The Clinical Guide to Supportive and Palliative Care for HIV/AIDS

A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 10: Psychiatric ProblemsOne national study of alcohol or other substance-using individuals with HIV reported less adherenceto combination therapy (45% vs 59% adherence in the past seven days) than non-usingcounterparts.26 picas77 Some clinicians believe that waiting until the substance abuse and psychiatricdisorder are stabilized will decrease the probability of poor adherence leading to viral resistance.Many experienced HIV clinicians encourage dual diagnosis treatment. Treating eitherthe substance abuse or psychiatric disorder independently or in sequence has not been shownto be effective in stabilizing patients with co-morbidity. Harm reduction programs, when abstinenceprograms are not working, may offer an opportunity to keep patients engaged in treatment.The use of antidepressants and anti-anxiety agents in substance-using patients may be fraughtwith difficulty. Substance users are usually impatient for a response to psychiatric medications,preferring the rapid onset of action of BZs rather than buspirone or antidepressants. Efficacymay be delayed or diminished by current substance use. Efforts should be made to engage theHIV-positive substance user in both drug treatment and psychiatric care at the same time. Patientswith untreated psychiatric disorders may be less able to enroll and adhere to a drugtreatment program.The treatment of substance abuse in patients with HIV is often more complicated than in noninfectedsubstance users. Concerns about illness, depressed mood, hopelessness, and suicidalideation often impede progress in drug abuse treatment, requiring a harm-reduction approach.Inpatient detoxification may be necessary for medically ill HIV-positive substance users, as withdrawalfrom substances may precipitate relapse with serious potential for overdosing. Aftermedical stabilization and detoxification, treatment is geared to maintain sobriety and reducethe incidence of relapses. Cognitive impairments and psychiatric distress will be more evidentwithin a few weeks of detoxification.Retention in substance abuse programs may be enhanced by early treatment of emerging psychiatricdisorders, which may be precipitants for relapse. Methadone maintenance may be necessaryfor some opioid abusers to stay clean long enough to engage in psychiatric care. Methadonemust be monitored carefully, with increases and decreases in dosing when interactionswith medications occur. Nevirapine and rifampin may increase the elimination of methadone,requiring increased dosing to avoid opioid withdrawal. Methadone itself may reduce serum concentrationsof ddI, d4T, and AZT. Table 10-26 presents relevant medication interactions. 78 Methadonemust be maintained even when additional narcotics must be used to treat pain. Methadonemaintenance provides for many patients a stablization of the narcotic addiction, allowing formore consistent HIV and psychiatric care.In addition to intensive outpatient treatment, adjunctive pharmacologic treatments such asdisulfuram for alcohol dependence and naltrexone for opioid and alcohol dependence may helppatients manage cravings and enhance participation in 12-Step and dual diagnosis programs.Disulfuram is given in doses of 250 to 500mg per day, and naltrexone 50mg per day. Whiledisulfuram is an aversive drug, creating intense nausea and vomiting if taken with alcohol,naltrexone requires abstinence from opioids for seven to 10 days prior to initiating treatment toavoid precipitating an acute opioid abstinence syndrome. 79 It is particularly important to notethat naltrexone must not be used in patients who are treated with narcotic analgesics for paincontrol. Clonidine has also been used to treat the effects of opioid withdrawal.240U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau