SUBSTANCE USE

Care of Hospitalized Substance Users with HIV Guideline

Introduction

Substance Use Guidelines Committee, March 2009

RECOMMENDATIONS
  • Hospitalized HIV-infected substance users should optimally be managed by a multidisciplinary team that includes members with expertise in substance use and mental health treatment and access to case management.
  • The patient’s primary outpatient clinician should participate in the patient’s hospitalization either directly or through communication with the hospital care team to ensure continuity of care.
  • Clinicians should not initiate detoxification treatment for opioid withdrawal in opioid-dependent pregnant women. Rather, opioid replacement therapy should be used. Accordingly, clinicians should consult obstetric and prenatal clinicians experienced in managing both HIV infection and substance use in pregnant women and should also refer these patients for post-discharge methadone maintenance.
  • Patients with substance use diagnoses who require pain management should receive effective analgesia.

Substance-using HIV-infected patients may be hospitalized for a variety of reasons, including medical conditions, withdrawal or intoxication from alcohol or other substances, and/or acute psychiatric conditions.

In recognition of the diversity of practice environments, these guidelines are written for clinicians in settings where: 1) they may continue to care for their patients in the hospital care setting; or 2) the responsibility of their patients’ care may be transferred to the hospital or other inpatient care team, with the primary care clinician serving in a consulting role.

This chapter provides guidance for the following aspects of care for the hospitalized HIV-infected substance user:

  • Coordination of care between primary care providers and the inpatient care team
  • Continuation of pharmacotherapy for substance use treatment
  • Continuation of ARV therapy
  • Identification of symptoms of drug and alcohol withdrawal
  • Management of against medical advice (AMA) discharges
  • Use of brief interventions
  • Goals for disposition planning
KEY POINT
  • Medically ill substance-using patients may require pain management when presenting to the hospital. Patients should not be denied or receive only partially effective treatment for pain because of a history of substance use. Rather, standard pain assessment and treatment protocols should be followed (see Pain in the HIV-Infected Substance User).

Coordination of Care and Transference of Responsibility

March 2009

RECOMMENDATIONS
  • Communication between the primary care clinician and hospital care team should be established as early in the course of hospitalization as possible, including consent to disclose information about substance use treatment. If appropriate, the primary HIV care clinician should obtain consent for communication with the hospital care team before the patient is admitted.
  • The primary care clinician should provide hospital staff with a comprehensive history, including contact information for the patient’s substance use treatment program, if applicable, as well as information regarding buprenorphine or methadone dosing for patients receiving opioid agonist therapy.
  • If ARV treatment must be interrupted during hospitalization, such a decision should be coordinated between the primary HIV care clinician and the hospital care team. The primary HIV care clinician and hospital care team should also coordinate the timing for resumption of ARV treatment (see Continuing ART).
  • Pharmacotherapy for substance use should be continued during hospitalization unless an interruption is required to avert potential harm.

High rates of medication-related errors have been observed in hospitalized HIV-infected patients [1,2].When a patient is hospitalized, engagement on the part of the primary outpatient clinician is optimal to ensure continuity of care. If the primary care clinician is unable to care directly for the patient in the hospital, the clinician should provide hospital staff with as much information as possible regarding the patient’s history. Such communication between the primary care clinician and hospital care team should be established as early as possible in the course of the hospitalization. If appropriate, primary HIV care clinicians referring their patients for hospitalization should obtain consent for communication with the hospital care team before hospital admission. These steps can help prevent unnecessary ARV treatment interruption, drug-drug interactions, and other adverse side effects associated with initiation or discontinuation of specific medications during the hospital admission. Decisions regarding the initiation, interruption, or resumption of ARV treatment should be coordinated between the primary HIV care clinician and the hospital care team (see Continuing ART).

Changes to buprenorphine or methadone doses should generally be avoided or minimized; if required, they are best made in consultation with the physician prescribing these medications to the patient outside the hospital. With the patient’s consent, clinicians should communicate information regarding pharmacotherapy for opioid dependence, including buprenorphine or methadone dosing, as well as contact information for the patient’s substance use treatment program. Consent to disclose substance use treatment is not mandated if it is required for management of a medical emergency and strictly complies with Health Insurance Portability and Accountability Act (HIPAA) regulations. For detailed information regarding patient confidentiality regulations, refer to the Substance Abuse and Mental Health Services Administration’s Medical Records Privacy and Confidentiality.

