peers 

who had experience with HCV infection were 
57

more valuable than “even the most knowledgeable and well-trained staff person” (MunozPlaza et al., 2004, p. 874). Peers can facilitate 

or co-facilitate support groups; act as mentors 

to newly diagnosed clients; and provide information, support, and assistance (e.g., provide 

transportation, accompany clients to medical 

appointments). Peers can be clients who are 

farther along in hepatitis treatment, graduated 

clients, or volunteers from the community.

Family Support

Families might be supportive or might react 

badly to a family member’s diagnosis of hepatitis. Clients might need the counselor’s help in 

telling family members about a hepatitis diagnosis. Families might not be willing or able to 

support the client (e.g., family members might 

be using drugs). However, counselors can 

reduce families’ fears and encourage families 

through the following: 

•	 Educate family members about hepatitis. 

Families need the same information as 

clients about the illness, its treatment, 

the potential effects on a client’s SUD 

recovery, and the increased risk of relapse 

to substance use. 

•	 Help families adjust to lifestyle changes. 

Some clients might make lifestyle 

changes, particularly in diet and sexual 

behavior, following a diagnosis of hepatitis 

or as part of their substance abuse treatment (Castera, Constant, Bernard, de 

Ledinghen, & Couzigou, 2006; Fabris 

et al., 2006). These changes affect family 

members. 

•	 Help family members adopt new roles 

and routines. Clients might need time 

away from their families to attend 

support group meetings and medical 

appointments. These added demands, 

coupled with the symptoms of the 

disease and possible side effects of 

antiviral treatment, can affect a person’s 

ability to meet family obligations. Clients 

might need help negotiating with family 

members to establish new roles and 

routines that accommodate the client’s 

treatment for hepatitis and an SUD. 

•	 Help family members determine how 

best to support their loved one. Counselors 

can help the client identify needs and 

encourage family members to decide what 

they can do to support the client.

•	 Help family members recognize changes 

in behavior. Family members living with 

the client might be the first to notice an 

adverse reaction to antiviral treatment. 

Ask family members to provide feedback 

on any changes in mood, either elevated 

or depressed, and encourage the client to 

heed a family member’s observations.

•	 Help family members find support for 

themselves. Family members who have 

lived with a client who abused substances 

are now faced with helping that individual cope with another illness. Some might 

resent the additional burden. Family 

members can find support at hepatitis 

support groups. Some families need more 

education and support than do others. 

Counselors should be prepared to make 

referrals to local resources for couples or 

family therapy, if needed.

Providing Effective Case 

Management

Clients who have hepatitis might need intensive 

case management. Some clients receive case 

management services through their medical 

care providers, but many do not. Some 

substance abuse treatment programs have 

designated case managers to assist clients. 

Counselors or program nurses sometimes 

perform these functions. A program’s structure and administrative decisions about staff 
58

Addressing Viral Hepatitis in People With Substance Use Disorders

roles influence the level of case management 

counselors provide. Counselors should clearly 

convey the expectations of their programs 

to clients. If they cannot provide the level of 

case management a client needs, they should 

do what they can to connect the client with a 

case manager in another healthcare or social 

services system. 

Case management for clients who have 

hepatitis is often the same as that for clients 

with SUDs, but clients who have hepatitis 

might need more intensive and specialized 

help. Some clients who have hepatitis might 

be unable to work because of illness or hepatitis 

treatment side effects. Counselors can help by:

•	 Working with clients on budgeting or 

referring clients to consumer counseling 

agencies for debt management.

•	 Referring clients to local food banks, 

utility assistance programs, and rent 

assistance programs.

•	 Assisting in negotiating short-term 

disability claims or emergency family 

assistance.

Clients might need help accessing and 

navigating medical care systems. Counselors 

can help by:

•	 Identifying local providers who treat 

hepatitis; have experience working with 

people who have SUDs; and, when relevant, are comfortable treating people 

in medication-assisted treatment.

•	 Establishing relationships with clients’ 

medical care providers and staying abreast 

of clients’ hepatitis treatment.

•	 Helping clients understand and complete 

written documents and consent forms.

•	 Working with clients to establish procedures that help them remember medical 

appointments and adhere to medication 

regimens.

•	 Ensuring that clients have transportation 

to medical appointments.

Clients might need help understanding insurance requirements and, possibly, challenging 

insurers’ coverage decisions. If clients are uninsured, counselors can:

•	 Identify government sources of healthcare 

and support benefits (e.g., Medicaid, 

Medicare, food stamps, unemployment 

insurance). (See Appendix H.)

•	 Look for assistance programs in medical 

centers and clinics.

•	 Identify local, private nonprofit clinics 

that offer many types of services; public 

health departments might be a source 

of information about community health 

resources.

Even if clients are insured, co-payments 

might be very high. Counselors can help 

clients identify sources of assistance, such as 

State medication assistance programs and 

local and national medication assistance programs. Appendix H lists resources for patient 

financial assistance with medications and 

transplantation surgeries. 

Sources of information on SUD treatment 

and medical case management procedures 

include Treatment Improvement Protocol 27, 

Comprehensive Case Management for Substance 

Abuse Treatment (Center for Substance Abuse 

Treatment, 1998) and Case Management 

Adherence Guidelines, Version 2.0 (Case 

Management Society of America, 2006).
59

6—Counseling Approaches for People Who Have Viral Hepatitis

Chapter Summary

Counselors are in a unique position to provide education, emotional support, and tangible help for 

clients who have hepatitis. 

To be effective, counselors must first be well educated about hepatitis. 

Key counselor goals should include:

•	Ensuring the safety of clients.

•	Providing reliable information to clients and their families.

•	Building the therapeutic relationship with clients.

•	Helping clients understand their diagnoses.

•	Incorporating client needs in substance abuse treatment planning.

•	Developing a prevention plan.

•	Using motivational interviewing.

•	Confronting the social ramifications of hepatitis.

•	Addressing relapse issues.

•	Building support.

•	Providing case management.

Counselors also can help by:

•	Being flexible about treatment logistics (e.g., participation, treatment duration), within 

accreditation and licensing guidelines.

•	Being alert to co-occurring mental disorders, particularly depression.

•	Assessing clients’ readiness and using motivational approaches to help clients make medical 

treatment decisions.

•	Assessing and mobilizing clients’ strengths.

Counselors can help clients develop social support systems by:

•	Providing onsite support groups. 

•	Helping clients locate community-based support groups.

•	Facilitating onsite peer counseling and support programs.

•	Facilitating family support through education and counseling.

Counselors can provide effective, targeted case management, such as:

•	Helping clients understand and complete written documents and consent forms.

•	Helping clients obtain medical care and adhere to medical regimens.

•	Helping clients find sources for financing medical treatment and medications for hepatitis. 

61

7 Adding or Improving 

Hepatitis Services: A 

Guide for Administrators

IN THIS CHAPTER

•	Program Assessment 

and Planning

•	Screening for Viral 

Hepatitis

•	Medical Evaluation and 

Diagnosis

•	Treatment for Chronic 

Hepatitis

•	Prevention and 

Vaccination

•	Education 

•	Support Services

•	Outreach

•	Integrating Hepatitis 

Interventions With 

Existing HIV Services 

•	Developing Policies and 

Procedures

•	Evaluation

•	Successful 

Implementation

•	Legal and Ethical Issues

•	Chapter Summary

Program Assessment and Planning

A significant positive correlation has been found between administrators’ beliefs about the value of hepatitis services and the availability of hepatitis-related services at their substance abuse treatment programs (Astone, Strauss, Hagan, & Des Jarlais, 2004a). To 

determine the types of services to implement or enhance treatment, 

administrators must consider the client population, staffing patterns 

and issues, availability of local resources, potential partners, and 

sources of funding. Program administrators can support the provision of hepatitis services by allocating a budget for implementation 

and by training or hiring appropriate staff members to implement 

the new services. 

Hepatitis services include the following: 

•	 Screening for viral hepatitis

•	 Medical evaluation and diagnosis

•	 Treatment for chronic hepatitis

•	 Prevention and vaccination

•	 Education

•	 Support services

•	 Outreach

A first step toward implementing change is to assess the hepatitis 

services currently offered by the substance abuse treatment program 

and identify components that could be implemented or expanded. 

This assessment can be performed by a workgroup or task force consisting of staff members interested in implementing or expanding 

hepatitis services. A group comprising staff members from different 

disciplines can provide diverse information and viewpoints. The next 

step is to consider the staff at hand, possible funding sources, and 

local agencies that could partner with the treatment program to 

provide hepatitis services. 
62

Addressing Viral Hepatitis in People With Substance Use Disorders

Once these steps are completed, an implementation plan should be written. Organizational 

change might be needed to develop and 

sustain hepatitis treatment services. Technical 

Assistance Publication (TAP) 31, Implementing 

Change in Substance Abuse Treatment Programs

(Center for Substance Abuse Treatment 

[CSAT], 2009a), provides practical advice 

regarding this topic and about incorporating 

new components into a treatment program. 

Screening for Viral Hepatitis

Screening activities include:

•	 Assessing a client’s risks of acquiring 

or transmitting hepatitis.

•	 Obtaining a client’s history of hepatitis 

infection or vaccination.

•	 Conducting blood tests for hepatitis or 

working with local health departments 

and other medical facilities that provide 

screening tests.

Because drug use is a risk factor for contracting 

viral hepatitis, the Centers for Disease Control 

and Prevention recommends that all clients 

in substance abuse treatment programs have 

routine access to hepatitis screening services. 

Clients who use or have used injection drugs 

are at particular risk of contracting viral 

hepatitis. (Chapters 1 and 2 provide information on risk factors and screening, respectively.) 

Substance abuse treatment programs can 

screen for viral hepatitis during the intake 

medical examination (Hagan, Strauss, Astone, 

& Des Jarlais, 2005). Treatment Improvement 

Protocol (TIP) 40, Clinical Guidelines for 

the Use of Buprenorphine in the Treatment 

of Opioid Addiction (CSAT, 2004); and TIP 

43, Medication-Assisted Treatment for Opioid 

Addiction in Opioid Treatment Programs

(CSAT, 2005), provide information about 

screening and assessing clients. 

Most opioid treatment programs (OTPs) 

have onsite medical staff members who can 

draw blood samples for hepatitis screening 

tests. With the client’s consent, an OTP that 

routinely provides physical examinations could 

add a hepatitis test to a client’s initial blood 

work. Because viral hepatitis is a communicable disease, new cases must be reported. In 

many cases, the laboratory reports the case, 

but program administrators should contact 

local or State health departments for current 

information about reporting requirements and 

procedures; this information should be included 

in the program’s written procedures.

Medical Evaluation and Diagnosis

Evaluation and diagnosis activities include 

providing onsite medical evaluations after a 

screening, or referring clients to local providers 

for evaluation and diagnosis.

The medical screening and evaluation of 

hepatitis B and C can be complicated, and 

the required laboratory tests are expensive. 

However, a qualified and experienced medical 

care provider can order proper tests, evaluate 

the results, provide an accurate diagnosis, and 

make treatment recommendations. Evaluative 

services are needed after a positive test result 

for hepatitis B and C. The Institute of Medicine 

(2010) recommends that the inability of a 

facility to provide evaluation and diagnosis 

services should not be an impediment to its 

providing screening services. 

Treatment for Chronic Hepatitis

Hepatitis treatment activities include providing 

treatment onsite at the substance abuse treatment program or referring clients to local 

partners, establishing a multidisciplinary treatment team, and obtaining clients’ permission 

to share information among team members.
63

7—Adding or Improving Hepatitis Services: A Guide for Administrators

Case Study: Funding Comprehensive Services, Project Samaritan Health 

Services, New York City

Project Samaritan Health Services provides hepatitis C care at four residential treatment facilities 

and a community-based facility in the New York City area. The program was established in 

response to State recommendations that substance abuse treatment centers provide hepatitis 

screening and education to clients—a recommendation the program fully supported. Project 

Samaritan administrators also wanted to help all clients with hepatitis obtain proper treatment. 

Project Samaritan provides education and training to its counselors and medical health care 

personnel so that they are well versed in working with clients who have hepatitis. 

More than 25 percent of Project Samaritan’s clients do not have medical insurance. By forming a 

coalition of several large substance abuse treatment programs in New York State that collectively 

serve approximately 10,000 clients, Project Samaritan and its partners persuaded State officials 

to expand Medicaid to cover hepatitis-associated services, including testing for hepatitis C. 

The coalition also persuaded the State to convene a workgroup that created comprehensive 

guidelines for hepatitis care. Administrators worked with compassionate care programs to 

provide medications to eligible individuals; they also worked with a national medical laboratory 

to provide laboratory testing at no charge for individuals with incomes below the poverty level, 

and they negotiated with a local hospital to provide a substantially discounted rate for liver biopsy 

procedures. 

Other hepatitis services are provided by Project Samaritan’s medical staff. Physicians specializing 

in gastroenterology or hepatology provide hepatitis treatment. A nurse practitioner works 

approximately 8 hours per week; a physician, approximately 12 hours. 

Despite a rigorous treatment regimen and limited hours dedicated to providing hepatitis care, 

Project Samaritan has a low rate of attrition. The program’s hepatologist attributes the low dropout 

rate, in large part, to two factors: (1) extensive education offered to patients about treatment 

and its implications; and (2) patient empowerment to make decisions about their treatment. The 

program works to be client centered and strives to positively engage clients in treatment by 

emphasizing the steps that clients can take to improve their health.

Interviews by a JBS International, Inc., consultant with Administrators Marguerite Gebhardt and Pat 

Kennedy on April 22, 2008, and with hepatologist Nicholas Triantafillou, M.D., on April 23, 2008.

Substance abuse treatment program administrators tend to agree that hepatitis treatment 

for clients in recovery from substance use 

disorders (SUDs) is important. However, 

opinions diverge on when and how to treat 

clients for chronic hepatitis while they are in 

early recovery (Astone, Strauss, Hagan, & Des 

Jarlais, 2004b). Some administrators are reluctant to refer clients for hepatitis treatment, 

citing difficult treatment regimens and serious side effects that could jeopardize a client’s 

recovery. Research suggests, however, that 

people in recovery from substance abuse can 

successfully adhere to the prescribed course of 

antiviral medication. Some clients will need 

financial assistance for hepatitis treatment. 

Low- and no-cost healthcare sources are listed 

in Appendix H.

