A Guide to Primary Care of People with HIV/AIDS - Canadian Public ...

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A Guide to Primary Care of People with HIV/AIDS Chapter 13: Management of Substance Abuse (ABC) and all the PIs except indinavir (IDV), though pharmacologically measurable, are not clinically apparent and standard doses are appropriate. Potential interactions between illicit drugs and HIV medications are less well understood. Methamphetamine products have been associated with sudden death in individuals on protease inhibitors. Anecdotal reports describe how selective serotonin reuptake inhibitor (SSRI) antidepressant medications may produce side effects that mimic drug withdrawal and may decrease AIDS medication adherence. Table 13-7: Antiretroviral Drugs that Affect Methadone Levels NRTI NNRTI PI zidovudine (ZDV) ↔ nevirapine (NVP) ↓ indinavir (IDV) ↔ didanosine (ddI) ↔ delavirdine (DLV) ↑ ritonavir (RTV) ↓ zalcitabine (ddC) ↔ efavirenz (EFV) ↓ nelfinavir (NFV) ↓ Why are HIV and drug abuse both such noticeable issues now? HIV and substance abuse are both significant public health problems that merit the attention of public health officials and policymakers. Today, an estimated 40 million people worldwide are living with HIV. Of these, 2 to 3 million people are injection drug users. In the United States, approximately a third of HIV/ AIDS cases are related to injection drug use. Research shows that use of drugs, injected or not, can affect decisionmaking – particularly about engaging in unsafe sex – that can endanger the health of the drug user and of others. Substance abuse is a double-edged sword because it increases an individual’s risks for continuing drug use while also increasing the likelihood of exposure to HIV and other bloodborne infections. Infectious diseases that are more prevalent among injection drug users than in the general population are HIV, other STDs, including hepatitis B and C, and tuberculosis. Prevention and early treatment of drug abuse and drug-related diseases are critical public health measures to reduce the spread of new infections. stavudine (d4T) ↔ saquinavir (SQV) ? abacavir (ABC) ↓ amprenavir (APV) ↓ lopinavir (LPV) ↓ atazanavir (ATV) ↓ 13 ↓ = decreases methadone blood levels ↔ = indeterminate effect ↑ = increases methadone blood levels Source: Adapted from Gourevitch MN, Friedland GH. Interactions between methadone and medications used to treat HIV infection: a review. Mt Sinai J Med 2000 67:429-436. 112 U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau
A Guide to Primary Care of People with HIV/AIDS Chapter 13: Management of Substance Abuse KEY POINTS Substance abuse and addiction involve compulsive drug-seeking behavior that interferes with an individual’s ability to function normally in many aspects of daily life. Substance abuse and mental health problems often occur together and, unless treated, can lead to chronic social and medical consequences. Accurate and reliable diagnosis of substance abuse or dependence is not a perfect science. Screening techniques, in concert with a thorough medical history and evaluation, are important in detecting and correctly diagnosing a substance abuse-related disorder. HIV transmission is preventable in people who use drugs. For drug users and the community at large, drug addiction treatment is disease prevention. Hepatitis C is extremely common in patients with a past or current history of injection drug use. All patients with hepatitis C should be vaccinated against hepatitis A and B if serologic studies show no prior exposure. The clinical issues to be addressed are to treat comorbid conditions as soon as possible, treat drug use and HIV aggressively, and be aware of common drug interactions seen in patients treated for drug use and HIV simultaneously. SUGGESTED RESOURCES Brief Interventions and Brief Therapies for Substance Abuse. Treatment Improvement Protocol (TIP) Series 34. Rockville, MD: Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment; 1999. DHHS Publication No. (SMA) 99-3353. Available at http://www.health.org/govpubs/BKD341/ Accessed 1/04. Klein MB, Lalonde RG, Suissa S. The impact of hepatitis C virus coinfection on HIV progression before and after highly active antiretroviral therapy. J Acquir Immune Defic Syndr. 2003;33:365-372. WEBSITES American Society of Addiction Medicine: http://www.asam.org/ Accessed 11/03. National Institute on Drug Abuse: http://www.nida.nih.gov Accessed 11/03. Erowid (detailed biochemical and other information on drugs): http://www.erowid.org Accessed 11/03. Office on National Drug Control Policy: http://www.whitehousedrugpolicy.gov/ Accessed 11/03. Substance Abuse and Mental Health Services Administration (drug abuse statistics, clinical treatment information): http://www.samhsa.gov Accessed 11/03. 13 U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau 113
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