Different Clinical Picture
The clinical picture of HIV in drug using populations is significantly different from HIV in other populations. For example, there are almost no cases of Kaposi's Sarcoma in male IDU's (Injection Drug Users) who are also HIV+, but there is a five-fold risk of death from bacterial infections in HIV+ drug users vs. HIV+ non-drug users. IDUs are dying of bacterial pneumonia as a result of HIV infection. This condition and pulmonary tuberculosis (also common in the drug users) were added to the CDC definition of AIDS after 3 years of community pressure by AIDS activists.
A data base was established to look at particular manifestations of HIV in drug users. Many of the most common diseases are bacterial infections, pulmonary tuberculosis, sexually transmitted diseases, hepatitis, and malignancies other than KS and lymphomas. Clinicians and technicians must look at the whole spectrum of diseases which drug users with HIV infection get. When IDUs develop pneumonias, it is more often bacterial pneumonia or TB-related, not PCP. (Bacterial pneumonia will require a different course of treatment.)
Certain malignancies, not considered AIDS-defining but definitely life - threatening, are occurring mostly in IDUs. These include lung cancer and cancers of the GI tract. In HIV+ women, cervical diseases and superimposed HPV infection are important clinical conditions that must not be underestimated. Cervical cancer was also added to the CDC definition in 1993.
Hepatitis, delta-hepatitis (which can accompany hepatitis-B) and hepatitis-C show serologic abnormalities in the presence of HIV. They don't become more active or severe in people with HIV. However, HIV+ drug users are more likely to carry hepatitis longer and thus remain infectious for a longer period of time.
40% Users HIV Positive
There is a 40% HIV seroprevalence in the entire methadone-taking population. In a study of HIV+ asympto-matics, it was found that a large proportion presented with clinical diseases such as bacterial pneumonia, endocarditis/sepsis, herpes zoster, and pulmonary TB.
Herpes zoster is typically viewed as an early physical manifestation of immune decline. The study also showed that using T-cell counts is probably not the best way to determine whether or not these diseases will occur in drug users. Another surrogate marker of HIV progression, beta-2 micro globulin levels in the blood, is also not useful, because beta-2 levels are high in all drug users.
The ability to provide an array of social services, along with comprehensive medical care, including pediatric care, is a crucial, inseparable component in successfully providing treatment for HIV+ drug users. This is a population that has been disenfranchised and marginalized, and is without access to the health care system.
HIV comes with overall neglected health in these individuals. Providing a warm and non-judgmental medical team is key. Also, incentive payments to trial participants may be incorporated into study protocol.
If clinicians are going to provide care for IDUs, they must first accept their life style, which for most IDUs is not abstinence. Whether individuals are using drugs intravenously or not, they can still receive life-prolonging treatments. To get vital information on AIDS therapy strategies in this population, and to ensure some equity of access to care, policies must be carefully constructed so as not to rule out people on the basis of "active use".
Tolerance and dependence are two specific characteristics of drug addiction. Addiction occurs when a substance is required to maintain basic functioning. The compulsive, habitual, repeated use of a substance is continued in spite of harmful consequences, which the person involved recognizes fully. In other words, addicts know they're doing something which is self-destructive. Doctors must realize that addiction is something that the addicted individual cannot simply stop. The drug users' awareness of doing something destructive, and their perception of their ability to stop are clearly clouded by denial and avoidance. The notion of repetitive, continued self destructive behavior, even in the face of adverse consequences, is important to the understanding of addiction.
Drug addiction itself, and the pathophysiology of how drugs affect the central nervous system, drive people to do unsafe things, such as use contaminated needles. There is vast documentation of people able, in a sense, to stand outside their addiction and tell you that they have destroyed their families and their lives, and yet they can not stop. It is not a simple question of morality or failure or lack of character. Addiction and abuse should be viewed as a clinical phenomena.
Observation of the arms for tracks, awareness of attitude problems, financial difficulties and perhaps frequent unexplained accidents are indications of substance abuse. Urine toxicology testing, though not standard practice, is used to determine if someone is a substance user. Increasingly, clinicians are faced with the compounding factor of cocaine or crack use. They are finding these drugs in their patients through urine tests in both "on methadone" and "not on methadone" patients. Researchers are interested in the interaction of AZT and other antiretrovirals with methadone; of crack with AZT, etc., and crack and methadone with AZT. Obviously, doctors can't prescribe or administer crack, and they don't routinely screen for cocaine because laws require that doctors report findings of illicit drug use to the Health Department. Screening urine to confirm drug use would be helpful in clinical trial situations. Most researchers and clinicians admit that they have no intention of reporting cocaine or crack in the urine of their patients with HIV/AIDS.
