Transcript Substance Abuse in HIV

Substance Abuse in HIV
Patrick Marsh, M.D.
University of South Florida
Faculty, Florida/Caribbean AETC
Disclosure of Financial Relationships
This speaker has no significant
relationships with commercial entities to
disclose.
This speaker will discuss off-label use or
investigational product during the program.
This slide set has been peer-reviewed to ensure that there are no
conflicts of interest represented in the presentation.
Taking drugs if you
have HIV is BAD
Illicit drug use in patients living with HIV has
which of the following effects?
96%
A. Higher Viral Loads
B. Lower CD4 Counts
C. Increased Rates of
Resistance
D. All of the above
0%
A.
0%
B.
4%
C.
D.
Drug Effect on HIV
• Higher viral loads
• Lower CD4 counts
• Increased rates of resistance
Gonzalez 2011
Reduced compliance
• HAART regimen
• Hep C regimen
• Prophylaxis
– PCP
– Toxo
– TB
Gonzalez 2011
Increased rates transmission
• Unprotected sex
– Anal intercourse
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Group sex or multiple partners
Internet partners
Injection drug users
High or intoxicated during sex
Sex work
Sex with serodiscordant partner
Gonzalez 2011
Substance Abuse Effect on CNS
• AIDS dementia
– Heroin – poor recall and working memory
– THC/cocaine- verbal fluency
– Hepatitis C co-infection
Grassi 1993
HIV and Alcohol
• Poor adherence
– Never on ART
– Stopping ART to drink
• Reduced CD4 counts (independent of
ART)
• Poor viral suppression (independent of
ART)
• Increased rates of Hep C co-infection
Baum 2010
HIV and Heroin
• Less likely to be on ART
• Poor adherence
• Poor virologic and immunologic
response to ART
• Increased transmission
Gonzalez 2011
HIV and Cocaine
• Poor adherence
• Reduced CD4 count
– 2 times as likely to have <200 cells per ml
(independent of ART)
• Increased viral loads (independent of
ART)
Baum 2009
Gonzalez 2011
Marijuana has no negative impact in patients living with HIV and so I
don’t really need to ask about its use.
100%
A. True
B. False
0%
A.
B.
HIV and Marijuana
• Marijuana use in moderate to severe
nausea may increase adherence
• Marijuana use in mild to no nausea
– Reduced adherence with ART
– Missed appointments
deJong 2005
HIV and Methamphetamines
• Reduced adherence
• Increased viral loads
• Higher rates of resistant virus in HAART
naive patients
– NNRTI resistant
• Higher rates of unprotected and risky sex
– sildenafil
Rajasingham R, 2011
HIV and Tobacco
• 40-70% of people living with HIV smoke
vs 20% baseline.
• Lower adherence
• Lower CD4 counts
• Increased non-AIDS defining illness and
mortality
• Reduced ART efficacy via promoting HIV
1 gene expression
Morbid Mortal Wkly Rep. 2010;59
Webb MS 2009
Substance Treatment in the USA
• Forty million Americans ages 12 and
older (16 percent)
– 40-74% HIV/AIDS
• Only about 1 in 10 people receive
treatment
• Addiction treatment programs are not
adequately regulated
The CASA Columbia National Advisory Commission on Addiction Treatment
Gonzalez 2011
Substance Treatment in the USA
• In 2010 $28 billion was spent to treat the
40 million people with addiction.
• 95.6 cents of every dollar spent by
federal, state and local governments on
risky substance use and addiction go to
pay for the consequences; only 1.9 cents
go to prevention and treatment
The CASA Columbia National Advisory Commission on Addiction Treatment
Substance abuse is a moral problem and therefore I
have no business addressing it in a medical visit.
97%
A. True
B. False
3%
A.
B.
Medicine and Substance Use
• 1956 – AMA declared alcoholism an illness
that can and should be treated within the
medical profession
• 1989 – AMA adopted a policy declaring
addiction involving other drugs, including
nicotine, to be a disease
• 47% of Americans would turn to a health
professional if someone close to them needed
help for addiction
• < 6% of referrals to publically‐funded addiction
treatment come from a health care provider
The CASA Columbia National Advisory Commission on Addiction Treatment
No medical training required:
• 14 states – do not require all addiction
counselors to be licensed or certified
• 6 states – no minimum degree requirements
• 14 states – minimum requirement of high
school degree or GED
• 10 states – minimum requirement of
associates degree
• 6 states – minimum requirement of bachelors
degree
• 1 state – minimum requirement of masters
degree
The CASA Columbia National Advisory Commission on Addiction Treatment
Florida
• Certified Addiction Specialist
– No degree, 150 hours of training and 100
hours of supervision
• Certified Addiction Counselor
– High School degree, 250 hours of training
and 300 hours of supervision
• Certified Addiction Professional
– Bachelor degree, 350 hours of training and
300 hours of supervision
http://www.flcertificationboard.org/Certifications_Addiction.cfm
WWW.CASACOLUMBIA.ORG
Substance abuse treatments
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Psychological
Pharmacological
Combination
Public Health
Psychosocial
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Motivational
Cognitive behavioral
Community reinforcement
Contingency management
Behavioral/couples/family
Which of the following is NOT an FDA approved
treatment for alcohol dependence?
