Your SlideShare is downloading. ×
0
Patologie infettive e doppia diagnosi
Patologie infettive e doppia diagnosi
Patologie infettive e doppia diagnosi
Patologie infettive e doppia diagnosi
Patologie infettive e doppia diagnosi
Patologie infettive e doppia diagnosi
Patologie infettive e doppia diagnosi
Patologie infettive e doppia diagnosi
Patologie infettive e doppia diagnosi
Patologie infettive e doppia diagnosi
Patologie infettive e doppia diagnosi
Patologie infettive e doppia diagnosi
Patologie infettive e doppia diagnosi
Patologie infettive e doppia diagnosi
Patologie infettive e doppia diagnosi
Patologie infettive e doppia diagnosi
Patologie infettive e doppia diagnosi
Patologie infettive e doppia diagnosi
Patologie infettive e doppia diagnosi
Patologie infettive e doppia diagnosi
Patologie infettive e doppia diagnosi
Patologie infettive e doppia diagnosi
Patologie infettive e doppia diagnosi
Patologie infettive e doppia diagnosi
Patologie infettive e doppia diagnosi
Patologie infettive e doppia diagnosi
Patologie infettive e doppia diagnosi
Patologie infettive e doppia diagnosi
Patologie infettive e doppia diagnosi
Patologie infettive e doppia diagnosi
Patologie infettive e doppia diagnosi
Patologie infettive e doppia diagnosi
Patologie infettive e doppia diagnosi
Patologie infettive e doppia diagnosi
Patologie infettive e doppia diagnosi
Patologie infettive e doppia diagnosi
Patologie infettive e doppia diagnosi
Patologie infettive e doppia diagnosi
Patologie infettive e doppia diagnosi
Patologie infettive e doppia diagnosi
Patologie infettive e doppia diagnosi
Patologie infettive e doppia diagnosi
Patologie infettive e doppia diagnosi
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×
Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

Patologie infettive e doppia diagnosi

953

Published on

Patologie infettive e doppia diagnosi

Patologie infettive e doppia diagnosi

Published in: Health & Medicine
0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total Views
953
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
0
Comments
0
Likes
0
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide

Transcript

  • 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. <ul><li>Since the beginning of the HIV epidemic, dual disorders (psychiatric and substance use) have raised the attention of clinicians </li></ul><ul><li>These disorders: </li></ul><ul><li>increase the risk of acquiring HIV, </li></ul><ul><li>can be reactive to the state of having an incurable and often fatal illness, </li></ul><ul><li>can be engendered by CNS complications of the infection and its treatment, and </li></ul><ul><li>impact access to care and treatment opportunities – both due to providers and patients issues. </li></ul>Background
  • 3. Prevalence of Triple Diagnosis <ul><li>In a US sample (n=1097) receiving HIV care: </li></ul><ul><ul><li>60% percent reported symptoms of mental illness (general population rate 22%) </li></ul></ul><ul><ul><li>32% reported substance use problems (general population rate 9.5%) </li></ul></ul><ul><ul><li>23% reported both substance use problems and symptoms of mental illness (general population rate 3%) </li></ul></ul><ul><li>Soto, T. (2005) </li></ul>
  • 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. <ul><li>Sexual risk behaviors associated with drug use: </li></ul><ul><ul><li>sex with IDU partners </li></ul></ul><ul><ul><li>sex in exchange for money / drugs </li></ul></ul><ul><ul><li>impaired judgment, reduced impulse control, unsafe sexual activity while high on alcohol / drugs </li></ul></ul><ul><ul><li>drug use is associated with  rates of STIs and HCV/HBV </li></ul></ul>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. <ul><li>Multiple U.S. studies: Adults with severe mental illness have elevated rates of HIV infection </li></ul><ul><li>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. </li></ul><ul><li>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. </li></ul>Association of Mental Illness and HIV Risk
  • 9. <ul><li>COSMIC Study (UK, 2003): </li></ul><ul><li>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 </li></ul><ul><li>Most comorbidity patients appear ineligible for cross-referral between services </li></ul>Co-occurrent Disorders Drug & Alcohol Abuse Centres
  • 10. <ul><li>Drug Report (Italy, 2007) </li></ul><ul><li>22% (range: 13-51%) of 6000 Drug & Alcohol Centres patients – compliant with assessment – reported psychiatric disorders </li></ul><ul><ul><li>Personality Dis. 56% </li></ul></ul><ul><ul><li>Affective Psych. 18% </li></ul></ul><ul><ul><li>Neurotic Dis. 10% </li></ul></ul><ul><ul><li>Schizophrenic Dis. 7% </li></ul></ul>Co-occurrent Disorders Italian National Survey
  • 11. <ul><li>COSMIC Study (UK, 2003): </li></ul><ul><li>44% of Community Mental Health Users (95% CI 38.1-49.9) reported past-year problem drug use and/or harmful alcohol use </li></ul>Co-occurrent Disorders Community Mental Health Centres
  • 12. <ul><li>Drug Use Report (Italy, 2007) </li></ul><ul><li>4% (range: 2,6-4,4%) of Community Mental Health Centres patients – compliant with assessment – reported substance abuse </li></ul>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 <ul><li>Access to and integration of mental health / substance use and infectious diseases services. </li></ul><ul><li>Adherence in patients with three chronic relapsing disorders. </li></ul><ul><li>Drug interactions, side effects and toxicities </li></ul>
  • 23. Triple Diagnosis: Treatment <ul><li>People with mental illness and drug use are less likely to receive ART than any other population </li></ul><ul><li>Factors associated with poor access to treatment include </li></ul><ul><ul><li>Active drug use </li></ul></ul><ul><ul><li>Younger age </li></ul></ul><ul><ul><li>Female gender </li></ul></ul><ul><ul><li>Sub-optimal health care </li></ul></ul><ul><ul><li>Not being in a drug treatment program </li></ul></ul><ul><ul><li>Recent incarceration </li></ul></ul><ul><ul><li>Lack of health care provider expertise (DHHS, 2008) </li></ul></ul>
  • 24. Triple Diagnosis: Treatment <ul><li>DHHS Guidelines state that ART can be successful in IDUs (DHHS, 2008) </li></ul><ul><li>ART requires </li></ul><ul><ul><li>Supportive clinical care sites </li></ul></ul><ul><ul><li>Awareness of interactions with methadone </li></ul></ul><ul><ul><li>Awareness of increased risk of side effects and toxicities </li></ul></ul><ul><ul><li>Use of simple regimens to enhance adherence </li></ul></ul>
