Figure 1-9
CDC Regional Breakdown of U.S. States and Territories
Northeast
South
Midwest
West
Territories
Connecticut
Maine
Massachusetts
New Hampshire
New Jersey
New York
Pennsylvania
Rhode Island
Vermont
Alabama
Arkansas
Delaware
District of Columbia
Florida
Georgia
Kentucky
Louisiana
Maryland
Mississippi
North Carolina
Oklahoma
South Carolina
Tennessee
Texas
Virginia
West Virginia
Illinois
Indiana
Iowa
Kansas
Michigan
Minnesota
Missouri
Nebraska
North Dakota
Ohio
South Dakota
Wisconsin
Alaska
Arizona
California
Colorado
Hawaii
Idaho
Montana
Nevada
New Mexico
Oregon
Utah
Washington
Wyoming
American Samoa
Commonwealth of the Northern Mariana Islands
Federated States of Micronesia
Guam
Puerto Rico
Republic of the Marshall Islands
Republic of Palau
U.S. Virgin Islands
Figure 2-1
Models of Medical Care in Substance Abuse Treatment Programs
There is considerable variation in the levels of medical care provided by substance abuse treatment programs.
Inpatient treatment programs generally have fairly extensive onsite medical capabilities for providing medical care to clients or are closely affiliated with a nearby medical center. These programs can provide only acute, short-term medical care. Some residential treatment programs are affiliated with a medical center, but many have only a loose affiliation.
Intensive outpatient treatment programs may be located in or closely affiliated with a hospital or medical center.
Social model programs, whether residential or day and evening programs, have no medical capabilities and may be only loosely affiliated with a medical facility. These programs generally concentrate on providing psychosocial services.
Methadone maintenance programs are required to have a medical director, although this individual's active clinical presence may be minimal. Nursing staff is onsite primarily to dispense methadone or LAAM (levo-alpha-acetyl-methadol). Some methadone programs have started to develop more comprehensive onsite primary medical care services, although wide variations persist. These programs serve clients who have used heroin or other opiates.
Therapeutic communities are residential and generally have minimal onsite medical capabilities.
Figure 2-3
Recommended Elements of a Contractual Arrangement For Primary Medical Care Services
The following are services that substance abuse treatment facilities should consider including in a contractual arrangement for primary medical care services:
Phlebotomy (drawing blood samples)
Clinical laboratory services
Access to physician and midlevel providers (e.g., nurse practitioner, physician's assistant)
Diagnostic and treatment services, such as radiology, specialty medical clinics, and hospitalization
At a minimum, freestanding substance abuse treatment units that have no physician on staff and provide no screening services for HIV should have an individual trained in HIV issues available for triage and referral when necessary.
Figure 2-5
Indications for Plasma HIV RNA Testing*
Clinical Indication
Information
Use
Syndrome consistent with acute HIV infection
Establishes diagnosis when HIV antibody test is negative or indeterminate
Diagnosis**
Initial evaluation of newly diagnosed HIV infection
Baseline viral load "set point"
Decision to start or defer therapy
Every 3-4 months in clients not on therapy
Changes in viral load
Decision to start therapy
4-8 weeks after initiation of antiretroviral therapy
Initial assessment of drug efficacy
Decision to continue or change therapy
3-4 months after start of therapy
Maximal effect of therapy
Decision to continue or change therapy
Every 3-4 months in clients on therapy
Durability of antiretroviral effect
Decision to continue or change therapy
Clinical event or significant decline in CD4+ T cells
Association with changing or stable viral load
Decision to continue, initiate, or change therapy
* Acute illness (e.g., bacterial pneumonia, TB, herpes simplex virus, PCP) and immunizations can cause increases in plasma HIV RNA for 2-4 weeks; viral load testing should not be performed during this time.
** Plasma HIV RNA results should be verified with a repeat determination before starting or making changes in therapy. HIV RNA should be measured using the same laboratory and the same assay.
Figure 2-7
Interactions of HIV Medications With Street Drugs
Drug
Interaction and Effects
Ecstasy
3- to 10-fold buildup of 3,4-methylene-dioxymethamphetamine (MDMA) in the blood, bruxism (teeth grinding), palpitations, joint stiffness, dehydration. Possibility of liver and kidney damage. May be deadly.
Speed/Methamphetamine
2- to 3-fold buildup of methamphetamine in the blood, increased anxiety, manic behavior, shortness of breath, racing heart beat, and dehydration.
Heroin
Heroin is metabolized more quickly; less "hit," less "buzz," withdrawal symptoms.
Special K (ketamine hydrochloride)
Buildup of ketamine is likely; increased sedation, disorientation, and hallucinations. Effects last longer.
Cocaine
Little is known about cocaine's interaction with PIs as no studies have been conducted, but if an individual has HIV, smoking, shooting, or even snorting cocaine may compromise the immune system. In one test-tube study, cocaine made HIV reproduce 20 times faster than normal.
GHB (gamma hydroxybutyric acid)
Combining GHB with the antiprotease drugs is another unknown. Like many recreational drugs, GHB may suppress the immune system.
Figure 2-9
Recommended CD4+ T Cell Testing Frequencies and Thresholds for Initiation of Antiretroviral Therapy
Testing Frequency
CD4+ T cell count = 500 and over: Every 6 months
CD4+ T cell count < 500 but > 50: Every 3 months
CD4+ T cell count < 50: Many experts see no need for testing (except in relation to initiation of new antiretroviral therapy, to observe whether therapy results in an increased CD4+ T cell count)
CD4+ T cells < 500/mm3or HIV RNA > 10,000 (bDNA)
or > 20,000 (RT-PCR)
Treatment should be offered. Strength of recommendation is based on prognosis for disease-free survival and willingness of the client to accept therapy.*
Asymptomatic
CD4+ T cells > 500/mm3 and HIV RNA < 10,000 (bDNA)
or < 20,000 (RT-PCR)
Many experts would delay therapy and observe; however, some experts would treat.
*Some experts would observe clients whose CD4+ T cell counts are between 350 and 500/mm3 and HIV RNA levels < 10,000 (bDNA) or < 20,000 (RT-PCR).
Source: CDC, 1998i.
Hypersensitivity reaction, nausea, vomiting, malaise, headache, diarrhea, or anorexia; rarely clients may develop lactic acidosis with severe hepatomegaly and steatosis
Didanosine
Videx
NRTI
ddI
400 mg b.i.d.
(125 mg b.i.d. if <60 kg)
Pancreatitis, peripheral neuropathy, diarrhea (take on empty stomach)
Lamivudine
Epivir
NRTI
3TC
150 mg b.i.d.
Anemia, gastrointestinal upset
Stavudine
Zerit
NRTI
D4T
40 mg b.i.d.
(30 mg b.i.d. if <60 kg)
Peripheral neuropathy
Zalcitabine
Hivid
NRTI
ddC
0.75 mg t.i.d.**
Peripheral neuropathy, stomatitis and aphthous esophageal ulcers, pancreatitis, hepatitis
Zidovudine
Retrovir
NRTI
AZT, ZDV
300 mg b.i.d.
Bone marrow suppression, gastrointestinal upset, headache, myopathy
Figure 2-11
Summary of HIV Medication Schedules for NRTIs, NNRTIs, and PIs
NRTIs--must use two, along with another drug at the same time
Medication
Dosage
Common side effects
AZT, ZDV (Retrovir) Combivir is one pill containing AZT and lamivudine; it is not a different drug.
Take 2 or 3 times daily, with or without food.
May cause anemia. Some are afraid to take AZT because for many years it was used alone, but clients died anyway. In combination it can be far more effective. Do not combine with stavudine.
Stavudine (Zerit)
Take 2 times daily, with or without food.
If numbness or tingling develops in the toes, see a medical professional. Do not combine with AZT.
Lamivudine (Epivir)
Take 2 times daily, with or without food.
Active against hepatitis B. Discontinuing in the face of persistent hepatitis B can result in a flareup of hepatitis B. Do not combine with zalcitabine. Can be combined with AZT and called Combivir; can also be combined with didanosine.
Didanosine (Videx)
Take 1 or 2 times daily, without food.
If numbness or tingling develops in the toes, see a medical professional. If persistent abdominal pain with or without vomiting develops, see a medical professional immediately.
Zalcitabine (Hivid)
Take 3 times daily, with or without food.
If numbness or tingling develops in the toes, see a medical professional. Combines with AZT.
Abacavir (Ziagen)
Take 2 times daily.
Warning: Fatal hypersensitivity reactions have been associated with therapy with abacavir. If symptoms of hypersensitivity occur (fever, rash, fatigue, gastrointestinal upset), client should discontinue use as soon as possible. It should not be restarted following such a reaction because more severe symptoms will recur within hours and may include life-threatening hypotension and death (from Ziagen package insert).
NNRTIs--must use with at least two NRTIs
Medication
Dosage
Common side effects
Efavirenz (Sustiva)
Take once daily, with or without food.
Vivid dreams, dissociation. See medical professional if rash appears.
Nevirapine (Viramune)
Start once a day, then take 2 times daily, with or without food.
See medical professional if rash appears.
Delavirdine (Rescriptor)
Take 3 times daily, with or without food.
See medical professional if rash appears.
Ritonavir (Norvir)
Take 2 times daily, best with food.
Often causes nausea and diarrhea, may cause numbness around the mouth. Multiple important drug reactions.
Nelfinavir (Viracept)
Take 3 times daily, best with food.
Often causes nausea and diarrhea.
Indinavir (Crixivan)
Take 3 times daily, without food, drink plenty of water.
Often causes kidney stones, some nausea and diarrhea.
Indications. All clients with CD4+ T cell counts of 200 or below; all clients with oral candidiasis, recurrent bacterial infections, TB, and chronic constitutional symptoms; and all clients with a history of PCP, regardless of CD4+ T cell count, should receive PCP prophylaxis.
Dosage. TMP-SMX is the most effective prophylactic agent. One double-strength tablet daily (160 mg TMP + 800 mg SMX) is commonly prescribed. One double-strength tablet 3 times weekly is also acceptable; however, daily dosing may promote adherence. One single-strength tablet daily (80 mg TMP + 400 mg SMX) may also be effective. Dapsone (50 mg per day, 100 mg per day, 100 mg 3 times weekly) is an alternative for clients who cannot tolerate TMP-SMX. Aerosolized pentamidine (NebuPent), 1 x 300 mg monthly by nebulizer, is an option in settings with adequate ventilation.
Side effects. TMP-SMX: rash, leukopenia, nausea/vomiting, liver function abnormalities, fever. Side effects are usually dose related. HIV+ clients should be monitored for sulfonamide allergy because they have a high incidence of allergic and/or other reactions to this class of drug. Dapsone: rash, nausea/vomiting, anemia. Aerosolized pentamidine: cough, bronchospasm, metallic taste. Desensitization and rechallenge protocols for TMP-SMX.
Complications. TMP-SMX: Stevens-Johnson syndrome, mucous membrane ulceration, hepatitis, serum sickness (infrequent). Dapsone: hemolytic anemia in G6PD-deficient clients. Peripheral neuropathy or other nervous system effects (infrequent). Pentamidine: Breakthrough PCP, extrapulmonary pneumocystosis.
Management of pregnant clients. Same indications as for clients who are not pregnant. TMP-SMX should be given until 36 weeks' gestation, then give aerosolized pentamidine to prevent neonatal exposure to sulfonamides.
Toxoplasmosis
Indications. Positive antitoxoplasma antibody test, especially for clients with CD4+ T cell counts < 100 and/or a history of HIV symptomatic disease.
Dosage. TMP-SMX (see "PCP Prophylaxis," above) has been suggested by several studies to offer protection against toxoplasmosis. Dapsone (100 mg 3 times weekly) plus pyrimethamine (Daraprim)
(50 mg 1 time weekly) is an alternative for clients who cannot tolerate TMP-SMX.
Side Effects. TMP-SMX: See "PCP Prophylaxis," above. Pyrimethamine: Rash and anemia or leukopenia are possible but unlikely at 50 mg/week dose.
