the medical spectrum of hiv and substance use jacqueline peterson tulsky ucsf/sfgh positive health...

UCSF, JT9UCSF, JT9

The Medical Spectrum of HIV and Substance Use

The Medical Spectrum of HIV and Substance Use

Jacqueline Peterson TulskyJacqueline Peterson Tulsky

UCSF/SFGH Positive Health ProgramUCSF/SFGH Positive Health Program

National HIV/AIDS Clinicians Consultation National HIV/AIDS Clinicians Consultation Center Center

UCSF, JT9UCSF, JT9

HIV Care at the End of the 20th CenturyHIV Care at the End of the 20th Century

““Science and technology are evolving at a blinding pace, Science and technology are evolving at a blinding pace,

impacting on the way we provide medical care as wellimpacting on the way we provide medical care as well

as on almost every other aspect of our life. But our as on almost every other aspect of our life. But our

human psychological make-up, our higher consciousness human psychological make-up, our higher consciousness

and sense of social justice, has not evolved at the same and sense of social justice, has not evolved at the same

rate. Just think about the last HIV-infected, homeless, rate. Just think about the last HIV-infected, homeless,

mentally ill or drug addicted person you tried to take mentally ill or drug addicted person you tried to take

care of and you begin realize that all our science and allcare of and you begin realize that all our science and all

our technology still do not have much to offer for our our technology still do not have much to offer for our

most human problems.”most human problems.”

adapted from Anita Friedman, PhD

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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.

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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 UNWorld Prevalence according to UN

Primary modePrimary mode of transmission in regions of North of transmission in regions of North Africa & Middle East, East Asia & Pacific, Eastern Africa & Middle East, East Asia & Pacific, Eastern Europe & Central Asia. Europe & Central Asia.

Secondary modeSecondary mode in Latin America, Western Europe, in Latin America, Western Europe, North America and Australia & New ZealandNorth America and Australia & New Zealand

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Current epidemiology cont…..Current epidemiology cont…..

US Prevalence by June, 1999 N=US Prevalence by June, 1999 N=702,748

IDU only IDU only 179,228 (26%), 179,228 (26%),

IDU and MSM IDU and MSM 45,266 (6%)45,266 (6%)

Sex w/ IDU Sex w/ IDU 27,265 (4%)27,265 (4%)

TotalTotal 251,759 (36%)251,759 (36%)

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Current epidemiology cont... Current epidemiology cont...

““IDU only” accounts for large category of women IDU only” accounts for large category of women with AIDS (42% vs 40% for Sex w/IDU).with AIDS (42% vs 40% for Sex w/IDU).

Approx 90,000 addicts in SF Bay Area, 14% of Approx 90,000 addicts in SF Bay Area, 14% of IDUs are HIV infected. Up to 25% do not know IDUs are HIV infected. Up to 25% do not know their HIV status.their HIV status.

Mortality rates - remain higher in AIDS cases Mortality rates - remain higher in AIDS cases associated with IDU. In 1995, decline of 18% in associated with IDU. In 1995, decline of 18% in mortality in MSM, but only 6% in IDUs. mortality in MSM, but only 6% in IDUs.

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Special Medical Issues in HIV-infected Substance Users

Special Medical Issues in HIV-infected Substance Users

Drug interactions - Both prescription drugs and Drug interactions - Both prescription drugs and recreational drugs may interact with HIV medsrecreational drugs may interact with HIV meds

Some diseases have higher incidence in drug Some diseases have higher incidence in drug users and may have different presentation or users and may have different presentation or clinical course due to HIV infection. Examples: clinical course due to HIV infection. Examples: TuberculosisTuberculosis

Hepatitis B and CHepatitis B and C

Drug related hepatitisDrug related hepatitis

Soft tissue infections and pneumoniaSoft tissue infections and pneumonia

HTLV 1HTLV 1

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Medical Issues cont (2)...Medical Issues cont (2)...

Drug InteractionsDrug Interactions

Little well studied pharmacologic data, almost none Little well studied pharmacologic data, almost none in in vivo 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

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Drug InteractionsDrug Interactions

HeroinHeroin -- Increased levels with ritonavir, but -- Increased levels with ritonavir, but extremely conflicting reports. extremely conflicting reports.

