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Presented by John W. Hogan, MD Unity Health Care, Inc., Regional Addiction Prevention At the end of the presentation participants will: Discuss the difference between substance abuse and substance dependence/addiction. State the relationship between substance use and HIV. Discuss barriers that prevent minorities from accessing care for substance use. Discuss various substance abuse interventions. Discuss why drug treatment is also HIV prevention. • SUBSTANCE ABUSE: – Recurrent substance use resulting in failure to fulfill role obligations at work, school, or home. – Recurrent use in physically hazardous situations. – Recurrent substance-related legal problems. – Continued use despite social or interpersonal problems caused by the substance. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition, Text Revision. Washington, DC; 2000. SUBSTANCE DEPENDENCE (Addiction)-Need to satisfy three or more of the following in the same 12 month period: – Tolerance: need for use of increasing amounts of the substance in order to achieve intoxication. – Withdrawal symptoms typical for the substance. – Substance taken in larger amounts or over a longer period of time than intended. – Desire to cut down or control use. – Great deal of time spent on using, obtaining, or recovering from the substance. – Reduced social, occupational or recreational activities because of substance use. – Continued use despite adverse physical or psychological consequences. DSM-IV criteria for substance dependence include several specifiers, one of which outlines whether substance dependence is: with physiologic dependence (evidence of tolerance or withdrawal) or without physiologic dependence (no evidence of tolerance or withdrawal). In addition, remission categories are classified into four subtypes: (1) full, (2) early partial, (3) sustained, and (4) sustained partial. This is based on whether any of the criteria for abuse or dependence have been met and over what time frame. The remission category can also be used for patients receiving agonist therapy (such as methadone maintenance) or for those living in a controlled, drug-free environment. Addiction is a chronic medical disorder that includes: multifactorial genetic components, biologic changes due to exposure to addictive substances, and behavioral components. Treatment for addictive disorders frequently must address both neurobiological and behavioral components. Recovery This is the SAMHSA definition: ▪ Recovery from alcohol and drug problems is a process of change through which an individual achieves abstinence and improved health, wellness and quality of life. It is a voluntarily maintained lifestyle characterized by sobriety with a healthy and productive way of life. Drug Name (Class) Cocaine (Stimulant) Heroin (Opiate) Route of Administration Cognitive Effects Snorted, injected, or smoked • Binge patterns of use may lead to irritability, restlessness, anxiety, and paranoia • Cocaine abusers can suffer a temporary state of paranoid psychosis, in which they lose touch with reality and may experience auditory hallucinations Snorted, injected, or smoked • Users report feeling a surge of euphoria (“rush”) accompanied by dry mouth, a warm flushing of the skin, and a heaviness of the extremities • Following initial euphoria, the user goes “on the nod,” an alternately wakeful and drowsy state during which mental functioning becomes clouded Marijuana Smoked Methamphetamine (Stimulant) Snorted, injected, or smoked • Use is associated with distorted perceptions, impaired coordination, difficulty in thinking and problem solving, and problems with learning and memory • Use is associated with reduced motor performance, impaired verbal learning, emotional and cognitive problems Drug Name (Class) Route of Administration MDMA-Ecstasy (Stimulant and hallucinogen) Orally ingested as a capsule or tablet • Use associated with confusion, depression, sleep problems, drug craving, and severe anxiety GHB/Ketamine/ Rohypnol (Club drugs) Orally ingested, snorted, or injected (Ketamine only) • Use associated with anterograde amnesia, distorted perceptions of sight/sound, and feelings of detachment Inhalants Sniffed (fumes), sprayed (aerosols) into the nose/mouth, or soaked rag placed in mouth (“huffing”) • Effects are similar to those of alcohol, including euphoria, slurred speech, lack of coordination, and dizziness Orally ingested, snorted, or smoked • Users report seeing images, hearing sounds, and feeling sensations that seem but are not real • Some hallucinogens produce intense emotional swings LSD/Peyote, Psilocybin/PCP (Hallucinogens) Cognitive Effects Outside of sub-Saharan Africa, an estimated 10% of all new HIV infections are attributed to injection drug use (IDU) despite significant regional variations. According to the Joint United Nations Program on HIV/AIDS, IDU is responsible for more than 80% of all HIV infections in eastern Europe and central Asia. The epidemic in countries in the Middle East and North Africa have been largely attributed to IDU, and it is currently linked to the growing epidemic in Indonesia, Vietnam, and Malaysia. Joint United Nations Program on HIV/AIDS (UNAIDS). AIDS Epidemic Update '09. UNAIDS; November 2009. Geneva, Switzerland: UNAIDS, WHO; November 2009. UNAIDS/09.36E/JC1700E. In the U.S. Drug abuse is a significant risk factor for HIV/AIDS An estimated 1 million people in the U.S. are living with HIV/AIDS; about one-third of these cases are linked directly or indirectly to injection drug use. In 2003, more than one quarter (11,326) of the 43,171 AIDS cases reported in the U.S. involved injection drug use. Linked Epidemics: Drug Abuse and HIV/AIDS A Research Update from the National Institute on Drug Abuse — October 2005 National Survey on Drug Use and Health 2008 In 2008, an estimated 20.1 million Americans aged 12 or older were current (past month) illicit drug users This estimate represents 8.0 percent of the population aged 12 or older. The overall rate of current illicit drug use among persons aged 12 or older in 2008 (8.0 percent) was the same as the rate in 2007 and has remained stable since 2002 (8.3percent). • • • • • Marijuana was the most commonly used illicit drug (15.2 million past month users). In 2008, marijuana was used by 75.7 percent of current illicit drug users and was the only drug used by 57.3 percent of them. Illicit drugs other than marijuana were used by 8.6 million persons or 42.7 percent of illicit drug users aged 12 or older. Current use of other drugs but not marijuana was reported by 24.3 percent of illicit drug users, and 18.4 percent used both marijuana and other drugs. Among persons aged 12 or older, the overall rate of past month marijuana use in 2008 (6.1 percent) was similar to the rate in 2007 and the rates in earlier years going back to 2002 (Figure 2.2). An estimated 8.6 million people aged 12 or older (3.4 percent) were current users of illicit drugs other than marijuana in 2008. The majority of these (6.2 million persons or 2.5 percent of the population) used psychotherapeutic drugs nonmedically. An estimated 4.7 million persons used pain relievers nonmedically in the past month in 2008, 1.8 million used tranquilizers, 904,000 used stimulants, and 234,000 used sedatives. Among pregnant women aged 15 to 44 years, 5.1 percent used illicit drugs in the past month based on data averaged for 2007 and 2008. This rate was significantly lower than the rate among women in this age group who were not pregnant (9.8 percent). The rate of current illicit drug use in the combined 2007-2008 data was lower for pregnant women than for nonpregnant women among those aged 18 to 25 (7.1 vs. 16.2 percent, respectively) and among those aged 26 to 44 (3.0 vs. 6.7 percent). Among women aged 15 to 17, however, those who were pregnant had a higher rate of use than those who were not pregnant (21.6 vs. 12.9 percent). Current illicit drug use among persons aged 12 or older varied by race/ethnicity in 2008, with the lowest rate among Asians (3.6 percent). Rates were: – – – – – – 14.7 percent for persons reporting two or more races, 10.1 percent for blacks, 9.5 percent for American Indians or Alaska Natives, 8.2 percent for whites, 7.3 percent of Native Hawaiians or Other Pacific Islanders, and 6.2 percent for Hispanics. There were no statistically significant changes between 2007 and 2008 in the rate of current illicit drug use for any racial/ethnic group among persons aged 12 or older. The level of alcohol use was associated with illicit drug use in 2008. Among the 17.3 million heavy drinkers aged 12 or older, 29.4 percent were current illicit drug users. Persons who were not current alcohol users were less likely to have used illicit drugs in the past month (3.3 percent) than those who reported: (a) current use of alcohol but did not meet the criteria for binge or heavy use (6.1 percent), (b) binge use but did not meet the criteria for heavy use (16.4 percent), or (c) heavy use of alcohol (29.4 percent). Use of illicit drugs and alcohol was more common among current cigarette smokers than among nonsmokers in 2008, as in prior years since 2002. Among persons aged 12 or older, 20.4 percent of past month cigarette smokers reported current use of an illicit drug compared with 4.2 percent of persons who were not current cigarette smokers. Past month alcohol use was reported by 67.4 percent of current cigarette smokers compared with 46.7 percent of those who did not use cigarettes in the past month. The association also was found with binge drinking (44.6 percent of current cigarette smokers vs. 16.5 percent of current nonsmokers) and heavy drinking (16.8 vs. 3.8 percent, respectively). Past year illicit drug use in 2008 was higher among adults aged 18 or older with past year SMI (serious mental illness) (30.3 percent) than among adults without SMI (12.9 percent). Similarly, the rate of past year cigarette use was higher among adults with SMI (50.5 percent) than among adults without SMI (28.5 percent). Among adults aged 18 or older with past year SMI in 2008, the rate of binge alcohol use (drinking five or more drinks on the same occasion [i.e., at the same time or within a couple of hours of each other] on at least 1 day in the past 30 days) was 29.4 percent, which was higher than the 24.6 percent among adults who did not meet the criteria for SMI. Similarly, the rate of heavy alcohol use (drinking five or more drinks on the same occasion on each of 5 or more days in the past 30 days) among adults with SMI in the past year (11.6 percent) was