Onsite Treatment

Onsite medical care in substance abuse treatment programs has been shown to be more 

effective than outside referrals for improving 

clients’ overall health and their access to comprehensive medical care (Samet, Saitz, & 
64

Addressing Viral Hepatitis in People With Substance Use Disorders

Larsen, 1996; Umbricht-Schneiter, Ginn, 

Pabst, & Bigelow, 1994). Advantages of providing onsite medical care include the ability 

to address both needs in one visit and streamlined communication between substance abuse 

treatment counselors and medical care providers (Sorensen, Masson, & Perlman, 2002). 

Onsite medical care providers learn more about 

clients’ substance use behaviors and can monitor and manage psychiatric disorders (Vassilev, 

Strauss, Astone, Friedmann, & Des Jarlais, 

2004), which might encourage adherence to 

treatment. Communication among counseling 

and medical staff members about a client’s 

hepatitis status, while maintaining appropriate client confidentiality, can improve client 

care. Administrators should keep abreast of 

guidelines about hepatitis treatment eligibility 

(Exhibit 7-1).

Referring Clients to a Hepatitis 

Treatment Provider

In referring clients for hepatitis care, a major 

undertaking is finding medical care providers 

who understand the challenges facing people 

who have co-occurring hepatitis and SUDs 

and developing cooperative working relationships with them. Medical care providers might 

not have the experience or training needed to 

work with people who have SUDs and hepatitis. When medical care providers lack knowledge about how to treat clients with SUDs, 

clients are less likely to follow medical advice 

and more likely to relapse to substance use 

(Astone-Twerell, Strauss, Hagan, et al., 2006). 

To locate health professionals who are experienced in treating hepatitis and sensitive to 

the needs of people in early recovery, administrators can contact potential partners who 

indicate an interest in reducing the spread of 

hepatitis in the community. These partners 

can include public health departments, nearby 

teaching hospitals and medical schools, nonprofit hepatitis organizations, and programs 

that offer HIV treatment. Health departments 

might be able to provide some hepatitis care 

for clients and assist with transportation 

needs. Many clients need assistance in contacting medical service providers (Sylvestre & 

Zweben, 2007). 

Multidisciplinary Teams

Once a relationship is established with inhouse or external medical care providers, a 

treatment team should be developed. Explicit 

permission must be obtained from clients to 

share information among identified clinical 

staff members. After permission is obtained, 

collaborative communication among the medical care and substance abuse treatment providers can begin. A case manager, either within 

the healthcare system or at the substance 

abuse treatment facility, can promote communication between clients and staff members 

and treatment providers. 

Exhibit 7-1 Hepatitis Treatment Guidelines

•	Substance Abuse and Mental Health Services Administration’s Division of Pharmacologic 

Therapies: http://www.dpt.samhsa.gov/comor/hepatitis.aspx

•	Practice Guidelines of the American Association for the Study of Liver Diseases: http://www.

aasld.org, Practice Guidelines section

•	Centers for Disease Control and Prevention: http://www.cdc.gov/hepatitis

•	U.S. Department of Veterans Affairs: http://www.hepatitis.va.gov 
65

Prevention and Vaccination

Prevention activities include:

•	 Providing counseling before and after 

hepatitis screening.

•	 Educating clients about the role of 

injection drug use (IDU), sharing drug 

paraphernalia, and risky sexual behaviors 

in virus transmission.

•	 Providing vaccinations against hepatitis A 

and B.

Vaccines against hepatitis A virus (HAV) 

and hepatitis B virus (HBV) exist, but vaccination can be provided most efficiently with 

the combined hepatitis A/hepatitis B vaccine 

(sold under the brand name, Twinrix). It is 

the only U.S. Food and Drug Administrationapproved combination hepatitis A and hepatitis 

B vaccine. The vaccine is administered in three 

intramuscular injections on a 0-, 1-, and 6-month

schedule, or may be given on an accelerated 

schedule of four doses, given on days 0, 7, 

and 21–30 with a booster dose at 12 months 

(FDA, 2010a). Vaccinating clients for HAV 

and HBV can be done onsite or by referral. 

State-by-State information on obtaining nocost vaccinations is available at http://www.

hepclinics.com/templates/hepclinic/index.

html.

OTPs, which maintain frequent interactions 

with clients over a long period, are good settings in which to offer hepatitis vaccinations 

because clients are likely to complete the full 

vaccination course during treatment. When 

determining whether to offer onsite hepatitis 

vaccinations, some questions to consider are: 

•	 Does the facility have sufficient space to 

store the vaccine and give the injections 

in private?

•	 Does the facility have the proper 

equipment?

•	 Can the facility follow cold chain 

(temperature control) procedures to 

ensure the vaccine is effective?

•	 Does the facility have staff members 

licensed to give injections? 

Full adherence to HAV and HBV vaccination 

regimens can be challenging because months 

separate immunizations. Whether clients are 

vaccinated at the substance abuse treatment 

program or at another program or agency, substance abuse treatment program administrators 

can take the following steps to ensure that 

clients complete their vaccination regimens:

1. Keep medical records of client’s completed 

and needed vaccinations.

2. Use reminder tools to alert clients when 

the next vaccination is scheduled.

3. Allow flexible vaccination schedules 

(higher doses in a condensed timeframe). 

4. Provide transportation to the clinic if the 

vaccine is administered offsite.

5. Offer incentives if the program’s budget 

allows (National Alliance of State and 

Territorial AIDS Directors [NASTAD], 

2005).

Education

Based on research and clinical expertise, the 

Consensus Panel strongly recommends an 

increased substance abuse treatment program 

investment in hepatitis education for all staff 

members and clients. These investments begin 

with training staff, learning about community 

resources available to clients who have chronic 

hepatitis, and designing education protocols in 

line with substance abuse treatment programs’ 

missions and approaches. 
66

Addressing Viral Hepatitis in People With Substance Use Disorders

Staff Education

To properly inform clients about hepatitis, 

staff members must be adequately trained to 

convey information accurately and completely, 

and they must be proficient in teaching methods that help clients understand and retain the 

information presented. Staff preferences and 

program resources need to be considered when 

designing hepatitis training. Literature, manuals, and other print materials can be valuable 

sources for training, but alone they are insufficient. Hands-on opportunities (e.g., classes 

and workshops that provide an opportunity 

for role play), are generally more effective 

than reading print material. Staff members 

want to learn, for example, how to educate 

clients about hepatitis C virus (HCV) without alarming clients to the point of impeding 

their recovery from substance abuse (MunozPlaza et al., 2004). Hepatitis training can be 

incorporated into inservice training schedules. 

Some training needs are presented in Exhibit 

7-2. 

Several training resources are available, and 

many are free. Resources for hepatitis training 

programs developed for substance abuse treatment program staff are presented in Appendix I.

Client Education 

Most substance abuse treatment programs do 

not offer education about hepatitis to their 

clients (Strauss, Astone, Hagan, & Des Jarlais, 

2004; Strauss et al., 2007). Program budget 

and audience determine the format and delivery of hepatitis education, which can range 

from printed matter to educational sessions. 

Hepatitis education can be incorporated into 

the general educational component of the 

treatment program, with one or more sessions devoted to hepatitis, for example. For 

clients in OTPs who have chronic hepatitis, 

more extensive education sessions could be 

developed. Individual sessions with counselors 

or other treatment staff members allow clients 

the opportunity to ask questions, review information, and learn how SUDs affect hepatitis. 

Chapter 6 provides information for counselors 

to use to educate their clients. Resources for 

information on hepatitis are in presented in 

Appendix C.

Support Services

Some clients will need additional support 

services, such as services to obtain healthcare 

coverage from Medicaid or other sources. 

These clients might also need incentives and 

intensive case management services to adhere 

to hepatitis treatment, keep medical appointments, and locate hepatitis support groups. 

Administrators might need to assign staff 

members as case managers or work with the 

medical team to access these services. For 

example, a medical facility might have transportation services, but the clients might not 

be aware of them. Information on support 

groups is in Appendix C. Resources for 

financial assistance are in Appendix H.

Outreach

Outreach activities include:

•	 Joining community leaders, client representatives, and public health officials 

in providing information about viral 

hepatitis and substance use.

•	 Participating in health fairs and taking 

advantage of other outreach opportunities.

•	 Building ties to outreach agencies (e.g., 

HIV counseling and testing centers, community outreach agencies, public health 

departments, correctional facilities, local 

hospitals).

In addition to partnering with local agencies 

and organizations, substance abuse treatment 
67

Exhibit 7-2 Staff Training for Hepatitis in Substance Abuse Treatment Programs

Service Topic

Assessment and screening •	Assessing a client’s risk factors of acquiring or transmitting 

infection

•	Obtaining a history of hepatitis disease or vaccination when 

collecting medical information

•	Knowing the procedures for conducting or referring for 

hepatitis screening

•	Counseling before and after screenings

•	Assessing potential barriers to screening 

Preventing infection (primary 

prevention)

•	Educating clients about the use of drug paraphernalia 

and risky sexual behaviors to prevent their contracting or 

transmitting the virus

•	Identifying clients in need of hepatitis C treatment or HAV/

HBV vaccinations

•	Understanding the procedures for referring or providing 

HAV/HBV vaccinations

•	Including hepatitis in client/family educational components

•	Collaborating with other agencies (e.g., HIV counseling and 

testing centers, nonprofit organizations, community outreach 

agencies, community health clinics, private medical care 

providers) that treat hepatitis B and C

•	Retaining clients who relapse 

Limiting disease consequences 

(secondary prevention)

•	Linking clients to hepatitis medical care or providing care 

onsite

•	Promoting medication adherence (e.g., through reminder 

systems, social support, incentives)

General information and 

communication

•	Research, ethical, and legal issues

•	Coordinated care with medical staff members while 

maintaining client confidentiality

•	Quality improvements identified by regular assessment of 

program components and processes related to hepatitis

•	Followups with clients and other medical care providers 

•	Case management

programs that implement hepatitis services 

can direct outreach and educational activities 

toward populations at risk for SUDs and 

viral hepatitis—particularly toward people 

who inject drugs—to raise awareness of liver 

disease and risky behaviors, promote screening 

and early treatment, and encourage vaccination against hepatitis A and B. 
68

Addressing Viral Hepatitis in People With Substance Use Disorders

Case Study: Support Groups at OASIS, Oakland, California

The Organization to Achieve Solutions in Substance-Abuse (OASIS) developed a peer-based hepatitis C group that provides education, testing, and treatment of HCV infection among people who 

abuse substances (Sylvestre & Zweben, 2007). It integrates services for hepatitis C, IDU, mental 

disorders, and psychosocial issues for an inner-city population. The OASIS model demonstrates the 

ability of a small clinic not associated with major healthcare facilities to implement hepatitis care. 

At the model’s core are support groups called Educate-Motivate-Facilitate, in which HCVknowledgeable peers and a medical provider co-lead groups that address a range of topics. The 

groups include clients with different knowledge levels and who are at different stages, from hepatitis screening through treatment. As participants become knowledgeable and stable in recovery, 

they are encouraged to serve as group leaders. 

The groups discuss participants’ experience with HCV treatment and side effects, substance use, 

depression, and other topics. Medical staff members interject correct information or add information, as needed. The interactive format and peer support seem to improve attendance and adherence to medical recommendations. 

Integrating Hepatitis Interventions 

With Existing HIV Services

Some substance abuse treatment facilities have 

programs for managing blood-borne infections, 

such as HIV. The benefits of incorporating 

hepatitis services within existing HIV services 

include the following: 

•	 Counselors working with HIV/AIDS 

are familiar with the challenges of chronic 

infection and complex therapeutic regimens,

as well as with psychosocial issues that 

accompany a chronic disease. 

•	 Relationships are already established with 

medical care providers and public health 

departments. 

•	 Federal or State funding might be 

available (Strauss et al., 2005; StringariMurray, Clayton, & Chang, 2003).

Some substance abuse treatment program staff 

members have described integrated HCV 

and HIV services as a “natural fit” (Strauss et 

al., 2005). With adequate training, counselors 

can adapt HIV/sexually transmitted disease 

prevention messages to HCV prevention. 

Integration need not entail providing all 

services onsite; it could mean a simple 

coordinated referral system (NASTAD, 

2005). 

Administrators who would like to incorporate 

hepatitis services into existing HIV services 

should consider the following (Strauss et al., 

2005):

•	 There are different prevention messages 

for HIV and hepatitis, which are based 

on different rates of parenteral and sexual 

transmission.

•	 Clients often know less about HCV than 

about HIV.

•	 Some funding might be dedicated to 

support services for one virus, while prohibiting funds from being redirected to 

or shared with other activities.

•	 Counselors and staff might be reluctant 

to integrate services.
69

Developing Policies and 

Procedures 

Once the workgroup decides which services to 

implement, policies and procedures need to be 

established. Examples include: 

•	 Developing an overall policy regarding 

the program’s approach to providing 

hepatitis services. 

•	 Implementing and revising policies and 

procedures to reflect the organization’s 

goal to provide quality services to clients 

who need screening or treatment for 

hepatitis. 

•	 Establishing a system to monitor and 

evaluate policies and procedures and to 

revise them, as needed. 

•	 Providing staff development and educational opportunities related to hepatitis.

Writing and implementing new policies and 

procedures often involve adapting existing 

ones. Programs might already have a variety 

of policies and procedures that apply to clients 

who have hepatitis. For example, most programs 

probably have policies on what actions to take 

when a client has an infectious disease, who 

will work with the client, or where the client 

could be referred for additional medical treatment. The workgroup can review current policies and procedures to see which ones need to 

be adapted and revised. Exhibit 7-3 provides 

an example policy.

Evaluation

Once the treatment program implements 

hepatitis services, it can incorporate quality 

improvements identified by regular evaluation of the new program components and 

processes. The program can use the existing 

quality assurance function to develop a tracking system, which could measure the number 

of clients with hepatitis A, B, and C; hepatitisrelated treatment outcomes; and the severity 

of co-occurring substance use and mental 

disorders. This information can be used to 

improve services, to request funding, and to 

motivate staff.

Exhibit 7-3 Sample Policy: Screening for Hepatitis

Policy Statement: All counseling staff members will receive training in screening for viral hepatitis 

and will demonstrate competence in supporting, educating, and referring clients for hepatitis 

screening.

Procedures:

1. All counselors will participate in training about hepatitis and its relationship to substance 

abuse, attitudes toward clients who have hepatitis, and hepatitis screening intervention and 

referral resources. 

