Treatment for HIV-Infected Alcohol and Other Drug Abusers Treatment Improvement Protocol (TIP) Series: 15
[Exhibits]
Exhibit 2-1 DSM-IV Diagnostic Criteria For Substance Dependence
DSM-IV Diagnostic Criteria For Substance Dependence
The DSM-IV defines AOD addiction as "substance dependence," which is described as a maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by three or more of the following occurring at any time in the same 12-month period:
Tolerance, as defined by either of the following:
The need for markedly increased amounts of the substance to achieve intoxication or desired effect.
Markedly diminished effect with continued use of the same amount of the substance.
Withdrawal, as manifested by either of the following:
The characteristic withdrawal syndrome for the substance.
The same (or closely related) substance is taken to relieve or avoid withdrawal symptoms.
The substance is often taken in larger amounts or over a longer period than was intended.
Persistent desire or unsuccessful efforts to cut down or control substance use.
A great deal of time is spent in activities necessary to obtain or use the substance or to recover from its effects.
Important social, occupational, or recreational activities are given up or reduced because of substance use.
Continued substance use occurs despite user's knowledge that he or she has a persistent or recurrent physical or psychological problem that is probably caused or exacerbated by the substance.
Adapted with permission from American Psychiatric Association, 1994.
Exhibit 2-2 Components of CSAT's Comprehensive AOD Treatment Model
Components of CSAT's Comprehensive AOD Treatment Model
Assessment, to include a medical examination, drug use history, psychosocial evaluation, and where warranted, a psychiatric evaluation, as well as a review of socioeconomic factors and eligibility for public health, welfare, employment, and educational assistance programs.
Same-day intake, to retain the patient's involvement and interest in treatment.
Documenting findings and treatment, to enhance clinical case supervision.
Preventive and primary medical care, provided onsite.
Testing for infectious diseases, at intake and at intervals throughout treatment, for infectious diseases, such as hepatitis, retrovirus, tuberculosis, HIV/AIDS, syphilis, gonorrhea, and other sexually transmitted diseases.
Weekly random drug testing, to ensure abstinence and compliance with treatment.
Pharmacotherapeutic interventions, by qualified medical practitioners, as appropriate for patients having mental health disorders, addiction to opiates, and HIV-seropositivity.
Group counseling interventions, to address the unique emotional, physical, and social problems of HIV/AIDS patients.
Basic substance abuse counseling, including psychological counseling, psychiatric counseling, and family or collateral counseling provided by persons certified by State authorities to provide such services. Staff training and education are integral to successful treatment programs.
Practical life skills counseling, including vocational and educational counseling and training, frequently available through linkages with specialized programs.
General health education, including nutrition, sex and family planning, and HIV/AIDS counseling, with an emphasis on contraception counseling for adolescents and women.
Peer/support groups, particularly for those who are HIV-positive or who have been victims of rape or sexual abuse.
Liaison services with immigration, legal aid, and criminal justice system authorities.
Social and athletic activities, to retrain patients' perceptions of social interaction.
Alternative housing for homeless patients or for those whose living situations are conducive to maintaining the addicted lifestyle.
Relapse prevention, which combines aftercare and support programs, such as Alcoholics Anonymous and Narcotics Anonymous, within an individualized plan to identify, stabilize, and control the stressors which trigger and promote relapse to substance abuse.
Outcome evaluation, to enable refinement and improvement of service delivery.
Exhibit 3-1 Models of Medical Care in AOD Treatment Programs
There is considerable variation in the levels of medical care provided by AOD treatment programs.
Inpatient treatment programs generally have fairly extensive onsite medical capabilities for providing medical care to patients or are closely affiliated with a nearby medical center. 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 but concentrate on providing psychosocial services.
Opioid substitution therapy programs, formerly referred to as methadone maintenance programs, are required to have a medical director, although this individual's active clinical presence may be minimal. Nursing staff are onsite primarily to dispense methadone. Some programs have begun to dispense LAAM (levo-alpha-acetyl-methadol). Many methadone programs have begun to develop more comprehensive onsite primary medical care services, although wide variations persist. These programs serve clients who have abused heroin or other opioid drugs.
Therapeutic communities are residential and generally have minimal onsite medical capabilities. They tend to rely on outside sources of medical care. They also primarily serve opioid users.
The most successful onsite medical systems provide a range of medical services, including
Health maintenance and prevention
Screening for infectious diseases
HIV counseling and testing
Prophylaxis against TB and HIV-related opportunistic infections
Antiretroviral therapy
Immunizations
Family planning and pregnancy services
Treatment of episodic illness, hospital followup, and coordination of care.