higher than the rate reported among adults without SMI in the past year (7.3 percent). In 2008, of the 2.9 million persons aged 12 or older who used illicit drugs for the first time within the past 12 months, a majority reported that their first drug was marijuana (56.6 percent). The average age at initiation among persons aged 12 to 49 was 18.8 years. Nearly one third initiated with psychotherapeutics (29.6 percent, including 22.5 percent with pain relievers, 3.2 percent with tranquilizers, 3.0 percent with stimulants, and 0.8 percent with sedatives). A sizable proportion reported inhalants (9.7 percent) as their first drug, and a small proportion used hallucinogens as their first illicit drug (3.2 percent). Between 2007 and 2008, the percentage of past year illicit drug initiates whose first drug was tranquilizers decreased from 6.5 to 3.2 percent, while the percentage whose first drug was inhalants decreased between 2003 and 2008 from 12.9 to 9.7 percent. Although IDU-related HIV transmission is most closely related to sharing injection equipment, a significant portion of transmission is related to sexual behaviors. Even after controlling for other potential risk factors, HIV infection rates tend to be higher among individuals who abuse alcohol. Individuals who abuse one drug or alcohol are more likely to use/abuse other substances as well. Over half of cocaine-dependent and 17–50% of heroindependent individuals abuse alcohol and alcohol use is associated with needle sharing in both heroin- and cocaineabusing persons (Petry, 1999). Drug use and drug abuse play other, less recognized, roles in HIV transmission. Drug and alcohol intoxication affects users' mental status and judgment, which, in turn, can increase the likelihood that they will engage in high-risk sexual behavior. Addiction to drugs, as documented for crack cocaine, can further increase users' exposure to unprotected sex as a means to obtain drugs. Physiological consequences of drug abuse may alter susceptibility to infection and interact with HIV treatment drugs. – Linked Epidemics: Drug Abuse and HIV/AIDS – A Research Update from the National Institute on Drug Abuse — October 2005 The role of non-injection substance use (non-IDU) to the HIV/AIDS epidemic is important. Research has shown that among heterosexuals, alcohol and non-injection drug use are consistent predictors of HIV risks and new infections. Among MSM, substance use is more prevalent compared with the general population and is a known risk factor for HIV infection. In prospective studies, substance abuse is consistently found to be a powerful predictor of new HIV infections. The use of crack cocaine has been associated with high-risk behaviors and has disproportionately affected African American women. Studies have shown that smoking crack cocaine and exchanging sex for money are co-factors for the risk of HIV infection, especially for women. Women who smoke crack are more likely than non-crackusing women to 1) sell sex, 2) have more sexual partners, 3) have an STD. Women who use crack are also more likely to be assaulted during a sex exchange. Culture is a set of shared behaviors, ideas and values which are symbolic, systematic, cumulative and transmitted from generation to generation. “Culture is a particular set of values, norms, attitudes, and expectations about the world that shapes the personalities of those reared in that culture.” Marin, 1991 ( ) Cultural Competency has been defined as a “set of academic and interpersonal skills that allow individuals to increase their understanding and appreciation of cultural differences and similarities within, among, and between groups.” (L.A. County, Dept. of Health Services) Primary Dimensions 1. Age 2. Ethnicity 3. Gender 4. Race 5. Language 6. Physical Abilities and Qualities 7. Sexual /Affectional Orientation 8. Childhood Experiences and Family Factors (Family religion, place of birth and household location, family social class, parents occupations, etc.) Secondary Dimensions 1. 2. 3. 4. 5. 6. 7. 8. 9. Education Geographic Location Income Marital Status Military Experience Parental Status Religion Work Experience Current Social Class Tertiary Dimensions 1. Experiences with Immigration, Exile, etc. 2. Lifestyle 3. Degree of Assimilation “Cultural Competency in the Context of ALL RISE” S. Wolfgram , H. Teuber *Kinship bonds and extended family *Takes a “Village” mentality-Grandparents key *Value balance between nurture-discipline *Women social equals and interdependent relationships *Importance of the Black Church and religiousity *History oppression = mistrust of the dominant majority and system. (Wolfgram, 2010) Familial/tribal communities as support- Collectivists Sharing- Humble – “Place” (Role) in WORLD Cooperation VS. Competition Deep spirituality/ritual-Living in harmony with all creation Communal sharing of childcare responsibilities Respect for elderly Mistrust of whites because of oppression history Boarding school history has contributed to Native families displacement (Wolfgram, 2010) Patriarchy Suffering/sacrificing self Fatalism: things are meant to happen the way they happen Shamanism Conflict Avoidance Collectivism: protecting family name at all costs-harmony Saving Face/Avoiding Shame Obligation of younger generation to