Presentation on theme: "Triple Challenge: MI, SA, HIV"— Presentation transcript:
1Triple Challenge: MI, SA, HIV Sarz Maxwell MD FASAMyahoo.comwww. anypositivechange.org
2The New Face of HIVOtherHeterosexualMSMMSM+IVDUIVDU
3Psychiatric Diagnoses in Opiate Dependent Patients Abbott et al, 1994
4Treatment Challenges: Addiction and MI can Impair self-care and compliance with HIV treatmentWeaken immune systemInvolve drugs (e.g., cocaine) that may speed replication of the HIV virusAddicts are suspicious of health care systemFor example, symptoms consistent with AIDS Dementia Complex might instead be related to a primary psychotic disorder, the abuse of cocaine, or the development of Wernicke’s syndrome in alcohol withdrawal. (Characteristics of HIV-related dementia include greater insight impairment than in people with alzheimer’s disease, vascular dementia, or depression; and less impairment of sense of humor.)Adherence to a demanding medical regimen can be challenging for a well organized person with good resources and a strong support network. Substance use disorders and mental disorders can seriously impair people’s ability to concentrate, remember appointments and medication doses, tolerate the discomfort of medication side-effects, assess health-related problems and needs, find and request needed services, take initiative in their own care, and overcome logistical obstacles.Abuse of alcohol or other drugs, with or without the presence of addiction, can also weaken immune functioning. The drugs themselves may also affect the progress of the HIV virus. For example, HIV-positive mice who were fed cocaine had nearly 200 times the level of virus of those who did not receive the drug (Roth et al., 2002; Mundell, 2002).
5Treatment Challenges: Complicate HIV treatment (interactions between psychiatric medications, illicit drugs and HIV medications)Complicate pain managementAdd more stigma to the lives of people with HIVThe next module will give you an overview of some of the more common drug interactions, and the following module looks at ways of distinguishing between addiction-related behaviors and pain-relief behaviors.Some of the handouts address these issues as well.
6Treatment challenges Barriers and challenges – from the system end Systems not integratedSystems often turf back & forthAttitudinal barriers with addicts
7Clinical Model of Thought Beliefs are based on empirical informationNew information leads to new beliefsConstant interplay of information & beliefThe medical model of thought is second nature to experienced clinicians, so it is helpful to delineate it here to remind ourselves of the thought patterns we use in everyday clinical care.The medical model is a data-driven model of thought. Beliefs (dx, tx plans) are based on data, and changes in the data (response to treatment, side effects) lead to change in our beliefs. There is a constant interplay of information, belief, action, and new information.
8Spiritual Model of Thought Beliefs are based on faith, and do not require empirical informationEmpirical information does not alter beliefsThe moral model of thought is the appropriate model for thinking about spirituality. It is characterized by faith, defined as beliefs that are not dependent on empirical information. It would be hard to develop a working spirituality if our spiritual beliefs were dependent on empirical proof. Faith, the ability to believe without empirical proof, is the bedrock of spiritual thinking. It is not a good precept for medical practice.Because of the focus on spirituality in psychosocial treatments of addiction, people often slip into moral models of thought when thinking about addictions treatment. Moral models of thought are seldom useful for good medical care.
9“Why are you drinking?” demanded the little prince. “So that I may forget,” replied the tippler.“Forget what?” inquired the little prince, who alreadywas sorry for him.“Forget that I am ashamed,” the tippler confessed,hanging his head.“Ashamed of what?” insisted the little prince, whowanted to help.“Ashamed of drinking!” The tippler brought his speechto an end, and shut himself up in animpregnable silence.And the little prince went away puzzled.“The grown-ups are certainly very, very odd,” hesaid to himself.--Antoine de Saint-Exupery, The Little Prince
10Treatment - multiple needs HIV / medical treatmentPsychiatric treatmentAddictions treatmentPain managementSocial and other interventions
11Suicide: Assessment of Ideation Passive vs. active:Have you ever felt so bad you don’t want to be alive?Do you want to be dead?Have you thought about killing yourself?Chronic vs. acute:Have you ever felt like killing yourself in the past?What did you do about it?Do you always kind of wish you were dead?One of your handouts contains these questions, designed to help you explore the type of ideation.
