# Presentation: 313550

## Addressing the Linkages between 

**Addressing the Linkages between **
**HIV/AIDS and Drug Abuse**

**Timothy P. Condon, Ph.D.**
**Deputy Director**
**National Institute on Drug Abuse**
**June 13, 2007**

## NIDA Research 

## DRUGS

**DRUGS**

**NEUROTOXICITY**
**OBESITY**
**AIDS**
**CANCER****MENTAL ILLNESS**

**HEALTH CARE **
**  ****COSTS**
**PRODUCTIVITY **
**  ****LOSS**
**ACCIDENTS**

**Addiction**

**Medical**

**HOMELESSNESS**
**CRIME**
**VIOLENCE**

**Social**

**Economic**

## Drug abuse

**Drug abuse**

**Smoking**

**HIV/AIDS**

**Child abuse**

**Violence**

**Stress**

**Cancer**

**Drunk driving**

**Heart disease**

**Alcohol abuse**

## Drug Abuse & HIV/AIDS are Co-Occurring, Intertwined Epidemics

**DRUG ABUSE**

**Drug Abuse & HIV/AIDS are Co-Occurring, Intertwined Epidemics**

## A Large Portion of AIDS Deaths Are Related to Drug Abuse

**A Large Portion of**** AIDS**** Deaths Are Related to Drug Abuse**

- Source: CDC, HIV/AIDS Surveillance Report, 2005, Vol. 17

- 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.

## Drugs of Abuse Have Had A Major Impact

***Source: Centers for Disease Control and Prevention (CDC)***

**Drugs of Abuse Have Had A Major Impact**
**on the HIV/AIDS Epidemic**

## Slide 8

## 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**

## 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

**Notes:**
Updated 9/12/05

## Advances in Science Have Revolutionized Our Fundamental Views of Drug Abuse and Addiction

## Slide 12

## What have we learned?

## Addiction is a Brain Disease

**Addiction is a Brain Disease**

## Slide 15

**Notes:**
Slide 30:  Summary;  addictive drugs activate the reward system via increasing dopamine neurotransmission
In this last slide, the reward pathway is shown along with several drugs that have addictive potential.  Just as heroin (morphine) and cocaine activate the reward pathway in the VTA and nucleus accumbens, other drugs such as nicotine and alcohol activate this pathway as well, although sometimes indirectly (point to the globus pallidus, an area activated by alcohol that connects to the reward pathway). While each drug has a different mechanism of action, each drug increases the activity of the reward pathway by increasing dopamine transmission.  Because of the way our brains are designed, and because these drugs activate this particular brain pathway for reward, they have the ability to be abused.   Thus, addiction is truely a disease of the brain.  As scientists learn more about this disease, they may help to find an effective treatment strategy for the recovering addict.

## Circuits Involved In 

**Circuits Involved In **
**Drug Abuse and Addiction**

## Effects of Drugs and Natural Reinforcers on Dopamine Levels in NAc

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**Time After Amphetamine**

**% of Basal Release**

**AMPHETAMINE**

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**Time After Cocaine**

**% of Basal Release**

**COCAINE**

***Di Chiara and Imperato***

**Effects of Drugs and Natural Reinforcers on Dopamine Levels in NAc**

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**Time (min)**

**% of Basal Release**

**Empty**

**Box**

**Feeding**

***Di Chiara et al.***

**FOOD**

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**% of Basal release**

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**0**

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**10**

**Copulation Frequency**

**Sample**
**Number**

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**Scr**

**Scr**

**Female 1 Present**

**Female 2 Present**

***Fiorino and Phillips***

**SEX**

## Prolonged Drug Use Changes

**the Brain In Fundamental**
**and Long-Lasting Ways**

***Science Has Generated A Lot of***
***Evidence Showing That... ***

## Normal

- Cocaine Abuser (10 Days)

- Cocaine Abuser (100 Days)

- Sources: Volkow, et al.,  *Synapse*, 11:184-190, 1992
-            & Volkow, et al.,  *Synapse*, 14:169-177, 1993

## Dopamine D2 Receptors are Lower in Addiction

- DA D2 Receptor Availability

- Control

- Addicted

***Cocaine***

***Alcohol***

***Heroin***

***Meth***

**Dopamine D2 Receptors are Lower in Addiction**

## Circuits Involved In 

**Circuits Involved In **
**Drug Abuse and Addiction**

## Cocaine Suppresses Brain Glucose Metabolism

- micromol/100g/min

- micromol/100g/min

**CG**

**OFC**

**CG**

***P < 0.005***

***P < 0.01***

## Why Can’t Addicts Just Quit?

**Why Can’t Addicts Just Quit?**

***Because Addiction Changes Brain Circuits***

**Notes:**
Addiction changes brain circuitry, making it hard to “apply the brakes” to detrimental behaviors.  In the non-addicted brain, control mechanisms constantly assess the value of stimuli and the appropriateness of the planned response, applying inhibitory control as needed. In the addicted brain, this control circuit becomes impaired through drug abuse, losing much of its inhibitory power over the circuits that drive response to stimuli deemed salient.

