HIV and Substance Use. Disclosure. Learning Objectives

Transcription

1 HIV and Substance Use Thomas E. Freese, Ph.D. Director, Pacific Southwest Addiction Technology Transfer Center Director of Training, UCLA Integrated Substance Abuse Programs Florida AIDS Education and Training Center May 2009 Disclosure I have no real or perceived vested interests that relate to this presentation nor do I have any relationships with pharmaceutical companies, biomedical device manufacturers, and/or other corporations whose products or services are related to pertinent therapeutic areas. Learning Objectives Identify the neurocognitive impact of substance dependence Describe the strategies for providing services to substance using clients with or at risk for HIV Identify the primary drug trends impacting clients with or at risk for HIV

2 Why do people take drugs? To feel good To have novel: Feelings Sensations Experiences AND To share them To feel better To lessen: Anxiety Worries Fears Depression Hopelessness Withdrawal A Major Reason People Take a Drug is They Like What it Does to Their Brains

3 Natural Rewards Elevate Dopamine Levels % of Basal DA Output Empty FOOD Box Feeding NAc shell Time (min) Source: Di Chiara et al. DAConcentration (% Baseline) ScrScr BasFemale 1 Present SEX Scr Sample Number Mounts Intromissions Ejaculations Source: Fiorino and Phillips Scr Female 2 Present Copulation Frequency

4 % of Basal Release Effects of Drugs on Dopamine Release Accumbens AMPHETAMINE DA DOPAC HVA hr Time After Amphetamine % of Basal Release Accumbens COCAINE DA DOPAC HVA hr Time After Cocaine % of Basal Release NICOTINE Accumbens Caudate hr Time After Nicotine Source: Di Chiara and Imperato Prolonged Drug Use Changes The Brain In Fundamental and Long-Lasting Lasting Ways We Have Evidence That These Changes Can Be Both Structural and Functional AND We Have Evidence That These Changes Can Be Both Structural and Functional

5 Normal Cocaine Abuser (10 Days) Cocaine Abuser (100 Days) Sources: Volkow, et al., Synapse, 11: , 1992 & Volkow, et al., Synapse, 14: , 1993 Dopamine D2 Receptors are Lower in Addiction Cocaine DA DA DA Meth Alcohol DA D2 Receptor Availability DA DA DA DA DA DA DA DA DA Reward Circuits Non-Drug Abuser DA DA DA DA DA DA Heroin control addicted Reward Circuits Drug Abuser Repeated drug exposure (e.g., via neurotrophic factors, FosB, CREB?) Normal responses to drugs Use-dependent plasticity leading to sensitized responses to drug and environmental cues Nestler, 2001

6 Chronic cocaine increases density of dendritic spines and neuronal branching in the nucleus accumbens Branches 50 COC 8 CTL COC CTL COC 45 CTL COC CTL Robinson, T.E. & Kolb, B. Eur. J. of Neuro Ferrario, C.R. et al. Biol. Psychiatry, Methamphetamine PET Scan of Long-Term Impact of Methamphetamine on the Brain

7 Dopamine Transporters in Methamphetamine Abusers Normal Control Methamphetamine Abuser p < Dopamine Transporter (Bmax/Kd) Dopamine Transporter Bmax/Kd Motor Activity Time Gait (seconds) Memory Delayed Recall (words remembered) Control > MA MA > Control

8 How much does the brain heal? PET Scan of Long-Term Meth Brain Damage Partial Recovery of Brain Dopamine Transporters in Methamphetamine (METH) Abuser After Protracted Abstinence 3 0 Normal Control METH Abuser (1 month detox) METH Abuser (24 months detox) ml/gm Source: Volkow, ND et al., Journal of Neuroscience 21, , 2001.