Mycobacterium avium complex (MAC)
Indications. Clients most at risk are those with late-stage HIV disease (CD4+ T cell count < 50).
Dosage. Azithromycin 1,200 mg weekly or clarithromycin 500 mg twice daily. Rifabutin is approved for prophylaxis; 300 mg daily has been shown to be effective. Rifabutin for MAC prophylaxis is contraindicated in clients with active TB; exclude active TB before initiating therapy. Rifabutin has multiple potential drug interactions.
Side Effects. Nausea/vomiting, gastrointestinal distress, rash, brown-orange discoloration of urine (rifabutin only). Rifabutin may interact adversely with other HIV medications (fluconazole, clarithromycin) and may accelerate methadone and other opioid metabolism.
Cryptococcosis
Indications. Infrequent complication of HIV infection.
Dosage. Fluconazole may have a prophylactic effect, but routine prophylaxis could promote the development of resistant fungi (e.g., candida species).
Herpes simplex virus (HSV)
Indications. Recurrent HSV infection (most common in the genital area). Likelihood of recurrence increases with declining CD4+ T cell count. No strict threshold for initiation of prophylaxis.
Dosage. VAL Acyclovir (Zovirax) 500 mg two or three times a day
The CDC recommends immunization of HIV-infected individuals against pneumococcal pneumonia, influenza, and hepatitis B.
Haemophilus influenzae type B vaccine and hepatitis A vaccine may also be considered.
HIV-infected clients are likely to benefit from and unlikely to be harmed by immunization against polio (using killed polio vaccine), diphtheria, and tetanus.
Measles vaccination should be considered for HIV-infected substance abuse disorder clients at risk of contracting measles.
Immunization is more effective in clients who are not severely immunocompromised.
Figure 2-15
Factors Hindering Food Consumption in HIV-Infected Clients
Problem
Intervention
Anorexia (poor appetite)
Small, frequent meals; calorie- and protein-dense foods; relaxation techniques before meals; appetite stimulants (e.g., Megestrol acetate). Must investigate HIV medications as a potential cause of anorexia (e.g., ritonavir).
Nausea
Cold, bland, dry foods. Investigate HIV medications as a possible cause.
Vomiting
Liquid diet (temporarily). Eat when asymptomatic; antiemetics as needed.
Diarrhea
Use of bulking agents; fluid replacement.
Early satiety
Small, frequent meals.
Dysphagia (difficulty swallowing)
Evaluate for oral diseases, opportunistic infection, and CNS disease. Soft, blenderized or pureed foods or baby foods as tolerated; calorie- and protein-dense supplements.
Odynophagia (pain when swallowing)
Same as for dysphagia, plus avoidance of foods that cause pain (soda bubbles or citrus, spicy, or rough-textured foods).
Difficult or painful chewing
Same as for dysphagia and odynophagia, plus sucralfate slurry or viscous lidocaine swish before meals.
WIDTH="60%"Source: New York State Department of Health AIDS Institute; adapted from Rakower and Galvin, 1989.
Figure 3-1
Abbreviated San Francisco General Hospital Neuropsychiatric AIDS Rating Scale (NARS)
Cognitive/Behavioral Domains
NARS Staging
Orientation
Memory
Motor
Behavioral
Problem Solving
Activities of Daily Living (ADLs)
0 (normal)
Fully oriented
Normal
Normal
Normal
Can solve everyday
problems
Fully capable of self-care
0.5 (minor)
Full oriented
Complains of memory problems
Fully ambulatory; slightly slowed movements
Normal
Has slight mental slowing
Slight impairment in business dealings
1 (mild)
Fully oriented but may have brief periods of "spaciness"
Mild memory problems
Balance, coordination, and handwriting difficulties
More irritable, labile, or apathetic and withdrawn
Difficulty in planning and completing work
Can do simple ADLs; may need prompting
2 (moderate)
Some
disorientation
Memory moderately impaired; new learning impaired
Ambulatory
but may
require a cane
Some
impulsivity
or agitated
behavior
Severe impairment; poor social judgment; gets lost easily
Needs assistance with ADLs
3 (severe)
Frequent
disorientation
Severe memory loss; only fragments of memory remain
Ambulatory
with assistance
May have an organic
psychosis
Judgment
very poor
Cannot live independently
4 (end stage)
Confused and disoriented
Virtually no memory
Bedridden
Mute and unresponsive
No problem-solving ability
Nearly vegetative
Source: The NARS was developed by A. Boccellari, Ph.D.; J.W. Dilley, M.D.; and I. Barlow, M.D., Department of Psychiatry, San Francisco General Hospital, in collaboration with S. Hernendez and B. Haskell, San Francisco Department of Public Health. This figure was adapted from Price and Perry, 1994; Hughes et al., 1982; and the American Academy of Neurology, 1991.
Figure 3-3
Use of Medications for Psychiatric Disorders in HIV-Infected Substance Abusers
A hierarchical or stepwise strategy should be followed in prescribing medications to HIV-infected substance abusers. Low doses of safer and less abusable medications should be tried first, and higher doses or less safe agents used only if the initial approach is ineffective.
Sleep Disorders When treating sleep disorders in patients who have HIV/AIDS and substance abuse disorders, choose an approach that minimizes abuse potential.
First Tier
Simple "sleep hygiene" aids such as a glass of warm milk, a warm bath, meditation, or soothing music are the first recommended ways to deal with insomnia.
Second Tier
Trazodone (Desyrel) is an antidepressant and sleeping medication with no known abuse potential and low adverse effects. Dosage can start at 25 to 50 mg at bedtime and increase as needed to 100 to 200 mg. Side effects include hypotension (low blood pressure) and very rarely priapism (persistent painful erection). (Priapism occurs in fewer than 1 in 4,000 men taking trazodone.)
Doses of Hydroxyzine (Vistaril, Atarax) or diphenhydramine (Benadryl) can start at 25 to 50 mg at bedtime and increase to 100 to 150 mg. These medications are generally moderate in abuse potential, but they can cause anticholinergic side effects, such as dry mouth and lowering of the seizure threshold if given in very high doses (over 250 mg per day).
