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An Internist Encounters Addiction: Heroin, Alcohol, and HIV Infection in a 42 -Year-Old Man An Internist Encounters Addiction: Heroin, Alcohol, and HIV Infection in a 42 -Year-Old Man With Abdominal Pain Jeffrey H. Samet, MD, MA, MPH Professor, Boston University School of Medicine and Boston University School of Public Health Chief, General Internal Medicine, Boston Medical Center

Ray Charles Dick Van Dyke Betty Ford Tatum O’Neal ? Franklin D Roosevelt Darryl Ray Charles Dick Van Dyke Betty Ford Tatum O’Neal ? Franklin D Roosevelt Darryl Strawberry Rush Limbaugh

Ray Charles Dick Van Dyke Betty Ford Tatum O’Neal Addiction Franklin D Roosevelt Darryl Ray Charles Dick Van Dyke Betty Ford Tatum O’Neal Addiction Franklin D Roosevelt Darryl Strawberry Rush Limbaugh

Heroin Alcohol Heroin Addiction Tobacco Prescription Opioids Cocaine Heroin Alcohol Heroin Addiction Tobacco Prescription Opioids Cocaine

Overview • • Definitions Prevalence and costs Detection Comorbidity Primary medical care Addiction as Overview • • Definitions Prevalence and costs Detection Comorbidity Primary medical care Addiction as a chronic disease Pharmacological and non-pharmacological treatments • Risk reduction • Future issues

Case Presentation (12/99) • Mr. CB, 42 y/o male, presented to ED with chief Case Presentation (12/99) • Mr. CB, 42 y/o male, presented to ED with chief complaint “belly pain. ” • Moderately severe mid-abdominal pain increasing over 3 weeks

Hospitalization (11/99) 1 month prior to current admission -42 y/o male • Addiction – Hospitalization (11/99) 1 month prior to current admission -42 y/o male • Addiction – Injection drug use (IDU) for 10 years – Heroin withdrawal symptoms – Vague alcohol use • Endocarditis – LVEF 75%, mitral valve vegetation – Antibiotics for 6 weeks • Abdominal pain onset during hospitalization – CT abd & KUB unremarkable – Dx: constipation – Rx: laxatives & manual disimpaction

Initial Evaluation (12/99) -42 y/o male -11/99 endocarditis -LVEF 75% -12/99 -c/c”abd pain” • Initial Evaluation (12/99) -42 y/o male -11/99 endocarditis -LVEF 75% -12/99 -c/c”abd pain” • “Cramping” pain, constipation, poor PO intake • Intranasal heroin use “to treat abdominal pain” past 10 days • No recent IDU • Smoked 10 cigarettes/day

Physical Exam -42 y/o male -11/99 endocarditis -LVEF 75% -12/99 -c/c”abd pain” • Pleasant Physical Exam -42 y/o male -11/99 endocarditis -LVEF 75% -12/99 -c/c”abd pain” • Pleasant male NAD • P: 95, R: 18, weight: 120 lbs, afebrile • Nodes: bilateral cervical and axillary adenopathy • CV: III/VI holosystolic murmur RUSB radiating to axilla • Abd: tender RLQ and LLQ without rebound • Rectal: no focal tenderness; stool brown guaiac negative • WBC: 5. 1, Hct: 26, Plts: 267 K

Overview • • Definitions Prevalence and costs Detection Comorbidity Primary medical care Addiction as Overview • • Definitions Prevalence and costs Detection Comorbidity Primary medical care Addiction as a chronic disease Pharmacological and non-pharmacological treatments • Risk reduction • Future issues

Definitions • Drug/Alcohol abuse • Drug/Alcohol dependence • Addiction Definitions • Drug/Alcohol abuse • Drug/Alcohol dependence • Addiction

DSM IV Criteria: Drug Abuse 1 or more of the following in a year: DSM IV Criteria: Drug Abuse 1 or more of the following in a year: üRecurrent use resulting in failure to fulfill major role obligations üRecurrent use in hazardous situations üRecurrent drug-related legal problems üContinued use despite social or interpersonal problems caused or exacerbated by drugs

DSM IV Criteria: Drug Dependence 3 or more of the following in a year: DSM IV Criteria: Drug Dependence 3 or more of the following in a year: ü Tolerance ü Withdrawal ü A great deal of time spent to obtain drugs, use them, or recover from their effects ü Important activities given up or reduced because of drugs ü Using more or longer than intended ü Persistent desire or unsuccessful efforts to cut down or control substance use ü Use continued despite knowledge of having a persistent or recurrent physical or psychological problem caused or exacerbated by drug use

Addiction • Characterized by behaviors that include 1 or more of the following: * Addiction • Characterized by behaviors that include 1 or more of the following: * – Loss of control with drug use – Compulsive drug use – Continued use despite harm • A condition involving activation of the brain’s mesolimbic dopamine system; a common denominator in the acute effects of drugs of abuse† *American Society of Addiction Medicine 2001. www. asam. org/ppol/paindef. htm †Leshner AI. JAMA. 1999; 282: 1314 -1316.

