SUBSTANCE USE

Working With the Active User Guideline

Introduction

Substance Use Guidelines Committee, May 2015

RECOMMENDATION
  • Clinicians should ensure that substance users are engaged in medical care regardless of whether or not they are actively using drugs.

Substance users with HIV infection may face the burdens of comorbid psychiatric conditions, limited education, or difficulty navigating the healthcare system, or they may lack the financial resources to obtain care. Because it is common for healthcare providers to have negative feelings toward active substance users, these patients are also vulnerable to discrimination when seeking treatment.

Barriers to obtaining and providing effective treatment for active substance users can be minimized. For clinicians to ensure that substance users are engaged in medical care, regardless of whether or not they are actively using drugs, is a challenge and requires a foundation of trust that involves both a nonjudgmental, supportive approach and a spectrum of interventions to achieve both substance use and medical treatment goals. By accessing the resources of multiple services and programs, implementing brief interventions, educating patients about the risks of substance use, and using harm-reduction and motivational interviewing techniques, clinicians can effectively address the complex conditions and problems that active substance users experience.

Quick tips for working with substance users:

  • Design strategies to keep the patient in care, such as reminder systems and peer support
  • Ask the patient about his/her treatment goals
  • Express concern for the patient’s health and wellness and a willingness to address the patient’s health needs
  • Establish systems to ensure coordination of care across multiple disciplines
  • Assess the patient’s readiness to change and tailor appropriate interventions
  • Encourage behavior change through the use of brief interventions and motivational interviewing
  • Introduce harm-reduction techniques for patients who are not yet able to abstain from substance use

Coordinating Multidisciplinary Care

May 2015

RECOMMENDATIONS
  • Clinicians should coordinate with providers from multiple disciplines to ensure optimal patient care.
  • Clinicians should provide information and referrals to enable HIV-infected substance users to access available community resources needed for comprehensive care and management.

Comprehensive care for HIV-infected substance users involves the coordination of multiple services, including HIV primary care, mental health care, substance use treatment, case management, housing and legal services, and pharmacy support services. Coordinated care also ensures that patients have access to HIV testing and counseling, education about risk reduction for sexual and substance use behaviors, and safer sex and injection materials.

Co-Located Services

Ideally, comprehensive care for HIV-infected substance users can be provided when services are co-located at one site, under a common programmatic aegis, or linked across several sites and administrative structures [1]. Co-located services can optimize interdisciplinary care. Benefits of single-site treatment may include weekly case discussions, integrated medical records, and use of a common information system. Co-located programs can be provided within a primary care center by staff from other disciplines, including psychologists, social workers, and addiction treatment providers.

The New York State co-location model integrates HIV prevention, HIV primary care, and substance use treatment with the goal of increasing access to care for high-risk patients, including HIV-infected active substance users. This model of care has been associated with improved adherence to medical treatment [2].

Interagency Coordination

RECOMMENDATIONS
  • Clinicians and service providers from other sites should establish systems to ensure coordination of care.
  • The primary care clinician should help ensure that team members’ responsibilities for important elements of the patient’s care are clearly assigned.

When patients receive care from providers in multiple disciplines or in diverse settings, effective communication between representatives of each program is critical for minimizing fragmentation of care or divergent treatment strategies. The functions and responsibilities of each program should be clear. Responsibilities assigned to specific team members should include the following:

  • Making referrals to social services
  • Following up with the patient and other members of the healthcare team if the patient drops out of treatment
  • Notifying other members of the healthcare team if a major change in status occurs

Adherence to regulations that protect the privacy of patient information may be complex in some cases. Laws regulating the disclosure of patient information pertaining to HIV care, substance use treatment, and general medical care are designed to protect the patient’s confidentiality, although each has distinct stipulations. Health Insurance Portability and Accountability Act (HIPAA) regulations also affect the exchange of health-related information. For more information about HIPAA, see the NYSDOH HIPAA Information Center.

KEY POINT
  • Programs that frequently provide referrals to each other may benefit from developing written, working interagency agreements.

Program directors may find it useful to develop interagency agreements and qualified service agreements to simplify routine communications. Interagency agreements may include admission criteria, services offered, and the referral process. The Legal Action Center is an excellent source of guidance regarding these issues.

Case Management

RECOMMENDATIONS
  • Clinicians should refer substance-using patients for case management to enhance coordination when care is provided by multiple disciplines and in multiple settings.
  • Clinicians should regularly involve case managers in case conferences to discuss medical, psychological, social, and substance use issues that may affect a patient’s ability to adhere to care.

To ensure that these issues are addressed and risk of fragmentation of care is minimized, the clinician should work with the case management team to coordinate medical care, referrals, and ongoing services in the community.

KEY POINT
  • Appropriate management of substance use issues should include the use of social work, case management, or mental health services, in conjunction with substance use counselors, when available.

Referral for Drug Treatment Services

RECOMMENDATION
  • Clinicians should collaborate with social work staff and other mental health providers, when available, to determine which treatment programs or substance use services best meet the patient’s needs.

Drug treatment services may be available in hospitals or community-based organizations. Many community-based organizations offer a range of services, such as mental health, home health, and complementary services; relapse prevention; education and/or support groups; and programs such as harm reduction [3], detoxification, rehabilitation, and day treatment. Clinicians should be familiar with both the mechanisms of referral and the resources available in the community.