Source: Batki and London, 1991; O'Connor et al., 1992; Selwyn et al., 1993; Umbricht-Schneiter et al., 1994.
Exhibit 3-3 Recommended Elements of a Contractual Arrangement For Primary Medical Care Services
Recommended Elements of a Contractual Arrangement For Primary Medical Care Services
The following are service elements that AOD 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 (for example, nurse practitioner, physician assistant)
Diagnostic and treatment services, such as radiology, specialty medical clinics, and hospitalization.
At a minimum, freestanding chemical dependency 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.
Exhibit 3-4 1993 Revised Classification System for HIV Infection and Expanded AIDS Surveillance Case Definition for Adolescents and Adults
1993 Revised Classification System for HIV Infection and Expanded AIDS Surveillance Case Definition for Adolescents and Adults
Clinical Categories
CD4+ T-cell categories
(A) Asymptomatic, Acute (Primary) HIV or PGL*
(B) Symptomatic, Not (A) or (C) Conditions
(C) AIDS-- Indicator Conditions
(1) >=500/µL
A1
B1
C1
(2) 200-499/µL
A2
B2
C2
(3) <200/µL AIDS-Indicator T-cell count
A3
B3
C3
(Shaded area indicates that the individual has AIDS.)
CD4+ T-Lymphocyte Categories
The three CD4+ T-lymphocyte categories are defined as follows:
Category 1: >500 cells/µL
Category 2: 200--499 cells/µL
Category 3: <200 cells/µL
These categories correspond to CD4+ T-lymphocyte counts per microliter of blood and guide clinical and therapeutic actions in the management of HIV-infected adolescents and adults. The revised HIV classification system also allows for the use of the percentage of CD4+ T-cells.
HIV-infected persons should be classified based on existing guidelines for the medical management of HIV-infected persons. Thus, the lowest accurate, but not necessarily the most recent, CD4+ T-lymphocyte count should be used for classification purposes.
Clinical Categories
The clinical categories of HIV infection are defined as follows:
Category A
Category A consists of one or more of the conditions listed below in an adolescent or adult (>= 13 years) with documented HIV infection. Conditions listed in Categories B and C must not have occurred.
Asymptomatic HIV infection
Persistent generalized lymphadenopathy
Acute (primary) HIV infection with accompanying illness or history of acute HIV infection
Category B
Category B consists of symptomatic conditions in an HIV-infected adolescent or adult that are not included among conditions listed in clinical Category C and that meet at least one of the following criteria: a) the conditions are attributed to HIV infection or are indicative of a defect in cell-mediated immunity, or b) the conditions are considered by physicians to have a clinical course or to require management that is complicated by HIV infection. Examples of conditions in clinical Category B include, but are not limited to
Bacillary angiomatosis
Candidiasis, oropharyngeal (thrush)
Candidiasis, vulvovaginal: persistent, frequent, or poorly responsive to therapy
Cervical dysplasia (moderate or severe)/cervical carcinoma in situ
Constitutional symptoms, such as fever (38.5 C) or diarrhea lasting >1 month
Hairy leukoplakia, oral
Herpes zoster (shingles), involving at least two distinct episodes or more than one dermatome
Idiopathic thrombocytopenic purpura
Listeriosis
Pelvic inflammatory disease, particularly if complicated by tubo-ovarian abscess
Peripheral neuropathy.
For classification purposes, Category B conditions take precedence over those in Category A. For example, someone previously treated for oral or persistent vaginal candidiasis (and who has not developed a Category C disease) but who is now asymptomatic should be classified in clinical Category B.
Category C
Category C includes the clinical conditions listed in the AIDS surveillance case definition (Appendix below ). For classification purposes, once a Category C condition occurs, the person will remain in Category C.
APPENDIX. Conditions Included in the 1993 AIDS Surveillance Case Definition
Candidiasis of bronchi, trachea, or lungs
Candidiasis, esophageal
Cervical Cancer, invasive **
Coccidioidomycosis, disseminated or extrapulmonary
Mycobacterium avium complex or M. kansasii, disseminated or extrapulmonary
Mycobacterium tuberculosis, any site (pulmonary or extrapulmonary)
Mycobacterium, other species or unidentified species, disseminated or extrapulmonary
Pneumocystis carinii pneumonia
Pneumonia, recurrent**
Progressive multifocal leukoencephalopathy
Pulmonary pneumonia**
Salmonella septicemia, recurrent
Toxoplasmosis of brain
Wasting syndrome due to HIV
* PGL-persistent generalized lymphadenopathy. Clinical Category A includes acute (primary) HIV infection. **Added as AIDS-defining illness in the 1993 expansion of the AIDS surveillance case definition, when occurring in persons with HIV infection.
