EVALUATION OF TREATMENTS OF OPIOID DEPENDENCE IN HIV PATIENTS

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This project assesses the safety and efficacy of pharmacological treatments of opioid dependence in HIV-infected patients. The AIDS epidemic has rapidly extended to injection drug users, many of them dependent on opioids. These patients represent a challenge to the health care system, as they require medical care and hospitalization for chronic medical disorders. Withdrawal syndromes represent added stresses that may negatively affect the outcome of medical treatments in compromised patients. In addition, patients with AIDS may experience pain, such as that due to peripheral neuropathies, that may be affected by opioid withdrawal. Opioid withdrawal may result in negative mood states (dysphoria) and anxiety that may induce patients to engage in disruptive behaviors such as drug seeking, surreptitious illicit drug use, inappropriate verbal or physical confrontations with health care workers, or non-adherence to medical treatment, such as premature discharge from the hospital against medical advice. Physicians lack guidelines for appropriate behavioral and pharmacological management of substance abuse. There are no controlled studies comparing the outcome of different detoxification treatments in patients hospitalized for medical illnesses, including HIV-infected patients. We are currently conducting a study to compare the effectiveness of clonidine, methadone, and buprenorphine for short opioid detoxification and to develop guidelines for opioid detoxification in opioid-dependent patients, hospitalized for an acute AIDS related illness. Subjective and objective measures are recorded, including withdrawal and pain variables. The hypothesis is that patients receiving buprenorphine will show lower withdrawal and pain scores and fewer disruptive behaviors. The study is designed as a double blind, double dummy, randomized trial of oral clonidine, oral methadone and parental buprenorphine (IM) for short opioid detoxification. Opioids may have detrimental effects on the immune system and enhance HIV replication according to laboratory findings. Epidemiologic studies, however, fail to confirm a deleterious effect of continuous illicit drug use or of methadone maintenance on the progression of HIV diseases. Methadone maintenance appears to decrease HIV transmission risk behaviors which protect drug users from HIV seroconversion and may help contain the HIV epidemic. We are evaluating the effects of methadone maintenance on immune function (CD4, viral load) in HIV-infected drug users.