12Determining Need for Intervention Assessment of threat of harmAssessment of your own level of comfort with the situationDuty to warnYour own anxiety may tell you when the risk warrants more vigorous interventions.Most people in the mental health field have a legal duty to warn of the danger of homicide if they perceive that there is danger to a specific person (as opposed to cases in which they perceive a general level of danger).If you perceive danger to a specific person in the patient’s life, you can — and have a legal duty to — call the police and tell them about the threat, and call the intended victim and tell him or her about it. In these types of situations you can break the patient’s confidentiality in this respect.
13Antidepressants Most of the newer antidepressants are very safe and effective for people with HIV and / or addiction:Cymbalta (duloxetine)Prozac (fluoxetine HCl)Zoloft (sertraline)Paxil (paroxetine)Celexa (citalopram hydrobromide)Effexor (venlafaxine)Wellbutrin (bupropion HCl)Remeron (mirtazapine)Patients can tolerate low to moderate, or even high, levels of the (newer) SSRI antidepressants without interactions with the ARV medications. Of the SSRIs, Celexa has the least Cytochrome P450 interactions, and therefore may be the safest in patients taking ARVs. Effexor and Wellbutrin are also good. The SSRIs, however, are not as useful as the tricyclics as adjunctive analgesics.Tricyclics are no longer first-line options for depression, because of their side effects and potential for toxicity in overdose. This toxicity makes them a risky choice for patients who may have suicidal tendencies. Tricyclics are non-addictive and may be helpful with neuropathy, insomnia, or migraines. One caution: The problem with Elavil is that drug-seeking patients will ask for it.Medication is not the only route of intervention for depression. Some patients will need medication, some will need psychotherapy, and many will need both. If you present a variety of options to the patient and help the patient make an informed decision, the patient will be more likely to adhere to the course of treatment.
14Other antidepressants Serzone – AVOID – drug/drug interactionsTCAs (doxepin, Elavil etc)Potential for drug interactions and side effectsLimit to adjunctive use (low dose) for pain / sleep / anxiety
15Antipsychotics and Mood Stabilizers Older antipsychotics have increased risk of side effects, particularly irreversible movement disorders (e.g., tardive dyskinesia)Newer antipsychotics (Zyprexa, Seroquel, Geodon, Risperdal, Abilify) much safer, and used in lots of conditions besides psychosisPsychotic disorders and mania are challenging to treat, and unless the patient is very stable, he or she should be under specialty care.The older antipsychotics are no longer first-line choices for a number of reasons.The risk of irreversible movement disorders is higher among HIV patients because of the effects of both the HIV virus and these drugs on the basal ganglia.The newer antipsychotics have fewer side effects and treat more symptoms. They include Zyprexa, Risperdal, Seroquel, and Geodon.
16BenzodiazepinesMOST people with mental illness do better with a benzo addedSafest with longer-acting (Valium, Klonopin)Avoid XanaxBenzos are not therapeutic, only palliativeBenzo misuse is a clue to undertreated mental illnessXanax is problematic for many patients, because it is very rapidly absorbed and very short acting, and produces a significant “rush.” This increases its addictive potential.Misuse of benzodiazepines may indicate the presence of other conditions, e.g., depression.At high doses triazolam, diazepam, zolpidem, and midazolam can be deadly when mixed with protease inhibitors. In high doses these drugs slow down components of the P450 engine, particularly those that process protease inhibitors. Norvir has the strongest negative effect when these medications are abused. (Project Inform, 2002).For sleep disorders in substance-dependent patients, you might use one of the following in low doses:Benadryl (25-50 mg)Trazodone ( mg)Doxepin (25-50 mg)Beyond that, you may want to coordinate care with a psychiatrist
17Pseudoaddiction Symptoms are identical to addiction Cause is UNDERTREATMENTResults in bilateral misperception:Patient perceives physician as uncaringPhysician perceives patient as dishonestAdequate treatment causes symptoms to abate