Many of the medical problems that care providers see in drug users are due to the substances themselves, and some are due to HIV infection. There definitely is an overlapping of symptoms: the clinical manifestations of HIV can be combined with, masked by, or mimicked by the effects of drugs and alcohol. Certainly fever, infection and diarrhea are quite common in drug users. Bacterial infections are more severe when HIV is present. Symptoms of HIV such as weight loss, diarrhea, and fever may be caused either by drug use or withdrawal.
Often so-called behavioral problems are misdiagnosed disorders associated with brain lesions or central and peripheral nervous system toxicities. It is absolutely imperative that clinicians look beyond stereotypes and prejudices when treating drug addicts and recognize coexistent, parallel pathophysiology that may be occurring.
Scientists suggest starting drug users on 60mg to 65mg of methadone and steadily increasing the dose every one or two weeks, to a stabilized opiate dosage(which usually takes six weeks with an average dose of 90mg of methadone, and a maximum dose of 120mg.).
Medications and methadone exhibit interesting drug interaction. When prescribing rifampin (used to treat TB; Rifadin, Rifabutin, and Mycobutin are in this same family of drugs) one must double the dose of methadone within two or three days because there is an increase in the metabolism of methadone (due to the induction of certain enzymes) which can cause serious, immediate opiate withdrawal. Rifampin not only increases the metabolism of methadone, it also decreases the half life. So, it's important to not only double the dose of methadone, but also to divide it. One should give two-thirds dose in the morning and 1/3 at night, because a person may experience withdrawals before the end of the usual 24hr period.
Another important thing when using rifampin is that drug users are very aware of the effects that drugs and medications have on their bodies. When they realize that rifampin is causing withdrawal, they stop taking it. Prescribing rifampin alone is a set-up for drug resistant TB. The use of dilantin or phenobarbital with AZT can cause opiate withdrawal at a slower rate. Methadone dosages should be increased but not necessarily doubled.
AZT does not absorb methadone or cause opiate withdrawal, though the side effects of AZT mimic withdrawal symptoms. Increasing methadone dosages does not make the side effects of AZT less severe. There does not appear to be any increased toxicity with AZT in drug users taking methadone or another opiate compared to those who are not. There is little to nothing known about street-drug interactions with the new protease inhibitors. Interactions might possibly be life-threatening.
When prescribing pain medications, one must keep in mind that a narcotics addict having pain needs more narcotic, not less. Dosages that are considered dangerous for other people, may be required for drug users, because of their astounding capacity and tolerance for narcotics. Methadone has absolutely no analgesic effect. It does not kill pain. Therefore, continue the same methadone dose but give higher, more frequent doses of Demerol.
Former addicts and recovering addicts may also need slightly higher doses of pain medications. Just because a person may have a history of drug addiction doesn't mean that they shouldn't be given pain medication when they need it.
There is a valid fear among HIV+ drug users and former drug users that when they are in pain, they won't be medicated. Many in the medical field have the opinion that if a patient is already on an opiate, they don't need pain medication; nothing is further from the truth. When a person is on methadone, more methadone will not kill their pain. It's best to administer pain medication around the clock when a person is in the hospital. (when taking a patient off of medication, taper off gradually, not abruptly.) Often a struggle ensues between patient and care provider if the patient has to repeatedly ask for pain-relieving medications.
A street practice of buying and selling antibiotics, that existed even before the AIDS pandemic, is relevant when treating addicts. In our culture there is a lot of self-medication, with illicit drugs as well as prescription drugs such as antibiotics. A drug addict can get any drug on the street including penicillin, ampicillin, etc. (in some locations AZT is referred to as "Horse Pills" on the streets because of the Burroughs Wellcome unicorn logo.) So, when clinicians ask if patients are taking "any other drugs", they should ask specifically about antibiotics and the use of AIDS-related therapies as well as marijuana or other so-called recreational drugs.
Also, if some doctors and social service providers get over being judgmental, they could learn something from dug users.
This article was first printed in the Being Alive newsletter in 1992, the author has updated it for 1996.