Substance Use Disorder and HIV

Announcer

Welcome to the Academy Exchange, HIV Today and tomorrow. In this podcast, we discuss the latest advances in HIV prevention care and treatment, as well as examine the societal and systemic issues facing people with HIV. Thank you for joining us.

Bruce

Welcome back to the Academy Exchange podcast. Once again, my name is Bruce Packet and I'm the Executive Director for the American Academy of HIV Medicine, which is a DC based organization that represents HIV care providers and all their attendant issues and concerns. What we normally do on this podcast is talk to our health care practitioners and other subject matter experts on clinical and social issues around HIV care and treatment and of course, prevention.

But we try to render all that heavy clinical medical language into more everyday speak for a general listenership. I think maybe not surprisingly, most of our episodes so far have probably focused most heavily on the sexual side of HIV transmission risk, and those behaviors that drive the epidemic. But we haven't talked much specifically on this podcast about substance use disorder, which is of course, another epidemic that has really ravaged many parts of the country in terms of deaths, overdoses, the overall burden on the health care system and of course, the transmission of infectious diseases.

To talk to us today about the specifics of substance use disorder and its overlap with the HIV epidemic, I have with me Dr. Hannan Braun. Dr. Braun uses either he/him or she/her pronouns and is an HIV Primary Care doctor and Addiction Medicine Specialist at Denver Health in Denver, Colorado. He completed an internal medicine residency at Boston Medical Center in 2021 and fellowship in Addiction Medicine at Brown University in 2022.

Dr. Braun, welcome to the Academy Exchange. I look forward to speaking with you for a few minutes today about your work in addiction medicine and the substance use disorder epidemic in this country. So welcome.

Dr. Braun

Thanks for having me. I’m excited for this conversation.

Bruce

Absolutely. Before we dive directly into substance use disorder and HIV, I'm hoping you can tell us a little bit more about your work, specifically your clinic and sort of a day in the life of Dr. Braun to kind of set the stage for our conversation today.

Dr. Braun

Oh, sure. So I practice at a large urban safety net hospital in Denver, Colorado, and my work is a mixture of general internal medicine, primary care, a couple addiction focused clinics, and a couple of HIV primary care clinics. There's obviously a lot of overlap between those areas, and I do my best to integrate it in a way that for patients feels easy.

I work primarily in the outpatient space, although do a few weeks a year on the inpatient Addiction Medicine Council service as well.

Bruce

That's really great. Thanks to that background. So now diving specifically into, you know, addiction medicine and substance use disorder. Can we just start, as I normally like to do, by defining our term. So we can start with defining substance use disorder? And I want to make sure that we can draw a fairly clean clinical line between what we might recognize as casual recreational use and then the diagnostic substance use disorder and how it's specifically diagnosed.

Can you sort of walk us through those definitions?

Dr. Braun

Absolutely. So I'm a physician, so I tend to operate in a medical model. And I understand a substance use disorder to be a chronic condition with periods of remission, perhaps return to use. And as you said, your question, it was actually a very good one in that acknowledging that not all substance use is disordered use. The vast majority of Americans will try an addictive, potentially addictive substances in their lifetime. Most Americans don't go on to develop a use disorder, so we do have diagnostic criteria to help us. 

So largely, it is defined as continued use of a substance, despite its negative consequences. We also see, along with the continued use, despite negative consequences, a lack of, a loss of control as well as use that has become compulsive. So those are the main hallmarks of a substance use disorder.

Bruce

Right. That's really helpful is sort of diagnostic criteria. I have a follow up question to that that I'm curious about. Is there any difference in the kinds of substances being used to be able to apply a diagnosis or do you apply the diagnostic categories across different potentially addictive substances?

Dr. Braun

Yeah, it's a good question. There are DSM criteria to define a substance use disorder. There are 11 criteria. And depending on how many a patient meets, we can further define a substance use disorder as mild, moderate or severe. That said, not all substances are in the DSM.  For example, caffeine is not in the DSM. But in clinically speaking, what you're what I think your question is asking is, clinical approach to managing a patient who has an opioid use disorder versus, let's say, methamphetamine use disorder does.The treatments are different. The complications can be different. So clinically, it obviously does matter quite a bit.

Bruce

Of course. I think a lot of our listeners at this point in history are probably pretty aware of the scale of the devastation caused by substance use disorder. I mean, we even have some TV dramas and other cultural representations of things like opiate prescribing practices in the nineties, Purdue Pharmaceuticals and their hand in worsening the crisis.

