Alcohol and other drug (AOD) abusers, whether or not they are HIV-infected, are subject to higher rates of mental disorders than the rest of the population. The Epidemiologic Catchment Area study found that nearly 30 percent of AOD abusers living in the community had comorbid psychiatric disorders (Regier et al., 1990).
Other studies have shown higher rates of psychiatric disorders among AOD abusers in treatment programs. In some studies, the lifetime prevalence of such disorders is as high as 80 percent (Ross et al., 1988).
It is not clearly known what proportion of HIV-infected AOD abusers has psychiatric disorders. One recent study found that 79 percent of HIV-infected injection drug users (IDUs) in treatment required psychiatric consultation and 59 percent had psychiatric disorders other than AOD abuse. Forty-five percent of these patients had organic mental disorders such as cognitive impairment, organic anxiety disorders, and organic mood disorders (Batki et al., 1992).
Counselors working with HIV-infected AOD abusers should be aware of the variety of both HIV-induced and AOD-induced psychiatric symptoms that may be seen in these patients. It is also important to recognize that psychiatric symptoms may be caused by starting, stopping, or mixing medications used to treat HIV disease.
Ideally, AOD abuse treatment programs that do not possess resources to adequately assess and treat mental illness onsite should have the capacity to rapidly refer patients to closely linked mental health services. It is helpful to have clearly identified lines of communication between AOD abuse treatment programs and mental health services to facilitate clinical interaction concerning patients with complex needs.
Most mental health programs are not adequately equipped to provide AOD treatment. The AOD abuse treatment program should therefore maintain contact with the patient and continue the patient's AOD treatment during and after the psychiatric referral. AOD treatment staff may need to help patients obtain transportation to the psychiatric referral site. Providing concrete assistance such as transportation may increase the likelihood of patients' success in following through on referrals to psychiatric services.
Because it may be difficult for any one clinician to address the complex mental health and counseling needs of HIV-infected AOD abusers, the care of these patients is likely to involve multiple providers. A coordinated, holistic approach should be taken to the multiple problems of this target population.
In general, mental disorders that are of particular concern in HIV-infected AOD abusers may be divided into three broad categories:
Alcohol and drug-induced mental disorders
HIV-related mental disorders
Medication-related disorders
Pre-existing mental disorders.
Any given patient may fall into one or more of these categories. Common mental disorders among HIV-infected AOD abusers include the following. (Terms used are those found in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders [DSM-IV].)
Adjustment Disorders. Often characterized by anxious mood, these disorders tend to be time-limited (for example, 3 to 4 weeks) acute responses to acute stresses such as receiving news of HIV infection or increasing disease severity. Stages of adjustment to the stress of life-threatening HIV infection have been described as analogous to the stages of adjustment to other illnesses. These generally begin with a crisis and progress to acceptance of and adaptation to the stressor.
Insomnia. This is a frequently seen problem that is often associated with some forms of AOD abuse such as stimulant intoxication or withdrawal from alcohol or other depressants. The incidence of insomnia also increases with the development of HIV disease (Wiegand et al., 1991).
Depressive disorders. Depression is a common response to learning of HIV infection or becoming more ill. Depression can also exist with or precede substance abuse. Patients may also become depressed for prolonged periods of time after withdrawal from abuse of alcohol, opiates, stimulants, and other substances (Kanof et al., 1993).
Mania. Mania is frequently seen in HIV patients. In one study, mania was seen in as many as 8 percent of patients in an HIV medical clinic. Mania can also be a complication of AOD abuse, particularly abuse of cocaine and other stimulants. It can be difficult to determine whether mania is AOD- or HIV-induced (Lyketsos et al., 1993;Mirin et al., 1988).
Dementia. Dementia may be due to alcoholism, head trauma, and numerous other causes, in addition to HIV disease. Differentiating these dementias can be difficult. All forms of dementia can be present with cognitive, behavioral, and motor abnormalities. Neuropsychological examination is useful in helping to make the diagnosis of dementia.
Delirium. Mental confusion associated with acute encephalopathy or delirium can stem from many sources, including infection, AOD intoxication or withdrawal, toxicity from medication, or metabolic disturbances.
Psychosis. Psychotic symptoms may be seen in advanced HIV dementia or in delirium and can be difficult to differentiate from substance-induced hallucinations and delusions as in, for example, paranoid psychosis resulting from the use of "crack" cocaine.
