The Triple Challenge:Optimizing HIV Treatment for

Patients with Co-occurring Mental Illness and Substance Use Disorder

Glenda Clare

G. Portlynn Clare & Associates

g_portlynnclare@hotmail.com

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