Communication between the primary care provider and hospital care team is equally important for patients admitted to the hospital for management of severe withdrawal from alcohol or other substances. A comprehensive patient history enables case managers to determine the substance use treatment resources that are most appropriate for patients once they are discharged. Effective case management will help ensure that all of a patient’s care needs are addressed.

References:
  1. Pastakia SD, Corbett AH, Raasch RH, et al. Frequency of HIV-related medication errors and associated risk factors in hospitalized patients. Ann Pharmacother 2008;42:491-497. [Abstract]
  2. Purdy BD, Raymond AM, Lesar TS. Antiretroviral prescribing errors in hospitalized patients. Ann Pharmacother 2000;34:833-838. [Abstract]

Continuing ART

March 2009

RECOMMENDATIONS
  • Primary HIV care clinicians should provide the hospital care team with information regarding the patient’s currently prescribed ARV medications and should assist the hospital care team with appropriate substitutions as necessary.
  • If patients who are receiving ARV therapy at the time of admission cannot receive a fully effective ARV regimen while in the hospital, the primary care clinician and hospital care team should coordinate the decision to withhold ARV treatment during hospitalization.

Some hospital formularies may not include all HIV medications and formulations. However, many hospital pharmacies are able to meet requests for nonformulary medications. Primary HIV care clinicians should advocate for their hospitalized patients to receive a medication regimen that ensures continuity of HIV treatment, especially for long-term admissions. If a hospital is able to provide only a partially effective ARV regimen, and is not able to accommodate administration of the patient’s own medication supply, careful consideration should be given to the possibility of a period of ARV treatment interruption during the hospitalization.

For information regarding ARV treatment, see Antiretroviral Therapy.

Identifying Substance Use and Withdrawal

March 2009

RECOMMENDATIONS
  • Hospitalized HIV-infected patients should be screened for drug and alcohol use and dependence as part of their admission assessment.
  • Clinicians should be able to recognize the signs and symptoms of withdrawal from alcohol and other substances regardless of the reason for a patient’s hospitalization.
  • Clinicians should inquire about prior history of withdrawal or delirium tremens in the initial assessment of patients presenting with possible alcohol withdrawal syndrome.

Identification of substance use and abuse can be clinically challenging. Patients who are hospitalized for causes unrelated to drug withdrawal or intoxication may be at risk for withdrawal, particularly under circumstances in which the hospital and/or primary care clinician is unaware of a patient’s substance use. Because alcohol and drug dependence still carry significant stigma, patients often do not communicate the extent of use to their providers. For example, patients may have been described as “social drinkers” until the first episode of pancreatitis, or a withdrawal seizure may unmask the diagnosis of significant alcohol dependence. For information regarding screening for substance use, see Screening and Ongoing Assessment for Substance Use.

Many common presenting complaints can represent drug or alcohol effects, such as seizures or psychosis among users of stimulants (cocaine, crystal methamphetamine). In addition, drug and alcohol use can complicate the course of unrelated illnesses. Risk for alcohol withdrawal may be missed in patients presenting to the hospital. Trauma patients are at particularly high risk for this, with the attendant danger that alcohol withdrawal will complicate the subsequent course of hospitalization or post-discharge recovery.

Clinicians may encounter patients experiencing, or who are at imminent risk for experiencing, withdrawal. Patients may also present with acute intoxication after using one or multiple substances. Evidence of use of one substance, such as cocaine or marijuana, should alert clinicians to the possible use of other substances, such as alcohol, opioids, and benzodiazepines.

When a patient experiencing severe withdrawal is identified, the following considerations are essential:

  • What is the patient withdrawing from?
  • What stage of withdrawal is he/she experiencing?
  • Are there any co-occurring medical conditions that could complicate the withdrawal?

Many physical symptoms of HIV infection overlap with those of substance use and withdrawal, such as malaise, weight loss, fever, and night sweats. For example, opportunistic infections of the CNS and HIV-associated dementia can present with seizures, neurovegetative symptoms, apathy, disorientation, and aggression, all of which are symptoms associated with intoxication and withdrawal from alcohol and other substances. Patients may have an acute medical illness that may prevent them from accessing substances and/or alcohol and precipitate rapid manifestation of withdrawal symptoms.

For pregnant HIV-infected substance users, withdrawal symptoms can threaten the pregnancy and pose serious risks to the mother. Detoxification treatment should not be initiated for opioid withdrawal in opioid-dependent pregnant women. Rather, opioid replacement therapy should be used. Accordingly, clinicians should consult obstetric and prenatal clinicians experienced in managing both HIV infection and substance use in pregnant women and should refer these patients for post-discharge methadone maintenance.

Familiarity with the common signs and symptoms of alcohol and drug withdrawal can enable clinicians to manage or even prevent the consequences of withdrawal (see Table 1). When serving as attending physicians of their hospitalized patients, clinicians should be familiar with the withdrawal treatment protocols of the institution. Obtaining drug toxicology in patients with a known history of substance use is a clinically useful indicator that can help reduce morbidity from misdiagnosis and subsequent use of inappropriate medications. Clinicians should be aware of the policies specific to their hospital regarding toxicology screening. In general, the medical management and treatment protocols for drug and alcohol withdrawal in HIV-infected patients will not differ from the management of non-HIV-infected patients.

Table 1 gives common signs and symptoms of alcohol and drug withdrawal.

Table 1: Signs and Symptoms of Alcohol and Drug Intoxication Withdrawal
  Intoxication Symptoms Intoxication Signs Withdrawal Symptoms Withdrawal Signs
Alcohol Lightheadedness, euphoria, depression, confusion, nausea, vomiting Slurred speech, ataxia, decreased muscular coordination, nystagmus, stupor, coma Anxiety; panic; paranoid delusions; illusions; visual, tactile and auditory hallucinations (often derogatory and intimidating); depression; euphoria; incoherent thoughts; hostility; grandiosity; disorientation; suicidal ideation Elevated blood pressure, pulse, and temperature; hyperarousal; agitation; cutaneous flushing; tremors; diaphoresis; dilated pupils; ataxia; disorientation; increased psycho-motor activity; muscular weakness; delirium; convulsions; seizures
Benzodiazepines Sedation, drowsiness, memory impairment, disinhibition Psychomotor retardation, ataxia, respiratory depression Anxiety, insomnia, tremulousness, headache Tachycardia, elevated blood pressure, seizures
Stimulants (cocaine, amphetamines, and derivatives) Euphoria, energy, reduced fatigue, loss of appetite, increased interest in sex Agitation, paranoia, seizures Depression, anhedonia, suicidal thoughts and behavior, paranoid delusions Social withdrawal, psychomotor retardation, hypersomnia, hyperphagia
Opiates (heroin)* Euphoria, pleasant dreams/visions Decreases blood pressure and heart rate, miosis, “nodding,” stupor, coma, respiratory arrest Intense desire for drugs, muscle cramps, arthralgia, anxiety, nausea, vomiting, malaise Drug-seeking, mydriasis, piloerection, diaphoresis, rhinorrhea, lacrimation, diarrhea, insomnia, elevated blood pressure and pulse (mild)
*Although they are often milder, many of the signs and symptoms of buprenorphine and methadone withdrawal are similar to those of heroin withdrawal.

For additional information about withdrawal symptoms, see What Are These Drugs? 

Assessing Tobacco Use and Nicotine Withdrawal

March 2009

RECOMMENDATIONS
  • Clinicians should assess smoking status in HIV-infected substance users upon admission to the hospital.
  • Hospitalized patients who smoke should be offered pharmacologic treatment of withdrawal symptoms in a timely manner to prevent nicotine withdrawal.
  • Clinicians should advise all smokers to quit and should offer continued smoking cessation assistance, including pharmacotherapy, to smokers who are interested in quitting.

Hospitalization often imposes involuntary abstinence from nicotine, thus precipitating physical withdrawal, which can occur in as little as 1 hour from the last cigarette. Smokers may experience increased anxiety or heightened cravings for cigarettes [1,2]. Withdrawal symptoms may worsen within 1 to 3 days after abstinence and may remain for 2 to 6 weeks.

For more guidance on smoking cessation interventions, see Smoking Cessation in HIV-Infected Patients.

References:
  1. Fiore MC, Bailey WC, Cohen SJ, et al. Clinical Practice Guideline: Treating Tobacco Use and Dependence. Washington, DC. US Department of Health and Human Services; 2000.
  2. Rigotti NA, Arnsten JH, McKool KM, et al. Smoking by patients in a smoke-free hospital: Prevalence, predictors, and implications. Prev Med2000;31:159-166. [Abstract]

Brief Interventions and Harm Reduction

March 2009

RECOMMENDATIONS
  • Brief interventions should be used to address barriers to treatment of substance abuse and dependence.
  • Clinicians should discuss with patients other options for accessing new needles and syringes, including use of the Expanded Syringe Access Demonstration Program and Syringe Exchange Programs, New York State’s two syringe access initiatives.