## This is why treatment is essential

**This is why addicts can’t just quit**

**Notes:**
Treatment is therefore essential.  Most people addicted to substances cannot quit on their own.

## Treating a Biobehavioral Disorder Must Go Beyond Just Fixing the Chemistry

**Pharmacological **
**(medications)**

**We Need to Treat the**
**Whole       Person!**

**In Social         Context**

**Behavioral Therapies**

**Medical and             Social Services**

**Notes:**
Addiction requires treatment that addresses its complexity.  Substance abuse treatment should address the whole person and can include medications, behavioral therapies, and ancillary support services.

## Treatment Can Work

**Treatment Can Work**

**Notes:**
Treatment Can Work.  More than 30 years of research have shown this to be true. Behavioral therapies can engage people in treatment, modify their attitudes and behaviors related to drug abuse, and increase their life skills. Medications are now available to treat opioid, alcohol, and tobacco addiction, while others are on the horizon. Behavioral therapies can enhance the effectiveness of these medications and can help people stay in treatment longer. 

## ADDICTION CAN BE TREATED

**Partial Recovery of Brain Dopamine Transporters**
**in Methamphetamine (METH)**
**Abuser After Protracted Abstinence **

**Normal Control**

**METH Abuser**
**(1 month detox)**

**METH Abuser**
**(24 months detox)**

**0**

**3**

**ml/gm**

***Source:  Volkow, ND et al., Journal of Neuroscience 21, 9414-9418, 2001.***

**ADDICTION CAN BE TREATED**

## Apart from obvious public health impacts, drug abuse and addiction treatment is also important for preventing and treating HIV/AIDS.

- In fact...

## Drug Abuse Treatment IS HIV Prevention

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

## Drug Abuse Treatment Decreases Seroconversion

**0**

**5**

**10**

**15**

**20**

**25**

**Rate of Seroconversion (%)**

**Treatment Status**

**No treatment**

**Partial treatment**

**Continuous treatment**

**Source: Metzger, D. S., Woody, G. E., McLellan, A. T., O’Brien, 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.**

**HIV Seroconversion at 18 Months****By Receipt of Treatment**

**Drug Abuse Treatment Decreases Seroconversion**

## 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.

**Drug Abuse Treatment Decreases HIV Infection Rates**

## “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

## Adherence with antiretroviral therapy is adversely affected by drug use 

|  | Not using cocaine (n=57) | Using cocaine (n=20)
 | P value |
| --- | --- | --- | --- |
| Adherence 
(MEMS Caps) | 68% | 27% | 0.005 |
| Viral suppression | 46% | 13% | 0.005 |

- Arnsten JH. J Gen Intern med 2002;17:377

**Drug Abuse Decreases HIV Treatment Adherence**

## Drug Abuse Exacerbates Disease Progression

**Cocaine Accelerates HIV Degeneration of Dopamine Cells**

**Seronegative**

**HIV**

**HIV + Drug**

**Drug Abuse Exacerbates Disease Progression**

**Notes:**
  Generalized cerebral atrophy most prominent in the frontal and temporal regions as well as basal ganglia atrophy with its shrinkage of the head of the caudate is noted.
  Diffuse periventricular white matter high signal intensity lesions are seen on a T2 weighted image.

## We Must Work to Ensure That 

**They Actually **_***Can***_** be Used***** *****in Practice **
**And **_***Are***_*** *****Used in Practice”**
**                                                              **

**“****Advances in Science Are Giving Us A Broad Range of Promising Options For Treating Addiction (and Reducing HIV Transmission)**

**BUT...**

## Our Strategy Involves BLENDING

***Our Strategy Involves BLENDING***

***Bringing Science-Based Technologies ***
***Into Ongoing Community Practice***

## 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

-     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*

**Clinical Trials Network**

** **

**A research infrastructure of 17 RRTCs & 240 CTPs across 34 States, and Puerto Rico**

**National Drug Abuse Treatment Clinical Trials Network**

**Notes:**
Since 1999, the CTN has grown into a stable infrastructure of 17 university centers affiliated with almost  240 community based treatment programs across 34 states and Puerto Rico.