Personality disorders. The presence of antisocial personality disorder or borderline personality disorder often complicates AOD abuse treatment for the HIV-infected patient. Please see the TIP, Assessment and Treatment of Patients with Coexisting Mental Illness and Alcohol and Other Drug Abuse for information regarding the interaction of personality disorders with AOD abuse treatment. HIV-infected AOD abusers have high rates of personality disorders, particularly antisocial personality disorder. The management of these chronic disorders is generally similar in both HIV-infected and non-HIV-infected AOD abuse patients.
Medication-related mental disorders. It is essential to be aware that psychiatric symptoms in HIV-infected AOD abusers may result from the use of prescription medication. For example, high doses of zidovudine (AZT) (greater than 600 mg per day) can produce anxiety, insomnia, or hyperactivity.
In cognitively impaired AOD abusers with late-stage HIV disease, memory and other cognitive functions may be worsened by combinations of medications, particularly central nervous system depressants such as benzodiazepines (for example, diazepam [Valium and other drugs]) and anticholinergic medications such as the tricyclic antidepressants (for example, amitriptyline [Elavil and others]).
Interventions. Both pharmacologic and psychotherapeutic interventions should be used in the treatment of mental disorders in HIV-infected AOD abuse patients. This chapter describes some of the basic interventions and notes particular concerns, risk factors, and other issues relevant to HIV-infected patients. The important role of support groups in counseling this patient population is also discussed. Psychotherapy and support groups are also important parts of treatment for HIV-infected AOD-abusing patients who are not mentally ill.
Therapeutic interventions related to patients' mental health must be sensitive to the culture and ethnicity of the patient population. Whenever possible, therapists and support group leaders should share the culture of their patients and should speak the same language or vernacular. Cultural compatibility between therapists and patients is important in creating an atmosphere of trust in which sensitive issues such as family support and group mores can be addressed.
Some individuals may have strong spiritual beliefs that differ from dominant cultural norms. If their cultural context is not understood, such beliefs may be labeled delusional. Generally, the clinician's best guide is the patient's immediate family or community context. If the patient's beliefs are consistent with his or her community or culture of origin, it is less likely that they are delusional (Perez-Arce et al., 1993.)
The healthcare needs of HIV-infected AOD abusers with mental disorders are complex, and treatment may involve multiple providers from a variety of disciplines. Communication and coordination among physicians, counselors, and other practitioners involved in a patient's care are therefore essential. Case management may be a useful way of ensuring that such coordination occurs.
For example, patients may not always fully divulge to a treating physician that they have a history of psychiatric disorder or that they are already receiving psychotropic or analgesic medication from another medical provider. By facilitating communication among providers, a case manager can help to ensure that all parties involved in the care of an individual patient are as fully informed as possible about the patient's treatment status.
A comprehensive treatment plan and an individualized risk reduction plan should be prepared and followed for each patient. Case management must be flexible so that patients receive more attention as their needs increase. (See Case Management section in Chapter 5.)
Exhibit 4-1 outlines the major categories of information necessary for a basic mental health assessment.
Assessment and diagnosis of mental illness in HIV-infected AOD abuse patients can present a daunting challenge because of these patients' complex problems. It is important to evaluate patients' behavior in context. For example, acute depression is relatively common among individuals who learn that they are HIV-positive. This type of time-limited adjustment disorder may lead to worsened AOD use. In turn, depression may be made more severe or prolonged by concurrent AOD abuse.
It can be difficult to determine whether AOD abuse preceded the psychiatric disorder or vice versa. AOD abuse may be an attempt at self-medication in response to an underlying psychiatric disorder. Although mental disorders may predate AOD abuse, generally the reverse is true.
Because an accurate and complete history cannot always be obtained from the patient, corroborative sources of information (such as the patient's family or a previous healthcare provider) are essential to a complete assessment.
History-taking. Counseling staff should begin the assessment of the HIV-infected AOD abuse patient by taking a psychosocial history that is as judgment free as possible and that includes open-ended questions. It is important that this questioning acknowledge and respect not only ethnic and cultural differences but also alternative sexual lifestyles.
A complete medical history focusing on HIV and AOD abuse should be taken at intake to AOD treatment. A recent physical examination and laboratory test results should be readily accessible because they may help in the assessment of the patient's counseling needs. For example, a CD4+ lymphocyte count ("T" cell count) below 200 informs the mental health or counseling professional that the patient is at higher risk for organic mental disorders such as HIV-related dementia.
Mental status examination. A comprehensive mental status examination is the key to detecting mental disorders. Among other things, this exam may reveal cognitive problems such as deficit memory. The cognitive portion of the mental status examination can be expedited by the use of standardized questionnaires such as the Mini Mental State Exam.
