What is the Management of Substance Use Disorders in HIV?

This transcript has been edited for clarity.

You know, it's sad and it's unfortunate, but substance use disorders are really common among people living with HIV. And I think it's appropriate to consider this a major comorbidity. We think of comorbidities, such as cardiovascular disease or osteopenia-osteoporosis, but we really don't think of substance abuse and substance use disorders in the same vein. And I think we should. And that we don't really speaks to how, in society, we differentiate mental health and substance use disorders really differently from those that we consider more physical or more overtly physical. And I think that's part of the problem and maybe, really, where we can start looking at solutions. When we talk about, well, how do we manage it, you know—this conundrum. And I don't have any magic answers or pearls of wisdom. There are evidence-based approaches that we can apply easily and readily to help folks who have substance use disorders do better with their HIV. I think understanding this is really the first part of coming up with answers. 

So, we all know, obviously, that substance use threatens people on a number of different levels, right? It directly can affect your health. If you're drinking heavily, alcohol, we know that clearly, there are risks for liver damage and brain damage and GI toxicity, etc. We also know that there are collateral problems from substance use, including adherence to people's meds and their care. People who use substances, almost of any sort, generally tend to not be as engaged in their care as those who do not use substances, and they don't necessarily take their medicines well. There are exceptions and there are data that can point in the other direction, based upon what kind of substances, and the setting, and the type of person we're talking about, and the medical systems in place. But in general, this is never a good thing for your health, never a good thing for your care.^[1]

 Another thing that we have to think about with substance use is its contribution to sexual risk. So, we know people engage not only in chemsex, which would certainly be on one end of the spectrum, but we also know that people engage in more risky behaviors when they're inebriated or when they're high.^[1] And so I think another consequence of that is not only secondary transmission, but even more so I think that in people living with HIV, it's just their risk for acquiring an STI themselves, because many of them are undetectable. So, we don't worry so much about them spreading their virus, but we do worry about them acquiring syphilis or hepatitis C acutely. I think that there are a whole bunch of things that we can identify—rather than just that they're taking drugs and they're not coming to clinic—that really are threats to people's health. And not only personal health, but also public health, directly from substance use. 

So, how do we manage this? Well, this is really a tough topic. And I think it depends upon the person, right? It depends upon their personality, their history, their comorbid conditions other than substance use, their HIV treatment, and also the substance that we're talking about. The approach to alcohol abuse, by necessity, has to be different than when we're talking about opioid abuse. And while there are some commonalities of addiction and substance use, there are some differences in our approaches. And even in sort of the legal standing, as we can see, in the case of alcohol and with illicit drugs. So there's a lot that has to really depend on the individual, the substances, and the context. What's very interesting, too, is that how we perceive—we being providers—and how patients or people living with HIV perceive substance use as a threat is very different. 

There was a recent study that looked at over 200 people living with HIV and almost 2 dozen providers, and asked them about ranking—what are the things that really matter, you think, in the care of people living with HIV.^[2] And for the providers, among the top 8 things that they felt were important—like half of them—had to do with abuse of some sort. Substance abuse or alcohol abuse or tobacco abuse, and they were worried more about that. But when you start asking people living with HIV, that was way down on the list, and the things they cared more about was staying on their medicines, about depression, about stigma, about pain and physical function. So there's a disconnect. And while we place a premium on this, especially when we talk amongst ourselves, our patients really don't see this as much of a problem, although they do identify mental health risks. And I think that's the key. I think the general approach to dealing with substance use among people living with HIV is to understand its antecedents. 

And it's not generally the case that someone just picks up a substance for kicks and then continues to use it. It's satisfying some need; it's providing some fill for some vacuum that really beforehand was a void that was unsustainable, that people couldn't deal with. So, in many cases, that's loss—loss of control, a loss of health, loss of money, loss of family members, loss of love. And loss breeds depression and mood disorders. So many of our people, of course, are self-medicating, and we know that and we say that, but we really don't do as much about it as we should. There are clear data that showed that even in people who heavily use alcohol from the CNICS [CFAR Network of Integrated Clinical Systems] cohort, it's only with the overlay of depression that we really see an impact on adherence and viral suppression. So depression alone is significant; alcohol use with depression is even more significant. Alcohol use alone wasn't as big a deal as far as getting people to stay undetectable and stay suppressed. So we have to deal better with depression. And in that study, it was untreated depression.  There's an opportunity to identify depression and to better treat it. 

There are other mental health disorders beyond depression. Again, depression is pretty prevalent. People are dealing with stigma. We don't have medications for stigma, but we have to have some other ways that we deal with this or at least recognize it, so people feel validated. People also drink or do drugs because of the abuse that they've suffered in the past—PTSD—or currently and to try to “numb the pain.” Sometimes we don't know about that. And I think it's really important that we appreciate that, that we look for it^[1] in short, quick visits. We really can't get underneath people's skin and understand how they tick. I think the more that we do that, the better we can do. And that may not be me. It may not be me with my stethoscope, and my white coat, and my otoscope finding that out during a visit. It may be that we have to have some of the people who work with me spend some time in doing this. I can take care of some of the aspects but have a partner who understands mental health better, who could help us. In many of our clinics we have this; in some of our clinics we don't, and it does fall on our shoulders. So, I think dealing with the underlying cause is really key—understanding people and what's going on with them, and then applying evidence-based interventions. If it is depression, really working to try to get people on antidepressants. Substance abuse programs can be effective if they're evidence-based. And there are some really good ones, especially residential ones, that work really well, and in-clinic support, as we talked about. 

Another aspect, especially now that we're in the midst of an opioid crisis, is really looking at medication-assisted treatment.^[1] So, replacement therapy can be very effective. We have to think more and more about how do we integrate this into HIV care. I don't think we're as advanced as we could be in that. Many of us are not knowledgeable about this; many of us are not certified to provide this care. It isn't that difficult. We do a lot of difficult things. And I think more and more, we have to integrate this into the treatment options for our patients. It's integral, not only to the patient's health, but I think, again, to how our clinics function and to public health.

Lastly, I'll just add that it’s really key—and we all know this, and this is what we do in HIV care. We're very sensitive to the fact that our people who we deal with and treat and work with have led tough lives. So, I think not being punitive, not being judgmental, allowing there to be trust so that people come in, they feel comfortable saying, yeah, I've relapsed; yeah, I have a problem.^[3] Otherwise, it's underground, and we don't know about it, and it complicates things, and it frustrates them and frustrates us. I think part of being a good doctor and a good HIV provider is, again, being open and understanding of where people are coming from and dealing with them on a level that makes sense to them and makes sense to us, so that it's a priority for both of us together.