Cocaine use and HIV risk behavior in methadone maintenance patients

doi:10.1016/0376-8716(94)01058-S

Drug and Alcohol Dependence

Volume 37, Issue 1, January 1995, Pages 29-35

https://doi.org/10.1016/0376-8716(94)01058-S Get rights and content

Abstract

This study examined sexual and drug use behavior in 247 methadone maintenance patients, to explore the association of cocaine use with human immunodeficiency virus (HIV) risk behavior. In univariate analyses, cocaine use was positively associated with any drug injection, number of injections, and sexual intercourse without condoms. These relationships remained significant after controlling for other drug use and demographic factors. Heroin use also contributed to injection-related risk. We conclude that cocaine use represents a continued source of risk for exposure to HIV in this population, and that more aggressive efforts are warranted to reduce illicit drug use, particularly of heroin and cocaine, in methadone patients.

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Cited by (97)

Alcohol use disorders are associated with increased HIV risk behaviors in cocaine-dependent methadone patients
2017, Journal of Substance Abuse Treatment
People who inject drugs (PWID) are at increased risk of HIV infection. Although methadone maintenance therapy can help lower this risk, many methadone patients continue to engage in HIV risk behaviors, especially patients who use cocaine and alcohol. The purpose of the current study was to investigate relations between alcohol use disorders and HIV risk behavior in 239 cocaine-dependent methadone patients participating in a randomized controlled trial of a behavioral intervention to promote cocaine abstinence. Past 3-month HIV Risk-taking Behavior Scale (HRBS) scores were compared between cocaine-dependent methadone patients who met DSM-IV-TR diagnostic criteria for alcohol abuse or dependence and those who did not meet these criteria. No significant differences in HRBS drug subscale scores were observed between participants with and without alcohol use disorders, indicating risky drug use was similar between groups. However, alcohol use disorder was significantly associated with HRBS sex subscale scores (t = 2.59, p = 0.01), indicating participants with alcohol use disorders were more likely to engage in risky sexual behavior. Item-level analyses of the sex-related HRBS questions showed participants with alcohol use disorders were significantly more likely than participants without alcohol use disorders to have unprotected sex, engage in transactional (paid) sex, and have anal sex. Interventions are needed to reduce risky sexual behavior and attenuate the spread of HIV in this high-risk population.
Hepatitis C Virus seroconversion among persons who inject drugs in relation to primary care physician visiting: The potential role of primary healthcare in a combined approach to Hepatitis C prevention
2015, International Journal of Drug Policy
Meaningful reductions in Hepatitis C Virus (HCV) transmission rates among persons who inject drugs (PWID) require a comprehensive prevention approach, including access to harm reduction measures and to healthcare-related interventions, such as HCV screening, testing and antiviral treatment. Little is known, however, about the role of visiting a primary care physician (PCP) in relation to HCV infection risk among PWID, when integrated within a combined prevention approach. This study assessed the association between PCP visiting and HCV seroconversion among PWID attending needle exchange programs (NEP).
A prospective cohort study, HEPCO, was conducted among active PWID in Montréal (2004–2013). Interviews scheduled at 3- or 6-month intervals included completion of an interviewer-administered questionnaire, and collection of blood samples for HCV antibody testing. HCV-seronegative participants who reported NEP attendance at baseline and had at least one follow-up visit were eligible for this study. HCV incidence was calculated using the person-time method. Time-varying Cox regression modeling was conducted to evaluate the relationship between self-reported recent PCP visiting and HCV incidence.
At baseline assessment, of 226 participants (80.5% male; median age: 30.6 years), 37.2% reported having recently visited a PCP. During 449.6 person-years of follow-up, 79 participants seroconverted to HCV [incidence rate: 17.6 per 100 person-years, 95% confidence interval (CI): 14.0–21.8]. Covariate-adjusted analyses indicated that visiting a PCP was associated with a lower risk of HCV infection [Adjusted Hazard Ratio: 0.54, 95% CI: 0.31–0.93]. Other independent predictors of HCV infection included unstable housing, cocaine injection and prescription opioid injection.
Among PWID attending NEP, visiting a PCP was associated with a lower risk of HCV infection. Yet, only a minority of participants reported PCP visiting. Efforts to intensify engagement with PCP among PWID could potentially contribute to lower HCV transmission when integrated within a combined approach to prevention.
Randomized clinical trial of disulfiram for cocaine dependence or abuse during buprenorphine treatment
2014, Drug and Alcohol Dependence
Disulfiram may be efficacious for treating cocaine dependence or abuse, possibly through inhibiting dopamine β-hydroxylase (DβH). Consequently, this randomized, placebo-controlled clinical trial of disulfiram during buprenorphine maintenance treatment evaluated the study hypothesis that disulfiram is superior to placebo and explored whether disulfiram response is greatest for participants with a single nucleotide polymorphism coding for genetically low DβH (T-allele carriers).
We randomized 177 buprenorphine-treated opioid dependent participants with cocaine dependence or abuse to 12 weeks of double-blind treatment with disulfiram 250 mg daily (n = 91) or placebo (n = 86). Of 155 participants genotyped, 84 were CC-homozygous, and 71 CT or TT genotypes. Primary outcomes included days per week cocaine use, number of cocaine-negative urine tests, and maximum consecutive weeks of cocaine abstinence. We analyzed an intention-to-treat comparison between disulfiram and placebo. We also explored potential pharmacogenetic interactions and examined treatment responses of four participant groups based on medication (disulfiram or placebo) by genotype (CC-homozygous or T-allele carrier) classification.
Disulfiram participants reported significantly less frequent cocaine use; the differences in cocaine-negative urine tests or consecutive weeks abstinence were not significant. Frequency of cocaine use was lowest in disulfiram-treated T-allele carriers; differences in cocaine-negative urine tests or consecutive weeks abstinence were not significant among the four medication-genotype groups.
