Correspondence
The Care of Injection-Drug Users with HIV Infection
N Engl J Med 1994; 331:1773-1774December 29, 1994
- Article
To the Editor:
O'Connor and his colleagues (Aug. 18 issue)1 describe the devastating array of medical problems presented by injection-drug users infected with the human immunodeficiency virus (HIV). The authors recognize that, “To care for HIV-positive injection-drug users, physicians need to be familiar with the common approaches to the treatment of substance abuse, as well as with specific drug-treatment programs in their communities.” They do not comment, however, on the fact that in virtually every city in America, the demand and need for drug treatment vastly exceed its availability. Delays of many months between application and enrollment are the norm. This is the inevitable consequence of the fact that methadone “as a treatment of opioid dependence is generally restricted to inpatient settings or licensed outpatient methadone-treatment programs.” It is time to question why this restriction persists and at what expense in terms of lives and costs to society.
Those who accept the challenge of managing the medical conditions of narcotic addicts are permitted (and expected) to treat the whole patient rather than to focus on any specific component. With the exception of methadone, there is no medication in the pharmacopeia that is proscribed in the effort to carry out this daunting responsibility. Indeed, even methadone may be used -- except for the treatment of narcotic dependence.
The unique restrictions on the prescription of methadone present an enormous obstacle in attracting HIV-positive, narcotic-dependent patients to treatment and gaining their extended compliance with the therapeutic regimen. It is hoped that this scholarly review article will stimulate practitioners as well as policy makers to reconsider the appropriateness and effectiveness of our long-standing approach to addiction.
1 ReferencesRobert G. Newman, M.D.
Beth Israel Medical Center, New York, NY 100031
O'Connor PG ,Selwyn PA ,Schottenfeld RS . Medical care for injection-drug users with human immunodeficiency virus infection. N Engl J Med 1994;331:450-459
Full Text | Web of Science | Medline
To the Editor:
In their comprehensive discussion of the medical and psychosocial needs of injection-drug users with HIV infection, O'Connor and colleagues surprisingly omitted the nearly universal oral manifestations that accompany the progression to AIDS.1,2
The severity of HIV disease is significantly associated with the prevalence of oral lesions, which is well over 90 percent in patients with AIDS.2 It is our experience that in HIV-infected injection-drug abusers poor oral hygiene complicates HIV-associated diseases of the head and neck. Oral lesions include candidiasis, hairy leukoplakia, HIV-associated gingivitis, HIV-associated periodontitis, necrotizing ulcerative gingivitis, Kaposi's sarcoma, recurrent herpes simplex, bacterial glossitis, major aphthous ulcers, condyloma acuminata, molluscum contagiosum, patchy depapillated tongue, hairy tongue, and angular cheilitis. In addition, cervical and submandibular lymphadenopathy are common.
When patients present with esophageal symptoms, the oral cavity should be examined for signs of oropharyngeal candidiasis, among other lesions. Oral Kaposi's sarcoma is not uncommon in homosexual or bisexual patients with AIDS but is unlikely to be present in heterosexual injection-drug users.2 Patients with normal CD4 cell counts may have oral colonization with candida species, but major aphthous ulcers occur predominantly when the CD4 cell count is below 100 per cubic millimeter.3
We hope that oral conditions will receive the attention required to improve the quality of life for HIV-infected patients.
3 ReferencesLeslie G. Selbovitz, M.D.
Baystate Medical Center, Springfield, MA 01199Leslie Zide-Selbovitz, D.M.D.
Western Massachusetts Hospital, Westfield, MA 010851
Husack WA, Zide-Selbovitz L. Care of the HIV-infected patient: a dental perspective. Boston: Massachusetts Department of Public Health, AIDS Action Committee of Massachusetts, 1990.
