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

A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 3: Assessment of Physical SymptomsA full discussion of the assessment of the patient with a past history of, or active involvement in,substance abuse is beyond the scope of this chapter. (For a more in-depth discussion, see Chapter11: Substance Use Problems.) The complex issues involved in the medical care of this population26 have picas been extensively reviewed in other texts. 47-50 Such care must include attention toboth the HIV-related illness(es) and the substance abuse, along with the social and medicalissues that each involves. In addition, it is important that clinicians who care for people withsubstance use problems be committed to providing optimal medical care. Such care must involvesymptom management. An ongoing relationship between the clinician and patient thatcan foster both trust and continuity of care is optimal in all cases of advanced illness and is alsodesirable in this setting.A detailed history, as described in this chapter, should be undertaken in those with, or suspectedto have, a history of substance use problems. As in all cases of patients reporting distress,it is crucial for clinicians to focus on the detail of symptoms and on the distress associatedwith them, in order to define the underlying pathology and diagnosis and develop a treatmentplan. Careful assessment, combined with knowledge on the part of the clinician of pain syndromes,other symptoms, and common symptom complexes should facilitate the developmentof a diagnosis and treatment plan. Careful attention should be given specifically to assessmentfor concurrent psychiatric conditions, many of which have an increased prevalence in peoplewho have problems with substance use. Initially, it is important for the clinician to learn aboutthe patient’s current status with regard to drug use and the situations and triggers that, in thepast, may have prompted the patient to turn to substance abuse. Clearly not all patients will beforthcoming with information relating to their substance use activities. Any inconsistenciesthat are uncovered during historytaking or from other clinicians or family must also be notedand their implications considered.In cases where substance abuse is being considered, eliciting the patient’s social history is vital,as is speaking with others involved in the patient’s medical care, where this is possible and withrespect for privacy issues. In this context it is important to consider the concept of aberrantdrug-related behaviors. 48, 49 These include a broad range of behaviors that have been consideredproblematic by clinicians prescribing opioids for pain. Table 3-4 presents the spectrum ofaberrant drug-related behaviors clinicians may encounter during treatment of the medically ill48, 49with prescription drugs.Table 3-4: Aberrant Drug-Related Behaviors*Behaviors more suggestiveof addictionSelling prescription drugsPrescription forgeryStealing drugs from othersInjecting oral formulationsObtaining prescription drugs fromnonmedical sourcesConcurrent abuse of alcohol or illicit drugs58U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau