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Patologie infettive e doppia diagnosi


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Patologie infettive e doppia diagnosi

Patologie infettive e doppia diagnosi

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  • 1. Patologie infettive e dipendenze patologiche: epidemiologia, management e organizzazione Fabrizio Starace Direttore, UOC Psichiatria, A.O. Cotugno Docente Psichiatria Sociale, Università di Napoli Hon. Lecturer in Public Health, UCL (UK)
  • 2.
    • Since the beginning of the HIV epidemic, dual disorders (psychiatric and substance use) have raised the attention of clinicians
    • These disorders:
    • increase the risk of acquiring HIV,
    • can be reactive to the state of having an incurable and often fatal illness,
    • can be engendered by CNS complications of the infection and its treatment, and
    • impact access to care and treatment opportunities – both due to providers and patients issues.
  • 3. Prevalence of Triple Diagnosis
    • In a US sample (n=1097) receiving HIV care:
      • 60% percent reported symptoms of mental illness (general population rate 22%)
      • 32% reported substance use problems (general population rate 9.5%)
      • 23% reported both substance use problems and symptoms of mental illness (general population rate 3%)
    • Soto, T. (2005)
  • 4. Tasso di incidenza (casi x 1.000.000 ab.) di casi AIDS tra i consumatori di stupefacenti per via iniettiva negli Stati membri dell’EU. Anni 1997 - 2007
  • 5. Distribuzione percentuale delle nuove diagnosi di infezione da HIV per modalità di trasmissione e anno
  • 6.
    • Sexual risk behaviors associated with drug use:
      • sex with IDU partners
      • sex in exchange for money / drugs
      • impaired judgment, reduced impulse control, unsafe sexual activity while high on alcohol / drugs
      • drug use is associated with  rates of STIs and HCV/HBV
    Association of Alcohol/Other Drug Use with Risk for HIV
  • 7. Casi cumulativi di AIDS da contatto eterosessuale in adulti, per tipo di rischio e sesso
  • 8.
    • Multiple U.S. studies: Adults with severe mental illness have elevated rates of HIV infection
    • National U.S. health survey: Adults with depression and certain anxiety disorders (GAD, PD) were more likely to engage in HIV risk behavior than those without these disorders.
    • National U.S. study of substance use programs: Adults with both psychiatric and substance abuse disorders have higher rates of HIV infection than those with substance abuse disorders alone.
    Association of Mental Illness and HIV Risk
  • 9.
    • COSMIC Study (UK, 2003):
    • 75% (95% CI 68.2-80.2) of drug service and 85% of alcohol service patients (95% CI 74.2-93.1) had a past-year psychiatric disorder
    • Most comorbidity patients appear ineligible for cross-referral between services
    Co-occurrent Disorders Drug & Alcohol Abuse Centres
  • 10.
    • Drug Report (Italy, 2007)
    • 22% (range: 13-51%) of 6000 Drug & Alcohol Centres patients – compliant with assessment – reported psychiatric disorders
      • Personality Dis. 56%
      • Affective Psych. 18%
      • Neurotic Dis. 10%
      • Schizophrenic Dis. 7%
    Co-occurrent Disorders Italian National Survey
  • 11.
    • COSMIC Study (UK, 2003):
    • 44% of Community Mental Health Users (95% CI 38.1-49.9) reported past-year problem drug use and/or harmful alcohol use
    Co-occurrent Disorders Community Mental Health Centres
  • 12.
