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Didactic Series

Didactic Series. Screening for Alcohol and Substance Abuse in HIV-infected Patients Chris Mathews, M.D., MSPH UCSD Owen Clinic Pacific AETC June 12, 2014. Learning Objectives. Review prevalence of substance use and substance use disorders (SUDs) in HIV-infected patients under care

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Didactic Series

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  1. Didactic Series Screening for Alcohol and Substance Abuse in HIV-infected Patients Chris Mathews, M.D., MSPH UCSD Owen Clinic Pacific AETC June 12, 2014

  2. Learning Objectives • Review prevalence of substance use and substance use disorders (SUDs) in HIV-infected patients under care • Review impact of active substance use and SUDs on HIV-related health outcomes • Summarize the rationale for & limitations of substance abuse screening tools in HIV-infected patients • Describe available screening tools, how to get them and how to use them

  3. Self-Reported Substance Abuse Prevalence at Owen Clinic Entry (n=1,682)

  4. Poll Question 1 • How often you use any self report substance use screening tools on new HIV patients in your practice? • Always • Most of the time • Sometimes • Rarely • Never

  5. Poll Question 2 • When should urine drug screening be performed on HIV patients in your practice? (select as many as apply) • Routinely on all new patients • Routinely on all patients prescribed opiates • Only when abuse or diversion is suspected • As part of a work-up for altered mental status

  6. Consequences of Unrecognized and Untreated Substance Use Disorders (SUDs) for HIV Care • Poorer engagement in care • Less likely to be prescribed antiretroviral therapy • Worse adherence • More likely to be treated at advanced stages of HIV disease • More rapid disease progression • More likely to have worse treatment outcomes • Risk behavior disinhibition Chitsaz et al. AIDS Behav (2013) 17:S118–S127

  7. Conceptual Model of HIV-related Health Behaviors Chitsaz et al. AIDS Behav (2013) 17:S118–S127

  8. Consequences of Unrecognized and Untreated Substance Use Disorders (SUDs) for HIV Care Chitsaz et al. AIDS Behav (2013) 17:S118–S127

  9. Consequences of Unrecognized and Untreated Substance Use Disorders (SUDs) for HIV Care • Drug use severity was negatively and independently correlated with three outcomes just before incarceration: • having an HIV care provider AOR = 0.28 (2) being prescribed antiretroviral therapy AOR = 0.12 (3) high levels (> 95 %) of antiretroviral medication adherence AOR = 0.18 Chitsaz et al. AIDS Behav (2013) 17:S118–S127

  10. Consequences of Recent Substance Use for ART Adherence Rosen et al. AIDS Behav. 2013 Jan;17(1):142-7

  11. Consequences of Recent Substance Use for ART Adherence (ACTG 362) Cohn et al. AIDS Care. 2011 Jun;23(6):775-85

  12. Consequences of Recent Substance Use for Mortality(ACTG 362) Cohn et al. AIDS Care. 2011 Jun;23(6):775-85

  13. ASAM Definition of Addiction • Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social, and spiritual manifestations. • This revised definition of addiction is characterized by: • Inability to consistently abstain • Impairment in behavioral control • Craving • Diminished recognition of significant problems with one’s behaviors and interpersonal relationships • A dysfunctional emotional response http://www.asam.org/research-treatment/definition-of-addiction

  14. Substance Use Disorders and DSM-5 • The term addiction is not applied in DSM-5 • The more neutral term of substance use disorder (SUD)used to describe a wide range of disorder, from mild to severe, chronically relapsing, compulsive drug taking • SUD includes the previous DSM-4 categories of substance abuse and substance dependence • 2 defined criteria necessary for SUD diagnosis (DSM-4 required only 1) • Distinction made between SUD and substance-induced disorders (intoxication and withdrawal)

  15. The Screening Process • Is defined as a range of evaluation procedures and techniques • Does not enable treatment personnel to make a clinical diagnosis • Indicates whether a probability exists that the condition sought is present • Is a preliminary assessment to determine whether key features of a targeted problem are present in an individual. • Limitations of self-report associated with stigma SAMHSA TIP 11

  16. The Screening Process • A comprehensive assessment is a thorough evaluation to establish the presence or absence of a disorder or disease. • Once screening results are known, one of the following three conclusions can be drawn: • The individual is likely to benefit from referral for a comprehensive assessment. • Further assessment is unwarranted. • Screening should be repeated at a later time. SAMHSA TIP 11

  17. Screening tools: Options to Consider • Single item vs. multi-item • Alcohol, other substances, or combined • Self-administered vs. interviewer administered vs. computer-assisted

  18. Substance Screening Tools: Examples Alcohol Screening Combined substance screening DAST NIDA-ASSIST CRAFFT (for adolescents) CAGE-AID Single question screener for drug abuse • CAGE • MAST • AUDIT • Maximum drinks screener • Frequency of 5+/4+ drinking screener

  19. SBIRT Recommended Screening Tools: CAGE Agerwala et al. J Psychoactive Drugs. 2012 Sep-Oct;44(4):307-17

  20. SBIRT Recommended Screening Tools: CRAFFT Agerwala et al. J Psychoactive Drugs. 2012 Sep-Oct;44(4):307-17

  21. SBIRT Recommended Screening Tools: AUDIT Agerwala et al. J Psychoactive Drugs. 2012 Sep-Oct;44(4):307-17

  22. SBIRT Recommended Screening Tools: ASSIST Agerwala et al. J Psychoactive Drugs. 2012 Sep-Oct;44(4):307-17

  23. SBIRT Recommended Screening Tools: Single Item Tools Agerwala et al. J Psychoactive Drugs. 2012 Sep-Oct;44(4):307-17

  24. Screening Resources • SAMHSA screening tools URL • http://www.integration.samhsa.gov/clinical-practice/screening-tools#drugs • SAMHSA SBIRT (Screening, Brief Intervention, Referral, Treatment) • http://beta.samhsa.gov/sbirt • CRAFFT • http://www.ceasar-boston.org/CRAFFT/ • AUDIT • http://www.integration.samhsa.gov/AUDIT_screener_for_alcohol.pdf • DAST • http://www.emcdda.europa.eu/attachements.cfm/att_61480_EN_DAST%202008.pdf

  25. Screening Resources • AUDIT-C • http://www.integration.samhsa.gov/images/res/tool_auditc.pdf • CAGE-AID • http://www.integration.samhsa.gov/images/res/CAGEAID.pdf • NIDAMED (resources for health professionals) • http://www.drugabuse.gov/nidamed-medical-health-professionals • NIDA Drug Screening Tool (online) • http://www.drugabuse.gov/nmassist/

  26. http://www.drugabuse.gov/nmassist/ NIDA-ASSIST Online

  27. Poll Question 3 • How likely are you to implement in the next 3 months routine substance abuse screening using a standardized tool on new HIV patients? • Very likely • Somewhat likely • Possible • Unlikely • Very unlikely

  28. Poll Question 4 • How likely are you to implement in the next 3 months routine substance abuse screening using a standardized tool on follow-up HIV patients? • Very likely • Somewhat likely • Possible • Unlikely • Very unlikely

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