Substance Use Disorders (1/16/18)

  • Older adults living with HIV have higher rates of substance abuse than their HIV-negative counterparts, which does not tend to decline with age.
  • There are issues and barriers to identifying and treating substance use disorders among older PLWH.
  • Brief screening and treatment programs integrated in primary care settings may be the most appropriate for optimal outcomes given the demands in busy practices.

Psychiatric disorders that are typically excluded in the literature on older persons living with HIV (PLWH) are alcohol and substance use disorders, although this is slowly changing. Illicit drug use has been reported by 45.1% of younger PLWH and by 29.7% of older PLWH[1], and the causes for substance use may differ between younger and older cohorts[2]. Substance use may also be more common among older HIV-positive men than women[3]. In a study of a cohort of HIV-positive veterans, those with current substance use disorders who were over 50 years of age numbered more than 20%[4-6]. Further, it has been shown that older adults living with HIV have higher rates of substance abuse than their HIV-negative counterparts, and while rates tend to decline with increasing age in the general population, this is not the case for older adults with HIV[7, 8].

Substance use disorders among PLWH are associated with risk of poor medication adherence, neurocognitive impairment[9], psychosocial issues[7], and disease progression, and HIV transmission via injection and high risk sexual behavior. Regarding neurocognitive impairment, one study found a “legacy” effect of drug-related neurotoxicity, such that a remote history of methamphetamine dependence had a detrimental impact on cognitive and daily functioning (e.g., unemployment) in older but not younger adults with HIV[9].

A recent pilot study of drug use among HIV-positive adults aged 50 and older currently engaged in HIV care found that over 80% of the sample was at medium or higher risk for an alcohol use disorder.  This study also found that over 48% of participants had used an illicit drug in the past year, 52% of whom were dependent. Less than half of these patients were in substance use treatment program or 12 step programs[10]. This study highlights that there are missed opportunities for identifying and addressing substance use problems among care providers for older PLWH. More research is clearly needed in the impact of alcohol and substance use disorders in older PLWH. It is also important to note the emergence of misuse of antiretroviral medications for their psychoactive properties (e.g., efavirenz, ritonavir) alone and in combination with illicit drugs.

Older Age and General Psychiatric Comorbidity

Despite the high prevalence of mood and substance use disorders in older PLWH, 40%-90% of this populations’ mental health issues remain undetected in primary care settings[11]. Treatment of HIV positive adults

Table 1.  Pharmacotherapies with Evidence for the Potential to Treat Substance Disorders*
         
Opioids Alcohol Smoking Stimulants (Cocaine & Methamphetamine) Benzodiazepines
Buprenorphine/ naloxone X
Methadonea X
Naloxoneb X
Disulfiramc X
Acamprosate X
Naltrexonec X X
Varenicline X
Bupropionc X
Flumazenild X
aMethadone is NOT office-based; available only within a federally qualified opiate treatment program; bwhen naloxone used alone, reserved for use in overdose situation only; cAlso used off-label for stimulant use disorder; dFlumazenil is only FDA approved for the treatment of overdose of GABA medications or the reversal of GABA-based anesthesia; not approved for sedative-hypnotic use disorder [15-18]..

*Additionally the following medications are used off-label for treatment of substance use disorders:  Gabapentin is off-label for opioid, alcohol and benzodiazepines; Topiramate is off-label for alcohol and stimulants; N-acetylcysteine is used off-label for smoking cessation and stimulants; Modafinil and armodafinil are used off-label for stimulants; mirtazapine is used off-label for stimulants

with mental health and substance use disorders results in the benefit of more consistent treatment of their HIV infection[12, 13]. Yet, it remains the case that little research targeting psychiatric comorbidities in older adults compared to younger adults (in both HIV and the broader aging population) has been reported to date. HIV-related stigma may be another unique barrier to treatment in older populations specifically[11]. It is important to note a caveat that the impact of mental health or substance abuse treatment alone on sexual and substance use risk behaviors may be limited, thus highlighting the importance of comprehensive care models that integrate behavioral health services with medical treatment of older adults living with HIV. This is especially germane given that older adults may underestimate their HIV risk and many clinicians are less likely to discuss sexual risk with older patients. Further there likely exists a bidirectional association between substance abuse and mental health (e.g., depression, anxiety).

Assessment & Treatment

While counseling strategies are the most commonly used treatment for substance use disorders, an expanding number of pharmacotherapies that are considered fairly safe when prescribed appropriately have been reported to primarily affect substance use outcomes; these include methadone, bupropion, acamprosate, topiramate, buprenorphine, gabapentin, varenicline, modafinil, armodafinil, flumazenil, naltrexone, N-acetylcysteine, mirtazapine, and most recently naloxone administered by a new hand-held auto-injector to reverse opioid overdose (Table 1).