But what can you tell us about the latest state of the overdose crisis? Where are we now on the arc of the overdose epidemic in this country?

Dr. Braun

So we think about the opioid overdose crisis in three waves traditionally. And as I said, we are in a fourth wave now. In the nineties, we had overdose deaths related to prescribed opioids. And then once prescribing became more restrictive, we did see heroin use driving overdose deaths. And then several years later around 2013, 2014, depending on where in the country you are, the emergence of illicitly manufactured fentanyl and its analogs are quite potent and also quite dangerous. The potency can vary from sample to sample driving overdose deaths. 

And we're really now in a fourth wave, which is characterized by poly substance use, particularly stimulants such as methamphetamines and cocaine. And unfortunately, we're seeing we're seeing fentanyl contaminating other substances as well, such as such a stimulant. So folks who are intending to consume a stimulant and not an opioid may still be at risk for an opioid overdose. And that's really scary.

Bruce

Scary proposition for sure. And any sense of where the overdose peak might be? You know, could we be reaching peak overdose or are we are yet to hit that point? And what can we expect in the near future?

Dr. Braun

We don't know where the overdose peak is. And that's very scary. We're running out of wall space on our memorial walls at a local harm reduction organization or volunteer. And it's just really scary.

Bruce

It's a really vivid and frightening image for sure. Now, as we start to pivot into the overlap of substance use disorder and HIV as an infectious disease, I'm hoping you can underscore some of the epidemiological considerations of the two together. For example, can you help us disaggregate HIV risk from injection and HIV risk from sex? What do those numbers look like demographically, epidemiologically?

Dr. Braun

So currently about one in ten new HIV diagnosis in the United States are among people who inject drugs. One thing that I think is underappreciated is that sexual risk and injection risk really do go hand-in-hand for many patients. So as a clinician, it's important to be asking about any activity behavior that will carry a risk of transmission.

And unfortunately not all communities face that experience these numbers equally. We do see, for example, 1 in 7 Black women who inject drugs will contract HIV in her lifetime. And that is as opposed to 1 in 26 women generally and 1 in 42 men who inject drugs. So we are we do have quite a bit of disparities in HIV transmission unfortunately.

Bruce

So, again, in your clinic, when you have a patient who you discern likely requires treatment for a substance use disorder, what's your method for then assessing HIV risk for that person who is also actively using substances?

Dr. Braun

So as you said, what's behind your question, which I just want to call out is that, assessing HIV risk really should be integrated into all of our standard substance use disorder treatment spaces. Oftentimes, unfortunately, our care is quite siloed, which will probably not be news anyone listening to this podcast. And, as an addiction medicine provider, we're often good about asking about an injection related risk factors in sexual health clinics we might be good at asking about sexual risk factors.

But really we should be asking all patients about all of these potential risk factors and behaviors. I ask about specific injection practices, and I do that because it will change my management.

I ask questions like, how many times a day do you use the substance? How do you inject where you inject? Where do you get your needles from? When was the last time you shared? 

And oftentimes people think about sharing as the syringe itself, although we also know that sharing other injection equipment like your cottons or your cookers also carries risks as well. So I ask about all of the above. I try to ask, use phrases like how often do you use rather than a yes/no question, do you use or not?

Because that obviously, who would respond to a question like that with it with a yes?

Bruce

And that's all super important data as you're sort of assessing HIV risk, all of those things you mentioned, and it's really consonant with the sort of novel HIV status neutral approach. And then prevention methods are implemented where needed and treatment and care on the other side. And I think that kind of leads us to what the biggest question I want to ask you today, which is how is it that we can help prevent HIV transmission in people who inject drugs?

Dr. Braun

Yeah, this is an exciting space and that we do have very effective strategies that prevent HIV transmission and overall improve the health and safety of folks who inject drugs. So just to go over it broadly, we have medications for opiate use disorder, which I'm happy to talk more about. We have syringe exchange programs, syringe access programs, condoms. We have pre and post-exposure prophylaxis, which kind of the questions that I was asking about timing beforehand will help me determine the right approach to that patient. And condoms, of course.

Bruce

We do talk about, sorry to interrupt. We don't talk about PrEP and PEP quite a lot in some of the other episodes. Can you just briefly describe those interventions and what they are?