2. The clinical supervisor of new employees will provide site-specific information on the 

procedures for facilitating the screening, treatment, or referral of clients who either are already 

diagnosed with hepatitis or are at risk for developing hepatitis.

3. Clinical competence checklists completed at hire and annually thereafter will ensure that all 

clinical staff members (1) have basic knowledge of the benefits of addressing hepatitis with 

clients who abuse substances, (2) understand the protocols for assessing key risk factors for 

hepatitis, and (3) are aware of appropriate referral procedures.
70

Addressing Viral Hepatitis in People With Substance Use Disorders

Case Study: Overcoming Staff Resistance, Minneapolis Healthy Liver Program

The Minneapolis Healthy Liver Program was established in the Minneapolis Veterans Affairs 

Medical Center Substance Use Disorder Clinic (Hagedorn et al., 2007). A stakeholders group 

composed of clinical and administrative personnel from the medical center’s substance abuse 

treatment clinic and hepatitis clinic designed the program. Components included screening for 

hepatitis A, B, and C, which was added to routine blood work during intake, and intervention, 

which included a 60-minute group educational session and vaccinations against HAV and HBV, if 

indicated. As a result:

•	Testing rates for HCV increased from 72 percent to 98 percent.

•	Testing rates for HAV and HBV increased from less than 20 percent to 98 percent.

•	Referral rates of clients newly diagnosed with chronic hepatitis C to a hepatitis clinic increased 

from 50 percent to 100 percent. 

A major challenge was addressing staff resistance to accepting additional responsibility. Lessons 

learned include:

•	Invite staff representatives at all levels—from administration to support— to be represented in a 

stakeholders’ group.

•	Keep general staff informed of stakeholders’ group’s progress via meeting announcements and 

emails. 

•	Give staff members an opportunity to comment on the program’s plans and revise the plans 

based on their concerns. 

•	Provide staff with ongoing education about potential medical services to improve treatment 

retention and outcomes.

Successful Implementation 

Munoz-Plaza et al. (2006) analyzed four treatment programs that implemented or expanded 

hepatitis services. The programs provided 

educational and social support services (e.g., 

health education class, hepatitis C education 

and support sessions, a peer-led hepatitis C 

seminar). The researchers identified three 

features that facilitated the implementation 

of hepatitis services in these programs: 

•	 At least one program administrator 

promoted efforts to incorporate hepatitis 

services into the treatment program. 

At all four programs, supervisory staff 

encouraged adoption and innovation 

regarding hepatitis services. 

•	 At least one change agent on staff advocated for the services. One or more people 

were generally credited for increasing 

staff awareness about hepatitis, promoting 

the implementation of hepatitis services, 

leading the incorporation of hepatitis 

education and support services, and often 

taking on associated responsibilities 

without significant additional compensation. These change agents frequently had 

a commitment to incorporating hepatitis 

services, and they often identified themselves as having hepatitis C.

•	 There was collective buy-in from the 

substance abuse treatment team. A majority of the staff members at each program 

eventually supported the incorporation 

of hepatitis services once they were 

implemented.

Buy-in from staff members is necessary for 

success. Administrators can encourage progress by advocating change or supporting staff 
71

members’ efforts to implement change. Some 

staff members are resistant to implementing 

hepatitis services because they believe these 

services are outside the scope of substance 

abuse treatment. Information in Chapters 

1–6 of this TIP can mitigate staff members’ 

resistance for implementing change by helping 

them understand the numerous links between 

viral hepatitis and substance use. 

Legal and Ethical Issues

Substance abuse treatment program administrators need current knowledge of the legal 

and ethical issues about providing hepatitis 

care and, in particular, about providing medical 

care to people in their programs. The most 

significant issues concern confidentiality, 

informed consent, and staff member rights. 

Programs that include a peer education component must ensure that peers, like others 

involved in care, maintain client confidentiality 

as required by applicable laws and regulations. 

Confidentiality and Privacy Issues

Programs must closely guard information 

about clients. Although information must be 

shared with program staff members to the 

extent necessary to support clients’ needs, its 

dissemination must be carefully restricted to 

protect client confidentiality. 

The privacy rule under the Health Insurance 

Portability and Accountability Act (HIPAA) 

sets limits on how health plans and covered 

providers might use health information. It 

allows healthcare providers to share information needed to provide treatment, but 

it prohibits most other releases of medical 

information without the client’s authorization. 

Information about the HIPAA privacy rule 

as it pertains to substance abuse treatment is 

available at http://www.hipaa.samhsa.gov.

Substance abuse treatment programs covered 

under HIPAA must generally comply with 

longstanding requirements under 42 Code 

of Federal Regulations (CFR), Part 2, 

Confidentiality of Alcohol and Drug Abuse 

Patient Records, which gives substance abuse 

treatment clients a right to confidentiality. 

These requirements largely parallel those 

under the HIPAA privacy rule and prohibit 

most disclosures of client information unless 

the client provides consent. Information about 

42 CFR is at http://www.gpoaccess.gov/cfr/

retrieve.html. 

Other Federal and State laws and regulations 

might govern confidentiality of drug referral 

and treatment information. For assistance in 

complying with applicable requirements, treatment programs can request input from State 

agencies, provider organizations, and legal 

counsel. 

Informed Consent

Where testing or treatment is involved, 

informed consent is a legal and ethical prerequisite to administering care. Informed 

consent ensures that a client understands the 

therapeutic approach and has the power to 

make medical decisions. In addition to receiving descriptions of therapeutic options, the 

client must be informed of the expected risks 

and benefits. Clients generally have the right 

to refuse therapeutic interventions and must 

not be discriminated against based on such 

decisions. 

Staff Member Rights

All employees whose jobs involve the risk of 

direct contact with blood or other potentially 

infectious materials must be offered the 

hepatitis B vaccination without charge. If they 

decline, they must sign a form to document 

the decision.
72

Addressing Viral Hepatitis in People With Substance Use Disorders

Chapter Summary

Administrators can add a variety of viral hepatitis services to their programs, such as:

•	Hepatitis screening, evaluation, and diagnosis.

•	Hepatitis prevention activities, including education and vaccination.

•	Hepatitis treatment or referral to vetted medical care providers for treatment. 

•	Support services for clients needing hepatitis treatment.

•	Outreach to at-risk groups.

Successful programs tend to have: 

•	At least one administrator to promote efforts to incorporate hepatitis services into the treatment 

program. 

•	At least one change agent on staff who advocated for the services. 

•	Collective buy-in from the treatment team. 

Administrators should be familiar with:

•	Confidentiality and privacy issues.

•	Legal requirements for informed consent.

•	Staff member rights pertaining to risks of hepatitis exposure.
73

Appendix A—Bibliography

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drug users: A review. Addictive Disorders & Their Treatment, 7(4), 190–198. 

Alberti, A., Vario, A., Ferrari, A., & Pistis, R. (2005). Review article: Chronic 

hepatitis C—Natural history and cofactors. Alimentary Pharmacology and 

Therapeutics, 22(Suppl 2), 74–78. 

Alter, M. J., Krusran-Moran, D., Nainan, O. V., McQuillan, G. M., Gao, F., 

Moyer, L. A., et al. (1999). The prevalence of hepatitis C virus infection in 

the United States, 1988 through 1994. New England Journal of Medicine, 

341(8), 556–562. 

American Psychiatric Association. (2000). Diagnostic and statistical manual of 

mental disorders (4th ed., text revision). Washington, DC: Author. 

American Psychiatric Association. (2010). Practice guideline for the treatment 

of patients with major depressive disorder (3rd ed.). Arlington, VA: Author. 

Retrieved March 4, 2011, from http://www.psych.org/guidelines/mdd2010 

Anand, B. S., Currie, S., Dieperink, E., Bini, E. J., Shen, H., Ho, S. B., et al. 

(2006). Alcohol use and treatment of hepatitis C virus: Results of a national 

multicenter study. Gastroenterology, 130(6), 1607–1616. 

Astone, J. M., Strauss, S. M., Hagan, H., & Des Jarlais, D. C. (2004a). Outpatient 

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87

Appendix B—Glossary

acetaminophen—The generic name for a common nonprescription medication 

used to treat mild pain or fever.

acute hepatitis—An inflammatory process in the liver that resolves in 6 months. 

adefovir dipivoxil—A U.S. Food and Drug Administration-approved antiviral 

medication for treating chronic hepatitis B, taken orally.

alanine aminotransferase (ALT)—An enzyme found in the liver; an increased 

level of ALT in the blood indicates liver inflammation.

albumin—A protein made in the liver that helps move small molecules through 

the bloodstream. It plays an important role in keeping the fluid from the blood 

from leaking into the tissues. If albumin drops to very low levels, fluid might leak 

into tissues from the blood vessels, resulting in edema (swelling).

alkaline phosphatase (ALP)—An enzyme found in the liver and other parts of 

the body; elevated levels might indicate liver injury. 

antibody—A type of protein produced by the body’s immune system. Antibodies 

protect the body from disease by binding to antigens (see below) and destroying 

them.

antigens—Foreign substances (e.g., bacteria, viruses) in the body that are capable 

of causing disease. The presence of antigens in the body triggers an immune 

response, usually the production of antibodies (see above).

antiviral (literally against-virus)—Any medicine capable of destroying or weakening a virus or suppressing its ability to replicate.

aspartate aminotransferase (AST)—An enzyme found in the liver; an increased 

level of AST in the blood indicates liver inflammation.

asymptomatic—Presenting no symptoms of disease.

boceprevir—A U.S. Food and Drug Administration-approved medication for 

treating chronic hepatitis C, taken orally.
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Addressing Viral Hepatitis in People With Substance Use Disorders

chronic hepatitis—An inflammatory process 

in the liver that lasts longer than 6 months.

cirrhosis—Irreversible scarring of the liver 

caused by ongoing damage, which might affect 

liver function. Cirrhosis in some cases can lead 

to liver failure, liver cancer, and death. 

co-infection—The condition of an organism 

or cells being infected simultaneously by two 

different pathological microorganisms, such as 

infection with both hepatitis C virus and HIV.

contagious—Capable of being transmitted 

from one person to another by contact or close 

proximity.

coronary heart disease—A narrowing of the 

small blood vessels that supply blood and oxygen to the heart. Also called coronary artery 

disease.

decompensated cirrhosis—A progression 

of cirrhosis that can be life threatening. 

Symptoms include internal bleeding, large 

amount of fluid in the abdomen, encephalopathy (confusion), and jaundice. 

end-stage liver disease—Severe damage to 

the liver. End-stage complications include liver 

failure and liver cancer. These conditions occur 

primarily in people who develop permanent 

scarring of the liver (cirrhosis).

entecavir—An oral prescription medicine 

used for chronic infection with hepatitis B 

virus in adults.

enzyme—A protein (or, rarely, ribonucleic 

acid) that catalyzes a chemical reaction; it is 

produced by living cells and catalyzes specific 

biochemical reactions at body temperatures.

exposure—Coming in direct contact with an 

agent that might cause a disease or infectious 

process (e.g., exposure to hepatitis B virus 

might result in hepatitis B infection). 

fecal–oral route—A mode of transmission of 

an infectious agent from person to person by 

putting something in the mouth that has been 

contaminated with infected stool (feces). 

fibrosis—Scar tissue developed as a result of 

chronic infection and inflammation. The presence of fibrosis usually means infection has 

been active for several years.

genotype—The genetic makeup of the virus 

that describes the “family” to which the specific virus belongs.

hepatitis—Inflammation of the liver. The 

most common cause is infection with a hepatitis virus, but hepatitis can also be caused 

by other viruses, bacteria, parasites, and toxic 

reactions to drugs, alcohol, and chemicals.

hepatitis A—An inflammatory process of the 

liver caused by the hepatitis A virus. 

hepatitis B—An inflammatory process of the 

liver caused by the hepatitis B virus. 

hepatitis B core antibody—A protein that 

appears at the onset of symptoms in acute 

hepatitis B and persists for life. Its presence 

indicates previous or ongoing infection with 

the hepatitis B virus.

hepatitis B surface antibody—A protein that 

the immune system produces to attack hepatitis B virus. Its presence generally indicates 

recovery and immunity from the hepatitis B 

virus. 

hepatitis B surface antigen—A serologic 

marker on the surface of the hepatitis B 

virus. It can be detected in high levels in 

serum during acute or chronic hepatitis. 

hepatitis B virus DNA (deoxyribonucleic 

acid)—A molecule that controls the manufacture of the hepatitis B virus. Its presence 

indicates active viral replication; high levels 

correlate with high rates of replication. Levels 

predict response to antiviral therapy.
89

Appendix B—Glossary

hepatitis C—An inflammatory process of the 

liver caused by the hepatitis C virus. 

hepatitis C virus RNA (ribonucleic acid)—A 

fragment of the replicating hepatitis C virus. 

It can be detected using sophisticated tests to 

determine the level of the virus in serum. 

hepatocellular carcinoma—The most common primary liver cancer. 

high-risk behavior—Behavior that puts a 

person at risk of contracting hepatitis (e.g., 

sharing needles or drug paraphernalia; having 

multiple sex partners).

high-risk group—A group with an elevated 

risk of disease. 

immune system—The complex system in 

the body responsible for fighting disease. It 

identifies foreign substances in the body (e.g., 

bacteria, viruses, fungi, parasites) and develops 

a defense against them known as the immune 

response. It produces protein molecules called 

antibodies to eliminate foreign organisms that 

invade the body. 

immunity—Protection against a disease. 

There are two types of immunity: passive and 

active. Immunity is indicated by the presence 

of antibodies in the blood and can usually be 

determined with a laboratory test. 

immunization—The process by which a 

person or animal becomes protected against a 

disease.

immunoglobulin—Proteins found in the 

blood that function as antibodies that fight 

infection. 

infection—An invasion of an organism by 

a pathogen such as bacteria or viruses. Some 

infections lead to disease.

infectious—Capable of spreading disease. 

Also called communicable.

interferon—A group of proteins produced 

naturally by the cells of human bodies; interferon increases the resistance of surrounding 

cells to attacks by viruses. 

jaundice—Yellow color in the skin, the 

mucous membranes, and the eyes. 

lamivudine—A U.S. Food and Drug 

Administration-approved antiviral medication 

for treating chronic hepatitis B, taken orally. 

liver enzyme—A protein that catalyzes 

chemical reactions needed for body functions. 