Exhibit 3-6 Recommended CD4+ Testing Frequencies and Thresholds For Initiation of Antiretroviral Therapy
Recommended CD4+ Testing Frequencies and Thresholds
For Initiation of Antiretroviral Therapy
Testing Frequency
500 and over = Every 6 months
Less than 500 down to 50 = Every 3 months
Less than 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+ count).
Antiretroviral Therapy
Recommendations from the 1993 National Institute of Allergy and Infectious Diseases (NIAID) State-of-the-Art Conference (Sande et al., 1993):
Clinical Status
CDR+ Range, Cell Count
Recommendation
No Previous Antiretroviral Therapy
Asymptomatic
>500
No therapy
Asymptomatic
200-500
Zidovudine or no therapy
Asymptomatic
<200
Zidovudine
Symptomatic
<200
Zidovudine
Previous Antiretroviral Therapy
Stable
>300
Continue zidovudine
Stable
<300
Continue zidovudine or change to didanosine
Progressing
50 to 500
Change to didanosine or zalcitabine
Progressing
<50
Change to didanosine or zalcitabine
Intolerant to Zidovudine
Stable or progressing
<50
Change to didanosine or zalcitabine
NOTE: Since the State-of-the-Art Conference made its recommendations, another antiretroviral agent--stavudine (d4T)-has been licensed by the Food and Drug Administration. The expert panel did not issue a formal recommendation on combination antiretroviral therapy (i.e., zidovudine + didanosine, zidovudine + zalcitabine, zidovudine + stavudine). However, combination therapy is an option that clinicians may wish to consider, and clinical trials are actively attempting to address the possible benefits and risks of this approach. Clinicians not familiar with this strategy should undertake consultation with an expert in HIV management before initiating combination therapy.
Exhibit 3-7 Initial Comprehensive Medical Evaluation for HIV-Infected Patients
Initial Comprehensive Medical Evaluation for HIV-Infected Patients
Clinical data supporting specific guidelines for comprehensive medical evaluation of HIV-infected patients are scarce. However, the following guidelines are generally accepted as reasonable.
Complete Medical History
Pay special attention to
Constitutional symptoms: fever, weight loss, fatigue, night sweats
Pulmonary: cough, shortness of breath
Gastrointestinal: sore throat, white plaques in mouth, odynophagia (painful swallowing), diarrhea, abdominal pain, hepatitis, or preexisting liver disease
Prior infections: sinusitis; pneumonia and other bacterial infections; exposure to hepatitis B virus (HBV); syphilis; history of TB, TB exposure, and results of previous tuberculin skin tests
Sexual history: sexual orientation; oral, vaginal, and anal intercourse; known risk behaviors of sexual partners; sexually transmitted diseases (STDs)
History of victimization (physical or sexual abuse)
In women, obstetrical and gynecological history: menstrual and pregnancy history, contraceptive use, sexually transmitted diseases (STDs), abnormal Pap smears, pelvic infections (including yeast infections)
Underlying medical conditions and comorbidity factors
Prescribed and nonprescribed medication use (including alternative and over-the-counter remedies)
Drug, alcohol, and tobacco use: type of substance, duration of use, amount, frequency, route of administration (for example, injection), treatment history.
Comprehensive Physical Examination
Pay special attention to
General: weight change, evidence of muscle wasting, adenopathy
Eye: exudates associated with cytomegalovirus (CMV) retinitis, toxoplasmosis
Skin: seborrheic dermatitis, psoriasis, evidence of molluscum contagiosum, Kaposi's sarcoma. (Also examine for skin signs of injection drug use, for example, fresh or old track marks, cellulitis, abscesses, old abscess scars, hyperpigmentation, and other evidence of multiple prior skin infections.)
Neurologic: complete neurologic examination including mental status exam changes, sensory and/or motor deficits. Assessment of functional status and mobility
Genitourinary: rectal exam; pelvic exam (women); evidence of chancroid, syphilis, HSV infection, molluscum contagiosum, candida infection, condylomata acuminata (human papillomavirus [HPV] infection), and other genital and perianal lesions.
Laboratory Tests and Followup
TB skin test with intradermal PPD (tuberculin) anergy panel (two intradermal antigen tests: mumps, tetanus, and/or candida)
CD4+ count
Syphilis serology: IDUs are known to have false-positive nontreponemal tests, for example, RPR, VDRL; confirm positive results via direct treponemal antibody testing, for example, FTA-Abs, MHA-TP
Gonorrhea and chlamydia culture (women and symptomatic men)
Pap smear: Screen all women every 6-12 months; women with HIV infection have more aggressive cervical dysplasia and cancer and more frequent candida infections.
