Transcript - PAETC | Pacific AIDS Education and Training Center

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
ACCREDITATION STATEMENT: University of California, San Diego School of Medicine is accredited by the Accreditation Council for Continuing Medical Education
to provide continuing medical education for physicians. The University of California, San Diego School of Medicine designates this educational activity for a maximum
of one credit per hour AMA PRA Category 1 Credits™.
Physicians should only claim credit commensurate with the extent of their participation in the activity.
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Learning Objectives
1) Review prevalence of substance use and
substance use disorders (SUDs) in HIVinfected patients under care
2) Review impact of active substance use and
SUDs on HIV-related health outcomes
3) Summarize the rationale for & limitations of
substance abuse screening tools in HIVinfected patients
4) Describe available screening tools, how to get
them and how to use them
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Self-Reported Substance Abuse Prevalence
at Owen Clinic Entry (n=1,682)
70.00%
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
Lifetime
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Current
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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
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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
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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
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Conceptual Model of HIV-related
Health Behaviors
Chitsaz et al. AIDS Behav (2013) 17:S118–S127
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Consequences of Unrecognized and
Untreated Substance Use Disorders
(SUDs) for HIV Care
Chitsaz et al. AIDS Behav (2013) 17:S118–S127
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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:
(1) 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
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Consequences of Recent Substance Use for
ART Adherence
Rosen et al. AIDS Behav. 2013 Jan;17(1):142-7
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Consequences of Recent Substance Use for
ART Adherence
(ACTG 362)
Cohn et al. AIDS Care. 2011 Jun;23(6):775-85
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Consequences of Recent Substance Use for Mortality
(ACTG 362)
Cohn et al. AIDS Care. 2011 Jun;23(6):775-85
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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
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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 (DSM4 required only 1)
• Distinction made between SUD and substanceinduced disorders (intoxication and withdrawal)
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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
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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
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Screening tools: Options to Consider
• Single item vs. multi-item
• Alcohol, other substances, or combined
• Self-administered vs. interviewer
administered vs. computer-assisted
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Substance Screening Tools: Examples
Alcohol Screening
• CAGE
• MAST
• AUDIT
• Maximum drinks screener
• Frequency of 5+/4+
drinking screener
Combined substance
screening
• DAST
• NIDA-ASSIST
• CRAFFT (for
adolescents)
• CAGE-AID
• Single question screener
for drug abuse
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SBIRT Recommended
Screening Tools: CAGE
Agerwala et al. J Psychoactive Drugs. 2012 Sep-Oct;44(4):307-17
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SBIRT Recommended
Screening Tools: CRAFFT
Agerwala et al. J Psychoactive Drugs. 2012 Sep-Oct;44(4):307-17
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SBIRT Recommended
Screening Tools: AUDIT
Agerwala et al. J Psychoactive Drugs. 2012 Sep-Oct;44(4):307-17
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SBIRT Recommended
Screening Tools: ASSIST
Agerwala et al. J Psychoactive Drugs. 2012 Sep-Oct;44(4):307-17
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SBIRT Recommended Screening Tools:
Single Item Tools
Agerwala et al. J Psychoactive Drugs. 2012 Sep-Oct;44(4):307-17
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Screening Resources
• SAMHSA screening tools URL
– http://www.integration.samhsa.gov/clinical-practice/screeningtools#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
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Screening Resources
• AUDIT-C
– http://www.integration.samhsa.gov/images/res/tool_a
uditc.pdf
• CAGE-AID
– http://www.integration.samhsa.gov/images/res/CAGE
AID.pdf
• NIDAMED (resources for health professionals)
– http://www.drugabuse.gov/nidamed-medical-healthprofessionals
• NIDA Drug Screening Tool (online)
– http://www.drugabuse.gov/nmassist/
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NIDA-ASSIST Online
http://www.drugabuse.gov/nmassist/
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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
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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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