9 Methamphetamine and HIV and the Brain Meth Abuse, HIV Infection Cause Changes in Brain Structure Methamphetamine abuse and HIV infection cause significant alterations in the volume of brain gray matter structures and cognitive functions In both cases the changes may be associated with impaired cognitive functions, such as difficulties in learning new information, solving problems, maintaining attention and quickly processing information. Co-occurring methamphetamine abuse and HIV infection appears to result in greater impairment than each condition alone. SOURCE: Meth Abuse, HIV Infection Cause Changes in Brain Structure Methamphetamine abuse is associated with increases in the volume of the brain's parietal cortex (which helps people to understand and pay attention to what's going on around them) and basal ganglia (linked to motor function and motivation). HIV infection is associated with prominent volume losses in the cerebral cortex (involved in higher thought, reasoning, and memory), basal ganglia, and hippocampus (involved in memory and learning). SOURCE:

10 Meth Abuse, HIV, and Brain Volume CRACK COCAINE AND HIV Crack Cocaine and HIV Infection HIVNET: 4,892 persons at high-risk for HIV infection enrolled in cohort between Cohort incidence: 1.3 infections per 100 persons per year (ppy) MSM incidence: 2.0 per 100 ppy Definitely interested in vaccine: 2.0 per 100 ppy Female crack cocaine users: 1.6 per 100 ppy Seague et al., 2001

11 Crack Cocaine and HIV Risks HIV risk behaviors in 637 crack, powder cocaine and heroin users in central Harlem: Injectors (OR = 2.5) Engaged in fraud/cons (OR = 2.6) Separated/divorced/widowed (OR = 2.2) Multiple sex partners (OR = 1.7) Females (OR = 1.7) Davis et al., 2006 Crack Cocaine and HIV Risks for Females? Crack cocaine use causes significant problems with response to HIV treatment In 113 HIV-positive individuals in methadone maintenance, ART adherence was 46% for females; 73% for males (p<.05; Berg et al., 2004) Factors associated with worse adherence in separate gender strata were: No HIV support group (p<.0001) Crack cocaine use (p<.005) Medication side effects (p<.005) Among females, reported heavy alcohol use (p<.05) Crack Cocaine Use and HIV Disease In one study, the majority of 137 HIV-infected African American crack cocaine users reported ARV adherence 53% claim full adherence with 1 or more medications (Crisp et al., 2004) In 1,196 African American HIV-infected women, crack users (26%) were significantly less likely than non users to take ART exactly as prescribed (OR =.37; Sharpe et al., 2004) Among HIV-infected individuals, crack cocaine use (OR = 1.8) and HIV symptoms (OR = 1.7) significantly predicted progression to AIDS (Webber et al., 1999)

12 What s new and what s next Prescription Drug Abuse What is Rx & OTC Drug Misuse? Any Rx and OTC drug can be misused Misuse = Non-medical use = Any use that is outside of medically prescribed regimen Examples include: Taking for psychoactive high effects Taking for effects not indicated Taking non-medical extreme doses Mixing meds Using with alcohol or other substances Obtaining from non-medical source Obtaining from multiple sources at a time (Dr. Shopping) Should there be Concern? Populations most at risk are Youth Young Adults Older Adults

13 Rx Drug Misuse in the U.S. 6.4 million (2.6%) aged 12 or older used prescription-type drugs non-medically. Reported Non-Medical Prescription Drugs of Abuse (2005) S edatives Tranquilizers S timulants P ainkillers 4,700,000 1,800,000 1,100, ,000 NSDUH, 2006 Commonly Misused Rx Drugs Classified in 3 classes Opiates: pain-killers Eg. Vicodin, Oxycontin, Tylenol Codeine CNS Depressants (Sedatives/Tranqualizers): treat anxiety and sleep disorders Ex. Xanax, Ativan, Valium, Soma Stimulants: ADHD, weight loss Ex. Aderall, Ritalin, Concerta, Dexedrine, Fastin OTC Medicine Abuse Dextromethorphan DXM is the active ingredient in over 100 cold/cough remedies. Found in tablets, capsules, gel caps, lozenges & syrups, teens discovered: using mass quantities of DXM-containing products get them high.

14 Examples of Popular OTC Products Coricidin HBP Cough & Cold Robitussin Cough products Sudafed Cough medicines Dimetapp DM Tylenol Cold products Vicks 44 Cough Relief Vicks NyQuil and Dayquil Triaminic Cough syrups Alka-Seltzer Plus Cold & Cough Access & Availability The Home Retail Pharmacies The Internet Online Access No Prescriptio n Required!