It is helpful to have a psychiatrist or psychologist perform the examination, but most nonpsychiatric physicians are familiar with the basic components of a brief mental status examination. Nursing staff and counselors can also be taught to administer screening examinations such as the Mini Mental State Exam.
A good screening instrument can assist clinicians in asking appropriate questions. In addition to the Mini Mental State Exam, other examinations, such as the Beck Depression Inventory, may be particularly useful in assessing the severity of depressive symptoms (Beck, 1993).
In addition to receiving an initial assessment of needs, HIV-infected patients should be periodically reassessed. Fluctuating health status and functional capacity will mean that clients' needs change over time. Repeated mental status examination is also helpful when a change in cognitive or behavioral status is noted by AOD counselors or medical staff.
Treatment goals. It is essential to set realistic treatment goals that vary with the patient's functional capacity. For example, immediate abstinence from AODs may be too much to expect from severely psychiatrically disturbed AOD abusers, and AOD programs may need to have a flexible range of treatment goals for such patients. (See Dealing With Ongoing AOD Abuse, below.)
Neurocognitive impairment is a common complication of HIV disease. In its severe form it is known as AIDS dementia complex (ADC). This complication is one of the most challenging and anxiety-provoking manifestations of HIV disease for the patient and his or her family, as well as for the AOD treatment provider.
The diagnosis of dementia in the HIV-infected AOD abuser is based on the presence of significant and disabling impairment of functioning. Usually, impairment is present in three areas:
Cognitive functioning (for example, memory disturbance),
Behavioral functioning (for example, altered behavior such as agitation or psychosis)
Motor functioning (for example, gait disturbance or incontinence).
Diagnosis requires neuropsychological evaluation employing a battery of neuropsychological tests. A diagnosis cannot reliably be made using a brief cognitive capacity examination such as the Mini Mental State Exam. However, poor performance on a brief cognitive screen is an indication that dementia may be present and calls for further testing (see Exhibit 4-2).
HIV-related neurocognitive loss usually progresses gradually. Early signs and symptoms of neurocognitive impairment include
Short-term memory loss (forgetting appointments, misplacing items, forgetting to take important medications)
Loss of visual, spatial, and fine coordination (impaired handwriting, difficulty assembling objects or equipment)
Cognitive slowing (taking longer to speak or to understand, appearing "slow" in interviews)
In later stages of dementia major impairments become obvious, such as
Mutism or unresponsiveness to speech
Agitation, hallucinations, paranoia or other delusions
Severe neurological problems (incontinence, inability to walk).
The risk of dementia and other cognitive deficits is highest in HIV-infected patients who are severely immunocompromised. The CD4+ lymphocyte count ("T-cell count") is a useful index of an individual's risk for AIDS dementia. Generally, dementia is most likely to occur in patients with CD4+ counts below 200 (Boccellari et al., 1993a, 1993b).
Standard pharmacologic approaches may be taken in the treatment of psychiatric disorders in HIV-infected AOD abuse patients, with some specific caveats. Without exception, a medical/psychiatric diagnostic evaluation should always be carried out before medication is provided.
Some AOD abuse treatment staff may oppose the use of pharmacologic interventions in AOD abuse patients because of a concern that these medications may place patients at risk for relapse into substance abuse. While these concerns must be acknowledged, it is necessary to distinguish medications from drugs of abuse. An approach to care that does not permit the use of psychiatric medications when appropriate may deprive patients of the opportunity to benefit from a legitimate and necessary treatment option.
Exhibit 4-3 lists abusable and nonabusable psychiatric medications.
In animal and human testing, most of the major classes of psychiatric medications have been proven not to have abuse potential. Examples are antipsychotic medications such as chlorpromazine (Thorazine), mood stabilizers such as lithium, and nonpsychostimulant antidepressants such as fluoxetine (Prozac).
On the other hand, two types of medications are known to have abuse potential:
Central nervous system depressant, antianxiety, and anti-insomnia medications such as diazepam (Valium) and chlordiazepoxide (Librium)
Psychostimulants such as amphetamine and methylphenidate (Ritalin).
When working with any AOD-abusing patient, it is reasonable to expect that some misuse of legally prescribed controlled substances may take place. A hierarchical approach to prescribing is recommended to minimize the potential for abuse of psychiatric medications.
In this approach, the least abusable medications are prescribed first and the most potentially abusable are used only when other agents have not been effective. Dispensing medication in small amounts (for example, 1 day or 1 week's supply) helps to limit the overuse, misuse, or abuse of potentially abusable medications.
HIV-infected persons may be more than usually sensitive to prescription medications as well as to drugs of abuse. When prescribing, clinicians should attempt to use the lowest effective dose to minimize side effects. With patients who have advanced HIV disease, it may be wise to start out with very low doses of the magnitude generally associated with geriatric psychiatry.
