(Profa. Dra. Jennifer Mcneely, no III Simpósio de Neurociências da Grande Dourados em 14 de setembro de 2012)
Clinical case discussion:Jennifer McNeely, MD, MS – email@example.com
McNeely_unhealthy alcohol use_fin -aula da profa Dra Jennifer McNeely
1. Impact of substance use on HIV treatment:
Patient DP: 56yo man HIV diagnosed 2008 during a hospital admission. He was hospitalized for a myocardial infarction, and HIV test was done as part of routine care. Risk factor = heterosexual transmission At time of diagnosis, CD4 381/22%, HIV viral load 81,000 He was homeless and had few social supports Substance use: Drinking 1 pint vodka/day. Cocaine intermittent, IN only, patient was unwilling to quantify amount but denied daily use. Smoking ½ pack per day. Lost to follow-up for 1 year. Returned in clinic Spring 2009, restarted ARVs. HIV viral load suppressed in May 2009, then poor adherence and viral load >100,000 between April 2010-April 2011. Developed herpes zoster in >1 dermatome during this time.
Questions for discussion:
a. What is the diagnosis?
Alcohol dependence, cocaine abuse
b. Will substance use affect his HIV treatment?
Yes. Patients with substance use disorders are less likely to receive antiretroviral treatment, have more HIV-related symptoms, and have higher rates of hospitalization. Andersen RM, Bozzette SA, Shapiro MF, et al. Access of vulnerable groups to antiretroviral therapy among persons in care for HIV disease in the United States. HCSUS Consortium. HIV Cost and Services Utilization Study. Health Serv Res. 2000;35:389–416.
c. What is most likely to improve his HIV?
Many clinical interventions are available. Examples include improve adherence support counseling, peer education/support, drug treatment, directly observed treatment, etc.) This patient engaged in an intensive medical case management program, which led to him engaging in substance abuse treatment and finding stable housing.
Drug treatment reduces HIV risk behavior and improves adherence to HIV treatment: Metzger DS, Woody GE, O’Brien CP. Drug treatment as HIV prevention: a research update. J Acquire Immune Defic Syndr 2010; 55 Suppl. 1: S32-6.
Drug treatment improves adherence to HIV medications: Turner BJ, Laine C, Cosler L, et al. Relationship of gender, depression, and health care delivery with antiretroviral adherence in HIV-infected drug users. J Gen Intern Med. 2003;18:248–257.
d. What are the substance abuse treatment options?
This patient is likely to benefit from a structured treatment program. However, he could be supported with pharmacotherapy. This could be integrated with his HIV care. Options include (as discussed in plenary): naltrexone (oral or injectable), acamprosate, disulfiram.
e. Does he need detoxification?
Yes. With the amount he is drinking, he is likely to have withdrawal symptoms. Detox is indicated, whether or not he is going to start pharmacotherapy for alcohol dependence.
Jennifer McNeely, MD, MS is Assistant Professor at the NYU School of Medicine in the Department of Population Health, and a general internist specialized in addiction treatment. She completed medical school at Albert Einstein College of Medicine, followed by residency training in Internal Medicine/Primary Care at Brigham and Women’s Hospital (Harvard Medical School), and a post-doctoral fellowship in Medicine and Public Health Research at NYU School of Medicine. Dr. McNeely’s research focuses on the implications of substance use for individuals and health systems, and on improving the identification and treatment of addiction in general medical settings. In 2010 she received a K23 career development award from the National Institute on Drug Abuse (NIH/NIDA) to study patient self-administered substance use screening in primary care settings. Dr. McNeely is also a clinician in the Adult Primary Care and HIV (Virology) clinics at Bellevue Hospital