18Broaching the Subject of Substance Use Connect with the symptoms the patient agrees withAsk about weekend behaviors, as a way of approaching the subjectAddress specific behaviors, rather than using labels (e.g., “substance abuse” or “alcoholic”)Give permission for the truthRather than press patients about symptoms they aren’t aware of or don’t feel are important, make connections on the symptoms they do agree with. For example, if their HIV medications make it difficult to sleep, and they find themselves getting sleepy at work, that might be an opportunity to ask how they manage to stay awake at work.One way to get information about substance use is to ask about people’s weekend behaviors, asking what the average weekend is like, and what factors might affect their ability to take their meds on the weekend. This might lead to a discussion of substance use. Get to the information by whatever route the client takes. It’s not his job to give us the information; it’s our job to find the information we need.Labels like “alcoholic,” “addict,” or “mentally ill” will bring out resistance. Instead of using these kinds of labels, address behaviors, but in ways that they won’t misinterpret as judgments of them (e.g., rather than saying “You have to avoid drinking alcohol with this medicine,” you might say, “Drinking alcohol with this medicine causes serious problems. Will it be difficult for you not to drink?” And if the answer is yes: “How can we help?”)As you know, people tend to make changes in their lives and behaviors only when they’re ready. The changes necessary for successful treatment of substance use disorders and mental illness are particularly frightening. People are very likely to want to avoid these changes. We can’t talk them into changing, but we can help them move slowly toward it, if we start by understanding their experience now. Two questions that Miller and Rollnick (1991) suggest are: “What changes do you feel it’s important for you to make?” and “What changes do you feel you’re capable of making right now?”
19Most people believe that addiction is caused by using drugs Most people believe that addiction is caused by using drugs. This is not true.95% of the American population drink alcohol, but only 10% of Americans are alcoholic. Drinking alcohol does not make people alcoholic. Using cocaine does not make people cocaine addicts. There is no drug known that automatically causes addiction. Use of drugs does not result in addiction unless the person has a pre-existing, genetically-determined chemical imbalance.Because drugs do not cause addiction, addicts are not cured by eliminating drugs. The 12 steps of AA are based on this. Only the first 3 steps are concerned with getting rid of the drug. The remaining nine steps address the underlying disease that occurs in the brain, not in the bottle.ADDICTION
20Addiction -- Diagnostic Criteria Tries to cut down or control use, unsuccessfullyIntoxication and/or withdrawal interferes with normal functioningImportant activities neglectedContinued use despite knowledge of consequences
21What Is Addiction?This slide illustrates beautifully a big misunderstanding about addiction.Addiction is no more about people doing drugs than about dogs sniffing cracks. Virtually all dogs sniff cracks, and virtually all people use drugs. It’s not what the dog does to the crack, it’s what the crack does to the dog that makes it disease!In the case of this ‘poor bastard’, the crack makes the dog crazy, and this craziness impacts everyone around him.
22Management of Chronic Disease DiabetesHeart DiseaseAddictionMentalIllnessBiology and environment contributeOften poor response to behavioral changes aloneMedication is usually necessaryMost chronic diseases are caused by a biological basis that is activated or aggravated by behavioral and environmental factors. For example, heart disease is caused by a biological predisposition aggravated by unhealthy diet and stress.There is no doubt that drug use contributes to the development of addiction. However, no one uses drugs in order to become an addict any more than one eats hamburgers for the purpose of having a heart attack.In most chronic diseases, behavioral interventions alone (e.g. diet and exercise) are often insufficient to manage the condition, and medication is usually necessary.Though behavioral changes usually help the medication work better, we do not withhold medication if the patient won’t make the changes. No doctor would stop high blood pressure medicine because the patient continues to eat potato chips.
