Drug Abuse Treatment Called 'Lynchpin' To Defeating HIV/AIDS, Hepatitis C Psychiatric News June 02, 2000 Three public health epidemics are now intertwined, complicating the work of health care providers and public policy officials. Part of the answer in dealing with this emergency is to integrate treatment, legal, funding, and privacy issues. BY AARON LEVIN Hepatitis C, HIV/AIDS, and substance abuse can no longer be perceived as separate health threats, say two leading health officials. The confluence of these three public health epidemics challenges conventional, separate approaches to each disease, according to Alan Leshner, Ph.D., director of the National Institute on Drug Abuse (NIDA), and H. Westley Clark, M.D., J.D., M.P.H., director of the Center for Substance Abuse Treatment (CSAT). "Doctors can’t turn a blind eye to substance abuse," said Clark. "The delivery system must be integrated." Half of all new adult AIDS cases and 60 percent of new hepatitis C cases are related to drug abuse, said Leshner. In response, Clark called for coordination among previously discrete groups—specialists in primary care, mental health, substance abuse, and social services, as well as traditional public health practices like testing and partner notification. The two federal officials spoke at a meeting last month in Baltimore cosponsored by CSAT, NIDA, and the Centers for Disease Control and Prevention (CDC) and introduced the latest volume in CSAT’s Treatment Improvement Protocol Series, Substance Abuse Treatment for Persons With HIV/AIDS (TIP 37). Dealing with this emergency, said Clark, means battling HIV/AIDS, hepatitis C, and sexually transmitted diseases by making substance abuse treatment a lynchpin of the public health system, integrating treatment, legal, funding, and privacy issues. Conventional social divisions of lifestyle, race, socioeconomic status, and drug-using status provide no real barriers to viral transmission, said Clark. While the primary route of HIV infection is still homosexual sex, he said, the focus of the transmission has shifted from older, white, urban men to poorer African-American and Hispanic men and men abusing illegal drugs. This abuse includes not just injecting drugs, but also abusing alcohol, methamphetamine, MDMA, cocaine, crack, and other street drugs that are not injected. Users of these drugs are more likely to have unprotected sex and become infected with HIV, said Clark. Both Clark and Leshner observed that because of this nexus, only a coordinated response to the current crisis would cut rates of infection and addiction. Leshner said that the best approach was to help drug users and their partners change their risky behaviors. This means going directly to drug abusers—"where they live"—with people to whom they’ll listen, peer counselors who may be ex-addicts. Outreach strategies recruit 30 percent to 40 percent of users, said Leshner, although other approaches may be needed for those who can’t or won’t agree to treatment. Getting addicts into treatment would lessen the chances of transmitting either virus by needle sharing. Using that opportunity to instruct these new patients in the consequences of risky sexual behavior could further cut down on the likelihood of transmission. If physicians who specialize both in substance abuse and HIV/AIDS are not available, then other physicians should know where to turn for appropriate information. Without this dual awareness, they said, treatment for one illness may impair treatment for another. For example, medications used for HIV/AIDS can affect treatment for hepatitis, or can combine with street drugs like MDMA (ecstasy) to produce severe, even fatal, liver or kidney damage. Or an intravenous line ordered for an AIDS patient may be used by the patient to administer drugs of abuse. Clark also cited cases where medications that needed to be taken with food might be reconsidered for persons abusing opiates, amphetamines, or cocaine—patients who are unlikely to be eating regularly. Compliance, too, is often a problem in this population. Physicians should not demand prior substance abuse treatment as a condition for treatment of infectious diseases, said Steven L. Batki, M.D., a professor of psychiatry at SUNY Upstate Medical University in Syracuse, N.Y., and chair of the consensus panel that produced TIP 37. "We need to do stage-appropriate treatment, but not withhold treatment." Both Clark and Leshner stressed that political and ideological barriers have too often stood in the way of effective treatment programs. Stigmatization of both drug abusers and people infected with HIV have led to the belief that nothing can be done to stop drug abuse or risky sexual behavior, said Leshner. "Ignorance about drug abuse treatment and its outcomes make people reluctant to support it," he said. "But it is possible, and we know what to do about it." In contrast, managed care decisions often preclude access to substance abuse treatment, said Clark. HMOs claim that including such treatment within health plans would raise the cost of premiums. But Clark said that such increases would amount to only 0.1 percent of current premiums. "Our society is willing to pay for the consequences of substance abuse but not for treatment," he said. "To have a major impact on public health, we must reach out to the forgotten members of our society—the poor, hard-to-reach, inner-city dweller—and get them into treatment before injection drug use or unprotected sex leads to infection with HIV or hepatitis C." NIDA’s "Community Drug Alert Bulletin on Hepatitis C" is posted at <165.112.78.61/HepatitisAlert/Hepatitis Alert.html>.