Substance Use in U.S. Vietnam War Era Veterans and Nonveterans: Results from the Vietnam Era Health Retrospective Observational Study.

Background: Substance use (SU) is associated with physical injury and mental health disorders in older persons, but recent research has scarcely examined SU in U.S. Vietnam-era veterans who are mostly in or near their eighth decade of life. Objectives: We compared the prevalence of self-reported lifetime and current SU and modeled current usage patterns in a nationally representative sample of veterans versus a matched nonveteran cohort. Methods: Cross-sectional, self-reported survey data were analyzed from the 2016-2017 Vietnam Era Health Retrospective Observational Study (VE-HEROeS) (n = 18,866 veterans, n = 4,530 nonveterans). We assessed lifetime and current alcohol and drug use disorders; lifetime and current use of cannabis, opioids, stimulants, sedatives, "other drugs" (psychedelics, prescription or over-the-counter drugs not prescribed/used as intended); and current SU patterns (alcohol-use-only, drug-use-only, dual-SU, no SU). Weighted descriptive, bivariable, and multivariable statistics were calculated. Covariates in multinomial modeling included sociodemographic characteristics, lifetime cigarette smoking, depression, potentially traumatic events (PTEs), and current pain (SF-8TM). Results: Prevalence of lifetime opioid and sedative use (p ≤ .01), drug and alcohol use disorders (p < .001), and current "other drug" use (p < .001) were higher in veterans versus nonveterans. Current use of alcohol and cannabis was high in both cohorts. In veterans, very severe/severe pain, depression, and PTEs were highly associated with drug-use-only (p < .001) and dual-SU (p < .01), but these associations were fewer for nonveterans. Conclusion: This research confirmed existing concerns over substance misuse in older individuals. Vietnam-era veterans may be at particular risk due to service-related experiences and later-life tribulations. Era veterans' unique perceptions toward healthcare assistance for SU may need greater provider focus to maximize self-efficacy and treatment.

Medication adherence strategies for drug abusers with HIV/AIDS.

This paper describes two clinical techniques aiming to improve adherence to medications for HIV/AIDS in methadone maintenance patients. The first technique, providing on-site dispensing of antiretroviral medications, enhanced medication adherence but did not produce enduring effects beyond the time of the intervention. To develop a more long-lasting intervention, the programme is experimenting with more individualized medication management, in which a staff member provides assessment and problem solving to help improve medication adherence. Clinical and practical issues are presented--including each technique's aims, screening and recruitment of participants, description of the technique, staff and administrative support issues, and research results. The paper aims to assist staff in drug treatment programmes to implement interventions that can increase adherence to medications for HIV/AIDS.

A comprehensive pharmacologic-psychosocial treatment program for HIV-seropositive cocaine- and opioid-dependent patients. Preliminary findings.

HIV-seropositive opioid-dependent patients maintained on an opiate-agonist who continue to use cocaine and to engage in other high-risk behaviors may benefit from enhanced treatment services; however, there is currently little data to guide the formulation of such services. We report on a preliminary study in which six HIV-seropositive opioid-and cocaine-dependent patients were provided a 12-week comprehensive pharmacologic/psychosocial treatment program developed specifically to meet the treatment needs of HIV-seropositive drug users. This program was comprised of buprenorphine (12 mg/day), bupropion (150 mg/day), and twice weekly manual-guided group therapy. Results showed significant decreases in intravenous cocaine use, cocaine craving, and symptoms of depression. A post-hoc comparison to outcomes of eight HIV-seropositive patients receiving standard methadone-maintenance found no improvements for patients receiving standard care. Controlled investigation of enhanced drug treatment programs for HIV-seropositive patients may be warranted.

A preliminary investigation of lamotrigine for cocaine abuse in HIV-seropositive patients.

Theoretical considerations as well as pre-clinical data suggest a potential role for glutamate-inhibiting agents in the treatment of cocaine addiction. At present, however, there is little clinical data to inform the use of these agents for this application. In this preliminary study eighteen HIV-seropositive cocaine dependent, opiate-agonist maintained patients received lamotrigine (300 mg/day), an indirect glutamate release inhibitor, on either a standard (n = 8) or accelerated (n = 10) induction schedule for 12 weeks. Results showed a significant decrease in percentage of cocaine-positive urine screens in the standard induction lamotrigine group but not in the accelerated induction group. There were fewer reports of side-effects and fewer dropouts in the standard-induction lamotrigine group compared to the accelerated induction group. Neuropsychological assessments suggested a decrement in the Trail Making Tests, but no other decreases in cognitive functioning. We conclude that standard-induction lamotrigine warrants further investigation for the treatment of cocaine abuse in this patient population.

Human immunodeficiency virus seroconversion among intravenous drug users in- and out-of-treatment: an 18-month prospective follow-up.

Our objective was to determine the prevalence and incidence of human immunodeficiency virus (HIV) infection and related risk behaviors among opiate-abusing intravenous drug users (IVDUs) either in or out of methadone treatment. The subjects, 152 in-treatment and 103 out-of-treatment intravenous opiate users, were followed prospectively for 18 months. Behavioral and serologic assessments were made at 6-month intervals, with complete information available on 89% of the sample. Subjects were recruited from a single methadone maintenance program and the surrounding neighborhood in north-central Philadelphia. At baseline, the HIV seroprevalence rate for the total sample was 12%: 10% for the methadone-maintained group and 16% for the out-of-treatment group. Out-of-treatment subjects were injecting drugs, sharing needles, visiting shooting galleries, and practicing unsafe sex at significantly higher rates than in-treatment subjects. Follow-up of HIV-negative subjects over the next 18 months showed conversion rates of 3.5% for those who remained in methadone maintenance versus 22% for those who remained out of treatment. The sixfold difference in rate of seroconversion between the two groups suggests that although rapid transmission of HIV still occurs, opiate-abusing IVDUs who enter methadone treatment are significantly less likely to become infected. In contrast, those opiate addicts who do not enter treatment are at significantly higher risk of contracting and spreading the disease. Implications for developing additional risk interventions for out-of-treatment IVDUs are discussed.

Attitudes toward mandatory human immunodeficiency virus testing and contact tracing. A survey of intravenous drug users in treatment.

Legal initiatives and treatment policies regarding mandatory human immunodeficiency virus testing and contact tracing often are considered without the input of those groups most affected by the proposed legislation. A survey of attitudes toward the testing and tracing issues was conducted on one such group--intravenous drug users in treatment. Interview and self-report questionnaire data were collected on 196 methadone-maintained patients from two Philadelphia clinics. Data indicate that although most methadone patients supported mandatory testing, their support appears to be influenced by past testing experience. That is, significantly more untested than tested individuals were opposed to the policy. Regarding contact tracing, data indicate that most patients with seronegative results supported tracing, but of the three patients with seropositive results who were surveyed, two were opposed to it. However, most seropositive and seronegative patients reported a willingness to comply with tracing if it were to become law.