Hospitalization provides a unique opportunity to address the negative impact of high-risk behaviors on the patient’s health. Brief interventions can help motivate patients to seek substance use treatment or reduce their substance use once they are discharged.

Harm reduction may be an effective strategy for reducing risk among injection drug users (IDUs) who are not ready for treatment or who are at risk for relapse. By educating IDUs about where to access new needles and syringes, safe disposal and storage of needles/syringes, safe techniques for injection, and how to prevent overdose, clinicians can reduce harm to the patient and to others even though the patient is still using. For a complete discussion regarding brief intervention and patient education, as well as motivational interviewing and harm-reduction strategies, refer to Working with the Active User > Spectrum of Interventions.

Hospitalization also provides an opportunity to obtain a sexual risk assessment, screen for STIs, and provide risk-reduction counseling regarding HIV transmission.

AMA Discharges

March 2009

RECOMMENDATION
  • When patients express the desire to leave the hospital against medical advice, the care team should work with the patient to remain in the hospital until medically discharged. If attempts to keep the patient hospitalized are unsuccessful, the patient should be assessed for competency.

As many as 25% of hospitalizations of HIV-infected patients with a history of injection drug use result in against medical advice (AMA) discharge [1], and up to 77% of patients who leave AMA have been found to be injection drug users [2]. Substance-using patients may leave the hospital AMA for many reasons, including the following:

  • Anxiety about impending substance withdrawal
  • Undertreated withdrawal or withdrawal that is not treated in a timely manner
  • Skepticism about effectiveness of withdrawal treatment
  • Psychosocial factors, such as family responsibilities, unstable housing or employment, and anticipation of public assistance payments
  • Staff attitudes toward substance-using patients

A patient’s desire to leave AMA should prompt reassessment of the patient’s medical management. The risk of AMA discharge has been found to be reduced in patients who receive inpatient methadone treatment, are of older age, and have social supports [1]. Proactive case management, as well as addiction treatment and interventions that enhance social supports, should be used to reduce risk of AMA discharge among hospitalized HIV-infected substance users.

References:
  1. Chan AC, Palepu A, Guh DP, et al. HIV-positive injection drug users who leave the hospital against medical advice: The mitigating role of methadone and social support. J Acquir Immune Defic Syndr 2004;35:56-59. [Abstract]
  2. Anis AH, Sun H, Guh DP, et al. Leaving hospital against medical advice among HIV-positive patients. CMAJ 2002;167:633-637. [Abstract]

Disposition Planning

March 2009

RECOMMENDATIONS
  • Hospital staff should initiate discharge-planning for HIV-infected substance users as early as possible, and in conjunction with social services, to ensure that a comprehensive treatment plan is in place before the patient leaves the hospital.
  • Hospitalized patients in need of alcohol or opioid detoxification should not be discharged until detoxification has been completed or until detoxification can be completed safely after discharge.
  • The hospital care team should arrange for post-discharge primary outpatient care for HIV-infected substance-using patients without an established outpatient clinician.

The hospital care team can play a crucial role in establishing effective long-term strategies for a patient’s post-discharge treatment. Discharge plans should be initiated as early as possible and in conjunction with social services, particularly for patients who lack health insurance. Treatment goals that correspond to the patient’s functional capacities are important:

  • Short-term goals
    • Detoxification
    • Treatment induction
  • Long-term goals
    • Referral for treatment (with consideration or likelihood of readmissions)
    • Outpatient treatment, including methadone maintenance for opioid-dependent patients
    • Outpatient/inpatient treatment for triply diagnosed patients
    • AA/NA/CA/MA and other self-help groups

Patients without an established outpatient clinician should be referred for post-discharge primary outpatient care. This is particularly important because HIV-infected substance users who present to the hospital are more likely to have a low CD4 count, to not be receiving ARV therapy, and to have more advanced illness [1]. In some cases, referral for outpatient care from a member of the care team who has established rapport with the patient may be optimal.

Whenever possible, patients requiring subacute rehabilitation or nursing home care should be referred to facilities that have demonstrated an ability and willingness to care for HIV-infected substance users. Optimal treatment includes referral for substance use treatment to prevent relapse upon discharge into the community. Referrals for mental health services and support groups should also be made as necessary. For further information regarding treatment services for HIV-infected substance users, refer to Treatment Modalities for Substance Users with HIV Infection.

