Medical students
throughout the
country are
currently training
to be the physicians of
tomorrow, but what is often
forgotten is the health care
system in which they are
learning to serve a system
that obstructs a physician’s
ability to provide their patients
with the best care. How can
medical students say they
stand for fairness and equity
when the health care system
perpetuates injustice, which
restricts their ability to treat all
their patients equally.?1 This
question comes up when
medical students refl ect on
how the health care system
treats those with hepatitis
C patients who use injection
drugs, or in over 13 states,
how the health care system
seeks to not treat these
patients.
Hepatitis C is an infectious
disease that can be passed
through blood and can become
chronic, leading to liver damage,
34 DALLAS MEDICAL JOURNAL • October 2021
cirrhosis, cancer, or even
death when left untreated. The
annual incidence of hepatitis
C virus (HCV) infection in the
United States has tripled in
the last decade, due primarily
to a rise in injection drug
use, and affects 50% of all
people who use injection drugs
(PWID).2,3,4,5,6,7,8 HCV can be
prevented with early diagnosis
and treatment using directacting
antivirals (DAAs), which
cure over 95% of those with
HCV.11,12,13,14 Despite PWID’s
high susceptibility to HCV,
intervention and treatment
of HCV using DAAs is often
restricted by state policies that
impose arbitrary abstinence
periods on prospective patients
with HCV. Some Medicaid
groups require abstinence from
alcohol and substance use
for up to six months prior to
receiving any DAA therapy.5,15,16
This means physicians are
often unable to treat their
patients solely because of
their substance use disorder,
and this completely destroys
the physician’s ability to “do
no harm.” Because many
patients cannot refrain from
illegal drug use for long enough
to treat and eliminate HCV
early, these required periods
of abstinence, also known as
sobriety restrictions, go against
the Social Security Act, since
they result in “denial of access
to effective, clinically appropriate,
and medically necessary
treatments using DAA drugs for
benefi ciaries with chronic HCV
infections.”17,18,19,20
Not only does federal law
oppose the use of barriers like
sobriety restrictions, but these
policies are rooted only in bias
rather than informed medical
opinion. Alcohol and injectable
drugs have no impact on
the effectiveness of the DAA
treatment. In fact, those with
substance use disorders have
the same HCV cure rates as
those without substance use
disorders, demonstrate high
adherence to treatment, and
even experience low six-month
reinfection rates.6,8,21 State
laws requiring abstinence
greatly limit those who receive
hepatitis C treatment and most
likely lead to higher costs later
for the state as the patient
becomes sicker over time.
Individuals across the United
States are being impacted by
these policies. As of 2020,
26% of state Medicaid
programs maintain sobriety
restrictions for patients expecting
to receive lifesaving HCV
therapy.22,23,24,25,26,27 A lot of
people who are supportive of
sobriety restrictions argue that
By Whitney Stuard,
Tori Pierce, Tanooha
Veeramachaneni,
Brittany Wagner,
Brianna Marschke,
Makenzie Stuard,
Chandana Golla, and
Emmanuella Oduguwa
CLINICAL
Editorial: We Do Harm Sobriety Restrictions for Hepatitis C Treatment are
Dangerous and Unnecessary Barriers to Health Care