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Chapter
13
Management Of Substance Abuse
Henry Francis,
MD
Assessment
of Substance Abuse Problems
TOP
What is
the definition of a substance abuser?
A substance
abuser is an individual who repeatedly uses an addictive substance
or performs a certain behavior even with the knowledge of its negative
health consequences. A person is drug dependent or addicted if he
or she uses drugs repeatedly despite the social, interpersonal,
or other problems associated with their use and has a physical or
psychological tolerance to the drug and experiences withdrawal symptoms
after the effects of the drug wear off. Long-term drug abuse can
interfere with normal brain activity and metabolism and can become
a chronic, relapsing condition characterized by compulsive drug
craving and drug seeking. There are other kinds of addiction that
may not involve the use of substances, such as gambling, sex, and
eating-related disorders, all of which involve a range of dysfunctional
behaviors with undesirable social, medical, and economic consequences
(see Table 13-1).
Table
13-1: Range of Substances and Behaviors That Can Be Abused
- Marijuana
- Cocain
- Heroin
- Amphetamines,
other stimulants
- Tranquilizers
- Hallucinogens
- Steroids
and recreational drugs
|
- Eating
disorders: anorexia, bulimia, binging
- Sex
disorders: compulsive sexual activity
- Gambling
- Internet
addictions: compulsive use of the internet
|
How should
primary care providers address substance use problems in their patients?
The first task
is to consciously look for behavioral and physical signs of maladaptive
drug use and to use a simple screening tool such as the CAGE examination
(described below) to detect it. Common indicators of drug abuse
are frequent absence from work or school, recurrent injuries, motor
vehicle accidents, depression, anxiety, labile hypertension, sleep
problems, sexual dysfunction, or abdominal symptoms. Physical signs
of drug abuse such as tremor, liver disorders, and physical changes
such as nasal irritation caused by cocaine are well known to health
care providers.
The second task is to tell the patient his or her diagnosis of drug
abuse or dependence. Providers are often concerned about upsetting
a patient with a stigmatizing diagnosis. Giving a concise, objective
description of clinical findings without making judgments is important.
Common pitfalls for providers to avoid during this discussion are
listed as the DEATH Glossary (Table 13-2).
Table
13-2. The DEATH Glossary
Common Pitfalls for Providers to Avoid when
Diagnosing Drug Abuse Problems
|
Do
not spend much time on how drug use started but focus on getting
the person to treatment. |
|
Avoid
arguing at all costs. No meaningful conversation will occur
in an argument. |
|
Guilt
and shame do not promote recovery from chemical dependency.
Threats or evoking guilt will not promote successful therapy. |
|
Hedging
hurts your credibility. Being ambivalent about giving the
diagnosis will not help the patient. If the patient disagrees
with you, unequivocally agreeing to disagree is a valid starting
point for getting to successful recovery. |
The third task
before sending a patient to treatment is to try a brief intervention
in the office. It has clearly been shown that brief interventions
given in community centers, hospitals, and ambulatory clinics decrease
the morbidity and mortality associated with drug abuse (see Suggested
Resources). For physicians who have received training on buprenorphine
treatment for opiate addicts, there is the added opportunity to
treat opiate drug users in the private practice setting without
referring the individuals to drug use centers (see section on Treatment
of Substance Abuse below).
Why is substance
abuse such a big issue in HIV care?
Injection drug
use is estimated to be responsible for 25% of HIV transmission in
the United States and is directly or indirectly responsible for
57% of HIV transmission to women. Less well appreciated is the fact
that drug-using behaviors may be a significant HIV transmission
risk factor for many men who do not inject drugs. In a recent study
of men who have sex with men (MSM), up to 16% may have drug use
as a risk factor for acquiring HIV (Chesney, 2003). The high degree
of association between injection and noninjection drug use underscores
the importance of primary care providers' being able to diagnose
drug using behaviors.
Diagnosing
drug or alcohol dependence or addiction is not an easy task. Many
people who are addicted to alcohol or drugs attempt to conceal or
deny that they have an addiction. In addition, diagnostic tests
for drug dependence and addiction lack specificity and sensitivity.
Although blood and urine tests are usually quite reliable at detecting
recent drug use, individuals can be adept at avoiding being tested
or at manipulating test results. See Table 13-3 for the duration
of time substances are detectible in urine.
Table
13-3: Duration of Time Drugs Are Detectable in Urine
Alcohol
|
48
hours
|
Amphetamines
|
12
hours
|
Barbiturates
|
10-30
days
|
Valium
|
4-5
days
|
Cocaine
|
24-72
hours
|
Heroin
|
24
hours
|
Marijuana
|
3-30
days (in heavy users)
|
Methaqualone
|
4-24
days
|
Phencyclidine
(PCP)
|
3-10
days
|
Methadone
|
3
days
|
Sex,
food, gambling
|
Not
applicable
|
Are there
tools to help providers assess patients for drug and alcohol use?
Experts in
addiction medicine use a combination of behavioral and clinical
testing to diagnose drug abuse. There are 9 commonly used drug-use
screening tests: Addiction Severity Index (ASI), Alcohol Dependence
Scale, Alcohol Use Disorders Identification Test (AUDIT), CAGE (see
below), Clinical Institute Withdrawal Assessment for Alcohol, Revised
(CIWA-Ar), Drinker Inventory of Consequences (DrInC), Michigan Alcohol
Screening Test (MAST and SMAST), Problem Oriented Screening Instrument
for Teenagers (POSIT), and Self-Administered Alcoholism Screening
Test (SAAST) (American Society of Addiction Medicine, 1998). Six
of them are specifically designed to detect alcohol use.
Which screening
tests are most useful in primary care practice?
The CAGE test
is a non-threatening quick screening test for detecting drug use
in adults (see Table 13-4) and the POSIT test useful for screening
adolescents aged 12-19. The questions below are designed to assess
key substance-using behaviors. The letters in CAGE correspond to
important emotions or behaviors indicative of drug use.
Table
13-4. The CAGE Indicators of Drug Use
|
2.
Have people Annoyed you by criticizing your drinking or drug
use? |
|
3.
Have you ever felt bad or Guilty about your drinking or drug
use? |
|
4.
Have you ever had a drink or used drugs first thing in the
morning (Eye opener) to steady your nerves, to get rid of
a hangover, or to get the day started? |
The Problem
Oriented Screening Instrument for Teenagers (POSIT) examination
is a 139 item yes/no questionnaire for assessing adolescent risk
factors in substance abuse, physical health, mental health, family
and peer relationships, educational and vocational status, social
skills, leisure and recreation, aggressive behavior, and delinquency.
A nonexperienced provider can conduct the test in 20 to 25 minutes.
The questionnaire is available free in English and Spanish from
the National Clearinghouse for Alcohol and Drug Information by mail
at P.O. Box 2345, Rockville, MD 20847-2345 or by telephone at 1-800-729-6686.
What would
provide a more in-depth assessment of drug and alcohol use?
Two detailed
evaluations of drug and alcohol use are the Diagnostic and Statistical
Manual of Mental Disorders, fourth edition (DSM-IV) and Addiction
Severity Index (ASI) for alcohol or drug use. The DSM-IV defines
the diagnostic criteria for substance dependence as a maladaptive
pattern of substance use, leading to clinically significant impairment
or distress, as manifested by 3 or more of the following, occurring
at any time in the same 12-month period:
- Presence
of drug withdrawal symptoms
- Escalation
of drug doses
- Persistent
inability to reduce or control drug use
- Increased
time spent obtaining drugs
- Personal
and business activities reduced by drug use
- Development
of drug tolerance
- Knowing
drug use's negative health and personal effects, yet continuing
to use drugs
Treatment
of Substance Abuse Problems
TOP
What should
you do before referring a person for treatment?
The decision
to refer a person for drug abuse treatment should come after the
provider has detected a substance use problem, conducted initial
evaluations to determine the degree of drug use and physical harm
done by the drug use, and provided brief interventions to stop drug
abuse. After the diagnosis and brief interventions (if appropriate),
the provider should refer the patient to a drug treatment system
or an addiction physician.
