Getting HIGH(and keeping viral loads low)

Pooja R. Raval, M.D.Internal Medicine

Codman Square Health CenterBoston University Medical Center

Disclosures• I have no disclosures

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Who is a Buprenorphine or Methadone (for addiction) Prescriber– or part of a Substance Use Disorder Team?

. 1.) MD, NP, PA, RN- that directly provides care to patients with opioid and alcohol use disorder?2.) Other provider that works closely or is part of a Substance Use Disorder Team (above + SW, MA, BH)3.) Not directly involved in substance use disorder care, but have patients and clients that have SUD of some sort

. 4.) Just tired of being asked for/about Gabapentin

Let’s put things into context…

US Census: population aged 50 or older is expected to increase 39% from 83.2 million in 2002–06

past-year SUD among people aged 50or older was 44% higher than 2002-2006

(2.8 million people)

In 2020 Adults 50+ years old with SUD will increase to approximately 5.7 million

Han B1, Gfroerer JC, Colliver JD, Penne MA. Substance use disorder among older adults in the United States in 2020.Addiction. 2009 Jan;104(1):88-96. doi: 10.1111/j.1360-0443.2008.02411.x.

The things that drive us crazy…

• Tobacco• Alcohol• Methamphetamines• Cocaine• Opiates• Benzodiazepines• And… more

• Medication adherence• Healthcare Utilization and

Engagement • Psychiatric co-morbodity• High risk sexual behavior and

transmission• Trauma background• Direct organ injury– liver

disease• Housing and employment

instability

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How long is active HIV found on syringes and other paraphernalia?

A. 1. less than 30 minutesB. 2.) 6 hoursC. 3.) 1 weekD. 4.) > 1 month

Know Your Paraphernalia

What is the day to day of injecting drugs like?

• 2.8 injections/ day on average

• Injecting about 80% of the time (over a year period)

Opioid Treatment 101• Suboxone- Buprenorphine-Naloxone• Methadone Maintenance Treatment• Naltrexone or Vivitrol

− Patients with chronic pain− Concomitant drug use particularly

benzodiazepine use

Vivitrol for Opiates – Worth it?

Buprenorphine

Buprenorphine vs. Methadone

Mattick RP, Breen C, Kimber J, Davoli M. Buprenorphine maintenance versus placebo or methadone maintenance for opioid use disorder. Cochrane Database of Systematic Reviews 2014, Issue 2. Art. No.: CD002207. DOI: 10.1002/14651858.CD002207.pub4

Diversion of Buprenorphine

Fox, A.D., et al., Illicit buprenorphine use, interest in and access to buprenorphine treatment among syringe exchange participants, Journal of Substance Abuse Treatment (2014), http://dx.doi.org/10.1016/j.jsat.2014.07.015

Sittambalam CD, Vij R, Ferguson RP. Buprenorphine Outpatient Outcomes Project: can Suboxone be a viable outpatient option for heroin addiction?. J Community Hosp Intern Med Perspect. 2014;4

Buprenorphine Outpatient Outcomes Project

ARVs and Opioid Substitution Therapy• Methadone

− Protease Inhibitors decrease AUC (plasma concentration) Largely outdated PIs (Lopinavir) May need to increase Methadone dosing 7 days to see effect

− Nevirapine and Efavirenz will need to increase Methadone dosing

• Buprenorphine− dosing does not need to be altered for most HAART− No clinically significant effects

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Addiction Treatment and Health Outcomes

• Adherence, viral suppression, engagement in care

• Preventing co-infection with HCV (and downstream effects)

• OBAT and ARVs (DOT vs pill count vs. increase touches)

Lessons from Austin, Indiana

Lessons from Indiana: PrEP in PWID

Truvada = $10,000 per patient per year

“Cost scales fast… Providing [PrEP] to 25% of HIV negative people who inject drugs for just one year would require an upfront investment of over $3 billion.”

And for those still using– stay connected to NEP

• Harm reduction:− Reduces fatal overdoses

• Frequency of injection: − Current users were more likely than never-users to

report a > 75% reduction in injection w/ NEP

• Connection to MMT or OBAT:− New users of the exchange were five times more

likely to enter drug treatment than never-exchangers.

