September 25, 2018
An international authority on addiction medicine with a special interest in addictions among people with HIV infection, Dr. Samet is the John Noble, MD, Professor in General Internal Medicine and Professor of Public Health at Boston University. He is a practicing primary care physician at Boston Medical Center, with a research focus on substance use in HIV infection. Dr. Samet holds an MD from Houston's Baylor College of Medicine, an MPH in biostatistics and epidemiology from Boston University School of Public Health, and an MA in chemistry from Brandeis University. The coauthor of 270 peer-reviewed articles and 20 textbook chapters, he is Editor-in-Chief of Addiction Science & Clinical Practice. Dr. Samet has been a Visiting Scholar or Visiting Professor at the London School of Hygiene and Tropical Medicine, Kings College School of Medicine, London, the British Columbia Centre on Substance Use, and the University of Sydney School of Medicine.
Mark Mascolini: How does alcohol use disorder prevalence compare in people with and without HIV?
Jeffrey Samet: Alcohol use disorder is more common in people with HIV than in HIV-negative people. HIV population prevalence ranges from a low of 8% in the HCSUS study of patients in care in the 1990s1 to a high of 42% in a US veterans study.2 It's not surprising that the higher number might be in veterans living with HIV. If you look at how common alcohol use disorder is in the general population, the number quoted most often is 14% meeting criteria for past-year alcohol use disorder. So overall we can say this problem is more common with HIV than in the general population.
Mascolini: Alcohol has a broad clinical impact in any problem drinker. Are those impacts worse in people with HIV?
Samet: Some are and some are not. It's impossible to generalize because there are so many complications of alcohol in general, particularly when it's used in excess. I'll give you an example. We know that people often won't take their medicines as consistently when they are also using alcohol at levels considered at risk. Because those medications are central to good care in someone with HIV, the consequences can be worrisome. That's one example of alcohol use having a worse consequence in people with HIV than in people who might have hyperlipidemia, for example, where the medicine is helpful but perhaps not as lifesaving as antiretrovirals.
Liver function is another example of an alcohol complication that may be worse in people with HIV. The liver is one of the target organs most affected by alcohol. Coinfection with hepatitis C, which also targets liver cells, is common in certain HIV populations. In people coinfected with HIV and HCV, alcohol can be a particularly bad actor. So in certain clinical situations, there is cause to be more vigilant in the setting of HIV.
On the other hand, we can't say that alcohol withdrawal syndrome is worse in people with than without HIV. There aren't data to support that; alcohol withdrawal syndrome is bad in both cases. So the answer to your question depends on which complications you choose to discuss.
Mascolini: The National Institute on Alcohol Abuse and Alcoholism (NIAAA) cites moderate drinking levels as 1 drink per day in women and 2 per day in men. Are those levels "safe" in people with HIV?
Samet: I'd put it this way: There is scant data to say that those levels are unsafe in people with HIV. There are a few reports of people drinking about that much alcohol and not being as good in taking their antiretrovirals in the days when there were a lot of pills to be taken and a need to take them 90% of the time to reach maximum effectiveness. But for the most part I would not tell a patient of mine who has HIV that drinking at those NIAAA "not-risky" levels would put them at risk.
Now if they had hepatitis C in addition to HIV, or if they had some other comorbidity that put them at higher risk at lower drinking levels, yes, there might be cause for concern. But we cannot suggest that one person with HIV and no other liver complications has a higher risk at low drinking levels. I don't believe we have a basis to change those NIAAA recommendations.
Mascolini: When should HIV clinicians screen for unhealthy alcohol use?
Samet: Given that the prevalence of unhealthy alcohol use is greater in people with HIV, and given that certain consequences of drinking can be more severe in HIV populations, it certainly makes sense to ask about alcohol use at the initial patient encounter.
The frequency of screening for alcohol use after the initial encounter has never been settled based on data. There are recommendations that endorse annual screening for people in general, but there is little data to support that. My clinical advice -- not backed by data -- would still be to check in with patients on an annual basis, given the higher risk in people with HIV.
Mascolini: How should HIV clinicians screen for unhealthy alcohol use?
Samet: The approach is the same for people with HIV as in the general population. NIAAA recommends single-question screening.3 That recommendation has been supported in the general population,4-6 though I don't know that it's been looked at specifically in people with HIV.
It's a straightforward question: Do you drink alcohol? If the answer is yes, you follow it up with another question: In the last year, how many times have you had more than 4 drinks [for men] or more than 3 drinks [for women]. Those are the standard screening questions for alcohol problems. And any response to the second question that is 1 or greater is a positive response.
A positive screen in the general population will occur in one quarter to one third of people. In HIV it's likely to be higher than that. If someone says no, they don't drink alcohol, you don't necessarily have to go any further. If they say yes, you should explore the extent to which this drinking is having consequences.
I would add that if the response is no, they don't drink alcohol, I ask, "Why not?" A significant number of people will say they don't drink because they're in recovery, or because they have a parent or sibling who has alcohol use disorder. So by asking why not, you might learn something you don't know already.
Mascolini: When should clinicians try to manage alcohol use disorder in people with HIV and when should they refer a patient to a specialized treatment program?