29Opiate Receptors and Endorphins: “Normal” Balance ofOpiate Receptors and Endorphins:Majority of receptors StabilizedAbundance of free Endorphin
30Imbalance of Endorphins and Opiate Receptor: Majority of receptors emptyDeficiency of free Endorphin
31Missing Endorphin replaced with Illicit Opiates: Intoxication state achieved
32Imbalance Stabilized with Methadone Maintenance: Normal balance Restored
33Inadequate Methadone Dosage: Patient must supplementwith illicit opiate
34Drugs That Lower Methadone Concentrations Tegretol (carbamazepine)Dilantin (phenytoin)IsoniazidViramune (nevirapine)Videx (didanosine, ddI)Sustiva (efavirenz)Viracept (nelfinavir)Rifadin (rifampin)Norvir (ritonavir)Fortovase (saquinavir)Zerit (stavudine, d4T)The use of some ARV medications with methadone may decrease methadone concentrations. It’s important to monitor patients for signs of withdrawal, and it may be necessary to increase methadone dosage.In one study nevirapine and efavirenz each increased methadone metabolism by 50-60%, and some patients experienced withdrawal.The combination of lopinavir and ritonavir has also been shown to reduce methadone concentrations (Kashuba & Lim, 2002).Hepatitis C Infection
36Drugs That Raise Methadone Concentrations Prozac (fluoxetine HCl)Serzone (nefazodone)Tagamet (cimeticline)Cipro (ciprofloxacin HCl): significant elevationsErythromycinNizoral (ketoconazole)Luvox (fluvoxamine)Retrovir (zidovudine)Cytochrome P450 3A4 is the primary enzyme that metabolizes methadone. Cipro may inhibit 3A4 up to 65%, decreasing methadone metabolism and raising the concentration of methadone.Some ARV medications that use the 1A2 enzyme can also raise methadone concentration. Methadone levels may be elevated significantly, in some cases leading to clinical opioid overdose.
37Duration of TherapyRelapse rate in abstinence-based treatment is >90%Trebly diagnosed patients do not tend to have a lot of internal or external resourcesAny attempt to limit treatment for a chronic disease is inappropriate
42http://buprenorphine .samhsa .gov/ Drug informationInformation sheets for patientsPHYSICIAN LOCATOR
43Pain ManagementMost people with substance dependence disorders legitimately need higher doses of pain medicationsMethadone raises extra pain-management issuesNeed higher doses, given more frequently, to override opiate blockadeAll patients experience pain. People with substance use disorders might need higher levels of pain medications. In addressing this issue, it’s both difficult and important to balance two opposing facts:That some chemically dependent patients abuse some psychotropics and pain medications as a way of feeding their addictions, or sell them on the street to get money for other types of drugs.That many other chemically dependent patients are in successful recovery from their addictions. They don’t abuse their pain medications, but need them to relieve pain—and often need higher doses because of the changes that addiction has made to their neurological functioning.Many physicians have been manipulated into prescribing medications that have then been sold or abused—and many others have refused to prescribe medications that were legitimately needed and wouldn’t have been abused.Make sure you do a pain assessment and location. If it’s a diffuse pain, you can seek more information (is it depression, another medical problem? Drug seeking?) Contracts with patients and supplementing medication with alternative pain management techniques can help patients who want to avoid abusing pain medications. For chronic pain patients who seem to be drug seeking, it’s helpful to work with an addictionologist and a pain specialist.You have a handout to help you distinguish between addiction-related behaviors and pain-relief behaviors.
44Interactions of HIV with Drug Use Videx (didanosine) + alcohol >> increased risk of pancreatitisToxicity of “ecstasy” significantly increased with some protease inhibitors, e.g., Norvir (ritonavir)Amphetamine levels may be increased with protease inhibitors, particularly NorvirWhether or not patients self-disclose about their use of alcohol or street drugs, if you suspect the use or abuse of these substances, you can keep this in mind in your prescribing practices and give patients basic information about possible interactions with ARV medications.For example, ritonavir slows down the enzyme that metabolizes ecstasy, making the ecstasy dose 5-10 times stronger. (3-10% of the white population is already deficient in this enzyme, increasing their risk of overdose even more.)Ritonavir may increase amphetamine levels by a factor of It is unclear how the smaller amounts of ritonavir that are presently used in HIV regimens (low dose Norvir or Kaletra augmenting other protease inhibitors) affect ecstasy or amphetamines. Caution and education are the key words for you and your patients.
45Interactions of HIV with Drug Use GHB (gamma-hydroxy-butyrate, or liquid X) can be dangerous with protease inhibitorsKetamine (special K) and Norvir can lead to chemical hepatitisSynthetics sold as heroin may be toxic at very small doses when combined with medicationsThe contents of liquid x are not consistent. A number of pollutants are often mixed with it, increasing the opportunities for drug interactionsKetamine is a PCP-like agent, often snorted.The chemicals fentanyl and alpha-methyl-fentanyl are sometimes sold as heroin. These chemicals can be potent even in tiny doses, and might be deadly if mixed with medications or other drugs.People on the street often don’t have accurate knowledge of the drugs that are out there, or their composition.Certainly most of these drugs at intoxication levels impair judgment and perception, which often leads to non-adherence no matter what the HIV regimen.