Suicide. AOD abusers are at increased risk of suicide. HIV-infected individuals may also be at risk of suicide, especially if they are suffering from a mood disorder. Medication should be dispensed in small amounts (one week's supply or less) until a patient's level of responsibility can be fully assessed. Tricyclic antidepressants (TCAs) such as amitriptyline (Elavil) and others are especially likely to be lethal in overdose.
Abuse of intravenous infusion lines. Patients with advanced HIV disease are frequently prescribed narcotic analgesics and may have an indwelling intravenous line for infusion therapy. Clinical experience has shown that IDUs are at very high risk of using this indwelling intravenous line to administer heroin, cocaine, and other drugs of abuse. It is therefore essential that patients with such lines be cared for in residential settings where adequate monitoring and support can be provided.
Side effects. As HIV infection progresses, some medications may cause adverse side effects in some patients.
Medications whose anticholinergic effects block saliva flow cause dry mouth.
For example, tricyclic antidepressants (TCAs) and antipsychotics can produce dry mouth and cause oral candidiasis and other mouth infections.
Stimulation from antidepressants may trigger hyperactive or manic behavior, especially in the HIV-infected AOD abuser who may already have mild central nervous system impairment because of HIV.
HIV-infected patients are more sensitive than others to movement disorders such as extrapyramidal symptoms (EPS) that can be caused by antipsychotic medications like haloperidol (Haldol).
Central nervous system depressants such as sedative-hypnotics should be used with caution because they may cause confusion, memory impairment, and depression.
It is reasonable to suspect that any sudden behavior change or new physical symptom in a patient on medication may be medication related. With some medications, such as lithium, the TCAs (for example, amitriptyline), and certain antipsychotics (for example, haloperidol), blood levels should be tested periodically to avoid drug toxicity.
Adverse interactions. Clinicians must be aware of the potential for adverse interactions between HIV treatment medications and psychiatric medications. HIV-infected patients are often prescribed complex medication regimens. Medications, either alone or in various combinations, may cause confusion and other psychiatric symptoms.
For example, a patient may be prescribed fluoxetine (Prozac) for depression plus an antianxiety medication such as lorazepam (Ativan) and may also be receiving zidovudine and the antibiotic trimethoprim-sulfamethaxazole (Septra), as well as other medications.
In any individual patient it can be difficult to predict the outcome of interactions among so many medications.
Because of the potential for adverse interactions among medications, it is essential that medical and psychiatric care providers communicate with each other when treating an HIV-infected AOD-abuse patient (see Case Management section in Chapter 5).
Communication may also be significantly helped by the pharmacist who fills the patient's prescriptions. Pharmacists can play a role in educating patients and helping to reduce possible adverse effects of drug interactions. In addition, pharmacists are invaluable sources of information about what medications other healthcare providers may have prescribed to the patient.
If a patient appears to be adversely affected by multiple medications, the AOD abuse treatment provider must report the observed physical or behavioral change to the patient's primary medical provider as soon as possible so the problem can be addressed.
Exhibit 4-4 offers a brief guide to appropriate pharmacologic therapy for patients with HIV/AIDS and chemical dependency. (See also Pharmacologic Interactions section in Chapter 3.)
Counseling is an important part of treatment for all AOD abusers, including those with comorbid psychiatric disorders. The goal of counseling is to help HIV-infected AOD abusers maintain health, achieve recovery from AOD abuse, and attain the best possible level of psychological functioning. Counseling may be done individually, in groups, or with patients' families.
Counselors need to be aware that patients are likely to move through different stages in the course of both AOD abuse and HIV disease. Part of the counselor's role is to help the patient to adapt as well as possible to these changes. (See Exhibit 4-5.)
Preventing the transmission of HIV must be a major focus of counseling interventions. Discussion of risk reduction should be incorporated as much as possible into all types of counseling. (See Risk Reduction Counseling, below.)
Individual therapy can be a particularly important component of treatment for a patient who may not be ready to share intimate information with a group. Individual counseling may allow patients to discuss subjects such as sexual behavior, fear of death, and other issues related to HIV infection, AOD abuse, or sexual identity.
For some AOD abusers, a possible disadvantage of individual therapy is that it may not be as potent as group intervention in reducing the sense of isolation, shame, and guilt that many patients feel because of HIV infection. One aim of individual therapy may be to prepare patients to participate in group therapy.
Most treatment programs working with HIV-infected AOD abuse patients are finding that supportive group therapy can be a highly beneficial modality.