    • Drug Use Report (Italy, 2007)
    • 4% (range: 2,6-4,4%) of Community Mental Health Centres patients – compliant with assessment – reported substance abuse
    Co-occurrent Disorders Italian National Survey
  • 13. HIV testing in IVDUs : an unmeet need 1990: HIV prev. 31% 2000: HIV prev. 16% Dati su 1.299.972 soggetti di 510 SerT B. Suligoi et al J Medical Virology 73:1-6 (2004) Prev. HIV Solo il 35% dei tossicodipendenti viene testato 10 - 19% < 10% 20 - 25% 26-40% > 40%
  • 14. Utenti sottoposti a test sierologico HIV sul totale assistiti e percentuale utenti positivi al test sul totale soggetti testati. Anni 1991 - 2009
  • 15. Percentuale utenti positivi al test HIV sul totale soggetti testati, secondo il genere e il tipo di contatto con il servizio. Anni 1991 - 2009
  • 16. Utenti sottoposti a test sierologico HIV sul totale assistiti, per area geografica. Anno 2009
  • 17. Percentuale utenti positivi al test HIV sul totale soggetti testati, per area geografica. Anno 2009
  • 18. HIV testing: PERSONE DETENUTE HIV test solo nel 32,5% (3-100% a seconda dell’istituto) ( Ministero della Giustizia-Dipartimento dell’Amministrazione penitenziaria –DAP) Indagine in 12 istituti carcerari 38% HCV+ 6,7% HBSAg+ HIV 7,5%-12% Co-infezione HIV/HCV: 58%-85% Co-infezione HIV/HBV 6,8%-10% (Hepatitis Summit 2009)
  • 19. HIV testing : PERSONE MIGRANTI Nel 2009 4,5 milioni di immigrati in Italia (Circa 25% illegali) PRISHMA Study (ISS) Tested 3303 Illegal adult migrants (2004-2007) HIV+ prevalence: 0,97% (vs. 0,26% popolazione gen.) HIV+ estimated incidence: 52-64 x 100.000 (vs. 6,7 x 100.000 popolazione gen.) (Pezzoli C et al , EID; 2009) New cases of HIV infection from 11% (1992) to 31,6% (2008) (ISS, COA, 2010)
  • 20. Schwartz-Watts et al., 1995 223 USA 5.4% Acuda & Sebit, 1996 143 ZIMBAWE 23.8% Ayuso-Mateos et al., 1997 390 SPAGNA 5.1% Hutchinson & Simenon, 1999 1227 TRINIDAD & TOBAGO 6.9% Blank et al., 2002 391.454 USA 3.8% Essock et al., 2003 969 USA 3.6% Tharyan et al., 2003 1160 INDIA 1.03% Pirl et al., 2005 655 USA 2.7% 62 testati per l'HIV 29% Autori Popolazione Sieroprevalenza HIV testing : PERSONE CON DISTURBI PSICHIATRICI
  • 21. Majority: Alcohol / substance use disorders and HIV with comorbid depressive, anxiety, personality disorders. Minority: Recurrent psychotic disorders (schizophrenia, mania, depression with psychosis, psychosis NOS) with comorbid alcohol / substance use disorders and HIV. The Triply Diagnosed Patient: HIV Infection, Mental Illness, and Alcohol / Other Drug Use (AOD) Disorders
  • 22. Patients with HIV, Mental Illness, and AOD: Treatment dilemma
    • Access to and integration of mental health / substance use and infectious diseases services.
    • Adherence in patients with three chronic relapsing disorders.
    • Drug interactions, side effects and toxicities
  • 23. Triple Diagnosis: Treatment
    • People with mental illness and drug use are less likely to receive ART than any other population
    • Factors associated with poor access to treatment include
      • Active drug use
      • Younger age
      • Female gender
      • Sub-optimal health care
      • Not being in a drug treatment program
      • Recent incarceration
      • Lack of health care provider expertise (DHHS, 2008)
  • 24. Triple Diagnosis: Treatment
    • DHHS Guidelines state that ART can be successful in IDUs (DHHS, 2008)
    • ART requires
      • Supportive clinical care sites
      • Awareness of interactions with methadone
      • Awareness of increased risk of side effects and toxicities
      • Use of simple regimens to enhance adherence
  • 25. Drug Interactions: HIV+ AOD Users
    • + psychiatric medications
    • + drugs of abuse
    • + HIV medications
    • + medications to treat substance use disorders
    • = Drug Interactions
    • Consider drug-drug interactions:
      • absorption may be changed by HIV medications
      • competition for protein binding affects free drug
      • overlapping metabolic pathways in cytochrome P-450 system (3A4 and 2D6) may produce induction/inhibition of CYP450 altering drug levels
  • 26. Interactions Between Antiretrovirals and Other Medications
    • Many interactions occur and much is unknown
    • Methadone dose may need to increase (decrease) depending on the antiretroviral regimen (delavirdine, nevirapine)
    • St. John’s Wart lowers antiretrovirals
    • A lethal overdose reported in a patient on ritonavir who used ecstasy (MDMA)
    • Sildenafil (Viagra ® )
      • Increases Ritonavir, Saquinavir & Amprenavir
      • Poppers- fatal
  • 27. Methadone Maintenance and ARVs (1)
    • Methadone is metabolized by the cytochrome P450 system
      • Increases or decreases in methadone levels are mainly caused by inhibition or induction of cytochrome P450 by other drugs
      • This can result in opiate withdrawal or overdose and/or increase in toxicity or decreased efficacy of drugs administered concurrently with methadone
  • 28. Methadone and Antiretrovirals NRTIs Recommendations abacavir
    • combination appears safe
    didanosine/ stavudine
    • no data to guide dose adjustments
    • monitor for virologic failure
    didanosine EC
    • combination appears safe
    • monitor for zidovudine-related toxicities (e.g., nausea, vomiting, bone marrow suppression)
  • 29. Methadone and Antiretrovirals NNRTIs Recommendations delavirdine
    • since delavirdine inhibits 3A4, monitor for symptoms of opiate toxicity (e.g., myosis, drowsiness,  rate/depht respiration, constipation, bradychardia, hypotension) until further data
    • monitor for symptoms of opiate withdrawal (e.g., lacrimation, rhinorrhea, diaphoresis, restlessness, insomnia, dilated pupils, piloerection)
    • adjust methadone dose as needed
    • monitor for symptoms of opiate withdrawal
    • adjust methadone dose as needed
  • 30. Methadone and Antiretrovirals PIs Recommendations amprenavir
    • combination appears safe based on preliminary data
    • combination appears safe
    indinavir, nelfinavir, ritonavir, saquinavir
    • monitor for symptoms of opiate withdrawal
    • adjust methadone dose as needed
    lopinavir/ ritonavir
    • combination appears safe; monitor for symptoms of opiate withdrawal
    • adjust methadone dose as needed
    • monitor for symptoms of opiate withdrawal
    • adjust methadone dose as needed
    ritonavir/ saquinavir
    • monitor for symptoms of opiate withdrawal
    • adjust methadone dose as needed
  • 31.