care for older generation, “filial piety” (Wolfgram, 2010) Familism; extended family as sole support system Machismo: head of household protector, provider, honor, pride, hyperaggressive sign of strength (Marianismo) Respeto: respect owed to others who are older Catholic Fatalism, “suffering expected on earth and reward in heaven” Santeria: an Afro-Cuban belief system= cultural medicinal practice (Wolfgram, 2010) Understanding racial and ethnic differences and disparities in drug treatment is necessary in order to develop a more effective referral system and to improve the accessibility of treatments (Saunders et al, 2006) Racial and ethnic minorities appear to have significantly higher rates of unmet needs for substance use disorders and are less likely to seek or complete treatment (Campbell et al, 2006) Studying Black and Hispanic populations is particularly important given their anticipated growth and that they make up the majority of the nation's urban population (Kang et al, 2006) Blacks utilized multiple service types that have strong community and network connections (Perron et al, 2009) Underestimation of the extent of the problem Underutilization of treatment services (delaying or not seeking treatment) due to: Shame Stigma Lack of knowledge Health insurance Lack of cultural & language appropriate treatment programs Different historical background Different family structure, inter-personal relationships Different cultural values Different substance abuse preferences Different help-seeking patterns Different languages & dialects This study investigated the time between HIV testing and presentation to primary care. One hundred eighty-nine consecutive outpatients without prior primary care for HIV infection were assessed at 2 urban hospitals: Boston City Hospital, Boston, Mass, and Rhode Island Hospital, Providence. Socio-demographics, alcohol and drug use, social support, sexual beliefs and practices, and HIV testing issues were examined in bivariate and multivariate analyses for association with delay in presentation to primary care after positive test results for HIV. Samet JH, Freedberg KA, Stein MD, et al. Trillion virion delay: time from testing positive for HIV to presentation for primary care. Arch Intern Med. 1998;158(7):734-740 Delay After Positive HIV Test Results and Patient Characteristics on Initial Presentation to Primary Medical Care: Not having a spouse or partner Injection drug use 8.6 mo 13.9 mo 18 mo 30.4 mo 19.2 mo Interaction of sex and CAGE ▪ Men, positive CAGE results ▪ Women, positive CAGE results 14.6 mo -10 mo Not having a living mother Not aware of HIV risk at testing Not told positive status in person Strong stigma for substance abuse problems Communities hold moralistic attitude towards individuals with addiction problems Insufficient outreach & prevention services Substance abuse treatment & recovery not communities’ priority Lack of recovery support services & organizations The stigma and discrimination associated with drug and alcohol abuse, as well as the disorganization often seen in the lifestyle of those with active substance abuse, can lead to denial, delay in diagnosis of HIV, and reluctance to seek care. Accurate information about HIV transmission, as well as the reduction of stigmas associated with infection, is a critical measure for prevention. Research has shown that people who fear HIV related stigma and discrimination are less likely to seek information about prevention, may delay being tested for HIV and implementing treatment, and may be reluctant to discuss their HIV status. Women with drug and alcohol abuse are more likely to experience poor health and are less likely to access services, receive treatment, or seek health care, partially because of the stigma of substance abuse. Suspicion, fear, and distrust of the health care system result in reluctance among drug users to disclose medically necessary information. Negative sanctions, such as mandatory HIV testing during pregnancy and incarceration of drug-using pregnant women for child abuse, have intensified fears about contact with the health system. • • • • • Often they do not consider alcohol as a harmful drug, using it with herbal medicine & cooking. Moderate use of alcohol at social & ceremonial occasions. Outward drunkenness and acting out behavior is not tolerated. Some use of substance at some communities for special groups of people is acceptable. Alcohol and drug problems, especially related to criminal activities considered extreme shame & disgrace to family. There is insufficient credible research data & small sample sizes make meaningful analysis impossible. Generally they drink less, ”Flush Syndrome” & high percentage of persons not drinking at all. Less illicit drug use. Drug treatment admissions among AAPI increased by 37% (SAMHSA 2000) between 1994 and 1999 There is a different pattern of use for different ethnic groups, American or foreign born, age groups. Mental Health problems Close relations to addiction problems Strong stigma Long waiting list for MH services Gambling problems Asian-Americans and American Indians have a long history of accepting gambling as a community and family recreation High prevalence of problem gambling & pathological gambling Understanding the cultural and practical barriers that exist are the first step in reducing them. Increase & enhance language & culturally appropriate community education, outreach, screenings & interventions. Increase language & cultural appropriate treatment services in all levels of care. Improve linkages within the providers networks and with community based organizations. Address the workforce issues for the communities. Create alternative self-help/support group that is less confrontational and more supportive & educational. Work with families separately, to reduce enabling and negative feelings. HIV infected substance abusers have more: Bacterial infections: ▪ Cellulitis, abscesses, endocarditis, pneumonia, Tb Viral hepatitis: ▪ Chronic Hepatitis B and C Renal disease: ▪ HIVAN, chronic kidney disease Neurologic disorders: ▪ Toxoplasmosis, Cryptococcus, Tb Some specific self-care concerns among HIV patients that impact quality of life and HIV outcomes for the patients themselves include: medication adherence, depression, sexual risk-taking, and substance abuse. These concerns can sometimes be additive if and when they co-occur. Depression and substance abuse may decrease quality of life and can impact adherence to medical regimens. “Behavioral Aspects of HIV Care: Adherence, Depression, Substance Use, and HIV-Transmission Behaviors” BergCJ, et al:Infectious Disease Clinics of North America - Volume 21, Issue 1 (March 2007) What is the relationship between drug use and overall adherence? Is there an association between drug use and rate of decline in adherence rates? What is the differential impact of stimulant use versus other drugs on adherence? Do adherence rates vary as a function of recent of use? What is the impact of substance abuse and dependence on adherence? Hinkin CH et al:AIDS and Behavior. 2007;11(2):185-194 Drug use was associated with a 4.1 times greater risk of being a poor adherer (adherence <90%). During the 6-month study, the drug-negative group's adherence rate was 79% as compared to 63% for the drugpositive group. The adherence rates for the drug-using group dropped more than twice as much as the non drug users. The stimulant positive group's adherence rate was significantly lower than both the other-drug-positive group (P = .001) as well as the non-drug group (P < .001). The three-day mean adherence rate for participants who tested positive for recent stimulant use was 51.3% compared to a three-day mean adherence rate of 71.7% for the same participants when they had not recently used stimulants. The abuse/dependence group evidenced poorer medication adherence than did the non-abuse group (61.0% vs. 72.7%, respectively). • • • Both substance use disorders and HIV/AIDS individually impact tens of millions of people adversely, with explosive epidemics of both described worldwide. Management of HIV infection among chemically dependent individuals requires considerable knowledge about multiple disciplines, including expertise in addiction medicine and psychiatry because of the overlapping epidemics of HIV, substance abuse, and mental illness . The capability of managing these conditions varies considerably between resource-rich and resource-limited regions of the world – Bruce RD et al:Clinical Care of the HIV-Infected Drug User:Infectious Disease Clinics of North America - Volume 21, Issue 1 (March 2007) The clinician should incorporate selected brief screening instruments into the history-taking process. The chosen screening instruments should be tailored for optimal use at initial, annual, and interim visits and adjusted for the patient’s substance use history. To obtain more reliable results, the clinician should perform screening tests when patients are not under the influence of substances. The clinician should carefully screen patients who are heavy smokers for other addictions because heavy smoking is often a surrogate marker of other substance and alcohol dependence. When a patient’s response to a query indicates substance use, clinicians should inquire about drug use, both currently and anytime in the past. The clinician should use nonjudgmental language when inquiring about substance use. Screening for Drug Use in Primary Care A single question could be useful "How many times in the past year have you used an illegal drug or used a prescription medication for non-medical reasons?“ Compared with the structured interview, the sensitivity of the single-question screen was 100%, and the specificity was 74% for detecting current drug use. A single-question screening test for drug use in primary care. Smith PC et al: Arch Intern Med 2010 Jul 12; 170:1155. History – History of referrals or participation in substance/alcohol treatment programs – Trauma, especially after drinking/substance use – Legal problems – Job loss, turnover, downward mobility – Relationship problems – Medical history: seizures, pancreatitis, liver disease, cytopenias, tachyarrhythmias, endocarditis, abscesses – History of psychiatric symptoms, especially affective disorders – History of or current heavy smoking Physical signs: – – – – – – – – – – – Hypertension (alcohol, cocaine, methamphetamine) Resting tachycardia (alcohol, cocaine, marijuana, methamphetamine) Tremor (alcohol withdrawal or stimulant intoxication) Alcohol on breath Dilated pupils (stimulant use or