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

A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 11: Substance Use ProblemsFinally, a social history remarkable for repeated incarcerations, violence, inability to sustainlong-term interpersonal relationships, sporadic employment and/or a family history of substanceuse should raise the provider’s index of suspicion for substance use.26 picasIf a history of substance use is identified, further exploration is needed. It is important to beaware that poly-substance use is common. At a minimum, the type of substance(s), amount,route of administration, frequency of use, and medical complications, including signs of toleranceand dependence should be understood (see below). If a patient has been in substance usetreatment, the palliative care team should know the approach that was used and its impact onthe patient’s drug use. In these circumstances, the palliative care team should include an expertin treating addictions.GENERAL MEDICAL CARE■ While this chapter does not attempt to review the myriad medical complications of substanceuse and HIV, it is important that the palliative care provider be aware of the scope of issues thathe or she may face and be prepared to seek consultation when necessary. 3, 4Substance users can be at higher risk for diseases besides HIV/AIDS. Hepatitis B, C, and deltaare transmitted parenterally, as are bacteria causing endocarditis, soft tissue infection and otherinfections. Tuberculosis and sexually transmitted diseases are more common in this populationand must be ruled out. Chronic lung disease associated with exposure to substances used to“cut” cocaine and heroin and chronic liver disease associated with alcohol can make provisionof palliative care medically complex.Active drug users are at risk for withdrawal (from opiates, alcohol, barbiturates and benzodiazepines),which can be a life-threatening emergency. Cocaine, particularly when injected orsmoked, can cause cardiac arrhythmias, hypertension, hyperpyrexia, rhabdomyolysis, and cerebralor coronary artery vasospasm. Substances that suppress consciousness and respiration caninduce coma and death. Opiates, in addition, can cause non-cardiogenic pulmonary edema.XIPAIN■ Pain is often poorly managed in the substance-abusing patient or in the patient with a historyof substance use. 5 This can be because pain is not recognized as such and is interpreted asmanipulation or “drug-seeking;” because unique predispositions to pain are not understood; orbecause of ignorance of basic principles of addiction and/or pain management. To manage painappropriately, providers need a systematic and thoughtful approach.Substance Use and PainIt must first be understood and accepted that a history of substance use does not precludesomeone from having real pain. In many cases, in fact, substance use may predispose a patientto experience physical pain (secondary to trauma, chronic venous insufficiency, infections, alcoholicor nutritional neuropathies, etc.) or to have pain that is difficult to control for a variety ofreasons. Patients who have developed tolerance to opiates may require doses of narcotic medicationsconsiderably higher than non-tolerant patients, and this may make some providers uncomfortable.Additionally, it has been shown that some substance users treated with methadonemay have a lower pain threshold than others. 6 Finally, the profound emotional, practical, andeven spiritual complications of substance use contribute to pain symptoms and must be addressedto manage pain successfully.U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau 255