49%
A. Disulfram
B. Naltrexone
C. Fluoxetine
D. Acamprosate
21%
21%
10%
A.
B.
C.
D.
FDA approved pharmacologic
• Alcohol
– disulfiram
• 125-500mg QAM
• Must be abstinent for > 12 hrs
– Acamprosate
• 666mg TID
– Naltrexone
• 50mg QD/380mg q4wk IM
• Opioid free times 7-10 days
• Liver function tests
FDA approved pharmacologic
• Nicotine
– Buproprion
• 150-300mg PO BID
• Stop smoking 5-7 days after starting tx
– Varenicline
• 1mg PO BID x 11 wk
• Stop smoking 8-35 days after starting tx
– nicotine replacement
• Gum, lozenge, inhaled, nasal, transdermal
FDA approved pharmacologic
• Opioid
– Methadone maintenance
• Restricted to federal approved facilities
– Buprenorphine
• 2-8mg qd x 1day then 8-16mg qd x 2 days
• Begin 8-12 hours after last opioid
– Buprenorphine/naloxone
• 2-8mg qd x 1 day then 8-16mg qd x 2day
• Begin 8-12 hours after last opioid
FDA approved pharmacologic
• Opioid
– Naltrexone (PO/IM)
• 25mg PO once, repeat in one hour if no
withdrawal
• 50mg PO QD/100mg PO QOD/150mg PO
q3day/380mg IM q4wk
• Increased rates of overdose
Experimental Pharmacology
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Naltrexone
Disulfram
Mecamylamine
N- acetylcystein
Nalmafene
Topiramate
vaccinations
Public Health
• Needle exchange/sales/prescription
– http://www.cdc.gov/idu/facts.htm
• Syringe disinfection
– http://www.cdc.gov/idu/facts/disinfection.htm
Substance Abuse Outcomes
• Abstinence
• Harm reduction
– Reduced use
• Fewer days of drinking/using
– Reduced consequences
• Reduced mortality
• Reduced crime
• Reduced transmission
Alcohol Dependence
- 16 weeks of treatment
- 9 visits in 16 weeks
- One year follow up
Alcohol Dependence
Alcohol Dependence
Alcohol Dependence
Alcohol Dependence
Psychology of Substance User
• Impulsive
• Fearless
• Incapable of delayed gratification
• Opposite of people who go into health
care!!!
Traditional counseling
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Immediate and Total Abstinence
Provider set goals
Confrontational
Dichotomis
– Good (What I say)
– Bad (What you do)
• Nearly Completely Ineffective!!
Harm Reduction
• Behavioral Shaping
– Health behavior change is gradual
– Customized treatment to meet patient’s
needs
– Develop an alliance
• Mutually agreed upon goals
• Reduced confrontation
Harm Reduction
• Transtheoretical Model of Behavioral
Change
– Prochaska & DiClemente, 1982
• Motivational Interviewing
– Miller & Rollnick, 2002
Transtheoretical Model
• Gradual Behavioral Change
• Conceptualized stages
– Identify patients current stage
– Strategies to advance the stage
• Understanding of backward and forward
progress of change
– Reduced provider frustration
– Increased patient acceptance
As a primary care provider there is little
difference I can make in a brief visit.
90%
A. True
B. False
10%
A.
B.
Primary Care Intervention
Primary Care Intervention
• Toxicological and questionnaire
screening
• Brief motivational interviews
• Active referrals
• A list of treatment providers
• Follow-up booster phone call.
Risk Diagnosis Questionnaire
• Starting point for clinical interaction
• Simple self report instrument
– 13 questions
– Clinically validated
• Rapidly elicits risk behavior without
appearing judgmental
Callahan 2007
Callahan 2007
Callahan 2007
Motivational Interviewing
Miller & Rollnick, 2002
• Patient’s are ambivalent
– Immediate positive reward for current
behavior
– Delayed ambiguous reward for change
• Recognize the patient’s desire to
continue current behavior
• Support and encourage recognition of
helpfulness of behavioral change
• Strategy to move patient along stages
of change
Principles of MI
• Express Empathy
– seeing the world through the client's eyes
• Support Self-Efficacy
– no "right way" to change
– Clients responsible for choosing and carrying
out actions
• Roll with Resistance
– counselor does not fight client resistance
• Develop Discrepancy
– Motivation for change occurs when people
perceive a discrepancy between where they
are and where they want to be
OARS
1) Open-ended questions
2) Affirmations
3) Reflective listening
4) Summaries
Open Ended Questions
• Typical approach to initial patient
interactions
• Cannot be answered with “yes” or “no”
• Encourage discussion
– “So you stayed sober for a week after
treatment. How were you able to stay sober
for that week?”