Complete blood count (CBC) with differential
Multichannel chemistry panel (renal and liver function tests)
HBV panel: HIV seropositivity may lengthen duration of viremia from HBV.
Hepatitis C serology
Toxoplasmosis serology
Urinalysis: Access to urinalysis results from the AOD treatment provider is very helpful in assessing patients, but may be problematic without the patient's written consent for the release of such information.
Pregnancy test in women of childbearing age.
NOTE: There are no data to support the efficacy of routine chest x-rays for TB as a part of core services; however, all patients who are anergic to skin testing, who are PPD-positive and who have respiratory symptoms or other symptoms compatible with TB should receive a chest x-ray.
Source: Adapted from Hecht and Soloway, 1992-1993, with additional material from the New York State Department of Health, AIDS Institute.
Exhibit 3-8 Medical Complications of Substance Abuse That May Affect Differential Diagnosis of IDUs With HIV Infection
Medical Complications of Substance Abuse That May Affect Differential Diagnosis of IDUs With HIV Infection
Possible Diagnoses
Symptoms
HIV-Related
Substance Abuse-Related
1. Constitutional
Anorexia
Weight loss
Fever
Night Sweats
Diarrhea
HIV Infection Mycobacterium avium complex Tuberculosis
Cocaine use Injection-related bacterial infections Tuberculosis Herion withdrawal
Source: Reprinted with permission from the New England Journal of Medicine (O'Connor et al., 1994)
Exhibit 3-9 Preventive Healthcare for Injection-Drug Users With HIV Infection
Preventive Healthcare for Injection-Drug Users With HIV Infection
Complication
Activity
1. HIV infection:
Complete blood cell and CD4+ count
Antiretroviral therapy (if indicated)
Assessment for opportunistic infections
Prophylaxis against opportunistic infections (e.g., Pneumocystis carinii pneumonia)
2. Bacterial infection:
Pneumococcal vaccination (recommended) Hemophilus influenza vaccination (to be considered)
3. Tuberculosis:
Skin testing (including assessment for anergy)
Chest roentgenogram (x-ray)
Isoniazid (INH) chemoprophylaxis, if indicated
4. Sexually transmitted disease:
Syphilis serology
5. Hepatitis:
Liver function testing
Hepatitis serology (A, B, C)
Hepatitis B vaccination
6. Cervical cancer:
Pap smear
Exhibit 3-10 Opportunistic Infections (OIs) in HIV Disease
Exhibit 3-11 Factors Hindering Food Consumption in HIV-Infected Patients
Factors Hindering Food Consumption in HIV-Infected Patients
Problem
Intervention
Anorexia (poor appetite)
Small, frequent meals; calorie- and protein-dense foods; relaxation techniques before meals; appetite stimulants, e.g., megestrol acetate
Nausea
Cold, bland, dry foods
Vomiting
Liquid diet (temporarily). Eat when asymptomatic; antiemetics as needed.
Diarrhea
Use of bulking agents; fluid replacement
Early satiety
Small, frequent meals. Avoid liquids before meals.
Dysphagia (difficulty swallowing)
Soft, blenderized or pureed foods or baby foods as tolerated; calorie- and protein-dense supplements
Odynophagia (pain upon swallowing)
Same as for dysphagia, plus avoidance of foods that cause pain (soda bubbles, 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
Source: New York State Department of Health AIDS Institute; adapted from Rakower and Galvin, 1989.
Exhibit 3-12 Alternative Therapies and Unapproved Medications Used by HIV-Infected AOD Abuse Patients
Alternative Therapies and Unapproved Medications Used by HIV-Infected AOD Abuse Patients
Alternative therapies
"Lifestyle" treatments--acupuncture, massage, exercise, meditation, special diets, 12-step programs.
Nonprescription products--vitamins, other antioxidants, and herbal and homeopathic remedies.
"Off label" uses of approved medications and other unapproved remedies
Nonprescribed antibiotic use. AOD users commonly self-treat for fever and respiratory infections with nonprescribed antibiotics (Novick and Ness, 1984). In one large study, antibiotic misuse was associated with the occurrence of methicillin-resistant staphylococcal endocarditis among injection drug users in Detroit (Crane et al., 1986).
Off-label (i.e., not FDA-approved) use of immunomodulators. HIV-infected patients may take medications reported to have immunomodulating effects (e.g., cimetidine, disulfiram, naltrexone, pentoxiphylline) off label in the belief that these agents will enhance immune functioning.