LSDLSD -- No known interactions -- No known interactions

MarijuanaMarijuana -- Increased THC level with any PI -- Increased THC level with any PI

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Drug Interactions with prescription drugsDrug Interactions with prescription drugs

AnxiolyticsAnxiolytics -- Dangerously increased levels with -- Dangerously increased levels with ritonavir, but possibly decreased levels of indinavir. ritonavir, but possibly decreased levels of indinavir.

DronabinolDronabinol -- Increased levels with any Protease -- Increased levels with any Protease InhibitorInhibitor

OpiatesOpiates -- Increased levels with ritonavir ??. -- Increased levels with ritonavir ??. Decreased levels with NNRTIs, but variableDecreased levels with NNRTIs, but variable

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Tuberculosis and HIVTuberculosis and HIV

High prevalence of TB infection and disease High prevalence of TB infection and disease associated with IDU. Probably higher in alcoholics associated with IDU. Probably higher in alcoholics and crack addicts as well.and crack addicts as well.

Short course prevention regimens effective, but Short course prevention regimens effective, but concern about safety and drug interactions remains.concern about safety and drug interactions remains.

Rifampin/RifabutinRifampin/Rifabutin and and PyrazinamidePyrazinamide for 60 daily for 60 daily doses versus 9 months Isoniazid. doses versus 9 months Isoniazid.

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Hepatitis BHepatitis B Most adult IDUs infected in first few years of use, due Most adult IDUs infected in first few years of use, due

to increased sexual transmission partners at risk. to increased sexual transmission partners at risk.

Check Hep B core total and surface Check Hep B core total and surface antibodiesantibodies for for natural infection. Some with continued viremia with natural infection. Some with continued viremia with undetectable Hep B surface undetectable Hep B surface antigen.antigen.

Vaccine series still useful, especially in young Vaccine series still useful, especially in young injectors, but lower seroconversion rates than injectors, but lower seroconversion rates than reported in standard 3 series.reported in standard 3 series.

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Hepatitis CHepatitis C

Over 90% of IDUs infected in early years, but 15-20% Over 90% of IDUs infected in early years, but 15-20% of these will have antibody only . of these will have antibody only .

HIV accelerates Hep C damage, probably not the HIV accelerates Hep C damage, probably not the other way around.other way around.

Hep C complicates treatment HIV directly through Hep C complicates treatment HIV directly through liver toxicity and indirectly with risk of lactic liver toxicity and indirectly with risk of lactic accidosis and changed drug metabolism.accidosis and changed drug metabolism.

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Hepatitis C treatmentHepatitis C treatment

Case reports and small series of treatment of Hep C Case reports and small series of treatment of Hep C in HIV infected persons looks no worse (and no in HIV infected persons looks no worse (and no better) than Hep C infection alone. better) than Hep C infection alone.

Response rates reported at 30-40% depending on Response rates reported at 30-40% depending on Hep C subtype.Hep C subtype.

Highly charged issue of willingness by GI specialist Highly charged issue of willingness by GI specialist to treat drug users with Hepatitis C. to treat drug users with Hepatitis C.

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Soft Tissue Infection and PneumoniaSoft Tissue Infection and Pneumonia

Abscess, cellulitis and bacterial pneumonia rates Abscess, cellulitis and bacterial pneumonia rates may not be significantly higher by HIV status. may not be significantly higher by HIV status.

Bacteremia may be more common in HIV-infected Bacteremia may be more common in HIV-infected usersusers

Response to treatment seems similar by HIV status. Response to treatment seems similar by HIV status.

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Psychiatric Issues in HIV-infected Substance Users

Psychiatric Issues in HIV-infected Substance Users

One study of nonalcoholic persons with drug One study of nonalcoholic persons with drug dependence and HIV, rate of mental illness dependence and HIV, rate of mental illness diagnosis 53%. diagnosis 53%.

In opiate dependent persons in treatment one In opiate dependent persons in treatment one study reported co-morbid psychiatric diagnosis study reported co-morbid psychiatric diagnosis over 90%. over 90%.

Multiple Axis I disorders (Mood, psychotic and Multiple Axis I disorders (Mood, psychotic and anxiety diagnosis) common.anxiety diagnosis) common.

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Pychiatric Issues cont (2)...Pychiatric Issues cont (2)...

Axis I disordersAxis I disorders

Prevalence over 80% in one methadone treatment Prevalence over 80% in one methadone treatment study. study.

Complicates diagnosis of dementia and other CNS Complicates diagnosis of dementia and other CNS infections.infections.

Intermittently affect both decision to offer and Intermittently affect both decision to offer and ability to ability to adhere toadhere to HIV treatment. HIV treatment.

