HIV and Substance Use

PHASE, Canadian Psychological Association and Health Canada

Module developed by Bill Coleman, Ph.D.

BC Centre for Disease Control

Vancouver, B.C.

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What we are here to learn:

• How to effectively work with persons who use drugs

• What HIV issues are involved in drug use, safe sex and safe drug use.

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Concepts in HIV and alcohol/drug counselling

• Respect clients and their choices

• Why do people use drugs?

• New coping strategies are necessary to make change.

• What is the therapist’s role in this context?

• Harm reduction is one way of approaching substance use.

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12-step programs are not for everyone!

12-step programs:

• Are concrete

• Involve rules and prescriptions for behaviour

• Are structured

• Are spiritual

• Have a social atmosphere; offer peer support.

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Drug use and safe sex

• Many people say it is hard to be safe when high.

• Drug use may NOT be the CAUSE of unsafe sex, it may be the excuse for it: “I don’t want to worry about safe sex; if I am drunk, I can just enjoy sex.”

• Being high often enables unsafe sex.

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Substance use can be a coping strategy.

Drugs and alcohol serve a purpose for people who use them. They seem to help a person cope. Even though there may be other ways to cope that are less problematic, sometimes life is just too painful for some people to experience without drugs.

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One theory about substance use is:

Drugs are often people substitutes, and therefore, people can be drug substitutes.

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How does the theory work?

• Drugs can be a safe refuge from a hurtful world.

• People and relationships can also provide meaning and fulfillment.

• Learning to have meaningful relationships with reliable people is a first step.

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Harm ReductionHarm reduction means finding less harmful

alternatives, not “fixing” the problem

These less harmful alternatives may include:– Less frequent use of drugs– Lower quantity of drug use each time– Substitution of less “risky” drugs– Substitution of other coping strategies– Safer (cleaner) injection practices– Decrease of needle sharing– Increase of condom use when high.

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How Therapists can HelpRespect and understanding can allow

for change.

Therapists can:• Understand how drugs are “useful” for that

person• Communicate that understanding to the

person• Respect individual choices.

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Drug use has a meaning for each user.

• Drugs can seem to make the world less scary.

• Drugs can make it easier to socialize.• Sex may be more fun when one is high.• There may be many more meanings …

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Understand the client’s needs and how drug use is

meaningful for them.

• Often drugs are substitutes for “connecting” with people.

• Drugs can be a safe refuge from a fearful world.

• Drugs can feel safe … other people can feel threatening.

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New Coping Strategies:Engaging the client in the process of

finding alternatives

• Making a change in routine

• Rediscovering old coping strategies

• Learning new behaviours.

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Protease Inhibitors and Street Drugs

• Street drugs and HIV medications can have severe interaction effects.

• Clients who are informed of these interactions can make safer decisions.

• Stay informed of new research on street drugs.

• www.thebody.com is a good source of current research on street drugs and HIV.

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Ecstasy

• 3-10 times more drug is absorbed into the bloodstream

• More teeth grinding, joint stiffness

• Heart palpitations• Possible kidney

damage

Harm reduction

• Take only one half of the usual amount

• If taking Crixivan, drink more water the day after using Ecstasy.

Interaction effects with HIV medication

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Speed/Methedrine

• 2 to 3 times more drug is absorbed into the bloodstream

• Increased anxiety• Manic behaviour• Shortness of breath• Dehydration

Harm reduction

• Use much smaller amounts of the drug.

Interaction effects with HIV medication

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Heroin

• Heroin is metabolized more quickly.

Harm reduction

• Increase amount only if necessary to get high.

• Substitute another drug for heroin.

Interaction effects with HIV medication

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Special K

• Buildup of ketamine in the bloodstream

• Increased sedation• Disorientation• Hallucinations• Effects last longer, can

easily overdose

Harm reduction

• Take one third to one half of the usual amount.

• Have a friend monitor drug use.

Interaction effects with HIV medication

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Cocaine

• Little is known about interactions with this drug.

• Can increase HIV reproduction by up to 20 times.

Harm Reduction

• Substitute less damaging drugs.

• Remember to take HIV medications when high.

Interaction effects with HIV medication

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GHB(Grievous bodily harm)

• Little is known about this drug.

• May suppress the immune system.

• Difficult to evaluate the correct dosage.

Harm reduction

• Substitute other drugs.

Interaction effects with HIV medication

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Therapists can help by:

• Creating a safe place

• Assisting in discovering alternative coping strategies for making change

• Teaching clients about the interactions of street drugs and HIV medications BUT …

• Scaring a person is rarely helpful

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When individuals feel safe and understood, they can decide for themselves to change their behaviour.

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Case Studies

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Case Study: Betty

• Betty, age 28 and single, has known she is HIV+ for about six months.

• She has had a hard life. She had alcoholic parents who physically and verbally abused her. Her parents were never very loving. She was the oldest child and she took on the responsibility of caring for her two younger siblings. She was very responsible and is still very close to her siblings. Betty never did well in school. She has a pleasant personality. (cont…)

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Case Study: Betty (cont)

• Betty has found it difficult to find a man who is loving and understanding. Most of her relationships are with men who are somewhat abusive and have drug and/or alcohol problems. She is very worried about being HIV+. She would like to have children but now fears she cannot.

• Betty has come for counselling, stating that she has many problems. She has not been able to develop a loving relationship. She feels she drinks too much. She had many drug experiences and is afraid she may begin taking heroin again. She is afraid and states that she just wants to be happy and have a normal life.

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Case Study: James

• James, a 26-year-old gay man, has known he is HIV+ for about a year and a half. He is taking combination therapy. His last blood tests showed a low viral load.

• James has completed a university degree but has had some difficulty finding a job that he finds rewarding. He is currently working in an office where he is well liked and can complete his work effectively.

• James is single, but has had a few relationships lasting a few months to a couple of years. He appears to be comfortable being gay and he seems to have accepted being HIV+. Only one of James’ closest friends knows he is HIV+. (cont…)

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Case Study: James (cont)• James likes to party; he always has. He is well liked

and very sociable. When James goes out he frequently drinks, but if he is with his friends who are doing drugs he will readily partake. The amount of alcohol that James drinks has increased over the last year. He enjoys sex and usually finds partners when he is drinking. When he has sex, he is sometimes safe. However, he feels that if he has sex, then others are not at risk, so he doesn’t worry too much about safety. If asked, he would probably say that his drug of choice is marijuana but he also does a lot of Ecstasy. James is coming for counselling because his friends think he “parties too much and too hard.”

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Group Exercise on Drug Use: Case Discussions

1. Divide the participants into four to eight persons. Chose either James or Betty and give each participant a copy of their case description

2. Each group will:• Create a list of “harm reduction” options.• Choose the one or two options that are likely to be most helpful.• Present each list of alternative behaviours to the class.

3. The class will create a master list of alternative behaviours, then examine it for common scenarios and creative solutions.