Educating correctional health care providers and inmates about drug-drug interactions: hiv-medications and illicit drugs

A. Macher et al. / Californian Journal of Health Promotion 2005, Volume 3, Issue 2, 139-143 Educating Correctional Health Care Providers and Inmates About Drug-Drug Interactions: HIV-Medications and Illicit Drugs Abe Macher1, Deborah Kibble2, Karen Bryant3, Ana Cody4, 1U.S. Department of Health and Human Services 2Prince William Manassas Regional Adult Detention Center 6Office of the Federal Public Defender for the District of Columbia Abstract
This paper demonstrates how federal clinicians are collaborating with correctional health care providers
in a unique continuing education initiative regarding HIV-medications and drug-drug interactions. Three
clinical cases are presented to illustrate the potential dangers associated with concomitant use of ritonavir
(a frequently prescribed antiretroviral agent) and illicit drugs. Such clinical cases are regularly presented
in an exemplar program that draws clinicians together to share current medical information and notes
“from the field” regarding problems that correctional health care providers and administrators are likely to
face. Collaboration between federal clinicians, correctional and community health officials has resulted
in a unique forum for disseminating medical information, and represents a prototypical method for broad-
based health education.
2005 Californian Journal of Health Promotion. All rights reserved.
Keywords: drug interactions, correctional health care providers, illicit drugs, antiretroviral agents

The Challenges of Correctional Health Care
U.S. pass through the corrections system each Health Care (NCCHC) has provided estimates for the numbers of inmates released with Since the clinical management of HIV disease communicable diseases and the percentages and hepatitis is constantly evolving, correctional relative to the United States population with health care providers and health services those infections. Data from 1996 revealed that administrators must have access to continuing at least 1.3 million inmates released from medical education. This paper examines a pilot correctional facilities in that year were infected continuing-education-project in Washington, with hepatitis C virus (HCV) (NCCHC, 2002) D.C., that involves collaboration between and these former inmates represented 29 percent federal clinicians, correctional providers, and of all U.S. cases of HCV infection. Hepatitis B health services administrators. The Correctional virus (HBV) infection, on the other hand, was found in 155,000 released inmates, accounting representatives from correctional facilities in for 15.5 percent of all U.S. cases. Significant fractions of HIV infection (98,000; 13 percent) Columbia. Dr. Abe Macher, who serves as a and AIDS cases (39,000; 17 percent) were also volunteer clinical consultant to the Sub- reported among persons released from jails and committee, has recruited representatives from prisons. It has been estimated that approximately the Federal Bureau of Prisons, the U.S. Marshals one fourth of all HIV-infected persons in the Service, the Veterans Administration, the Office of the Federal Public Defender for the District of A. Macher et al. / Californian Journal of Health Promotion 2005, Volume 3, Issue 2, 139-143 Columbia, the Centers for Disease Control and State-of-the-art treatment updates regarding Prevention, local and state departments of HIV/AIDS, hepatitis, bioterrorism, methicillin- health, community-based clinics, and hospice resistant Staphylococcus aureus, tuberculosis organizations (see Table 1) to participate in and other infectious disease issues are presented monthly multidisciplinary meetings where clinical cases are presented and discussed. Participants of the Metropolitan Washington Council of Governments’ Correctional Health Care Subcommittee Meetings City, County, and Regional Detention Centers State Departments of Corrections Federal Bureau of Prisons U.S. Marshals Service Office of the Federal Public Defender for the District of Columbia Health Resources and Services Administration, U.S. Public Health Service Centers for Disease Control and Prevention, U.S. Public Health Service Veterans Administration County and State Departments of Health Community-Based HIV Clinics (e.g., La Clinica del Pueblo; Whitman Walker) AIDS Drug Assistance Programs Hospice of the Chesapeake University and Community Hospitals American Correctional Association American Jail Association Public Safety Division, Council of Governments A major concern of the Subcommittee is the proper use of FDA-approved HIV-medications antiretroviral treatment and avoidance of illicit and their potential toxicities and drug-drug interactions. An emerging dilemma within the metropolitan Washington, D.C. area is the Inter-Agency Collaborative Education: An