Neurobiology of Addiction Prefontal cortex VTA Nucleus accumbens Neurobiology of Addiction Prefontal cortex VTA Nucleus accumbens

Overview • • Definitions Prevalence and costs Detection Comorbidity Primary medical care Addiction as Overview • • Definitions Prevalence and costs Detection Comorbidity Primary medical care Addiction as a chronic disease Pharmacological and non-pharmacological treatments • Risk reduction • Future issues

Prevalence Data, U. S. 2005 • Substance dependence or abuse – Alcohol only – Prevalence Data, U. S. 2005 • Substance dependence or abuse – Alcohol only – Illicit drugs only – Both alcohol and illicit drugs 22. 2 mil 15. 4 mil 3. 6 mil 3. 3 mil • Marijuana • Cocaine 4. 1 mil 1. 5 mil • Pain relievers 1. 5 mil • Heroin 0. 2 mil http: //www. oas. samhsa. gov/nsduh/2 k 5 results. htm#Ch 7

Estimated Leading Causes of Disability. Adjusted Life-Years (DALYS) in the U. S. , 1996 Estimated Leading Causes of Disability. Adjusted Life-Years (DALYS) in the U. S. , 1996 * * * Michaud CM, Murray CJL, Bloom BR. JAMA 2001; 285(5): 535 -539.

Estimated Leading Causes of Disability. Adjusted Life-Years (DALYS) in the U. S. , 1996 Estimated Leading Causes of Disability. Adjusted Life-Years (DALYS) in the U. S. , 1996 * * * Michaud CM, Murray CJL, Bloom BR. JAMA 2001; 285(5): 535 -539.

Estimated Economic Costs of Drug and Alcohol Abuse in the U. S. (in billions) Estimated Economic Costs of Drug and Alcohol Abuse in the U. S. (in billions) Health care expenditures $42. 1 (e. g. , Specialty treatment, prevention, research, and medical consequences) Productivity losses Other effects $262. 8 $60. 5 (e. g. , criminal justice, property) Total costs $365. 4 Office of National Drug Control Policy. 2004. The Economic Costs of Drug Abuse in the United States, 1992 -2002. http: //www. whitehousedrugpolicy. gov/publications/economic_costs/ Harwood H. Updating Estimates of the Economic Costs of Alcohol Abuse in the United States. The Lewin Group for the NIAAA, 2000. www. niaaa. nih. gov/publications/economic-2000/#table 3

Billions of Dollars Who Bears the Cost of Substance Abuse? Government Drug Abusers Victims Billions of Dollars Who Bears the Cost of Substance Abuse? Government Drug Abusers Victims & Their Households Private Insurance Swan N. NIDA Notes. Drug Abuse Costs To Society. 1998; Volume 13 (4).

Medical Record Review -42 y/o male -11/99 endocarditis • Several urgent care and ED Medical Record Review -42 y/o male -11/99 endocarditis • Several urgent care and ED visits over past 10 years -LVEF 75% -12/99 -c/c”abd pain” • No prior primary care • No mention of alcohol or drug abuse

Overview • • Definitions Prevalence and costs Detection Comorbidity Primary medical care Addiction as Overview • • Definitions Prevalence and costs Detection Comorbidity Primary medical care Addiction as a chronic disease Pharmacological and non-pharmacological treatments • Risk reduction • Future issues

What Do Patients With Substance Abuse Look Like? What Do Patients With Substance Abuse Look Like?

Detection of Alcohol and Drug Abuse in Primary Care • Patients presenting for addiction Detection of Alcohol and Drug Abuse in Primary Care • Patients presenting for addiction treatment who had a primary care (PC) physician (n=1440)* – 45% stated their physician was unaware of their substance abuse. • 28% of a national sample of PC patients reported alcohol/drug screening, past 12 months (n=7301)† *Saitz R, Mulvey KP, Plough A, Samet JH. Am J Drug Alcohol Abuse. 1997; 23: 434 -354. † Edlund MJ, Unutzer J, Wells KB. Med Care. 2004; 42: 1158 -1166.

U. S. Preventive Services Task Force Screening for Alcohol Misuse • Recommends screening and U. S. Preventive Services Task Force Screening for Alcohol Misuse • Recommends screening and behavioral counseling interventions to reduce alcohol misuse by adults in primary care settings Whitlock EP, Pole MR, Green CA, Orleans T, Klein J. Ann Intern Med. 2004; 140: 557 -568. Fleming MF, Barry KL, Manwell LB, Johnson K, London R. JAMA. 1997; 277: 1039 -1045.