Levels of certain enzymes, such as alanine 

aminotransferase and aspartate aminotransferase, are higher when the liver is injured, as 

they leak into the bloodstream when the cell is 

inflamed, injured, or destroyed.

liver panel—Common blood tests that are 

used to evaluate liver function. Also called 

liver function tests. 

medication-assisted treatment (MAT)—

Treatment for substance use disorders 

that uses medications such as methadone, 

buprenorphine, or naltrexone. 

neutropenia—Low count of a type of white 

blood cell. Neutropenia has several causes 

including side effects of medications, viral 

infections, and autoimmune diseases. 

pulmonary disease—A disease of the lungs.

ribavirin—A U.S. Food and Drug 

Administration-approved antiviral medication 

that improves the effectiveness of interferon in 

treating chronic hepatitis C, taken orally. 

ribonucleic acid (RNA)—Chemical found in 

the nucleus and cytoplasm of cells; plays an 

important role in protein synthesis and other 

chemical activities of the cell. 

sustained virologic response (SVR)—

Achieving and sustaining a virus negative state 

for 6 months or longer after completing treatment for a virus, such as hepatitis C. 
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Addressing Viral Hepatitis in People With Substance Use Disorders

telaprevir—A U.S. Food and Drug 

Administration-approved medication for 

treating chronic hepatitis C, taken orally.

telbivudine—A U.S. Food and Drug 

Administration-approved medication for 

treating hepatitis B, taken orally.

tenofovir—A U.S. Food and Drug 

Administration-approved medication for 

treating hepatitis B, taken orally.

transmission—An incident in which an 

infectious agent is passed from one person to 

another.

viral load—Measurement of the amount of 

virus in the bloodstream. 

virologic relapse—A return of the hepatitis C 

virus after antiviral treatment.

virus—An organism that multiplies within 

cells and causes diseases such as chickenpox, 

measles, mumps, rubella, pertussis, and hepatitis. It is not affected by antibiotics, the medications used to kill bacteria.
91

Appendix C—Hepatitis 

Resources

Organization Contact Information Topics Covered

American Association 

for the Study of Liver 

Diseases

http://www.aasld.org/

Pages/Default.aspx

1-703-299-9766

•	Hepatitis A

•	Hepatitis B

•	Hepatitis C 

•	Biopsy

•	Transplantation (members 

only)

American Liver 

Foundation

http://www.liverfoundation.

org

1-800-405-4837

•	Hepatitis A

•	Hepatitis B

•	Hepatitis C

•	Support groups 

•	Information for special 

populations

•	Patient education materials 

•	Resources in English and 

other languages

Centers for Disease 

Control and Prevention

http://www.cdc.gov/ncidod/

diseases/hepatitis

1-800-232-4636

•	Hepatitis A

•	Hepatitis B

•	Hepatitis C

•	Information for special 

populations

•	Patient education materials 

•	Resources in English and 

other languages

Department of 

Veterans Affairs

http://www.hepatitis.va.gov •	Hepatitis A

•	Hepatitis B

•	Hepatitis C

•	Biopsy (for medical care 

providers)

•	Transplantation 

•	Information for special 

populations

•	Patient education materials
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Addressing Viral Hepatitis in People With Substance Use Disorders

Organization Contact Information Topics Covered

HCV Advocate http://www.hcvadvocate.org •	Hepatitis B

•	Hepatitis C

•	Biopsy 

•	Support groups

•	Information for special 

populations

•	Patient education materials 

•	Resources in English and other 

languages

Hepatitis B Foundation http://www.hepb.org

1-215-489-4900

•	Hepatitis B

•	Support groups

•	Information for special 

populations

•	Patient education materials 

•	Resources in English and other 

languages 

Hepatitis C Association http://www.hepcassoc.org

1-866-437-4377

•	Hepatitis C

•	Support groups 

•	Information for special 

populations

•	Patient education materials 

Hepatitis C University http://www.hcvu.org/et_patient.php

1-877-428-8123

•	Resources for medical care 

providers

Hepatitis Education 

Project

http://www.hepeducation.org

1-206-732-0311

•	Hepatitis A

•	Hepatitis B

•	Hepatitis C

•	Support groups 

•	Transplantation

•	Information for special 

populations

•	Patient education materials

Hepatitis Foundation 

International

http://www.hepfi.org

1-800-891-0707

•	Hepatitis A

•	Hepatitis B

•	Hepatitis C

•	Support groups 

•	Information for special 

populations

•	Patient education materials 

•	Resources in English and other 

languages
93

Organization Contact Information Topics Covered

HepClinics http://www.hepclinics.com/

templates/hepclinic/index.html

•	Hepatitis A

•	Hepatitis B

•	Information for special 

populations

•	Patient education materials

Immunization Action 

Coalition

http://www.immunize.org

1-651-647-9009

•	Hepatitis A

•	Hepatitis B

•	Information for special 

populations

•	Patient education materials 

•	Resources in English and other 

languages

Indian Health Service http://www.ihs.gov 

1-651-647-9009

•	Hepatitis A

•	Hepatitis B

•	Hepatitis C

•	Information for special 

populations

•	Patient education materials

Massachusetts General 

Hospital

http://www.mgh.harvard.edu/

default.aspx

1-617-726-2000

•	Hepatitis A

•	Hepatitis B

•	Hepatitis C

•	Biopsy

Medline Plus http://www.nlm.nih.gov/medlineplus/

tutorials/hepatitisc/htm/index.htm

•	Hepatitis C

Methadone Anonymous 

Support

http://www.MethadoneSupport.org •	Hepatitis C

•	Support groups (for methadone)

•	Resources in English and other 

languages

National AIDS Treatment 

Advocacy Project

http://www.natap.org

1-888-266-2827

•	Hepatitis B

•	Hepatitis C

•	Transplantation 

•	Patient education materials

National Digestive 

Diseases Information 

Clearinghouse

http://digestive.niddk.nih.gov

1-800-891-5389

•	Hepatitis A

•	Hepatitis B

•	Hepatitis C

•	Biopsy

•	Transplantation

•	Resources in English and other 

languages

Appendix C—Hepatitis Resources
94

Addressing Viral Hepatitis in People With Substance Use Disorders

Organization Contact Information Topics Covered

National Foundation for 

Transplants

http://www.transplants.org

1-800-489-3863

•	Transplantation

•	Resources in English and other 

languages

National Hepatitis C 

Advocacy Council

http://www.hepcnetwork.org •	Hepatitis C

•	Resources in English and other 

languages

National Transplant 

Assistance Fund

http://www.ntafund.org

1-800-642-8399

•	Transplantation

•	Resources in English and other 

languages

New York State Office 

of Alcoholism and 

Substance Abuse 

Services

http://www.oasas.state.ny.us/

admed/documents/HEPATITIS.pdf

•	Hepatitis A

•	Hepatitis B

•	Hepatitis C

StopHep.Com http://www.stophep.com/StopHep •	Hepatitis A

•	Hepatitis B

•	Hepatitis C

•	Patient education materials

•	Special populations

Transplant Recipients 

International 

Organization

http://www.trioweb.org

1-800-874-6386

•	Support services

•	Transplantation
95

Appendix D—Managing 

Side Effects of Hepatitis C 

Antiviral Treatment

Side Effect Potential Management Strategy

Bad taste in mouth •	Try sugar-free lemon drops or lemon wedges.

•	Eat a small amount of yogurt 1⁄2 hour before meals.

•	Eat dark chocolate or drink lemonade or cranberry 

juice.

•	Eat food cold or at room temperature.

•	Brush teeth frequently. 

•	Use plastic utensils if experiencing metallic taste.

Cough •	Increase fluid intake (noncaffeinated).

•	Use a humidifier. 

•	Try sugar-free hard candy or cough drops.

Diarrhea •	Eat more fiber foods like bananas, white rice, 

applesauce, and white toast (the BRAT diet).

•	Avoid spicy or acidic foods (like citrus) and dairy 

products for several days after diarrhea resolves.

•	Drink plenty of fluids (six to eight 8-oz glasses/day).

Dry mouth or mouth ulcers •	Brush teeth frequently, especially after eating.

•	Avoid mouthwash containing alcohol.

•	Drink plenty of water or use ice chips or sugar-free 

lemon drops.

•	Ask medical care provider about medications for 

mouth sores/ulcers. 

Dry skin/rashes •	Avoid long, hot showers or baths.

•	Use moisturizing soap and lotions, sunscreen, and 

mild unscented laundry detergents.

•	Avoid fabric softeners.

•	Rub or press on the itchy areas rather than scratch 

them. 

•	Use petroleum jelly on affected areas and ask 

medical care provider about other solutions.

Fatigue •	Try low-impact exercise such as walking or lowimpact aerobics, if approved by medical care 

provider.

•	Drink plenty of fluids and get plenty of rest. 

•	Lessen work schedule if possible.

•	Eat well-balanced meals every day.
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Addressing Viral Hepatitis in People With Substance Use Disorders

Side Effect Potential Management Strategy

Fever/Chills •	Notify medical care provider if the temperature is above 101oF for 

more than 24 hours.

•	Inject interferon at bedtime. 

•	Take acetaminophen 30–60 minutes before weekly interferon 

injection and repeat 4–6 hours later, if approved by medical care 

provider. 

•	Use ibuprofen or naproxen, if approved by medical care provider.

•	Try a cool sponge bath, ice pack, or cold pack.

•	Use extra blankets and clothes. 

Hair thinning or hair loss •	Avoid harsh hair products such as dyes, perms, gels, sprays, and 

mousses.

•	Use mild shampoo such as baby shampoo.

•	Avoid braiding hair.

•	Use a wide-tooth comb or soft brush.

Headaches •	Drink plenty of fluids and get plenty of rest. 

•	Try taking acetaminophen or ibuprofen, if approved by medical care 

provider. 

•	Keep lights dim, wear sunglasses, or stay in darkened rooms.

Injection site reactions •	Warm the vial by gently rolling it in between two hands for a minute 

before injecting.

•	Rotate injection sites—thigh, upper arm, and abdomen.

•	Do not inject into an area that is irritated, bruised, or red.

•	Do not rub injection site. 

•	Apply a cold pack.

•	Apply hydrocortisone cream or other medications, if approved by 

medical care provider. 

Insomnia •	Go to bed and get up at the same times every day.

•	Do not read or watch TV in bed.

•	Limit daytime naps.

•	Take ribavirin in the late afternoon instead of before bedtime, if it 

causes the jitters.

•	Limit fluid intake for 2 hours before bedtime to avoid getting up to 

go to the bathroom.

•	Avoid caffeinated products, especially in the afternoon and at night. 

•	Avoid heavy meals close to bedtime.

•	Take warm baths, read or listen to music, get a massage.

•	Drink a glass of warm milk (contains tryptophan, a natural sleep 

agent).

•	Take diphenhydramine (Benadryl) or other medications 

recommended by medical care provider.
97

Side Effect Potential Management Strategy

Muscle and body aches •	Try low-impact exercise such as walking or low-impact aerobics, if 

approved by medical care provider.

•	Drink plenty of fluids, at least six to eight noncaffeinated 8-oz 

glasses/day.

•	Apply warm moist heat or massage affected areas.

Nausea and vomiting •	Take ribavirin with food. 

•	Eat small meals.

•	Avoid foods or smells that trigger nausea; eat cold foods and avoid 

cooking smells.

•	Eat healthful foods; avoid greasy, spicy, acidic, or sweet foods.

•	Try ginger tea, ginger ale, or gingersnaps.

•	Eat crackers or dry white toast for morning nausea.

Poor appetite •	Eat small, more frequent (4–6) meals throughout the day. 

•	Try protein drinks and snacks (cheese, peanut butter, eggs).

•	Eat whatever appeals to you even if not hungry; eat a variety of 

foods.

•	Walk before a meal.

Source: National Hepatitis C Program, U.S. Department of Veterans Affairs, 

http://www.hepatitis.va.gov/pdf/treatment-side-effects.pdf

Appendix D—Managing Side Effects of Hepatitis C Antiviral Treatment

99

Appendix E—Medicinal 

Plants/Alternative Treatments 

Potentially Harmful to People 

Who Have Hepatitis

Clients who have hepatitis should check with their medical care providers before 

taking nutritional supplements or alternative treatments. The substances listed 

below might harm the liver. 

Artemisia (mugwort, sagebrush, wormwood)

Aspalathus linearis (bush tea)

Atractylis gummifera (pine thistle)

Callilepis laureola 

Crotalaria

Ephedra sinica (ma huang)

Gnaphalium (Gordolobo herbal tea)

Hedeoma (pennyroyal, squaw mint oil)

Heliotropium

Iron supplements

Kombucha mushroom tea

Larrea tridentata (chaparral leaf, creosote bush, greasewood)

Margosa oil

Mate (Paraguay) tea

Myristica (nutmeg)

Piper methysticum (kava)

Sassafras

Scutellaria lateriflora (skullcap)
100

Addressing Viral Hepatitis in People With Substance Use Disorders

Senecio aureus

Senecio jacobaea (tansy ragwort, variation of ragwort)

Senna

Symphytum officinale (comfrey)

Valeriana officinalis (valerian root)

Viscum album (mistletoe)

Vitamin A supplements

Yerba tea

Source: Alternative and Complementary Therapies, U.S. Department of Veterans Affairs, http://www.hepatitis.va.gov/

patient/alternative-therapies/index.asp
101

Appendix F—Mental Health 

Treatment Considerations for 

People Who Have Chronic 

Viral Hepatitis C

Mental illness and hepatitis frequently co-occur (Rosenberg et al., 2001; 

Rosenberg et al., 2003). People who have mental illness are at greater risk than 

the general public for exposure to infectious diseases, including chronic hepatitis 

(Rosenberg et al., 2001). For instance, in a study of veterans with hepatitis C, 

Fireman, Indest, Blackwell, Whitehead, and Hauser (2005) found that 93 percent 

of subjects had one or more psychiatric or substance use disorders at the time of 

or before the study. 

Behavioral health conditions are not absolute contraindications for chronic hepatitis 

treatment. As healthcare providers increasingly consider treating hepatitis in 

patients with mental disorders, they might turn to behavioral health providers 

to assess their patients for readiness for antiviral treatment. In addition, behavioral health treatment providers might have clients who have chronic hepatitis 

and who require support through the lengthy and challenging hepatitis treatment 

process.