The findings provide limited support for the efficacy of disulfiram for reducing cocaine use and suggest that its mechanism of action may involve inhibition of DβH. Further studies of its efficacy, mechanism of action, and pharmacogenetics of response are warranted.
Pharmacogenetic randomized trial for cocaine abuse: Disulfiram and dopamine β-hydroxylase
2013, Biological Psychiatry
Disulfiram has been an effective cocaine addiction pharmacotherapy, and one of its possible mechanisms of efficacy is through copper chelation and inhibition of an enzyme involved in catecholamine metabolism, dopamine β-hydroxylase (DβH), which converts dopamine to norepinephrine. A variant in the gene encoding DβH leads to reduced DβH activity, and as such, disulfiram might not be an effective treatment of cocaine dependence for individuals with this variant. This study explored that potential matching.
Seventy-four cocaine- and opioid-codependent (DSM-V) subjects were stabilized on methadone for 2 weeks and subsequently randomized into disulfiram (250 mg/day, n = 34) and placebo groups (n = 40) for 10 weeks. We genotyped the DBH gene polymorphism, −1021C/T (rs1611115), that reduces DβH enzyme levels and evaluated its role for increasing cocaine free urines with disulfiram.
With repeated measures analysis of variance, corrected for population structure, disulfiram pharmacotherapy reduced cocaine-positive urines from 80% to 62% (p = .0001), and this disulfiram efficacy differed by DBH genotype group. Patients with the normal DβH level genotype dropped from 84% to 56% on disulfiram (p = .0001), whereas those with the low DBH level genotype showed no disulfiram effect.
This study indicates that the DBH genotype of a patient could be used to identify a subset of individuals for which disulfiram treatment might be an effective pharmacotherapy for cocaine dependence.
Prevalence of mood and substance use disorders among patients seeking primary care office-based buprenorphine/naloxone treatment
2013, Drug and Alcohol Dependence
Citation Excerpt :
While the prevalence of psychiatric and substance use comorbidity among patients seeking or enrolled in methadone maintenance treatment has been systematically investigated (Brooner et al., 1997; Darke and Ross, 1997; Ross et al., 2005; Rounsaville et al., 1982b; Schäfer et al., 2011; Strain, 2002), these rates have not been examined among persons seeking or receiving primary care office-based buprenorphine/naloxone treatment. Psychiatric and substance use comorbidity can affect treatment outcomes among patients receiving opioid agonist treatment (Brooner et al., 1997; Bux et al., 1995; Cacciola et al., 2001; Darke et al., 1993; el-Bassel et al., 1993; Havard et al., 2006; Kosten et al., 1988; McKay and Weiss, 2001; Rounsaville et al., 1982a; Schäfer et al., 2011; Srivastava et al., 2008; Sullivan et al., 2010). Since buprenorphine/naloxone is attracting new patients to medication assisted treatment, it is important to determine the prevalence of mood and substance use disorders among these patients.
Psychiatric comorbidity can adversely affect opioid dependence treatment outcomes. While the prevalence of psychiatric comorbidity among patients seeking methadone maintenance treatment has been documented, the extent to which these findings extend to patients seeking primary care office-based buprenorphine/naloxone treatment is unclear.
To determine the prevalence of mood and substance use disorders among patients seeking primary care office-based buprenorphine/naloxone treatment, via cross sectional survey.
237 consecutive patients seeking primary care office-based buprenorphine/naloxone treatment were evaluated using modules from the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I). Current (past 30 days) and past diagnoses were cataloged separately.
Patients ranged in age from 18 to 62 years old (M = 33.9, SD = 9.9); 173 (73%) were men; 197 (83%) were white. Major depression was the most prevalent mood disorder (19% current, 24% past). A minority of patients met criteria for current dysthymia (6%), past mania (1%), or past hypomania (2%). While 37 patients (16%) met criteria for current abuse of or dependence on at least one non-opioid substance (7% cocaine, 4% alcohol, 4% cannabis, 2% sedatives, 0.4% stimulants, 0.4% polydrug), 168 patients (70%) percent met criteria for past abuse of or dependence on at least one non-opioid substance (43% alcohol, 38% cannabis, 30% cocaine, 9% sedatives, 8% hallucinogens, 4% stimulants, 1% polydrug, and 0.4% other substances).
Mood and substance use comorbidity is prevalent among patients seeking primary care office-based buprenorphine/naloxone treatment. The findings support the need for clinicians to assess and address these conditions.
Efficacy of disulfiram and Twelve Step Facilitation in cocaine-dependent individuals maintained on methadone: A randomized placebo-controlled trial
2012, Drug and Alcohol Dependence
Citation Excerpt :
Concurrent cocaine use (Hubbard et al., 1997) remains a major problem within many methadone maintenance programs and is associated with poorer drug use outcomes (Hubbard et al., 1997) and a host of other medical and psychiatric problems (Bux et al., 1995; Grella et al., 1995; Peirce et al., 2006).
Cocaine use remains a major problem within methadone maintenance programs. Disulfiram's efficacy in reducing cocaine use has been demonstrated in several trials, but its relative efficacy among individuals who use versus abstain from alcohol remains unclear. Treatment approaches which seek to enhance substance users’ involvement in self-help activities (Twelve Step Facilitation, TSF) have been associated with better outcomes among alcohol and cocaine users, but have rarely been evaluated among methadone-maintained cocaine-opioid users.
We conducted a randomized, placebo-controlled, double blind (for medication condition), factorial (2 × 2) trial with 4 treatment conditions: Disulfiram plus TSF, disulfiram plus standard counseling only, placebo plus TSF, and placebo plus standard counseling in the context of a community-based methadone maintenance program. Participants (N = 112) received either disulfiram (250 mg/d) or placebo in conjunction with daily methadone maintenance.
Assignment to TSF was associated with less cocaine use throughout treatment and a higher number of cocaine-negative urines. While there were no significant main effects of disulfiram versus placebo, individuals without an alcohol use disorder demonstrated greater reductions in cocaine use over time when assigned to disulfiram.
TSF appears feasible in this methadone maintenance program and was associated with modest reductions in cocaine use, an often intractable problem in this setting. Support for the efficacy of disulfiram was weaker, as it appeared effective only for those without a current alcohol use disorder for this sample.

