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The Triple Challenge:Optimizing HIV Treatment for Patients with Co-occurring Mental Illness and Substance Use Disorder This presentation was made by Dr. Glenda Clare at a state conference in Georgia.
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The Triple Challenge:Optimizing HIV Treatment for
Patients with Co-occurring Mental Illness and Substance Use Disorder
Glenda Clare
G. Portlynn Clare & Associates
Introductions
Who are you?
What type of work do you do? Where?
Why are you attending this workshop?
Training Objectives
Discuss the prevalence of substance use disorders and mental illness among people with HIV/AIDS
Discuss the range of substance and mental disorders that patients might be experiencing
Identify key considerations in screening for these disorders and screening tools and diagnostic criteria
Identify some of the effects of these disorders on treatment adherence and effectiveness
New Face of HIV
50% of currently HIV positive population have substance use disorder and mental illness
New Face of HIV
HIV Cost and Services Utilization Study found• 36% with major depression
• 26.5% with dysthymia
• 15.8% with generalized anxiety disorder
• 10.5% with panic attacks
• 12% with drug dependence
• 6.2% with “frequently heavy drinking”
Etiological Connections
Substance use disorders increase HIV risk behaviors
Symptoms of some mental disorders can increase impulsivity and impair problem solving processes, leading to HIV risk behavior
HIV can increase risk of depression, anxiety, mania, sleep disorders, HIV related CNS disorders
Addiction & Other Mental Health Disorders
Confuse assessment of HIV related symptoms and conditions
Impair self-care, treatment attendance, and adherence to HIV regimen
Weaken immune system Involve drugs that may speed replication
of HIV
Addiction & Other Mental Health Disorders
Complicate HIV treatment Complicate pain management Add more stigma to the lives of people
living with HIV
Medical Management:General Questions - Patients
Which psychotropics are problematic with your HIV medications?
Do you know what psychotropics you are already taking?
Does the psychiatrist know the HIV medications you’re taking?
Medical Management:General Questions - Agency
When are psychiatric medications prescribed (in house), and when do you refer?
How does methadone interact with HIV medications?
How do “street drugs” interact with HIV medications?
Psychotropics & Antiretovirals
Drug interactions may interfere with liver’s ability to filter medications
*Make a list of your client’s medications. Obtain information about drug actions from your local pharmacist
Antidepressants
Most new antidepressants are safe and effective
Use tricyclics – used for pain and sleep disorders - with pain and with caution
Avoid Serzone – risk of hepatic failure
Benzodiazepines
Start low – highly addictive Never use alone Avoid shorter acting forms of the drug Abuse of trizzolam, diazepam, zolpidem
and midazolam can be deadly with protease inhibitors
If patient is having trouble with meds - refer
Antipsychotics & Mood Stabilizers
Refer to a psychiatrist Older antipsychotics have increased risk
of side effects – irreversible movement disorders
Patients using lithium should be under the care of a psychiatrist
Methadone
Used for treatment of opioid addiction Some drugs lower methadone
concentration, with risk of withdrawal Some drugs raise methadone
concentration, with risk of overdose Some patients may be afraid to disclose
methadone use because of stigma
Drugs That Lower Methadone Concentrations
Alcohol Barbiturates Nevirapine Carbamazepine Didanosine (ddl) Efavirenz Isoniazid
Nelfinavir Phenytoin Rifampin Ritonavir Saquinavir Stavudine (d4t)
Drugs That Raise Methadone Concentrations
Cimeticline Cipro (significant elevations) Erythromycin Ketoconazole Fluvoxamine Fluoxetine Nefazodone Zidovudine
Patients Using Alcohol & “Street Drugs”
Videx can increase the risk of pancreatitis
Toxicity of “ecstasy” significantly increased with some protease inhibitors
Amphetamine levels may be increased with protease inhibitors, particularly ritonavir
Patients Using Alcohol & “Street Drugs”
GHB can be dangerous with protease inhibitors
Ketamine and ritonavir can lead to chemical hepatitis
Synthetics sold as heroin may be toxic at very small doses when combined with medications
Complications Caused By HCV C--infections
Hepatitis C accelerates and exhausts liver filtration system
ARV medications have to compete for depleted liver cells
Side effects of interferon can include fatigue, depression, or confusion, which interfere with appointment and medication adherence
Pain Management for Patients With Substance Use Disorders
Pain relief vs Drug Seeking Pain meds may have high potential for
abuse and dependence Most people with substance use
disorders legitimately need higher doses of pain medication
Methadone raises extra pain management issues