Behavioral Health Counseling 

Goldsmith and Hauser (2003) advocate the participation of an informed 

behavioral health treatment provider in a client’s antiviral treatment for chronic 

hepatitis. They assert that, to provide effective support in the treatment process, 

behavioral health treatment providers need to know: 

•	 The natural history of hepatitis C virus infection (see Chapter 1 in this 

Treatment Improvement Protocol [TIP]).

•	 Standard treatment for chronic hepatitis (Chapter 5).

•	 Common adverse effects of treatment (Chapter 5).

•	 How to manage side effects of treatment (Appendix D).

•	 How to work with high-risk populations (Chapters 4, 5, and 6).

•	 How to manage (particularly with psychotropic medications) a client’s mood 

and cognitive changes that might result from antiviral treatment (see below).

Behavioral health treatment providers can partner with healthcare providers to 

help patients with chronic hepatitis get evaluated for treatment (see Chapter 3) 

and adhere to treatment (Chapter 6). Psychiatrists are especially well suited 

to monitor patients being treated for hepatitis for psychiatric side effects of 

treatment (Straits-Tröster, Sloan, & Dominitz, 2003). 
102

Addressing Viral Hepatitis in People With Substance Use Disorders

Issues Clients Who Have Chronic 

Hepatitis B or C Might Bring to 

Counseling

Treatment for chronic hepatitis is challenging 

for most people. Behavioral health treatment 

providers might have clients who need assistance with making psychological adjustments 

to having a chronic disease (e.g., coping with 

a chronic disease, learning about hepatitis, 

making healthful lifestyle changes) and making decisions related to having hepatitis (e.g., 

whether/how to disclose the condition to others, deciding on whether to undertake antiviral 

therapy, adhering to the treatment regimen). 

Helping clients make medical decisions about 

hepatitis treatment is the subject of Chapter 4. 

Chapter 6 of this TIP includes the following 

relevant topics: 

•	 Using effective counseling strategies, 

including motivational approaches

•	 Ensuring safety of the counselor 

•	 Providing reliable information about 

hepatitis

•	 Building the therapeutic relationship 

•	 Helping clients understand their 

diagnoses 

•	 Incorporating client needs in substance 

abuse treatment planning 

•	 Developing a plan to prevent infecting 

others and to prevent further liver damage

•	 Using motivational approaches

•	 Confronting the social ramifications of 

disclosing hepatitis status

•	 Addressing relapse 

•	 Building support systems 

•	 Providing effective case management 

Patients with baseline depression, anxiety, 

bipolar disorder, post-traumatic stress disorder 

(PTSD), or other behavioral health conditions might face additional challenges that 

come with the neuropsychiatric side effects of 

hepatitis treatment, such as worsening of their 

symptoms, or relapse. Therefore, the issue of 

readiness for treatment is particularly relevant 

for mental health care professionals.

Readiness for Treatment

Many clients who have mental illnesses do 

not receive hepatitis pharmacotherapy because 

they are not prepared (in their view or in a 

care provider’s view) to successfully complete 

the regimen. For example, some healthcare 

providers might defer treatment until an 

individual’s mental illness, such as depression, 

can be stabilized. Individuals might choose to 

defer treatment until they are in stable housing or until they have built strong support 

networks. 

Little information is available on how frequently 

clients receive a second referral for chronic 

hepatitis treatment if they are initially deferred 

but later become eligible for treatment. One 

study reported that none of the 306 patients 

who deferred had a second referral for treatment (Yawn, Wollan, Gazzuola, & Kim, 2002). 

A more recent study reported that of 111 

patients deferred for psychiatric issues (including psychiatric instability and suicidal ideation), 53 percent received a followup referral, 

of which only 18 percent (20 individuals) were 

ultimately treated (Evon et al., 2007). These 

rates suggest that, if treatment for hepatitis is 

deferred at the initial assessment, few clients 

have opportunities to receive treatment after 

they become eligible. 

In addition, although some clients might have 

healthcare providers who defer hepatitis treatment because of the client’s behavioral health 

issues, some data suggest that some individuals 

do not follow through with steps necessary 

to get treatment (Butt, Wagener, Shakil, & 

Ahmad, 2005). 
103

Behavioral health treatment providers can 

help clients who are currently ineligible for 

hepatitis treatment become eligible. For example, they can motivate clients to attend medical appointments. Helping a client become 

ready for treatment can take several months 

(Scheft & Fontenette, 2005). Behavioral 

health treatment providers can work with a 

client’s healthcare provider and advocate a 

referral for hepatitis treatment when clients 

are ready.

An expanded psychiatric evaluation can 

enhance the assessment of client readiness 

for hepatitis treatment (Scheft & Fontenette, 

2005; Silberbogen, Mori, & Sogg, 2005). 

Silberbogen et al. (2005) developed a structured interview to help determine a client’s 

readiness for treatment. Facets of the structured 

interview include the following:

•	 Hepatitis C history

•	 Social support network

•	 Understanding of chronic hepatitis C 

and its treatment

•	 History of motivation and adherence 

to treatment

•	 Psychiatric history

•	 Mental status exam

Tools that might assist the psychiatric assessment include the following:

•	 Beck Anxiety Inventory 

•	 Beck Depression Inventory 

•	 Bipolar Spectrum Diagnostic Scale

•	 Brief Psychiatric Rating Scale 

•	 Center for Epidemiologic Studies 

Depression Scale

•	 Geriatric Depression Scale

•	 Major Depression Inventory 

•	 Mood Disorders Questionnaire

•	 Montgomery Asberg Depression Rating 

Scale

•	 Post-Traumatic Stress Disorder Checklist 

(civilian version) 

•	 Quick Inventory of Depressive Symptoms 

•	 State-Trait Anxiety Inventory 

•	 Young Mania Rating Scale

•	 Zung Self-Rating Depression Scale

An important part of the expanded assessment 

is screening for substance use disorders. Tools 

to assess substance use disorders include the 

following:

•	 Alcohol, Smoking, and Substance 

Involvement Screening Test (ASSIST)

•	 Alcohol Use Disorders Identification Test 

(AUDIT)

•	 Alcohol Use Disorders Identification 

Test—Consumption (AUDIT-C)

•	 CAGE Adapted to Include Drugs 

(CAGE-AID)

•	 Drug Abuse Screening Test 

•	 Michigan Alcoholism Screening Test 

(MAST) (MAST-G for older adults)

•	 Patient Health Questionnaire (PHQ9)

Pharmacological approaches (see the section 

on Medications for People Who Have 

Behavioral Health Disorders, below) and 

nonpharmacological approaches (see Chapter 

6) might be beneficial for helping the client 

become ready for treatment of hepatitis.

Effects of Antiviral Treatment for 

Chronic Hepatitis on Behavioral 

Health

People who never had problems with anxiety, 

depression, or irritability might experience 

these as a result of treatment for chronic 

hepatitis, and stable patients with previous mental health problems might have 

Appendix F—Mental Health Treatment Considerations for People Who Have Chronic Viral Hepatitis C
104

Addressing Viral Hepatitis in People With Substance Use Disorders

exacerbations. Some early symptoms of 

treatment-related depression might also 

mimic opioid withdrawal. This can complicate 

clinical management for the large subset of 

patients with chronic hepatitis C who have a 

history of opioid injection drug use (Schaefer 

& Mauss, 2008).

In a review article by Robaeys and Buntinx 

(2005), neurobehavioral changes leading to 

depression often begin by the eighth week 

of antiviral therapy, which coincides with the 

peak time for quitting medication treatment. 

Addressing mental health symptoms is 

important to antiviral treatment success 

because close adherence to and completion 

of multiple-week therapy are required for 

achieving treatment success (Sylvestre & 

Clements, 2007). 

Clients with mental illness who decide to 

undergo treatment for chronic hepatitis 

will require regular psychiatric monitoring. 

In addition, treatment adherence might be 

enhanced with the following supports: 

•	 Psychosocial interventions 

•	 Medication, therapy, or both to manage 

anger, anxiety, irritability, depression, or 

other side effects of interferon treatment 

•	 Support groups to combat social isolation 

and discrimination resulting from a 

hepatitis diagnosis 

•	 Support to prevent relapse to substance 

use

•	 Motivational therapy to inspire changes 

in daily life that support antiviral 

treatment 

•	 Education on how to prevent transmission of the hepatitis C virus

For patients with risk factors for depression 

(e.g., personal or family history of depression, 

suicide attempts, alcohol abuse, poor sleep 

quality) preemptive treatment with selective 

serotonin reuptake inhibitors (SSRIs) has been 

used as a prevention strategy (Schaefer & 

Mauss, 2008). Concurrent use of interpersonal 

psychotherapy, behavioral psychotherapies, 

and psychosocial support might also be beneficial to these clients (American Psychiatric 

Association, 2010; Wilson, Castillo, & Batey, 

2010). 

Preexisting psychiatric medication regimens 

might need modification during hepatitis 

treatment. For example, a patient with bipolar 

disorder who takes valproic acid might need 

to change to a mood stabilizing medication 

that is less toxic to the liver while on antiviral 

therapy. A patient who was previously stable 

on an SSRI might need an increased dosage or 

a medication change. Psychiatric medications 

and care might need to continue for at least 6 

to 12 weeks after antiviral treatment is completed because mood disorders, neurocognitive 

changes, and other psychological problems 

might persist (Schaefer & Mauss, 2008). 

With pretreatment screening to determine 

need for medication, continuous monitoring, and individualized treatment, patients 

with preexisting or emerging mental health 

problems might be able to mitigate the 

adverse IFN-alpha psychiatric side effects, 

complete treatment, and achieve sustained 

viral response. These positive outcomes have 

been reported with collaborative care provided 

by multidisciplinary management teams that 

include healthcare providers, psychologists, 

psychiatrists, addiction specialists, and other 

behavioral health workers (Belfiori et al., 2009; 

Guadagnino et al., 2007; Schaefer et al., 2003; 

Sylvestre & Clements, 2007). 
105

Medications for People Who Have 

Behavioral Health Disorders

Affective Disorders

Depression is common among patients who 

require antiviral treatment of chronic hepatitis C (Schaefer & Mauss, 2008). Others can 

develop major depression during the course 

of antiviral treatment. The medications most 

commonly prescribed for depression include 

SSRIs (e.g., fluoxetine, citalopram, sertraline, 

paroxetine, escitalopram), serotonin and norephedrine reuptake inhibitors (e.g., duloxetine, 

venlafaxine), and the chemically unique bupropion. Older antidepressant medications (e.g., 

monoamine oxidase inhibitors, tricyclics) are 

less often prescribed because they have more 

side effects and drug interactions (National 

Institute of Mental Health [NIMH], 2008). 

Depression screening scales that rely on 

patient self-reporting can be used, but the 

Diagnostic and Statistical Manual of Mental 

Disorders (DSM-IV-TR) criteria (APA, 2000) 

and clinical evaluation are essential to guide 

treatment decisions. 

Bipolar disorder is another affective disorder 

in which patients cycle through alternating 

episodes of depression and mania. Patients 

are treated with mood stabilizers (e.g., 

carbamazepine, lamotrigine, lithium, oxcarbazepine, valproic acid). Antidepressants are 

sometimes added to mood stabilizers to treat 

symptoms of depression in bipolar disorder, 

but these medications need to be used with 

great care because of the risk of exacerbating 

manic symptoms and/or inducing suicidality 

(NIMH, 2008). Atypical antipsychotics (e.g., 

aripiprazole, clozaril, olanzapine, risperidone, 

ziprasidone) are sometimes added to treat 

depression or bipolar disorder. 

Anxiety Disorders

Anxiety disorders include obsessive-compulsive disorder, PTSD, generalized anxiety 

disorder, panic disorder, social phobia, and 

others (APA, 2000). When patients undergoing treatment for chronic hepatitis exhibit 

symptoms related to anxiety disorders, it is 

important to determine whether symptoms are 

related to the psychological demands of coping with a chronic disease, whether they are 

due to the rigors of treatment, or whether they 

are an exacerbation of a preexisting condition 

so that appropriate pharmacological and nonpharmacological treatments can be arranged. 

Cognitive behavioral therapy is frequently 

used for the treatment of anxiety disorders and 

can improve symptoms significantly within a 

short timeframe. Other nonpharmacological 

treatments include group therapy, systematic 

desensitization, acupuncture, and biofeedback. 

Suicidality 

Suicide is the worst outcome of major depressive disorder, and treatment of modifiable risk 

factors (anxiety, insomnia, agitation, psychotic 

symptoms, and substance abuse) are recommended in addition to treating the depressive 

episode (APA, 2010). 

Some of the medications that are used to treat 

depression and bipolar disorder might increase 

the risk of suicidal thoughts and behaviors 

(U.S. Food and Drug Administration, 2009). 

All clients should be screened for risk of suicide. People at risk for suicide should be closely monitored for new or worsening symptoms 

of depression, suicidal thoughts or behaviors, 

or unusual changes in mood or behavior 

(NIMH, 2008). More information can be 

found in TIP 50: Addressing Suicidal Thoughts 

and Behaviors in Substance Abuse Treatment

Appendix F—Mental Health Treatment Considerations for People Who Have Chronic Viral Hepatitis C
106

Addressing Viral Hepatitis in People With Substance Use Disorders

(Center for Substance Abuse Treatment, 

2009b). Other materials are available at the 

National Suicide Prevention Lifeline (http://

www.suicidepreventionlifeline.org). 

Treating Patients With Hepatitis C 

and Serious Mental Illness 

Adults with a serious mental illness (SMI) 

are people ages 18 and older who, at any time 

during a given year, have a diagnosable mental, 

behavioral, or emotional disorder that meets 

the criteria of DSM-IV-TR (APA, 2000) and 

that results in functional impairment which 

substantially interferes with or limits one or 

more major life activities (Substance Abuse 

and Mental Health Services Administration 

[SAMHSA], 1999).

Whether SMIs such as psychotic disorders 

and major mood disorders should be contraindications to undergoing antiviral therapy 

for hepatitis C is controversial. The American 

Psychiatric Association (APA, 2010) states 

that SMIs are not necessarily contraindications to antiviral treatment. Psychotic symptoms (hallucinations and delusions) make 

effective coping with a chronic infectious 

disease difficult, increase patient risk of suicide, and might make adherence with complex 

antiviral regimens impossible. Patients with 

psychotic symptoms frequently need antipsychotic medications (e.g., aripiprazole, chlorpromazine, clozaril, fluphenazine, haloperidol, 

olanzapine, paliperidone, perphenazine, quetiapine, risperidone, ziprasidone) alone or in 

combination with other medications (NIMH, 

2008). These complex psychiatric medication 

treatment regimens can be difficult to manage during antiviral treatment. Patients with 

depression frequently experience increased 

depressive symptoms during antiviral treatment (Ghany et al., 2009). This increase in 

symptoms has not been reported for patients 

with schizophrenia (Huckans, Mitchell, & 

Pavawalla 2010); however, this has not been 

well studied.

