Download Infectious Diseases in Addiction Treatment

• Why do we need statistics? Statistics govern research most certainly,
but for us clinicians in the trenches, statistics tell us what is
increasing and what is decreasing in the real world.
• HIV infections were decreasing for a time but the numbers are
increasing again. Why?
• Tuberculosis numbers increased when HIV was increasing.
Why?
• What is the most common bacterial infection?
• What is the least prevalent/least common bacterial infection at
this time?
• Are women impacted differently from men?
• Are certain cultural groups impacted more than others?
• The series of slides that make up this Module contain data collected
by the Centers for Disease Control (CDC), which is charged with
monitoring infections and epidemics and pandemics.
• As you study the slide – what patterns do you notice? What surprises
you?
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• STDs
• STIs
= sexually transmitted diseases (AIDS is an STD)
= sexually transmitted infections (HIV is an STI)
• The risk of transmission of an STI/STD is possible with only 1
contact with another person’s bodily fluids, or skin-to-skin contact.
• Vulvovaginal health relates to the health of the human female’s
vulva and vagina.
• Candidiasis is a yeast infection that also can lead to thrush. Yeast
is present on all persons, and an overgrowth causes a yeast or
thrush infection.
• 75% of all women are likely to have a yeast infection at some point
in life time (CDC)
• 1 in 4 women have an STD/STI at any given time in the United
States. (CDC)
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University of Edinburgh (2011, January 18). Link between chlamydia and ectopic pregnancy
explained. ScienceDaily. Retrieved January 27, 2011, from http://www.sciencedaily.com
/releases/2011/01/110111132717.htm:
• A new study provides evidence for the first time of how chlamydia can increase the risk of
an ectopic pregnancy . In an ectopic pregnancy the embryo implants outside the womb,
generally in the fallopian tube.
• University researchers found that women who had sexually transmitted infections were
more likely to produce a particular protein in their fallopian tubes. Increased production of
this protein -- known as PROKR2 -- makes a pregnancy more likely to implant in the fallopian
tube.
• The study, funded by the Wellbeing of Women and the Medical Research Council, is
published in the American Journal of Pathology. It follows on from University research,
which showed that production of a similar protein increased the likelihood of smokers
having an ectopic pregnancy.
• Chlamydia is the most common sexually transmitted infection in the UK and the United
States. It can be treated but often goes undiagnosed because it can occur without
symptoms. The infection is known to cause infertility as it can lead to scarring and
blockages in the fallopian tube. This research shows, however, that chlamydial infection
linked to ectopic pregnancy causes much more subtle changes in the fallopian tube, without
evidence of severe scarring.
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A new study from the Indiana University School of Medicine and the Regenstrief Institute has found
that Black and especially Hispanic young women are screened for chlamydia at a significantly higher
rate than young white women. This discrepancy in screening rates may contribute to nationwide
reporting of higher rates of this sexually transmitted disease among minority young women.
The research, which used data from more than 40,000 visits to health care facilities, appears in the
February issue of the journal Pediatrics, published online ahead of print on Jan. 24.
Despite a recommendation from the U.S. Preventive Services Task Force to annually screen all sexually
active young women for this disease, only about half of sexually active women, ages 14 to 25, who
receive health care, are screened appropriately. The IU and Regenstrief researchers found that black
young women were 2.7 times more likely and Hispanic young women 9.7 times more likely to be
screened for chlamydia, compared with white young women.
In addition to race or ethnicity, the researchers found screening likelihood varied by insurance status and
also by age. Women with public insurance had greater odds of chlamydia testing, compared with women
with private insurance.
"For some common conditions like breast cancer, white women are more likely to receive a screening
test like mammography. For chlamydia infections -- which are highly stigmatized STDs -- white women
are less likely, while minority women are more likely, to receive screening. This may mean that
providers make judgments about a woman's likelihood of infection based on her race or ethnicity. Yet
in an asymptomatic condition like chlamydia, all sexually active young women should be screened,"
said study first author Sarah E. Wiehe, M.D., M.P.H., assistant professor of pediatrics at the IU School
of Medicine and a Regenstrief Institute affiliated scientist.
A medical history of STDs was more important than race or ethnicity or insurance status in terms of
differences in chlamydia screening. Young women who had a previous STD were more likely to be
screened for chlamydia, no matter their race or ethnicity, and differences by race or ethnicity in testing
decreased substantially in this subgroup. The same was not true for young women who had been
pregnant in the past. After a pregnancy, young minority women were much more likely (24 times for
Hispanic women and 4 times for black women) to be screened than young white women.
