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 13 Tuberculosis Past tuberculosis exposure is common in injection drug users (as many as 30% are PPD positive); they should be screened for TB. Skin and soft tissue infections Cellulitis and skin abscesses are very common in injection drug users. The practice of “skin popping” markedly increases the risk of abscess formation. Noninfectious health problems Treat accordingly. Drug users and alcoholics have multiple health problems that should be treated aggressively. The fewer medical problems patients have, the more likely they are to adhere to the treatment plan. Common problems to be aware of: • Drug interactions (between medications and between medications and illicit drugs) • Diabetes mellitus and hypertension • Social environment (housing, child care) • Pain management How do you manage pain in opiate-addicted patients? It is incorrect to assume that individuals addicted to opiates or any other kind of drug should receive less pain medication because they are addicted. They should receive pain therapy based on the diagnosed cause of the pain just like nonaddicted patients. The therapeutic approach differs according to whether the pain is acute or chronic. How should you treat acute pain in a person diagnosed as a drug abuser? Appropriate actions to take for drug-abusing patients in acute pain related to a recent diagnosable injury involve managing the pain: 1. Determine the source of the pain. 2. Provide pain medication that relieves the symptoms. Opiates may be used if they are what will stop the pain. 3. Give the medication in regularly scheduled doses. This prevents undesirable drug-seeking behaviors resulting from treatment on an as-needed (PRN) basis. 4. If pain is persistent or the cause is unclear, check for underlying psychiatric problems or an undetected source of pain. 5. If opiates are used, taper the doses slowly to avoid drug withdrawal. How should you treat chronic pain in a person diagnosed as a drug abuser? If the pain is chronic, the treatment strategies shift to not only finding the source of the pain, but also to using the entire spectrum of pain-relieving strategies with or without nonopiate pain medication (see Table 13-6). One exception is a patient with cancer-associated pain, for whom any effective medication (potentially addictive or not) is appropriate. Table 13-6: Treatments for Chronic Pain in Known Drug Abusers Medications used for pain control Nonsteroidal anti-inflammatory drugs (eg, 30 mg ketorolactromethamine, which is equivalent to 6-10 mg morphine) Tricyclics Anticonvulsants Muscle relaxants Topical agents Opiates Physical interventions for pain control Thermal: heat and cold are both effective and underutilized Peripheral counterstimulation: transcutaneous electrical nerve stimulation (TENS) and vibration Manual therapies: massage and chiropractic and osteopathic manipulation Active movement: stretching and active exercise Orthotics: splints and other supportive devices 110 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 HIV/AIDS ISSUES Can HIV transmission be prevented in active substance abusers? A comprehensive HIV prevention strategy in a primary care practice includes interventions to provide drug treatment, to take care of mental health problems, and to prevent HIV transmission during drug use and sexual activity. The primary care provider should routinely screen for drug abuse and treat or refer for treatment as quickly as possible. This is particularly important for adolescents who are at high risk for HIV, hepatitis B and C, and other infections. One study has shown that once adolescents start injecting drugs, over 90% will become infected with hepatitis C within 18 months. The provider should also counsel patients who are actively using drugs not to share needles with others and to take advantage of programs that distribute clean needles. Programs use the needle distribution strategy as a first step to engage individuals who can then be encouraged to accept medical and drug abuse treatment services. When is an active substance abuser ready for HIV treatment? The most important clinical decision for successful treatment of drug-abusing patients with HIV is deciding when they are ready -- both substance abuse treatment and antiretroviral therapy (ART). Patients fall into 3 categories: those who do not want treatment, those who are ambivalent, and those who want treatment. For patients who do not want treatment, the provider should continue to be available with information on HIV and drug abuse treatment until they are ready to consider treatment. For those who are ambivalent about treatment, time is well spent during several clinical visits discussing the health issues of AIDS and drug abuse until they are ready for treatment. For patients who are ready for treatment the next step is to assess what factors will affect their adherence (see Chapter 7: Adherence to HIV Therapies). History of injection drug use, race, gender, age, socioeconomic status, level of education, and occupation are poor predictors of medication adherence. Accurate predictors of adherence are: • The patient’s health beliefs • Ease of access to health care providers • Familiarity with the treatment setting • Existence of a social support system • Perceived support from clinical staff members • Simplicity of medication regimens Interaction with providers and ambiance of the treatment setting account for almost half of the support factors needed to encourage drug users to adhere to treatment regimens. This pattern is true for active drug users, with the possible exception of persons addicted to crack cocaine. Difficult economic and social situations, including unemployment and unstable housing, may make adherence to clinical treatment plans for both drug addiction and HIV even more difficult to follow. For these reasons some drug abuse treatment centers provide residential treatment to minimize outside influences on drug use. Also, methadone clinics provide an ideal opportunity for rehabilitated substance users to receive adherence support for ART through directly observed therapy (DOT) at the clinic. What immunizations should drug abusers with HIV receive? Because of the higher risk of tetanus in injection drug users, tetanus boosters should be given when due. Pneumococcocal and influenza vaccines are recommended for all patients with HIV. Drug abusers with no antibodies to hepatitis A and hepatitis B should be immunized. Hepatitis A can be fatal in individuals with hepatitis C. Are there important drug interactions between antiretrovirals and medications for drug treatment? A common problem in treating patients with HIV who are drug users is the drug interactions between medications. Studies have shown that interactions of methadone and antiretroviral medications are linked to CYP450 3A4 sites in the liver. The most significant interactions are between methadone and nevirapine (NVP) or efavirenz (EFV), which precipitate rapid drug withdrawal symptoms (see Table 13-7). Methadone programs should be alerted when methadone patients are started on efavirenz or nevirapine, as dose escalation of methadone will probably be required. When methadone and didanosine (ddI) are coadministered the uptake of didanosine may be lowered requiring a higher dose of didanosine (See Drug Tables 7 and 8 in the Pocket Guide). Other interactions caused by drugs such as abacavir 13 U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau 111
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:
Page 67 and 68:
Page 69 and 70: A Guide to Primary Care of People w
Page 119: A Guide to Primary Care of People w
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 ...

Create successful ePaper yourself

Delete template?

Save as template?