Antiviral therapy can be successful for chronic 

hepatitis C patients with SMIs but often 

requires expert psychiatric management and 

close monitoring by clinical staff. Intensive 

case management by a behavioral health case 

manager might be needed to support treatment adherence, make and monitor treatment 

appointments, and assist with housing, food, 

and employment needs. More frequent physician appointments might be needed for 

laboratory monitoring of liver function and 

to detect any dangerous medication interactions. The decision to treat needs to consider 

the social support network and the availability of social services, as well as the patient’s 

abilities. 

Drug Interactions 

A combined medication regimen consisting 

of pegylated interferon and ribavirin is the 

standard of care for chronic hepatitis C 

(Ghany et al., 2009). Both antiviral drugs 

have side effects and potential toxicities, but 

they have few specific interactions with medications used to treat behavioral health disorders (see Exhibit F-1). Interferon has no clinically significant interactions with methadone 

used to treat opioid addiction; however, its 

potential interaction with buprenorphine has 

not been adequately studied to identify such 

interactions. Ribavirin’s potential interactions 

with methadone or buprenorphine have also 

not been studied indepth and are unknown 

(McCance-Katz, Sullivan, & Nallani, 2009). 

Ribavirin does not interact adversely with any 

medications listed in Exhibit F-1. The patient 

should be monitored closely for any adverse 

effects or drug interactions when receiving 

medications that are metabolized by the liver. 
107

Appendix F—Mental Health Treatment Considerations for People Who Have Chronic Viral Hepatitis C

Exhibit F-1 Potential Interactions Among Medications Used to Treat Chronic 

Hepatitis and Behavioral Health Conditions

Prescription 

Medication

Indication Potential Interaction With Hepatitis 

Medications

Alprazolam Anxiety The use of telaprevir with alprazolam increases 

exposure to alprazolam. Clinical monitoring for dose 

adjustment is recommended. 

The use of boceprevir could result in increased 

sedation or respiratory depression when used with 

alprazolam. A lower dose of alprazolam should be 

considered.

Buprenorphine Opioid dependence The use of boceprevir could result in an increase 

or decrease in buprenorphine levels. However, 

the combination of buprenorphine and boceprevir 

has not been studied. Clinical monitoring for dose 

adjustment is recommended.

Bupropion Depression; nicotine 

dependence

The use of bupropion is associated with an increased 

risk of seizures. Use of interferon and bupropion 

together might increase seizure risk as well.

Clozapine Schizophrenia; 

psychosis

Clozapine might cause marrow disorders, neuroleptic 

malignant syndrome, and increased seizure risk. 

When taken with interferon, the risks of these might 

increase.

Desipramine Depression The use of telaprevir or boceprevir could result in an 

increase in desipramine concentration, which might 

lead to adverse events (e.g., nausea, dizziness). 

The combination of telaprevir or boceprevir and 

desipramine should be used with caution and a lower 

dose of desipramine should be considered.

Disulfiram Alcohol use disorders Disulfiram might cause or worsen hepatitis. When 

taken with interferon alpha 2a, there is increased risk 

of peripheral neuropathy.

Escitalopram Depression The use of telaprevir can result in decreased 

escitalopram concentration. Clinical monitoring for 

dose adjustment is recommended.

Methadone Opioid dependence The use of telaprevir is associated with decreased 

methadone concentration. Clinical monitoring for 

dose adjustment is recommended. 

The use of boceprevir could result in an increase 

or decrease in methadone levels. However, the 

combination of methadone and boceprevir has not 

been studied. Clinical monitoring for dose adjustment 

is recommended.
108

Addressing Viral Hepatitis in People With Substance Use Disorders

Exhibit F-1 Potential Interactions Among Medications Used to Treat Chronic 

Hepatitis and Behavioral Health Conditions (continued)

Prescription 

Medication

Indication Potential Interaction With Hepatitis 

Medications

Midazolam Anxiety Telaprevir is contraindicated with oral midazolam. 

The interaction could result in increased sedation or 

respiratory depression.

The use of boceprevir could result in increased 

sedation or respiratory depression when used with 

intravenous midazolam. A lower dose of intravenous 

midazolam should be considered. 

Naltrexone Opioid and alcohol 

use disorders

When taken with interferon alpha 2a, naltrexone 

might exacerbate liver damage.

Trazodone Depression The use of telaprevir or boceprevir can result in an 

increase in trazodone concentration, which might 

lead to adverse events (e.g., nausea, dizziness). 

The combination of telaprevir or boceprevir and 

trazodone should be used with caution and a lower 

dose of trazodone should be considered.

Triazolam Insomnia Telaprevir and boceprevir are contraindicated with 

triazolam. The interaction could result in increased 

sedation or respiratory depression.

Zolpidem Insomnia The use of telaprevir can result in decreased 

zolpidem concentration. Clinical monitoring and dose 

adjustment of zolpidem is recommended to achieve 

the desired response.

Sources: Physicians’ Desk Reference 2010 (64th ed.), 2009; U.S. Food and Drug Administration, 2011c and 2011d.
109

Appendix G—Motivational 

Interviewing and Counseling 

Resources

•	 Case Management Adherence Guidelines, Version 2.0 (Case Management 

Society of America, 2006), http://www.cmsa.org/portals/0/pdf/CMAG2.pdf 

•	 Enhancing Motivation for Change in Substance Abuse Treatment (Center for 

Substance Abuse Treatment [CSAT], 1999), http://www.ncbi.nlm.nih.gov/

bookshelf/br.fcgi?book=hssamhsatip&part=A61302 

•	 Enhancing Motivation for Change Inservice Training (CSAT, 2006), http://

www.kap.samhsa.gov/products/manuals/tip35c/index.htm 

•	 Group Treatment for Substance Abuse: A Stages-of-Change Therapy Manual. M. 

Velasquez, G. Maurer, C. Crouch, & C. DiClemente. New York: Guilford 

Press, 2001

•	 Motivational Groups for Community Substance Abuse Programs. K. Ingersoll, 

C. Wagner, & S. Gharib. Kansas City: Addiction Technology Transfer 

Center Network, 2000

•	 Motivational Interviewing: Preparing People for Change, 2nd ed. W. Miller & 

S. Rollnick. New York: Guilford Press, 2002

•	 The Motivational Interviewing Web Page, http://www.motivationalinterview.org 

111

Appendix H—Sources for 

Financial Assistance

•	 A source for identifying government sources of healthcare and support benefit programs by State. (http://www.benefits.gov/)

•	 Low-income clients might be eligible for Medicaid, but benefits vary significantly across States. (http://cms.hhs.gov) 

•	 Federally funded health centers provide medical services to people who are 

uninsured and underinsured. (1-800-ASK-HRSA [1-800-275-4772]).

•	 The Veterans Healthcare System offers hepatitis C virus screening, treatment, and support services to eligible U.S. veterans. 

(http://www.hepatitis.va.gov)

•	 The Ryan White CARE Act provides medications to eligible low-income 

U.S. residents who have HIV, including those co-infected with hepatitis. 

(http://hab.hrsa.gov)

•	 Needymeds.org is a consumer site providing sources on pharmaceutical, 

State, Medicare, and Medicaid financial support for the treatment of serious 

diseases, including hepatitis. 

(http://www.needymeds.org/) 

•	 Partnership for Prescription Assistance is a pharmaceutical-companysponsored resource that offers low- or no-cost medication to people who 

lack prescription drug coverage. 

(http://www.pparx.org)

•	 National Foundation for Transplants helps individuals find financial support for transplantation operations. 

(http://www.transplants.org)

•	 National Transplant Assistance Fund raises funds for uninsured medical 

expenses related to transplantation. 

(http://www.transplantfund.org)

•	 Hepatitis clinical trials are available to a limited number of people. 

(http://clinicaltrials.gov/ct2/results?term=hepatitis)

113

Appendix I—Hepatitis C 

Training Programs for 

Substance Abuse Treatment 

Program Staff

Focus on Hepatitis C was developed by the Hepatitis C Association, sponsored 

by the Substance Abuse and Mental Health Services Administration. The 3-hour 

training includes a PowerPoint presentation, a question-and-answer session, and 

a discussion of local resources. Content includes functions of the liver, risk factors, 

modes of transmission, diagnostic process and treatment of HCV, natural history 

and progression of HCV and HCV/HIV co-infection, healthful lifestyle choices 

that preserve liver health, counseling guidelines, and issues and challenges in 

providing care for clients with hepatitis C in treatment centers. Training provides 

information on locating community resources; Web sites, toll-free support lines, 

and venues for medical care; and information on obtaining treatment assistance 

for people who are not insured or are underinsured. Continuing education credits 

can be earned (http://www.hepcfocus.com).

•	 The Centers for Disease Control and Prevention (CDC) maintains 

numerous trainings and resources (http://www.cdc.gov/ncidod/diseases/

hepatitis/resource/training/counseling.htm).

•	 HCV Advocate offers training resources and information from the client’s 

perspective (http://www.hcvadvocate.org/hepatitis/training_resources.asp).

•	 CDC’s Division of Viral Hepatitis provides funding to HCV coordinators 

across the country to offer viral hepatitis counseling, testing, vaccinations, 

and other services (http://www.cdc.gov/hepatitis/index.htm). 

•	 Pharmaceutical manufacturers of hepatitis medications are often willing to 

conduct free onsite training sessions for counseling staff. Contact manufacturers 

directly.

115

Appendix J—Stakeholders 

Meeting Participants

Cheryl Anderson

Bureau of Primary Health Care 

Quality Improvement

Health Resources and Services 

Administration

Rockville, Maryland

Joanna Buffington, M.D., M.P.H.

Medical Officer

Prevention Branch, Division of Viral 

Hepatitis

Centers for Disease Control and 

Prevention

Atlanta, Georgia

H. Westley Clark, M.D., J.D., 

M.P.H., CAS, FASAM

Director

Center for Substance Abuse Treatment

Substance Abuse and Mental Health 

Services Administration

Rockville, Maryland

Edwin M. Craft, Dr.P.H.

Lead Government Project Officer, 

Methamphetamine

Center for Substance Abuse Treatment

Substance Abuse and Mental Health 

Services Administration

Rockville, Maryland

Christina Currier

Government Project Officer

Center for Substance Abuse Treatment

Substance Abuse and Mental Health 

Services Administration

Rockville, Maryland

David A. Fiellin, M.D., Chair

Professor of Medicine and of Public 

Health and Associate Professor of 

Investigative Medicine

Yale University School of Medicine

New Haven, Connecticut

Robert Hendricks

Special Assistant to the Director

Center for Substance Abuse Treatment

Substance Abuse and Mental Health 

Services Administration

Rockville, Maryland

Warren Hewett, Jr.

AIDS Coordinator

Center for Substance Abuse Treatment

Substance Abuse and Mental Health 

Services Administration

Rockville, Maryland
116

Addressing Viral Hepatitis in People With Substance Use Disorders

Kirk E. James, M.D.

Medical Officer

Systems Improvement Branch

Center for Substance Abuse Treatment

Substance Abuse and Mental Health Services 

Administration

Rockville, Maryland 

Leslye D. Johnson, Ph.D.

Chief, Enteric and Hepatic Diseases Branch

Division of Microbiology and Infectious 

Diseases

National Institute of Allergy and Infectious 

Diseases

National Institutes of Health

Bethesda, Maryland

Stella P. Jones, M.S.W., LICSW, BCD

Senior Program Management Officer

Center for Substance Abuse Treatment

Substance Abuse and Mental Health Services 

Administration

Rockville, Maryland

Jag H. Khalsa, Ph.D.

Chief, Medical Consequences Branch, DPMC

National Institute on Drug Abuse

National Institutes of Health

Bethesda, Maryland

Andrea Kopstein, Ph.D., M.P.H.

Practice Improvement Branch Chief

Division of Services Improvement

Center for Substance Abuse Treatment

Substance Abuse and Mental Health Services 

Administration

Rockville, Maryland

Thomas F. Kresina, Ph.D.

Senior Public Health Advisor

Division of Pharmacologic Therapies 

Center for Substance Abuse Treatment

Substance Abuse and Mental Health Services 

Administration

Rockville, Maryland

Robert Lubran, M.S., M.P.A. 

Director 

Division of Pharmacologic Therapies 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services 

Administration

Rockville, Maryland

Eileen M. McGrath, J.D.

Executive Vice President

American Society of Addiction Medicine

Chevy Chase, Maryland

Shirley Mikell

NAADAC—The Association for Addiction 

Professionals

Alexandria, Virginia

Daniel Raymond

Policy Director

Harm Reduction Coalition

New York, New York

Leonard B. Seeff, M.D.

Senior Scientist for Hepatitis Research

National Institute of Diabetes and Digestive 

and Kidney Diseases

National Institutes of Health

Bethesda, Maryland

Dennis Simon

Secretary/Treasurer

Hepatitis C Association

Scotch Plains, New Jersey
117

Appendix J—Stakeholders Meeting Participants

Jack Stein, M.S.W., Ph.D.

Director

Division of Services Improvement

Center for Substance Abuse Treatment

Substance Abuse and Mental Health Services 

Administration

Rockville, Maryland

Chris Taylor

Viral Hepatitis Program Manager

National Alliance of State and Territorial 

AIDS Directors

Washington, D.C.

Thelma King Thiel, RN

Chair and Chief Executive Officer

Hepatitis Foundation International

Silver Spring, Maryland

David C. Thompson

HIV/AIDS Team Leader

Center for Substance Abuse Treatment

Substance Abuse and Mental Health Services 

Administration

Rockville, Maryland

Mary R. Vienna

Health Resources and Services Administration

Rockville, Maryland

119

Appendix K—Field Reviewers

Corinna Dan, RN, M.P.H.

Hepatitis Foundation International

Silver Spring, Maryland 

Brenda Davis

Clinic Manager

Beth Israel Medical Center

Methadone Maintenance Treatment 

Program

New York, New York 

Leonard Gill

President, HCV Peer Educator/

Patient Advisory Committee

Albert Einstein College of Medicine

Division of Substance Abuse

Bronx, New York 

Carol L. Kuprevich, Ed.D.

Director of Community Planning, 

Program Development, and 

Training

Delaware Division of Alcohol, 

Drug Abuse and Mental Health

New Castle, Delaware 

Shirley Mikell

NAADAC—The Association for 

Addiction Professionals

Alexandria, Virginia

Rosa Rodriguez

Substance Abuse Counselor

Albert Einstein College of Medicine

Peekskill, New York

Leonard B. Seeff, M.D.

Senior Scientist for Hepatitis 

Research

National Institute of Diabetes and

Digestive and Kidney Diseases,

Division of Digestive Diseases and 

Nutrition

National Institutes of Health

Bethesda, Maryland

Carol Sholiton

President and Founder

Methadone Support Org 

Scottsdale, Arizona

Dee-Dee Stout, M.A., CADC II, 

MINT

Director

Responsible Recovery

Emeryville, California

Lynn E. Sullivan, M.D.

Assistant Professor of Medicine

Yale University

New Haven, Connecticut
120

Addressing Viral Hepatitis in People With Substance Use Disorders

Lynn E. Taylor, M.D.

Assistant Professor of Medicine

The Warren Alpert Medical School of Brown 

University

Providence, Rhode Island

Thelma King Thiel, RN

Chair and Chief Executive Officer

Hepatitis Foundation International

Silver Spring, Maryland

Jeanne Wells

Social Worker

Rocky Mountain Health Services

Woodland Park, Colorado

Kimberly Wright

Medical Services Coordinator

Missouri RAIN

Columbia, Missouri 

and 

National Institute of Diabetes and 

Digestive and Kidney Diseases

National Institutes of Health

Bethesda, Maryland
121

Appendix L—

Acknowledgments

Numerous people contributed to the development of this Treatment 

Improvement Protocol (TIP), including the TIP Consensus Panel (p. xiii), 

stakeholders (Appendix J), and field reviewers (Appendix K).

This publication was written and produced under contract numbers 270-04-

7049 and 270-09-0307, by the Knowledge Application Program (KAP), a Joint 

Venture of JBS International, Inc., and The CDM Group, Inc., for the Center 

for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health 

Services Administration (SAMHSA), U.S. Department of Health and Human 

Services (HHS).

Lynne MacArthur, M.A., A.M.L.S., served as the JBS KAP Executive Project 

Co-Director, and Barbara Fink, RN, M.P.H., served as the JBS KAP Managing 

Project Co-Director. Other JBS KAP personnel included Candace Baker, 

M.S.W., MAC, Deputy Director for Product Development; Deborah Steinbach, 

M.A., Senior Writer; Patricia Kassebaum, M.A., Senior Writer; Kris Rusch, 

M.A., Senior Writer; Martha J. Horn, Ph.D., Senior Writer; Frances Nebesky, 

M.A., Quality Assurance Editor; Wendy Caron, Quality Assurance Manager; 

Erin P. Doherty, Copy Editor; Terrie Young, Graphic Designer; and 

Erin Sandor, Graphic Designer.