NIAAA Guidelines—Screening and Brief Intervention Procedures — 2005 • Recommended screening and brief intervention NIAAA Guidelines—Screening and Brief Intervention Procedures — 2005 • Recommended screening and brief intervention procedures include 4 steps: – Step 1: ASK about alcohol use – Step 2: ASSESS for alcohol-use disorders – Step 3: ADVISE and ASSIST – Step 4: At Follow-up: CONTINUE SUPPORT http: //pubs. niaaa. nih. gov/publications/Practitioner/Clinicians. Guide 2005/clinicians_guide. htm

Week 1—Hospitalization (12/99) -42 y/o male -11/99 endocarditis -LVEF 75% -12/99 -c/c”abd pain” • Week 1—Hospitalization (12/99) -42 y/o male -11/99 endocarditis -LVEF 75% -12/99 -c/c”abd pain” • • Blood cultures negative Methadone Pain medications Abd w/: surg consult, imaging studies UGI SBFT – “Focal area of small bowel dilatation and loss of mucosal folds within the mid to distal ileum. Differential diagnosis includes a small bowel lymphoma, however, inflammatory bowel disease and mastocytosis can also be considered. ” • Cardiac Echo LVEF 70%; vegetation no longer visible

Week 2—Hospitalization (12/99– 1/00) -42 y/o male -11/99 endocarditis -LVEF 75% -12/99 -c/c”abd pain” Week 2—Hospitalization (12/99– 1/00) -42 y/o male -11/99 endocarditis -LVEF 75% -12/99 -c/c”abd pain” -UGIabnormal • Abd pain and poor PO intake persisted • HBSAg-, HBCAb+ (past Hepatitis B, resolved) • HCV Ab+ (Hepatitis C) • HIV+, CD 4 503, HVL 15, 085

Mr. CB -42 y/o male • What is your leading diagnosis? -11/99 endocarditis -LVEF Mr. CB -42 y/o male • What is your leading diagnosis? -11/99 endocarditis -LVEF 75% -12/99 -c/c”abd pain” -UGIabnormal -HIV+, HCV+ CD 4 503 • What is your next diagnostic test?

Week 2—Hospitalization (1/00) -42 y/o male -11/99 endocarditis -LVEF 75% -12/99 -c/c”abd pain” -UGIabnormal Week 2—Hospitalization (1/00) -42 y/o male -11/99 endocarditis -LVEF 75% -12/99 -c/c”abd pain” -UGIabnormal -HIV+, HCV+ CD 4 503 • CT with angiogram – Superior Mesenteric Artery (SMA) occlusion possibly secondary to mitral valve vegetation embolus – Dx: ischemic colitis – Transferred to surgery for partial colectomy

Mesenteric Vascular Occlusion F. Netter, MD CIBA Mesenteric Vascular Occlusion F. Netter, MD CIBA

Week 2—Hospitalization (1/00) -42 y/o male -11/99 endocarditis -LVEF 75% -12/99 -c/c”abd pain” -UGIabnormal Week 2—Hospitalization (1/00) -42 y/o male -11/99 endocarditis -LVEF 75% -12/99 -c/c”abd pain” -UGIabnormal -HIV+, HCV+ CD 4 503 • Prior to surgery, when Mr. CB complained of ongoing pain, house staff expressed annoyance by his multiple requests for pain medication.

Physician Management of Opioid Addiction • Qualitative analysis of interviews with illicit drug-using patients Physician Management of Opioid Addiction • Qualitative analysis of interviews with illicit drug-using patients and their physicians and direct observation of patient care interactions • Inpatient medical service of an urban teaching hospital (6/97 -12/97) Merrill JO, Rhodes LA, Deyo RA, Marlatt GA, Bradley KA. J Gen Intern Med. 2002; 17: 327 -333.

Physician Management of Opioid Addiction: Themes 1. Physician Fear of Deception Physicians question the Physician Management of Opioid Addiction: Themes 1. Physician Fear of Deception Physicians question the “legitimacy” of need for opioid prescriptions (“drug seeking” patient vs. legitimate need). “When the patient is always seeking, there is a sort of a tone, always complaining and always trying to get more. It’s that seeking behavior that puts you off, regardless of what’s going on, it just puts you off. ” -Junior Medical Resident

Physician Management of Opioid Addiction: Themes 2. No Standard Approach The evaluation and treatment Physician Management of Opioid Addiction: Themes 2. No Standard Approach The evaluation and treatment of pain and withdrawal is extremely variable among physicians and from patient to patient. There is no common approach nor are there clearly articulated standards. “The last time, they took me to the operating room, put me to sleep, gave me pain meds, and I was in and out in two days. . This crew was hard! It’s like the Civil War. ‘He’s a trooper, get out the saw’. . . ’” -Patient w/ Multiple Encounters

Physician Management of Opioid Addiction: Themes 3. Patient Fear of Mistreatment Patients are fearful Physician Management of Opioid Addiction: Themes 3. Patient Fear of Mistreatment Patients are fearful they will be punished for their drug use by poor medical care. “I mentioned that I would need methadone, and I heard one of them chuckle. . . in a negative, condescending way. You’re very sensitive because you expect problems getting adequate pain management because you have a history of drug abuse. . . He showed me that he was actually in the opposite corner, across the ring from me. ” -Patient

Physician Management of Opioid Addiction: Conclusions • Physicians and drug-using patients display mutual mistrust. Physician Management of Opioid Addiction: Conclusions • Physicians and drug-using patients display mutual mistrust. • Physicians’ clinical inconsistency, avoidance behaviors and fear of deception, problematically interact with patients’ fear of mistreatment and stigma. • Medical education should focus greater attention on addiction medicine and pain management.