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Psychiatric Issues cont (3)...Psychiatric Issues cont (3)...

Axis II personality disordersAxis II personality disorders

Includes narcissistic, borderline, schizoid, Includes narcissistic, borderline, schizoid, antisocial and paranoid personalities.antisocial and paranoid personalities.

One study of cocaine addicts, 73% meet criteria for One study of cocaine addicts, 73% meet criteria for Axis II diagnosis. Axis II diagnosis.

Little data quantifies incidence in HIV-infected Little data quantifies incidence in HIV-infected substance users separately.substance users separately.

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Psychiatric Issues cont (4)...Psychiatric Issues cont (4)...

Axis II personality disordersAxis II personality disorders

Maybe tougher than Axis I for providers to cope Maybe tougher than Axis I for providers to cope with because of lack of clear treatment or with because of lack of clear treatment or management guidelines.management guidelines.

High burnout of providers attempting to care for High burnout of providers attempting to care for these patients if done as a single practitioner these patients if done as a single practitioner without multi-disciplinary support. without multi-disciplinary support.

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The Complex Problem of Pain in Substance Users

The Complex Problem of Pain in Substance Users

How we fail our patients with painHow we fail our patients with pain

Judging adequate pain control Judging adequate pain control

Pain control for those trying to maintain “recovery”Pain control for those trying to maintain “recovery”

Strategies for really hard-to-manage addicts in pain Strategies for really hard-to-manage addicts in pain

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Pain Management cont (2)...Pain Management cont (2)...

How we fail our patients in painHow we fail our patients in pain

Over 30% of HIV patients with pain reported that Over 30% of HIV patients with pain reported that their symptoms were not well controlled. their symptoms were not well controlled.

Poor pain control independent of “mode of Poor pain control independent of “mode of transmission” category. transmission” category.

Neglect of search for cause of pain after initial Neglect of search for cause of pain after initial evaluation.evaluation.

Discussion of pain and the interaction with Discussion of pain and the interaction with suffering.suffering.

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Pain Managament cont (3)...Pain Managament cont (3)...

Judging adequate pain controlJudging adequate pain control

Behavior as a guide to adequate control. Once Behavior as a guide to adequate control. Once adequate control achieved behavior often becomes adequate control achieved behavior often becomes more stable, reliable and less intrusive.more stable, reliable and less intrusive.

Pain scales may be helpful in monitoring control. Pain scales may be helpful in monitoring control.

Where addiction or abuse of meds is the overriding Where addiction or abuse of meds is the overriding issue, less willingness to try alternative therapies.issue, less willingness to try alternative therapies.

Rapid self taper, with encouragement, often occurs Rapid self taper, with encouragement, often occurs when cause of pain resolves.when cause of pain resolves.

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Special Issues for those in recoverySpecial Issues for those in recovery

Maximize alternative therapies to respect patient’s Maximize alternative therapies to respect patient’s wishes, but search for pain relief.wishes, but search for pain relief.

Work with treatment program to avoid rigidity in Work with treatment program to avoid rigidity in approach to pain management.approach to pain management.

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Strategies for really hard-to-manage addicts in painStrategies for really hard-to-manage addicts in pain

Single provider for all medications, esp pain Single provider for all medications, esp pain medications.medications.

Strict prescription contracts which include drug, Strict prescription contracts which include drug, amount and where it will be filled.amount and where it will be filled.

Involve pharmacists in helping to manage refills Involve pharmacists in helping to manage refills precisely.precisely.

Maximize slow-release preparations.Maximize slow-release preparations.

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Antiretroviral Therapy in Substance Users

Antiretroviral Therapy in Substance Users

Can substance users adhere to antiretroviral Can substance users adhere to antiretroviral therapy?therapy?

Do substance users want antiretroviral therapy? Do substance users want antiretroviral therapy?

Strategies to improve ARV treatment adherenceStrategies to improve ARV treatment adherence Drug regimen issuesDrug regimen issues

Environmental issuesEnvironmental issues

Co-morbid disease issues (especially substance use Co-morbid disease issues (especially substance use and psychiatric disease)and psychiatric disease)

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ARV Therapy cont (2)...ARV Therapy cont (2)...

AdherenceAdherence

Single largest issue for both providers and patients.Single largest issue for both providers and patients.

Little data looking at adherence to ART in drug Little data looking at adherence to ART in drug using populations, but what exists is mostly in using populations, but what exists is mostly in IDUs.IDUs.