References:
  1. Samet JH, Friedmann P, Saitz R. Benefits of linking primary medical care and substance abuse services: Patient, provider, and societal perspectives. Arch Intern Med 2001;161:85-91. [Abstract]
  2. American Society of Addiction Medicine. ASAM News. November-December 1990. Vol. 5, No. 6; page. 9. Available at: www.asam.org/docs/default-source/publications/1990-11-12vol5-6ocr.pdf?Status=Master&sfvrsn=2
  3. Harm Reduction Coalition. Available at: www.harmreduction.org

Engaging and Maintaining Patients in Care

May 2015

Building a Therapeutic Relationship

RECOMMENDATIONS
  • Clinicians who are uncomfortable or inexperienced with treating substance-using patients should seek guidance from providers with more experience in this area.
  • Clinicians should tailor interactions with substance-using patients to facilitate a trusting relationship for engaging and retaining patients in care.

A strong patient-provider relationship and expressions of empathy and nonjudgmental attitudes from the healthcare team can encourage patients to remain in treatment or return if they have dropped out. Building relationships with patients should be individualized because each patient has a different tolerance for relationships, and some could perceive too much provider involvement as intrusive. A therapeutic relationship can be strengthened by:

  • Establishing open, respectful avenues of communication (see below for strategies for effective patient-provider communication [1])
  • Providing clear and direct ways for the patient to reach the clinician
  • Asking permission to contact the patient as needed, asking whether there are family members and/or friends who the clinician has permission to contact if needed, and establishing best ways to stay in contact with each other
  • Consistently emphasizing concern for the patient’s health and willingness to address the patient’s needs

Stigma and shame are powerful barriers to both effective communication and participation in treatment. Because many substance users have experienced stigma and discrimination, many distrust the healthcare system, which may contribute to their difficulty in receiving effective treatment [2,3].

To avoid stigmatizing patients because of their drug use or any other behavior or attribute, clinicians and staff should use nonjudgmental language with “positive regard.” Positive regard has been defined as the ability to appreciate and respect another person’s worth and dignity.

It is not uncommon for clinicians to possess negative feelings toward substance users; clinicians need to acknowledge and manage negative feelings so that they are able to provide the same quality of care to substance users as to patients who do not use substances. Reflective practice allows for clinicians to manage feelings of negative regard for patients, disclose true feelings of frustration outside of the examination room, and receive support and advice from colleagues on how to proceed.

Patient-Provider Communication as a Collaborative Process

  • Build trust
    • Ask the patient about his/her treatment goals
    • Be explicit (both to the patient and to yourself) regarding how you intend to provide treatment for the patient
    • Be consistent and respectful
    • Meet the patient “where they’re at”
  • Avoid shaming the patient in any way
    • Address ongoing drug use or resumption of use in a nonpunitive fashion
    • Address substance use in clinical terms and avoid judgmental language that can exacerbate stigma, such as “substance abuse”
  • Provide positive feedback
    • Improved clinical results when applicable
    • Adoption of healthful behaviors
    • Elimination or reduction of less healthful behaviors

Encouraging Patient Participation

RECOMMENDATION
  • Clinicians should actively engage HIV-infected substance users early in the treatment-planning process.

Although not unique to substance users, early and active engagement by the patient in the treatment-planning process is crucial to optimal treatment and may help retain the patient in care for a longer period of time. Studies suggest that patients with comorbid substance use and HIV infection are more likely to leave treatment when they are given treatment goals that they are not ready to accept. The inclusion of patients early in the planning process may lead to more successful treatment outcomes. Treatment goals will vary to reflect patients’ needs and will typically include elements as diverse as keeping appointments, adherence to medications (e.g., ARV therapy, PCP prophylaxis, psychotropics), or getting regular Pap tests or vaccinations.

Treatment expectations should be discussed with the substance-using patient. If a patient does not fully understand his/her HIV diagnosis and management, he/she may not be able to achieve the desired outcome.

References:
  1. Dunn C, Rollnick S. Rapid Reference to Lifestyle & Behavior Change: Rapid Reference Series. London: CV Mosby; 2003.
  2. Weiss L, Kluger M, McCoy K. Health Care Accessibility and Acceptability Among People That Inject Drugs or Use Crack Cocaine. New York: The Office of Special Populations, The New York Academy of Medicine; 2000.
  3. US Department of Health and Human Services. Improving substance abuse treatment: The National Treatment Plan Initiative. In: Changing the Conversation. Washington DC: US Department of Health and Human Services; Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration; 2000. Available at: www.samhsa.gov

Treatment Readiness and Relapse Prevention

May 2015

Assessing Treatment Readiness

RECOMMENDATION
  • Clinicians should address substance use with active substance users and assess their readiness for substance use treatment at the initial visit and routine monitoring visits.

Many behavior-change interventions are directed at immediate action, such as abstinence, but some patients may not be ready for immediate change. These situations can be challenging for both the clinician and patient, especially if strategies other than abstinence are not discussed. Disappointment and frustration caused by conflicting goals may disrupt the therapeutic relationship.