Mirtazapine (Remeron) is a sedating antidepressant. In the lower end of this dose range (15 mg taken at bedtime), mirtazapine can be effective in helping initiate sleep. Side effects include weight gain. Mirtazapine is probably safer than antihistamines or tricyclics (see below).
Doses of tricyclic antidepressants (TCAs) such as amitriptyline or doxepin (Sinequan) for sleep can start at 25 to 50 mg at bedtime. TCAs have numerous adverse effects (see "Mood Disorders" section below) and are often lethal in overdose amounts (> 1 g [1,000 mg]). These antidepressants also are often abused by patients in methadone programs (especially amitriptyline).
Sedating antipsychotic medications such as chlorpromazine (Thorazine) should be used only in the presence of psychotic or manic symptoms, never for insomnia alone.
Third Tier
If the medications listed above fail, a brief course of benzodiazepines should be considered, preferably on a short-term basis (ideally, for less than 2 weeks). They should be moderately short acting, such as temazepam (Restoril) and lorazepam (Ativan), to minimize accumulation of medication and resultant sedation. An alternative agent that shares most of the properties of benzodiazepines, but may be somewhat less abusable, is zolpidem (Ambien).
Ultra-short-acting agents such as triazolam (Halcion) should be avoided because they may cause withdrawal psychosis and confusion, including memory loss. Be cautious when prescribing long-acting medications such as diazepam (Valium) because of their cumulative effects. Flurazepam (Dalmane) also can have cumulative effects and may cause morning confusion ("hangover"). Caution is also urged with alprazolam (Xanax), which may be more abusable than other benzodiazepines and is associated with considerable rebound anxiety.
Anxiety
Chronic anxiety
First Tier
Alternatives to pharmacologic intervention include relaxation techniques, meditation, supportive psychotherapy, and counseling, as well as stress management and reduction, and possibly acupuncture. Some of these approaches should be tried before medications are introduced.
Second Tier
Buspirone (Buspar) is a nonabusable medication for chronic anxiety, such as in generalized anxiety disorder. Buspirone is not effective in the treatment of acute anxiety, as it takes at least 2 weeks to act.
Selective serotonin reuptake inhibitors (SSRIs), such as sertraline (Zoloft), fluoxetine (Prozac), and paroxetine (Paxil), have been shown to be effective in the treatment of panic disorder. Due to their delayed onset of action, SSRIs are not effective for treating acute anxiety.
TCAs such as imipramine (Tofranil) also are alternatives to potentially dependence-producing agents such as the benzodiazepines and have been demonstrated to be effective for treating both generalized anxiety disorder and panic disorder. They are not effective for acute anxiety.
Patients must be warned that it is usually necessary to take buspirone, SSRIs, or TCAs for at least 2 weeks before antianxiety effects are felt.
Third Tier
See third-tier section of Sleep Disorders above with the same cautions for the use of benzodiazepines: Choose relatively short-acting medications for limited-time use and at limited dosages.
Acute anxiety
Other possible alternatives to the benzodiazepines for treatment of acute anxiety disorders are beta-blockers such as propranolol (Inderal) and the antihypertensive agent clonidine. However, clonidine may pose a danger of overdose and should be dispensed in limited amounts (e.g., 1 week's supply). Hydroxyzine (Vistaril, Atarax) can also be used in doses of 25 to 50 mg in the daytime as needed as an antianxiety agent, although it is highly sedating. If these fail, then short-term use (less than 2 or 3 weeks) of benzodiazepines may be indicated.
Antipsychotics should not be used to treat anxiety if there is no evidence of psychosis, mania, or severe dementia. (Whenever possible, psychotherapy, such as cognitive-behavioral therapy, should be tried before moving on to pharmacological treatments for panic disorder.)
Panic attacks
First Tier
A nonbenzodiazepine medication such as an SSRI (e.g., sertraline) or if an SSRI fails, then a TCA, such as desipramine, should be administered. Dosing should start very low and then advance gradually to levels approaching those used to treat depression. For example, sertraline should be begun at no more than 25 mg per day, but may be increased to 50 or 100 mg per day; fluoxetine should be started at 10 mg per day and may be increased to 20 mg per day; paroxetine should be started at 10 mg per day and increased to 30 if needed. TCAs may have to be started as low as 10 mg per day and gradually increased over several weeks to as much as 150 mg per day if needed. Response takes 2 to 4 weeks. TCAs have numerous moderately troublesome side effects (see "Mood Disorders" section below) and can be lethal in overdose amounts (> 1 g [1,000 mg]).
Second Tier
If SSRIs or TCAs are ineffective, too risky, or not tolerated because of adverse effects, benzodiazepines should be used. Alprazolam is probably the most frequently used benzodiazepine, but may not be the best choice in patients with substance abuse disorders because of its relatively short duration of action and the need for multiple daily doses. Diazepam or chlordiazepoxide (Librium) may be preferable because they may produce slower onset of side effects. Any benzodiazepine is likely to be effective when used in divided doses totaling approximately 10 to 60 mg per day of diazepam or its equivalents.
See "Sleep Disorders" section for the risks of benzodiazepine use.
Mood Disorders
Major depressive disorders
First Tier
The initial approach should include supportive psychotherapy (individual or group) and possibly peer-based supportive counseling. If these approaches fail, however, pharmacologic interventions should be made readily available to the substance abuse disorder patient with HIV/AIDS.
A careful evaluation must always be done before medications are prescribed. Mood disorder patients are at risk of suicide. Patients also should be warned that it usually is necessary to take medications for at least 2 weeks before antidepressant effects are felt.
Second Tier
The SSRI antidepressants-fluoxetine, 20 mg per day; sertraline, 100 to 200 mg per day; paroxetine, 20 to 50 mg per day; citilopram (Celexa) 20 to 40 mg per day; and fluvoxamine (Luvox) 100 to 300 mg per day--are all safe and effective. They tend to be nonsedating and generally are safe even in overdoses. They are usually the most tolerable antidepressants. Side effects in 10 to 20 percent of patients may include jitteriness, insomnia, muscle tightness or twitching, mild appetite loss, and mild gastrointestinal illness, as well as some loss of sexual interest and delayed orgasm or ejaculation.