Medically hospitalized patients in need of alcohol or opioid detoxification should not be discharged until detoxification has been completed or until detoxification can be completed safely after discharge. Most hospitals with dedicated detoxification units will not accept transfers of patients from one acute care hospital to another.

Reference:
  1. Pulvirenti JJ, Glowacki R, Muppiddi U, et al. Hospitalized HIV-infected patients in the HAART era: A view from the inner city. AIDS Patient Care STDS 2003;17:565-573. [Abstract]

All Recommendations

Substance Use Guidelines Committee, March 2009

ALL RECOMMENDATIONS: CARE OF THE HOSPITALIZED HIV-INFECTED SUBSTANCE USER
Introduction
  • Hospitalized HIV-infected substance users should optimally be managed by a multidisciplinary team that includes members with expertise in substance use and mental health treatment and access to case management.
  • The patient’s primary outpatient clinician should participate in the patient’s hospitalization either directly or through communication with the hospital care team to ensure continuity of care.
  • Clinicians should not initiate detoxification treatment for opioid withdrawal in opioid-dependent pregnant women. Rather, opioid replacement therapy should be used. Accordingly, clinicians should consult obstetric and prenatal clinicians experienced in managing both HIV infection and substance use in pregnant women and should also refer these patients for post-discharge methadone maintenance.
  • Patients with substance use diagnoses who require pain management should receive effective analgesia.
Coordination of Care and Transference of Responsibility
  • Communication between the primary care clinician and hospital care team should be established as early in the course of hospitalization as possible, including consent to disclose information about substance use treatment. If appropriate, the primary HIV care clinician should obtain consent for communication with the hospital care team before the patient is admitted.
  • The primary care clinician should provide hospital staff with a comprehensive history, including contact information for the patient’s substance use treatment program, if applicable, as well as information regarding buprenorphine or methadone dosing for patients receiving opioid agonist therapy.
  • If ARV treatment must be interrupted during hospitalization, such a decision should be coordinated between the primary HIV care clinician and the hospital care team. The primary HIV care clinician and hospital care team should also coordinate the timing for resumption of ARV treatment.
  • Pharmacotherapy for substance use should be continued during hospitalization unless an interruption is required to avert potential harm.
Continuing ART
  • Primary HIV care clinicians should provide the hospital care team with information regarding the patient’s currently prescribed ARV medications and should assist the hospital care team with appropriate substitutions as necessary.
  • If patients who are receiving ARV therapy at the time of admission cannot receive a fully effective ARV regimen while in the hospital, the primary care clinician and hospital care team should coordinate the decision to withhold ARV treatment during hospitalization.
Substance Use and Withdrawal
  • Hospitalized HIV-infected patients should be screened for drug and alcohol use and dependence as part of their admission assessment.
  • Clinicians should be able to recognize the signs and symptoms of withdrawal from alcohol and other substances regardless of the reason for a patient’s hospitalization.
  • Clinicians should inquire about prior history of withdrawal or delirium tremens in the initial assessment of patients presenting with possible alcohol withdrawal syndrome.
Assessing Tobacco Use and Nicotine Withdrawal
  • Clinicians should assess smoking status in HIV-infected substance users upon admission to the hospital.
  • Hospitalized patients who smoke should be offered pharmacologic treatment of withdrawal symptoms in a timely manner to prevent nicotine withdrawal.
  • Clinicians should advise all smokers to quit and should offer continued smoking cessation assistance, including pharmacotherapy, to smokers who are interested in quitting.
Brief Interventions and Harm Reduction
  • Brief interventions should be used to address barriers to treatment of substance abuse and dependence.
  • Clinicians should discuss with patients other options for accessing new needles and syringes, including use of the Expanded Syringe Access Demonstration Program and Syringe Exchange Programs, New York State’s two syringe access initiatives.
AMA Discharges
  • When patients express the desire to leave the hospital against medical advice, the care team should work with the patient to remain in the hospital until medically discharged. If attempts to keep the patient hospitalized are unsuccessful, the patient should be assessed for competency.
Disposition Planning
  • Hospital staff should initiate discharge-planning for HIV-infected substance users as early as possible, and in conjunction with social services, to ensure that a comprehensive treatment plan is in place before the patient leaves the hospital.
  • Hospitalized patients in need of alcohol or opioid detoxification should not be discharged until detoxification has been completed or until detoxification can be completed safely after discharge.
  • The hospital care team should arrange for post-discharge primary outpatient care for HIV-infected substance-using patients without an established outpatient clinician.