The Transtheoretical Stages-of-Change model focuses on behavior change as a process, rather than an event, and proposes that individuals at different stages in this process may need interventions specific to their situation [1,2]. Interventions that are tailored to the patient’s stage of readiness to change are critical for effective treatment. The five stages identified in this model are described below [3,4]:

Transtheoretical Stages of Change

  • Precontemplation: Stage at which the patient does not intend to change behavior in the foreseeable future. A patient at this stage may be unaware or only vaguely aware of his/her problem.
  • Contemplation: Stage at which the patient is aware of the problem and is seriously considering changing behavior but does not make a commitment to take action. Patients at this stage are often ambivalent about the sense of loss they may feel despite the perceived gain of overcoming their problem.
  • Planning and preparation: Stage at which the patient intends to take action within the next 30 days and has taken some steps toward treatment. This stage combines intention and behavioral criteria, such as making small modifications to behavior that signal a decision to change.
  • Action: Stage at which the patient changes behavior and commits a considerable amount of time and energy to overcoming the problem. This stage lasts from the time of the initial action to 6 months.
  • Maintenance: Stage at which the patient continues to prevent relapse from 6 months to an indefinite period beyond the initial action.

These stages are conceptualized as a cycle or spiral because the process is fluid; individuals often move back and forth between stages and do not necessarily move directly from one stage to the next. The model accepts the repetitive nature of an individual’s alcohol and/or substance use and understands that relapse may occur.

Relapse Prevention

RECOMMENDATION
  • Clinicians should ask patients who have been abstinent from illicit drug use for less than 1 year about the date of last use at routine monitoring visits.

By definition, recovery from substance use behavior can be interrupted by periods of relapse. Relapse is defined by the American Society of Addiction Medicine as the “recurrence of psychoactive substance-dependent behavior in an individual who has previously achieved and maintained abstinence for a significant period of time beyond withdrawal” [5].

KEY POINT
  • Stable abstinence depends on relapse prevention and not just detoxification.

Patients with a known history of substance/alcohol dependence are at high risk for relapse, especially when they are in an early recovery period (<1 year) or when stressed by a new diagnosis of HIV or its complications. Some common reasons for relapse and strategies to prevent relapse are shown below.

  • Common reasons for relapse:
    • Patient not well prepared for the significant and prolonged effort needed to maintain sobriety
    • Patient not clear about the specific overall treatment goals
    • Patient not properly equipped with strategies (refusal skills, recognition of cues, coping skills) to anticipate and react to high-risk situations
  • Strategies to prevent relapse:
    • Careful use of medications to avoid inadvertently treating the patient with medications that could lead to relapse
    • Appropriate treatment of pain because untreated pain may be a trigger for relapse
    • Careful observation for periods of increased stress

By asking patients about the date of last use of substances at every monitoring visit, clinicians can diagnose relapse earlier as well as reinforce successful efforts. If relapse occurs, the clinician should not view it as a failure but as an opportunity to learn from what happened and to change tactics to more effectively prevent future relapse.

KEY POINT
  • A patient’s unwillingness to discuss his/her recovery program with the primary care clinician may be one of the first signs of relapse.

If a patient does relapse, the clinician should:

  • Be nonjudgmental and voice continued optimism
  • Ask what the specific circumstances were that led the patient to use again
  • Encourage a return to treatment
  • Discuss difficulties and stresses
  • Reassess the need to initiate pharmacotherapy or adjust doses
  • Refer to or include other providers, such as social workers, in the patient’s care
  • Schedule more frequent visits
  • Prescribe clean syringes and needles, furnish them through the Expanded Syringe Access Program, or refer patients to a syringe exchange program
References:
  1. Prochaska JO, DiClemente CC, Norcross JC. In search of how people change: Applications to addictive behaviors. Am Psychologist 1992;47:1102-1114. [Abstract]
  2. Prochaska JO, Velicer WF. The transtheoretical model of health behavior change. Am J Health Promot 1997;12:38-48. [Abstract]
  3. Cancer Prevention Research Center. Transtheoretical model: Stages of change. Kingston, RI: University of Rhode Island. Available at:http://web.uri.edu/cprc/transtheoretical-model-stages-of-change
  4. Zimmerman GL, Olsen CG, Bosworth MF. A ‘stages of change’ approach to helping patients change behavior. Am Fam Physician 2000;61:1409-1416. [Abstract]
  5. American Society of Addiction Medicine. ASAM News. November-December 1990. Vol. 5, No. 6; page. 9. Available at: Available at:www.asam.org/docs/default-source/publications/1990-11-12vol5-6ocr.pdf?Status=Master&sfvrsn=2

Spectrum of Interventions

May 2015

RECOMMENDATION
  • Clinicians should offer and support a repertoire of substance use treatment goals, such as abstinence, a reduction in use, or safer use, and should advocate safer sex practices among HIV-infected substance users.

Brief Interventions and Education

RECOMMENDATIONS
  • Clinicians should educate substance-using patients about the detrimental effects of illicit drug use, alcohol use, and misuse of prescription drugs to help stimulate behavior change.
  • Clinicians should present information in language that is easily understood by the patient, avoiding medical jargon and ensuring that written materials are tailored to the intended audience.

Brief interventions refer to providers’ offering education, advice, and counseling, which may vary from brief advice to a short motivational interview. Brief interventions may foster patients’ motivation to seek referral to a specialist or a treatment program. Such interventions may also help some substance users reduce use, which would potentially reduce risky behaviors and associated adverse medical and social consequences.