"Even when we accounted for provider-level differences in testing patterns, the bias to screen black
and Hispanic young women persisted. We must encourage pediatricians, internists, family medicine
physicians and gynecologists to screen all sexually active young women under their care. Chlamydia is
a serious and usually asymptomatic disease that may have serious health repercussions," said Dr.
Wiehe, a pediatrician and health services researcher.
Source: Indiana University School of Medicine (2011, January 24). Young minority women screened at higher
rate for chlamydia than young white women. ScienceDaily. Retrieved January 27, 2011, from
http://www.sciencedaily.com /releases/2011/01/110124111148.htm
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• Anyone who is sexually active can get gonorrhea.
• If gonorrhea is present, it is caused by Neisseria gonorrhea
bacterium. Gonorrhea grows and multiplies in warm, moist places,
like the reproductive tract (cervix, uterus, fallopian tubes) and the
urethra. The bacterium also grows in the mouth, throat, eyes and
anus.
• The CDC estimates that more than 700,000 persons in the US get new
gonorrhea infections every year – these are the ones that are
reported.
• A sidekick bacterial STI that occurs frequently with Gonorrhea is
Chlamydia.
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• Any sexually active person can be infected with gonorrhea. In the US,
the highest reporting rates of infection are among sexually active
teenagers, young adults and African Americans and Hispanics.
• In women, gonorrhea is a common cause of pelvic inflammatory
diseases (PID). About one million women each year in the United
States develop PID. The symptoms may be quite mild or can be very
severe and can include abdominal pain and fever. PID can lead to
internal abscesses (pus-filled “pockets” that are hard to cure) and
long-lasting, chronic pelvic pain. PID can damage the fallopian tubes
enough to cause infertility or increase the risk of ectopic pregnancy.
Ectopic pregnancy is a life-threatening condition in which a fertilized
egg grows outside the uterus, usually in a fallopian tube.
Source: http://www.cdc.gov/std/Gonorrhea/STDFact-gonorrhea.htm
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CDC: How common is syphilis?
• In the United States, health officials reported over 36,000 cases of syphilis in
2006, including 9,756 cases of primary and secondary (P&S) syphilis. In 2006,
half of all P&S syphilis cases were reported from 20 counties and 2 cities; and
most P&S syphilis cases occurred in persons 20 to 39 years of age. The incidence
of P&S syphilis was highest in women 20 to 24 years of age and in men 35 to 39
years of age. Reported cases of congenital syphilis in newborns increased from
2005 to 2006, with 339 new cases reported in 2005 compared to 349 cases in
2006.
• Between 2005 and 2006, the number of reported P&S syphilis cases increased
11.8 percent. P&S rates have increased in males each year between 2000 and
2006 from 2.6 to 5.7 and among females between 2004 and 2006. In 2006, 64%
of the reported P&S syphilis cases were among men who have sex with men
(MSM).
• Syphilis is passed from person to person through direct contact with a syphilis
sore. Sores occur mainly on the external genitals, vagina, anus, or in the rectum.
Sores also can occur on the lips and in the mouth. Transmission of the organism
occurs during vaginal, anal, or oral sex. Pregnant women with the disease can
pass it to the babies they are carrying. Syphilis cannot be spread through contact
with toilet seats, doorknobs, swimming pools, hot tubs, bathtubs, shared
clothing, or eating utensils.
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CDC: How does syphilis affect a pregnant woman and her baby?
• The syphilis bacterium can infect the baby of a woman during her
pregnancy. Depending on how long a pregnant woman has been
infected, she may have a high risk of having a stillbirth (a baby born
dead) or of giving birth to a baby who dies shortly after birth. An
infected baby may be born without signs or symptoms of disease.
However, if not treated immediately, the baby may develop serious
problems within a few weeks. Untreated babies may become
developmentally delayed, have seizures, or die.
Source: http://www.cdc.gov/std/syphilis/STDFact-Syphilis.htm
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CDC: PID can lead to serious consequences including infertility.
• PID occurs when certain bacteria, such as chlamydia or gonorrhea, move upward
from a woman's vagina or cervix (opening to the uterus) into her reproductive
organs.
• Women can protect themselves from PID by taking action to prevent STDs or by
getting early treatment if they have any genital symptoms such as vaginal
discharge, burning during urination, abdominal or pelvic pain, pain during sexual
intercourse, or bleeding between menstrual cycles.
• Prompt and appropriate treatment of PID can help prevent complications,
including permanent damage to female reproductive organs.
Source: http://www.cdc.gov/std/PID/default.htm
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CDC: What is PID?
• Pelvic inflammatory disease (PID) refers to infection of the uterus (womb),
fallopian tubes (tubes that carry eggs from the ovaries to the uterus) and other
reproductive organs that causes symptoms such as lower abdominal pain. It is a
serious complication of some sexually transmitted diseases (STDs), especially
chlamydia and gonorrhea. PID can damage the fallopian tubes and tissues in and
near the uterus and ovaries. PID can lead to serious consequences, including
infertility, ectopic pregnancy (a pregnancy in the fallopian tube or elsewhere
outside of the womb), abscess formation, and chronic pelvic pain.
CDC: How common is PID?
• Each year in the United States, it is estimated that more than 750,000 women
experience an episode of acute PID. More than 75,000 women may become
infertile each year as a result of PID, and a large proportion of the ectopic
pregnancies occurring every year are due to the consequences of PID.
Source: http://www.cdc.gov/std/PID/STDFact-PID.htm
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• Ectopic pregnancy presents a major health problem for women of childbearing
age. It is the result of a flaw in the human reproductive physiology that allows
the egg to implant and mature outside the endometrial cavity, which ultimately
ends in death of the fetus. Without timely diagnosis and treatment, ectopic
pregnancy can become a life-threatening situation.
• Ectopic pregnancy currently is the leading cause of pregnancy-related death
during the first trimester in the United States, accounting for 9% of all
pregnancy-related deaths. In addition to the immediate morbidity caused by
ectopic pregnancy, the woman's future ability to reproduce may be adversely
affected as well.
• Ectopic pregnancy was first described in the 11th century, and, until the middle
of the 18th century, it was usually fatal. John Bard reported the first successful
surgical intervention to treat an ectopic pregnancy in New York City in 1759.
• The survival rate in the early 19th century was dismal. One report demonstrated
only 5 patients of 30 surviving the abdominal operation. Interestingly, the
survival rate in patients who were left untreated was 1 of 3.
Source: http://emedicine.medscape.com/article/258768-overview
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• During the transition from childhood to adulthood, adolescents
establish patterns of behavior and make lifestyle choices that affect
both their current and future health. Adolescents and young adults
are adversely affected by serious health and safety issues such as
motor vehicle crashes, violence, substance use, and sexual behavior.
They also struggle to adapt behaviors that could decrease their risk of
developing chronic diseases in adulthood—behaviors such as eating
nutritiously, engaging in physical activity, and choosing not to use
tobacco. Environmental factors such as family, peer group, school,
and community characteristics also contribute to the challenges that
adolescents face.
• Source: http://www.cdc.gov/HealthyYouth/az/index.htm
• Copy this link into your internet browser:
http://apps.nccd.cdc.gov/youthonline/App/Results.aspx?LID=CO
This link will take you to the Colorado High School Youth Risk
Behavior Survey, 2009. The risk behaviors can be identified for
several column variables, including sex, race and grade. You change
the column variable and then hit “go” button.
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• Gay and bisexual men and other men who have sex with men (MSM) represent
an incredibly diverse community. Gay and bisexual men have both shared and
unique experiences and circumstances that affect their physical health and
mental health needs as well as their ability to receive high-quality health
services.
• Sexually Transmitted Diseases (STDs) have been increasing among gay and
bisexual men. Recent increases in syphilis cases have been documented across
the country. In 2008, men who have sex with men (MSM) accounted for 63% of
primary and secondary syphilis cases in the United States. MSM often are
diagnosed with other bacterial STDs, including chlamydia and gonorrhea
infections.
• Gay and bisexual men can be infected with HPV (Human Papillomavirus), the
most common STD in the United States. Some types of HPV cause genital and
anal warts and some can lead to the development of anal and oral cancer. Men
who have sex with men are 17 times more likely to develop anal cancer than
heterosexual men. Men who are HIV-positive are even more likely than those
who are uninfected to develop anal cancer.
• Gonorrhea and chlamydia are sexually transmitted by genital secretions, such as
urethral secretions from the penis.
• Genital herpes and syphilis are transmitted primarily through skin-to-skin
contact with sores/ulcers or infected skin that looks normal.
• HPV is transmitted through contact with infected genital skin or mucosal
surfaces/secretions, such as the penis and anus.
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Effects on Education and Health
• Verbal and physical harassment experienced by LGBT youth has negative effects
on their education and on their health. In 2009, almost 1 in 3 LGBT middle and
high school students responding to an online survey reported that they had
missed at least one day of school in the past month because they were
concerned about their safety [2]. LGBT youth who experience more frequent
harassment perform lower in school by almost half a grade point compared to
their non-LGBT peers who experience less frequent or no harassment (gradepoint average of 2.7 for frequently harassed students versus 3.1 for other
students) [2].