123

Index

A

Acupuncture, 46, 105

Acute hepatitis, 4, 6, 7, 8, 42

Adefovir dipivoxil, 41, 87

Administrators’ guide

education, 65–66

funding comprehensive services, 63

integrating interventions with HIV services, 68

legal and ethical issues, 71

medical evaluation and diagnosis, 62

outreach activities, 66–68

policies and procedures development, 69

prevention and vaccination, 65

program assessment and planning, 61–62

program evaluation, 69

screening for hepatitis, 62

successful implementation, 70–71

support services, 66, 68

treatment guidelines, 62–66

Affective disorders, 105

AIDS. See HIV co-infection

Alcohol abuse

hepatitis treatment and, 34

Alternative medicine, 46, 99–100

American Association for the Study of Liver Diseases Guidelines, 33, 64

Anemia

as treatment side effect, 44

Antibodies, 13, 14, 15, 16, 22, 87, 89

Antigens, 13, 14, 22, 87

Antiviral treatment, 3, 20, 25–29, 31–38, 40–50, 53, 55, 57 

Anxiety disorders, 105

B

Behavioral health disorders

counseling, 37, 47, 67, 101–102, 109

hepatitis treatment and, 49–50
124

Addressing Viral Hepatitis in People With Substance Use Disorders

Biopsy, liver, 23, 27–29, 45, 63

Boceprevir, 25, 26, 43, 87, 107, 108

C

CAM. See Complementary or alternative 

medicine

Case management, 57–58, 102, 106

CDC. See Centers for Disease Control and 

Prevention

Center for Substance Abuse Treatment, ii, vii, 

xi, 58, 62, 106, 109, 115–117, 121

Centers for Disease Control and Prevention, 

5, 6, 8, 14, 15, 62, 64, 91, 113, 115

Chronic hepatitis

genotype test, 25–26

liver biopsy, 27–29

liver panel, 23–24

symptoms of, 4

treatment counseling, 35–36, 42

treatment guidelines, 62–66

viral load tests, 24–25

Cirrhosis, 1, 4, 6, 8, 11, 12, 24, 27, 32, 88

Client counseling. See Counseling approaches

Client education, 66

Combating the Silent Epidemic of Viral 

Hepatitis: U.S. Department of Health 

and Human Services Action Plan for the 

Prevention, Care and Treatment of Viral 

Hepatitis, 2

Complementary or alternative medicine, 46, 

99–100

Confidentiality issues, 64, 67, 71, 72

Consensus Panel, viii, ix, 7, 16, 65, 121

Counseling approaches

addressing relapse, 55–56, 102

building therapeutic relationship, 52

case management, 57–58

confronting social factors, 54–55

developing prevention plans, 54

ensuring safety, 52

helping clients understand diagnoses, 53

hepatitis B, 42

hepatitis education, 10, 18–19

liver biopsy decision, 27–28

motivational approaches, 48, 54, 59, 102, 

104, 109

providing reliable information, 52, 102 

resources, 109

risky behavior, 16, 18, 19, 46, 54, 67

screening process, 15–21

strategies, 51, 52

substance abuse treatment planning, 53

support systems, 56–57

treatment based on HCV status, 35–36

treatment decisions, 31, 35–37, 42

CSAT. See Center for Substance Abuse 

Treatment

D

Deoxyribonucleic acid tests, 24, 88

Depression, 32, 34, 41, 44, 49, 50, 53, 55, 59, 

68, 102, 103–105

hepatitis treatment considerations, 34

as treatment side effect, 44

Dietary supplements, 46, 99–100

DNA tests, 24

Drug interactions, 105, 106–108

E

Educate-Motivate-Facilitate groups, 68

Education activities, 38, 48, 51, 52, 61, 63, 

65–66, 69, 91, 92, 93, 104, 113

End-stage liver disease, 32, 36, 42, 46, 49, 88

Entecavir, 40, 41, 50

Ethical issues, 71

Ethnicity

impact on hepatitis treatment, 35, 37

Eye disorders

as treatment side effect, 44

F

Family support, 57, 59

FDA. See U.S. Food and Drug Administration

Fibrosis, 4, 8, 27, 36, 88

Financial assistance sources, 111

Focus on Hepatitis C, 113
125

Index

G

Genotypes

impact on hepatitis treatment, 34

tests, 23, 25–26

Glossary, 87–90

H

HAV. See Hepatitis A

HBV. See Hepatitis B

HCV. See Hepatitis C

HCV Advocate, 113

HDV. See Hepatitis D virus

Health Insurance Portability and Accountability 

Act, 71

Hepatitis

causes of, 3

Hepatitis, acute, 4, 42

Hepatitis, chronic

genotype test, 25–26

liver biopsy, 27–29

liver panel, 23–24

symptoms of, 4

treatment counseling, 35–36

treatment guidelines, 62–66

viral load tests, 24–25

Hepatitis, viral. See also Counseling approaches

causes of, 3

co-infections, 3–4, 10–11

interagency working group, 1–2

liver damage, 4

medical evaluation, 23–29

program services, 61–72

screening process, 13–22, 62

symptoms, 4

treatment, 39–50, 62–66

treatment decisions, 31–38

types of, 3–4, 10

Hepatitis A 

course of disease, 5

disease burden, 5

duration of illness, 4–5

HIV co-infection, 11

modes of transmission, 5

overview, 3–4

prevention of infection, 5–6

screening process, 14

substance use and, 5

treatment for, 40

vaccination, 65

Hepatitis B 

course of disease, 6–7

disease burden, 6

HIV co-infection, 11

modes of transmission, 6

overview, 3–4

prevention of infection, 7

screening process, 14

substance use and, 7

treatment for, 40–42

vaccination, 65

Hepatitis C Association, 113

Hepatitis C 

antiviral treatment, 42–44, 95–97

course of disease, 8–9

disease burden, 8

duration of illness, 7–8

HIV co-infection, 11, 48–49

mental health treatment considerations, 

101–108

modes of transmission, 8

overview, 3–4

prevention of infection, 9

screening process, 14–15

substance use and, 9

treatment counseling, 35–36

treatment for, 40, 42–49

treatment response classifications, 34

Hepatitis D virus, 10

Hepatitis E virus, 10

Hepatitis F virus, 10

Hepatitis G virus, 10

Herbal treatments, 46, 99–100

HEV. See Hepatitis E virus

HFV. See Hepatitis F virus

HGV. See Hepatitis G virus

HHS. See U.S. Department of Health and 

Human Services

HIPAA. See Health Insurance Portability and 

Accountability Act
126

Addressing Viral Hepatitis in People With Substance Use Disorders

HIV co-infection

integrating hepatitis interventions with 

existing services, 68

treatment issues, 11, 35, 45, 48–49

I

IDU. See Injection drug use

Implementing Change in Substance Abuse 

Treatment Programs, 62

Informed consent, 29, 71–72

Injection drug use, 1, 6, 8, 15, 17, 34, 48, 54, 

65, 104

Institute of Medicine, 1, 4, 8, 62

Interferon, 25, 32, 41, 43, 89, 96, 104, 106–108

IOM. See Institute of Medicine

K

KAP Keys, 123

Knowledge Application Program, ii, viii, 121, 

123

L

Lamivudine, 41, 89

Legal issues, 67, 71

LFTs. See Liver function tests

Liver

biopsy, 23, 27–29, 45, 63

function of, 3

hepatitis damage, 4, 35

Liver function tests, 23–24

Liver panel, 23–24

Liver transplantation, 36, 42, 45–46

M

Mania

as treatment side effect, 44

MAT. See Medication-assisted treatment

Medication. See Treatment

Medication-assisted treatment, 37, 45, 46–47, 

58, 62

Medicinal plant treatments, 46, 99–100

Men who have sex with men, 5, 7

Mental health disorders

affective disorders, 105

anxiety disorders, 105

behavioral health counseling, 101–102

effects of antiviral treatment, 103–104

hepatitis treatment and, 49–50

psychiatric assessment, 103

serious mental illness, 106–108

suicidality, 34, 104, 105–106

treatment readiness, 102–103

Minneapolis Healthy Liver Program, 70

Motivational approaches, 54, 102, 109

MSM. See Men who have sex with men

Multidisciplinary teams, 64

N

NASTAD. See National Alliance of State and 

Territorial AIDS Directors

National Alliance of State and Territorial 

AIDS Directors, 65

National Institutes of Health Consensus 

Statement, 33

Neutropenia

as treatment side effect, 44

New York State Department of Health 

Guidelines, 33

Nucleic acid tests, 24

O

OASIS. See Organization to Achieve 

Solutions in Substance-Abuse

Onsite treatment, 63–64

Opioid dependence

hepatitis treatment and, 34, 37, 45, 46–47, 

107

Opioid treatment programs, 47, 62, 65

Organization to Achieve Solutions in 

Substance-Abuse, 68

OTP. See Opioid treatment program

Outreach activities, 66–68

P

Peer counseling, 56–57, 68

Practice Guidelines of the American 

Association for the Study of Liver 

Diseases, 33, 64

Pregnancy

antiviral treatment considerations, 32, 33, 

53
127

Prevention activities, 5–7, 9, 54, 65

Privacy issues, 71

Program services

education, 65–66

evaluation of, 69

funding comprehensive services, 63

integrating interventions with HIV 

services, 68

legal and ethical issues, 71

medical evaluation and diagnosis, 62

outreach activities, 66–68

policies and procedures development, 69

prevention and vaccination, 65

screening for hepatitis, 62

successful implementation, 70–71

support services, 33, 61, 66, 68, 70, 94

treatment guidelines, 62–66

Project Samaritan Health Services, 63

Psychiatric assessment, 103

Pulmonary disorders

as treatment side effect, 44

Q

Quick Guide, 123

R

Referrals, 19, 38, 47, 57, 64

Resources, 91–94, 109

Ribavirin, 25, 26, 32, 33, 39, 43, 44, 89, 96, 97, 

106

Ribonucleic acid tests, 15, 24

Risky behavior, 16, 18, 19, 22, 46, 54, 67

RNA tests, 15, 24

S

SAMHSA. See Substance Abuse and Mental 

Health Services Administration

Screening process

antigens and antibodies, 13

client counseling, 15–21

hepatitis A, 14

hepatitis B, 14

hepatitis C, 14–15

program services, 62

results, 20–21

staff training, 69

treatment program’s role, 13

Serious mental illness, 106–108

Services. See Program services

SMI. See Serious mental illness

Social factors, 54–55

Spleen, 4

Staff education, 66–67, 69, 113

Staff member rights, 71

Substance Abuse and Mental Health Services 

Administration

Focus on Hepatitis C, 113

general, ii, vii, viii, xi, 64, 106, 115–117, 121

publications ordering, 123

website, 64

Substance use disorders. See also Program 

services

counseling strategies, 51

hepatitis risk, 1, 5, 7, 9

opioid dependence and hepatitis treatment, 

34, 46–47

relapses, 47–48, 55–56, 64

treatment planning, 53

SUDs. See Substance use disorders

Suicidality, 34, 104, 105–106

Superinfection, 10

Support groups, 56

Support services, 56–57, 66, 68

Sustained virologic response, 34, 42–43

SVR. See Sustained virologic response

T

TAP 31. See Technical Assistance Publication, 31

Technical Assistance Publication, 31, 62

Telaprevir, 25, 26, 43

Telbivudine, 41, 90

Tenofovir, 40, 41, 50, 90

Terminology, 2–3

TIPS. See Treatment Improvement Protocols

Training. See Staff education

Transplantation, liver, 36, 42, 45–46

Treatment

adherence to, 33–34, 35, 36, 44, 47, 49, 53, 

58, 64, 65, 67, 68, 103, 104, 106

antiviral, 42–44
128

Addressing Viral Hepatitis in People With Substance Use Disorders

barriers to, 37–38, 49, 52, 67

for behavioral health disorders, 105–106, 

101–108

behavioral health disorders and, 49–50

complementary or alternative medicine, 46, 

99–100

contraindications, 32–33

counselor’s role, 31

deferring, 44–45

drug interactions, 106–108

effects of antiviral treatment on behavioral 

health, 103–104

guidelines, 46, 62–66

health problems and, 33, 44

for hepatitis A, 40

for hepatitis B, 40–42

for hepatitis C, 40, 42–49

HIV co-infection and, 48–49, 113

likelihood of success, 34–35

liver transplantation, 36, 42, 45–46

multidisciplinary teams, 64

onsite, 63–64

opioid dependence and, 34, 37, 45, 46–47

options, 2, 31–32, 36, 39, 42, 48

pregnancy and, 32, 33, 53

readiness for, 102–103

recommendations, 39–40

referral to hepatitis treatment providers, 64

response classifications, 34

side effects, 27, 28, 36, 37, 39, 40, 43–44, 

46, 47, 95–97

supporting decisions, 36–37

timing of, 32

Treatment Improvement Protocols

audience for, 2

development process, viii

format, vii–viii

purpose of, 2, 123

terminology, 2–3

website, vii

Twinrix, 7, 65

U

U.S. Department of Health and Human Services

interagency working group on viral 

hepatitis, 1–2

U.S. Department of Veterans Affairs, 56, 64

U.S. Food and Drug Administration, 15, 25, 

65, 87, 89, 90, 105, 108

V

Vaccination, 1, 5, 6, 7, 10, 12, 16, 20, 21, 35, 

36, 40, 54, 61, 62, 65, 67, 70, 71, 113 

Viral hepatitis. See Hepatitis, viral

Viral Hepatitis Action Plan, 2

Viral load

impact on hepatitis treatment, 34

tests, 24–25

Virologic relapses, 34
129

CSAT TIPs and Publications Based on TIPs

What Is a TIP?

Treatment Improvement Protocols (TIPs) are the products of a systematic and innovative process that 

brings together clinicians, researchers, program managers, policymakers, and other Federal and non-Federal experts to reach consensus on state-of-the-art treatment practices. TIPs are developed under CSAT’s 

Knowledge Application Program to improve the treatment capabilities of the Nation’s alcohol and drug 

abuse treatment service system.

What Is a Quick Guide?

A Quick Guide clearly and concisely presents the primary information from a TIP in a pocket-sized 

booklet. Each Quick Guide is divided into sections to help readers quickly locate relevant material. Some 

contain glossaries of terms or lists of resources. Page numbers from the original TIP are referenced so 

providers can refer back to the source document for more information.

What Are KAP Keys?

Also based on TIPs, KAP Keys are handy, durable tools. Keys may include assessment or screening 

instruments, checklists, and summaries of treatment phases. Printed on coated paper, each KAP Keys set 

is fastened together with a key ring and can be kept within a treatment provider’s reach and consulted 

frequently. The Keys allow you—the busy clinician or program administrator—to locate information 

easily and to use this information to enhance treatment services.

Ordering Information

Publications may be ordered for free at http://store.samhsa.gov. To order over the phone, please call 

1-877-SAMHSA-7 (1-877-726-4727) (English and Español). Most publications can also be downloaded at http://www.kap.samhsa.gov.

TIP 1 State Methadone Treatment Guidelines—

Replaced by TIP 43

TIP 2* Pregnant, Substance-Using Women—

BKD107

TIP 3 Screening and Assessment of Alcohol- and 

Other Drug-Abusing Adolescents—Replaced 

by TIP 31

TIP 4 Guidelines for the Treatment of Alcoholand Other Drug-Abusing Adolescents—

Replaced by TIP 32

TIP 5 Improving Treatment for Drug-Exposed 

Infants—BKD110

TIP 6* Screening for Infectious Diseases Among 

Substance Abusers—BKD131 

Quick Guide for Clinicians QGCT06

KAP Keys for Clinicians KAPT06

TIP 7 Screening and Assessment for Alcohol and 

Other Drug Abuse Among Adults in the 

Criminal Justice System—Replaced by TIP 44

TIP 8 Intensive Outpatient Treatment for Alcohol 

and Other Drug Abuse—Replaced by TIPs 46 

and 47

TIP 9 Assessment and Treatment of Patients With 

Coexisting Mental Illness and Alcohol and 

Other Drug Abuse—Replaced by TIP 42

TIP 10 Assessment and Treatment of CocaineAbusing Methadone-Maintained Patients—

Replaced by TIP 43 

TIP 11* Simple Screening Instruments for Outreach 

for Alcohol and Other Drug Abuse and 

Infectious Diseases—BKD143 

 Quick Guide for Clinicians QGCT11

 KAP Keys for Clinicians KAPT11

TIP 12 Combining Substance Abuse Treatment 

With Intermediate Sanctions for Adults in 

the Criminal Justice System—Replaced by TIP 

44 

TIP 13 Role and Current Status of Patient 

Placement Criteria in the Treatment of 

Substance Use Disorders—BKD161

 Quick Guide for Clinicians QGCT13 

 Quick Guide for Administrators QGAT13

 KAP Keys for Clinicians KAPT13 

*Under revision
130

Addressing Viral Hepatitis in People With Substance Use Disorders

TIP 14 Developing State Outcomes Monitoring 

Systems for Alcohol and Other Drug Abuse 

Treatment—BKD162 

TIP 15 Treatment for HIV-Infected Alcohol and 

Other Drug Abusers—Replaced by TIP 37 

TIP 16 Alcohol and Other Drug Screening of 

Hospitalized Trauma Patients—BKD164 

Quick Guide for Clinicians QGCT16

KAP Keys for Clinicians KAPT16 

TIP 17 Planning for Alcohol and Other Drug Abuse 

Treatment for Adults in the Criminal Justice 

System—Replaced by TIP 44

TIP 18 The Tuberculosis Epidemic: Legal and 

Ethical Issues for Alcohol and Other Drug 

Abuse Treatment Providers—BKD173

Quick Guide for Clinicians QGCT18

KAP Keys for Clinicians KAPT18

TIP 19 Detoxification From Alcohol and Other 

Drugs—Replaced by TIP 45

TIP 20 Matching Treatment to Patient Needs in 

Opioid Substitution Therapy—Replaced by 

TIP 43

TIP 21 Combining Alcohol and Other Drug Abuse 

Treatment With Diversion for Juveniles in 

the Justice System—(SMA) 08-4073

Quick Guide for Clinicians and 

Administrators QGCA21

TIP 22 LAAM in the Treatment of Opiate 

Addiction—Replaced by TIP 43

TIP 23 Treatment Drug Courts: Integrating 

Substance Abuse Treatment With Legal 

Case Processing—(SMA) 08-3917

Quick Guide for Administrators QGAT23 

TIP 24 A Guide to Substance Abuse Services for 

Primary Care Clinicians—(SMA) 08-4075

Concise Desk Reference Guide BKD123

Quick Guide for Clinicians QGCT24

KAP Keys for Clinicians KAPT24

TIP 25 Substance Abuse Treatment and Domestic 

Violence—(SMA) 08-4076

Linking Substance Abuse Treatment and 

Domestic Violence Services: A Guide for 

Treatment Providers MS668 

Linking Substance Abuse Treatment and 

Domestic Violence Services: A Guide for 

Administrators MS667 

Quick Guide for Clinicians QGCT25 

KAP Keys for Clinicians KAPT25 

TIP 26 Substance Abuse Among Older Adults—

(SMA) 08-3918

Substance Abuse Among Older Adults: A 

Guide for Treatment Providers MS669 

Substance Abuse Among Older Adults: A 

Guide for Social Service Providers MS670 

Substance Abuse Among Older Adults: 

Physician’s Guide MS671 

Quick Guide for Clinicians QGCT26

KAP Keys for Clinicians KAPT26 

TIP 27 Comprehensive Case Management for 

Substance Abuse Treatment—(SMA) 

08-4215

Case Management for Substance Abuse 

Treatment: A Guide for Treatment Providers 

MS673

Case Management for Substance Abuse 

Treatment: A Guide for Administrators 

MS672

Quick Guide for Clinicians QGCT27

Quick Guide for Administrators QGAT27

TIP 28* Naltrexone and Alcoholism Treatment—

Replaced by TIP 49

TIP 29 Substance Use Disorder Treatment for 

People With Physical and Cognitive 

Disabilities—(SMA) 08-4078 

Quick Guide for Clinicians QGCT29 

Quick Guide for Administrators (SMA) 

08-3592 

KAP Keys for Clinicians KAPT29 

TIP 30 Continuity of Offender Treatment for 

Substance Use Disorders From Institution to 

Community—(SMA) 08-3920

Quick Guide for Clinicians QGCT30 

KAP Keys for Clinicians KAPT30 

TIP 31 Screening and Assessing Adolescents for 

Substance Use Disorders—(SMA) 08-4079

See companion products for TIP 32. 

TIP 32 Treatment of Adolescents With Substance 

Use Disorders—(SMA) 08-4080

Quick Guide for Clinicians QGC312 

KAP Keys for Clinicians KAP312 

TIP 33 Treatment for Stimulant Use Disorders—

(SMA) 06-4209

Quick Guide for Clinicians QGCT33 

KAP Keys for Clinicians KAPT33 

*Under revision
131

TIP 34 Brief Interventions and Brief Therapies for 

Substance Abuse—(SMA) 07-3952 

Quick Guide for Clinicians QGCT34 

KAP Keys for Clinicians KAPT34

TIP 35 Enhancing Motivation for Change in 

Substance Abuse Treatment—(SMA) 

08-4212 

Quick Guide for Clinicians QGCT35 

KAP Keys for Clinicians KAPT35 

TIP 36 Substance Abuse Treatment for Persons 

With Child Abuse and Neglect Issues—

(SMA) 08-3923 

Quick Guide for Clinicians QGCT36 

KAP Keys for Clinicians KAPT36 

Helping Yourself Heal: A Recovering Woman’s 

Guide to Coping With Childhood Abuse 

Issues (SMA) 08-4132

Available in Spanish: PHD981S 

Helping Yourself Heal: A Recovering Man’s 

Guide to Coping With the Effects of 

Childhood Abuse (SMA) 08-4134

Available in Spanish: PHD1059S 

TIP 37 Substance Abuse Treatment for Persons 

With HIV/AIDS—(SMA) 08-4137 

Quick Guide for Clinicians MS678 

KAP Keys for Clinicians KAPT37 

Drugs, Alcohol, and HIV/AIDS: A Consumer 

Guide (SMA) 08-4127 

Drugs, Alcohol, and HIV/AIDS: A Consumer 

Guide for African Americans (SMA) 07-4248

TIP 38 Integrating Substance Abuse Treatment and 

Vocational Services—(SMA) 06-4216 

Quick Guide for Clinicians QGCT38

Quick Guide for Administrators QGAT38 

KAP Keys for Clinicians KAPT38

TIP 39 Substance Abuse Treatment and Family 

Therapy—(SMA) 08-4219 

Quick Guide for Clinicians QGCT39

Quick Guide for Administrators QGAT39

TIP 40 Clinical Guidelines for the Use of 

Buprenorphine in the Treatment of Opioid 

Addiction—(SMA) 07-3939

Quick Guide for Physicians QGPT40

KAP Keys for Physicians KAPT40

TIP 41 Substance Abuse Treatment: Group 

Therapy—(SMA) 05-3991

Quick Guide for Clinicians QGCT41

TIP 42 Substance Abuse Treatment for Persons 

With Co-Occurring Disorders—(SMA) 

08-3992

Quick Guide for Clinicians (SMA) 07-4034

Quick Guide for Administrators QGAT42

KAP Keys for Clinicians (SMA) 08-4036 

TIP 43 Medication-Assisted Treatment for Opioid 

Addiction in Opioid Treatment Programs—

(SMA) 08-4214

Quick Guide for Clinicians QGCT43 

KAP Keys for Clinicians (SMA) 07-4108 

TIP 44 Substance Abuse Treatment for Adults in the 

Criminal Justice System—(SMA) 05-4056 

Quick Guide for Clinicians QGCT44

KAP Keys for Clinicians (SMA) 07-4150 

TIP 45 Detoxification and Substance Abuse 

Treatment—(SMA) 08-4131 

Quick Guide for Clinicians (SMA) 06-4225

KAP Keys for Clinicians (SMA) 06-4224 

Quick Guide for Administrators (SMA) 

06-4226 

TIP 46 Substance Abuse: Administrative Issues in 

Outpatient Treatment—(SMA) 06-4157 

Quick Guide for Administrators (SMA) 

07-4232 

TIP 47 Substance Abuse: Clinical Issues in 

Outpatient Treatment—(SMA) 06-4182

Quick Guide for Clinicians (SMA) 07-4233

KAP Keys for Clinicians (SMA) 07-4251

TIP 48 Managing Depressive Symptoms in 

Substance Abuse Clients During Early 

Recovery—(SMA) 08-4353 

TIP 49 Incorporating Alcohol Pharmacotherapies 

Into Medical Practice—(SMA) 09-4380

Quick Guide for Counselors (SMA) 10-4542

KAP Keys for Clinicians (SMA) 10-4544

Quick Guide for Physicians (SMA) 10-4543

TIP 50 Addressing Suicidal Thoughts and Behaviors 

in Substance Abuse Treatment—(SMA) 

09-4381

TIP 51 Substance Abuse Treatment: Addressing the 

Specific Needs of Women—(SMA) 09-4426

*Under revision
132

Addressing Viral Hepatitis in People With Substance Use Disorders

TIP 52 Clinical Supervision and Professional 

Development of the Substance Abuse 

Counselor—(SMA) 09-4435

TIP 53 Addressing Viral Hepatitis in People With 

Substance Use Disorders—(SMA) 11-4656

TIP 54 Managing Chronic Pain in Adults With or in 

Recovery From Substance Use Disorders—

(SMA) 12-4671
HHS Publication No. (SMA) 11-4656

Printed 2011

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

Center for Substance Abuse Treatment