Concern about their own health status may be an encouraging stimulus for some substance users to change their substance use behavior. Implementing measures such as brief interventions that support the patient in addressing a specific health behavior has been shown to be effective in primary care populations. Meta-analyses have found that brief interventions are effective in reducing cigarette smoking [1] and excessive alcohol use [2]. Some studies have shown that brief interventions targeting illicit drug use may also be effective for reducing use [3]. Brief interventions may also help more impaired patients engage in additional treatment.

Clinicians should include the following intervention topics when discussing substance use with patients:

  • Risks commonly associated with substances used, either present or past
  • Means to reduce physical, mental, and social problems attributable to substance use
  • Benefits of change
  • Referrals to other services if needed

Motivational Interviewing

Motivational interviewing encourages open, productive discussions about behavior and uses the patient’s own strengths and beliefs as a tool to motivate behavior change [4]. Motivational interviewing is a therapeutic treatment style that may be used to explore issues of ambivalence and conflict regarding substance use and treatment. Through use of motivational interviewing, the clinician attempts to stimulate change by identifying discrepancies in the patient’s current behavior and the patient’s goals of healthier behaviors. When the patient begins to understand how the consequences of current behavior conflict with personal values, the clinician reflects the discordance back to the patient, until the patient realizes that change is necessary and makes the decision to commit to change. This approach encourages patients to describe their behaviors and develop their own solutions.

Motivational interviewing is not a set of tools to be used with all patients, but one of many options for interacting with them. For patients who have difficulty tolerating direct communication or who may not be able to identify their own needs, use of motivational interviewing may not be suitable. Direct persuasion and aggressive confrontation are not part of motivational interviewing. With this approach, clinicians do not give advice or directives.

Principles of Motivational Interviewing

Clinicians should understand the underlying principles of motivational interviewing before using it. The four key components of motivational interviewing are described below.

Expressing empathy: Understanding and being aware of and sensitive to the feelings, thoughts, and experiences of the patient. Accomplished through reflective, nonjudgmental listening.

Supporting self-efficacy: Supporting the patient with the sense that he/she can identify and meet his/her needs and goals. Providing examples of positive change and the importance of taking responsibility.

Avoiding argumentation and rolling with resistance: Listening to the patient’s expression of resistance to change. Working collaboratively with the patient to examine alternatives to resistance and to develop his/her input regarding the treatment plan.

Discovering discrepancies: Helping the patient identify discrepancies between his/her current behavior and desired future behavior or goals. Examining the consequences of continuing unhealthy behavior and discussing the advantages of adopting a new behavior.

Motivational Interviewing Approach

The acronym OARS outlines the basic approach to interactions in motivational interviewing:

Open-ended questions invite patients to identify goals and explore their own motivators for change if they have change goals. This strategy lets the patient know that the clinician is interested in his/her situation, while allowing the clinician to obtain needed information and insight into the patient’s issues.

Affirmations provide opportunities for clinicians to recognize the patients’ strengths.

Reflective listening helps the clinician identify areas of ambivalence. It is particularly important to reflect back any statements that indicate that the patient is motivated to change. Simple reflections acknowledge the patient’s statements about disagreements, feelings, or perceptions. Double-sided reflections acknowledge both what the patient has said and the ambivalence. Amplified reflections reveal the patient’s ambivalence in a slightly exaggerated form.

Summaries will emphasize the main points of the discussion and should capture both sides of the patient’s ambivalence. The summary can also be used to shift focus or direction when the patient is expressing impassible resistance. After the clinician summarizes, he/she should invite the patient to make any corrections.

More resources on motivational interviewing are available at the Motivational Interviewing Network of Trainers website

Promoting Safer Sex Practices

RECOMMENDATION
  • Clinicians should discuss behavioral risk-reduction measures for prevention of sexually transmitted infections, including correct and consistent condom use, on a routine and ongoing basis.

Individuals under the influence of some substances are more likely to engage in sexual risk-taking behavior than individuals not under the influence of substances [5-8]. It is important to address risk associated directly with substance use, such as needle-sharing and sexual risk-taking, which may result from impaired judgment due to substance use, as well as risks associated with the exchange of sex for drugs.

Clinicians should discuss safer sex practices with HIV-infected substance users. Sex that takes place in the context of substance use, or in exchange for money or drugs, is associated with increased risk of HIV exposure and transmission. Specific discussions with patients about using barrier protection, about how to speak with partners about safer sex, and about the circumstances under which they engage in high-risk sexual behavior may enhance the effectiveness of patients’ efforts to protect themselves and their partners from further transmission.

Clinicians who treat sexually active patients should counsel them on how to reduce the negative consequences of unprotected sex, such as unplanned pregnancy, HIV transmission, and sexually transmitted infections, and should provide them with condoms. This promotes the message “be safe,” which is different from “just say no.”

Harm-Reduction Approach

Harm reduction focuses on reducing the negative health, social, and economic consequences associated with risk behaviors that are related to substance use [9]. Methods to reduce risk behaviors that cannot be entirely eliminated have become common in medical and public health practice. The approach of harm reduction is intended to engage the patient in health care through the clinician’s nonjudgmental stance toward the patient’s current substance use, enabling the clinician and patient to work together toward reducing risk behavior while promoting health. When working with active substance users, clinicians can engage the patient in any level of care, including medical care for HIV infection, harm-reduction services, treatment for substance use, or all three.