Trazodone also is safe but its sedating properties limit its usefulness. Patients can rarely take it in large enough doses or in the divided doses necessary for antidepressant effectiveness. However, it can be useful as a sleeping medication.
Bupropion (Wellbutrin SR) is a non-TCA that is generally safer in overdose than the TCAs. It is more complicated to use than the SSRIs because it must be given in two divided doses totalling 200 to 300 mg per day. Bupropion tends to increase the risk of seizures more than than with other antidepressants. Note: bupropion levels are increased by coadministration of the protease inhibitor ritonavir.
Nefazodone (Serzone) is also a non-TCA, and is generally better tolerated than TCAs. It may be helpful for patients who experience sleep difficulties or adverse sexual effects because of SSRIs. Nefazodone generally is given in at least two doses per day, with a daily dose ranging from 300 to 600 mg/day. Side effects may include light-headedness, visual disturbance, and mild sedation.
Mirtazapine is yet another non-TCA. It is sedating and is associated with weight gain, but has few adverse effects on sexual functioning and can be given in a single nighttime dose ranging from 15 to 45 mg per day.
Citalopram was recently approved by the FDA for use as an antidepressant. The drug is a new addition to the SSRIs, which are now considered the preferred agents for treatment of this condition. The most common adverse effects of citalopram are nausea, dry mouth, increased sweating, somnolence, and insomnia. A few men have reported difficulty with ejaculation and temporary impotence. No serious cardiovascular side effects have been reported with use of the drug during clinical trials. Some patients may experience a slight weight loss during therapy. The incidence of some adverse events increases as the dose of drug increases. Citalopram can be administered in either 20 or 40 mg doses daily.
Third Tier
TCAs are not addictive, but they have a number of troublesome side effects, including dry mouth and short-term memory loss. Other side effects--blurry vision, constipation, tremor, and low blood pressure--may contribute to falls, weight gain, and oversedation. Side effects may be offset by low dosages. HIV-infected patients may be more sensitive to side effects. Substance-abusing patients may be more likely to request TCAs that have sedating effects, such as doxepin and amitriptyline.
All of the TCAs are lethal in overdose and should not be given to unmonitored suicidal patients.
Fourth Tier
Psychostimulants may be useful for late-stage AIDS patients with severe psychomotor retardation (Fernandez, 1990). Some dramatic, rapid improvement has been observed.
Methylphenidate (Ritalin) is the safest and easiest to manage of the psychostimulants. Methylphenidate and amphetamines such as dextroamphetamine (Dexedrine) should not be used until other medications have failed, but they should not be withheld solely because of a patient's substance abuse history. Psychostimulants should be administered early in the day and monitored carefully because they cause insomnia. If prescribed to an outpatient, daily dispensing is recommended. If this is impractical, prescriptions should be written for limited quantities and compliance closely monitored.
Other side effects of psychostimulants include jitteriness, agitation, delusions, hallucinations, and anorexia, as well as abuse and dependence.
Monoamine oxidase (MAO) inhibitors should be avoided unless all other treatments fail. Use of these medications requires dietary restrictions and carries the potential for lethal hypertensive interactions with other drugs.
Bipolar disorder
When evaluating the substance abuser with mania, clinicians must consider that the disorder is caused by abuse of substances such as stimulants.
Lithium is as effective in substance-abusing patients with HIV/AIDS as in the general population in treating mania caused by bipolar disorder. It has no known abuse potential but must be monitored carefully because of side effects, which include dehydration, diarrhea, and altered mental state. Other adverse effects of lithium include tremor, excessive thirst, frequent urination, and weight gain.
The anticonvulsant medication carbamazepine (Tegretol) is also useful but it can cause severe neutropenia (bone marrow suppression). This may be dangerous when combined with AZT, which has a similar adverse effect.
Patients maintained on methadone and carbamazepine may induce liver enzymes that can metabolize methadone more rapidly than normal and lead to opiate withdrawal symptoms, which may necessitate higher doses of methadone.
Valproic acid or divalproex sodium (Depakote) is another alternative to lithium. It avoids the problems of carbamazepine and may be safer but is less proven as a mood stabilizer.
Psychosis/Severe Manic States
Psychosis is frequently caused by substance abuse such as "crack" cocaine intoxication or alcohol withdrawal. Substance abuse should always be evaluated thoroughly before prescribing.
Antipsychotic medications are nonaddictive and can be used effectively to treat both acute mania and psychosis. The lowest possible effective dosage should be used, with side effects closely monitored, and the patient should be frequently reevaluated. Abuse of antipsychotic medications, even by substance abusers, is rare.
Antipsychotic medications include the older or "typical" agents such as haloperidol (Haldol), chlorpromazine, and many others, as well as the newer, "atypical" agents such as risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), and clozapine (Clozaril). These medications are also occasionally used for the management of agitated confusional states, such as in late-stage dementia.
Clozapine should probably be avoided in most HIV-infected patients because it can cause profound reduction of bone marrow and blood cell production in 1 to 2 percent of patients.
Some patients develop extrapyramidal side effects (EPS)-involuntary muscle spasms, jerking, muscle stiffness, or tremor-from antipsychotic medications. Diphenhydramine (Benadryl) and other medications can be used to counter EPS, but these agents can produce anticholinergic side effects such as dry mouth, agitation, and confusional states. An alternative medication to treat EPS may be amantadine (Symmetrel).
High-potency antipsychotic medications that have the fewest sedating or anticholinergic adverse effects, such as haloperidol, may have the most EPS side effects. EPS may be more severe in HIV-infected patients than in otherwise healthy patients with psychoses.
Other adverse effects of antipsychotic medications include oversedation, low blood pressure, constipation, dry mouth, and blurry vision.
