SCREENING PERSONS WITH HIVAIDS FOR DRUG AND ALCOHOL RELATED DISORDERS

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SCREENING PERSONS WITH HIV/AIDS FOR DRUG AND
ALCOHOL RELATED DISORDERS

• Carlos A. Santana, MD
• Associate Professor
• Psychiatry and Behavioral Medicine
• University of South Florida College of Medicine

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Goal
To increase the ability to more effectively serve
substance using patients living with or affected
by HIV/AIDS
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HIV/AIDS

• There is an estimated 40 million people worldwide
  living with AIDS
  
• 22 million have died 500,000 in the USA
• 3.2 million are children under the age of 15
• Every 6 seconds a new person is infected with
  HIV
  
• Every 10 seconds a person dies of AIDS related
  illness
  
• Approximately 1million persons in the USA are
  living with HIV/AIDS
  
• 32 of men living with AIDS were IDUs or MSM who
  were also IDUs
  
• 57 of AIDS cases in women were IDUs or had sex
  with partners who injected drugs
  

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Mental Health

• A relative state of emotional well-being
• Freedom from incapacitating conflicts
• Ability to cope with environmental stresses and
  internal pressures

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Mental Illness

• Impairment in psychosocial or cognitive
• Function due to one or more of the following
• Processes
• Chemical
• Physiological
• Psychological
• Genetic
• Social
• Vary in severity, duration and prognosis

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Characteristics of Substance Dependence

• A maladaptive pattern of substance use leading
• to clinically significant impairment or distress
• as manifested by 3 or more of the following
• occurring at any time in the same 12-month
• period
• Substance taken in larger amounts than intended
• Unsuccessful effort cut down intake
• Great deal of time spent to obtain the substance
• Abandon important social, occupational, or
  recreational activities due to substance use
  
• Continued use despite recognition of problem
• Development of tolerance. Withdrawal symptoms
  when substance use is stopped

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Continuum for Substance Use
(Traditional Model)
Occasional Use
Frequent/ Integrated Use
Substance Abuse
Dependence/ Addiction
Experimentation
Milestones for HIV/AIDS
Infection Treatments
Treatments Loss
Pre-Infection Testing
Symptoms Disclosure
OIs
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Past Month Illicit Drug Use among Persons Aged 12
or Older, by Age 2002-2005
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Past Month Illicit Drug Use among Persons Aged 12
or Older, by Age 2005
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Current, Binge, and Heavy Alcohol Use among
Persons Aged 12 or Older, by Race/Ethnicity 2005
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Current, Binge, and Heavy Alcohol Use among
Persons Aged 12 or Older, by Age 2005
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Past Year Initiates for Specific Illicit Drugs
among Persons Aged 12 or Older 2005
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Locations Where Past Year Substance Use Treatment
Was Received among Persons Aged 12 or Older 2005
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Substance Dependence or Abuse in the Past Year,
by Age and Gender 2005
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Dependence on or Abuse of Specific Illicit Drugs
in the Past Year among Persons Aged 12 or Older
2005
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Substance Dependence or Abuse in the Past Year
among Persons Aged 12 or Older 2002-2005
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Need for and Receipt of Specialty Treatment in
the Past Year for Illicit Drug or Alcohol Use
among Persons Aged 12 or Older 2005
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Past Year Perceived Need for and Effort Made to
Receive Specialty Treatment among Persons Aged 12
or Older Needing But Not Receiving Treatment for
Illicit Drug or Alcohol Use 2005
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Reasons for Not Receiving Substance Use Treatment
among Persons Aged 12 or Older Who Needed and
Made an Effort to Get Treatment But Did Not
Receive Treatment and Felt They Needed Treatment
2004-2005 Combined
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Past Year Treatment among Adults Aged 18 or Older
with Both Serious Psychological Distress and a
Substance Use Disorder 2005
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Reasons for Not Receiving Treatment in the Past
Year among Adults Aged 18 or Older with an Unmet
Need for Treatment Who Did Not Receive Treatment
2005
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Number and percentage of persons who reported
using noninjection drugs and being under the
influence of noninjection drugs while having sex
during the preceding 12 months, by type of drug
used United States, National HIV Behavioral
Surveillance System Men Who Have Sex with Men,
November 2003-April 2005
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Action Step 1

• Screen/assess all patients for substance use,
• mental health status, and HIV (and other
• health issues) from a Bio-psycho-social-
• spiritual perspective

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Bio-Psycho-Social Spiritual
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Treatment Modalities

• Abstinence Model This approach traditionally
  uses confrontation, consistency of expectations,
  behavioral contracting, and limit setting as
  treatment modalities, with the goal of achieving
  abstinence from all substance use. The approach
  may involve termination from treatment if
  abstinence is not achieved.
• Public Health Model This approach, sometimes
  called the harm reduction model, emphasizes
  incremental decreases in alcohol/drug use of HIV
  risk behaviors as treatment goals. This approach
  tends to try to keep clients in treatment and/or
  moving towards behavior change even if complete
  abstinence is not achieved.

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Some Thoughts on Harm Reduction

• Habit is habit, and not to be flung out the
  window, but coaxed downstairs a step at a time.
  
• Mark Twain
• Harm reduction is anything that reduces the risk
  of injury whether or not the individual is able
  to abstain from the risky behavior.
  
• David Ostrow, MD, PhD

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Stages of Change Behavior-InterventionsRelapse
Avoid discouragement. Resume stages of change
Allow grieving loss identify reasons and benefits
of change
Show concern and respect. Reframe negative
statements
Maintenance
Relapse
Pre- contemplation
Relapse
Relapse
Action
Assess/ Reassess need for treatment or referral
Contemplation
Find success in past attempts. Link to positive
role models
Relapse
Planning Preparation
Relapse
Best course of action is a detailed plan with
small steps
Prochaska, J.O and DiClimente, C.C
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Treatment Plan Includes

• Responsiveness to the patient needs and
  strengths
  
• Consideration of the needs of the support
  systems, family, and significant others as
  defined by the client
  
• Meeting the patient level of change readiness
• Considering / assessing for the likelihood of
  relapse
  
• Promotion of wellness, health, and
  medication/treatment adherence
  
• A cultural framework

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3 Things We Know About Treatment for People Who
are HIV and Substance Abusers

• No single treatment is appropriate for all
  individuals
  
• Effective treatment attends to multiple needs of
  the individual, not just his/her drug use of
  medical diagnosis
  
• Effective treatment must address medical,
  psychological, social, vocational, existential,
  spiritual, and legal needs

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Comprehensive Approach to Services
Housing
Mental Health Services
Substance Abuse Treatment Services
Family Services
Financial Services
Child Care
HIV Services
Education and Vocational
Others?
Medical Services
Transportation
Legal Services
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Substance Abuse and Dependence

• Dependence or addiction is a chronic disease of
  the brain expressed in a behavioral and social
  context
  
• People often use drugs for three reasons
• To feel good
• To feel better
• To not feel
• Many experts feel that the patients active
  substance abuse must first be addressed then HIV
  medication treatment can begin

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Action-Based Practice Model

• Action Step One Screen/assess all patients
• Action Step Two Assess level of behavior change
  readiness
  
• Action Step Three Identify areas of harm
  reduction
  
• Action Step Four Be realistic and flexible with
  treatment goals
  
• Action Step Five Identify community resources
  and referrals

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Counter-transference

• Attitudes and behaviors associated with the
  complexities of patients with multiple diagnoses
  may leave caregivers feeling overwhelmed or
  discouraged by the situation
• Caregivers fears, beliefs and attitudes can come
  into play, including the fear of encouraging
  dependency or of being manipulated by the patient

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Drug Use Risk Assessment

• It is important to be non-judgmental and non
  moralistic
  
• Start with less threatening questions
• What over the counter or prescription medications
  are you taking?
  
• How often do you use alcohol?
• Have you ever used drugs from a non medical
  source?
  
• Have you ever injected any kind of drug?

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Drug Use Risk Assessment (cont)

• Do not assume anything
• Drug use occurs in all social economic classes
• Look for other clues in the history and physical
  
  
• Antisocial behavior, criminal arrest and needle
  tracts, etc

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Asking Alcohol or Drug Screening Questions

• General
• In a typical week, how many days would you
• use alcohol or drugs?
• Which drugs do you use?
• How often do you drink alcohol?

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Asking Alcohol or Drug Screening Questions (cont)

• Impact
• What negative impact has using had on your
• life? Relationships? Career? Family?
• Has your use caused legal problems? Health
• problems? Work problems?

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Asking Alcohol or Drug Screening Questions (cont)

• CAGE questions
• Have you tried to Cut back?
• Are you ever Annoyed when people complain about
  your use?
  
• Do you feel Guilty because of using or
  drinking?
  
• Do you ever need an Eye-Opener?

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Asking Alcohol or Drug Screening Questions (cont)

• Observations
• What do other people say about your use?
• How do people you care about feel about
• your drinking/using?
• Do you agree or disagree with people who
• see this as a problem?

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Asking Alcohol or Drug Screening Questions (cont)

• Plans
• How would you change your using or drinking?
• Can you see any reason to change?
• What impact would drinking/using less have
• on your life?

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Substance Abuse Diagnostic Algorithm
Occurrence of alcohol or drug use
Self-report of problematic alcohol or drug use,
family report problematic use, clinical markers
(e.g., positive toxicology screen) or physical
Symptomatology during exam
4 Question CAGE Screen Have you felt you ought t
o cut down on your drinking or drug use?
Have people annoyed you by criticizing your
drinking or drug use? Have you felt bad or guilt
y about your drinking or drug use?
Have you ever had a drink or used drugs first
thing in the morning to steady your nerves or to
get rid of a hangover (eye-opener)?
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Substance Abuse Diagnostic Algorithm (cont)
Probably not substance abuse/dependence. Continue
periodic assessments.
0 YES responses
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Substance Abuse Diagnostic Algorithm (cont)

• Brief intervention FRAMES
• Feedback
• Responsibility
• Advice
• Menu
• Empathy
• Self-efficacy

1 YES responses
Assessment for Withdrawal Symptomatology
Alcohol, benzodiazepines, and opiates should be
assessed for physiological withdrawal potential.
All drugs will have psychological and social
impact during withdrawal.
Successful outcome resulting in abstinence or
less chaotic use.
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Substance Abuse Diagnostic Algorithm (Cont)
Drug/alcohol use escalates or consequences
increase
2 YES responses

• In-depth assessment of the following three
  dimensions
  
• Further Screening Withdrawal potential
  Patient readiness
  
• AUDIT Physiological for ETOH
  Socrates (avail for
  
• DAST opiates, and
  benzodiazepines both ETOH and
  
• and other drugs

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Substance Abuse Diagnostic Algorithm (Cont)

• Other Options
• Family interview
• Intervention
• Watchful waiting
• Contingency agreement
• Pre-treatment programs

Patient refuses treatment
Consider referral for specialized treatment
Relapse from treatment
Successful intervention Continue follow-up and re
lapse prevention
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Typical Testing and Detection Times for Various
Substances of Abuse
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Relative Detection Times of Drugs in Various
Biologic Specimens
Hair Nails
Blood
Saliva
Urine
Sweat
Minutes
Hours
Days
Weeks
Months
Years
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Screening for Alcoholism
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DAST (Drug Abuse Screening Test)
Name ________ Date ________ Score ________
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DAST (Drug Abuse Screening Test) cont
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DAST (Drug Abuse Screening Test) cont
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DAST (Drug Abuse Screening Test) cont
DAST Interpretation Guidelines
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Standardized Assessment for Alcohol and Drug Use

• Addiction Severity Index (ASI)
• Two hundred items
• Fifty to sixty minute long
• Alcohol Use Disorder Identification Test (AUDIT)
• Ten item screening questionnaire
• Two minutes long
• CAGE
• Four items. Less than one minute long

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Standardized Assessment for Alcohol and Drug Use
(cont)

• Chemical Dependency Assessment Profile
• Two hundred thirty two items
• Forty five minutes long
• CRAFFT
• Six items. Screens for alcohol and drug use in
  adolescence
  
• Michigan Alcoholism Screening Test (MAST)
• Twenty five items
• Ten minutes
• Readiness to Change Questionnaire (RTCQ)
• Twelve items
• One minute long

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HIV Medication and Alcohol or Other Drug
Interactions

• Combination of drugs can cause serious medical
  consequences
  
• In patients already infected with HIV, the immune
  suppressant qualities of many illegal drugs are
  considered a potential contributor to HIV disease
  progression
• May also lead to opportunistic infections and
  complications (hepatitis, TB and STDs)
  
• Damage to internal organs in combination with HIV
  medications

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Depression in HIV/AIDS

• 5.8 general population in USA suffer from
• depression
• 9.5 in chronically ill persons
• In HIV/AIDS rate of depression 20-35
• Among HIV positive women rate of depression
  19.4
  
• Among HIV negative 4.8

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Clinical Manifestations of Depression in HIV
Disease

• Depressive symptoms in patients with HIV
  infection range from appropriate sadness to MDD
  
• Depression can occur secondary to

• HIV-CNS disease
• HIV-related therapies neurotoxicity
• OIs
• CNS malignancies
• Pain

• Ineffective analgesia
• Fatigue
• Bereavement
• Illness induced despondency
• hospitalizations

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Risk Factors for Depression in HIV

• Personal history of prior mood disorder
• Personal history of alcoholism, substance use,
  suicide attempt, anxiety disorders
  
• Family history of the above
• Current alcohol or drug use
• Inadequate social support

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Clinical Diagnosis of Depression in HIV Disease

• Dysphoria and/or anhedonia of at least two weeks
  duration, 4 or more of the following
  
• Sleep disturbance
• Lack of Interest
• Guilt or hopelessness, helplessness,
  worthlessness
  
• Lack of Energy
• Concentration difficulties or cognitive
  inefficiencies
  
• Appetite disturbance
• Psychomotor agitation or retardation
• Suicidal ideation, intent, gesture

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HIV Associated Dementia

• Acquired abnormality in at least two of the
  following cognitive abilities for at least one
  month
  
• Attention/concentration
• Speed of information processing
• Abstraction/reasoning
• Visuospatial skill
• Memory/learning
• Speech/language

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HIV Associated Dementia (cont)

• At least one of the following
• Acquired abnormality in motor function
• Decline in motivation or emotional control or
  change in behavior
  
• Absence of clouding of consciousness (delirium)

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Minor Cognitive Motor Disorder

• Two or more of the following for 1 month
• Impaired attention or concentration
• Mental slowing
• Impaired memory
• Slowed movements
• Poor coordination
• Personality change, irritability or
  
  emotional lability

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How Can Drug Users Reduce Their Risk HIV/AIDS

• Stop using and injecting drugs
• Enter and complete drug abuse treatment including
  relapse prevention
  
• If they continue to inject drugs
• Never reuse or share syringes/needles
• When this is not possible, clean and disinfect

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Comprehensive HIV/AIDS prevention

• Strategies and components of community base drug
  abuse treatment
  
• Sterile syringe access programs
• Testing and counseling for HIV and other
  infections
  
• Studies have consistently shown that
  participation in drug abuse treatment is
  associated with lower rates of drug injection

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HIV Prevention

• Reducing the risk of HIV/AIDS in drug users is an
  achievable goal
  
• Effective prevention programs require a
  comprehensive range of coordinated services
  
• Prevention programs should work with the
  community to plan and implement intervention and
  services
  
• Prevention programs must be based on a continuing
  assessment of local community needs and the
  effectiveness and impact of these programs must
  be continually assessed
• Prevention services can most effectively reach
  drug using populations when they are available at
  a variety of locations and at a range of
  operating times

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HIV Prevention (cont)

• Prevention and treatments should target drug
  users who already have an HIV infection and their
  sex partners
  
• Prevention - interventions must be personalized
  for each person at risk
  
• Drug users and their sex partners must be treated
  with dignity and respect and with sensitivity to
  cultural, racial/ethnic, age and gender based
  characteristics
• Injection drug users should have ready assess to
  sterile injection equipment
  
• Risk reduction information alone can not help
  drug users and their sex partners make lasting
  behavioral changes
  
• HIV/AIDS risk reduction interventions must be
  sustained over time

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HIV Transmission Overview
Highest Risk
No Risk
receptive anal intercourse---genital
intercourse---oral sex---hugging and dry kisses
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HIV Transmission Overview (cont)

• Receptive anal intercourse carries the highest
  risk
  
• It is slightly easier to pass the virus from a
  man to a woman than it is from a woman to a man
  
• Oral sex appears to be less risky than genital
  intercourse, but there are documented cases in
  which oral sexual (male to male) activity appears
  to be the only known means of HIV exposure

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HIV Transmission Overview (cont)

• Any sexually transmitted disease that causes
  ulcers or inflammation can increase the risk of
  becoming infected because access to the
  bloodstream becomes easier during sex
• Hugging and dry kisses constitute no risk of HIV
  exposure

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Burnout

• Reduce productivity
• Impaired performance
• Increase opposition to change
• Chronic fatigue, insomnia, bodily aches and
  pains
  
• Decrease interest in interacting with co-workers
  and patients
  
• Dislike of work environment
• Increase of use formal procedures to process
  complaints

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Resources

• AETC Resources on Substance Use/Abuse
  htpp//www.aidsetc.org
  
• Pain Management/Addition Management Medications
  and HIV Antiretrovirals A Guide to Interactions
  for Clinicians
  June 2004. New York/New Jersey AETC. A variety
  of research on known and potential interactions
  with prescription pain management / addiction
  management drugs and antiretroviral.
  http//www.aidsetc.com/pdf/p02-et/et-03-00/painmgm
  t.pdf
• Recreational Drugs and HIV Antiretroviral A
  Guide to Interactions for Clinicians.
  June 2005.
  New York/New Jersey AETC. Pocket reference with
  interaction and patient education information.
  
  http//www.aidsetc.com/pdf/tools/nynjrecdrugintera
  ctions.pdf
• Center for Disease Control and PreventionThe
  CDCs Role in HIV Prevention, online Rockville,
  MD Author. Available www.cdc.gov/hiv/pubs/facts.
  htm

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Resources

• Principles of Drug Addiction Treatment A
  Research-Based Guide.
  2000. National Institute on Drug
  Abuse. Reviews of evidence-based approaches,
  principles of effective treatment, resource
  directory, and more. Available in English and
  Spanish. http//www.aidsetc.com/pdf/references/PO
  DAT.pdf
• For further information, visit one of the
  following websites
  
• www.hivatis.org/druginteractions.html
• http//aidsinto.nih.gov
• www.hivguidelines.org
• www.samhasa.gov
• www.nattc.org
• www.nynjaetc.org

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Resources

• Carlos A. Santana MD
• csantana_at_health.usf.edu