AOD abuse treatment groups can be structured in a variety of ways but generally involve a dozen or so participants with one or two group leaders. HIV-infected AOD abusers who are strongly self-identified as heterosexual may not feel comfortable in a group with openly gay members, and vice versa. AOD abusers may be more reticent about exploring sexuality and sexual behavior in groups.
In general, however, it is not absolutely necessary to segregate group members on the basis of sexual orientation. Good results can be achieved in a group whose membership includes both HIV-infected and non-HIV-infected AOD abusers, as has been shown in the Stimulant Treatment Outpatient Program (STOP) at San Francisco General Hospital (Perez-Arce et al., 1993).
Stage-of-diagnosis model. A current model for structuring groups, based on the patients' stage of diagnosis, has been used successfully by Boston's Fenway Community Health Center. In this model, patients are grouped as follows:
Those who have just learned about their HIV infection
Those in the early stages of HIV disease.
These groups focus on healthy lifestyles and improving quality of life. As the sessions progress, patients often exchange information about treatment.
Those in the later stages of HIV disease. This group focuses on adapting to illness, grief, and coming to terms with death and dying.
(See Support Groups, below, for further discussion of structuring groups.)
In addition to their therapeutic role, groups may have important roles to play in educating patients about HIV risk reduction. Discussions about risk reduction should be encouraged. Because it is important to promote behavior change among all AOD abuse patients, those who are not HIV infected should also have the opportunity to attend HIV education groups.
For some HIV-infected AOD abuse patients, "family" may need to be defined as broadly as possible. Some patients will have traditional nuclear families. For other patients, family may include a nonmarital partner, a same-sex lover, and other significant others. Adult patients have the right to define their families and to decide whether or not to include the people they regard as family in the treatment process. For a socially isolated person, a buddy from an AIDS service organization may fill the role of significant other.
Supporting patients in their recovery from AOD abuse is often a principal goal of family therapy. Questions related to partner or child abuse may also be addressed. In addition, family therapy may be a useful opportunity to address issues of risk reduction for family members who are not (or not yet) HIV infected. This therapeutic setting is uniquely positioned to offer risk-reduction education to people who may not have been identified either as HIV-infected or as AOD abusers.
Both AOD abuse and HIV infection may cause cognitive impairment that can reduce adherence to medical care. The effect of cognitive impairment should be taken into account when undertaking patient education. It is important, for example, to allow time for recovery from the acute effects of AOD intoxication or withdrawal. Patients' ability to understand the content of counseling sessions should be assessed before such counseling takes place (Forstein, 1992). In general, it is preferable that counseling be offered in the later stages of a detoxification program.
Communication between medical and counseling staff is important to ensure that cognitively impaired patients are not perceived as deceitful or manipulative. Care providers must keep in mind that cognitively impaired patients' nonadherence to treatment is a result of the impairment and not caused by denial, resistance, or unwillingness to accept care. (See Dementia in HIV Disease, above.)
Changing risk behavior such as AOD use and unsafe sex requires more than a knowledge of why these are risk behaviors. Patients' attitudes and beliefs must also be addressed. AOD use can lower inhibitions and increase impulsivity, which may significantly contribute to risk behavior.
In promoting risk reduction, the AOD abuse counselor's roles are to
Help the patient understand the need for behavior change
Provide psychological support for behavior change
Assist the patient in developing the appropriate skills to sustain the behavior change.
Discussion of risk behaviors should take place in language that is both culturally appropriate and clear and understandable to the target audience. AOD programs should be familiar with how to refer family members for HIV antibody testing and with providing appropriate pre- and posttest counseling to patients. If onsite testing is not possible, referral should be available to an easily accessible site.
Risk-reduction counseling can be particularly difficult when a patient is sent back to a nonsupportive community where high-risk AOD and sexual behaviors are not discouraged. Issues such as poverty and homelessness must be acknowledged and addressed when attempting to change high-risk behavior. Practical assistance, such as providing emergency housing, is usually needed before behavior change can occur.
Sexual practices history. A comprehensive sexual practices history is important and should be taken early in counseling, although not necessarily at the first session. Patients must be reassured of the confidentiality of the information they provide.
Counselors should address the full range of potential risk behaviors in their questioning, including both needle sharing and unsafe sex. They need to take into account a wide range of sexual practices, including homosexual, bisexual, and heterosexual relations. Condom use must be a special focus of counseling.
A counselor can often proceed from taking the patient's history to HIV education and then to risk reduction. A patient who was diagnosed with HIV infection before the encounter with the counselor may already have discussed sensitive issues and risk reduction with someone. Therefore, it is important for the counselor to discuss with the patient what he or she has been told before.