Figure 3-4
Abuse Potential of Common Psychiatric Medications
Medication Class
High Abuse
Potential
Moderate Abuse
Potential
Low Abuse
Potential
Sleep medications
Benzodiazepines:
Diazepam
Flurazepam
Chlordiazepoxide
Clonazepam (Klonopin) and others
Chloral hydrate
Barbiturates
Meprobamate
Diphenhydramine
Hydroxyzine (Vistaril)
TCAs
Trazodone (Desyrel)
Antianxiety
Benzodiazepines
None
TCAs
Buspirone
Antidepressants
Methylphenidate
Dextroamphetamine
None
Fluoxetine and others
SSRIs
TCAs
Bupropion
Venlafaxine (Effexor)
Nefazodone (Serzone)
Mirtazapine
Mood stabilizers
Clonazepam
None
Lithium carbonate
Carbamazepine
Sodium valproate (Depakote)
Gabapentin (Neurontin)
Phenytoin (Dilantin)
Antipsychotics
None
None
All, for example:
Chlorpromazine
Thioridazine
Haloperidol
Risperidone (Risperdal)
Olanzapine (Zyprexa)
Anti-Parkinsonian medications
None
Trihexyphenidyl (Artane)
Benztropine (Cogentin)
None
Agents for treating substance abuse
Methadone
LAAM
Buprenorphine
Clonidine (Catapres) (This drug should be prescribed with caution since it can be used to self-administer for heroin withdrawal and can cause a rapid drop in blood pressure.)
Figure 3-5
The San Francisco--UCSF AIDS Health Project's AIDS Substance Abuse Program
This group, sponsored by San Francisco General Hospital, is a popular support group for HIV-infected substance abusers who are ill or recently discharged from the hospital. Groups meet in a conference room adjacent to the main hospital cafeteria. Participants who are recovering from substance use discuss their experiences of withdrawal, and current abusers discuss the difficulties of discontinuing substance use. Members of the group also discuss whether abstinence should be the goal of all members of the group.
Figure 4-3
Use of Bleach for Disinfection of Drug Injection Equipment
On April 19, 1993, the Centers for Disease Control and Prevention (CDC), the Center for Substance Abuse Treatment, and the National Institute on Drug Abuse issued a joint bulletin updating recommendations to prevent HIV transmission through the use of bleach to disinfect drug injection equipment. Thebulletin particularly addresses persons who cannot or will not stop injecting drugs. This bulletin states that:
Bleach disinfection of needles and syringes continues to play an important role in reducing the risk of HIV transmission for injection drug uses who reuse or share them.
Sterile, never-used needles and syringes are safer than bleachdisinfected, previously used needles and syringes.
The bulletin contains provision recommendations for the use of bleach to disinfect needles and syringes (including the recommendation for using full-strength household bleach). CDC recommendations for disinfecting environmental surfaces contaminated with blood are unchanged.
Provisional Recommendations
There is currently insufficient laboratory and behavioral research to make definitive recommendations on the best procedures for bleach disinfection. However, the following steps will enhance the effectiveness of bleach disinfection of needles and syringes:
Cleaning should be done twice-once immediately after use and again just before reuse of needles and syringes.
Before using bleach, wash out the needle and syringe by filling them several times with clean water. (This will reduce the amount of blood and other debris in the syringe. Blood reduces the effectiveness of bleach.)
Use full-strength liquid household bleach (not diluted bleach).
Completely fill the needle and syringe with bleach several times. (Some suggest filling the syringe at least three times.)
The longer the syringe is completely full of bleach, the more likely HIV will be inactivated. (Some suggest the syringe should be full of bleach for at least 30 seconds.)
After using bleach, rinse the syringe and needle by filling several times with clean water. Don't reuse water used for initial prebleach washing; it may be contaminated.
For every filling of the needle and syringe with prebleach wash water, bleach, and rinse water, fill the syringe to the top.
Shaking and tapping the syringe are recommended when the syringe is filled with pre-bleach wash water, bleach, and rinse water. Shaking the syringe should improve the effectiveness of all steps.
Taking the syringe apart (removing the plunger) may improve the cleaning/disinfection of parts (e.g., behind the plunger) that might not be reached by solutions in the syringe.
Staff of HIV prevention programs should review how the use of bleach is currently taught and promoted and how injection drug users are using bleach. The principles of bleach disinfection just described should be incorporated into guidance provided to them. Program staff, outreach staff, and drug users should work together to develop easily understood messages to communicate these steps.
Transmission of HIV is highly unlikely within institutions such as health care facilities, residential facilities, correctional facilities, residences, and substance abuse treatment programs when universal precautions are observed.
Because medical history and examination cannot reliably identify all HIV-infected patients, universal precautions should be used consistently with all patients.
1. Barrier Precautions
In any setting in which workers may come into contact with a patient's blood or bodily fluids, the following precautions should always be observed:
Gloves should be worn when touching blood or bodily fluids, mucous membranes, or nonintact skin; handling items or surfaces soiled with blood or bodily fluids; or performing vascular access procedures such as venipuncture (inserting a syringe into a vein to draw blood or administer fluids).
Gloves should be changed after each patient contact.
Masks and protective eyewear should be worn during any procedure likely to expose mucous membranes of the mouth, nose, and eyes to droplets of blood or other bodily fluids.
Gowns or aprons should be worn during procedures likely to generate splashes of blood or other bodily fluids.
Hands and other skin surfaces should be washed immediately and thoroughly when contaminated with blood or other bodily fluids and whenever gloves are removed.
2. Use of Sharp Instruments The following precautions should be taken to prevent injuries when using, cleaning, disposing of, or otherwise handling syringes, scalpels, and other sharp instruments:
Do not recap syringes, bend or break them by hand, remove needles from disposable syringes, or otherwise handle them.
Place disposable "sharps" in puncture-resistant disposal containers immediately after use.
Place large-bore reusable syringes in puncture-resistant containers for reprocessing.
3. Other Precautions
Ventilation devices such as mouthpieces and resuscitation bags should be available for use in areas where the need for resuscitation is predictable.
Workers with exudative (oozing) lesions or weeping dermatitis should refrain from all direct patient care and from handling patient care equipment until their condition resolves.
Pregnant workers should be especially familiar with, and should strictly adhere to, all of the above precautions.