2
Barone R ,Ficarra G ,Gaglioti D ,Orsi A ,Mazzotta F . Prevalence of oral lesions among HIV-infected intravenous drug abusers and other risk groups. Oral Surg Oral Med Oral Pathol 1990;69:169-173
CrossRef | Medline3
Muzyka BC ,Glick M . Major aphthous ulcers in patients with HIV disease. Oral Surg Oral Med Oral Pathol 1994;77:116-120
CrossRef | Medline
To the Editor:
It is imperative that serious attention be given to educating physicians about psychoactive-drug use, with an emphasis on the medical nature of the neuroadaptive disorder called addiction. Society, including the medical profession, views drugs and those who use them with fear and loathing. This reaction fits the definition of a phobia -- “addictophobia,” to be exact.1 To contain the spread of HIV among heterosexual drug injectors and their sexual partners, we physicians must accept their compulsive drug use as a bona fide illness that merits compassionate care and attention. This approach requires in-depth education in the physiologic, biochemical, and social consequences of chemical dependency.2
The use of methadone for opioid addiction should be liberalized, and the drug should be promoted as a long-acting medication taken orally once a day as a replacement for opioid injection.3 This substitution treatment has been shown to normalize the lives of relapsing opioid-dependent people, allowing them to return to productive patterns of living, free of the risks associated with black-market drugs and diseases spread by unsanitary injection practices.4 As a rational public health measure, methadone treatment must be greatly expanded and made attractive and readily available to opioid users. Program rules must be amended so that opioid users are encouraged to stay in treatment instead of being dismissed for behavior and “offenses” that do not harm others.
4 ReferencesHenry N. Blansfield, M.D.
1 Cedarcrest Dr., Danbury, CT 068111
Blansfield HN . Addictophobia. Conn Med 1991;55:361-361
Medline2
Goldstein A. Addiction: from biology to drug policy. New York: W.H. Freeman, 1994.
3
Blansfield HN . Oral methadone and HIV. AIDS Public Policy J 1994;9:75-774
Dole VP . Methadone treatment and the acquired immunodeficiency syndrome epidemic. JAMA 1989;262:1681-1682
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Author/Editor Response
The authors reply:
To the Editor: Drs. Selbovitz, Zide-Selbovitz raise the important issue of oral health among injection-drug users with HIV infection. People who are HIV-positive have an increased risk of oral candidiasis, a variety of viral infections, neoplastic lesions, other lesions such as aphthous ulcers. In addition, substance abuse itself, especially alcohol and tobacco abuse, has been associated with oral and pharyngeal disease. Thus, it is important for physicians caring for injection-drug users with HIV infection to take a history of oral symptoms and perform a careful oral and head and neck examination. HIV-positive drug users often come from poor, inner-city populations with severely limited access to dental care.
We agree with Dr. Blansfield that it is imperative that physicians and other health care providers be educated in the field of addiction medicine. “Addictophobia” is a barrier that needs to be addressed. A variety of efforts are being made to educate physicians and other health care professionals about issues related to HIV infection and substance abuse.1
As both Dr. Blansfield and Dr. Newman note, there is an urgent need to increase the availability of drug treatment. Expansion of treatment capacity, however, requires additional funding and should not be undertaken at the expense of quality or effectiveness. Although treatment with low-dose methadone and programs providing limited counseling, structure, or rehabilitative services cost less than more comprehensive programs and may be appealing to some patients, they have not been shown to be effective in reducing illicit-drug use or its adverse medical consequences.2,3 Even with stringent regulations governing methadone treatment, ineffective use of the drug is common.4 Relaxation or elimination of regulations will only compound this problem. However, there may be subpopulations of opioid-dependent people who could benefit from less intensive, less expensive programs. For example, protocols for opioid maintenance might be adapted for use in primary care settings.5 A clear delineation of these subpopulations and the development of new protocols for opioid maintenance are important areas for future research, in order to increase the effectiveness and availability of substance-abuse treatment for this population.
5 ReferencesPatrick G. O'Connor, M.D., M.P.H.
Peter A. Selwyn, M.D., M.P.H.
Richard S. Schottenfeld, M.D.
Yale University School of Medicine, New Haven, CT 06250-80251
O'Connor PG ,Bigby J ,Gallagher D . Substance abuse and AIDS: a faculty development program for primary care providers. J Gen Intern Med 1993;8:266-268
CrossRef | Web of Science | Medline2
McLellan AT ,Arndt IO ,Metzger DS ,Woody GE ,O'Brien CP . The effects of psychosocial services in substance abuse treatment. JAMA 1993;269:1953-1959
CrossRef | Web of Science | Medline3
Hartgers C ,van den Hoek A ,Krijnen P ,Coutinho RA . HIV prevalence and risk behavior among injecting drug users who participate in “low-threshold” methadone programs in Amsterdam. Am J Public Health 1992;82:547-551
CrossRef | Web of Science | Medline4
Cooper JR . Ineffective use of psychoactive drugs: methadone treatment is no exception. JAMA 1992;267:281-282
CrossRef | Web of Science | Medline5
Novick DM ,Pascarelli EF ,Joseph H , et al. Methadone maintenance patients in general medical practice: a preliminary report. JAMA 1988;259:3299-3302
CrossRef | Web of Science | Medline