Standardization of goals. Although counseling is necessarily an individualized process, some standardization of goals and methods can be helpful. Training, followup, and support for counselors is an integral part of the treatment program, especially for HIV-infected AOD-abusing patients with mental health problems. Counselors must be prepared to become familiar with all aspects of HIV disease. (See Counselor Training, below.)
Buddy system. The buddy system is an approach that has been tried in both HIV and AOD abuse treatment to increase patient compliance with treatment by increasing expectations about patients' responsibilities to one another.
The buddy system can place AOD abusers at risk if both buddies are in early recovery, in which case they may reinforce the possibility of relapse in each other. One strategy may be to pair a patient in early recovery with a buddy who has been in treatment longer. The appropriateness of the buddy system needs to be assessed individually in each patient.
Many HIV-infected AOD abusers are unable to maintain abrupt and total discontinuation of substance use. In dealing with patients' ongoing AOD use, treatment programs must find a balance between the abstinence-oriented and the public-health-oriented approaches to substance abuse treatment.
Abstinence model. This approach traditionally uses confrontation, consistency of expectations, behavioral contracting, and limit setting as treatment modalities, with the goal of achieving abstinence from all substance use. This approach may involve termination from treatment if abstinence is not achieved.
Public health model. This approach, sometimes called the harm reduction model, emphasizes incremental decreases in AOD use or HIV risk behaviors as treatment goals. This approach tends to try to keep patients in treatment even if complete abstinence is not achieved.
The public health model may sacrifice some of the consistency of expectations that is such an important part of abstinence-oriented treatment. Rather, it seeks to keep abusers in treatment and to reduce, if not eliminate, AOD- and HIV-related risk behaviors. Each incremental change may be viewed as a success, helping individuals to see that they can positively affect their lives.
By contrast, a model that regards anything less than complete abstinence as failure may reinforce individuals' sense of helplessness and hopelessness at their inability to sustain behavior change.
Flexibility is needed with HIV-infected patients because of the public health importance of keeping these patients in AOD treatment (they are likely to continue to put others at risk if they leave treatment and resume injection or other drug use). If reduction in the spread of HIV is an important goal, it may be necessary to keep working with these patients despite continuing abuse.
Each AOD treatment program must establish its own balance between the abstinence and public health approaches, based on the needs of the community it serves. For example, harm reduction models may be employed to educate active IDUs about safer sex and drug use practices, such as using condoms and sterilizing needles with bleach. (See Appendix C.)
Differential standards of care. One current model for applying a flexible approach to the AOD abuse treatment of HIV-infected patients is the differential standards of care approach used by the Opiate Treatment Outpatient Program at San Francisco General Hospital's Substance Abuse Services. (See Appendix F.)
This approach applies different standards of care to patients, based on an assessment of the individual's level of functioning in the areas of physical health, mental health, social support, housing, and employment. Very ill patients generally are treated according to lower expectations of AOD abuse treatment outcome, while higher functioning patients are treated with higher expectations (for example, to maintain drug-negative urine tests, attend self-help group activities, etc.).
Declining health as a result of HIV disease is a recognized risk factor for relapse into AOD abuse. Physical and psychological stresses associated with HIV disease include pain, decreased functional ability, fatigue and weakness, as well as fear, anxiety, and grief, all of which increase individuals' risk of resuming substance use.
In particular, certain "milestones" in the progression of HIV present an elevated risk of patient relapse. Many patients may need additional support at these times. It is important that counselors review a patient's treatment plan when one of these milestones is reached and consider whether the patient would benefit from changes in treatment.
For most patients, four major milestones are
Deciding to be tested for HIV infection and waiting for the test results. (Although making this decision can be a risk factor for relapse in some patients, for other individuals it may be a stimulus to begin AOD abuse treatment.)
Obtaining the results of an HIV antibody test
Developing the first symptoms of HIV disease
Being diagnosed with AIDS.
AOD treatment counselors may wish to suggest the following strategies to patients who are at risk of relapse because of HIV-related stress:
Individual counseling
Participation in a peer support group
Medical attention to relieve physical discomfort and alleviate anxiety
The most successful relapse counseling is nonjudgmental. However, patients should understand that preventing relapse is their responsibility. If a patient relapses into a risk behavior for AOD or HIV, the counselor's role is to help the patient to understand the conditions that caused the behavior to occur and to identify alternative behaviors that could have been substituted to prevent the relapse.