Nonprescription use of HIV medications. In certain parts of the country, there is evidence of nonprescription ("street") use of zidovudine and other HIV-related medications such as acyclovir and TMP-SMX.
Kemron (low-dose alpha interferon). This unproven alternative remedy is used by HIV-infected patients in some communities.
Prescription Drug Abuse
Use of medications with abuse potential. Medications frequently prescribed to HIV-infected AOD abusers often have a high "street" value. Medications for pain or anxiety (e.g., oral opioids and benzodiazepines) are frequently abused. In addition, some medications are reported by drug users to treat drug-use-related symptoms or to have an enhancing effect on drugs of abuse (e.g., ranitidine and other H2 blockers for gastrointestinal distress; tricyclic antidepressants used with opiates; and inhaled bronchodilators used with crack cocaine).
Exhibit 3-13 Universal Precautions for AOD Programs Treating HIV-Infected Patients
Universal Precautions for AOD Programs Treating HIV-Infected Patients
The transmission of HIV infection is highly unlikely within institutions such as healthcare 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.
Barrier Precautions In any setting in which workers may come into contact with a patient's blood or body fluids, the following precautions should always be observed:
Gloves should be worn when touching blood or body fluids, mucous membranes, or nonintact skin; handling items or surfaces soiled with blood or body fluids; or performing vascular access procedures such as venipuncture.
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 body fluids.
Gowns or aprons should be worn during procedures likely to generate splashes of blood or other body fluids.
Hands and other skin surfaces should be washed immediately and thoroughly when contaminated with blood or other body fluids and whenever gloves are removed.
Use of Sharp Instruments
The following precautions should be taken to prevent injuries when using, cleaning, disposing of, or otherwise handling needles, scalpels, and other sharp instruments:
Do not recap needles, bend or break them by hand, remove them from disposable syringes, or otherwise handle them.
Place disposable "sharps" in puncture-resistant disposal containers immediately after use.
Place large-bore reusable needles in puncture-resistant containers for reprocessing.
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 lesions or weeping dermatitis should refrain from all direct patient care and from handling patient-care equipment until the condition resolves.
Pregnant workers should be especially familiar with, and should strictly adhere to, all of the above precautions.
Source: CDC, 1987b.
Exhibit 3-14 TB Infection Control Precautions for AOD Abuse Treatment Programs
TB Infection Control Precautions for AOD Abuse Treatment Programs
TB infection control practices within AOD abuse treatment programs should include the following:
Ventilation systems should conform to recommended standards of air exchange and circulation in healthcare facilities. In some substance abuse treatment settings (e.g., those housed in older buildings), all options for improving ventilation may need to be explored.
In areas with poor air circulation in which there are few practical remedies for improving ventilation, the use of properly shielded ultraviolet lights should be strongly considered, along with high-efficiency particulate air (HEPA) filters to remove contaminants from circulated air.
Programs should provide facial tissue in waiting rooms, and patients should be instructed to cover their mouths and noses with tissue when they cough or sneeze.
All patients with a persistent cough (lasting longer than 1 week) should be evaluated promptly for active TB. This is particularly important if patients also have constitutional symptoms (e.g., chronic fever, weight loss, or night sweats). The evaluation should include collection of sputum and a chest x-ray. If a program cannot provide these services onsite, patients should be accompanied to an appropriate outpatient or hospital referral site (with which the treatment program has a formal relationship) for evaluation.
The prompt and efficient evaluation of patients for active TB should be standardized and directly overseen by a medical staff person within the AOD program who is specifically charged with this responsibility. Delays or lapses in protocol for obtaining chest x-rays and/or sputum samples for acid-fast bacilli smears and cultures can lead to unwarranted exposures and increased risk of TB transmission to staff and patients.
Patients suspected of having active TB should be required to wear properly fitting masks in the clinic until they have been adequately evaluated. This is particularly important in cases where TB is strongly suspected but there is a delay in obtaining a chest x-ray and sputum samples to confirm the diagnosis. When active TB is strongly suspected, prompt hospitalization for evaluation is often the most advisable approach. Clinical staff in close contact with patients suspected of having TB should also wear properly fitting HEPA respirators, as recommended by the CDC/NIOSH guidelines on TB control (CDC, 1994b).
All patients and staff should undergo PPD skin testing at least annually. In areas with a high incidence of TB, PPD testing at intervals of 6 months should be considered.