Addressing Opioid Withdrawal and Pain Management • Manage opioid withdrawal – Hospitalized patients with Addressing Opioid Withdrawal and Pain Management • Manage opioid withdrawal – Hospitalized patients with opioid dependence should be treated with methadone. • Manage pain – Treat with pain relievers in addition to methadone. O’Connor PG, Samet JH, Stein MD. Am J Med. 1994; 96: 551 -8. Alford DP, Compton P, Samet JH. Ann Intern Med. 2006; 144: 127 -134.

Week 4—Treatment (1/00) -42 y/o male -11/99 endocarditis • Transferred to med, endocarditis secondary Week 4—Treatment (1/00) -42 y/o male -11/99 endocarditis • Transferred to med, endocarditis secondary to central line infection -LVEF 75% -HIV+, HCV+ CD 4 503 • Total parenteral nutrition (TPN) -1/00 SMA thrombosis, small bowel resection • Cardiac Echo LVEF 40% • Evaluated by CT surgery

Overview • • Definitions Prevalence and costs Detection Comorbidity Primary medical care Addiction as Overview • • Definitions Prevalence and costs Detection Comorbidity Primary medical care Addiction as a chronic disease Pharmacological and non-pharmacological treatments • Risk reduction • Future issues

In the US, 25% of AIDS is from IDU. http: //www. cdc. gov/hiv/topics/surveillance/resources/slides/epidemiology/slides/EPIAIDS_16. ppt In the US, 25% of AIDS is from IDU. http: //www. cdc. gov/hiv/topics/surveillance/resources/slides/epidemiology/slides/EPIAIDS_16. ppt

Alcohol Problems among HIV-Infected Persons • Veterans with HIV (Veterans Aging Cohort Study) (n=881)* Alcohol Problems among HIV-Infected Persons • Veterans with HIV (Veterans Aging Cohort Study) (n=881)* – 36% were current “hazardous” drinkers • Patients establishing primary care for HIV infection (Boston Medical Center) (n=664)† – 42% had current or past alcohol problems *Conigliaro J, Gordon AJ, Mc. Ginnis KA, Rabeneck L, Justice AC. JAIDS. 2003; 33: 521 -525. †Samet JH, Phillips SJ, Horton NJ, Traphagen ET, Freedberg KA. AIDS Res Hum Retroviruses. 2004; 20: 151 -155.

Febrile Injection Drug Users— Major Illness at Presentation n=180 17% 6% 34% Samet JH, Febrile Injection Drug Users— Major Illness at Presentation n=180 17% 6% 34% Samet JH, Shevitz A, Fowle J, Singer DE. Am J Med. 1990; 89: 53 -57.

Comorbidities in Patients With Alcohol or Other Drug Disorders (AOD) Med/Psych DX % of Comorbidities in Patients With Alcohol or Other Drug Disorders (AOD) Med/Psych DX % of AOD Pts % of Controls Acid-related 5. 5 2. 1 Arthritis 3. 9 1. 3 Asthma 6. 8 2. 6 COPD 0. 7 0. 1 Headache 9. 2 3. 8 Hypertension 7. 2 3. 4 Low back pain 11. 2 5. 8 Injury/OD 25. 6 12. 1 Liver cirrhosis 0. 7 0. 1 Hepatitis C 0. 7 0. 2 Depression 28. 5 2. 7 Anxiety disorder 16. 9 2. 2 Major psychosis 6. 6 0. 4 Mertens JR, Lu YW, Parthasarathy S, Moore C, Weisner CM. Arch Intern Med 2003; 163: 2511 -2517.

Comorbidities in Patients With Alcohol or Other Drug Disorders (AOD) Med/Psych DX % of Comorbidities in Patients With Alcohol or Other Drug Disorders (AOD) Med/Psych DX % of AOD Pts % of Controls Acid-related 5. 5 2. 1 Arthritis 3. 9 1. 3 Asthma 6. 8 2. 6 COPD 0. 7 0. 1 Headache 9. 2 3. 8 Hypertension 7. 2 3. 4 Low back pain 11. 2 5. 8 Injury/OD 25. 6 12. 1 Liver cirrhosis 0. 7 0. 1 Hepatitis C 0. 7 0. 2 Depression 28. 5 2. 7 Anxiety disorder 16. 9 2. 2 Major psychosis 6. 6 0. 4 Mertens JR, Lu YW, Parthasarathy S, Moore C, Weisner CM. Arch Intern Med 2003; 163: 2511 -2517.