Abstinence-oriented approaches and harm-reduction approaches need not be mutually exclusive. Harm reduction acknowledges that the long-term, chronic-relapsing nature of substance use makes total abstinence difficult for many substance users and works to keep patients involved in care, regardless of the level of their current substance use. Many clinicians who work in traditional abstinence-oriented programs have adopted harm-reduction principles, recognizing relapse as a part of the process for some substance users. Abstinence-oriented programs should also continue to work with an individual toward reducing harm, even when substance use is continuing.

KEY POINT
  • Some patients using multiple substances may diminish or stop using one drug at a time rather than abstaining from all drugs at once. It is important that patients be positively recognized for such steps.

Harm-reduction techniques for HIV-infected injection drug users: Harm reduction may be an effective strategy for reducing risk in 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.

If a patient is not ready to stop using drugs, or cannot stop, the effects of substance use should be discussed to ensure that the patient understands the harm caused by substance use. This discussion may lead the patient to consider stopping or reducing drug use. Risk-reduction options to discuss include:

  • Discontinuation of illicit drug use
  • Discontinuation of injection of illicit drugs
  • The use of new needles and syringes for every injection if unable to stop injecting
  • Cleaning the needle and syringe with bleach and water if unable to obtain new needles and syringes
  • Avoiding sharing any equipment, including needles, syringes, filtration cotton and cooker, with others

Access to Clean Needles

RECOMMENDATIONS
  • Clinicians should issue prescriptions for new needles and syringes to patients who inject drugs.
  • Clinicians should discuss with patients other options for accessing new needles and syringes, including use of the Expanded Syringe Access Program and syringe exchange programs, New York State’s two syringe access initiatives.
  • Clinicians should discuss avoidance of needle/syringe-sharing activity with all injection drug users, regardless of viral load, to prevent HIV and hepatitis B and C virus transmission.

Evidence, including a 2014 meta-analysis, has demonstrated that providing access to clean syringes and education through syringe exchange programs can be effective in reducing HIV transmission and HIV risk behavior among injection drug users, without increasing drug use [10-14].

In New York State, pharmacies, healthcare facilities, and healthcare practitioners who are registered in the Expanded Syringe Access Program (ESAP) can sell or furnish, without a prescription, hypodermic needles and syringes to individuals 18 years of age and older. No more than 10 hypodermic needles or syringes can be sold or furnished to an individual at one time.

IDUs should be informed of this law and should receive instruction on how to locate participants. Safe storage and proper disposal of sharps should also be discussed. Clinicians can obtain more information on these issues from the New York State Department of Health (NYSDOH), or by contacting the NYSDOH by email: ESAP@health.ny.gov [15].

Safe Storage and Disposal of Sharps

RECOMMENDATION
  • Clinicians should ensure that injection drug users receive instructions concerning safe techniques for storage and disposal of sharps.

Used needles and syringes should be properly stored until they can be safely discarded. IDUs should be instructed to follow the guidelines below for safely storing used needles and syringes. To prevent harm caused by improper disposal of used needles, IDUs should take used sharps to any hospital, nursing home, syringe exchange program, or syringe-disposal site located throughout New York State. Healthcare providers, the local public works department, sanitation department, or trash collectors should also know how to advise individuals on how and where to dispose of sharps properly.

Box 1: Safe Storage of Used Sharps
DO THIS DON’T DO THIS
  • Put used sharps (needles, syringes, lancets) in a sharps container or a puncture-resistant, plastic bottle (e.g., bleach or laundry detergent bottle). Close the screw-on top tightly. Tape top. Label bottle: “Contains Sharps.”
  • Immediately dispose of sharps into container after use. Keep container closed between uses.
  • Keep sharps containers away from children and pets.
  • Bring sharps container when traveling and dispose of it at home upon return.
  • Clip, bend, or recap sharps.
  • Put sharps in soda cans, milk cartons, or in any containers that are not puncture resistant. Coffee cans are not recommended because plastic lids come off too easily and may leak.
  • Flush sharps down the toilet or drop them into a storm sewer.
  • Put sharps containers with the recycling.

Safer Injection Techniques

RECOMMENDATION
  • Safe injection techniques should be discussed with injection drug users who are not ready or willing to stop injecting drugs.

If the patient does not want to stop injecting drugs, the clinician should discuss safer injection techniques, such as sterile technique, rotating sites, and avoiding high-risk sites, such as the feet, groin, and neck, to reduce any harm that might result from bad injection habits [16]. Patients should be advised to clean the injection site with alcohol or soap and water as well as to wash their hands before injecting. Patients should be advised to avoid sharing any injection equipment including drug preparation equipment such as cookers (metal bottle caps), water for dissolving drugs and rinsing syringes, cotton for filtering the solution, and tourniquets.

Overdose Prevention

RECOMMENDATION
  • Clinicians should counsel substance-using patients about the risk of overdose and how it may be prevented.

Heroin and other opioid use is associated with a significant increase in mortality, approximately half of which is due to overdose. The risk of death may be as high as 2% per year. Opioid overdose is characterized by respiratory depression primarily due to reduction in brainstem sensitivity to carbon dioxide, which may lead to death. Death usually occurs 1 to 3 hours after injection, rather than suddenly, and is often witnessed by someone who does not recognize the danger or does not act on it [17]. In many cases of overdose, opioids are mixed with alcohol or benzodiazepines. Overdose is most common among those who have been using for 5 to 10 years, rather than in the new user. See below for other risk factors associated with overdose and harm-reduction topics related to overdose that clinicians should discuss with substance users who use opioids.