sedative withdrawal) Small pupils (opiate use) Needle marks/tracks (any injection use) Bruises or healed fractures, especially of the ribs (alcohol) Puffy facies (alcohol) Hepatomegaly (alcohol) Weight loss (cocaine, methamphetamine) Laboratory Tests Elevated mean cell volume (MCV), if not taking zidovudine Elevated GGT (associated with alcoholic liver disease, and a more sensitive marker than AST) AST>ALT Decreased serum B12 Urine drug screens Blood alcohol levels To prevent the spread of HIV and other blood-borne infections, drug users must reduce or eliminate those behaviors that place them and others at risk. Research has shown that appropriately designed prevention programs can reduce transmission of not only HIV but of other blood-borne diseases (e.g., hepatitis B [HBV], hepatitis C [HCV], and other sexually transmitted diseases [STDs]) as well. Principles of HIV Prevention in Drug-Using Populations NIDA's HIV Prevention Research Activities: Center on AIDS and Other Medical Consequences of Drug Abuse (CAMCODA), Given the diversity of drug users and their sexual partners, no single prevention strategy will work for everyone. A comprehensive approach that can readily adapt to changing needs and circumstances is the most effective approach for preventing HIV/AIDS and other blood-borne infections in drug users, their sexual partners, and their communities. This approach should include such services as: community outreach, HIV testing and counseling, drug abuse treatment, access to sterile syringes, and services delivered through community health and social service providers. Services must be carefully coordinated within a community. Pregnant HIV-infected substance users should be co-managed by an HIV Specialist and an obstetrical care provider experienced in the care of HIVinfected women. In studies of substance abuse treatment among women, pregnancy and childbearing are important events because they may represent barriers to seeking, receiving, or completing treatment. Women with substance use disorders may avoid seeking treatment for fear of losing custody of their children due to well-publicized cases of drug use during pregnancy resulting in prosecutions for child abuse, delivery of drugs to a minor, and other charges. 14 states consider substance use during pregnancy to be child abuse under civil child-welfare statutes, and 9 states require health care professionals to report suspected prenatal substance abuse. Substance abusers vary in their readiness to change their behaviors. Providers who are attuned to the patient’s stage of readiness (precontemplative to action-oriented) will have the greatest success in facilitating behavior change. Motivating factors for treatment readiness in women are most commonly associated with difficulty in raising their children or in response to interventions by social services departments. Unlike men, women are more likely to express their treatment readiness in nonsubstance use settings, especially in mental health care sites. Drug and alcohol treatment readiness should be evaluated in all health care settings. Evidence-based treatment: Why, what, where, when and how? Journal of Substance Abuse Treatment, 29, 267-276. Miller, W. R., Zweben, J. & Johnson, W. R. (2005). Cognitive-behavioral treatment Community reinforcement approach Motivational interviewing Relapse prevention (cognitive-behavioral) Social skill training Educational lectures and films Exploratory psychotherapies Undifferentiated counseling Confrontation Mandated AA Time in milieu (inpatient/residential) stress demoralization CNS inflammation substance abuse subcortical injury cognitive impairment Depression impulsivity hopelessness carelessness demoralization substance abuse cognitive impairment HIV Precontemplation Uninformed about the risk and need for change, uninterested in changing behavior Contemplation Thinking about change in the near future (next six months) Preparation Ready to make a change in the next month Action Implementation of specific action plans for six months Maintenance Continuation of desirable actions for greater than six months, or repeating periodic recommended step(s) Relapse* Successfully accomplished a behavior change in the past, but later returned to the unhealthy behavior The close association between drug use and HIV transmission suggests that the treatment of drug abuse can be considered primary HIV prevention. By helping drug users to reduce their frequency of use, participation in substance abuse treatment has been associated with the prevention of HIV infection. Human immunodeficiency virus prevention and the potential of drug abuse treatment. Metzger DS - Clin Infect Dis - 15-DEC-2003; 37 Suppl 5: S451-6 Treatment encourages users to see beyond the immediate “positive” effects gained from drug use toward the negative consequences of drug use that inevitably follow. Alternative coping mechanisms are then devised that will provide positive effects without the negative consequences of drug use. Finally, recovering addicts learn to manage their lives more successfully, increase their confidence and self-esteem, and set positive personal goals. Treatment also addresses other medical or mental health issues facing the user and includes education on the risks of HIV and AIDS associated