## 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

## 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. 

**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. **

## 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.

## NIDA Blending Initiative

- Blending Conferences
- Blending Teams
- State Agency Partnerships

-    The Blending Initiative encompasses three primary components:

## NIDA/SAMHSA Blending Teams Process

**Blending Products are Disseminated at Nearly the Same Time Research is Published**

**CTN **
**Protocols**

** ****Hand-Off **
**Meeting**

**Blending**
**Team**

**NIDA/SAMHSA Blending Teams Process**

**       ****Create the charge for the Blending Team, **
**        ****based on research results and how it can address   **
**        ****critical needs in the treatment field**

**    ****Goal is to develop dissemination strategies & products. Each Blending Team is composed **
**     ****of 3 ATTC members & 3 NIDA members**

**Other NIDA **
**Research **

##       Buprenorphine Treatment:      A Training for Multidisciplinary Addiction Professionals

-     SMART Treatment Planning: Utilizing the Addiction Severity Index (ASI)

-     Short-Term Opioid Withdrawal Using Buprenorphine

**NIDA-SAMHSA Blending Teams**

-     Motivational Interviewing Assessment: Supervisory  Tools for Enhancing Proficiency (MIA-STEP)

-     Promoting Awareness of Motivational Incentives  (PAMI)

## 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

## Buprenorphine-Naloxone Increases Patient Retention, Compared To Clonidine

- Source: Ling, et al. Addiction. 2005 Aug; 100(8), 1090-1100

- 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

**Notes:**
Figure 1 Proportion of patients retained over time for the in-patient (diamond symbols) and out-patient (square symbols) protocols as a function of assignment to bup-nx (closed symbols) or clonidine (open symbols) 

## Contingency Management for the 

**Contingency Management for the **
**Treatment of Methamphetamine Use Disorders**

**Notes:**
FIGURE 1. Outcome Measures for 113 Patients With Methamphetamine Use Disorders After 12 Weeks of Usual Treatment With or Without Contingency ManagementaUrine samples were tested for cocaine, amphetamine, and methamphetamine. Alcohol was sampled by breath tests. 

FIGURE 2. Negative Drug Samplesa Over 12 Weeks for Patients With Methamphetamine Use Disorders Receiving Usual Treatment With or Without Contingency ManagementaUrine samples were tested for cocaine, amphetamine, and methamphetamine. Alcohol was sampled by breath tests. 

## Promoting Awareness of Motivational       Incentives  (PAMI) –Training Materials

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

## We Are Also Reaching Out to the Criminal Justice Population

**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**

## NIDA releases Landmark Publication as Part of Its Criminal Justice Initiative

**NIDA releases Landmark Publication as Part of Its Criminal Justice Initiative**

## Delaware Work Release TC (Crest) + Aftercare

**Delaware Work Release TC (Crest) + Aftercare**
**Drug-Free an Arrest-Free 3 Years After Release (N=448)**

- *

- *

- *

- *

- *

**Drug-Free**

**Arrest-Free**

***Martin, Butzin, Saum, & Inciardi (1999), The Prison Journal***

***AFTERCARE ***
***is Indispensable***

**Notes:**
Treatment works and aftercare is essential
Three years after release from prison, still see significant reduction in drug use and criminal activity for individuals who participated in prison-based treatment, community-based residential treatment, and outpatient aftercare.
448 subjects

## CJ System Replete with Addiction: Access to Medications is Needed

**C = Counseling Only; **
**C+T = Counseling & Treatment Referral; **
**C+M = Counseling & Methadone Started in Prison**

**Maryland Prison Study: Treatment Linkage and Opiate-Free **
**One Month Post Release (N=100)**

***Preliminary Analysis:  Tim Kinlock, et al., 2006***

**CJ System Replete with Addiction: *****Access to Medications is Needed***

**C vs. C+M p < .05**

**In Treatment**

**C vs. C+T and C+M p < .01**

**Urine Test Positive**

**Notes:**
The data are from the first 100 participants in the Prison Methadone study.
The proportions of participants in treatment at 1-month post-release are:
-Counseling only, 9%
-Counseling+ Transfer, 42%
-Counseling + Methadone, 65% 
Chi-square goodness-of-fit tests found that there were significant differences between Counseling Only and Counseling+Methadone (p<.001) and Counseling+Transfer (p<.01).
The proportion of participants testing positive for opiates are:
-Counseling only, 76%
-Counseling + Transfer, 50%
-Counseling + Methadone, 34%
Chi-square goodness-of-fit tests found significant differences between Counseling Only and Counseling + Methadone (p<.05). 

## DRUG USE--------HIV/AIDS

**PREVENTION is Also Key to**
***Breaking the Cycle *****of **

**DRUG USE--------HIV/AIDS**

**NIDA’s Goal Is to Use the ****SCIENCE**** to **
**PREVENT Drug Abuse and HIV/AIDS **

## 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

## Slide 55

## Slide 56

## Slide 57

## World AIDS Day PSA (60 seconds)

## Drug Abuse Prevention and Drug Abuse Treatment ARE HIV Prevention

## Visit Our Website @

***Visit Our Website @***

## Slide 61

## Your Brain on Drugs - 1999

- <date/time>

**Your Brain on Drugs - 1999**

- Source: Breiter & Rosen, Ann N Y Acad Sci  1999