Hepatitis C (HCV) • 50%-80% of new injection drug users are infected with HCV Hepatitis C (HCV) • 50%-80% of new injection drug users are infected with HCV within 6– 12 months. * • Alcohol use and HIV co-infection independently increase the risk of HCV disease progression. *† • HCV has been associated with increased depressive symptoms in HIV-infected persons. ‡ • HCV is challenging to treat in patients with substance use and psychiatric illnesses. § *NIDA Drug Alert Bulletin—Hepatitis. www. drugabuse. gov/Hepatitis. Alert. html. †Sulkowski MS, Moore RD, Mehta SH, Chaisson RE, Thomas DL. JAMA. 2002; 288: 199 -206. ‡Libman H, Saitz R, Nunes D, Cheng DM, Samet JH. J Gastroenterol. 2006; 101: 1804– 1810. §Nunes D, Saitz R, Libman H, Cheng DM, Samet JH. Alcohol Clin Exp Res. 2006; 30: 1520 -1526.

Rehab Hospitalization (2/003/00) Wt 107 125 lbs with TPN Smoking continued No IDU past Rehab Hospitalization (2/003/00) Wt 107 125 lbs with TPN Smoking continued No IDU past 4 months CT surgeon: mitral valve replacement after patient in community with 6 wks recovery • Upon discharge from rehab hospital patient linked to • -42 y/o male • -11/99 endocarditis • -HIV+, HCV+ • CD 4 503 -1/00 SMA thrombosis, small bowel resection -LVEF 40% – Primary care – Methadone program – 12 -Step program

Overview • • Definitions Prevalence and costs Detection Comorbidity Primary medical care Addiction as Overview • • Definitions Prevalence and costs Detection Comorbidity Primary medical care Addiction as a chronic disease Pharmacological and non-pharmacological treatments • Risk reduction • Future issues

Management of Adults Recovering From Alcohol or Other Drug Problems • Primary care teams Management of Adults Recovering From Alcohol or Other Drug Problems • Primary care teams are ideally positioned to support recovery. – Establish a supportive relationship with regular follow up – Facilitate involvement in 12 -step groups – Help patients recognize and cope with relapse precipitants and craving – Manage depression, anxiety, and other comorbid conditions – Consider adjunctive pharmacotherapy – Collaborate with addiction and mental health professionals Friedmann PD, Saitz R, Samet JH. JAMA. 1998; 279: 1227 -1231. Friedmann PD, Rose J, Hayaki J, et al. J Gen Intern Med. 2006; 21: 1229 -1275.

Receipt of Primary Care (PC) • Impact of receiving PC on a cohort of Receipt of Primary Care (PC) • Impact of receiving PC on a cohort of alcohol, heroin, or cocaine dependent persons with no prior PC (n=391) – Receipt of PC (>2 visits) improved addiction severity • Lower odds of drug use or alcohol intoxication (AOR 0. 45, 95 % CI 0. 29 -0. 69, P=0. 002) • Lower alcohol severity (ASI) (P=0. 04) • Lower drug severity (ASI) (P=0. 01) Saitz R, Horton NJ, Larson MJ, Winter M, Samet JH. Addiction. 2005; 100: 70 -78.

Primary Care Problem List (4/00) -42 y/o male -11/99 endocarditis -HIV+, HCV+ CD 4 Primary Care Problem List (4/00) -42 y/o male -11/99 endocarditis -HIV+, HCV+ CD 4 503 -1/00 SMA thrombosis, small bowel resection -LVEF 40% • • • HIV (CD 4 12/99— 503, 4/00— 373) HCV+ Heroin dependence Alcohol abuse Smoking S/P SMA thrombosis with small bowel resection • Mitral valve insufficiency & CHF s/p endocarditis • Medications: methadone, lisinopril, furosemide

Overview • • Definitions Prevalence and costs Detection Comorbidity Primary medical care Addiction as Overview • • Definitions Prevalence and costs Detection Comorbidity Primary medical care Addiction as a chronic disease Pharmacological and non-pharmacological treatments • Risk reduction • Future issues

Drug Dependence— A Chronic Disease • Pathophysiology – Changes in the brain/dopamine system could Drug Dependence— A Chronic Disease • Pathophysiology – Changes in the brain/dopamine system could be permanent. • Diagnosis – DSM-IV: explicit criteria • Genetic heritability – Significant genetic component of addiction • Etiology/Role of personal responsibility – Voluntary behaviors interact with genetic factors. Mc. Lellan AT, Lewis DC, O’Brien CP, Kleber HD. JAMA. 2000; 284: 1689 -1695.