with meth use. Both substance use disorders and HIV/AIDS individually impact tens of millions of people adversely, with explosive epidemics of both described worldwide. Management of HIV infection among chemically dependent individuals requires considerable knowledge about multiple disciplines, including expertise in addiction medicine and psychiatry because of the overlapping epidemics of HIV, substance abuse, and mental illness [2] The capability of managing these conditions varies considerably between resource-rich and resource-limited regions of the world – Bruce RD et al:Clinical Care of the HIV-Infected Drug User:Infectious Disease Clinics of North America - Volume 21, Issue 1 (March 2007) The research literature of the past 25 years substantiates that methadone treatment is an effective HIV prevention intervention. Patients in methadone treatment use opiates significantly less often compared with those not in treatment. They also use significantly less while in treatment compared with what they were using pre- and post-treatment. Consistent with the observed reductions in opiate use, available data suggest that methadone patients will have 40% to 60% fewer instances of opiate injection and needlesharing events compared with those not in treatment. Bruce RD et al:Clinical Care of the HIV-Infected Drug User:Infectious Disease Clinics of North America - Volume 21, Issue 1 (March 2007) The association of drug treatment with decreased drug use has been reported in studies designed to compare methadone patients with heroin users not in drug treatment and in those assessing changes in cohorts of methadone patients during drug treatment. Research has also shown that rates of injection among patients who remain in treatment are significantly lower than those among patients who leave treatment. Bruce RD et al:Clinical Care of the HIV-Infected Drug User:Infectious Disease Clinics of North America - Volume 21, Issue 1 (March 2007) Strong associations have been reported for methadone participation and lower rates of HIV prevalence and incidence. Heroin users who remain in methadone treatment during periods of rapid HIV transmission in their surrounding communities have a dramatically lower prevalence of infection compared with those who do not. HIV prevalence rates are also correlated with length of time in treatment. Both prospective and retrospective studies have shown that the incidence of HIV infections is significantly and inversely associated with patient participation in and the duration of methadone treatment. Bruce RD et al:Clinical Care of the HIV-Infected Drug User:Infectious Disease Clinics of North America - Volume 21, Issue 1 (March 2007) Recent reports on buprenorphine as HIV prevention show significant reductions in risk behaviors among adults and adolescents who receive the medication through both officeand clinic-based practices, consistent with reports on methadone maintenance treatment. A randomized double-blind trial among heroin injectors in Malaysia found significantly fewer risk behaviors and longer treatment stays in those assigned to buprenorphine compared with those assigned to naltrexone or placebo. Bruce RD et al:Clinical Care of the HIV-Infected Drug User:Infectious Disease Clinics of North America - Volume 21, Issue 1 (March 2007) Research on drug treatment as HIV prevention has focused on the impact of treatment participation on the frequency of drug use and related behaviors, including injecting and sharing syringes, rinse water, and cotton. For HIV-infected drug users, accessing drug treatment can link them to HIV testing, antiretroviral treatment (ART), and HIV care. Not only are risk behaviors lower among patients in HIV care, but sustained reductions in viral load are achieved by the majority of adherent patients, regardless of mode of initial infection. Bruce RD et al:Clinical Care of the HIV-Infected Drug User:Infectious Disease Clinics of North America - Volume 21, Issue 1 (March 2007) 700 alcohol-dependent subjects completed a baseline assessment and a follow-up assessment an average of 13 months after receiving treatment. In comparing baseline and follow-up data, significant reductions in both sexual and drug-related risks were found: 58% reduction in injecting drug use, 15% reduction in reports of multiple sex partners, 26% reduction in the number of partners who were IDUs, and 77% increase in the use of condoms with all secondary sexual partners. Changes in HIV-related behaviors among heterosexual alcoholics following addiction treatment. AlvinsAL et al:Drug Alcohol Depend:1997;44:47-55. 