Dr. Braun

PReP, pre-exposure prophylaxis.  There are currently three FDA approved medicines for PrEP, although only one of which, TDF formulation tenofovir disoproxil fumarate formulation of PrEP has been approved for use of for HIV prevention among folks who inject drugs. It's a very potent HIV prevention strategy to reduce risk of HIV by 74% for those with detectable medication levels and by 49% overall.

Looking at specifically for folks who inject drugs, it's a massively underutilized tool, unfortunately. Large data really shows that our uptake among people who inject drugs really needs a lot of improvement.

Bruce

Just to kind of boil it down, do you think that you would strongly suggest or recommend PrEP for anyone who is an injection drug user?

Dr. Braun

Well, I a few things in that question. The CDC says that anyone who inject drugs, who reports any shared injection equipment, syringes or the cottons cookers, in the last six months qualifies for PrEP as well as any person who injects drug, who requests PrEP, knowing that these types of behaviors are often quite difficult to disclose to a provider.

I don't want to minimize the challenges for a patient who, with an unstable and active substance use disorder, who is experiencing multiple competing priorities. But I think that a lot of our, our meaning clinicians, reluctance to talk about PrEP with people who inject drugs is unfortunately rooted in stigma. And that's very frustrating as a clinician. We have very substantial evidence that people who inject drugs can succeed in taking daily medicines such as for HIV, for hepatitis C treatment, and especially with appropriate community based supports.

Bruce

And I actually want to ask you to try to put your public health hat on for a second. You know, I think a lot of our listeners may remember a very well known case of HIV clusters in injection drug users in Indiana back when Mike Pence was the governor there. What can you tell us about clusters of HIV incidence and how that comes to be and then what some of the mitigation tools are for those identified HIV clusters?

Dr. Braun

So the clusters that you're referring to, I think, are using a technology called molecular surveillance. It takes advantage of how rapidly the HIV virus can mutate and it can show how an outbreak is unfolding and it can connect people who might otherwise be missed by traditional public health methods. It can also be helpful when partners might be anonymous or a partner might not know the HIV status of their partners. So it's a helpful tool. 

I think what's also what you're asking about is ways to mitigate it. You know, as you noted for the outbreak in 2016 in Scott County, Indiana, that was where syringe exchange was unfortunately illegal at that time. And that's a policy decision that allowed for the transmission of HIV. Withholding a very evidence based strategy to prevent transmission of a viral illnesses.

Bruce

Harm reduction, right. Dr. Braun, I did want to ask you also about some of the other PrEP options that are FDA approved. There are two others we talked about. FTC/TDF or Truvada. But I'm hoping you could talk about the other PrEP options and whether or not they're available for these types of instances, with substance use disorder patients.

Dr. Braun

Yeah, thanks for the question. So as you note, there are now three FDA approved medicines for PrEP. Generally speaking, there is the TDF/FTC formulation. Brand name is Truvada. The TAF/FTC formulation, which is brand name is Descovy. And the injectable cabotegravir, which is a newer addition and very exciting, as a clinician and a primary care provider and HIV primary care doctor. But unfortunately, those other two formulations are not FDA approved for folks with injection risk factors.

for that is that unfortunately, trials have systematically excluded patients who use drugs among their study population. So these medicines that we could have great access to that could be quite helpful, unfortunately, we don't have FDA approval for them. For example, in cabotegravir, the long acting injectable that was recently released and showing really robust data that we don't often get in terms of prevention trials, folks who use drugs were mostly systematically excluded.

They noted that the investigator could exclude folks with a substance use. That data that could be problematic was in the words of the study. And they also excluded folks with hepatitis C antibody positive results. So the population did not reflect the community that I treat. And I wish the trials were designed differently.

Bruce

So you alluded earlier to treating substance use disorder itself and some of the novel treatments that are available for study. So jumping back from HIV a bit and focusing on that, how do you start conversations about treatment for a patient's substance use disorder?

Dr. Braun

I'm a clinician. I find treating substance use disorder to be very rewarding. We have very effective medications and interventions for our patients depending on their substance use disorder. And many, if not most, people get better. So those are all things that  I really value. And it's quite rewarding in my day to day work at Denver Health.

For opioid use disorder we have three FDA approved medicines. We have methadone, buprenorphine and naltrexone. Methadone has been the longest approved. It was approved in the seventies and been used to treat patients with opioid use disorder since the sixties. And by some measures, it's the most effective. It decreases, overdose, it decreases all causes of mortality, it decreases infectious complications.

