Addressing the Linkages between

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Addressing the Linkages between HIV/AIDS and
Drug Abuse
Timothy P. Condon, Ph.D. Deputy Director National
Institute on Drug Abuse June 13, 2007
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NIDA Research
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Addiction
Medical
NEUROTOXICITY OBESITY AIDS CANCERMENTAL ILLNESS
DRUGS
Economic
Social
HEALTH CARE COSTS PRODUCTIVITY
LOSS ACCIDENTS
HOMELESSNESS CRIME VIOLENCE
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Drug abuse
Cancer
Drunk driving
Heart disease
HIV/AIDS
Violence
Child abuse
Smoking
Alcohol abuse
Stress
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Drug Abuse HIV/AIDS are Co-Occurring,
Intertwined Epidemics
DRUG ABUSE
HIV/AIDS
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A Large Portion of AIDS Deaths Are Related to
Drug Abuse
In 2001, nearly 40 of all AIDS deaths were
linked to injection drug use. In 2005 36 of AIDS
deaths were linked to injection drug use.
Source CDC, HIV/AIDS Surveillance Report, 2005,
Vol. 17
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Drugs of Abuse Have Had A Major Impact on the
HIV/AIDS Epidemic
Proportions of AIDS Cases in Adults Adolescents
by Exposure in the USA
Source Centers for Disease Control and
Prevention (CDC)
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Drug Use Has Played a Prominent Role in the
HIV/AIDS Epidemic In Several Ways
Acquisition and Transmission IV Drug Use
High Risk Sexual Behaviors Resulting
from Drug User Disinhibition Other
Physiological Factors Progression of Disease
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In 2005, an estimated 19.7 million of people in
United States, or 8.1 percent of the population
aged 12 or older, were current illicit drug
users.
Sources 2005 National Survey on Drug Use and
Health (NSDUH), SAMHSA
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Advances in Science Have Revolutionized Our
Fundamental Views of Drug Abuse and Addiction
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What have we learned?
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Addiction is a Brain Disease
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Circuits Involved In Drug Abuse and Addiction
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Effects of Drugs and Natural Reinforcers on
Dopamine Levels in NAc
1100
AMPHETAMINE
COCAINE
400
1000
900
800
300
700
of Basal Release
600
of Basal Release
500
200
400
300
100
200
Di Chiara and Imperato
100
0
0
0
1
2
3
4
5 hr
0
1
2
3
4
5 hr
Time After Amphetamine
Time After Cocaine
FOOD
SEX
200
200

150
150
of Basal release
of Basal Release
100
100
15
10
Empty
Copulation Frequency
50
Box
Feeding
5
0
0
Scr
Scr
0
60
120
180
Female 1 Present
Female 2 Present
Time (min)
Sample Number
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
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Di Chiara et al.
Fiorino and Phillips
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Science Has Generated A Lot of Evidence Showing
That
Prolonged Drug Use Changes the Brain In
Fundamental and Long-Lasting Ways
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Normal
Cocaine Abuser (10 Days)
Cocaine Abuser (100 Days)
Sources Volkow, et al., Synapse, 11184-190,
1992 Volkow, et al., Synapse,
14169-177, 1993
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Dopamine D2 Receptors are Lower in Addiction
Cocaine
Meth
DA D2 Receptor Availability
Alcohol
Heroin
Control
Addicted
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Circuits Involved In Drug Abuse and Addiction
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Cocaine Suppresses Brain Glucose Metabolism
CG
CG
micromol/100g/min
P lt 0.01
OFC
micromol/100g/min
P lt 0.005
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Why Cant Addicts Just Quit?
Because Addiction Changes Brain Circuits
Source Adapted from Volkow et al.,
Neuropharmacology, 2004.
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This is why addicts cant just quit
This is why treatment is essential
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Treating a Biobehavioral Disorder Must Go Beyond
Just Fixing the Chemistry
We Need to Treat the Whole Person!

• Pharmacological
• (medications)

Behavioral Therapies
Medical and Social Services
In Social Context
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Treatment Can Work
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ADDICTION CAN BE TREATED
Partial Recovery of Brain Dopamine
Transporters in Methamphetamine (METH) Abuser
After Protracted Abstinence
3
0
ml/gm
METH Abuser (1 month detox)
Normal Control
METH Abuser (24 months detox)
Source Volkow, ND et al., Journal of
Neuroscience 21, 9414-9418, 2001.
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Apart from obvious public health impacts, drug
abuse and addiction treatment is also important
for preventing and treating HIV/AIDS.

• In fact

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Drug Abuse Treatment IS HIV Prevention

• Decreases Seroconversion
• Decreases HIV Risk Behaviors
• Increases HIV Treatment Adherence
• Decreases Disease Progression

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Drug Abuse Treatment Decreases Seroconversion
HIV Seroconversion at 18 MonthsBy Receipt of
Treatment
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No treatment
20
Partial treatment
15
Rate of Seroconversion ()
Continuous treatment
10
5
0
Treatment Status
Source Metzger, D. S., Woody, G. E., McLellan,
A. T., OBrien, C. P., Druley, P., Navaline, H.,
De Philipps, D., Stolley, P., Abrutyn, E.
(1993). Human immunodeficiency virus
seroconversion among intravenous drug users in-
and out-of-treatment An 18-month prospective
follow-up. Journal of Acquired Immune Deficiency
Syndromes, 6, 1049-1056.
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Drug Abuse Treatment Decreases HIV Infection Rates
Six year HIV infection rates by treatment status
at time of enrollment
Source David Metzger Presentation, Drug Abuse
and Risky Behaviors The Evolving Dynamics of
HIV/AIDS . Bethesda, MD. May 2007.
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Prevention interventions, including drug
treatment programs, peer outreach, and risk
reduction, have contributed to a steady decline
in new HIV/AIDS diagnoses among injection-drug
users in 35 areas with HIV reporting, from an
estimated 8,048 in 2001 to 5,962 in 2004.