Samet: It depends on the comfort level of the individual clinician. That goes for any condition, whether it be diabetes, lipids, or depression.
The same thing goes for alcohol. In general I would say, if you have someone who's drinking at a risky level but you've assessed them not to meet criteria for alcohol use disorder, then I think most clinicians would feel comfortable having that discussion about "how you're drinking at levels that put you at risk." The provider might tell that person, "You may not have had many consequences from drinking up to now, but your drinking level puts you at risk." That discussion could then move to the relation of drinking to HIV and the need to take medications regularly. This approach can be a way to say a person needs to cut back to notrisky levels or stop completely.
If a patient is having consequences from drinking -- for example, diminished ability to stop, withdrawal symptoms, craving, or tolerance -- primary HIV clinicians can begin to address that and see what progress they can make.
The key thing, I would say, is to stay on the issue and not let it drop. But if a clinician has the conversation and prescribed medication that hasn't worked, that's the time to get help. It's not very different from what we do for a patient with any complication. If I have a patient with diabetes, I do what I can to help someone get their hemoglobin A1c to a respectable level. If that doesn't work, I get help. The goal is the best care for the patient, and if we need input from subspecialists, we usually learn from it.
Mascolini: A related question is whether primary HIV clinicians should feel comfortable prescribing drugs licensed for alcohol dependence.
Samet: Yes, I think that's fine. Unfortunately we don't have a lot of those medicines. When you think of how many medicines we have for HIV, for example, we have very few for alcohol use disorder.
Naltrexone, acamprosate, and disulfiram are the three medications that are FDA-approved for alcohol use disorder in this country. And HIV clinicians can get comfortable using them. You have to be aware of the toxicities, which are not severe. Each medication is a little different. Naltrexone is probably the one to try first. But there are patients you can't use it in, including patients on chronic opioid therapy for pain conditions. Renal failure is a contraindication for acamprosate, which is probably the second-line agent for alcohol use disorder.
Mascolini: Which of these medications have you found effective in people with HIV?
Samet: I haven't seen a difference in effectiveness in people with versus without HIV. Nor has that been reported for these medications as yet. In terms of effectiveness, naltrexone would be the medication to start with in the patient who does not have contraindications.
Mascolini: Should clinicians recommend community support groups like Alcoholics Anonymous (AA)?
Samet: Counseling is very valuable for people with alcohol problems, as indicated in many studies of treating alcohol use disorder with combinations of medications and counseling.
In the same fashion 12-step meetings, AA, can also be a very helpful part of a treatment program. You know it's not for everyone, but it has been incredibly helpful for many. My advice to the patient is, "Try it!" The only thing you have to do to go to an AA meeting is to want to try to stop drinking alcohol. I advise patients to try more than one AA meeting because they're so very different. People need to try a number of meetings before deciding whether these meetings will help them.
I must say I am amazed at how many patients find AA meetings helpful and continue to go to them with some regularity even after being in recovery for years because of the benefit they derive.
Mascolini: What's the biggest mistake clinicians make in managing alcohol use in people with HIV?
Samet: I think the biggest mistake is when we don't do anything. Patients often think that if you don't raise the issue of drinking, then it must be OK. They think, "you should know I'm drinking, and if you never told me it's a problem, why should I stop?"
Just raising the issue of drinking or sharing your perspective that it harms them -- that won't necessarily stop the problem immediately -- although occasionally it does. But there is an unspoken license that we give to patients by not raising the issue at all, especially when we're aware of it.
Clinicians can think of this as just checking in. We can say, "we talked about your alcohol use and I'm sharing my concern. I'm not sure you have that concern as well, but I'd like to understand where things are at with you right now." Something as nonconfrontational as that can begin a conversation, without suggesting a patient is "bad" or nonresponsive. This checking-in can be quite brief. The biggest problem is saying to yourself, "I don't want to go there," and saying nothing.
Mascolini: Are there other issues about alcohol use in people with HIV we haven't addressed that you'd like to discuss?
Samet: There's incontrovertible evidence that people take more risks under the influence of alcohol than they would otherwise. In people with HIV infection, depending on where they're at in the care continuum, there can be worrisome consequences from that risk behavior:
The risk of spreading HIV is less if a person is on medications and virally suppressed, but if one's not suppressed the increased sex risk behavior is very clear.
We also have to remember that people taking medications for HIV and virally suppressed may still be taking illicit drugs or still injecting drugs, and we know that alcohol use on top of that can make it more risky. In this day when the number of overdose deaths is staggering, it would be wrong not to stress that alcohol use with other drugs in the setting of HIV puts one at risk. Many overdose deaths in people with or without HIV involve opioids and other drugs. And alcohol is the most common of those other drugs. There's some evidence to suggest the overdose problem is worse in people with HIV.7 That evidence is not totally solid, but we should certainly worry about overdose risk with other illicit drugs in people with HIV infection.
Mark Mascolini writes about HIV infection.
[Note from TheBodyPRO: This article was originally published by The Center for AIDS Information & Advocacy in Sept. 2018. We have cross-posted it with their permission.]
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