Behavioral risk factors for heroin and other opioid overdose:

  • Resumption of use after a period of abstinence from opioid use, such as recent release from detoxification, drug treatment, or correctional facility
  • Use of opioids without others present raises the risk of fatality
  • Mixing opioids with other drugs, particularly alcohol or benzodiazepines
  • Injection
  • Concurrent serious medical conditions, particularly AIDS and hepatic dysfunction

Topics of risk-reduction counseling to prevent overdose:

  • The risks of using alone
  • The risk of using after a period of abstinence
  • The danger of mixing other depressants with opioids
  • Recognition of the signs of a possible opioid overdose in another user
  • Learning mouth-to-mouth breathing or CPR
  • Calling 911 to report someone who is unconscious or not breathing. Be prepared for possible police involvement. When the ambulance comes, report exactly what the person took.
  • Use of and being prescribed naloxone, an antidote for opioids. Naloxone can precipitate withdrawal symptoms.

There is compelling evidence that opioid users and others who may witness an overdose may benefit from training in resuscitation and the provision of naloxone (Narcan), which can be administered to companions should they overdose [18]. Naloxone is a prescription medicine that reverses an overdose by blocking heroin (or other opioids) in the brain for 30 to 90 minutes. In New York State, a law that took effect in April 2006 allows for the use of naloxone as first aid if administered in good faith by a nonmedical person intending to reverse an opioid overdose. After being trained by State-approved overdose prevention programs and receiving a naloxone kit or prescription from a professional licensed to prescribe, responders are permitted to carry and administer naloxone without risk of prosecution.

For prehospital rescue of patients with suspected opioid overdose, the intramuscular (IM) route of naloxone is preferred. Although intranasal (IN) naloxone is not FDA-approved at the time of writing, recent randomized trials suggest that IN naloxone is of similar effectiveness to IM and intravenous (IV) naloxone as a treatment for opioid overdose [19,20]. For some individuals and in particular settings, IN naloxone offers a needleless alternative to IM naloxone [21-24].

Agencies providing naloxone training services include syringe exchange programs, drug treatment programs, HIV service providers, and other community-based organizations. Clinicians can refer patients to these services and/or register to prescribe naloxone to patients who have been trained in its use. Clinicians prescribing naloxone to responders in New York State must be registered with the New York State Department of Health. More information is available at NYSDOH Opioid Overdose Prevention.

KEY POINT
  • Opioid replacement therapy, as well as participation in opioid maintenance programs, are effective preventive measures for overdose and reduce mortality among opioid users [25,26]. Treatment with methadone, buprenorphine, or buprenorphine/naloxone reduces the use of illicit opioids and maintains a level of tolerance to the effects of opioids, including respiratory depression. For more information about the use of opioid replacement therapy in HIV-infected patients, see Treatment Modalities for HIV-Infected Substance Users and Guidance on the Use of Buprenorphine in HIV-Infected Patients.
References:
  1. Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: US Department of Health and Human Services, Public Health Service; 2000.
  2. Whitlock EP, Polen MR, Green CA, et al. U.S. Preventive Services Task Force. Behavioral counseling interventions in primary care to reduce risky/harmful alcohol use by adults: A summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2004;140:557-568. [Abstract]
  3. Bernstein J, Bernstein E, Tassiopoulos K, et al. Brief motivational intervention at a clinic visit reduces cocaine and heroin use. Drug Alcohol Depend2005;77:49-59. [Abstract]
  4. Motivational Interviewing. 2003. Available at: www.motivationalinterviewing.org/
  5. Semple SJ, Strathdee SA, Zians J, et al. Sexual risk behavior associated with co-administration of methamphetamine and other drugs in a sample of HIV-positive men who have sex with men. Am J Addict 2009;18:65-72. [Abstract]
  6. Trepka MJ, Kim S, Pekovic V, et al. High-risk sexual behavior among students of a minority-serving university in a community with a high HIV/AIDS prevalence. J Am Coll Health 2008;57:77-84. [Abstract]
  7. Woods WJ, Lindan CP, Hudes ES, et al. HIV infection and risk behaviors in two cross-sectional surveys of heterosexuals in alcoholism treatment. J Stud Alcohol 2000;61:262-266. [Abstract]
  8. Malow RM, Dévieux JG, Jennings T, et al. Substance-abusing adolescents at varying levels of HIV risk: Psychosocial characteristics, drug use, and sexual behavior. J Subst Abuse 2001;13:103-117. [Abstract]
  9. Robertson R. Management of Drug Users in the Community: A Practical Handbook. New York: Oxford University Press; 1998.
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  13. Aspinall EJ, et al. Are needle and syringe programmes associated with a reduction in HIV transmission among people who inject drugs: a systematic review and meta-analysis. Int J Epidemiol. 2014;43(1):235-48. [Abstract]
  14. Gibson DR, Flynn NM, Perales D. Effectiveness of syringe exchange programs in reducing HIV risk behavior and HIV seroconversion among injecting drug users. AIDS. 2001;15(11):1329-41. [Abstract]
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Appendix: Identification and Management of Withdrawal Symptoms

March 2009

Alcohol Withdrawal

Manifestations of symptoms: Although more than 95% of alcohol withdrawal cases are uncomplicated and self-limited, intoxication and withdrawal can be fatal. Alcohol withdrawal symptoms are characterized by autonomic hyperreactivity and neuropsychiatric alterations (see below). Withdrawal symptoms do not always progress from mild to severe in a predictable manner, and patients can progress quickly into delirium tremens (DTs), hallucinosis, or generalized seizures. The possibility of alcohol withdrawal should be seriously considered in any patient with persistent sinus tachycardia and elevated blood pressure.