Chronic Disease Management: A Collaborative Clinical Approach • Demonstrated effectiveness with chronic illnesses • Chronic Disease Management: A Collaborative Clinical Approach • Demonstrated effectiveness with chronic illnesses • Addresses patient and system barriers to receipt of needed treatment • Links primary and specialty health care Wagner EH. BMJ. 2000; 320: 569 -572. Casalino LP. JAMA. 2005; 293: 485 -488.

Rehab Hospitalization (2/00 -3/00) Wt 107 125 lb with TPN Smoking continued No IDU Rehab Hospitalization (2/00 -3/00) Wt 107 125 lb with TPN Smoking continued No IDU past 4 months CT surgeon: mitral valve replacement after patient in community with 6 wks recovery • Upon discharge from rehab hospital patient linked to • -42 y/o male • -11/99 endocarditis • -HIV+, HCV+ • CD 4 503 -1/00 SMA thrombosis, small bowel resection -LVEF 40% – Primary care – Methadone program – 12 -Step program

Overview • • Definitions Prevalence and costs Detection Comorbidity Linking to primary medical care Overview • • Definitions Prevalence and costs Detection Comorbidity Linking to primary medical care Addiction as a chronic disease Pharmacological and non-pharmacological treatments • Risk reduction • Future issues

Pharmacotherapy • Opioids – Methadone – Buprenorphine – Naltrexone • Alcohol – Naltrexone – Pharmacotherapy • Opioids – Methadone – Buprenorphine – Naltrexone • Alcohol – Naltrexone – Acamprosate – Disulfiram • Cocaine and other psychostimulants – No effective medication

Methadone Efficacy • • Improves overall survival Improves retention in treatment Decreases heroin and Methadone Efficacy • • Improves overall survival Improves retention in treatment Decreases heroin and other drug use Decreases HIV and hepatitis seroconversion Decreases criminal activity Increases social functioning Improves birth outcomes Strain EC, Stitzer ML. Methadone Treatment for Opioid Dependence. 1999.

Buprenorphine • 10/02 FDA approval to treat opioid dependence • Partial opioid agonist • Buprenorphine • 10/02 FDA approval to treat opioid dependence • Partial opioid agonist • Available in primary care Fiellin DA, O’Connor PG. N Engl J Med. 2002; 347: 817 -823.

Buprenorphine/Naloxone (Suboxone®): • Decreases abuse potential by injection route – Sublingual use: predominantly buprenorphine Buprenorphine/Naloxone (Suboxone®): • Decreases abuse potential by injection route – Sublingual use: predominantly buprenorphine effect – Parenteral use: predominantly naloxone effect

Buprenorphine Treatment • Efficacy and retention comparable to methadone • Milder withdrawal symptoms • Buprenorphine Treatment • Efficacy and retention comparable to methadone • Milder withdrawal symptoms • Very low risk of overdose • Decreased risk of abuse and diversion (buprenorphine/naloxone) Johnson RE, Chutuape MA, Strain EC, Walsh SL, Stitzer ML, Bigelow GE. New Engl J Med. 2000; 343: 1290 -1297.

12 -Step Programs 12 -Step Programs

12 -Step Programs • Alcoholics Anonymous (AA) • Narcotics Anonymous (NA) • Cocaine Anonymous 12 -Step Programs • Alcoholics Anonymous (AA) • Narcotics Anonymous (NA) • Cocaine Anonymous (CA) • • • Focus on abstinence Life long participation is emphasized Use of sponsor encouraged Free Research on effectiveness* *Morgenstern J, Bux D, Labouvie E, Blanchard KA, Morgan TJ. J Stud Alcohol. 2002; 63: 665 -672.

Mitral Valve Replacement (5/00) -42 y/o male -11/99 endocarditis -HIV+, HCV+ CD 4 373 Mitral Valve Replacement (5/00) -42 y/o male -11/99 endocarditis -HIV+, HCV+ CD 4 373 -1/00 SMA thrombosis, small bowel resection -LVEF 40% -3/00 Methadone program • St. Jude’s prosthetic valve • Surgery successful without complications

Primary Care (11/00) -42 y/o male -11/99 endocarditis -HIV+, HCV+ CD 4 373 -1/00 Primary Care (11/00) -42 y/o male -11/99 endocarditis -HIV+, HCV+ CD 4 373 -1/00 SMA thrombosis, small bowel resection -LVEF 40% -3/00 Methadone program -5/00 MVR • Primary care follow up with HIV RN • Methadone treatment • Urine tox screens documented 3 -4 months abstinence • alcohol use, 5 drinks/day • Returned to full-time employment • Weight 123 134 lbs