  • 25. Drug Interactions: HIV+ AOD Users <ul><li>+ psychiatric medications </li></ul><ul><li>+ drugs of abuse </li></ul><ul><li>+ HIV medications </li></ul><ul><li>+ medications to treat substance use disorders </li></ul><ul><li>= Drug Interactions </li></ul><ul><li>Consider drug-drug interactions: </li></ul><ul><ul><li>absorption may be changed by HIV medications </li></ul></ul><ul><ul><li>competition for protein binding affects free drug </li></ul></ul><ul><ul><li>overlapping metabolic pathways in cytochrome P-450 system (3A4 and 2D6) may produce induction/inhibition of CYP450 altering drug levels </li></ul></ul>
  • 26. Interactions Between Antiretrovirals and Other Medications <ul><li>Many interactions occur and much is unknown </li></ul><ul><li>Methadone dose may need to increase (decrease) depending on the antiretroviral regimen (delavirdine, nevirapine) </li></ul><ul><li>St. John’s Wart lowers antiretrovirals </li></ul><ul><li>A lethal overdose reported in a patient on ritonavir who used ecstasy (MDMA) </li></ul><ul><li>Sildenafil (Viagra ® ) </li></ul><ul><ul><li>Increases Ritonavir, Saquinavir & Amprenavir </li></ul></ul><ul><ul><li>Poppers- fatal </li></ul></ul>
  • 27. Methadone Maintenance and ARVs (1) <ul><li>Methadone is metabolized by the cytochrome P450 system </li></ul><ul><ul><li>Increases or decreases in methadone levels are mainly caused by inhibition or induction of cytochrome P450 by other drugs </li></ul></ul><ul><ul><li>This can result in opiate withdrawal or overdose and/or increase in toxicity or decreased efficacy of drugs administered concurrently with methadone </li></ul></ul>
  • 28. Methadone and Antiretrovirals NRTIs Recommendations abacavir <ul><li>combination appears safe </li></ul>didanosine/ stavudine <ul><li>no data to guide dose adjustments </li></ul><ul><li>monitor for virologic failure </li></ul>didanosine EC <ul><li>combination appears safe </li></ul>zidovudine <ul><li>monitor for zidovudine-related toxicities (e.g., nausea, vomiting, bone marrow suppression) </li></ul>
  • 29. Methadone and Antiretrovirals NNRTIs Recommendations delavirdine <ul><li>since delavirdine inhibits 3A4, monitor for symptoms of opiate toxicity (e.g., myosis, drowsiness,  rate/depht respiration, constipation, bradychardia, hypotension) until further data </li></ul>efavirenz <ul><li>monitor for symptoms of opiate withdrawal (e.g., lacrimation, rhinorrhea, diaphoresis, restlessness, insomnia, dilated pupils, piloerection) </li></ul><ul><li>adjust methadone dose as needed </li></ul>nevirapine <ul><li>monitor for symptoms of opiate withdrawal </li></ul><ul><li>adjust methadone dose as needed </li></ul>
  • 30. Methadone and Antiretrovirals PIs Recommendations amprenavir <ul><li>combination appears safe based on preliminary data </li></ul>indinavir <ul><li>combination appears safe </li></ul>indinavir, nelfinavir, ritonavir, saquinavir <ul><li>monitor for symptoms of opiate withdrawal </li></ul><ul><li>adjust methadone dose as needed </li></ul>lopinavir/ ritonavir <ul><li>combination appears safe; monitor for symptoms of opiate withdrawal </li></ul><ul><li>adjust methadone dose as needed </li></ul>nelfinavir <ul><li>monitor for symptoms of opiate withdrawal </li></ul><ul><li>adjust methadone dose as needed </li></ul>ritonavir/ saquinavir <ul><li>monitor for symptoms of opiate withdrawal </li></ul><ul><li>adjust methadone dose as needed </li></ul>
  • 31. <ul><li>Drug Interaction: Possible </li></ul><ul><li>Amphetamine  w/ritonavir (possibly fatal) </li></ul><ul><li>Ecstasy  w/ritonavir (fatal), PIs, efavirenz </li></ul><ul><li>Speed  w/PI - ritonavir </li></ul><ul><li>Heroin may  or  </li></ul><ul><li>Ketamine  w/ritonavir, nelfinavir, efavirenz, other ARV </li></ul><ul><li>Cocaine Unknown </li></ul><ul><li>GHB  w/ARV - specially ritonavir </li></ul><ul><li>LSD  w/ARV </li></ul><ul><li>PCP  w/ARV </li></ul>Interactions Between Antiretrovirals and Recreational Drugs
  • 32. ARVs and Psychotropics: Some Examples (1) <ul><li>Ritonavir co-administration can increase levels of: </li></ul><ul><ul><li>amitriptyline, desipramine </li></ul></ul><ul><ul><li>Mirtazapine </li></ul></ul><ul><ul><li>Paroxetine </li></ul></ul><ul><ul><li>Venlafaxine </li></ul></ul><ul><ul><li>Fluvoxamine </li></ul></ul><ul><ul><li>Risperidone </li></ul></ul><ul><ul><li>Zolpidem </li></ul></ul><ul><ul><li>Olanzapine </li></ul></ul>
  • 33. ARVs and Psychotropics: Some Examples (2) <ul><li>PI and NNRTI levels can be decreased with co-administration of: </li></ul><ul><ul><li>Carbamazepine </li></ul></ul><ul><ul><li>Oxcarbazepine </li></ul></ul>
  • 34. Psychiatric Complications of Antiretroviral Agents <ul><li>CNS effects of Efavirenz demonstrated in cohorts, clinical studies </li></ul><ul><ul><li>Up to 50% of patients in clinical studies experience dizziness, headache, confusion, impaired concentration, and abnormal or vivid dreams </li></ul></ul><ul><ul><ul><li>Usually resolve in 2-4 weeks </li></ul></ul></ul><ul><ul><li>Current practice indicates close monitoring in EFV-treated patients with current or history of psychiatric illness; EFV not contraindicated </li></ul></ul><ul><li>Case reports with other agents: </li></ul><ul><ul><li>Zidovudine: mania, depression, insomnia, headaches </li></ul></ul><ul><ul><li>Abacavir: psychosis </li></ul></ul><ul><ul><li>Nevirapine: psychosis </li></ul></ul>
  • 35. Treatment Models <ul><li>Sequential: The first and historically most common model of dual disorder is sequential. The client is treated by one system and then the other. </li></ul><ul><li>Parallel: The simultaneous involvement of the client in both mental health and addiction treatment settings </li></ul><ul><li>Integrated : Combines elements of both mental health and addiction treatment into unified and comprehensive treatment program for clients with dual disorders. </li></ul>
  • 36. Integrated Treatment <ul><li>Core Components </li></ul><ul><ul><li>Integration of Services </li></ul></ul><ul><ul><li>Comprehensiveness </li></ul></ul><ul><ul><li>Reduction of Negative consequences </li></ul></ul><ul><ul><li>Long-Term Perspective </li></ul></ul><ul><ul><li>Motivation-Based Treatment </li></ul></ul><ul><ul><li>Assertiveness </li></ul></ul>
  • 37. Integration of Services <ul><li>Provision of services for mental illness / substance abuse and HIV infection simultaneously </li></ul><ul><li>These services should be provided by the same team within the same organization </li></ul><ul><ul><li>Helps to avoid gaps of service delivery </li></ul></ul><ul><ul><li>Helps to ensure that both types of disorders are treated effectively </li></ul></ul>
  • 38. Comprehensiveness <ul><li>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 </li></ul><ul><ul><li>Housing -Vocational Functioning </li></ul></ul><ul><ul><li>Family/Social relationships </li></ul></ul><ul><ul><li>Ability to manage psychiatric illness </li></ul></ul>
  • 39. Reduction of Negative Consequences <ul><li>This is the philosophical dimension of integrated treatment </li></ul><ul><li>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 </li></ul><ul><ul><li>Do this without judging or imposing your personal values on the client regarding the causes or the moral responsibility for the consequences </li></ul></ul>
  • 40. Long-Term Perspective <ul><li>This addresses the need for time-unlimited services </li></ul><ul><li>Consider budget constraints ! </li></ul>
  • 41. Motivation-Based Treatment <ul><li>This orients the clinician as to specific interventions to use, depending of the clients desire to change their behavior </li></ul><ul><li>This avoids unnecessary and potentially destructive conflict between the client and clinician </li></ul><ul><li>This helps to maximize treatment gains through collaborative work </li></ul>
  • 42. Assertiveness <ul><li>This addresses the location of service provision and how a client is engaged in treatment </li></ul><ul><li>Effective treatment programs for the triply diagnosed client does not wait for often reluctant clients seeking treatment on their own </li></ul><ul><li>Effective treatment programs use assertive outreach and legal mechanisms to involve the client in treatment </li></ul>
  • 43. “ Drug addicts should not die in a queue” (2004) Bjarne Hakon Hanssen Minister of Health, Norway (2008-2009)

×