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HIV & Aging Clinical Recommendations
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. Psychoactive substance use has been reported by 45.1% of younger PLWH and by 29.7% of older PLWH (zanjani 2007), and the causes for substance use may differ between younger and older cohorts (Mannes 2017). Substance use may also be more common among older HIV-positive men than women (Rubstova 2017). 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% (Hawkins 2012; Green 2010; Bowe 2015). Further, it has been shown that older adults living with HIV have higher rates of substance use disorder 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 (Millar 2017; Rabkin 2004).
Substance use disorders among PLWH are associated with risk of poor antiretroviral (ART) medication adherence, neurocognitive impairment (Iudicello 2014), psychosocial issues (Millar 2017) (such as depressive disorders, high life stressor burden, a lack of social support and maladaptive coping strategies), HIV disease progression, and HIV transmission via injection and high-risk sexual behaviors. 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 (Iudicello 2014).
A recent pilot study of substance use among PLWH 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 any substance (e.g. marijuana, cocaine, methamphetamine, heroin, prescription opiates) in the past year, 23% of whose use would be classifed as dependence. Less than half of these persons were in substance use treatment program or 12-step programs (Ompad 2016). This study highlights that there are missed opportunities for identifying and addressing substance use problems 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 ART for their psychoactive properties (e.g., efavirenz, ritonavir) alone and in combination with non-prescribed psychoactive substances.
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 (Moore 2017).
Treatment of PWLH with mental health and substance-use disorders results in the benefit of more consistent treatment of HIV (Palepu 2004; Sambamoorthi 2000). 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 (Moore 2017). 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 psychoactive substance use and other aspects of mental health (e.g., depression, anxiety).
Behavioral intervention strategies continue to be the most commonly used treatment for substance use disorders. These include 12-step programs, motivational interviewing techniques (MI), motivational enhancement therapy, faith-based and secular rehabilitation programs, contingency management interventions, cognitive behavioral therapy, the matrix model, family behavioral therapy, and community reinforcement approaches, amongst others. Treatment readiness can be assessed in a standardized fashion with the SCORATES scale (Center for Substance Abuse Treatment 2017). People with severe mental illness and HIV should be assessed for psychotic symptom level and cognitive function before being approached with behavioral interventions.
An expanding number of pharmacotherapies are considered safe when prescribed appropriately and 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).
Table 1. Pharmacotherapies with Evidence for the Potential to Treat Substance Disorders*
|Opioids||Alcohol||Smoking||Stimulants (Cocaine & Methamphetamine)||Benzodiazepines|
|Buprenorphine / naloxone||X|
a Methadone is NOT office-based; available only within a federally qualified opiate treatment program; b when naloxone used alone, reserved for use in overdose situation only; c Also used off-label for stimulant use disorder; d Flumazenil 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 (Jayaram-Lindstrom 2008; Carroll 2004; Colfax 2010; Marsch 1998).
*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.
Overall, alcohol and substance use disorders are a concern among older adults living with HIV, given their high prevalence and the issues in identifying these disorders as well as gaps in linkage to treatment for them. Given that older adults with HIV often have many co-morbidities (both mental and physical), substance use disorder 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 (Madras 2009). 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 (Madras 2009).
RECOMMENDATIONS FOR CARE PROVIDERS
Screening for Smoking and Providing Cessation Counseling
Recommendations for the role of health care providers include the use of a brief intervention which consists of: routinely asking patients about tobacco use and their willingness to stop smoking, efforts to increase motivation to quit, and a range of cessation strategies such as providing nicotine substitution, and referral to stop smoking clinics.
Screen for Alcohol and Other Substance Use
Older PLWH are encouraged to limit or abstain from alcohol consumption. Those with positive screening scores for misuse, hazardous or binge drinking (4 drinks for women and 5 drinks for men) should receive brief behavioral counseling. Patients assessed with the likelihood of a moderate to severe substance use disorder should be referred to specialty treatment. This model has yielded positive outcomes across a range of health care settings and patient populations . Several screening tools are recommended for use with SBIRT, including computer-assisted self-interview instruments.
Provide Access to Drug Treatment and Harm Reduction Services
The use of a harm reduction approach with substance users has increased in acceptance in the health arena -- moving the focus of care from abstinence only to reducing the negative consequences of substance abuse. Harm reduction is consistent with the ethical codes for health care providers, which require respect for patients and use of evidence-based care, and has been found to help patients adopt healthy behaviors. For older PLWH, harm reduction efforts include assisting patients who wish to access treatment (HIV and substance use) and respecting patients’ choices to continue substance use, e.g., for those who engage in drug injection, referring them to needle exchange programs.
Training Programs on Beliefs About HIV, Sexual Minorities, and Substance Users
Both professional and non-professional care providers may hold stigmatizing attitudes and training should target myths or stigma that may be associated with older PLWH. Sexual minority men, other persons with non-traditional gender identities, and those who use substances may fear being stigmatized, which can interfere with effective communication. Staff training in such techniques as motivational Interviewing and substance use counseling can also be helpful in understanding the basis for continued substance use (e.g., peer influences and depression), and provide tools for engaging clients.
Education on Evidence-Based Treatment and Best Practices for Substance Use Disorders
The last decade has led to the expanded use of Medication-assisted treatment (MAT) for opioid treatment and harm reduction approaches. Practitioners in general health care or geriatric care may be unaware of new biomedical or behavioral treatment models for people who use substances. It has been reported that some nursing facilities refuse to admit patients if they are taking medication to treat opioid addiction. Problems emerging around this may be due to gaps in staff training and persistence in the erroneous belief that 12-step models requiring abstinence, because of their predominance, are the “gold standard” for substance use disorder treatment. Knowledge of these changes and support for MAT can help older PLWH find suitable care settings [24,25].
Center for Substance Abuse Treatment. Enhancing Motivation for Change in Substance Abuse Treatment. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 1999. (Treatment Improvement Protocol (TIP) Series, No. 35.) Chapter 8—Measuring Components of Client Motivation.