Exhibit 4-1 Initial Mental Health Assessment for the HIV-Infected AOD Abuse Patient
Initial Mental Health Assessment for the HIV-Infected AOD Abuse Patient
Developmental/social history
Childhood trauma or illness
Education
Employment
Sexual orientation
Relationship history
Current support system/social network
Family
Family relationships
Family psychiatric history
Medical history
HIV history:
Date of diagnosis
Stage of disease according to CDC classification system (see Classification of HIV and AIDS, Chapter 3)
Most recent CD4+ lymphocyte ("T-cell") count
HIV-related illnesses
Other medical illnesses
Current medications
AOD use history
Age of onset of AOD use
AOD abuse description:
Types of substances
Amounts
Frequency
Route of administration
Past AOD abuse treatment
Past psychiatric history
Age of first psychiatric problems
Outpatient treatment
Inpatient treatment
Past diagnosis/diagnoses
Past medications and response
Current psychiatric symptoms
Behavior:
Agitation
Appearance or psychomotor retardation
Cognitive:
Level of arousal/alertness
Attention/concentration
Orientation
Memory
Calculation
Mood:
Depression
Mania
Emotional instability
Anxiety:
Acute vs. chronic
Symptom pattern (episodic, e.g. panic attacks vs. generalized)
Psychotic symptoms:
Thought disorder
Hallucinations
Delusions
Danger to self or others
Ability to care for self
Suicidality
Assaultive/homicidal ideation
Exhibit 4-2 Abbreviated SFGH Neuropsychiatric AIDS Rating Scale (NARS)
1
Abbreviated SFGH Neuropsychiatric AIDS Rating Scale (NARS)1
Cognitive/Behavioral Domains
NARS Staging
Orientation
Memory
Motor
Behavioral
Problem Solving
Activities of Daily Living
0 (Normal)
Fully oriented
Normal
Normal
Normal
Can solve everyday problems
Fully capable of self-care
.5 (Minor)
Fully 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 planning and completing work
Can do simple daily activities; 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 indepen-dently
4 (End Stage)
Confused and disoriented
Virtually no memory
Bedridden
Mute and unresponsive
No problem- solving ability
Nearly vegetative
1 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. The exhibit was adapted from Price and Brew, 1993; Hughes et al., 1982; and American Academy of Neurology, 1991.
Exhibit 4-3 Abuse Potential of Common Psychiatric Medications
Exhibit 4-4 Use of Medications for Psychiatric Disorders In HIV-Infected AOD Abusers
Use of Medications for Psychiatric Disorders In HIV-Infected AOD Abusers
A hierarchical or stepwise strategy should be followed in prescribing medications to HIV-infected AOD 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.
Insomnia/Sleep Disorders
When treating insomnia and sleep disorders in AOD/HIV abusers, 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 is extremely uncommon, occurring in less than 1 in 4,000 men taking trazodone.)
Hydroxyzine (Vistaril, Atarax) or diphenhydramine (Benadryl). Doses can start at 25 to 50 mg at bedtime and increase to 100 to 150 mg. These medications are generally not abusable, 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).
Tricyclic antidepressants (TCAs) such as amitriptyline (Elavil) or doxepin (Sinequan). Doses for sleep can start at 25 to 50 mg at bedtime. Numerous adverse effects (see Mood Disorders section of table, below). Often lethal in overdose (amounts > 1 g [1,000 mg]).
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.
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.
Anxiety
First Tier
Alternatives to pharmacologic intervention include relaxation techniques, meditation, supportive psychotherapy, or counseling, as well as stress management and reduction and possibly acupuncture. Some of these approaches should be tried before medications are introduced.
Second Tier
TCAs such as imipramine (Tofranil) are alternatives to potentially dependence-producing agents like the benzodiazepines.
Buspirone (BuSpar) is another nonabusable medication for chronic anxiety.
Patients must be warned that it is usually necessary to take either buspirone or the TCAs for at least 2 weeks before antianxiety effects are felt.
Third Tier
See third-tier section of insomnia/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.
Other possible alternatives to the benzodiazapines for 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 (for example, 1 week's supply). Hydroxyzine (Vistaril, Atarax) can also be used in doses of 25-50 mg in the daytime as needed as an antianxiety agent, although it is highly sedating.
Antipsychotics should not be used to treat anxiety if there is no evidence of psychosis, mania, or severe dementia.
Panic Attacks
First Tier
A nonbenzodiazepine medication such as a TCA, e.g., desipramine. Dosage should be in the same range that would be used to treat depression, with a more gradual increase over 1 to 2 weeks from 25 mg at bedtime to 150 mg at bedtime. Response takes 2 to 4 weeks. TCAs have numerous, moderately troublesome side effects (see Mood Disorders section, below). TCAs can be lethal in overdose (amounts > 1 g [1,000 mg]).