Relapse should be viewed as a learning experience and part of the recovery process. Patients should not be dismissed from AOD abuse treatment or HIV support groups because of a relapse. Rather, peer pressure may be constructively used to help patients acknowledge the reasons for and the consequences of their actions.
Support groups fulfill a wide range of needs. In the AOD recovery process and in HIV treatment, they may be an important source of psychosocial support. They may also have an educational function, helping patients to gain knowledge and skills about the systems they must negotiate. Some support groups may have a patient advocacy role, helping to link programs and lobbying for funding to fill gaps in services.
No single organization can provide all the services needed by HIV-infected AOD abusers with mental health problems. AOD treatment programs should actively refer patients to appropriate outside support groups where their specialized needs can be met.
Among the factors that must be considered in structuring support groups are the need to protect patient confidentiality and the possible stigmatizing effect of identifying a group as being for HIV-infected patients. (See accompanying box that provides an example of a support group.)
Among the issues that should be considered in establishing and maintaining support groups are language and ethnicity, gender, sexual orientation, type of AOD use, stage of recovery from AOD use, and stage of HIV infection. Trust tends to develop more quickly in homogenous groups than in groups with a heterogenous membership, although the latter can also work very well.
Language. The language or language style of the therapist or support group leader sets a tone for the group and influences how successfully group members interact. Group leaders must be fluent in the language or vernacular spoken by patients.
Gender. Single-sex groups may be beneficial for both women and men in certain circumstances. Women who have suffered abuse may feel more able to divulge this information in a women-only group.
Many HIV-positive women may not have told their partners about their status and some may be afraid of losing custody of their children if their status becomes known. Women who have been involved in the sex industry or in sex-for-drugs transactions may have difficulty speaking about these experiences in mixed settings and may benefit from participation in specialized single-sex groups.
Single-sex groups may also be beneficial for men who have difficulty discussing issues of sexuality, such as sexual abuse and incest, in a mixed-gender group.
Sexual orientation. Some patients may have difficulty achieving full recovery from AOD abuse without addressing issues related to sexual orientation. Homosexual and heterosexual IDUs may not always be comfortable with one another in groups. Ideally, if resources allow, specialized groups should be offered that are defined by both sexual orientation and gender.
Type of AOD use. Patients' perceptions and prejudices about the use of different substances are likely to surface in groups and affect the treatment process. For example, alcohol abusers may consider themselves less addicted than IDUs and may be unwilling to admit that they also use illicit drugs. In general, it is preferable to have separate groups for alcohol abusers, heroin abusers, cocaine abusers, and so on.
Stage of recovery from AOD use. An individual's stage of recovery may be as important as the type of substance abused. Although most AOD abuse treatment programs stress abstinence, patients in early recovery who are also dealing with HIV infection may find total abstinence difficult to achieve.
Stage of HIV infection. Segregating groups by stage of HIV infection presents difficulties, but not doing so can also be problematic. Patients who are HIV-positive but asymptomatic and attending a support group for the first time may be uncomfortable at encountering patients in the late stages of AIDS. Such a meeting may force them to confront fears about their own mortality before they are ready to do so.
Because treatment programs have limited resources, separating groups by stage of HIV infection may be impractical. Programs able to support separate groups (See Group Therapy, above) may wish to use the three-group model with groups of
The interplay between AOD abuse and HIV infection in groups can be complicated. As patients move further into AOD recovery, they may be getting progressively more ill from HIV disease. In a mixed group, healthier patients may provide support to sicker ones.
In a group consisting solely of patients with advanced HIV disease, members are vulnerable to becoming involved in a process of continual grieving. Sometimes groups have to discontinue for a period of time when too many members become sick or die. For this reason, it may be helpful to establish support groups for time-limited periods. (See Grief and Bereavement, below.)
Peer programs can provide support for AOD recovery and other psychosocial services. There are many resources in the community for these interventions; all that a program has to provide is a meeting place. It is helpful if the peer group facilitator has some training, even if this consists solely of the orientation that all AOD program volunteers receive. Potential problems with peer programs are confidentiality and liability. Because they are not led by professionals, peer groups may be limited in what they can achieve. However, the absence of professional involvement may give peer groups greater credibility with hard-to-reach patients.
Role playing is an effective health education technique that can be used to build patients' skills at negotiating for the use of a condom during sex, telling a partner or family members that one is HIV-infected, turning down an offer of drugs, or dealing with a public official.
Acupuncture. There is some evidence that acupuncture may be a beneficial adjunct to treatment for many forms of AOD abuse. It may, for example, help some patients to continue in treatment longer than they otherwise might.
Meditation is another supplement to traditional treatment that some patients may find helpful.