interaction between prescribed HIV-medications Exemplar Program
(e.g., ritonavir) and illicit drugs such as hallucinogenic amphetamine derivatives (e.g., considerable number of HIV-infected inmates highlighted the problem within our nation’s and former inmates are polysubstance abusers, correctional facilities. The Caucus requested they are at considerable risk for drug-drug volunteers from the United States Public Health interactions between their prescribed HIV- Service (USPHS) to provide clinical assistance. medications and illicit drugs. In addition to Dr. Macher, a USPHS physician, volunteered to educating the correctional providers and create a regional correctional HIV program, and administrators, physicians educate inmates, volunteered to serve as clinical consultant to the A. Macher et al. / Californian Journal of Health Promotion 2005, Volume 3, Issue 2, 139-143 P450 2D6 (CYP2D6), an isoenzyme responsible for demethylenation – the principal pathway by Subcommittee. He recruited clinicians from the which MDMA is metabolized. Thus, ingestion region to join the Subcommittee. Since 1998, of MDMA in recreational amounts by a person taking ritonavir can lead to toxic effects due to monthly basis to address HIV/AIDS as well as high plasma concentrations of MDMA. This other infectious disease issues, including patient’s death was consistent with a severe bioterrorism. Dr. Macher presents patients’ serotoninergic reaction to MDMA. Adverse Subcommittee. The following three clinical sympathetic overload and include tachycardia, cases focus on drug-drug interactions between diaphoresis, tremor, hypertension, arrhythmias, the prescribed antiretroviral agent ritonavir and parkinsonism, and urinary retention. The most serious potential outcome of MDMA ingestion is hyperthermia and the associated “serotonin Clinical Case One: Ecstasy and Ritonavir
syndrome” manifested by grossly elevated core The patient, a man with HIV-infection with a body temperature, rigidity, myoclonus, and history of alcohol abuse and illicit use of autonomic instability; patients may develop “Ecstasy”(3,4 methylenedioxymethamphetamine rhabdomyolysis and acute renal failure, hepatic failure, adult respiratory distress syndrome, and Clarity; Adam; Essence; Ecky; Bicky; Yaoto- Wang) was prescribed an antiretroviral treatment regimen that included the protease inhibitor Clinical Case Two: Methamphetamine, Amyl
ritonavir. Two weeks after starting treatment Nitrate, and Ritonavir
with ritonavir, he went to a club and took three A man with HIV-infection and a history of MDMA (Ecstasy) tablets. In the past (prior to being prescribed ritonavir) he had taken MDMA antiretroviral treatment regimen that included on several occasions without untoward effects. ritonavir. Four months later, he was witnessed injecting himself twice with methamphetamine Four hours after his arrival at the club, a nurse (Meth, Crystal) as well as sniffing amyl nitrate. His friends left him at approximately 3:00 a.m., profusely, tachypneic (approximately 45 breaths apparently asleep, lying on his stomach on the per minute), tachycardic (in excess of 140 beats floor. The next day he was found dead in the per minute), and cyanosed. He was able to talk same position in which he had been left. in full sentences and gave a history of having taken two MDMA tablets with little effect, so he took a further half-tablet (estimated total dose amphetamine at a level of 0.5 mg/L in his blood (Hales, Roth, & Smith, 2000). This patient had content of the remaining half tablet), after which also been abusing amyl nitrate. Amyl nitrate is he began to “feel shaky.” Within 25 minutes of metabolized to nitric oxide which inhibits the first assessment he had an apparent tonic- clonic convulsion, but was able to respond to questions. He became increasingly tachypneic, methamphetamine metabolism. These drug-drug and his carotid pulse rate was approximately 200 interactions probably led to the high plasma per minute. A few minutes later he vomited and concentrations of methamphetamine. had a cardiopulmonary arrest. Attempts at Clinical Case Three: Ecstasy, GHB, and
Postmortem toxicology revealed MDMA in his A man with HIV-infection began taking an blood at a concentration of 4.56 mg/L (ten times antiretroviral treatment regimen that included the anticipated concentration). The protease ritonavir. Harrington, Woodward, Hooton, and inhibitor ritonavir is an inhibitor of cytochrome A. Macher et al. / Californian Journal of Health Promotion 2005, Volume 3, Issue 2, 139-143 Horn (1999, p. 2221) reported that five days Discussion
These three clinical cases underscore the hazards of mixing illicit drugs with prescribed HIV- medications. Given the variations in drug absorption and metabolism that exist between hydroxybutyrate, or GHB), the man became individuals, it is impossible to accurately predict unresponsive and exhibited a brief episode the effect of drug combinations in any one of repetitive, clonic contractions of both legs person. This is particularly important with regard to the use of illicit drugs, which are often taken by groups of people. Individuals within responsive only to painful stimuli, with the group may be falsely reassured by others that shallow respirations and a heart rate of only intubated and transferred to a local hospital. A prudent approach for HIV providers would be to caution their patients that the known and potential drug interactions between illicit next three hours, his vital signs normalized substances and HIV-medications are complex and unpredictable. Co-administration of HIV- Upon questioning, he admitted to ingesting medications with illicit substances should be strongly discouraged. Consequently, correctional health care providers should utilize each clinical admission, he ingested one half teaspoon of visit with their inmate-patients as opportunities immediately before becoming unconscious. preparation for post-release continuity-of-care. He stated that he took the GHB to counter the agitating effects of MDMA, which had Conclusions
Each year, some 630,000 persons are released ingestion. The patient noted that prior to his from state and federal prisons (Office of Justice use of ritonavir, he had taken a similar million persons are arrested, and are admitted occasions and he had never experienced any and discharged from county jails and juvenile adverse reactions. He also noted that his friends had consumed similar amounts of the Investigation, 2004). Rates of illicit drug use in same preparation of GHB every two to three this population are very high (see James, 2004), and these detainees and inmates also engage in The patient maintained that the duration (>29 hours) of the stimulatory effect of the Following admission to a correctional facility, inmates represent a “captive audience” and interventions that attempt to reduce their risky in the past (prior to his antiretroviral behaviors should be undertaken. Correctional treatment with ritonavir). He explained that officials and clinicians must first, however, have a clear understanding of the risks that their correctional health care initiative in Washington, experience clinical features typical of GHB DC, is an exemplar program that unites local, state, and federal agencies and organizations and consciousness, seizure-like activity, and promotes ongoing education, communication, respiratory depression. Ritonavir probably cooperation, collaboration, and continuity-of- care. We recommend that correctional facilities unite in their respective regions by accessing A. Macher et al. / Californian Journal of Health Promotion 2005, Volume 3, Issue 2, 139-143 area’s clinical and educational resources equivalent organizations) and pooling their
Federal Bureau of Investigation. (2004). Crime in the United States. Washington, DC: Author.
Gahlinger, P. M. (2004). Club drugs: MDMA, gamma-hydroxybutyrate (GHB), rohypnol, and ketamine.
American Family Physician, 69, 2619-2626. Hales, G., Roth, N., & Smith, D. (2000). Possible fatal interaction between protease inhibitors and methamphetamine. Antiviral Therapy, 5, 19. Harrington, R. D., Woodward, J. A., Hooton, T. M., & Horn, J. R. (1999). Life-threatening interactions between HIV-1 protease inhibitors and the illicit drugs MDMA and gamma-hydroxybutyrate. Archives of Internal Medicine, 159, 2221-2224. Henry, J. A., & Hill, I. R. (1998). Fatal interaction between ritonavir and MDMA. Lancet, 352, 1751- James, D. J. (2004). Profile of jail inmates, 2002. Washington, DC: Bureau of Justice Statistics. Laurence, J. (2005). The role of prisons in dissemination of HIV and hepatitis. AIDS Reader, 15, 54-55. Lettieri, J., & Fung, H. (1976). Absorption and first-pass metabolism of gamma-hydroxybutyric acid. Research Communications in Chemical Pathology and Pharmacology, 13, 425-437. Macher, A., Pearson, N., Schuster-Walker, M., Sturgess, A., Farmer, J., & Mayne, D. (2002). Issues in correctional HIV care: Regional collaboration among detention centers. American Jails, 16, 41-44. National Commission on Correctional Health Care. (2002). The health status of soon-to-be-released inmates: A report to congress. Retrieved March 3, 2005, from Office of Justice Programs. (2005). Reentry. Retrieved May 12, 2005, from Author Information Abe Macher U.S. Department of Health and Human Services E-Mail: Deborah Kibble Prince William Manassas Regional Adult Detention Center Karen Bryant Hospice of the Chesapeake Ana Cody La Clinica del Pueblo Todd Pilcher Whitman Walker Clinic Danielle Jahn Office of the Federal Public Defender for the District of Columbia


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