• Such victimization, in turn, is also associated with risky behaviors. One study
found that gay males who had been threatened or bullied at school were more
likely than those who had not been threatened or bullied to have
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Been diagnosed with an STD
Injected drugs
Had more than four sex partners
Not used a condom the last time they had sex [4]
• The stresses experienced by LGBT youth and those who are questioning their
sexual orientation, or LGBTQ also put them at greater risk for mental health
problems, substance use, suicide, and other health problems [1]. Of particular
concern is the increased risk for suicide. A nationally representative study of
adolescents in grades 7 through 12 found that lesbian, gay and bisexual youth
were more than twice as likely to have attempted suicide than their heterosexual
peers [5].
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Source: http://www.cdc.gov/lgbthealth/youth.htm
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• Gay, bisexual, and other men who have sex with men (MSM)1 represent approximately
2% of the US population, yet are the population most severely affected by HIV and are
the only risk group in which new HIV infections have been increasing steadily since the
early 1990s. In 2006, MSM accounted for more than half (53%) of all new HIV infections
in the United States, and MSM with a history of injection drug use (MSM-IDU)
accounted for an additional 4% of new infections. At the end of 2006, more than half
(53%) of all people living with HIV in the United States were MSM or MSM-IDU. Since
the beginning of the US epidemic, MSM have consistently represented the largest
percentage of persons diagnosed with AIDS and persons with an AIDS diagnosis who
have died.
New HIV Infections2
• In 2006, more than 30,000 MSM and MSM-IDU were newly infected with HIV.
• Among all MSM, whites accounted for nearly half (46%) of new HIV infections in 2006.
The largest number of new infections among white MSM occurred in those aged 30–39
years, followed by those aged 40–49 years.
• Among all black MSM, there were more new HIV infections (52%) among young black
MSM (aged 13–29 years) than any other racial or ethnic age group of MSM in 2006. The
number of new infections among young black MSM was nearly twice that of young
white MSM and more than twice that of young Hispanic/Latino MSM.
• Among all Hispanic/Latino MSM in 2006, the largest number of new infections (43%)
occurred in the youngest age group (13–29 years), though a substantial number of new
HIV infections (35%) were among those aged 30–39 years.
• Source: http://www.cdc.gov/hiv/topics/msm/index.htm
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HIV and AIDS Diagnoses3 and Deaths
• A recent CDC study found that in 2008 one in five (19%) MSM in 21 major US
cities were infected with HIV, and nearly half (44%) were unaware of their
infection. In this study, 28% of black MSM were HIV-infected, compared to 18%
of Hispanic/Latino MSM and 16% of white MSM. Other racial/ethnic groups of
MSM also have high numbers of HIV infections, including American
Indian/Alaska Native MSM (20%) and Native Hawaiian/Pacific Islander MSM
(18%).
• In 2007, MSM were 44 to 86 times as likely to be diagnosed with HIV compared
with other men, and 40 to 77 times as likely as women.
• From 2005–2008, estimated diagnoses of HIV infection increased approximately
17% among MSM. This increase was likely due to a combination of factors:
increases in new infections, increased testing, and diagnosis earlier in the course
of infection; it may also have been due to uncertainty in statistical models.
• In 2008, an estimated 17,940 MSM were diagnosed with AIDS in the 50 states,
the District of Columbia, and the US dependent areas—an increase of 6% since
2005.
• By the end of 2007, an estimated 282,542 MSM with an AIDS diagnosis had died
in the United States and 5 dependent areas.
• Source: http://www.cdc.gov/hiv/topics/msm/index.htm
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
There is a difference between screening and assessment. Screening
determines if an individual is a good fit for the treatment agency.
Once it is determined that the agency can meet the needs of the
client, an in-depth assessment is necessary for treatment planning
and coordination of care.
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As you consider what kind of information is necessary before
determining psychoeducation around health and sexual behaviors,
the following are important areas to assess:
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history of drug abuse – what, where, for how long, how
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psychosocial history - family of origin, family of choice
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sexual history
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history with system – legal, medical, Social Services
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services previously accessed – where, when, etc.
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integration of services necessary
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What else do you need to know to be able to assess for risky
behaviors?
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1.
In the attachments folder, look for a document named the DBH
Infectious Diseases Screening Document. I would like you to
open that document and study the questions and riskassessment determination.
2.
In the same Attachments folder, look for a document named the
Biopsychosocial Assessment. I would like you to open that
document and study the questions/format.
3.
Other things to consider when treatment planning around risky
behaviors and drug addiction:
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How did you learn about sex?
Have you ever had protected sex? When?