    • Drug Interaction: Possible
    • Amphetamine  w/ritonavir (possibly fatal)
    • Ecstasy  w/ritonavir (fatal), PIs, efavirenz
    • Speed  w/PI - ritonavir
    • Heroin may  or 
    • Ketamine  w/ritonavir, nelfinavir, efavirenz, other ARV
    • Cocaine Unknown
    • GHB  w/ARV - specially ritonavir
    • LSD  w/ARV
    • PCP  w/ARV
    Interactions Between Antiretrovirals and Recreational Drugs
  • 32. ARVs and Psychotropics: Some Examples (1)
    • Ritonavir co-administration can increase levels of:
      • amitriptyline, desipramine
      • Mirtazapine
      • Paroxetine
      • Venlafaxine
      • Fluvoxamine
      • Risperidone
      • Zolpidem
      • Olanzapine
  • 33. ARVs and Psychotropics: Some Examples (2)
    • PI and NNRTI levels can be decreased with co-administration of:
      • Carbamazepine
      • Oxcarbazepine
  • 34. Psychiatric Complications of Antiretroviral Agents
    • CNS effects of Efavirenz demonstrated in cohorts, clinical studies
      • Up to 50% of patients in clinical studies experience dizziness, headache, confusion, impaired concentration, and abnormal or vivid dreams
        • Usually resolve in 2-4 weeks
      • Current practice indicates close monitoring in EFV-treated patients with current or history of psychiatric illness; EFV not contraindicated
    • Case reports with other agents:
      • Zidovudine: mania, depression, insomnia, headaches
      • Abacavir: psychosis
      • Nevirapine: psychosis
  • 35. Treatment Models
    • Sequential: The first and historically most common model of dual disorder is sequential. The client is treated by one system and then the other.
    • Parallel: The simultaneous involvement of the client in both mental health and addiction treatment settings
    • Integrated : Combines elements of both mental health and addiction treatment into unified and comprehensive treatment program for clients with dual disorders.
  • 36. Integrated Treatment
    • Core Components
      • Integration of Services
      • Comprehensiveness
      • Reduction of Negative consequences
      • Long-Term Perspective
      • Motivation-Based Treatment
      • Assertiveness
  • 37. Integration of Services
    • Provision of services for mental illness / substance abuse and HIV infection simultaneously
    • These services should be provided by the same team within the same organization
      • Helps to avoid gaps of service delivery
      • Helps to ensure that both types of disorders are treated effectively
  • 38. Comprehensiveness
    • Provision of services directed not only at the problems of substance abuse / mental illness and HIV, but also the broad array of other areas of functioning that are frequently impaired in the lives of the triply diagnosed client
      • Housing -Vocational Functioning
      • Family/Social relationships
      • Ability to manage psychiatric illness
  • 39. Reduction of Negative Consequences
    • This is the philosophical dimension of integrated treatment
    • Due to the damaging impact dual disorders have on the lives of clients, the first and foremost goal of the clinician is to reduce harmful effects
      • Do this without judging or imposing your personal values on the client regarding the causes or the moral responsibility for the consequences
  • 40. Long-Term Perspective
    • This addresses the need for time-unlimited services
    • Consider budget constraints !
  • 41. Motivation-Based Treatment
    • This orients the clinician as to specific interventions to use, depending of the clients desire to change their behavior
    • This avoids unnecessary and potentially destructive conflict between the client and clinician
    • This helps to maximize treatment gains through collaborative work
  • 42. Assertiveness
    • This addresses the location of service provision and how a client is engaged in treatment
    • Effective treatment programs for the triply diagnosed client does not wait for often reluctant clients seeking treatment on their own
    • Effective treatment programs use assertive outreach and legal mechanisms to involve the client in treatment
  • 43. “ Drug addicts should not die in a queue” (2004) Bjarne Hakon Hanssen Minister of Health, Norway (2008-2009)