Primary Care (4/01) -42 y/o male -11/99 endocarditis -HIV+, HCV+ CD 4 373 -1/00 Primary Care (4/01) -42 y/o male -11/99 endocarditis -HIV+, HCV+ CD 4 373 -1/00 SMA thrombosis, small bowel resection -LVEF 40% -3/00 Methadone program -5/00 MVR • Heavy alcohol use, withdrawal; alcohol on breath, “had a nip this morning” • “Sniffed a bag or so”; no IDU • Anhedonia; no suicidal ideation • CD 4 313 • Medications: lisinopril, methadone, warfarin • Dx: depression • Rx: fluoxetine, psychiatric referral • ART not prescribed

Addiction Hospital (7/01) • 1 pint vodka/day past several months • Recent IV heroin Addiction Hospital (7/01) • 1 pint vodka/day past several months • Recent IV heroin use • Symptoms: sweats, nausea, vomiting, diarrhea, abdominal & muscle cramps, body aches, chills, anxiety, depression, sleep disturbance, and visual hallucinations • Discharge summary: PCP never called; no HIV diagnosis

Potential Benefits of Linking Primary Care (PC) and Substance Abuse (SA) Services • Patient Potential Benefits of Linking Primary Care (PC) and Substance Abuse (SA) Services • Patient Perspective – Facilitates access to SA treatment and PC – Improves substance abuse severity and medical problems – Increases patient satisfaction with health care • Societal perspective – Reduces health care costs – Diminishes duplication of services – Improves health outcomes Samet JH, Friedmann P, Saitz R. Arch Intern Med. 2001; 161: 85 -91.

Primary Care -42 y/o male -11/99 endocarditis -HIV+, HCV+, CD 4 313 -1/00 SMA Primary Care -42 y/o male -11/99 endocarditis -HIV+, HCV+, CD 4 313 -1/00 SMA thrombosis, small bowel resection -LVEF 40% -3/00 Methadone program -5/00 MVR -7/01 Addiction treatment (10/01) • Administrative taper from methadone program for threatening behavior • Alcohol use: ½– 1 six pack/day • New sexual partner – 100% condom use • CD 4 302, HVL 7000 • No ART

Primary Care (12/01) -42 y/o male -11/99 endocarditis -HIV+, HCV+, CD 4 313 -1/00 Primary Care (12/01) -42 y/o male -11/99 endocarditis -HIV+, HCV+, CD 4 313 -1/00 SMA thrombosis, small bowel resection -LVEF 40% -3/00 Methadone program -5/00 MVR -7/01 Addiction treatment • Married (11/01) • Not willing to decrease alcohol use – Discussed pros and cons – Suggested recovery as “wedding present” • ART deferred pending improvement in alcohol use

Should Antiretroviral Therapy Be Started in the Patient Who Continues to Abuse Substances? Should Antiretroviral Therapy Be Started in the Patient Who Continues to Abuse Substances?

Current IDU and ART • HIV-infected persons first prescribed ART between 1996 -2000 (n=578) Current IDU and ART • HIV-infected persons first prescribed ART between 1996 -2000 (n=578) – classified as current IDU, former IDU, or non drug user • Current IDUs were less likely to suppress their HIV-1 RNA to <500 copies/m. L compared to non-drug users. • Former IDUs were not less likely to achieve HIV-1 suppression compared to non-drug users. Palepu A, Tyndall M, Yip B, O’Shaughnessy MV, Hogg RS, Montaner JSG. JAIDS. 2003; 32: 522 -526.

Treatment Options • If in recovery, ART should be considered in the same manner Treatment Options • If in recovery, ART should be considered in the same manner as with a patient without this history. • It is reasonable to defer ART in active drug or alcohol users depending on CD 4 count. • Promoting optimal adherence and substance abuse treatment will influence positive outcomes. Sherer R. JAMA. 1998; 280: 567 -568.

Primary Care (10/02) -42 y/o male -11/99 endocarditis • VA opioid treatment program on Primary Care (10/02) -42 y/o male -11/99 endocarditis • VA opioid treatment program on LAAM -HIV+, HCV+, CD 4 313 • Alcohol: 2 -3 days/week with 3 drinks/day -1/00 SMA thrombosis, small bowel resection • Court mandated breathalyzers, moderated alcohol use -LVEF 40% • Attended AA meetings 4 X/week, no sponsor -3/00 Methadone program • Flu shot -5/00 MVR • Advised clean needles from NEP, if relapse -7/01 Addiction treatment

Overview • • Definitions Prevalence and costs Detection Comorbidity Primary medical care Addiction as Overview • • Definitions Prevalence and costs Detection Comorbidity Primary medical care Addiction as a chronic disease Pharmacological and non-pharmacological treatments • Risk reduction • Future issues

Needle Exchange Program (NEP) • Review of 42 studies from 1989 -1999 – Substantial Needle Exchange Program (NEP) • Review of 42 studies from 1989 -1999 – Substantial evidence that NEPs decrease HIV risk behavior and HIV seroconversion among injection drug users Gibson DR, Flynn NM, Perales D. AIDS. 2001; 15: 1329 -1341.

