Clinics that specialize in treating patients with stimulant use disorder (StUD) can play a key role in meeting the needs of people at risk for contracting HIV as well as those living with HIV, according to data presented by Justin Alves, RN, MSN, ACRN, CARN, CNE, at the Association of Nurses in AIDS Care (ANAC) annual meeting held November 17 to 19, 2022, in Tampa, Florida.
Stimulant-involved drug overdoses such as those involving methamphetamine increased by 50% between 2019 and 2020 (Figure), explained Alves who is a clinical nurse educator for Boston Medical Center’s Grayken Center for Addiction Training and Technical Assistance team and president of the ANAC Boston Chapter. Patients who use stimulants are more likely to engage in HIV risk behaviors than those who use nonstimulant drugs, and methamphetamine use among men who have sex with men has been reported to be the greatest risk factor for HIV seroconversion.
Alves led a multidisciplinary team from Boston Medical Center and Boston University Chobanian & Avedisian School of Medicine to establish an StUD treatment clinic using an adapted nurse care manager model. The program, which includes medication management of StUD and behavioral interventions, is funded by the Massachusetts Department of Public Health, Bureau of Substance Addiction Services.
Nurses Are Access Points for Stimulant Use Disorder Treatment
“The nurse acts as the hub, proffering different types of treatment for stimulant use disorder, either medical treatment or behavioral health treatment,” Alves said. “Then, we are able to get more and more patients into the clinic because they’re not waiting months and months to see a provider.”
“I see the nurse as an access point for people with StUD who may struggle to engage due to set times, dates, and barriers to entry,” said principle investigator Colleen LaBelle, MSN, RN-BC, CARN, who is Director of the BMC Grayken Center for Addiction Training and Technical Assistance program and the founder and director of Boston Medical Center’s Office Based Addiction Treatment Clinic. “The nurse can often see patients on demand to assess any clinical issues, order standard laboratory tests, and work curbside with providers to address acute issues such as sexually transmitted diseases, withdrawal, concrete service needs, and psychosis.”
In the first 18 months of the program, 200 patients were enrolled in the program out of 800 referrals, illustrating a “significant need” that was not being met, Alves noted. “We have people driving upwards of 4 hours just to come see us once a week.” The most common stimulants of use in this patient population are methamphetamine and crack cocaine.
Patients With Stimulant Use Disorder Rewarded for Positive Behaviors
By treating patients with StUD in an ambulatory setting with low barriers to entry, the team also sought to treat existing cases of HIV and prevent the spread of HIV among patients with StUD. The clinicians created a Recovery Rewards Program (RPP) that employed 2 evidence-based StUD treatment methods: contingency management (CM) and exercise-supported recovery along with medications to treat StUD. Patients are either self-referred into the program or are provider-referred.
“When patients engage in a positive recovery activity, such as submitting a urine sample that is negative for nonprescribed stimulant substances, exercising that week, or even coming to the clinic, they receive a positive reinforcer,” Alves said.
The typical cost of CM — a behavioral health intervention in which patients are given positive reinforcement for certain behaviors, such as abstaining from nonprescribed stimulants, during the recovery process — is between $300 and $500 per patient per year, according to Alves. The cost of CM in this program was limited to $75 per patient annually to comply with restrictions in the Stark Law. These limitations can reduce rates of abstinence, Alves noted.
“For that price point, you don’t usually see people abstain from stimulants entirely, but you just see people engage in treatment and care,” Alves said. Positive reinforcements include vouchers (such as $5) and prize goals, which are patient-directed. For example, one patient group is mostly older Black women and they requested wigs as prizes, Alves said.
Using Exercise for Stimulant Use Disorder
The second component of the RPP, exercise-supported recovery, is based on growing evidence that exercise regulates dopamine levels in the brains of patients in the initial stages of the recovery process from StUD.
“One of the drivers of stimulant use disorder is the dysregulation of dopamine because people get huge spikes in dopamine when they are intoxicated” and then experience a marked decrease in dopamine levels during withdrawal. “Exercise helps to reregulate dopamine in a more normal fashion,” he said.
Among the variety of exercise options available to patients in this program is a gym in Boston exclusive to people who have been sober for at least 48 hours. The researchers also partnered with physical therapy colleagues to develop low, moderate, and high-intensity exercise plans for patients.
In May 2021, 206 patients (mean age, 45 years; 61% male; 61% Black) completed an intake survey at the StUD clinic. Of those, 38% had liver disease, 18% had HIV/AIDS, 12% had cardiovascular disease, 10% had pulmonary disease, and 7% had chronic kidney disease.
“We have a lot of patients who have significant cardiovascular disease, pulmonary disease, and liver disease,” Alves said. “They can’t necessarily do high-intensity exercise like everybody else, and so we have moderated levels of exercise [programs that] folks can engage in.” Exercise engagement is verified by the gym staff, pedometer, phone tracking, and photos.
Alves and his team found that using evidence-based approaches to managing StUD in the ambulatory care setting not only meets the needs of patients with StUD but also is an effective way to engage with patients living with or at risk for contracting HIV. He noted that prior authorization requirements for injectable pre-exposure prophylaxis (PrEP) for HIV limited the team’s ability to consistently offer this treatment to this at-risk population during the study.
“Ultimately the goal is to expand the program to new sites and increase access to a vulnerable group of people who use stimulants that are living with and at risk for HIV,” Alves said.
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Alves J, Claude A, Salas D, King-McKeon S, LaBelle C. Where to START: building a stimulant treatment program that meets the needs of people living with and at risk for HIV using the nurse care manager model. Presented at: ANAC2022; November 17-19, 2022; Tampa, FL.