Issues in HIV Substance Users J Tulsky

The Medical Spectrum of HIV and Substance Use: 

The Medical Spectrum of HIV and Substance Use Jacqueline Peterson Tulsky UCSF/SFGH Positive Health Program National HIV/AIDS Clinicians Consultation Center

HIV Care at the End of the 20th Century: 

HIV Care at the End of the 20th Century 'Science and technology are evolving at a blinding pace, impacting on the way we provide medical care as well as on almost every other aspect of our life. But our human psychological make-up, our higher consciousness and sense of social justice, has not evolved at the same rate. Just think about the last HIV-infected, homeless, mentally ill or drug addicted person you tried to take care of and you begin realize that all our science and all our technology still do not have much to offer for our most human problems.' adapted from Anita Friedman, PhD

Why a special session on HIV and Substance Users? : 

Why a special session on HIV and Substance Users? Drug users directly and indirectly account for a significant population with HIV infection. Drug use impacts all aspects of the care of persons with HIV. There is a tremendous need for medical providers with insight and training on the physical, mental, emotional status of drug users and how that affects both prevention and treatment of HIV.

What is the current epidemiology of adult IDUs in HIV/AIDS? : 

What is the current epidemiology of adult IDUs in HIV/AIDS? World Prevalence according to UN Primary mode of transmission in regions of North Africa andamp; Middle East, East Asia andamp; Pacific, Eastern Europe andamp; Central Asia. Secondary mode in Latin America, Western Europe, North America and Australia andamp; New Zealand

Current epidemiology cont…..: 

Current epidemiology cont….. US Prevalence by June, 1999 N=702,748 IDU only 179,228 (26%), IDU and MSM 45,266 (6%) Sex w/ IDU 27,265 (4%) Total 251,759 (36%)

Current epidemiology cont... : 

Current epidemiology cont... 'IDU only' accounts for large category of women with AIDS (42% vs 40% for Sex w/IDU). Approx 90,000 addicts in SF Bay Area, 14% of IDUs are HIV infected. Up to 25% do not know their HIV status. Mortality rates - remain higher in AIDS cases associated with IDU. In 1995, decline of 18% in mortality in MSM, but only 6% in IDUs.

Special Medical Issues in HIV-infected Substance Users: 

Special Medical Issues in HIV-infected Substance Users Drug interactions - Both prescription drugs and recreational drugs may interact with HIV meds Some diseases have higher incidence in drug users and may have different presentation or clinical course due to HIV infection. Examples: Tuberculosis Hepatitis B and C Drug related hepatitis Soft tissue infections and pneumonia HTLV 1

Medical Issues cont (2)...: 

Medical Issues cont (2)... Drug Interactions Little well studied pharmacologic data, almost none in vivo Amphetamines -- Increased levels with ritonavir, possible other PIs Cocaine -- No known interaction, but question of increased HIV activity Ecstasy – Increased level with ritonavir, possibly with all PIs and NNRTIs

Medical Issues cont (3)...: 

Medical Issues cont (3)... Drug Interactions Heroin -- Increased levels with ritonavir, but extremely conflicting reports. LSD -- No known interactions Marijuana -- Increased THC level with any PI

Medical Issues cont (4)...: 

Medical Issues cont (4)... Drug Interactions with prescription drugs Anxiolytics -- Dangerously increased levels with ritonavir, but possibly decreased levels of indinavir. Dronabinol -- Increased levels with any Protease Inhibitor Opiates -- Increased levels with ritonavir ??. Decreased levels with NNRTIs, but variable

Medical Issues cont (5)...: 

Medical Issues cont (5)... Tuberculosis and HIV High prevalence of TB infection and disease associated with IDU. Probably higher in alcoholics and crack addicts as well. Short course prevention regimens effective, but concern about safety and drug interactions remains. Rifampin/Rifabutin and Pyrazinamide for 60 daily doses versus 9 months Isoniazid.

Medical Issues cont (6)...: 

Medical Issues cont (6)... Hepatitis B Most adult IDUs infected in first few years of use, due to increased sexual transmission partners at risk. Check Hep B core total and surface antibodies for natural infection. Some with continued viremia with undetectable Hep B surface antigen. Vaccine series still useful, especially in young injectors, but lower seroconversion rates than reported in standard 3 series.

Medical Issues cont (7)...: 

Medical Issues cont (7)... Hepatitis C Over 90% of IDUs infected in early years, but 15-20% of these will have antibody only . HIV accelerates Hep C damage, probably not the other way around. Hep C complicates treatment HIV directly through liver toxicity and indirectly with risk of lactic accidosis and changed drug metabolism.

Medical Issues cont (8)...: 

Medical Issues cont (8)... Hepatitis C treatment Case reports and small series of treatment of Hep C in HIV infected persons looks no worse (and no better) than Hep C infection alone. Response rates reported at 30-40% depending on Hep C subtype. Highly charged issue of willingness by GI specialist to treat drug users with Hepatitis C.

Medical Issues cont (8)...: 

Medical Issues cont (8)... Soft Tissue Infection and Pneumonia Abscess, cellulitis and bacterial pneumonia rates may not be significantly higher by HIV status. Bacteremia may be more common in HIV-infected users Response to treatment seems similar by HIV status.

Psychiatric Issues in HIV-infected Substance Users: 

Psychiatric Issues in HIV-infected Substance Users One study of nonalcoholic persons with drug dependence and HIV, rate of mental illness diagnosis 53%. In opiate dependent persons in treatment one study reported co-morbid psychiatric diagnosis over 90%. Multiple Axis I disorders (Mood, psychotic and anxiety diagnosis) common.