The Hilltop Center program in Longview, Texas, has clearly laid out the expectation that staff members must listen to clients from the beginning to gain a real understanding of where these clients are in their lives. Staff members are asked not to use labels or tag clients with what may be judgmental treatment jargon, such as
"He's in denial and very resistant and hasn't hit rock bottom yet."
"She's a borderline personality disorder."
Labels such as these do not help to develop an effective intervention and treatment plan or help the client and counselor to start working toward recovery.
Determine who the significant providers are in the client's network of care. Depending on the setting and area, there may be several candidates for the multidisciplinary team. When considering a biopsychosocial model, it is useful to have a representative from the client's medical, psychological, and social treatment providers. This could include a social worker, a physician, an alcohol and drug counselor, an HIV/AIDS case manager, and perhaps a representative from an agency (e.g., day health program) with whom the client has frequent contact. Additionally, consideration should be given to the cultural and linguistic makeup of the group.
The group can be a fixed one, in which members review the needs of several clients on an ongoing basis, or the group can form as needed for a specific client. Within fixed groups, members tend to be the same core set of providers, perhaps adding specific providers for a particular client's situation. The group that forms on an as-needed basis can be made up of different members each time.
When the group is brought together, members should first discuss the expectations of group members, the rules for how the group will interact, and how the group will structure the time. Time should be built in so that adaptations can be made as needed.
Expectations. Group members should discuss what it is that they want to achieve. Does the group exist to provide brief information about the clients to ensure a basic level of communication, or does it exist to solve problems and provide consultation about each others' clients?
Rules. Ground rules should be determined by the group members. Rules can include arrival and start times for meetings, keeping whatever is discussed in the group confidential, not interrupting when other group members are speaking, and not allowing one group member to dominate the discussion. Rules will vary depending on the purpose and structure of the group.
Structure. Group structure should be discussed so that meetings can be the most productive and efficient for all the busy professionals involved. Questions should be asked, such as "How much time will be spent on each client?," "How will the group document its work?," "Will there be a facilitator and/or a timekeeper?," and "Who puts together the agenda?"
Establishing formalized linkages with other agencies is one means of building a team. Affiliation agreements, for example, between a public health department and a hospital that serves low-income pregnant women can allow for formalized sharing of client information as well as a partnership approach to serving the client. It is important to discuss issues such as identifying the roles and responsibilities of each party, the mode of collaboration, and who the participants will be. An affiliation agreement should be drawn up that includes a renewal date for the agreement, so that both parties have the opportunity to periodically reconsider the reason for affiliating.
In multisystem work, there can be several case managers. If possible, one "lead" case manager should be identified who has the responsibility to ensure that services are coordinated. This lead person can also bring together the various providers for ad hoc multidisciplinary meetings.
Confidentiality should be kept in mind when forming multidisciplinary teams. It is imperative that the group keep client information confidential, and it is necessary that the client agree to allow the treatment professional to share information with the other members of the group.
Listed below are several situations in which a caregiver may find herself while working with a substance-abusing client. Rate your comfort level in response to each situation, with "1" being least comfortable and "5" being most comfortable.
_____Conducting an assessment of a client's substance abuse history.
_____Confronting a client who differs from your own race or ethnicity about his substance abuse.
_____Working with a substance-abusing client who is gay or lesbian.
_____Differentiating between depression, anxiety, delirium, psychosis, and substance abuse disorders.
_____Demonstrating the proper way to disinfect drug injection equipment.
_____Counseling an HIV-infected female client who is pregnant and actively using substances.
_____Referring a substance-abusing client to a local syringe exchange program.
_____Accompanying a client to an open meeting of Narcotics Anonymous (NA).
_____Confronting a colleague on his suspected substance abuse.
_____Advocating that an HIV-infected client with a history of substance abuse be placed on HIV combination therapy.
_____Supporting a non-substance-abusing client with HIV/AIDS who is considering using marijuana to help curb nausea and increase appetite.
_____Confronting a client who is actively putting others at risk.
_____Confronting a client whom you believe is not adhering to a medication regimen but who claims to be.
Figure 7-2
Homophobia Questionnaire for Counselors and Clients
Do you ever stop yourself from doing or saying certain things because someone might think you are gay or lesbian? What kinds of things?
Do you ever intentionally do or say things so that people will think you're not gay/lesbian? What kinds of things?
Do you think that lesbians or gays can influence others to become homosexual?
Do you think someone could influence you to change your sexual orientation?
If you are a parent, how would you (or do you) feel about having a lesbian daughter or a gay son?
How do you think you would feel if you discovred that one of your parents, a parent figure, or a brother or sister were gay or lesbian?
Are there any jobs, positions, or professions that you think gays and lesbians should be barred from holding or entering? Which ones and why?
Would you go to a physician whom you knew or believed to be gay or lesbian if he or she were a different gender from you? If he or she were the same gender as you? If not, why not?
If someone you cared about said to you, "I think I'm lesbian or gay," would you suggest that the person see a therapist?
Have you ever been to a gay or lesbian social club, party, bar, or sporting event? If not, why not?
Would you wear a button that says, "How dare you assume that I'm heterosexual?" If not, why not?
Can you think of three positive aspects of a lesbian or gay lifestyle? Can you think of three negative aspects of a heterosexual lifestyle?
Figure 7-3
Guidelines To Minimize Cultural Clashes
Plan to spend more time with clients holding values different from yours. The relationship is more complex, and it may take longer to establish trust.
Anticipate that past frustrations with insensitive or inappropriate providers may have made the client angry, suspicious, and resentful.
Acknowledge past frustrations.
Acknowledge the difference between your own experience and that of the client's.
Individualize (the clear message of all treatment planning)-a client is more than an "addict," an Asian, or a person with HIV/AIDS. Get to know the whole person.
Encourage disagreement and negotiation to ensure a workable plan.
Anticipate multiple needs: medical, legal, social, and psychological.
Be prepared to advocate for the client who may not have the resources, knowledge, or experience to negotiate the HIV/AIDS and substance abuse services systems.
Assist the client in getting other resources.