15 Social Networking Web Sites: Medicine Abuse Subculture MySpace YouTube LiveJournal Facebook Footage of teens high User Guides: Rx & OTC abuse instructions (recipes) Blogs & videos of experiences Medicalization of Youth Behavioral Problems Direct-to-Consumer (DTC) Advertising of Psychiatric Drugs Amazon.com pushing ADHD drugs with front-page, celebrity-endorsed

16 Teens Don t Understand the Risks & Effects of Abusing Rx and OTC Medicines Over 50% believe that abusing these medicines to get high is NOT risky Join Together, 2006 Dependence & Treatment Abusing Rx drugs before the age of 16 leads to a greater risk of dependence later in life. The # of teens going into treatment for Rx drug abuse has increased by more than 300% during the last 10 years. Between , the proportion of those seeking treatment for Rx drugs increased by 9%. TEDS, 2006

17 Risk Behaviors of Youth Living with HIV: Pre/Post HAART Era Pre-HAART 349 YLH recruited mean age: % males Post-HAART 175 YLH recruited mean age: % males Sexual Behavior Pre-HAART Post-HAART Number of Partners Number Acts of UPS Percent UPS 27% 42% Source: Marguerita Lightfoot, PhD et al, American Journal of Health Behavior, 2005 Risk Behaviors of Youth Living with HIV (YLH): Pre/Post HAART Era, cont. Frequent Substance abuse Odds Ratio 95% Confidence Limits Alcohol 2.51 ( 1.71, 3.68)** Marijuana (non prescribed) 2.36 ( 1.55, 3.58)** Stimulants 2.27 ( 1.29, 3.99)** Inhalants 3.29 ( 1.06, 10.21)* Cocaine 3.06 ( 1.07, 8.75)* Crack 3.43 ( 1.22, 9.58)* Heroin 2.41 (.72, 8.00) Hard Drugs 2.80 ( 1.74, 4.49)** Note. Pre-HAART is referent group * P<.05; ** P<.01 Source: Marguerita Lightfoot, PhD et al, American Journal of Health Behavior, 2005 Older Adults

18 Alcohol Prescribed drugs Over-the-counter meds Interactions between alcohol and Rx and OTC drugs Illicit Drugs ( street ) RX Drug Abuse in Older Adults Adults 65+ represent 13% of U.S population, and account for one-third of all medications prescribed in the U.S. 21.7% (7.2 million) receive at least 1 abusable Rx annually. Men: 17.7% Women: 24.6% Older adults use Rx drugs 3 times more than the general population. On average, older persons take 4.5 medications per day. The number of older adults who abuse Rx drugs is estimated to be as high as 2.8 million. SAMHSA, 2006; NIDA, 2005 Substance Abuse and Older Adults

19 Social Isolation and Health Status Characteristic Widowed/Divorced/Separated Married Lives Alone Lives w/ Spouse Poor/Fair Health Good/Excellent Health 0 ADLs 1-2 ADLs 3-4 ADLs 5-6 ADLs Annual Prevalence of Abusable Rx E+ 24.6% 19.9% 23.8% 20.0% 34.2% 18.0% 17.1% 31.0% 39.0% 40.7% SOURCE: Simoni-Wastila et al, under review, HIV and Aging #1 People living with HIV disease are growing older. Between 1991 and 1996, the number of new AIDS cases rose twice as fast in persons 50-plus years of age than it did in persons younger than 50 (22% vs. 9%, respectively; CDC, 1998). Older adults account for up to 15% of AIDS cases nationwide. SOURCE: National Institute on Drug Abuse, HIV and Aging #2 Older adults living with HIV/AIDS have: A more severe HIV disease course and a shorter survival rate Less desirable health indices at diagnosis (e.g., lower CD4+ cell counts) Shorter AIDS-free intervals Higher number of opportunistic infections Earlier development of tumors and lesions SOURCE: National Institute on Drug Abuse,

20 HIV and Aging: A Hidden Epidemic? The aging HIV population is living longer due to the success of anti-hiv therapies Older individuals may not be perceived to be at risk for HIV infection Therefore, they are less likely to undergo HIV testing, misdiagnosis is common, and HIV is diagnosed later in the course of HIV infection Alcohol and drug abuse have been found to confound the effects of neurocognitive functioning in older HIV-positive individuals SOURCE: Casau NC. Perspective on HIV infection and ageing: emerging research on the horizon. Clinical Infectious Diseases 41: , Sexual Risk of HIV among Older Adults Assumption older adults aren't sexually active or, if they are, they know how to avoid HIV infection Older adults and their healthcare providers usually avoid discussions of sexual behaviors and substance use Older adults may be unwilling to discuss risky behaviors because of the stigma that society attaches to these behaviors Others may be in monogamous relationships with a partner who engages in risky behavior without their knowledge SOURCE: HIV and Aging, by Andrew Shippy. Summary Older adults are at risk They need careful evaluation and screening Cognitive impairment is not a normal part of aging. Careful screening should be done for substance abuse, HIV and other medical conditions. Older people have sex talk to them about it.