Second Tier
If TCAs are ineffective, too risky, or not tolerable because of adverse effects, benzodiazepines should be used. Alprazolam (Xanax) is probably used most frequently. Any benzodiazepine is likely to be effective when used in divided doses totaling approximately 10 to 60 mg per day of diazepam (Valium) or its equivalents. (See Insomnia/Sleep Disorders section for 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 AOD/HIV patient.
A careful evaluation must always be done before medications are prescribed. Mood disorder patients are at risk of suicide.
Second Tier
The serotonin reuptake inhibitor (SSRI) antidepressants--fluoxetine (Prozac), 20 mg per day; sertraline (Zoloft), 100 to 200 mg per day; and paroxetine (Paxil), 20 to 50 mg per day, are all safe and effective. They tend to be nonsedating and are generally 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 (Desyrel) is also extremely 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 very useful as a sleeping medication.
Bupropion (Wellbutrin) is another 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 three divided doses totalling 225 to 450 mg per day. Bupropion tends to increase the risk of seizures more than other antidepressants. Other side effects include jitteriness and insomnia. There is a lower incidence of sexual adverse effects with bupropion than with other antidepressants.
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. AOD-abusing patients may be more likely to request TCAs that have sedating effects, such as doxepin (Sinequan) and amitriptyline (Elavil).
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 should not be used until other medications have failed, but they should not be withheld solely because of a patient's AOD 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
Evaluation of the AOD abuser with mania must include a high level of suspicion that the disorder is caused by abuse of substances such as stimulants.
Lithium is as effective in the AOD/HIV patient as in the general population in treating mania in bipolar disorders. It is nonabusable 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 zidovudine (AZT), which has a similar adverse effect.
In patients maintained on methadone, 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.
Sodium valproate (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 AOD use such as "crack" cocaine intoxication or alcohol withdrawal. AOD use 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 AOD abusers, is rare.
Antipsychotic medications include haloperidol (Haldol), chlorpromazine (Thorazine), thioridazine (Mellaril), trifluoperazine (Stelazine), and many others. These medications are also occasionally used for the management of agitated confusional states, such as in late-stage dementia.
Clozapine (Clozaril) 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.
Dementia
A thorough medical evaluation of confusional states and cognitive decline in the demented patient should precede the use of psychiatric medications. Treatment for HIV infection, including zidovudine (AZT) and other antiretroviral medications, may lead to improvement in dementia.
Coping techniques such as those used in the treatment of Alzheimer's disease may increase adherence to treatment regimens among patients with HIV-associated cognitive and motor complex. For example, patients should be encouraged to keep appointment books. Stable housing can increase patients' likelihood of keeping scheduled appointments and taking medications. Frequent reminders, notes, and other memory aids can help.
Stimulants are sometimes helpful in treating depression accompanying dementia, especially in cases of severe psychomotor retardation. (See discussion above of fourth-tier mood disorders.) Low doses of high-potency antipsychotic medications such as haloperidol may be helpful in controlling agitated behavior accompanying dementia.
Benzodiazepines and other sedating medications should be avoided if possible because they can cause further confusion, memory impairment, and depression.
The recovery process may be conceptualized as having three stages.
First stage: Indivuals are still using AODs but are interested in recovery. Counseling should emphasize risk reduction. Second stage: Patients have completed detoxification and are in early recovery. They may be experiencing mood changes and cognitive difficulties. Focus of counseling should be on immediate, concrete issues such as sobriety. Third stage: Recovery becomes sustained. Depper emotional issues, such as relationships, can be probed during this stage.
Operates such programs as Head Start, which may have funding available for AOD prevention and education activities.
Centers for Disease Control and Prevention (CDC).
Funds State and community HIV prevention programs; also funds and regulates sexually transmitted disease (STD), TB, and HIV programs. Works with directors of AOD abuse treatment and public primary healthcare programs to develop common agendas on issues such as confidentiality of HIV testing and counseling.
Health Resources and Services Administration (HRSA).
Sponsor of Ryan White CARE Act. Funds community health clinics that bring together health and substance abuse services (through Medicaid's coordination of substance abuse services).
National Institutes of Health(NIH):
Office of AIDS Research, within Office of NIH Director, coordinates AIDS-related research activities of all NIH institutes. Research institutes with a major focus on substance abuse and/or HIV/AIDS are:
National Institute on Drug Abuse (NIDA).
National Institute on Alcohol Abuse and Alcoholism (NIAAA).
National Institute of Mental Health (NIMH). Activities include coordinating research and conducting demonstration trials of preventive therapies.