Young Song’s work in methamphetamine users in Young Song’s work in methamphetamine users in SF reports around 80% adherence except during SF reports around 80% adherence except during runs.runs.

Tulsky/White data in jailed drug users shows Tulsky/White data in jailed drug users shows outstanding adherence to ARV therapyoutstanding adherence to ARV therapy

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AcceptabilityAcceptability

Clinical cohorts in Baltimore and San Francisco in Clinical cohorts in Baltimore and San Francisco in methadone treatment patients report only 50-60% of methadone treatment patients report only 50-60% of those who meet criteria for treatment are on ARVthose who meet criteria for treatment are on ARV Is this patient self-selection?Is this patient self-selection?

Is this provider selection?Is this provider selection?

Combination of both?Combination of both?

In San Francisco jail cohort, 75% of those offered In San Francisco jail cohort, 75% of those offered ARV therapy accepted.ARV therapy accepted.

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Guidelines for successful adherenceGuidelines for successful adherence

Minimize frequency of dosing.Minimize frequency of dosing.

Pill burden acceptability varies by person so this Pill burden acceptability varies by person so this may or may not be an issue.may or may not be an issue.

Maximize adherence tools….pill boxes, reminder Maximize adherence tools….pill boxes, reminder watches, computerized pill bottles.watches, computerized pill bottles.

Consideration of modified directly observed therapy Consideration of modified directly observed therapy especially during initiation phase of treatmentespecially during initiation phase of treatment

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Guidelines for successful adherenceGuidelines for successful adherence

Close monitoring of early side effects or aversion.Close monitoring of early side effects or aversion.

Open ended, persistent inquiries about adherence Open ended, persistent inquiries about adherence at each clinic appointment.at each clinic appointment.

Try to establish stability in other aspects of life…Try to establish stability in other aspects of life…housing, substance use treatment, mental health housing, substance use treatment, mental health treatment.treatment.

Use of incentives to motivate and reward.Use of incentives to motivate and reward.

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Identifying Problem Substance UseIdentifying Problem Substance Use

Problem of definition of “Problem Use”. Problem of definition of “Problem Use”.

Avoiding “Don’t Ask, Don’t Tell” interactions.Avoiding “Don’t Ask, Don’t Tell” interactions.

Look for signs and symptoms of substance useLook for signs and symptoms of substance use

Track marks, abscess (especially recurrent)Track marks, abscess (especially recurrent)

Abnormal liver function tests or elevated BPAbnormal liver function tests or elevated BP

Erratic or unusual behavior (missed appointments, lost Erratic or unusual behavior (missed appointments, lost

prescriptions, change in adherence). prescriptions, change in adherence).

*

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Identifying Your Problem Attitudes Towards Substance Users

Identifying Your Problem Attitudes Towards Substance Users

Caring for patients that you really don’t likeCaring for patients that you really don’t like

Issue not just limited to substance usersIssue not just limited to substance users

Process of professional distanceProcess of professional distance

Value of multi-disciplinary approach with attention Value of multi-disciplinary approach with attention to mutual support of team membersto mutual support of team members

Are you a patient-resistant provider? Are you a patient-resistant provider?

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Identifying Your Problem Attitudes...Identifying Your Problem Attitudes...

Setting limits and boundaries while avoiding rigidity.Setting limits and boundaries while avoiding rigidity.

““Tough Love” -- Rejecting the behavior, but not the Tough Love” -- Rejecting the behavior, but not the

patient.patient.

Absolute limits for behavior that cannot be tolerated Absolute limits for behavior that cannot be tolerated

such as violence, threats, forgery, theft.such as violence, threats, forgery, theft.

Grey zone behaviors - Takes some meds, sells or Grey zone behaviors - Takes some meds, sells or

gives some away.gives some away.

Contracting for fair practices (appt keeping, refills).Contracting for fair practices (appt keeping, refills).

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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, Most of us walk unseeing through the world,

unaware alike of its beauties, its wonders and the unaware alike of its beauties, its wonders and the

strange and sometimes terrible intensity of the strange and sometimes terrible intensity of the

lives being lived about us.“lives being lived about us.“

Rachel Carson (1907-1964)

the medical spectrum of hiv and substance use jacqueline peterson tulsky ucsf/sfgh positive health...

Documents

f f amphetamines

f f drug users

hiv meds f

pis f f cocaine

f approx

drug interactions f

hiv care

f mortality rates