Emergency Department (3/16/03) -42 y/o male -11/99 endocarditis -HIV+, HCV+, CD 4 313 -1/00 Emergency Department (3/16/03) -42 y/o male -11/99 endocarditis -HIV+, HCV+, CD 4 313 -1/00 SMA thrombosis, small bowel resection -LVEF 40% -3/00 Methadone program -5/00 MVR -7/01 Addiction treatment • Mr. CB collapsed at home • Wife performed CPR and called EMS • EMS – BP unobtainable – Administered naloxone with effect • In Emergency Department – – – Fresh track marks bilateral Alcohol level 188 p. H 6. 88 RR 2 Hematocrit 21 • 4 hours later pronounced dead

Acute Heroin Overdose Diagnosis • Altered level of consciousness plus 1 of the following: Acute Heroin Overdose Diagnosis • Altered level of consciousness plus 1 of the following: – Respiratory rate <12 breaths/min – Miotic pupils – Circumstantial evidence or history of heroin use • Response to naloxone usually a confirmation of heroin intoxication

Fatal Heroin Overdose • Major cause of death among heroin users • Most commonly Fatal Heroin Overdose • Major cause of death among heroin users • Most commonly a result of intravenous administration in drug dependent persons • Not usually due to a toxic quantity but polydrug use (e. g. , alcohol, benzodiazepines) Darke S, Zador D. Addiction. 1996; 91: 1765 -1772. Sporer KA. Ann Intern Med. 1999; 130: 583 -590.

Non-Fatal Heroin Overdose • 68% of active users* • Reasons – Higher than usual Non-Fatal Heroin Overdose • 68% of active users* • Reasons – Higher than usual dose – Stronger than usual heroin – Heroin combined with alcohol – Use of heroin after abstinence – Deliberate self-harm *Darke S, Zador D. Addiction. 1996; 91: 1765 -1772. Sporer KA. Ann Intern Med. 1999; 130: 583 -590. JD, Saitz R, Horton NJ, Lloyd-Travaglini C, Samet JH. Drug Alcohol Depend. In press. Wines

Drug Abuse and Suicidal Behavior • Drug abuse is a risk factor for suicidal Drug Abuse and Suicidal Behavior • Drug abuse is a risk factor for suicidal behavior, however, little is known of the causal relationship. • A better understanding of this relationship will help with suicide prevention efforts. Erinoff L, Compton WM, Volkow ND. Drug Alcohol Depend. 2004; 76 S: S 1 -S 2.

Drug Abuse and Suicidal Behavior • Cohort of detox patients (n=470) – Lifetime history Drug Abuse and Suicidal Behavior • Cohort of detox patients (n=470) – Lifetime history of • Suicidal ideation (SI): 29% • Suicide attempt (SA): 22% – Two year follow-up prevalence of • SI: 20% • SA: 7% Wines JD, Saitz R, Horton NJ, Lloyd-Travaglini C, Samet JH. Drug Alcohol Depend. 2004; 76 S: S 21 -S 29.

Mortality in Persons With Substance Dependence • Cohort of patients in addiction treatment (n=845; Mortality in Persons With Substance Dependence • Cohort of patients in addiction treatment (n=845; 1972 -1983)* – 241 deaths • 51% tobacco-related • 34% alcohol-related • Cohort of injection drug users in primary care (n=667; 1980– 2001)† – 153 deaths • 1980– 1990, principal cause of death was overdose • 1990– 2002, principal cause of death was HIV/AIDS • 1992– 2002, HCV emerged as a cause of death *Copeland L, Budd J, Robertson JR, Elton RA. Arch Intern Med. 2004; 164: 1214 -1220. RD, Offor KP, Corghan IT et al. JAMA. 1996; 275: 1097 -1103. R, Gaeta J, Cheng DM, Richardson JM, Samet JH. J Urban Health. In press. †Hurt Saitz

Post-Mortem • Negative – Relapses to substance use despite addiction treatment and medical care Post-Mortem • Negative – Relapses to substance use despite addiction treatment and medical care – Communication between addiction treatment hospital and PC suboptimal • Positive – Effective treatment for complicated medical, surgical, addiction, and psychiatric problems – Improved function and quality of life – Maintained relationships and responsibilities – Collaborative care between medical and methadone providers

Overview • • Definitions Prevalence and costs Detection Comorbidity Primary medical care Addiction as Overview • • Definitions Prevalence and costs Detection Comorbidity Primary medical care Addiction as a chronic disease Pharmacological and non-pharmacological treatments • Risk reduction • Future issues

Future Issues • Address the quality chasm for mental health and addictive disorders (IOM) Future Issues • Address the quality chasm for mental health and addictive disorders (IOM) • Develop and use effective pharmacotherapy • Incorporate optimal organization of health services • Mainstream addictive disorders into medical care

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