21 Methamphetamine and Sex Connection in Heterosexuals Q.1: My sexual thoughts, feelings, and behaviors are often associated with Percent Responding "Yes" opiates alcohol cocaine meth Primary Drug of Abuse male female Q.2: My sexual drive is increased by the use of Percent Responding "Yes" opiates alcohol cocaine meth Primary Drug of Abuse male female

22 Q.4: My sexual performance is improved by the use of Percent Responding "Yes" opiates alcohol cocaine meth male female Primary Drug of Abuse Q.10: I am more likely to have sex (e.g., intercourse, oral sex, masturbation, etc.) when using Percent Responding "Yes" opiates alcohol cocaine meth 61.1 male female Primary Drug of Abuse Q.12: I am more likely to practice risky sex under the influence of (e.g., not use condoms, be less careful about who you choose as a sex partner, etc.) Percent Responding "Yes" opiates alcohol cocaine meth male female Primary Drug of Abuse

23 Methamphetamine and HIV in MSM: Time-to to-response Association? % Percent HIV % 41% 62% 20 8% 0 Probability Sample* Recreational User** Chronic Non Treatment*** Outpatient Drug-Free**** Residential**** * Deren et al., 1998, Molitor et al., 1998; ** Reback et al., in prep, *** Reback, 1997; **** Shoptaw et al., 2002; ****VNRH, unpublished data Outpatient Treatment for Methamphetamine Abuse Investigational Medication for High Blood Pressure Blood Pressure Before Tx Tx Tx Removed Treatment Works!!!

24 Investigational Medication for Methamphetamine Use Level of Use Before Tx Tx Tx Removed Treatment Failed!!! Relapse Rates Are Similar for Drug Dependence and Other Chronic Illnesses Percent of Patients Who Relapse to 60% 30 to 50% 50 to 70% 50 to 70% Drug Type I Hypertension Dependence Diabetes Asthma Source: McLellan, A.T. etal., JAMA, Vol284(13), October 4,

25 Treatment: Medical & Behavioral Drugs Sedatives Stimulants Opioids Alcohol Medical Treatment Yes No Yes Yes Behavioral Treatment Yes Yes Yes Yes Medicines for Addiction Treatment What tools do we have? Medicines for Alcohol Disulfram (Antabuse ) Acamprosate (Campral ) Naltrexone (Revia, Depade ) Naltrexone XR Inj (Vivitrol )

26 Medicines for Opioids Methadone Buprenorphine/Naloxone or Buprenorphine Naltrexone (Revia, Depade ) Medicines for Methamphetamine and Cocaine Results from the CADDs Data System (2001) *The statewide data collection system, CADDs has information on the relative usefulness of treatment for MA users, by comparing them to cocaine users.

27 Sample Size and Early Drop Out Outpatient Treatment: MA users = 27,026 COC users = 11,160 Early Dropout: Outpatient COC admissions were slightly more likely to drop out of treatment before 30 days (25.5%) as compared to MA admissions (24.1%). P =.003 Predictors (cont ) Early dropout for both MA and COC users was associated with: 1. Being disabled 2. Chronic mental illness 3. Daily use of primary drug 4. Injection use Early dropout is less likely for those under legal supervision, older age of first use of primary substance, and older age at admission. Predictors of Retention in Treatment for more than 90 days 1. Higher rates of retention for men 2. Legal supervision increases treatment retention 3. Those who began use at an older age were retained better than those who started when younger 4. Those who are older at admission were retained better 5. Injection users were retained more poorly 6. Those with chronic mental illness were retained more poorly 7. Daily users are retained more poorly than those who use less often than daily

28 For more information, please contact Tom Freese at or or