Involve friends and family. This can help ensure that the client receives other needed services.
Pay attention to communication: nonverbal, expressive style, and word usage and meaning.
Make use of providers from other cultures.
Learn the strengths of a culture. In Hispanic culture, for example, the value of "respeto," demonstrating appropriate social respect, can be used to support an intervention plan.
Expect differences in beliefs about
Help-seeking behaviors
Caretaking/caregiving
Cause of disease/illness
Sexuality/homosexuality
Death and dying
Making eye contact and touching
Source: University of Hawaii AIDS Education Project.
L-Listen with empathy and understanding. Ask the client, "What do you feel may be causing the problem? How does this affect you?"
E-Elicit cultural information, explain your perception of the problem, have a strategy, and convey it to the client.
A-Acknowledge and discuss differences and similarities. Find areas of agreement and point out areas of potential conflicts so they can be discussed, understood, and resolved.
R-Recommend action, treatment, and intervention. Incorporate cultural knowledge to enhance acceptability of the plan.
N-Negotiate agreements and differences. Develop a partnership with the client and the family.
Figure 7-5
Guidelines for Working With Transgender Clients
Do
Don't
Use the pronouns based on their self-identity when speaking to or about transgender individuals.
Obtain clinical supervision if you have reservations about working with transgender individuals.
Allow transgender clients to continue the use of hormones when prescribed; advocate for the transgender client who is using "street" or illegally prescribed hormones to receive immediate medical care and legally prescribed hormones.
Ensure that all clinic staff receive training on transgender issues.
Ascertain a transgender client's sexual orientation before treating him or her.
Allow transgender clients to use appropriate bathrooms and showers based on their gender self-identity and gender role.
Require all clients and staff to create and maintain a hospitable environment for all transgender clients. Post a nondiscrimination policy, including sexual orientation and gender identity, in the waiting room.
Call someone who identifies as female "he" or "him," or someone who identifies as male "she" or "her."
Make transphobic comments to other staff or clients.
Ask the transgender client to choose between hormone therapy or substance abuse treatment.
Leave it to the transgender client to educate clinic staff.
Assume all transgender individuals are gay.
Force transgender clients identifying as male to use female facilities; likewise, don't force those identifying as female to use male facilities.
Statistics and information are constantly changing. The latest research from NIH still supports the Pediatric AIDS Clinical Trials Group Protocol 076 study, which indicated that about 8 percent of women treated with AZT during pregnancy and delivery transmitted HIV to their infants. It is unclear to date what the long-term health ramifications are for children who received AZT in utero and at birth. Are you willing to run the risk of having a child who is infected or has been affected by medications used to counter HIV infection?
Are you able and willing to love and care for a baby, whether or not it is infected?
How will pregnancy affect your health? In women with high T-cell counts, pregnancy has not been shown to make HIV/AIDS progress, but less is known about women who have AIDS or symptomatic HIV disease.
Do you have the support of a partner, family members, or friends who can help care for a child?
Who will care for your child if you become sick or die? Will there be people who will teach your child about his culture, help your child remember you, and raise your child according to your values?
In what ways (good or bad) will having a baby change your life?
What are the reasons that you want (or do not want) to have a child?
Do you have children now? How are things with them?
Do you feel pressured by others (partners, family, friends, your religion, cultural values) to have (or not have) a child?
Do you have a family physician or obstetrician who knows about HIV/AIDS and who can give you the health care that you need?
Do you have enough information to make an informed decision? If not, find someone who can give you information and who will not insist on telling you what to do.
Are you willing and able to go without substances for at least 9 months? Do you know how their use will affect your unborn child?
Figure 7-7
Case Study: Heterosexual Minority Men Living With HIV
One recent study recruited 18 HIV-positive, heterosexual, minority men from an outpatient HIV/AIDS clinic in upstate New York and a community-based AIDS service organization in New York City to explore the experience of heterosexual minority men living with HIV. Findings revealed that the experience of surviving HIV infection encompassed several stages.
The participants in this study identified the choices they made in adolescence that led them down a hazardous pattern of behavior as the majority became involved in substance abuse or other illicit activities. With the diagnosis of HIV infection came a "falling off" stage, in which the participants went "over the edge" and initially were afraid to die but then realized that they were okay but vulnerable.
The next stage was "hanging on," in which study participants attempted to reassert control, reevaluated priorities, and developed a new perspective on life and health. In the "pulling up" stage, participants realized that the rescue team included self, God, family, and friends, with self-rescue taking place on emotional, physical, and spiritual levels.
As the participants reached the "turning around" stage, they began to accept responsibility for their health, focused on their abilities rather than their limitations, and began to see themselves as "living with HIV" rather than "dying from HIV."
Consent for the Release of Confidential Information
I, ___________________________, authorize XYZ Clinic to receive
(name of client or participant)
from/disclose to ________________________________________
(name of person and organization)
for the purpose of _______________________________________
(need for disclosure)
the following information__________________________________
(nature of the disclosure)
I understand that my records are protected under the Federal and State Confidentiality Regulations and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it and that in any event this consent expires automatically on ____________________ unless otherwise specified below.
(date, condition, or event)
Other expiration specifications:
_________________________
Date executed
_________________________
Signature of client
________________________
Signature of parent or guardian, where required
Figure 9-3
Qualified Service Organization Agreement
XYZ Service Center ("the Center") and the _______________________________
(name of the program)
("the Program") hereby enter into a qualified service organization agreement, whereby the Center agrees to provide (nature of services to be provided)
Furthermore, the Center: (1) acknowledges that in receiving, storing, processing, or otherwise dealing with any information from the Program about the clients in the Program, it is fully bound by the provisions of the Federal regulations governing Confidentiality of Alcohol and Drug Abuse Client Records, 42 C.F.R. Part 2; and
(2) undertakes to resist in judicial proceedings any effort to obtain access to information pertaining to clients otherwise than as expressly provided for in the Federal Confidentiality Regulations, 42 C.F.R. Part 2.
Executed this ____________ day of _____________________, 199_____ __________________________ President XYZ Service Center [address]
__________________________ Program Director [name of program] [address]
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