46Complications Caused by HCV Co-infection Hepatitis C accelerates and exhausts cytochrome P450 systemARV medications have to compete for depleted liver enginesSide effects of interferon can include fatigue, depression, or confusion, which can interfere with appointment and medication adherencePegylated interferon is the most common treatment for hepatitis C.Other side effects of interferon include flu-like symptoms, nausea, diarrhea, loss of appetite, lowered blood counts (white, red, and/or platelets), hair loss, skin changes, and (rarely) heart problems.Because of the severity of the side effects, adherence to interferon regimes is often low.Most people with hepatitis C who are being treated with methadone require significant increases in methadone dosage during the period in which the liver is accelerating. When the liver wears down, it can fail to process either methadone or ARV medications.
47Some Dangerous Combinations MEDICATIONDRUGVidex (didanosine)AlcoholNorvir (ritonavir)EcstasyProtease inhibitors (particularly Norvir)AmphetaminesProtease inhibitorsGHB (liquid X)NorvirKetamine (special K)Whether or not patients self-disclose about their use of alcohol or street drugs, if you suspect the use or abuse of these substances, you can keep this in mind in your prescribing practices and give patients basic information about possible interactions with ARV medications.For example, ritonavir slows down the enzyme that metabolizes ecstasy, making the ecstasy dose 5-10 times stronger. (3-10% of the white population is already deficient in this enzyme, increasing their risk of overdose even more.)Ritonavir may increase amphetamine levels by a factor of It is unclear how the smaller amounts of ritonavir that are presently used in HIV regimens (low dose Norvir or Kaletra augmenting other protease inhibitors) affect ecstasy or amphetamines. Caution and education are the key words for you and your patients.
48Hepatitis C Worldwide prevalence 80 – 90% in intravenous drug users Hepatitis C accelerates and exhausts cytochrome P450 systemHIV medications have to compete for depleted liver enginesMay decrease methadone blood levelsSide effects of interferon can include fatigue, depression, or confusion, which can interfere with compliancePegylated interferon is the most common treatment for hepatitis C.Other side effects of interferon include flu-like symptoms, nausea, diarrhea, loss of appetite, lowered blood counts (white, red, and/or platelets), hair loss, skin changes, and (rarely) heart problems.Because of the severity of the side effects, adherence to interferon regimes is often low.Most people with hepatitis C who are being treated with methadone require significant increases in methadone dosage during the period in which the liver is accelerating. When the liver wears down, it can fail to process either methadone or ARV medications.
49~ 40 % mortality with primary HAV infection among those with pre-existing HCV infection. N Engl J Med 1998 Jan 29;338(5): The majority of HCV infections that progress to hepatic failure are superinfected with HBV
55Referral Relationships Best practice is integrated service deliveryPartnership with mental health and/or addiction professionalsBuild mutual referral/communication networksWork with cooperative agenciesHIV, substance use disorders, and mental illness are all serious chronic diseases that have profound effects on many aspects of people’s lives. A lack of proper treatment in any of these areas can jeopardize treatment in all the others, and effective treatment of each requires some understanding of the others. For those reasons, integrated service delivery is considered best practice in this area.The service systems and funding streams for these three categories of disorders are essentially separate, with no substantial history of collaboration. Patients often receive mixed and conflicting messages from providers, simply because the lines of communication among the providers have not been firmly established. It’s up to individual physicians, nurses, psychiatrists, addictionologists, and addiction and mental health practitioners to take the initiative to form relationships for sharing information, experience, and ideas. It’s also important to develop formal and informal communication and referral networks that will make truly integrated service delivery possible for your patients.Find the addiction and mental health treatment providers who are willing and able to work cooperatively with you. These relationships are win-win situations, because these agencies can also let you know when patients are having problems with their HIV treatment.