Overall, substance abuse is a concern among older adults living with HIV, given the high prevalence and issues in identifying these disorders and linkage to treatment. Given that older adults with HIV often have many co-morbidities (both mental physical), substance abuse screening and perhaps brief treatment may be best positioned in primary care settings. One such approach that may be helpful for addressing these issues in busy primary care practices is the Screening, Brief Interventions, Referral to Treatment (SBIRT) service program[14]. This program consists of evidence-based strategies to first identify a patient’s level of risk (using a brief screener) and determine if a brief intervention is necessary (such as a motivational discussion by the clinician to raise awareness of substance abuse consequences). Then, those patients assessed to be at a higher level of risk may then be referred to receive specialty treatment. This program model has yielded positive outcomes across a range of health care settings and patient populations[14].

Updated by Pariya Fazeli and Kat Grieco

September 2017

References

  1. Zanjani F, Saboe K, Oslin D. Age difference in rates of mental health/substance abuse and behavioral care in HIV-positive adults. AIDS Patient Care STDS 2007; 21(5):347-355.
  2. Mannes ZL, Burrell LE, 2nd, Dunne EM, Hearn LE, Whitehead NE. Contextualizing Psychosocial Determinants of Alcohol Use by Age Cohorts of Adults Living With HIV, Ages 50 and Older. J Assoc Nurses AIDS Care 2017; 28(2):279-288.
  3. Rubstova A. Healthy aging in older women living with HIV Infection: a Systematic Review of Psychosocial Factors. . Curr HIV/AIDS 2017; 14(1):17-30.
  4. Hawkins EJ, Grossbard J, Benbow J, Nacev V, Kivlahan DR. Evidence-based screening, diagnosis, and treatment of substance use disorders among veterans and military service personnel. Military medicine 2012; 177(8 Suppl):29-38.
  5. Green TC, Kershaw T, Lin H, Heimer R, Goulet JL, Kraemer KL, et al. Patterns of drug use and abuse among aging adults with and without HIV: a latent class analysis of a US Veteran cohort. Drug Alcohol Depend 2010; 110(3):208-220.
  6. Bowe A, Rosenheck R. PTSD and substance use disorder among veterans: characteristics, service utilization and pharmacotherapy. J Dual Diagn 2015; 11(1):22-32.
  7. Millar BM, Starks TJ, Gurung S, Parsons JT. The Impact of Comorbidities, Depression, and Substance Use Problems on Quality of Life Among Older Adults Living With HIV. AIDS Behav 2017; 21(6):1684-1690.
  8. Rabkin JG, McElhiney MC, Ferrando SJ. Mood and substance use disorders in older adults with HIV/AIDS: methodological issues and preliminary evidence. AIDS 2004; 18 Suppl 1:S43-48.
  9. Iudicello JE, Morgan EE, Gongvatana A, Letendre SL, Grant I, Woods SP, et al. Detrimental impact of remote methamphetamine dependence on neurocognitive and everyday functioning in older but not younger HIV+ adults: evidence for a legacy effect? J Neurovirol 2014; 20(1):85-98.
  10. Ompad DC, Giobazolia TT, Barton SC, Halkitis SN, Boone CA, Halkitis PN, et al. Drug use among HIV+ adults aged 50 and older: findings from the GOLD II study. AIDS Care 2016; 28(11):1373-1377.
  11. Moore RC, Marquine MJ, Straus E, Depp CA, Moore DJ, Schiehser DM, et al. Predictors and Barriers to Mental Health Treatment Utilization Among Older Veterans Living With HIV. Prim Care Companion CNS Disord 2017; 19(1).
  12. Palepu A, Horton NJ, Tibbetts N, Meli S, Samet JH. Uptake and adherence to highly active antiretroviral therapy among HIV-infected people with alcohol and other substance use problems: the impact of substance abuse treatment. Addiction 2004; 99(3):361-368.
  13. Sambamoorthi U, Walkup J, Olfson M, Crystal S. Antidepressant treatment and health services utilization among HIV-infected medicaid patients diagnosed with depression. J Gen Intern Med 2000; 15(5):311-320.
  14. Madras BK, Compton WM, Avula D, Stegbauer T, Stein JB, Clark HW. Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: comparison at intake and 6 months later. Drug Alcohol Depend 2009; 99(1-3):280-295.
  15. Jayaram-Lindstrom N, Hammarberg A, Beck O, et al. Naltrexone for the treatment of amphetamine dependence: a randomized, placebo-controlled trial. Am J Psychiatry. 2008 Nov;165(11):1442-8.
  16. Carroll KM, Fenton, LR, Ball, SA, Nich, C, Frankforter, TL, Shi, J and Rounsaville, BJ. Efficacy of disulfiram and cognitive behavior therapy in cocaine-dependent outpatients: A randomized placebo-controlled trial. Arch Gen Psychiatry 61 264–272 (2004).
  17. Colfax G, Santos GM, Chu P, et al. Amphetamine-group substances and HIV. Lancet. 2010 Aug 7;376(9739):458-74.
  18. Marsch LA. The efficacy of methadone maintenance interventions in reducing illicit opiate use, HIV risk behavior and criminality: a meta-analysis. Addiction.1998 Apr;93(4):515-32.

 

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