Substance Abuse and HIV

1
Substance Abuse and HIV

• German Molina, M.D.
• Asst. Professor of Clinical Psychiatry
• University of Miami
• Miller School of Medicine

2
Overview

• Significance
• Epidemiology
• Connections between SUDS and HIV
• Assessment
• Treatment
• -Psychiatric, HIV Medical, Substance
• Abuse

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Significance of SUDS in HIV Patients

• Comorbid substance use disorders are common in
  individuals with HIV infection
• Psychiatric problems are multilayered
• Assessment is more complex
• Treatment is more difficult
• Involves public health as well as personal health

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Epidemiology (2001,CDC)

• Males
• 54 MSM
• 24 IDU
• 15 Het contact
• 6 MSM IDU
• 1 other

• Females
• 65 Het contact
• 32 IDU
• 3 other

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Role of Substance Use in HIV Spread

• Injection (IV, IM, SQ, etc.) with contaminated
  injecting equipment
• -not just syringe/needle, but spoon, cottons,
  etc
• Non-injection blood exchange, e.g. intranasal use
• Other non-injection drug and alcohol use is also
  associated with higher risk for HIV
• Risky sexual behavior related to SUDS
• -effects on libido, disinhibition, sex for
  drugs exchange

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Etiology of Psychiatric Disorders in HIV and SUDS

• Multilayered effect
• Pre-existing psychiatric disorders are more
  common in patients with SUD than in overall
  community samples
• Multiple etiologic contributants in HIVSUD
  patients
• -Pre-existing psychopathology
• -CNS effects of substance use, HIV
  medications, and from direct viral invasion of
  the brain

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Psychiatric Disorders in Substance Abuse and HIV
Disease
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Guidelines for Psychopharmacologic Treatment

• Factors to consider in choosing medications
• -efficacy
• -safety
• -abuse liability
• -adherence
• Use a stepwise approach starting with safest and
  least abusable agents
• Avoid long term use of benzodiazepines in SUD
  patients, although little data on this issue

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Drug Interactions HIVSUD Patients

• Psychiatric medications
• drugs of abuse
• HIV Medications
• medications to treat substance used
• disorders
• drug interactions
• Track new information on websites such as HIV
  Insite (http//hivinsite.ucsf.edu)

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Abuse Potential of Psychiatric Medications

• Little or noneantipsychotics, mood stabilizers,
  anticonvulsants, nontricyclic antidepressants,
  buspirone
• Some (arguably, data unclear)-tricyclics,
  antiparkinsonians, zolpidem?, zaleplon?,
  modafinil?
• Significant-benzodiazepines, barbituates,
  stimulants

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Necessary Components of HIV Medical Care for
Patients with SUDs

• Access to care

• Adherence to care

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Barriers to Quality Care

• External barriersLeads to access problems

• Internal barriers--- Leads to adherence problems

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External Barriers to Access to care

• Lack of available medical services
• Lack of social supports
• Lack of housing
• Lack of child care
• Lack of financial resources
• Health provider attitudes

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Internal Barriers to Care

• Drug and alcohol use
• Psychiatric disorders
• Communication problems
• Lack of knowledge, education
• Lack of motivation
• Low self-efficacy

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Treatment Plan Considerations

• Factors affecting adherence
• patient characteristics knowledge, attitudes,
  beliefs, trust in the medical system, schedule
  complexity, lifestyle, social supports
• treatment regimen number of drugs, dosing
  schedule, costs, complexity, duration, side
  effects
• --A. Vinciquerra, SUNY UMU, 2001

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Strategies for Improving Adherence

• Patient education
• Treating substance abuse
• Treating psychiatric disorders
• Memory aids
• Observed medication administration
• Incentives

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Substance Abuse Treatment

• Different models
• --Abstinence oriented
• --Harm reduction

• Different Modalities
• --Psychosocial
• --Medical

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Psychosocial Treatments for Substance Use
Disorders

• Settingsinpatient, residential, day treatment,
  outpatient
• Modalitiesself help, individual, group
• Approaches cognitive-behavioral, relapse
  prevention, motivational, 12 step based

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Methadone Interactions in HIV, 1.

• Methadone chiefly metabolized by p450 3A4
• HIV medication interactions, examples
• ---rifampin induces p450 3A4, causes methadone
  withdrawal
• ---efavirens, nelfinavir, nevirapine and others
  decrease methadone levels
• Psychiatric medication interactions, examples
• ---CBZ induces 3A4
• ---fluvoxamine inhibits 3A4, causes methadone
  intoxication
• ---fluoxetine inhibits 3A4, increses methadone
  levels

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Methadone Interactions in HIV, 2.

• Drug interactions are a constantly expanding data
  set, difficult to track

• Best to refer to websites for most up-to-date
  information on interactions
• -e.g. HIV Insite
• http//hivinsite.ucsf.edu

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Opioid Detoxification for HIVIDUs

• Inpatient use of methadone, buprenorphine, or
  clonidine may all be effective in HIV IDUs
  undergoing hospitalization for acute medical
  illness (Umbricht et al, 2003)

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Treatment of Alcohol Dependence

• Benzodiazepines for acute withdrawal
• Naltrexone (ReVia) for relapse prevention
• Disulfiram (Antabuse) for relapse prevention

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Treatment of Stimulant Abuse

• Nor proven pharmacotherapies for cocaine or
  methamphetamine dependence
• Risky to use stimulant pharmacotherapy in
  stimulant abuses
• Psychosocial treatments are the basis.

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Acknowledgment This material was presented by
Steven L. Batki, M.D. at APA Component Workshop
in May,2003 in San Francisco.
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Questions and Discussion

• Gmolina_at_med.miami.edu