Introduction
Clinicians should ensure that substance users are engaged in medical care regardless of whether or not they are actively using drugs.
Table 1
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
|
Coordination of Multidisciplinary Care
Clinicians should communicate with providers from multiple disciplines to ensure optimal patient care.
Clinicians should have access to available community resources needed for the comprehensive care and management of human immunodeficiency virus (HIV)-infected substance users.
Interagency Coordination
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.
Key Point:
Programs that frequently provide referrals to each other may benefit from developing written, working interagency agreements.
Case Management
Clinicians should refer substance-using patients for case management to enhance coordination of care 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.
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
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 the Patient in Care
Building a Therapeutic Relationship
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.
Table 2
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
Clinicians should actively engage HIV-infected substance users early in the treatment-planning process.
Assessing Treatment Readiness and Relapse Prevention
Assessing Treatment Readiness
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.
Relapse Prevention
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.
Key Point:
Stable abstinence depends on relapse prevention and not just detoxification.
Table 3
Reasons for and Strategies to Prevent Relapse
|
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
|
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.
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.
Brief Interventions and Education
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.
Motivational Interviewing
Table 4
Key Components of Motivational Interviewing
|
| Component |
Involves |
| Expressing empathy |
Understanding and being aware of and sensitive to the feelings, thoughts, and experiences of another.
Accomplished through reflective listening.
|
| Supporting self-efficacy |
Supporting the patient with the sense that an individual can identify and meet one's needs and goals. |
| Avoiding argumentation and rolling with resistance |
Listening to the patient's resistance to change.
Working collaboratively with the patient to develop his/her input regarding the treatment plan.
|
| Discovering discrepancies |
Helping patients identify discrepancies between their current behavior and desired future behavior. |
Promoting Safer Sex Practices
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.
Harm-Reduction Approach
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.
Access to Clean Needles
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 Demonstration 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.
Safe Storage and Disposal of Sharps
Clinicians should ensure that injection drug users receive instructions concerning safe techniques for storage and disposal of sharps.
Refer to Table 5 in the original guideline document for information on safe storage of used sharps.
Safer Injection Techniques
Safe injection techniques should be discussed with injection drug users who are not ready or willing to stop injecting drugs.
Overdose Prevention
Clinicians should counsel substance-using patients about the risk of overdose and how it may be prevented.
Refer to Table 6 in the original guideline document for information on behavioral risk factors for heroin overdose.
Key Point:
Methadone and buprenorphine maintenance have been demonstrated to be effective preventive measures for overdose. Both reduce the use of illicit opioids and maintain a level of tolerance to the effects of opioids, including respiratory depression.
Table 7
Elements 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 heroin.
- Recognition of the signs of a possible heroin overdose in another user.
- Learning mouth to mouth breathing or cardio-pulmonary resuscitation (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.
|