What role
does the primary care provider's attitude play in successful drug
abuse treatment?
Drug abuse
treatment is successful if the provider addresses his or her own
biases about addiction, understands the factors contributing to
addiction, provides appropriate pharmacologic and behavioral care,
and recognizes that drug addiction is a chronic disease problem.
Many drug abuse treatment failures are associated with hostile or
unsupportive providers whose behaviors are based on the assumption
that drug use is voluntary. Since successful drug abuse therapy
depends on adherence to treatment regimens, any factors that facilitate
adherence will foster successful treatment outcomes. The patient's
perception that the primary care provider is nonjudgmental and supportive
is an essential factor in successful therapy.
How can
the primary care provider enhance the success of drug abuse treatment?
The primary
care provider must prevent or treat exogenous factors that negatively
affect successful drug abuse therapy. We now recognize significant
environmental (social), genetic, biologic, and behavioral factors
that facilitate drug addiction:
Environmental
factors Common factors are family or sibling drug use, poverty,
poor education, and homelessness. Patient referral to social services
and family referral into drug treatment will facilitate the patient's
therapy.
Genetic
factors Ten percent of drug users have multifactorial genetic
predispositions to drug use. Many patients have significant severe
drug use problems requiring care from addiction specialists as
soon as possible.
Biologic
factors Many patients have preexisting mental health problems
such as depression and attention deficit and hyperactivity disorder
(ADHD) which, if recognized and treated, may prevent or modulate
drug use.
Behavioral
risk factors For adolescents, peer pressure is a common cause
of drug use. Early education by parents and the primary care physician
about drug use are very important for preventing drug use by adolescents.
What is
the role of drug detoxification in drug abuse treatment?
Drug detoxification
is the transitional therapy between identifying drug abuse and beginning
a comprehensive program to treat it. The objective of drug detoxification
is to facilitate a safe drug withdrawal process in supportive surroundings.
Detoxification is not a treatment or cure for drug addiction; it
is an intervention to get a person to the stage of comprehensive
drug abuse therapy. Two common medical interventions to modulate
symptoms are benzodiazepines in alcohol withdrawal and clonidine
in opiate withdrawal.
What are
the components of a comprehensive drug abuse treatment plan?
Effective drug
abuse treatment encompasses a combination of behavioral and pharmacologic
therapies to treat the individual's particular substance abuse problems
and needs. Drug use medication is only one element of successful,
comprehensive drug treatment, which includes addressing the individual's
medical, psychological, social, vocational, and legal problems (see
Table 13-5). Behavioral drug abuse prevention and treatment programs
are provided in residential settings and in prisons. These programs
may provide medications to treat drug abuse, medical treatment for
coexisting illnesses, and /or behavioral interventions using a number
of personal, family, and community interventions. The most important
community interventions are the 12-step or self help programs such
as Narcotics Anonymous, Cocaine Anonymous, and Alcoholics Anonymous.
What should
you do after the patient has completed a drug treatment program?
The primary
care provider's task in assuring successful drug addiction treatment
is to treat drug abuse as a chronic disease. Drug abuse treatment
is effective if provided correctly and consistently. Approximately
50% of alcoholics, 60% of opiate addicts, 55% of cocaine addicts,
and 30% of nicotine (cigarette) addicts are successfully treated.
Note the success rate is generally lower for the legal addictive
drugs, which may be because of ready access to those substances.
For the illicit drug addictions, success occurs only if the drug
abuse therapy is given on a continual basis for the lifetime of
the patient. Drug use studies have clearly shown that drug abusers
will relapse as any patient would who has a chronic disease. In
direct comparisons, drug-addicted patients are actually less likely
to relapse into addiction and are more adherent to their medication
than persons with diabetes mellitus or hypertension.
Table
13-5. Components of Drug Abuse Treatment
Personal
Needs |
Treatment
Needs |
-
Family services
- Housing
and transport
- Financial
services
- Legal
services
- AIDS/HIV
services
- Educational
service
- Medical
service
- Vocational
service
- Child
care service
|
- Behavioral
therapy
- Clinical
and case management
- Intake
and processing
- Treatment
plans
- Pharmacotherapy
- Continuing
care
- Substance
use monitoring
- Self
help/peer support groups
|
How do you
use maintenance medications in treating drug abuse?