• Source Morbidity and Mortality Weekly Report,
  Centers for Disease Control and Prevention, June
  2, 2006 / 55(21)585-589

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Adherence with antiretroviral therapy is
adversely affected by drug use
Drug Abuse Decreases HIV Treatment Adherence
Arnsten JH. J Gen Intern med 200217377
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Drug Abuse Exacerbates Disease Progression
Cocaine Accelerates HIV Degeneration of Dopamine
Cells
Seronegative
HIV
HIV Drug
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Advances in Science Are Giving Us A Broad Range
of Promising Options For Treating Addiction (and
Reducing HIV Transmission)
BUT
We Must Work to Ensure That They Actually Can be
Used in Practice And Are Used in Practice


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Our Strategy Involves BLENDING
Bringing Science-Based Technologies Into Ongoing
Community Practice
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Clinical Trials Network

• Mission
• Conduct multi-site clinical trials to
  determine the
• effectiveness of drug abuse treatment
  interventions
• in diverse community-based treatment settings
  and
• diverse patient populations
• Transfer research results to treatment
  programs,
• clinicians, and their patients to improve the
  quality
• of drug abuse treatment throughout the nation

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National Drug Abuse Treatment Clinical Trials
Network
A research infrastructure of 17 RRTCs 240 CTPs
across 34 States, and Puerto Rico
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CTN 0032 HIV Rapid Test and Counseling

• FDA approved
• Only requires blood from a finger stick or oral
  fluid from a swab
• Results in 20 minutes
• Does not require laboratory facilities and can be
  done by drug counselors
• CDC Collaboration

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As we strengthen our knowledge of effective
treatments for addiction, we must also expand our
research on strategies to optimize their
translation into clinical practice and the
community.
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To help translate the results of our rich
research portfolio and to systematically move
science-based interventions and practices into
community settings for use by those who need
them, NIDA relies on a dynamic and multifaceted
approach, reflected in our Blending Initiative.
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NIDA Blending Initiative
The Blending Initiative encompasses three
primary components

• Blending Conferences
• Blending Teams
• State Agency Partnerships

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NIDA/SAMHSA Blending Teams Process
CTN Protocols
Other NIDA Research
Create the charge for the Blending Team,
based on research results and how it can
address critical needs in the
treatment field
Hand-Off Meeting
Goal is to develop dissemination strategies
products. Each Blending Team is composed of
3 ATTC members 3 NIDA members
Blending Team
Blending Products are Disseminated at Nearly the
Same Time Research is Published
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NIDA-SAMHSA Blending Teams
Motivational Interviewing Assessment
Supervisory Tools for Enhancing Proficiency
(MIA-STEP)
Promoting Awareness of Motivational
Incentives (PAMI)

• Buprenorphine Treatment A Training
  for Multidisciplinary Addiction Professionals

Short-Term Opioid Withdrawal Using
Buprenorphine

• SMART Treatment Planning Utilizing the
  Addiction Severity Index (ASI)

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Short-Term Opioid Withdrawal Using Buprenorphine
Available Training Materials

• 4-hour classroom training providing step-by-step
  instructions on using buprenorphine for opioid
  dependent patients
• PowerPoint slides and CD
• Brochure
• Resources and bibliography

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Buprenorphine-Naloxone Increases Patient
Retention, Compared To Clonidine
In a recent study, about 80 of those receiving
buprenorphine continued in further treatment,
compared to 30 receiving clonidine. Cite
Brigham et al., JSAT, 2007
Source Ling, et al. Addiction. 2005 Aug 100(8),
1090-1100
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Contingency Management for the Treatment of
Methamphetamine Use Disorders
Roll, J.M. et al., AJP 163(11) pp. 1993-1999,
November 2006.
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Promoting Awareness of Motivational
Incentives (PAMI) Training Materials

• PowerPoint presentation and training
  video             
• Trainers Toolkit 
• Brochure
• Resources and bibliography

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We Are Also Reaching Out to the Criminal Justice
Population
The Primary goal is to stop the vicious cycle of
drug abuse and criminal involvement
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NIDA releases Landmark Publication as Part of Its
Criminal Justice Initiative
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Delaware Work Release TC (Crest)
Aftercare Drug-Free an Arrest-Free 3 Years After
Release (N448)
AFTERCARE is Indispensable
Arrest-Free
Drug-Free





Martin, Butzin, Saum, Inciardi (1999), The
Prison Journal
p lt .05 from Comparison
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CJ System Replete with Addiction Access to
Medications is Needed
Maryland Prison Study Treatment Linkage and
Opiate-Free One Month Post Release (N100)
In Treatment
C vs. CM p lt .05
Urine Test Positive
C vs. CT and CM p lt .01
C Counseling Only CT Counseling
Treatment Referral CM Counseling Methadone
Started in Prison
Preliminary Analysis Tim Kinlock, et al., 2006
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PREVENTION is Also Key to Breaking the Cycle of
DRUG USE--------HIV/AIDS
NIDAs Goal Is to Use the SCIENCE to PREVENT
Drug Abuse and HIV/AIDS
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NIDA Partners in Getting the Message Out Have
Included

• American Academy of Child and Adolescent
  Psychiatry,
• AIDS Alliance for Children, Youth Families and,
  
• United Negro College Fund Special Programs
  Corporation

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World AIDS Day PSA (60 seconds)
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Drug Abuse Prevention and Drug Abuse
Treatment ARE HIV Prevention
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Visit Our Website _at_
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Your Brain on Drugs - 1999
Source Breiter Rosen, Ann N Y Acad Sci 1999