Affirmations
• Statements of recognition about client
strengths
– Rapport Building
– Rare commodity in stigmatized populations
– Must be genuine
Reflective listening
• Actively guide the client towards certain
materials
– Focus on client change talk
– "You don’t really like to take medications,
but you are afraid of becoming more ill and
your counts are down."
Shifting Focus
• Client: But I can't quit drinking. I mean,
all of my friends drink!
• Counselor: You're getting way ahead of
things here. I'm not talking about your
quitting drinking here, and I don't think
you should get stuck on that concern
right now. Let's just stay with what we're
doing here - talking through the issues and later on we can worry about what, if
anything, you want to do about it.
Summaries
• Specialized form of reflective listening
– communicate your interest in a client
– call attention to salient elements of the
discussion
– shift attention or direction
– “Let me stop and summarize……”
• This is an area where you need to watch
that your wisdom and experience doesn't
keep you from listening to your client's
understanding of the problem.
http://www.motivationalinterview.org/
Project MATCH
http://pubs.niaaa.nih.gov/publications/MATCHSeries3/
Desensitization
• Health care workers can be
uncomfortable discussing the details of
homosexual behavior and illicit drug use
• Develop a comfortable vernacular
• Practice with colleagues
Jargon
• Non-medical jargon can increase patient
comfort with discussion
– Echo the patient’s words, literally
• Asking patients to define terms builds
rapport
• Online sources for clarification of Jargon
– http://www.drugabuse.gov/drugsabuse/commonly-abused-drugs/commonlyabused-drugs-chart
– Caution advised!
Humor
• Reduce patient discomfort
• Carefully titrated doses
– Avoid mocking the patient
– Avoid minimizing serious concerns
– Avoid undermining your efficacy
References
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Centers for Disease Control and Prevention. Vital signs: current cigarette smoking among adults aged ≥18
years—United States, 2009. Morbid Mortal Wkly Rep. 2010;59:1135–40.
Fuster M, Estrada V, Fernandez-Pinilla MC, et al. Smoking cessation in HIV patients: rate of success and
associated factors HIV Med. 2009;10:614–9.
Webb MS, Vanable PA, Carey MP, Blair DC. Cigarette smoking among HIV+ men and women: examining
health, substance use,and psychosocial correlates across the smoking spectrum. J Behav Med.
2007;30:371–83.
Lifson AR, Neuhaus J, Arribas JR, et al. Smoking-related health risks among persons with HIV in the
strategies for management
Feldman DN, Feldman JG, Greenblatt R, et al. CYP1A1 genotype modifies the impact of smoking on
effectiveness of HAART among women. AIDS Educ Prev. 2009;21:81–93.
Baum MK, Rafie C, Lai S, et al. Alcohol use accelerates HIV disease progression. AIDS Res Hum
Retroviruses. 2010;26:511–8.
Iralu J, Duran B, Pearson CR, et al. Risk factors for HIV disease progression in a rural southwest American
Indian population. Public Health Rep. 2010;125:43–50.
Shuper PA, Neuman M, Kanteres F, et al. Causal considerations on alcohol and HIV/AIDS—a systematic
review. Alcohol. 2010;45:159–66.
de Jong BC, Prentiss D, McFarland W, et al. Marijuana use and its association with adherence to antiretroviral
therapy among HIV-infected persons with moderate to severe nausea. J Acquir Immune Defic Syndr.
2005;38:43–6.
Baum M, Rafie C, Lai S, et al. Crack-cocaine use accelerates IV disease progression in a cohort of HIVpositive drug users. J Acquir Immune Defic Syndr. 2009;50:93–9.
References
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Mehta SH, Lucas G, Astemborski J, et al. Early immunologic and virologic responses to highly active
antiretroviral therapy and subsequent disease progression among HIV-infected injection drug users. AIDS
Care. 2007;19:637–45.
Anton, Raymond F et al, Combined Pharmacotherapies and Behavioral Interventions for Alcohol Dependence,
JAMA, May 3, 2006—Vol 295, No. 17
Adam Gonzalez & Jennifer Barinas & Conall O’Cleirigh, Substance Use: Impact on Adherence and HIV
Medical Treatment, Curr HIV/AIDS Rep (2011) 8:223–234
The CASA Columbia National Advisory Commission on Addiction Treatment, Addiction Medicine: Closing the
Gap between Science and Practice, WWW.CASACOLUMBIA.ORG, June 2012
Rajasingham R, Mimiaga MJ, White JM, Pinkston MM, Baden RP, Mitty JA., AIDS Patient Care STDS. 2012
Jan;26(1):36-52. Epub 2011 Nov 9. A systematic review of behavioral and treatment outcome studies among
HIV-infected men who have sex with men who abuse crystal methamphetamine
Grassi MP, Perin C, Clerici F, Zocchetti C, Cargnel A, Mangoni A. Acta Neurol Scand. 1993 Aug;88(2):119-22.
Neuropsychological performance in HIV-1-infected drug abusers.