National Institute of Allergy and Infectious Diseases (NIAID). Conducts and funds most NIH-supported research on HIV/AIDS.
Substance Abuse and Mental Health Services Administration (SAMHSA):
Center for Substance Abuse Treatment (CSAT). Responsible for Substance Abuse Prevention and Treatment Block Grant program. Provides training and technical assistance to States.
Center for Substance Abuse Prevention (CSAP). Sponsors education and prevention efforts.
Center for Mental Health Services (CMHS). Interests include dual diagnosis (mental illness and substance abuse).
Indian Health Service (IHS). National AIDS Activities Office does national focus work (with main emphasis on prevention activities), funds all the nearly 300 IHS health facilities, and collects surveillance data for planning HIV/AIDS services funded by IHS.
Department of Housing and Urban Development (HUD). Funds Housing Assistance for People with AIDS (HAPWA) and Drug-Free Neighborhoods (DFN) programs.
Social Security Administration (SSA). Administers entitlement programs, including Supplemental Security Income (SSI), Social Security Disability Income (SSDI), and Medicaid.
Exhibit 7-1 Extract from Federal Regulations Concerning Sharing of Client Information
Extract from Federal Regulations Concerning Sharing of Client Information
The restrictions on disclosure in these regulations do not apply to communication of information between or among personnel having a need for the information in connection with their duties that arise out of the provision of diagnosis, treatment, or referral for treatment of alcohol or drug abuse if the communications are (i) within a program or (ii) between a program and an entity that has direct administrative control over that program (42 C.F.R. '2.12(c)(3)).
Exhibit 7-2Complying With Mandatory State HIV/AIDS Reporting Requirements and Federal AOD Disclosure Limitations
Complying With Mandatory State HIV/AIDS Reporting Requirements and Federal AOD Disclosure Limitations
Most States require reporting of HIV infection to public health authorities; all States require reporting of an AIDS diagnosis. Yet, Federal AOD regulations limit disclosure of client information. In resolving apparent conflicts between making mandated reports to States and not disclosing information as required by Federal AOD regulations, AOD programs should consider the following approaches in complying with both State and Federal requirements. (Considerations for reporting active TB cases to State authorities are covered further on in this chapter. In addition, for a more in-depth discussion of legal issues regarding TB, please see CSAT TIP, Legal and Ethical Issues Posed by the Tuberculosis Epidemic as it affects Alcohol and Other Drug Treatment Providers, in press.
Client consent. Programs could include a statement in the general AOD client consent form that the client's HIV/AIDS information will be reported to the State, as required by State law, and that the confidentiality of this information will be protected according to public health procedures.
Nonidentifying reporting. Some States allow for the use of nonidentifying codes instead of names in reporting HIV/AIDS information to public health authorities. Similarly, an AOD program that is part of a larger agency not identifiable as an AOD program could make mandated reports on behalf of the program and not mention the client's status in the AOD program. (This approach relates the exception to the prohibition of disclosure discussed under communications that do not disclose patient-identifying information, above.)
Qualified service organization agreements. A program can enter into a QSOA with the provider conducting HIV testing and testing for other reportable diseases (i.e., TB, STDs). The AOD program can then communicate to the provider the names of clients who have HIV/AIDS and the provider, in turn, can report these individuals to the public health authority as required, but without any AOD-identifying information. (This approach relates to the exception to the prohibition of disclosure discussed under QSOAs, above.)
Research. AOD abuse treatment programs can comply with State HIV/AIDS reporting requirements if the purpose of the State law is solely for research purposes (i.e., epidemiological tracking of the incidence and number of HIV/AIDS cases). This exception is not allowable if the State law's purpose is also to conduct contact-tracing of clients' sex and needle-sharing partners. (This approach relates to the exception to the prohibition of disclosure discussed under disclosure for research, audit, or evaluation purposes, above.)
Audit and evaluation. Several U.S. Department of Health and Human Services letters of opinion have approved use of the audit and evaluation provision for reporting HIV/AIDS information data to public health authorities. These HHS rulings allow the State to use the information in research as well as in carrying out contact tracing and partner notification. However, the rulings require that, in carrying out contact tracing and partner notification, the name of the infected client must remain anonymous.
Exhibit 7-3 Federal Law on Provision of Tuberculosis Services
Federal Law on Provision of Tuberculosis Services
States must require treatment entities receiving funds under grant to make available tuberculosis services to each individual receiving treatment; in the case of an individual denied admission due to a lack of capacity, entity will refer the individual to another provider of tuberculosis services (defined as counseling, testing, treatment).
(ADAMHA Reorganization Act of 1992, P.L. 102-321, '1924(a).
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