Symptoms (time of appearance after cessation):

  • Minor withdrawal symptoms: Insomnia, tremulousness, mild anxiety, gastrointestinal upset, headache, diaphoresis, palpitations, anorexia (6 to 12 hours)
  • Alcoholic hallucinosis: Visual, auditory, or tactile hallucinations (12 to 24 hours) that generally resolve within 48 hours.
  • Withdrawal seizures: Generalized tonic-clonic seizures (24 to 48 hours, but have been reported as early as 2 hours after cessation.)
  • Alcohol withdrawal delirium (delirium tremens): Hallucinations (predominately visual), disorientation, tachycardia, hypertension, low-grade fever, agitation, diaphoresis (48 to 72 hours); symptoms peak at 5 days.

Adapted from the Academy of Family Physicians. Bayard M, McIntyre J, Hill KR, et al. Alcohol withdrawal syndrome. Am Fam Physician 2004;69:1443-1450.

Management goals: The standard treatment of alcohol withdrawal is with benzodiazepines. Depending on the patient’s severity of symptoms, and on the protocols of the institution, different benzodiazepine treatment modalities may be used.

Opioid Withdrawal

Manifestations and assessment of symptoms: The following factors may affect the time of onset, intensity, and duration of opioid withdrawal symptoms:

  • Specific substance used
  • Total daily dose
  • Interval between doses
  • Duration of use
  • Individual sensitivity

Refer to Care of the Hospitalized HIV-Infected Substance User for the signs and symptoms of opioid withdrawal, including withdrawal from buprenorphine and methadone.

Management goals: Management of opioid withdrawal has two primary goals: (1) to minimize the severity of discomfort in a safe environment; and (2) to help the patient develop a realistic treatment plan

Opioid withdrawal in the hospital setting should be managed according to the institution’s protocols, which may include either methadone or buprenorphine. For patients who were receiving buprenorphine treatment or who were enrolled in a methadone maintenance program before hospitalization, the same dose of buprenorphine or methadone at the same time of day is generally indicated in the hospital setting. The dose and time of dose may be altered over the course of the hospitalization as clinically indicated; however, rapid tapering of methadone is not advisable, particularly if such tapering is against the patient’s wishes. Opioid-dependent patients who are not in treatment but want to participate after discharge should be referred for treatment with a methadone maintenance program or buprenorphine provider. Optimally, an established referral system should be in place between the hospital and providers who treat opioid dependence.

Benzodiazepine Withdrawal

Manifestations and assessment of symptoms: Benzodiazepine withdrawal syndrome presents similarly to alcohol withdrawal, but the time course and severity of benzodiazepine withdrawal will vary depending on the amount and type of benzodiazepine used (short- or long-acting), as well as the chronicity of the patient’s use. In general, onset of withdrawal symptoms occurs within 1 to 7 days and includes agitation, tachycardia, insomnia, and nightmares. Severe withdrawal can cause fevers, seizures, and psychosis and can be potentially fatal. Some individuals develop a protracted withdrawal syndrome that can fluctuate in intensity over several months.

Management goals: Members of the inpatient clinical team will inquire about the types and amounts of pills that the patient uses. A patient with a high level of benzodiazepine dependence requires a lengthy tapering period that he/she will likely be unable to complete while hospitalized. A realistic goal is to change to a longer-acting benzodiazepine, such as clonazepam or chlordiazepoxide, and provide the primary care clinician with an appropriate regimen for continuing the detoxification on an outpatient basis. Ensuring patient comfort and ability to adhere to outpatient treatment is an important consideration when switching to a longer-acting benzodiazepine and tapering after discharge. In general, the drug of addiction should not be the drug used for withdrawal treatment.

Stimulant Withdrawal

Cocaine and methamphetamine are the most commonly abused stimulants. Intermittent binge use of both is common.

Manifestations and assessment of symptoms: The withdrawal symptoms from stimulant use that occur after a 2- to 3-day binge are slightly different from those that occur after chronic high-dose use (see below). The typical clinical features of the cocaine withdrawal syndrome that may occur after the acute cessation of or reduction in heavy and prolonged cocaine use can be characterized as progressing through three phases:

  1. An acute withdrawal phase (crashing), which may include intense depression and fatigue, sometimes accompanied by suicidal ideation
  2. A period of more gradual withdrawal
  3. An extinction phase lasting 1 to 10 weeks

Following 2-to 3-day binge: For 24-48 hours following abstinence, the patient will experience exhaustion, dysphoria, and somnolence

Following chronic high-dose use: For 2-4 days following abstinence, the patient will experience dysphoria, irritability, insomnia, intense dreams, and, in severe cases*, suicidal ideation

*Trachtenberg AI, Fleming MF. Diagnosis and treatment of drug abuse in family practice. Bethesda (MD): National Institute on Drug Abuse; 1994.

