Individuals may enter drug treatment programs by a variety of pathways. Referrals from the courts, physicians, and social service agencies are common, as are self-referrals. Regardless of how the patient enters care, the initial patient contact establishes the basis for ongoing drug treatment, infectious disease screening, medical care, and the continuum of supportive services that are vital to the patient's recovery and health.
Studies show that an open, trusting relationship with treatment staff helps the patient to remain in and benefit from treatment services. The interviewer can begin creating this supportive relationship with the patient during the crucial first contact.
Characteristics of the interviewer that help establish such a relationship are an accepting and nonjudgmental attitude, a willingness to provide complete information about assessment and diagnostic procedures, a willingness to answer the patient's questions, and an ability to be open to and understanding of the needs and concerns of the patient.
A comfortable rapport encourages the patient to trust the interviewer with sensitive and personal information. To further facilitate patient responsiveness, the interviewer can
Introduce the objectives of the interview and explain to the patient that the questions asked are intended to help both treatment staff and the patient plan for and provide appropriate care.
Explain to the patient how Federal, State, and local laws and regulations affect the confidentiality of drug treatment information, infectious disease test results, contact tracing and partner notification procedures, and medical records.
Inform the patient that testing for infectious diseases, including human immunodeficiency virus (HIV), is voluntary.
Begin the process of taking a history with the least stressful areas of questioning. For example, gather general demographic information first, then address drug use, sexual practices, and infectious disease testing later in the interview.
A variety of protocols are used by drug treatment programs to obtain a patient history and to guide treatment planning. These protocols may include the use of standardized or program-modified questionnaires. Questionnaires may be partly self-administered by patients or treatment staff may complete them using an interview process.
Questionnaires and the interview process should obtain a clear picture of patient risk factors for infectious disease. Key areas and their significance for infectious disease screening and treatment planning follow.
The patient who has a history of certain infectious diseases, such as those that are sexually transmitted, is at increased risk for possible reinfection and co-infection. For example, the patient with one sexually transmitted disease (STD) is at increased risk for other STDs; the patient who is HIV positive is at increased risk for co-infection with tuberculosis.
The patient's history of treatment for infectious diseases may provide important clues for interpreting subsequent test results. The history of an allergic or adverse reaction to any nonprescription or prescription drugs used in the past, and any contraindicated medications, as well as other health problems, should be obtained and noted in a prominent place in the clinic chart.
A vaccine is available for hepatitis B. The patient with no serologic evidence of prior exposure should be offered hepatitis B vaccine to prevent future infection. Persons at risk for HIV may benefit from vaccination for other diseases for which vaccines are available.
Drug treatment staff must coordinate patient care with other health professionals who may be providing medical treatment for infectious diseases and other health conditions. Followup by drug treatment staff can ensure that the patient continues to receive needed medical care.
The early detection of infectious disease among pregnant drug-using women will help ensure that appropriate medical care for the mother and fetus is provided, contraindicated medications are avoided, and family planning counseling is offered.
Injection drug use is strongly associated with the risk of infection in drug users. The most important variable determining whether or not a person will be infected with any given disease is the infectivity rate in that person's cohort. In the instance of injection drug use, the cohort will consist of the people with whom the user has shared needles and syringes and other contaminated paraphernalia as well as the sex partners of the user. HIV, hepatitis B, and syphilis can all be transmitted through contaminated equipment. These diseases can be transmitted to sex partners through unsafe sex practices.
The sharing of needles, syringes, drug vials, and cookers can transmit infection since any part of this equipment may be contaminated. The more persons with whom the patient has shared needles and other contaminated equipment, the higher the risk of infection.
Attempts to sterilize needles or to use new needles should be carefully discussed. "New" needles and syringes sold to injection drug users by street sources may actually be recycled ones. Patients must be urged to not share drug paraphernalia and told that cleaning syringes, needles, or other drug paraphernalia with bleach may not kill the HIV virus. Treatment centers should contact the Centers for Disease Control and Prevention frequently to obtain updated guidelines on the disinfection of drug injection equipment. See Appendix G for new information on the limitations of bleach and proposed recommendations to prevent HIV transmission via shared injection equipment.
Patients may be at increased risk for certain infectious diseases based on their family history. Tuberculosis and hepatitis B, for example, can be transmitted through contact with infected family members.
If psychopathology is present and not treated aggressively, it may impair a patient's ability to engage and be retained in treatment. The counselor should inquire about psychological or psychiatric problems that may be present in some people who use drugs.