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Cocaine use and HIV risk behavior in methadone maintenance patients

Abstract

J. Subst. Abuse Treat.

Drug Alcohol Depend.

Am. J. Obstet. Gynecol.

New evidence on intravenous cocaine use and the risk of infection with human immunodeficiency virus type 1

Am. J. Epidemiol.

Reducing the risk of AIDS through methadone maintenance treatment

J. Health Soc. Behav.

The Effectiveness of Methadone Maintenance Treatment

The crack life: an ethnographic overview of crack use and sexual behavior among African-Americans in a midwest metropolitan city

J. Psychoactive Drugs

Exposure factors for HIV-1 infection among heterosexual drug abusers in New Jersey treatment programs

AIDS Res. Hum. Retroviruses

Cocaine use and HIV infection in intravenous drug users in San Francisco

J. Am. Med. Assoc.

HIV infection, genital ulcer disease and crack cocaine use among patients attending a clinic for sexually transmitted diseases

Am. J. Public Health

Drugs, sex and AIDS risk

Am. Behav. Sci.

Crack use and multiple AIDS risk behaviors

J. Acquir. Immune Defic. Syndr.

Crack cocaine use in a cohort of methadone maintenance patients

J. Subst. Abuse Treat.

Life-style factors and social circumstances of syringe sharing in injecting drug users

Br. J. Addiction

Drug use and sexual behavior of indigent African American men

Public Health Rep.

Early syphilis: relationship to sex, drugs and changes in high-risk behavior from 1987–1990

Sex. Transm. Dis.

Cocaine and other stimulants: actions, abuse and treatment

N. Engl. J. Med.

Behaviors of crack cocaine users and their impact on early syphilis intervention

Sex. Transm. Dis.

Incentives improve outcome in outpatient behavioral treatment of cocaine dependence

Arch. Gen. Psychiatry

Role of drug-abuse treatment in limiting the spread of AIDS

Rev. Infect. Dis.