Maintenance
treatment medications, important adjuncts to comprehensive drug
abuse and dependence treatment, are used in the same way the nicotine
patch is used for cigarette smokers. The medications help stabilize
the drug user by reducing drug craving and thereby reducing high-risk
behaviors associated with acquiring illicit drugs to attain the
drug-induced high. Medication is used most effectively by patients
who have good social support and higher education levels and are
highly motivated to get off illicit drugs.
What are
the common medications used in drug abuse treatment?
Use of medications
to treat illicit drug use is limited because most of the approved
medications are for opiate addiction and alcohol abuse. Effective
opiate addiction medications are divided into 2 classes: opiate
agonists and opiate antagonists. Opiate agonists are used to substitute
for the opiate without causing the euphoria associated with drug
abuse. The opiate agonists include methadone, L-alpha-acetyl-methadol
(LAAM), and buprenorphine, which has recently been approved for
medical use in the United States (Johnson, 2000). The other class
is the opiate antagonists, the most important of which is naltrexone.
Buprenorphine, actually a partial agonist-antagonist, may be used
by physicians who undergo an 8-hour training course on how to use
the medication. This medication has the highest potential for providing
care in the private practice setting. Details for obtaining buprenorphine
training and certification are available at the Office
of Substance Abuse and Mental Health Administrations website,
in the addiction treatment section under office-based therapies.
How do you
detect, manage, and prevent relapse?
After the patient
has been treated and is off drugs, the responsibility of the primary
care physician does not end. The most common complication after
patients have stopped using drugs is relapse. Four points to remember:
1) relapse should be expected to occur in most users; 2) on average
3-4 episodes may occur before complete abstinence; 3) relapse is
not a treatment failure; it is a time to intensify treatment; and
4) the primary care provider is critical in preventing episodes
of relapse. The most critical issues for the primary care provider
to keep track of in the detection and prevention of relapses are
to:
- Provide
close followup.
- Do not make
medical care dependent on drug abstinence.
- Recognize
missed appointments as a sign of relapse and need for followup.
- Encourage
and monitor the drug treatment/sobriety program of the patient.
- Treat comorbid
psychiatric conditions aggressively.
- Identify
drug use trigger points with the patient and discuss how to avoid
them.
- Develop
a plan to identify and manage relapse early.
- Make every
effort to keep communication open and nonjudgmental.
Medical
and Pain Management Issues
TOP
What exactly
do drugs do to the brain?
Researchers
continue to explore the variety of functional and structural changes
that occur in the brain during drug use. Drug dependencies have
been linked to disturbances in the dopaminergic pathways of the
mesolimbic reward system, which lies deep in the brain. This system
interconnects the ventral tegumentum to the nucleus accumbens with
other connections to the limbic system and orbitofrontal cortex
(Leshner, 1997). Disturbances in these areas are responsible for
the behavioral changes and drug craving that characterize the drug-addicted
person. Brain imaging studies have suggested that the changes in
the brain are chronic, even after the person stops consuming drugs
and may cause the relapses of most drug users.
What are
the common medical problems of patients who inject drugs?
Patients who
inject drugs often have comorbid clinical conditions, which are
listed below with specific recommendations.
Mental health
problems Treat early. Depression is the most common problem.
Hepatitis
C Screen all drug users for hepatitis C and B and treat when
indicated. Consult a specialist in HIV/AIDS and hepatitis C for
coinfected patients. Screen for depression before initiating therapy
for hepatitis C. Treating hepatitis is important for preventing
hepatotoxicity associated with ART.
Sexually
transmitted diseases Screen regularly and provide safe sex education.
Like other people, drug users often do not stop having sex even
if they are infected with multiple diseases.
Tuberculosis
Past tuberculosis exposure is common in injection drug users (as
many as 30% are PPD positive); they should be screened for TB.
Skin and
soft tissue infections Cellulitis and skin abscesses are very
common in injection drug users. The practice of "skin popping"
markedly increases the risk of abscess formation.