Pychiatric Issues cont (2)...: 

Pychiatric Issues cont (2)... Axis I disorders Prevalence over 80% in one methadone treatment study. Complicates diagnosis of dementia and other CNS infections. Intermittently affect both decision to offer and ability to adhere to HIV treatment.

Psychiatric Issues cont (3)...: 

Psychiatric Issues cont (3)... Axis II personality disorders Includes narcissistic, borderline, schizoid, antisocial and paranoid personalities. One study of cocaine addicts, 73% meet criteria for Axis II diagnosis. Little data quantifies incidence in HIV-infected substance users separately.

Psychiatric Issues cont (4)...: 

Psychiatric Issues cont (4)... Axis II personality disorders Maybe tougher than Axis I for providers to cope with because of lack of clear treatment or management guidelines. High burnout of providers attempting to care for these patients if done as a single practitioner without multi-disciplinary support.

The Complex Problem of Pain in Substance Users: 

The Complex Problem of Pain in Substance Users How we fail our patients with pain Judging adequate pain control Pain control for those trying to maintain 'recovery' Strategies for really hard-to-manage addicts in pain

Pain Management cont (2)...: 

Pain Management cont (2)... How we fail our patients in pain Over 30% of HIV patients with pain reported that their symptoms were not well controlled. Poor pain control independent of 'mode of transmission' category. Neglect of search for cause of pain after initial evaluation. Discussion of pain and the interaction with suffering.

Pain Managament cont (3)...: 

Pain Managament cont (3)... Judging adequate pain control Behavior as a guide to adequate control. Once adequate control achieved behavior often becomes more stable, reliable and less intrusive. Pain scales may be helpful in monitoring control. Where addiction or abuse of meds is the overriding issue, less willingness to try alternative therapies. Rapid self taper, with encouragement, often occurs when cause of pain resolves.

Pain Management cont (4)...: 

Pain Management cont (4)... Special Issues for those in recovery Maximize alternative therapies to respect patient’s wishes, but search for pain relief. Work with treatment program to avoid rigidity in approach to pain management.

Pain Management cont (5)...: 

Pain Management cont (5)... Strategies for really hard-to-manage addicts in pain Single provider for all medications, esp pain medications. Strict prescription contracts which include drug, amount and where it will be filled. Involve pharmacists in helping to manage refills precisely. Maximize slow-release preparations.

Antiretroviral Therapy in Substance Users: 

Antiretroviral Therapy in Substance Users Can substance users adhere to antiretroviral therapy? Do substance users want antiretroviral therapy? Strategies to improve ARV treatment adherence Drug regimen issues Environmental issues Co-morbid disease issues (especially substance use and psychiatric disease)

ARV Therapy cont (2)...: 

ARV Therapy cont (2)... Adherence Single largest issue for both providers and patients. Little data looking at adherence to ART in drug using populations, but what exists is mostly in IDUs. Young Song’s work in methamphetamine users in SF reports around 80% adherence except during runs. Tulsky/White data in jailed drug users shows outstanding adherence to ARV therapy

ARV Therapy cont (3)...: 

ARV Therapy cont (3)... Acceptability Clinical cohorts in Baltimore and San Francisco in methadone treatment patients report only 50-60% of those who meet criteria for treatment are on ARV Is this patient self-selection? Is this provider selection? Combination of both? In San Francisco jail cohort, 75% of those offered ARV therapy accepted.

ARV Therapy cont (4)...: 

ARV Therapy cont (4)... Guidelines for successful adherence Minimize frequency of dosing. Pill burden acceptability varies by person so this may or may not be an issue. Maximize adherence tools….pill boxes, reminder watches, computerized pill bottles. Consideration of modified directly observed therapy especially during initiation phase of treatment

ARV Therapy cont (5)...: 

ARV Therapy cont (5)... Guidelines for successful adherence Close monitoring of early side effects or aversion. Open ended, persistent inquiries about adherence at each clinic appointment. Try to establish stability in other aspects of life…housing, substance use treatment, mental health treatment. Use of incentives to motivate and reward.

Identifying Problem Substance Use: 

Identifying Problem Substance Use Problem of definition of 'Problem Use'. Avoiding 'Don’t Ask, Don’t Tell' interactions. Look for signs and symptoms of substance use Track marks, abscess (especially recurrent) Abnormal liver function tests or elevated BP Erratic or unusual behavior (missed appointments, lost prescriptions, change in adherence). *

Identifying Your Problem Attitudes Towards Substance Users: 

Identifying Your Problem Attitudes Towards Substance Users Caring for patients that you really don’t like Issue not just limited to substance users Process of professional distance Value of multi-disciplinary approach with attention to mutual support of team members Are you a patient-resistant provider?

Identifying Your Problem Attitudes...: 

Identifying Your Problem Attitudes... Setting limits and boundaries while avoiding rigidity. 'Tough Love' -- Rejecting the behavior, but not the patient. Absolute limits for behavior that cannot be tolerated such as violence, threats, forgery, theft. Grey zone behaviors - Takes some meds, sells or gives some away. Contracting for fair practices (appt keeping, refills).

Conclusions HIV Care at the End of the 20th Century: 

Conclusions HIV Care at the End of the 20th Century 'Most of us walk unseeing through the world, unaware alike of its beauties, its wonders and the strange and sometimes terrible intensity of the lives being lived about us.' Rachel Carson (1907-1964)