Have you ever been the victim of domestic violence?
What relationship boundaries exist? and don’t exist?
What does client understand about different communication
styles?
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Reporting Requirements: In Colorado
• Clients have the right to refuse to be tested for infectious diseases
and should not be denied treatment services based solely on that
refusal, except where there is a potential public health threat to other
clients or treatment staff.
• Treatment providers must evaluate the potential exposure risk for
other clients & treatment staff, particularly for potential exposure to
infectious tuberculosis.
• In all instances, clients should be educated about the benefits to
themselves & others from proper & early diagnosis & treatment of
infectious diseases.
• Primary physicians and other medical personnel who diagnose are the
mandated reporters to the Colorado Department of Public Health and
Environment, and to the county health department for all infectious
diseases.
• Counselors are not mandated reporters for infectious diseases.
Counselors do not determine the initial medical diagnosis, using blood
work , etc.
in
most States
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Clinicians need to be alert for the following as they are doing their
initial intakes, assessments, treatment planning and case management:
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injection drug use – if they have injected even 1 time, they need to be
tested for HIV and Hepatitis C
sexual partners of injection drug users – runs a greater risk for
contracting Hepatitis B or C, HIV, gonorrhea, syphilis
unprotected sexual contacts – raises the risk for all STIs, STDs, HIV
multiple sex partners – runs the risk of multiple asymptomatic STIs
poor urban dwellers – substandard housing: people in poverty are often
neglected regarding medical services and education
crowded living arrangements – greater risk for tuberculosis
homelessness – immune system is compromised, nutrition is poor
history incarceration and/or institutionalization – risk for tuberculosis
lower socioeconomic status – lack of services, education, insurance
history recurrent STDs, reactive tuberculosis – more susceptible to STIs,
STDs in future – also looking for dermatomal Herpes infection for HIV
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The mental health clinician has several roles that he or she must
navigate when working with clients. This training in Infectious
Diseases fall under the “biology” (health) component of our
bio-psycho-social-spiritual-emotional delivery of services.
Our treatment services differ with each client and often include the
following:
• assessing for immediate as well as long term client risk factors
• providing pre- and post-test counseling support
• providing and following-up on client referrals
• conducting and supporting harm reduction education and
treatment retention interventions
• facilitating contact tracing and partner notifications
• participating in staff development activities
• participating in and supports community-based interventions
SAMHSA: TIP 6: Screening for Infectious Diseases Among Substance Abusers
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Thoughts regarding risk reduction strategies:
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The longer the client remains in treatment , the better the client
outcomes not only for substance issues but also for infectious disease
containment and harm reduction. Working to prevent client’s return to
drug use is an important strategy for reducing the incidence of infectious
diseases.
Our agencies need to focus on maintenance efforts and not just on
treatment. A client should be in a continuum of care that lasts a
minimum of 12 months, preferably 18 months. This can include
inpatient, residential, IOP, OP and groups or meetings.
One area clients would like assistance with is learning how to develop
competent, proactive health care system utilization skills.
Clients need psycho-education from clinicians about the relationship
between drug use and the transmission of infectious diseases. They
need information presented in a neutral, caring, informative manner.
Clients should be encouraged to consider sobriety testing versus
abstinence (if they are not on paper) as an initial step towards harm
reduction.
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Additional thoughts regarding risk reduction strategies:
 Provide clients with pictures and information about various routes of
transmission and possible symptoms of infection or disease. DO not
use scare tactics – they usually work against us instead of for us.
 Review with clients ways they can avoid or minimize exposure. Talk
about condoms and alternatives. Demonstrate how to put on
condoms. Give them resources in your area for free condoms, dental
dams and female condoms.
 Encourage participation in a HIV/AIDS support group for HIV-positive
clients. HIV is no longer considered a fatal illness and is classified as
a chronic illness. Support and education are necessary to ensure a
higher quality of life and to decrease HIVs progression towards AIDs.
 Abstinence is the only way to prevent disease transmission and is a
viable option to consider.
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Forum Questions: Please post your answers to the following questions
and respond to the answers from two of your training-mates.
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1.
What statistics on the slides or the Colorado website
surprised you the most?
2.
What additional areas requirement assessment, in order to
have an informed and realistic treatment plan?
Point to ponder: You have just completed Module 1 of the
Infectious Diseases training – congratulations.
Module 2 will be very graphic as I present slides with pictures of all
of the infectious diseases we are studying, that are sexually or
contact transmitted.
“A picture is worth a thousand words” is the reason for showing you
these slides and why our clients should see the slides. Do the client
have sex in the dark, or when they are high? If so, this spells
danger!
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