Noninfectious
health problems Treat accordingly. Drug users and alcoholics
have multiple health problems that should be treated aggressively.
The fewer medical problems patients have, the more likely they are
to adhere to the treatment plan.
Common problems
to be aware of:
- Drug interactions
(between medications and between medications and illicit drugs)
- Diabetes
mellitus and hypertension
- Social environment
(housing, child care)
- Pain management
How do you
manage pain in opiate-addicted patients?
It is incorrect
to assume that individuals addicted to opiates or any other kind
of drug should receive less pain medication because they are addicted.
They should receive pain therapy based on the diagnosed cause of
the pain just like nonaddicted patients. The therapeutic approach
differs according to whether the pain is acute or chronic.
How should
you treat acute pain in a person diagnosed as a drug abuser?
Appropriate
actions to take for drug-abusing patients in acute pain related
to a recent diagnosable injury involve managing the pain:
- Determine
the source of the pain.
- Provide
pain medication that relieves the symptoms. Opiates may be used
if they are what will stop the pain.
- Give the
medication in regularly scheduled doses. This prevents undesirable
drug-seeking behaviors resulting from treatment on an as-needed
(PRN) basis.
- If pain
is persistent or the cause is unclear, check for underlying psychiatric
problems or an undetected source of pain.
- If opiates
are used, taper the doses slowly to avoid drug withdrawal.
How should
you treat chronic pain in a person diagnosed as a drug abuser?
If the pain
is chronic, the treatment strategies shift to not only finding the
source of the pain, but also to using the entire spectrum of pain-relieving
strategies with or without nonopiate pain medication (see Table
13-6). One exception is a patient with cancer-associated pain, for
whom any effective medication (potentially addictive or not) is
appropriate.
Table
13-6: Treatments for Chronic Pain in
Known Drug Abusers
Addictive
Substances |
Medications
used for pain control
- Nonsteroidal
anti-inflammatory drugs (eg, 30 mg ketorolactromethamine,
which is equivalent to 6-10 mg morphine)
- Tricyclics
- Anticonvulsants
- Muscle relaxants
- Topical agents
- Opiates
Physical
interventions for pain control
- Thermal:
heat and cold are both effective and underutilized
- Peripheral counterstimulation: transcutaneous electrical
nerve stimulation (TENS) and vibration
- Manual therapies: massage and chiropractic and osteopathic
manipulation
- Active movement: stretching and active exercise
- Orthotics: splints and other supportive devices
|
HIV/AIDS
Issues
TOP
Can HIV
transmission be prevented in active substance abusers?
A comprehensive
HIV prevention strategy in a primary care practice includes interventions
to provide drug treatment, to take care of mental health problems,
and to prevent HIV transmission during drug use and sexual activity.
The primary care provider should routinely screen for drug abuse
and treat or refer for treatment as quickly as possible. This is
particularly important for adolescents who are at high risk for
HIV, hepatitis B and C, and other infections. One study has shown
that once adolescents start injecting drugs, over 90% will become
infected with hepatitis C within 18 months. The provider should
also counsel patients who are actively using drugs not to share
needles with others and to take advantage of programs that distribute
clean needles. Programs use the needle distribution strategy as
a first step to engage individuals who can then be encouraged to
accept medical and drug abuse treatment services.
When is
an active substance abuser ready for HIV treatment?
The most important
clinical decision for successful treatment of drug-abusing patients
with HIV is deciding when they are ready -- both substance abuse
treatment and antiretroviral therapy (ART). Patients fall into 3
categories: those who do not want treatment, those who are ambivalent,
and those who want treatment. For patients who do not want treatment,
the provider should continue to be available with information on
HIV and drug abuse treatment until they are ready to consider treatment.
For those who are ambivalent about treatment, time is well spent
during several clinical visits discussing the health issues of AIDS
and drug abuse until they are ready for treatment. For patients
who are ready for treatment the next step is to assess what factors
will affect their adherence (see Chapter 7: Adherence to HIV Therapies).
