A Guide to Primary Care of People with HIV/AIDS - Canadian Public ...

More documents

Recommendations

Info

A Guide to Primary Care of People with HIV/AIDS Chapter 13: Management of Substance Abuse Table 13-2: The DEATH Glossary Common Pitfalls for Providers to Avoid when Diagnosing Drug Abuse Problems D Drinking or Drug-use Details are not relevant; talking with a person on drugs is not useful. The simple issue here is talking to the patient when he or she is sober, ie, has not taken a drug before the visit. Diagnosing drug or alcohol dependence or addiction is not an easy task. Many people who are addicted to alcohol or drugs attempt to conceal or deny that they have an addiction. In addition, diagnostic tests for drug dependence and addiction lack specificity and sensitivity. Although blood and urine tests are usually quite reliable at detecting recent drug use, individuals can be adept at avoiding being tested or at manipulating test results. See Table 13-3 for the duration of time substances are detectible in urine. E Etiology A Argument T Threats H Hedging Do not spend much time on how drug use started but focus on getting the person to treatment. Avoid arguing at all costs. No meaningful conversation will occur in an argument. Guilt and shame do not promote recovery from chemical dependency. Threats or evoking guilt will not promote successful therapy. Hedging hurts your credibility. Being ambivalent about giving the diagnosis will not help the patient. If the patient disagrees with you, unequivocally agreeing to disagree is a valid starting point for getting to successful recovery. Table 13-3: Duration of Time Drugs Are Detectable in Urine Alcohol Substance Amphetamines Barbiturates Valium Cocaine Heroin Marijuana Methaqualone Phencyclidine (PCP) Methadone Sex, food, gambling 48 hours 12 hours 10-30 days 4-5 days 24-72 hours 24 hours Duration 3-30 days (in heavy users) 4-24 days 3-10 days 3 days Not applicable 13 Why is substance abuse such a big issue in HIV care? Injection drug use is estimated to be responsible for 25% of HIV transmission in the United States and is directly or indirectly responsible for 57% of HIV transmission to women. Less well appreciated is the fact that drug-using behaviors may be a significant HIV transmission risk factor for many men who do not inject drugs. In a recent study of men who have sex with men (MSM), up to 16% may have drug use as a risk factor for acquiring HIV (Chesney, 2003). The high degree of association between injection and noninjection drug use underscores the importance of primary care providers’ being able to diagnose drug using behaviors. Are there tools to help providers assess patients for drug and alcohol use? Experts in addiction medicine use a combination of behavioral and clinical testing to diagnose drug abuse. There are 9 commonly used drug-use screening tests: Addiction Severity Index (ASI), Alcohol Dependence Scale, Alcohol Use Disorders Identification Test (AUDIT), CAGE (see below), Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA-Ar), Drinker Inventory of Consequences (DrInC), Michigan Alcohol Screening Test (MAST and SMAST), Problem Oriented Screening Instrument for Teenagers (POSIT), and Self-Administered Alcoholism Screening Test (SAAST) (American Society of Addiction Medicine, 1998). Six of them are specifically designed to detect alcohol use. 106 U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau
A Guide to Primary Care of People with HIV/AIDS Chapter 13: Management of Substance Abuse Which screening tests are most useful in primary care practice? The CAGE test is a non-threatening quick screening test for detecting drug use in adults (see Table 13-4) and the POSIT test useful for screening adolescents aged 12-19. The questions below are designed to assess key substance-using behaviors. The letters in CAGE correspond to important emotions or behaviors indicative of drug use. C A G E Table 13-4: The CAGE Screening Test 1. Have you felt that you ought to Cut down on your drinking or drug use? 2. Have people Annoyed you by criticizing your drinking or drug use? 3. Have you ever felt bad or Guilty about your drinking or drug use? 4. Have you ever had a drink or used drugs first thing in the morning (Eye opener) to steady your nerves, to get rid of a hangover, or to get the day started? The Problem Oriented Screening Instrument for Teenagers (POSIT) examination is a 139 item yes/no questionnaire for assessing adolescent risk factors in substance abuse, physical health, mental health, family and peer relationships, educational and vocational status, social skills, leisure and recreation, aggressive behavior, and delinquency. A nonexperienced provider can conduct the test in 20 to 25 minutes. The questionnaire is available free in English and Spanish from the National Clearinghouse for Alcohol and Drug Information by mail at P.O. Box 2345, Rockville, MD 20847-2345 or by telephone at 1-800-729-6686. What would provide a more in-depth assessment of drug and alcohol use? Two detailed evaluations of drug and alcohol use are the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) and Addiction Severity Index (ASI) for alcohol or drug use. The DSM-IV defines the diagnostic criteria for substance dependence as 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: 1. Presence of drug withdrawal symptoms 2. Escalation of drug doses 3. Persistent inability to reduce or control drug use 4. Increased time spent obtaining drugs 5. Personal and business activities reduced by drug use 6. Development of drug tolerance 7. Knowing drug use’s negative health and personal effects, yet continuing to use drugs TREATMENT OF SUBSTANCE ABUSE PROBLEMS What should you do before referring a person for treatment? The decision to refer a person for drug abuse treatment should come after the provider has detected a substance use problem, conducted initial evaluations to determine the degree of drug use and physical harm done by the drug use, and provided brief interventions to stop drug abuse. After the diagnosis and brief interventions (if appropriate), the provider should refer the patient to a drug treatment system or an addiction physician. What role does the primary care provider’s attitude play in successful drug abuse treatment? Drug abuse treatment is successful if the provider addresses his or her own biases about addiction, understands the factors contributing to addiction, provides appropriate pharmacologic and behavioral care, and recognizes that drug addiction is a chronic disease problem. Many drug abuse treatment failures are associated with hostile or unsupportive providers whose behaviors are based on the assumption that drug use is voluntary. Since successful drug abuse therapy depends on adherence to treatment regimens, any factors that facilitate adherence will foster successful treatment outcomes. The patient’s perception that the primary care provider is nonjudgmental and supportive is an essential factor in successful therapy. How can the primary care provider enhance the success of drug abuse treatment? The primary care provider must prevent or treat exogenous factors that negatively affect successful drug abuse therapy. We now recognize significant environmental (social), genetic, biologic, and behavioral factors that facilitate drug addiction: 13 U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau 107
Page 1 and 2:
Edited by John G. Bartlett, MD Laur
Page 3 and 4:
2004 Edition A Guide to Primary Car
Page 5 and 6:
A Guide to Primary Care of People w
Page 7 and 8:
Page 9 and 10:
Page 11 and 12:
Page 13 and 14:
Page 15 and 16:
Page 17 and 18:
Page 19 and 20:
Page 21 and 22:
Page 23 and 24:
Page 25 and 26:
Page 27 and 28:
Page 29 and 30:
Page 31 and 32:
Page 33 and 34:
Page 35 and 36:
Page 37 and 38:
Page 39 and 40:
Page 41 and 42:
Page 43 and 44:
Page 45 and 46:
Page 47 and 48:
Page 49 and 50:
Page 51 and 52:
Page 53 and 54:
Page 55 and 56:
Page 57 and 58:
Page 59 and 60:
Page 61 and 62:
Page 63 and 64:
Page 65 and 66: A Guide to Primary Care of People w
Page 115: A Guide to Primary Care of People w
Page 167 and 168:
Page 169 and 170:
Page 171 and 172:
Page 173 and 174:
Page 175 and 176:
Page 177 and 178:
Page 180:
Use these quick-reference page tabs
show all

A Guide to Primary Care of People with HIV/AIDS - Canadian Public ...

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?