Management goals: The treatment of stimulant intoxication is symptomatic and supportive. In the case of cocaine, which is quickly metabolized and cleared, most individuals recover within hours and often do not require treatment. However, treatment of acute cocaine and methamphetamine toxicity is required when symptoms of paranoid delusions, severe excessive aggravation, hypertension, or tachycardia are present. Short-acting benzodiazepines, such as lorazepam, may be helpful in selected patients who develop agitation or sleep disturbance. Treatment for paranoid psychosis may include haloperidol or thioridazine.

The risk of relapse for patients who use stimulants (e.g., crack, cocaine, and methamphetamine) is high during the early withdrawal period. A patient’s exposure to environments or people associated with his/her stimulant use can trigger drug craving.

Nicotine Withdrawal

Manifestations and assessment: Nicotine withdrawal can manifest as:

  • Depressed mood
  • Insomnia
  • Irritability or anger
  • Impaired concentration
  • Restlessness
  • Anxiety
  • Increase in appetite or weight gain
  • Decreased heart rate

Management Goals: Pharmacotherapy for nicotine dependence is important (patch, gum, inhaler) for avoiding withdrawal symptoms in smokers. Because hospitalization is a time when smokers have increased contact with health professionals who can provide detailed and personalized advice on abstaining from tobacco, all patients who use tobacco should receive counseling. It should not be assumed that actively using patients are unreceptive to learning about how to reduce or stop smoking.

Treatment for nicotine cessation includes several forms of nicotine replacement therapy and non-nicotine therapy, such as bupropion. If the smoker has severe withdrawal symptoms, cravings, or difficulty maintaining abstinence, a general treatment approach is to start with one agent and add a second. The nicotine patch may be particularly suitable in the hospital setting because of its ease of application and dosing schedule [1]. Bupropion can also manage nicotine withdrawal; however, because it takes approximately 1 week to achieve effective levels in the blood [1], the earlier bupropion is administered, the more likely it is to be effective. See Drugs Used for Smoking Cessation.

Reference:
  1. Lewis SF, Piasecki TM, Fiore MC, et al. Transdermal nicotine replacement for hospitalized patients: A randomized clinical trial. Prev Med  1998;27:296-303. [Abstract]

All Recommendations

Substance Use Guidelines Committee, May 2015

ALL RECOMMENDATIONS: WORKING WITH THE ACTIVE USER
Introduction
  • Clinicians should ensure that substance users are engaged in medical care regardless of whether or not they are actively using drugs.
Coordinating Multidisciplinary Care 
  • Clinicians should coordinate with providers from multiple disciplines to ensure optimal patient care.
  • Clinicians should provide information and referrals to enable HIV-infected substance users to access available community resources needed for comprehensive care and management.
  • Clinicians and service providers from other sites should establish systems to ensure coordination of care.
  • The primary care clinician should help ensure that team members’ responsibilities for important elements of the patient’s care are clearly assigned.
  • Clinicians should refer substance-using patients for case management to enhance coordination when care is provided by multiple disciplines and in multiple settings.
  • Clinicians should regularly involve case managers in case conferences to discuss medical, psychological, social, and substance use issues that may affect a patient’s ability to adhere to care.
  • Clinicians should collaborate with social work staff and other mental health providers, when available, to determine which treatment programs or substance use services best meet the patient’s needs.
Engaging and Maintaining Patients in Care 
  • Clinicians who are uncomfortable or inexperienced with treating substance-using patients should seek guidance from providers with more experience in this area.
  • Clinicians should tailor interactions with substance-using patients to facilitate a trusting relationship for engaging and retaining patients in care.
  • Clinicians should actively engage HIV-infected substance users early in the treatment-planning process.
Treatment Readiness and Relapse Prevention 
  • Clinicians should address substance use with active substance users and assess their readiness for substance use treatment at the initial visit and routine monitoring visits.
  • Clinicians should ask patients who have been abstinent from illicit drug use for less than 1 year about the date of last use at routine monitoring visits.
Spectrum of Interventions 
  • Clinicians should offer and support a repertoire of substance use treatment goals, such as abstinence, a reduction in use, or safer use, and should advocate safer sex practices among HIV-infected substance users.
  • Clinicians should educate substance-using patients about the detrimental effects of illicit drug use, alcohol use, and misuse of prescription drugs to help stimulate behavior change.
  • Clinicians should present information in language that is easily understood by the patient, avoiding medical jargon and ensuring that written materials are tailored to the intended audience.
  • Clinicians should discuss behavioral risk-reduction measures for prevention of sexually transmitted infections, including correct and consistent condom use, on a routine and ongoing basis.
  • Clinicians should issue prescriptions for new needles and syringes to patients who inject drugs.
  • Clinicians should discuss with patients other options for accessing new needles and syringes, including use of the Expanded Syringe Access Program and syringe exchange programs, New York State’s two syringe access initiatives.
  • Clinicians should discuss avoidance of needle/syringe-sharing activity with all injection drug users, regardless of viral load, to prevent HIV and hepatitis B and C virus transmission.
  • Clinicians should ensure that injection drug users receive instructions concerning safe techniques for storage and disposal of sharps.
  • Safe injection techniques should be discussed with injection drug users who are not ready or willing to stop injecting drugs.
  • Clinicians should counsel substance-using patients about the risk of overdose and how it may be prevented.