Methadone & Pain Management
Maintenance dose confers no analgesia You should use opiate analgesics for
patients on methadone maintenance Don’t use any opiate partial agonis for
people on methadone maintenance
Dosage & Intervals for People on Methadone
Start with higher doses of pain meds Assess frequently and titrate to pain
control Be prepared to administer at shorter
intervals
Strategies for Promoting Adherence
Prescribe for side-effects Learn from patient how his/her disabilities
affect adherence Understand lifestyle and culture, and effects
of these on adherence Look at housing, confidentiality issues Go over basic points in materials Don’t assume people will take materials or
read them
Substance Use Disorders
Multiple risk factors for HIV infection Some drugs may raise the risk of HIV
related CNS disorders Substance use disorders are defined as
“abuse” or “dependence” depending on the amount of dysfunction
Substance Use Disorders
Substance use disorders are chronic conditions often characterized by repeated recurrence
Dependence complicates HIV treatment and pain management
Methadone affects pain management Traditional referral techniques often don’t
work with substance dependence
Common Disorders
Mood Disorders Anxiety Disorders Schizophrenia Dementia Due to HIV Disease Personality Disorders
Mental Illness
Depression and stress can adversely affect immune functioning
Clinical depression isn’t a “normal” reaction to HIV/AIDS
Differential diagnosis can be tricky
Mental Illness
Patients may not disclose psychiatric diagnoses and medications
Some psychopharmaceuticals are contraindicated because of interactions with antiretrovirals
Signs of Substance Use Disorders
Lack of response to basic treatment Intoxication or withdrawal symptoms Nodding off during appointments Presence of Hepatitis C Track marks Bruises No clearance to get medical history Asking for a specific psychotropic
Screening for Drug-Seeking Behavior
Pain meds and some psychotropics have high potential for abuse/dependence
Many people in recovery need more medication for pain relief because of neurological effects of dependence
Thorough pain screening can help distinguish pain from drug seeking
If patient is suspected of abusing pain meds – consult a substance abuse counselor
Broaching the Subject of Substance Use
Ask evocative, open ended questions Connect with symptoms patient agrees
with Ask about weekend behaviors Address behaviors Avoid sounding judgmental Give permission for the truth
CAGE Questionnaire
C Have you ever tried to cut down? A Have you ever gotten annoyed or
angry when people talk to you about your drinking or drug use?
G Have you ever felt guilty about it? E Have you ever had a drink or a
drug first thing in the morning?
Signs of Mental Illness
Lack of response to basic treatment Disrupted sleep patterns Talk of suicide or homicide Memory, concentration deficits Changes in appearance, behavior, eye
contact, and speech
Suicide/Homocide
Passive vs active ideation Ideation vs intent Chronic vs acute
Suicide: Assessment of Ideation
Passive vs activeDo you want to be dead?
Have you thought about killing yourself?
Chronic vs activeHave you felt like killing yourself in the past?
What did you do about it?
Do you always wish that you were dead?
Distinguishing Ideation from Intent
Why haven’t you done it? Why are you still alive? – assess level and forms of deterrence
How would you do it? – assess means and availability
What preparations have you made?
Base Your Intervention on Your Level of Comfort
Contract Referral for psychiatric care Well being visit from police Trip to ER with patient Calling in a crisis team
Determining Need for Intervention
Assessment of threat of harm Assessment of your own level of comfort
with the situation Duty to warn
Referral Relationships
Best practice is integrated service delivery
Partnership with mental health and/or addiction professionals
Build mutual referral/communication networks
Work with cooperative agencies
When to Refer
If you are unsure, always get consult Refer at the assessment stage If unsure about meds, contact
psychiatrist and/or pharmacist If patient has symptoms of bipolar or
schizophrenia If patient is pregnant
Cues for Domestic Violence Referrals
Unexplained injuries Injuries with strange explanations Gynecological signs of violence Partner insists on accompanying patient
in office visit Parent insists on being with the child
Broaching the Subject of Getting Help
Explore pros and cons of getting help Give patient a menu of options Avoid arguing with the patient If the patient resists, back away from the
subject Bring it up at another time
Referral Practices
Be clear about the type of specialist the patient will be seeing
Keep in mind the agency’s fit with the patient
Give the patient the name of a person Make the call together with the patient –
Get an appointment Follow up with patient and provider