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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

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
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
poll question 1
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
poll question 2
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
consequences of unrecognized and untreated substance use disorders suds for hiv care
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

conceptual model of hiv related health behaviors
Conceptual Model of HIV-related Health Behaviors

Chitsaz et al. AIDS Behav (2013) 17:S118–S127

consequences of unrecognized and untreated substance use disorders suds for hiv care1
Consequences of Unrecognized and Untreated Substance Use Disorders (SUDs) for HIV Care

Chitsaz et al. AIDS Behav (2013) 17:S118–S127

consequences of unrecognized and untreated substance use disorders suds for hiv care2
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

consequences of recent substance use for art adherence
Consequences of Recent Substance Use for ART Adherence

Rosen et al. AIDS Behav. 2013 Jan;17(1):142-7

consequences of recent substance use for art adherence actg 362
Consequences of Recent Substance Use for ART Adherence (ACTG 362)

Cohn et al. AIDS Care. 2011 Jun;23(6):775-85

consequences of recent substance use for mortality actg 362
Consequences of Recent Substance Use for Mortality(ACTG 362)

Cohn et al. AIDS Care. 2011 Jun;23(6):775-85

asam definition of addiction
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

substance use disorders and dsm 5
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)
the screening process
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

the screening process1
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

screening tools options to consider
Screening tools: Options to Consider
  • Single item vs. multi-item
  • Alcohol, other substances, or combined
  • Self-administered vs. interviewer administered vs. computer-assisted
substance screening tools examples
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
sbirt recommended screening tools cage
SBIRT Recommended Screening Tools: CAGE

Agerwala et al. J Psychoactive Drugs. 2012 Sep-Oct;44(4):307-17

sbirt recommended screening tools crafft
SBIRT Recommended Screening Tools: CRAFFT

Agerwala et al. J Psychoactive Drugs. 2012 Sep-Oct;44(4):307-17

sbirt recommended screening tools audit
SBIRT Recommended Screening Tools: AUDIT

Agerwala et al. J Psychoactive Drugs. 2012 Sep-Oct;44(4):307-17

sbirt recommended screening tools assist
SBIRT Recommended Screening Tools: ASSIST

Agerwala et al. J Psychoactive Drugs. 2012 Sep-Oct;44(4):307-17

sbirt recommended screening tools single item tools
SBIRT Recommended Screening Tools: Single Item Tools

Agerwala et al. J Psychoactive Drugs. 2012 Sep-Oct;44(4):307-17

screening resources
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
screening resources1
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/
poll question 3
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
poll question 4
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