56When to Refer If you’re unsure, always get consult Refer at the assessment stageIf unsure about meds, contact psychiatrist or pharmacistIf patient has symptoms of bipolar or schizophrenia, referIf patient is pregnant, refer: e.g.,On heroin, methadone Tx is imperativeOn alcohol, even in third trimester, cutting down can improve outcomeIf the patient has symptoms of bipolar disorder or schizophrenia, and isn’t being treated for these disorders, refer the patient to a psychiatrist, then stay in communication with the psychiatrist about the psychotropics, ARV medications, and other medications the patient is taking.Even in state clinics with 3-6-month waiting lists, pregnant women are fast-tracked.If a pregnant woman is on heroin, you need to do everything possible to get her into methadone treatment, because of the danger of heroin withdrawal in a newborn baby.If a pregnant woman is abusing alcohol, it’s a near-emergency situation.Cocaine is not good for the developing fetus, but there is no known specific toxicity. It’s still an urgent situation, but not as urgent as with heroin or alcohol. The only two drugs with specific tetragenocity or fetal toxicity are alcohol and nicotine.Other examples of when to refer for substance dependence and/or mental health assessment:If the patient states or indicates a desire for substance dependence and/or mental health treatment.If your screening or observations tell you there may be a problem that requires assessment.If a patient has been treated with an adequate dose of antidepressants for two months and hasn’t experienced an improvement in the symptoms.If you have questions about a patient’s competency to make his/her own decisions about treatment or to adhere to your treatment regimen.
57Cues for Domestic Violence Referrals Unexplained injuriesInjuries with strange explanationsGynecological signs of violencePartner insists on accompanying patient in office visitParent insists on being with the childThe majority of triply diagnosed patients are experiencing or have experienced violence. By the very nature of substance use disorders and other mental disorders, we can expect people to have chaotic lives. Many people with a history of repeated trauma tend to have vague somatic and anxiety symptoms, and some use drugs to escape. It’s helpful to assume the existence or history of violence in these patients’ lives, rather than risk missing the cues.Post-trauma symptoms often grow very intense when people are abstinent from addictive substances for two or three weeks. It’s important for the patient to get treatment for the trauma when this starts to happen.Cues for partner violence may come from the patient’s physical or behavioral symptoms, or the partner’s behavior may tip you off. Partner violence is most common in male-female and male-male relationships, but it does exist in female-female couples too.Your handouts include a list of tips for management in office visits.Domestic violence is common in this population.
58Broaching the Subject of Getting Help Explore pros and cons of getting helpGive patient a menu of optionsAvoid arguing with the patientIf the patient resists, back away from the subjectBring it up at another time – few people take referrals the first time they’re offeredIf the patient chooses a particular form of treatment, he or she will be more likely to become engaged in that treatment and stick with it long enough to receive some benefit.Resistance to suggestions about getting help is a very common defense against some very painful and frightening truths. It’s helpful to take the patient’s resistance as a sign that it’s time to back away from the subject.Rather than let the subject drop permanently, it’s important to bring it up again at another time, and keep bringing it up at appropriate intervals until the patient is ready to get help.If you make a referral, help the patient see it as an important part of his or her HIV treatment.
59Referral PracticesBe clear about the type of specialist the patient will be seeingKeep in mind the agency’s fit with the patient (e.g., culture, gender)Give the patient the name of a personMake the call together with the patient; Get an appointmentFollow up with patient and providerWhen you make a referral, it’s important to explain to whom you’re referring and why. If the patient arrives without knowing these things, part of the patient’s evaluation time will have to be spent calming the patient down and explaining why he or she is there. (You have a handout that talks about more sensitive ways of phrasing the referral.)Refer patients to agencies that have the expertise to work with them, taking into account issues of culture, gender, sexual orientation, history of physical or sexual abuse, diagnosis, etc. When you refer patients to an agency you have reason to trust, the patient’s good relationship with you is extended to that agency too, and the patient is more likely to be open to help.It’s also important to know where not to send patients. If you know something about a particular referral site that makes it unsuitable for the patient, communicating this can be healing, because it provides further evidence that you care.A patient is much more likely to follow up on a referral if there’s the name of a specific person to contact.Many people are easily overwhelmed in contacting a new agency. If you help make that contact, obstacles can disappear.As busy as we all are, it’s hard to remember to call and ask about the outcome, but it’s essential.
60Keys to Success with IDUs Create an inviting environment for drug discussion.ACCEPT WHAT IS BEYOND YOUR CONTROL!Be prepared to learn from your client.Any Positive Change.