The Triple Challenge:Optimizing HIV Treatment for Patients with Co-occurring Mental Illness and Substance Use Disorder This presentation was made by Dr. Glenda Clare at a state conference in Georgia.

1. The Triple Challenge:
Optimizing HIV Treatment for
Patients with Co-occurring
Mental Illness and Substance
Use Disorder
Glenda Clare
G. Portlynn Clare & Associates
g_portlynnclare@hotmail.com

2. Introductions
Who are you?
What type of work do you do? Where?
Why are you attending this workshop?

3. Training Objectives
 Discuss the prevalence of substance use
disorders and mental illness among people
with HIV/AIDS
 Discuss the range of substance and mental
disorders that patients might be experiencing
 Identify key considerations in screening for
these disorders and screening tools and
diagnostic criteria
 Identify some of the effects of these disorders
on treatment adherence and effectiveness

4. New Face of HIV
 50% of currently HIV positive population
have substance use disorder and mental
illness

5. New Face of HIV
 HIV Cost and Services Utilization Study
found
• 36% with major depression
• 26.5% with dysthymia
• 15.8% with generalized anxiety disorder
• 10.5% with panic attacks
• 12% with drug dependence
• 6.2% with “frequently heavy drinking”

6. Etiological Connections
 Substance use disorders increase HIV
risk behaviors
 Symptoms of some mental disorders can
increase impulsivity and impair problem
solving processes, leading to HIV risk
behavior
 HIV can increase risk of depression,
anxiety, mania, sleep disorders, HIV
related CNS disorders

7. Addiction & Other Mental Health
Disorders
 Confuse assessment of HIV related
symptoms and conditions
 Impair self-care, treatment attendance,
and adherence to HIV regimen
 Weaken immune system
 Involve drugs that may speed replication
of HIV

8. Addiction & Other Mental Health
Disorders
 Complicate HIV treatment
 Complicate pain management
 Add more stigma to the lives of people
living with HIV

9. Medical Management:
General Questions - Patients
 Which psychotropics are problematic
with your HIV medications?
 Do you know what psychotropics you are
already taking?
 Does the psychiatrist know the HIV
medications you’re taking?

10. Medical Management:
General Questions - Agency
 When are psychiatric medications
prescribed (in house), and when do you
refer?
 How does methadone interact with HIV
medications?
 How do “street drugs” interact with HIV
medications?

11. Psychotropics & Antiretovirals
Drug interactions may interfere with liver’s
ability to filter medications
*Make a list of your client’s medications.
Obtain information about drug actions
from your local pharmacist

12. Antidepressants
 Most new antidepressants are safe and
effective
 Use tricyclics – used for pain and sleep
disorders - with pain and with caution
 Avoid Serzone – risk of hepatic failure

13. Benzodiazepines
 Start low – highly addictive
 Never use alone
 Avoid shorter acting forms of the drug
 Abuse of trizzolam, diazepam, zolpidem
and midazolam can be deadly with
protease inhibitors
 If patient is having trouble with meds -
refer

14. Antipsychotics & Mood
Stabilizers
 Refer to a psychiatrist
 Older antipsychotics have increased risk
of side effects – irreversible movement
disorders
 Patients using lithium should be under
the care of a psychiatrist

15. Methadone
 Used for treatment of opioid addiction
 Some drugs lower methadone
concentration, with risk of withdrawal
 Some drugs raise methadone
concentration, with risk of overdose
 Some patients may be afraid to disclose
methadone use because of stigma

16. Drugs That Lower Methadone
Concentrations
 Alcohol
 Barbiturates
 Nevirapine
 Carbamazepine
 Didanosine (ddl)
 Efavirenz
 Isoniazid
 Nelfinavir
 Phenytoin
 Rifampin
 Ritonavir
 Saquinavir
 Stavudine (d4t)

17. Drugs That Raise Methadone
Concentrations
 Cimeticline
 Cipro (significant elevations)
 Erythromycin
 Ketoconazole
 Fluvoxamine
 Fluoxetine
 Nefazodone
 Zidovudine

18. Patients Using Alcohol
& “Street Drugs”
 Videx can increase the risk of
pancreatitis
 Toxicity of “ecstasy” significantly
increased with some protease inhibitors
 Amphetamine levels may be increased
with protease inhibitors, particularly
ritonavir

19. Patients Using Alcohol
& “Street Drugs”
 GHB can be dangerous with protease
inhibitors
 Ketamine and ritonavir can lead to
chemical hepatitis
 Synthetics sold as heroin may be toxic at
very small doses when combined with
medications

20. Complications Caused
By HCV C--infections
 Hepatitis C accelerates and exhausts
liver filtration system
 ARV medications have to compete for
depleted liver cells
 Side effects of interferon can include
fatigue, depression, or confusion, which
interfere with appointment and
medication adherence

21. Pain Management for Patients
With Substance Use Disorders
 Pain relief vs Drug Seeking
 Pain meds may have high potential for
abuse and dependence
 Most people with substance use
disorders legitimately need higher doses
of pain medication
 Methadone raises extra pain
management issues

22. Methadone & Pain Management
 Maintenance dose confers no analgesia
 You should use opiate analgesics for
patients on methadone maintenance
 Don’t use any opiate partial agonis for
people on methadone maintenance

23. Dosage & Intervals for
People on Methadone
 Start with higher doses of pain meds
 Assess frequently and titrate to pain
control
 Be prepared to administer at shorter
intervals

24. Strategies for Promoting
Adherence
 Prescribe for side-effects
 Learn from patient how his/her
disabilities affect adherence
 Understand lifestyle and culture, and
effects of these on adherence
 Look at housing, confidentiality issues
 Go over basic points in materials
 Don’t assume people will take materials
or read them

25. Substance Use Disorders
 Multiple risk factors for HIV infection
 Some drugs may raise the risk of HIV
related CNS disorders
 Substance use disorders are defined as
“abuse” or “dependence” depending on
the amount of dysfunction

26. Substance Use Disorders
 Substance use disorders are chronic
conditions often characterized by
repeated recurrence
 Dependence complicates HIV treatment
and pain management
 Methadone affects pain management
 Traditional referral techniques often don’t
work with substance dependence

27. Common Disorders
 Mood Disorders
 Anxiety Disorders
 Schizophrenia
 Dementia Due to HIV Disease
 Personality Disorders

28. Mental Illness
 Depression and stress can adversely
affect immune functioning
 Clinical depression isn’t a “normal”
reaction to HIV/AIDS
 Differential diagnosis can be tricky

29. Mental Illness
 Patients may not disclose psychiatric
diagnoses and medications
 Some psychopharmaceuticals are
contraindicated because of interactions
with antiretrovirals

30. Signs of Substance
Use Disorders
 Lack of response to basic treatment
 Intoxication or withdrawal symptoms
 Nodding off during appointments
 Presence of Hepatitis C
 Track marks
 Bruises
 No clearance to get medical history
 Asking for a specific psychotropic

31. Screening for Drug-Seeking
Behavior
 Pain meds and some psychotropics have high
potential for abuse/dependence
 Many people in recovery need more
medication for pain relief because of
neurological effects of dependence
 Thorough pain screening can help distinguish
pain from drug seeking
 If patient is suspected of abusing pain meds –
consult a substance abuse counselor

32. Broaching the Subject of
Substance Use
 Ask evocative, open ended questions
 Connect with symptoms patient agrees
with
 Ask about weekend behaviors
 Address behaviors
 Avoid sounding judgmental
 Give permission for the truth

33. CAGE Questionnaire
 C Have you ever tried to cut down?
 A Have you ever gotten annoyed or
angry when people talk to you about
your drinking or drug use?
 G Have you ever felt guilty about it?
 E Have you ever had a drink or a drug
first thing in the morning?

34. Signs of Mental Illness
 Lack of response to basic treatment
 Disrupted sleep patterns
 Talk of suicide or homicide
 Memory, concentration deficits
 Changes in appearance, behavior, eye
contact, and speech

35. Suicide/Homocide
 Passive vs active ideation
 Ideation vs intent
 Chronic vs acute

36. Suicide: Assessment of
Ideation
 Passive vs active
Do you want to be dead?
Have you thought about killing yourself?
 Chronic vs active
Have you felt like killing yourself in the past?
What did you do about it?
Do you always wish that you were dead?

37. Distinguishing Ideation
from Intent
 Why haven’t you done it? Why are you
still alive? – assess level and forms of
deterrence
 How would you do it? – assess means
and availability
 What preparations have you made?

38. Base Your Intervention on Your
Level of Comfort
 Contract
 Referral for psychiatric care
 Well being visit from police
 Trip to ER with patient
 Calling in a crisis team

39. Determining Need for
Intervention
 Assessment of threat of harm
 Assessment of your own level of comfort
with the situation
 Duty to warn

40. Referral Relationships
 Best practice is integrated service
delivery
 Partnership with mental health and/or
addiction professionals
 Build mutual referral/communication
networks
 Work with cooperative agencies

41. When to Refer
 If you are unsure, always get consult
 Refer at the assessment stage
 If unsure about meds, contact
psychiatrist and/or pharmacist
 If patient has symptoms of bipolar or
schizophrenia
 If patient is pregnant

42. Cues for Domestic Violence
Referrals
 Unexplained injuries
 Injuries with strange explanations
 Gynecological signs of violence
 Partner insists on accompanying patient
in office visit
 Parent insists on being with the child

43. Broaching the Subject
of Getting Help
 Explore pros and cons of getting help
 Give patient a menu of options
 Avoid arguing with the patient
 If the patient resists, back away from the
subject
 Bring it up at another time

44. Referral Practices
 Be clear about the type of specialist the
patient will be seeing
 Keep in mind the agency’s fit with the
patient
 Give the patient the name of a person
 Make the call together with the patient –
Get an appointment
 Follow up with patient and provider