This project assesses the safety and efficacy of pharmacological and behavioral treatments of opioid dependence in HIV-infected patients and in methods for decreasing high risk HIV transmission behaviors in substance abusers. 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. 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 acute AIDS-related illnesses. 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. A third study will examine whether sustained HIV protective behavior can be achieved by adding a cognitive-behavioral coping skills and relapse prevention intervention to voucher-based contingency management. In a randomized clinical trial with inner city methadone-maintained cocaine- dependent subjects, patients will be taught self-control skills: 1) to increase non-drug sources of reinforcement to compete with reinforcing effects of drug use; and 2) to develop adaptive problem-focused and emotion-focused coping responses to manage drug specific and general life stressors related to drug use and HIV risk transmission.
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