Assess, refer, and treat: Keys for substance abusers
Assess, refer, and treat: Keys for substance abusers
Trouble is that it’s not that easy
HIV and substance abuse experts acknowledge that dealing with patients who have both of these issues can be challenging and often frustrating, but they say it’s possible to provide the best treatment to these patients if certain steps are taken. Here are some strategies for identifying and treating HIV patients who have substance use problems:
1. Assess HIV patients for alcohol and drug use.
The two most important factors in identifying HIV patients with substance use problems are for the patient to have a trusting relationship with the clinician and for the clinic or physician to use a written assessment form that could detect hidden substance addiction and abuse, according to HIV and substance abuse experts from clinics across the country.
The Whitman-Walker Clinic in Washington, DC, uses two very helpful tools, including the Barriers to Medication Adherence checklist and the Addiction Severity Index (ASI), says Anne Clements, LCSW, director of mental health, addiction, and day treatment services for the clinic, which serves HIV-infected clients in the D.C. area. (To see Medication Adherence Checklist, click here. Source: AIDS Healthcare Foundation of Los Angeles; Chris Matthews, MD, San Diego.)
"The ASI assesses not only a person’s pattern of use, but it also examines other mental health issues and gives a good assessment of how close they are to doing self-harm," Clements says. "And because addiction has such an impact on a person’s physical health when someone is HIV-positive and because of all of the destructive things that happen, both behaviorally and physiologically, the best thing is for a trained and certified addiction counselor to do the assessment because addicts lie."
Avoid stigmas or penalties
When it’s not feasible to use written assessment tools, physicians should have an honest dialogue with their patients, emphasizing that the patient will not be stigmatized or penalized for being honest about what he or she is doing, says Mark Gerse, deputy executive director of the Lower Eastside Harm Reduction Center in New York. "That requires a change in the provider," Gerse says. "The patient should be on the same page as the physician, and the physician has to trust the patient and the patient has to trust the doctor, and if that doesn’t exist it’s a huge problem."
Clinicians should acknowledge patients’ substance abuse in a nonjudgmental way, while also assessing the patient’s view of his or her drug use and the patient’s motivation to address their use, says Marc Gourevitch, MD, an internist and director of Addiction Medicine for the Albert Einstein College of Medicine and Montefiore Medical Center in the Bronx, NY.
2. Look for mental health issues in the same population.
Because so many people who have both substance abuse problems and HIV infection also have mental health problems, including depression, it’s also important for physicians to screen for mental health problems, says Jennifer Havens, MD, director of Pediatric Services at the New York Presbyterian Hospital in New York. Havens is a psychiatrist who used to run a clinic for women and children affected by AIDS. It’s not good enough to ask patients if they have a history of mental health treatment, because many people with mental health problems and HIV infection have never received treatment, Havens notes.
"I believe providers should use screeners that are structured to pick up major psychiatric disorders, and once they screen positively, then they should have on-site services where psychiatrists or social workers can assess the patient and provide treatment," Havens adds.
3. Make referrals to treatment programs.
HIV providers and patients both benefit when a clinic has its own programs to address substance abuse and mental illness. For example, the Whitman-Walker Clinic has several different programs, including everything from day treatment to residential, to help HIV-infected addicts and alcoholics, Clements says.
The state of New York has created the framework for integrated services between HIV providers and substance abuse treatment centers so that there is a an easy referring relationship between the two groups, says Bruce Agins, MD, MPH, medical director of the AIDS Institute of the New York State Department of Health in New York City.
Clinicians need to be able to both assess and refer HIV patients with substance abuse issues when indicated, Agins adds. "The coordination between the medical provider and the substance abuse provider is absolutely essential," Agins says. "It’s very important to share information back and forth and work together to support the patient to adhere to the plan." There is a variety of drug treatment modalities, including harm reduction, methadone treatment, and abstinence-based therapies, so the most important factor is to find the right approach that works for a particular individual, Agins says.