Needle Exchange Programs

72% new HIV cases

Public Funding (ish)• Results consistent in 26 other states

America, 2016:6,612,488 PWID

HIV prevalence 2.1%

Supervised Injection Facilities• a decrease in needle sharing and reuse of syringes• an increase in referrals to social services and addiction

counseling• NO apparent increase in police reports of drug dealing or crime• NO observed increase in new initiates into drug use

And for the critics— aesthetics:- No discarded needles- No public use- Methadone mile

Figure 1: Projected change in the prevalence of HIV infection among injection drug users in Vancouver with and without the

supervised injection facility.

Ahmed M. Bayoumi, MD MSc, and Gregory S. Zaric, PhD CMAJ 2008;179:1143-1151

©2008 by Canadian Medical Association

$10 million $70 million saved in downstream costs

A DOLLAR invested in syringe exchange programs saves at least SIX DOLLARS in avoided costs

associated with H.I.V. alone

Cost savings with SIFs & NEPs

EtOH Prevalence in HIV Infected persons

• 53% drinkers, 15% heavy drinkers • Lower CD4 count and higher VL- effect

on immune function

Alcohol Use Disorder- Beyond Naltrexone

Gaba-whaaaat?

NO Heavy DrinkingComplete Abstinence

#Drinks per week # Heavy drinking days

Gabapentin Combined With Naltrexone for the Treatment of Alcohol Dependence. Raymond F. Anton, M.D., Hugh Myrick, M.D., Tara M. Wright, M.D., Patricia K. Latham, Ph.D., Alicia M. Baros, Ph.D., L. Randolph Waid, Ph.D., and Patrick K. Randall, Ph.D. Published online: July 01, 2011 | https://doi.org/10.1176/appi.ajp.2011.10101436

Methamphetamine

2005: methamphetamine primary injection drug

2.5% of PWID

2015: • 29% injection heroin use• 20% injection meth use

• 50% BOTH heroin and meth use• 2x higher risk of overdose using both• Beware of Boosters (Ritonavir, Cobi)

Stimulant Use and MSM

Methamphetamine >>> Cocaine Neurotoxicity

Stimulants and PharmacotherapyBuproprion, Modafinil, Amphetamines, Methylphenidate, SSRIs, SNRIs

Alpha antagonist (Prazosin), Propanalol (withdrawal)

Jernigan TL, Gamst AC, Archibald SL, et al. Effects of methamphetamine dependence and HIV infection on cerebral morphology. Am J Psychiatry. 2005;162(8):1461–72.

Cocktails + Subtle Syndromes • Parkinsonianism with

methamphetamine use• Tardive dyskinesia with

cocaine use • Wernicke’s with alcohol

use• Neurocognitive deficits

in patients on MAT− Suboxone & Methadone

Arthur Margolin, S. Kelly Avants, Lara A. Warburton, and Keith A. Hawkins. AIDS Patient Care and STDs. July 2004, 16(6): 255-267. https://doi-org.ezproxy.bu.edu/10.1089/10872910260066697

Tobacco Use • What is the prevalence of smoking

cigarettes in HIV patients who inject drugs? − 1) 10% − 2) 20% (general population) − 3) 30%− 4) 50%

% smokers 3x as high in HIV populations >> general public in SF (54% vs 18%)

Cigarette Smoking in the HIV-Infected Population. Shiva Rahmanian, Mary Ellen Wewers, Susan Koletar, Nancy Reynolds, Amy Ferketich, Philip Diaz. Proc Am Thorac Soc. 2011 Jun 1; 8(3): 313–319. doi: 10.1513/pats.201009-058WR

A word about Cardiovascular Risk

Marijuana– but it’s natural!Cannabis Smoking

2-fold risk of Lung Cancer (40-year follow-up -after statistical adjustment for baseline tobacco use,

alcohol use, respiratory conditions, and socioeconomic status)

The Intangibles• Addiction as a disease

− Relapses are not failures− Terminology is important− Thresholds and boundaries

• Know your patients − Motivation− Priorities− Vulnerability

Advocate on YOUR Level• Teach trainees better language and to reduce stigma

• Get your X number (Buprenorphine waiver)

• Train in Trauma Informed Care

• Lobby for decriminalization of recreational drugs

• Support Prison Reform- transition and bridge to outpt

• Practice overdose prevention or support SIFs

• Discuss social determinants of health- housing, loneliness, financial stress, legal issues, transportation− Even if you can’t fix them!

Pooja.Raval@codman.org