232 cocaine-abusing or cocainedependent individuals who received up to six months of weekly drug counseling. Despite the fact that no formal HIV prevention interventions were delivered, individuals who completed treatment showed significant decreases in sexual risk behavior, primarily the result of a reduction in the number of sexual partners. Among those who demonstrated a treatment effect, the sexual risk reductions accompanied reductions in cocaine use as monitored by urinalysis. Bruce RD et al:Clinical Care of the HIV-Infected Drug User:Infectious Disease Clinics of North America - Volume 21, Issue 1 (March 2007) Data from research on the treatment of opiate dependence provide strong evidence on the effectiveness of medicationassisted treatment for reducing the frequency of: – drug use, – risk behaviors, and – HIV infections. Use of medications other than methadone (such as buprenorphine/naloxone and naltrexone) has increased in recent years with promising data on their effectiveness as HIV prevention and as new treatment options for communities heavily affected by opiate use and HIV infection. Few treatment interventions for stimulant abuse and dependence have shown efficacy in reducing HIV risk. – Bruce RD et al:Clinical Care of the HIV-Infected Drug User:Infectious Disease Clinics of North America - Volume 21, Issue 1 (March 2007) Use of medications other than methadone (such as buprenorphine/naloxone and naltrexone) has increased in recent years with promising data on their effectiveness as HIV prevention and as new treatment options for communities heavily affected by opiate use and HIV infection. Few treatment interventions for stimulant abuse and dependence have shown efficacy in reducing HIV risk. Bruce RD et al:Clinical Care of the HIV-Infected Drug User:Infectious Disease Clinics of North America - Volume 21, Issue 1 (March 2007) Risky sexual behaviors often co-occur with drug use, particularly in the setting of cocaine and other stimulant use. Few studies have found that participation in drug treatment is associated with reductions in sexual risk behaviors. Interventions to reduce sexual risks among drug users have had poor results or at least have not differed from basic educational intervention approaches. Bruce RD et al:Clinical Care of the HIV-Infected Drug User:Infectious Disease Clinics of North America - Volume 21, Issue 1 (March 2007) Positive findings have emerged from studies of sexual risk reduction interventions that are delivered within the drug treatment program setting with the drug treatment program as the platform for intervention delivery. Findings have thus far held for both individual and group sessions as well as for gender-specific and gender-mixed,68-70 yet these results are less consistent than those on the effects of drug treatment on reducing injection-related risks.71,72 Effective approaches for reducing sexual risk behaviors have been and continue to be elusive, possibly attributable in part to the link between sexual risk behaviors and stimulant use and the absence of effective medication assisted treatments for stimulant use. – Bruce RD et al:Clinical Care of the HIV-Infected Drug User:Infectious Disease Clinics of North America - Volume 21, Issue 1 (March 2007) Eddie 28 yr old AA male dx HIV+ 5 years ago at a mobile van. His risk was unprotected sex with women. No hx of an OI. No hx of ARV’s. Missed the last 2 appointments. He is a heavy alcohol user mostly on weekends. Occasional use of Estacy. Latest labs ▪ CD4-145 ▪ HIV RNA-288,000 How do you proceed? Emma 35 yo AA woman dx HIV+ 3 mo ago. Last test was 5 yr ago, did not return for the results. 15 yr hx of IVDA. Last used 12 hrs ago. Highest grade-10. Homeless, mother of 4. Hx of Schizophrenia. Residential treatment x 5. Several close friends died of AIDS. ▪ CD4-49 ▪ HIV RNA-88,000 What do you do next? Mario 26 yo Latina transgender dx 1 mo ago. Recently employed. Lives with parents. Kept appointment. Admit to multiple sex partners in the past. Adimts to alcohol and crystal meth use and often attend drug/sex parties. No hx of mental illness. CD4-410 HIV RNA-79,000 Hep C Ab-Positive How do you proceed? 48 yo AA Male dx 17 yrs ago. Hx of IVDA. Hx of ARV’s while incarcerated. Hx of IDDM, HTN, DJD. Wants to restart ARV’s. Incarcerated x 16 yrs until 9 mo ago. Returned to active alcohol/drug use after his release. College degree. Unemployed. Hx of treatment for depression. CD4-550 HIV RNA-29,000 How do you proceed? 58 yo AA man dx HIV+ 5 yrs ago. No hx of an OI. No hx of ARV’s. Hx of HTN, hyperlipidemia, obesity. 20 yr hx of crack cocaine addiction. Treatment x 6. Last drug use was 5 yrs ago at the time of dx. Comes with his fiance (HIV-). Currently taking herbals. Unsure about taking ARV’s. CD4-490 HIV RNA-56,000 How do you proceed? Substance Abuse and HIV IAS 2003 Substance Use Disorders in HIV-Infected Patients: Impact and New Treatment Strategies Topics in HIV Medicine 2004: 3;77-82 Substance Abuse Treatment for Persons with HIV SAMHSA/CSAT A Guide to the Clinical Care of Women with HIV/AIDS, 2005 edition HRSA HIV and SUBSTANCE ABUSE New York State Department of Health AIDS Institute MEDICAL CARE OF HIV-INFECTED SUBSTANCE-USING WOMEN New York State Department of Health AIDS Institute Methamphetamine Abuse American Family Physician - Volume 76, Issue 8 (October 2007) Clinical Care of the HIV-Infected Drug User Infectious Disease Clinics of North America - Volume 21, Issue 1 (March 2007) Kerry Hawk Lessard, MAA Michael R. Noss, DO Josepha Campinha-Bacote, PhD, MAR, PMHCNS-BC, CTN-A, FAAN Goulda Downer, Ph.D., RD, LN, CNS - Principle Investigator/Project Director (AETC-NMC) I Jean Davis, PhD, PA, AAHIVS John I. McNeil, M.D Michael R. Noss, DO Josepha Campinha-Bacote, PhD, MAR, PMHCNS-BC, CTNA, FAAN 1840 7th Street NW, 2nd Floor Washington, DC 20001 202-865-8146 (Office) 202-667-1382 (Fax) Goulda Downer, Ph.D., RD, LN, CNS Principle Investigator/Project Director (AETC-NMC) www.AETCNMC.org HRSA Grant Number: U2THA19645 98