Deciding what type of referral to make will depend on how well the doctor knows the patient, Havens says. "You need to establish a rapport with the person so they will be honest with you about what’s going on, and then you need to figure out what their goals are," Havens says. "If they say, I’m not going to stop using drugs,’ then don’t send them to an abstinence-based program." The harm reduction approach may work better for these individuals because its philosophy is, "How can we help you reduce substance abuse to the point where you are ready to take antiretrovirals?" Havens adds.
The Gay Men’s Health Crisis in New York City offers harm reduction services to HIV patients, and one philosophy of such programs is to base substance use treatment on the client’s own goals, says Sheila H. Mabry, CSW, assistant director of HIV Prevention. "We meet clients where they are at," Mabry says. "Some clients are ready to stop or reduce substance use, and other times there’s a process of exploration in which they can’t be judged about their use."
Of course, these approaches all are based on the philosophy that should an HIV patient need and desire substance abuse treatment, it will be available. Unfortunately, that’s not always possible. Even in New York City, where the two provider groups work well together, there still is a problem with availability because there are not enough substance abuse programs, says Joseph Masci, MD, director of AIDS Services at Queens Health Network and chief of Infectious Diseases at Elmhurst (NY) Hospital Center. "We need more programs and more openings in them," Masci says.
Treatment programs are in even shorter supply in many other parts of the country. Havens notes that in some states, such as North Carolina, there are no substance abuse services or mental health services designed to serve HIV-infected people. In those areas, clinicians will have to improvise, making referrals to general substance abuse treatment programs and counselors.
HIV-infected substance users also may need to be referred to organizations that could help them improve other parts of their lives, such as finding adequate housing. This is particularly an issue in expensive cities, such as San Francisco, says Susan Haikalis, LCSW, director of HIV Services and Treatment Support for the San Francisco AIDS Foundation. HIV-infected people might have disability income that amounts to $700 a month, while the average rent for a one-bedroom apartment is $1,400. Government funding can run out very quickly while picking up more than $1,000 a month in subsidized rent per person, Haikalis says.
4. Take substance use into consideration when designing a treatment strategy.
While some clinicians may choose to delay antiretroviral therapy until a patient is in treatment for substance abuse, others argue that various adherence strategies will work as well with this population as with other HIV patients. "I think common sense would tell you to defer treatment at least until the patient is leading the kind of structured life that lends itself to taking medications on these structured regimens," Masci says. Also, there might be a danger of interaction between antiretroviral drugs and alcohol or illegal drugs. These types of interactions have not been studied well enough, experts say.
No matter what, substance use continues
However, it is impractical to withhold treatment based solely on substance use, Gerse says. "In New York City, over half of the people infected are injection drug users, so we’d be talking about not treating half of the HIV-positive people in our city, because no matter how hard we try or how tough they make the laws, substance use continues," Gerse says.
The San Francisco AIDS Foundation carefully monitors HIV-infected patients with potential adherence issues by providing them with a drop-in pharmacy service where they can pick up their medications and take them while being observed by staff, Haikalis says. This type of service is limited because it’s only open on weekdays during normal business hours, she adds.
Other adherence solutions might work with patients who are actively abusing drugs or alcohol, so clinicians who do not wish to withhold treatment to active users might be able to find other ways to ensure their medication adherence. For example, clinicians could offer patients a placebo practice run in which the patient takes a fake tablet or vitamin on an antiretroviral schedule regimen to see how adherent he or she would be to the treatment, suggests Mary Jane Rotheram-Borus, PhD, professor and associate director of the AIDS Institute of the University of California - Los Angeles. "If the patient is not adherent, then it might influence the patient’s and doctor’s decision about whether to place the patient on antiretrovirals," Rotheram-Borus says.
Another way to improve adherence among this population is to offer access to other services that may help patients deal with socioeconomic issues, Gerse says. "People are struggling with a lot of pain that has not been dealt with, and HIV only compounds it," Gerse says. "So now the hopelessness is even greater, and it’s important to develop best practices that embrace substance users rather than leaving practices the way they are."
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