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
Strawberry
Rush
Limbaugh
Ray
Charles
Dick
Van Dyke
Betty Ford
Tatum
O’Neal
Addiction
Franklin D
Roosevelt
Darryl
Strawberry
Rush
Limbaugh
Heroin
Alcohol
Alcohol
Heroin
Addiction
Tobacco
Prescription
Opioids
Cocaine
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 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
– 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”
• “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 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: 267K
Overview
•
•
•
•
•
•
•
Definitions
Prevalence and costs
Detection
Comorbidity
Primary medical care
Addiction as a chronic disease
Pharmacological and non-pharmacological
treatments
• Risk reduction
• Future issues
Patterns of Substance Use
abstinence
moderate
use
hazardous
use
Asymptomatic
harmful use/
abuse
dependence
Clinically apparent
Definitions
• Drug/Alcohol abuse
• Drug/Alcohol dependence
• Addiction
DSM IV Criteria: Drug Abuse
1 or more of the following in a year:
Recurrent use resulting in failure to fulfill
major role obligations
Recurrent use in hazardous situations
Recurrent drug-related legal problems
Continued 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:
 Tolerance
 Withdrawal
 A great deal of time spent to
obtain drugs, use them, or
recover from their effects
 Important activities given up or
reduced because of drugs
 Using more or longer
than intended
 Persistent desire or
unsuccessful efforts to
cut down or control
substance use
 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:*
– 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
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
– 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/2k5nsduh/2k5results.htm#Ch7
Estimated Leading Causes of DisabilityAdjusted Life-Years (DALYS) in the U.S., 1996
*
*
**
*
*
*
*
*
*
*
Michaud CM, Murray CJL, Bloom BR. JAMA 2001; 285(5):535-539.
Estimated Leading Causes of DisabilityAdjusted 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)
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/#table3
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 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 a chronic disease
Pharmacological and non-pharmacological
treatments
• Risk reduction
• Future issues
What Do Patients With
Substance Abuse Look Like?
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 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 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/CliniciansGuide2005/clinicians_guide.htm
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”
-UGIabnormal
• Abd pain and poor PO intake persisted
• HBSAg-, HBCAb+ (past Hepatitis B,
resolved)
• HCV Ab+ (Hepatitis C)
• HIV+, CD4 503, HVL 15,085
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+
CD4 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
-HIV+, HCV+
CD4 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
Week 2—Hospitalization
(1/00)
-42 y/o male
-11/99
endocarditis
-LVEF 75%
-12/99-c/c”abd pain”
-UGIabnormal
-HIV+, HCV+
CD4 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 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 “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 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 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.
• 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 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
to central line infection
-LVEF 75%
-HIV+, HCV+
CD4 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 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
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, McGinnis 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
Cellulitis (37%)
Pneumonia
(34%)
17%
6%
37%
6%
Infective
Endocarditis (6%)
Abscess (6%)
34%
Other apparent
major illness
(17%)
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 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 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 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/HepatitisAlert/HepatitisAlert.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 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+ •
CD4 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 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 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
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+
CD4 503
-1/00 SMA
thrombosis,
small bowel
resection
-LVEF 40%
•
•
•
•
•
•
HIV (CD4 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 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 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.
McLellan 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
• 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 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+ •
CD4 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
Addiction as a chronic disease
Pharmacological and non-pharmacological
treatments
• Risk reduction
• Future issues
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 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
• 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
effect
– Parenteral use: predominantly naloxone effect
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
• 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+
CD4 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+
CD4 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+
CD4 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
• CD4 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 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 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+,
CD4 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
• CD4 302, HVL 7000
• No ART
Primary Care
(12/01)
-42 y/o male
-11/99
endocarditis
-HIV+, HCV+,
CD4 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?
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/mL 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 as with a patient without
this history.
• It is reasonable to defer ART in active drug
or alcohol users depending on CD4 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 LAAM
-HIV+, HCV+,
CD4 313
• Alcohol: 2-3 days/week with 3 drinks/day
-1/00 SMA
thrombosis,
small bowel
resection
• Court mandated breathalyzers, moderated
-LVEF 40%
• Attended AA meetings 4X/week, no sponsor
-3/00
Methadone
program
• Flu shot
-5/00 MVR
-7/01
Addiction
treatment
alcohol use
• Advised clean needles from NEP, if relapse
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 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+,
CD4 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
pH 6.88
RR 2
Hematocrit 21
• 4 hours later pronounced dead
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 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 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.
Wines JD, Saitz R, Horton NJ, Lloyd-Travaglini C, Samet JH. Drug Alcohol Depend. In press.
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; 76S:S1-S2.
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;
76S:S21-S29.
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
– 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 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)
• Develop and use effective pharmacotherapy
• Incorporate optimal organization of health
services
• Mainstream addictive disorders into medical
care
Thank You!