Lower income, homelessness, and residence in crowded and poorly ventilated living conditions (such as prisons, migrant worker camps, and residential mental health facilities) are associated with an increased risk of developing tuberculosis. Hepatitis B is associated with drug use, lower socioeconomic status, and residence in a long-term facility. A lack of income may also result in the patient engaging in unsafe sexual practices in exchange for money, drugs, or shelter.
The sexual history provides a basis on which to assess the patient's risk for certain infectious diseases, to plan for appropriate medical care, and to develop risk reduction and relapse prevention strategies. Initial questions concerning intimate sexual practices and episodes should be of a general nature. The interviewer can proceed gradually to more specific practices and events as is appropriate to and comfortable for the individual patient.
Some patients, for example, may indicate they have a stable, long-term relationship and do not engage in high-risk behaviors such as the exchange of sex for drugs, money, or shelter. As a result, questions about multiple sexual partners can be brief. Other patients may provide information that suggests multiple, high-risk sexual contacts and practices. In these cases, information about specific sexual practices and the circumstances of the sexual encounters may be appropriate.
It may be helpful during this process to assure the patient that a sexual history provides the treatment team with information that can be critical for the prevention and treatment of infectious diseases, and that this is the only purpose for gathering such information. The interviewer should briefly discuss the link between infectious diseases and drug use, and identify and probe, as appropriate, the following areas of sexual practice that are risk factors for infectious diseases.
Having, or having had, more than one sex partner increases a person's risk factor for contracting sexually transmitted diseases, HIV infection, and hepatitis B. The greater the number of past sex partners, the greater the risk. The risk of infection also increases if a person's partners have or have had multiple partners and if unsafe sex practices occur.
The geographic location of the patient's sexual encounters is significant since some areas in the United States have a higher incidence of certain infectious diseases. In addition, the risk of infection increases when sexual encounters have occurred in settings such as prisons, due to an increased likelihood of unprotected and multiple sexual encounters.
There are some sexual practices more likely than others to place the patient at risk for infection, such as anal intercourse and group sex. Information about preventive practices is relevant, including the use of condoms and spermicidal products containing nonoxynol-9.
People are more likely to engage in unintended and unsafe sexual practices while under the influence of alcohol or other drugs because of the disinhibitory effect of these substances.
Many of the women - and men - seeking treatment are the victims of physical abuse, sexual abuse, or both. As a result, patients of all ages are at risk for sexually transmitted diseases and HIV. Repeated infections of STDs due to abuse and victimization are not uncommon.
Every patient entering alcohol and other drug treatment should have a thorough physical examination. This examination should
Assist medical staff to diagnose infectious diseases in patients
Provide a basis for infectious disease testing
Assist medical staff to plan for and provide medical care for patients with infectious diseases
Provide a basis for planning preventive interventions
Provide a basis for planning followup medical care
The clinical symptoms, screening protocols, and treatments for tuberculosis, hepatitis, HIV and AIDS, and syphilis and other sexually transmitted diseases are discussed in detail in other sections of this TIP.
A comprehensive drug treatment plan for the patient is based, in part, on information that is gathered through the initial interview process and during the physical examination. The treatment plan, which should be discussed with and developed in concert with the patient, must include screening and medical care for infectious diseases. Changes to this plan may occur throughout the course of treatment as is appropriate to the patient's progress toward treatment goals. The following considerations for infectious disease screening are relevant to drug treatment planning.
All patients in treatment are at increased risk for infectious diseases and should be screened for HIV, hepatitis B and C, tuberculosis, syphilis, and for other sexually transmitted diseases if appropriate.
If possible, HIV status should be determined at the time of entry. HIV testing should be done only with the consent of the patient. Pre- and post-test counseling must be available.
Methadone clinic patients must be tested for syphilis and tuberculosis as required by Federal regulations.1
Followup testing should be scheduled at appropriate intervals for patients treated for infectious diseases.
Patients found to not have serologic evidence of prior hepatitis B infection and who have not received hepatitis B vaccine should be given the hepatitis B vaccine.
Risk reduction interventions, including education and counseling about safer sex practices and birth control should be offered to both men and women. Often women may be told that condoms are effective for disease prevention and birth control; however, they should be warned that condoms can break, and for maximum birth control protection, oral or barrier methods should be used in conjunction with condoms. The use of a spermicide can also give some additional protection against bacterially transmitted STDs.
Interventions appropriate to retaining the patient in treatment should be identified. If called for, a followup appointment should be scheduled.
Site Map
Help
Account
Cart
Home