In addition to facing the prospect of disability and death from AIDS, many HIV-infected AOD abusers experience grief and bereavement as a result of the deaths of friends, lovers, spouses, and other family members. For AOD programs, dealing with patients' grief and bereavement presents three sets of issues:
Providing support and counseling for patients who
are dying as well as for patients who are experiencing the deaths of significant others
Supporting staff who are experiencing grief and stress as a result of working with dying patients
Establishing flexible program policies that accommodate the limitations of symptomatic HIV-infected patients.
Patients facing progressive illness and disability need a variety of supportive services:
Support groups and supportive individual counseling
Education about healthcare and the expected course of illness (to reduce uncertainty, anxiety, and fear)
Support in dealing with denial, especially if it interferes with receiving medical care.
Counseling of ill and dying patients should be supportive and nonconfrontational, addressing issues relevant to the patient's illness at a pace determined by the patient. Patients who are in denial about their illness will delay making arrangements for medical and nursing care and procuring assistance with activities of daily living. Counseling can play an important role in helping patients to accept the eventual need for home health or hospice care.
Bereavement is a particular problem for programs with large numbers of HIV-infected patients. The following are some strategies that may be helpful in supporting patients who are dealing with bereavement:
Acknowledging the reality of bereavement in supportive individual counseling
Encouraging the expression of grief both verbally and nonverbally (for example, through art therapy and other similar interventions)
Providing group support for clients who are experiencing grief and bereavement
Acknowledging patients' deaths with memorial services, flowers, photographs, and participation in commemorative projects such as the NAMES quilt.
Staff working with HIV-infected AOD abuse patients may experience high levels of stress. Not only are counselors and other staff members continually confronting the illness and death of their patients, but AOD treatment personnel themselves -- many of whom are themselves recovering AOD abusers -- may also be infected with HIV and facing the same health problems as their patients.
To address these problems, staff should be rotated periodically, although not so frequently that there is no consistency for patients. Attendance at a staff support group should be mandatory; whatever the scheduling difficulties, this group should meet at least monthly. Staff members who are themselves recovering AOD abusers need to acknowledge their own potential for relapse because of the stress of their work.
Inservice training programs on stress management and issues related to death and dying can also be helpful to staff working with HIV-infected AOD abuse patients.
Programs may need to adjust their expectations of treatment outcome to accommodate patients who are facing progressive disability from HIV disease. Standards established for the treatment of relatively healthy AOD abusers may not be appropriate for symptomatic HIV-infected individuals.
Opioid substitution therapy programs. Patients maintained on methadone are normally expected to attend the methadone clinic every day to receive their medication. But as HIV-infected patients develop symptoms such as fatigue, shortness of breath, and nerve and muscle damage, daily clinic attendance will become more difficult and may eventually become impossible. Flexible policies regarding "take home" methadone doses are required to meet the needs of these patients.
Residential treatment programs. Patients with symptomatic HIV disease may be physically unable to perform all the tasks normally expected of members of a residential treatment program. Programs should have the flexibility to accommodate these patients' limitations by offering them lighter duties.
In addition, the length of residential treatment programs may be unrealistic for symptomatic HIV-infected patients. Walden House, a residential AOD treatment program in San Francisco, offers a 6- to 12-month program for patients with HIV disease. Shorter treatment programs may be necessary to meet the needs of individuals with HIV disease whose life expectancy may be limited but who nevertheless can benefit from AOD treatment.
HIV education. At this stage in the HIV epidemic, given the close links that exist between HIV and AOD, all those working in the AOD treatment field should be knowledgeable about HIV disease. In particular, AOD abuse counselors should understand HIV transmission routes, risk assessment and reduction techniques, and basic medical information about HIV/AIDS.
Sexuality. Good clinical supervision can help counselors overcome their difficulty in discussing sensitive issues such as sexuality. With training, AOD counselors can learn techniques for helping clients to talk about the intimate details of their sexual behavior. They can also learn how to use a candle, banana, or some other prop to demonstrate the proper use of a condom.
Education about mental illness. Counselors should receive training that addresses fundamental mental illness issues. Cross-training that addresses mental illness in relation to HIV disease is also important.
Risk reduction. Programs may find that discussions of risk reduction can best be handled by a staff member who specializes in HIV education. Educational material for patients about HIV is available from most State health department libraries. For information about training programs in HIV education for AOD abuse treatment providers, contact the appropriate State health department.
In this rapidly changing field, counselors must be ready to be honest about not knowing the answer to every question. Because of the large volume of new information that is continually being generated about both HIV infection and AOD abuse, regular educational updates for staff are essential. Educational sessions should be held at least once a month.
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