What is challenging about methadone is that it can only be delivered in a an OTP, an opioid treatment program that are federally regulated and further restrictions are applied at the state level. I work at an institution that fortunately has a methadone clinic within the institution, which makes it easier to get patients into methadone treatment. But unfortunately, the barriers are real and substantial for patients. 

A lot of the regulations, things around the dose that we can start methadone, add around policies around take homes, have not been updated since from 1973 when it was approved until really since COVID. And COVID has catalyzed a lot of the changes that a lot of us have been saying are needed for quite some time.

If I may say, it's frustrating as a clinician. All these regulations are not necessarily about the drug itself. It's more about the medical condition that I'm treating. I can and sometimes do prescribe methadone for treatment of chronic pain in my clinic, but I would not be able to prescribe that for a patient with opioid use disorder in my clinic.

Bruce

Right. There are other options for those patients.

Dr. Braun

Yeah. So I, I talked to folks about buprenorphine, which is also has incredibly robust data that it decreases overdose and also improves all cause mortality and infectious complications. It's often co-formulated with the drug naloxone in the brand name Suboxone, and that can be prescribed in any clinic and sent to any retail pharmacy. So my work at Denver Health is a lot of prescribing buprenorphine and we're trying to make it as low barrier as we can. The way buprenorphine works, it's an opioid, it's a partial agonist, which I don't want to get to medical, but it does decrease the risk of overdose, we think because of that partial agonist activity. It does make it more challenging to start in some ways because it requires a patient to be already in moderate withdrawal before starting buprenorphine. And we used to say that wait 12 to 24 hours since last opioid use before starting. And unfortunately with illicitly manufactured fentanyl, it can stick around in your body's fat tissue for quite a long time.

And where it's getting harder and harder to start it out under traditional methods. Luckily, we do have new protocols that help patients get on this lifesaving medicine.

Bruce

I don't know if you want to say anything about naltrexone and whether or not that's an option that you tend to use with SUD patients.

Dr. Braun

Yeah. So naltrexone is FDA approved for both opioid use disorder and alcohol use disorder. It's an opioid receptor antagonist, meaning that it's a blocker at that receptor and it is FDA approved. And unlike methadone and buprenorphine, it does not have the clear mortality benefits of the agonist treatments, the buprenorphine and methadone, although more research is needed.

The largest barrier to starting it is that it requires at least 7 to 10 days of abstinence from opioids before starting it. And that is quite challenging for patients with active substance use disorder.

Bruce

I mean, it certainly seems like there are there are several options and your job is to pick the right one. But it's certainly a positive that we do have all of these treatment options for substance use disorder here in 2023. And I love to end these podcast episodes on a positive note. So we'll kind of put a pin in that important part of the interview.

But just looking into your wish list of public policy, societal and health care system changes, what would you say rises to the top for you? What policy change or health care system change could be implemented to help you treat these clients more effectively and mitigate HIV overall?

Dr. Braun

Yeah, I would start by saying I'd love to be in the position where I have the opportunity to influence these types of policy decisions. We have exciting tools that are legal and/or being studied in other countries and I think we're way past due for a robust conversation about that in America. The first of which I would say are safer consumption sites, safer injection sites, overdose prevention centers, names for the same thing where folks can bring a pre obtained substance and use it in the facility and have access to other services, unused fresh needles, naloxone, Narcan, which is our opioid reversal drug, and can do it in a well-lit and clean environment.

The first two opened in New York City, the first two authorized rather, opened in New York City last year and have had quite great success. And I'm hopeful that we're able to get more authorized sites approved. As I said, one of our frustrations as a clinician is that I need to send my patients who are interested in methadone to a methadone clinic, which even working at Denver Health, the methadone clinic is literally across the street from my clinic is still represents a barrier for many patients who just don't want to establish care with a new provider, may have heard stigma, or have other misconceptions, or real perceptions, about what methadone treatment through a methadone clinic entails. 

I would love to, as a primary care doctor, be able to prescribe methadone for opioid use disorder. This is something that is a model that exists in other countries like Canada and Australia, and I think with appropriate caution, clinical caution, we primary care doctors, outpatient addiction providers are well equipped to manage methadone maintenance.

Bruce

This is all really important stuff. And I really want to thank you for being here and talking to us about HIV and substance use disorder in 2023 in the U.S., Dr. Braun. Because it is such a pressing crisis that we're facing in HIV is really only part of that, but certainly a significant piece. But thanks again for sharing your wisdom and your knowledge from your from your professional life. And yeah, thanks again.

Dr. Braun

Thank you for having me.

Bruce

Absolutely.