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Drug Use and HIV

The Role of Methadone in HIV Prevention And Treatment Sharon Stancliff, MD Medical Consultant AIDS Institute New York State Department of Health. Drug Use and HIV. Injection of heroin and cocaine is the driving force behind HIV in New York State. Addiction.

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Drug Use and HIV

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  1. The Role of Methadone in HIV Prevention And TreatmentSharon Stancliff, MDMedical ConsultantAIDS InstituteNew York StateDepartment of Health NYSDOH/AI

  2. Drug Use and HIV Injection of heroin and cocaine is the driving force behind HIV in New York State NYSDOH/AI

  3. Addiction • Opiates interact with receptors for endogenous peptides. • Short term changes in the dopamine secreting neurons, such as atrophy are documented • Long term changes are suspected. NYSDOH/AI

  4. Genetics •Twin and adoption studies show a strong familial trend in alcoholism •Addictive disorders are common among the families of heroin addicts •Anthenelli NYSDOH/AI

  5. “Drug Addiction is a Brain Disease”Alan Leshner, PhDNational Institute of Drug AbuseDirector NYSDOH/AI

  6. National Institute of Health “Methadone is the most effective treatment for heroin addiction.” National Institute of Health Consensus Development Conference on the Medical Treatment of Heroin Addiction NYSDOH/AI

  7. Methadone •A synthetic opiate with a 24-36 hour half-life •Methadone Maintenance Treatment (MMT) was first implemented by Dole and Nyswander in the 1960s as most “detoxed” addicts relapsed to heroin use NYSDOH/AI

  8. Methadone •Usual effective dose: 80-120 mg range:5mg- >500 Clinical response guide dose •Rettig, Leavitt •80-90% of those stopping MMT will return to heroin use so treatment is long term •Ball, Magura NYSDOH/AI

  9. Methadone •Safe during pregnancy •Kandall •No known long term detrimental effects •Novick •MMT is usually accompanied by counseling and sometimes other requirements NYSDOH/AI

  10. Benefits of Methadone Maintenance NYSDOH/AI

  11. Reduction in Heroin Use •Given a sufficient dose virtually all heroin users will stop using heroin •At lesser doses heroin use is decreased. •Ball 1991 NYSDOH/AI

  12. HIV Prevention MMT patients are 3-6 times less likely to become HIV positive when compared to out-of-treatment heroin users. Metzger, Drucker, Gibson, Hartel NYSDOH/AI

  13. Reduction in HIV seroconversion: a prospective study •Comparison of opiate users in and out of methadone treatment •Those out of treatment reported more risk behavior for HIV •In treatment: 3.5% seroconverted, Out-of-treatment 22% seroconverted •Metzger NYSDOH/AI

  14. HIV positive heroin users on methadone are hospitalized less often and live longer than their counterparts who are not on methadone Weber, Newschaffer, Laine Improved outcome in HIV NYSDOH/AI

  15. Other Benefits • A fourfold reduction in suicide • A fourfold reduction in lethal overdose • Capelhorn • Reductions in sex work • Bellis • Reduction in crime • Hubbard, Appel NYSDOH/AI

  16. Issues in Methadone Prescribing NYSDOH/AI

  17. Over regulation •Available only in methadone clinics •Frequent attendance required •Limited number of slots •Medical maintenance has been shown to be successful outside of these constraints NYSDOH/AI

  18. Under Dosing •A 1995 study of selected MMTPs found an average dose of less than 59mg •2/3s of the clinics set a dose ceiling of 80-100mgs •D”Aunno NYSDOH/AI

  19. Premature discharge •A 1995 study found that the majority of clinics encourage detox after only 1 year of treatment •Relapse can be deadly- Zanis found 8.2% mortality among 110 pts. leaving MMTP but only 1.2% among 397 remaining in treatment NYSDOH/AI

  20. Misunderstandings about methadone •Patients often believe that methadone causes bone or liver damage. •Physicians may have misconceptions about pain management in methadone patients. •It is also erroneously believed that MMT leads to cocaine use. NYSDOH/AI

  21. •Family •Friends •Physicians •Social service providers •Employers •Politicians •Drug users MMT patients are judged by: NYSDOH/AI

  22. Stigmatization by drug Treatment Providers •MMT patients are discouraged from speaking at Narcotics Anonymous meetings •Narcotics Anonymous Bulletin •Many facilities treating cocaine and alcohol abuse bar methadone NYSDOH/AI

  23. Role of the Primary Care Provider •Education of current and potential MMT patients and their families •Understanding medical issues such as drug interactions •Working with clinics to ensure the best possible care for patients NYSDOH/AI

  24. DRUGS WHICH MAY LOWER PLASMA LEVELS OF METHADONE •Phenobarbital •Carbamazepin (Tegretol) •Phenytoin (Dilantin )** •Ritonavir (Norvir) ** Major effect, may require large methadone dose increases •Nevirapine (Viraimmune)** •Rifampin** •Efavirenz (Sustiva)** •Abacavir (Ziagen) •ethanol (chronic use) Drug Interactions NYSDOH/AI

  25. Drug Interactions II • DRUGS WHICH MAY INCREASE PLASMA LEVELS OF METHADONE (none are major problems) • Amitriptyline (Elavil) • Cimetidine (Tagamet) • Diazepam (Valium) • Ethanol ( acute use) • Ketoconazole (Nizoral) • Zidovudine (AZT) levels may be increased by methadone. • DRUGS WHICH ARE CONTRAINDICATED • Pentazocine (Talwin), • Tramadol (Ultram) NYSDOH/AI

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