History of injection drug use, race, gender, age, socioeconomic
status, level of education, and occupation are poor predictors of
medication adherence. Accurate predictors of adherence are:
- The patient's
health beliefs
- Ease of
access to health care providers
- Familiarity
with the treatment setting
- Existence
of a social support system
- Perceived
support from clinical staff members
- Simplicity
of medication regimens
Interaction
with providers and ambiance of the treatment setting account for
almost half of the support factors needed to encourage drug users
to adhere to treatment regimens. This pattern is true for active
drug users, with the possible exception of persons addicted to crack
cocaine.
Difficult economic
and social situations, including unemployment and unstable housing,
may make adherence to clinical treatment plans for both drug addiction
and HIV even more difficult to follow. For these reasons some drug
abuse treatment centers provide residential treatment to minimize
outside influences on drug use. Also, methadone clinics provide
an ideal opportunity for rehabilitated substance users to receive
adherence support for ART through directly observed therapy (DOT)
at the clinic.
What immunizations
should drug abusers with HIV receive?
Because of
the higher risk of tetanus in injection drug users, tetanus boosters
should be given when due. Pneumococcocal and influenza vaccines
are recommended for all patients with HIV. Drug abusers with no
antibodies to hepatitis A and hepatitis B should be immunized. Hepatitis
A can be fatal in individuals with hepatitis C.
Are there
important drug interactions between antiretrovirals and medications
for drug treatment?
A common problem
in treating patients with HIV who are drug users is the drug interactions
between medications. Studies have shown that interactions of methadone
and antiretroviral medications are linked to CYP450 3A4 sites in
the liver. The most significant interactions are between methadone
and nevirapine (NVP) or efavirenz (EFV), which precipitate rapid
drug withdrawal symptoms (see Table 13-7). Methadone programs should
be alerted when methadone patients are started on efavirenz or nevirapine,
as dose escalation of methadone will probably be required. When
methadone and didanosine (ddI) are coadministered the uptake of
didanosine may be lowered requiring a higher dose of didanosine
(See Drug Tables 7 and 8 in the Pocket Guide). Other interactions
caused by drugs such as abacavir (ABC) and all the PIs except indinavir
(IDV), though pharmacologically measurable, are not clinically apparent
and standard doses are appropriate. Potential interactions between
illicit drugs and HIV medications are less well understood. Methamphetamine
products have been associated with sudden death in individuals on
protease inhibitors. Anecdotal reports describe how selective serotonin
reuptake inhibitor (SSRI) antidepressant medications may produce
side effects that mimic drug withdrawal and may decrease AIDS medication
adherence.
Table
13-7: Antiretroviral Drugs that
Affect Methadone Levels
x zidovudine (ZDV) |
¬ nevirapine (NVP) |
x indinavir (IDV) |
x didanosine (ddI) |
↑ delavirdine (DLV) |
¬ ritonavir (RTV) |
x zalcitabine (ddC) |
¬ efavirenz (EFV) |
¬ nelfinavir (NFV) |
x stavudine (d4T) |
|
? saquinavir (SQV) |
¬ abacavir (ABC) |
|
¬ amprenavir (APV) |
|
|
¬ lopinavir (LPV) |
¬ =
decreases methadone blood levels
x = indeterminate effect
↑ = increases methadone blood levels
Source: Adapted from Gourevitch MN, Friedland GH. "Interactions
between methadone and medications used to treat HIV infection:
a review." Mt Sinai J Med 2000 67:429-436.
Why are
HIV and drug abuse both such noticeable issues now?
HIV and substance
abuse are both significant public health problems that merit the
attention of public health officials and policymakers. Today, an
estimated 40 million people worldwide are living with HIV. Of these,
2 to 3 million people are injection drug users. In the United States,
approximately a third of HIV/AIDS cases are related to injection
drug use. Research shows that use of drugs, injected or not, can
affect decisionmaking - particularly about engaging in unsafe sex
- that can endanger the health of the drug user and of others. Substance
abuse is a double-edged sword because it increases an individual's
risks for continuing drug use while also increasing the likelihood
of exposure to HIV and other bloodborne infections. Infectious diseases
that are more prevalent among injection drug users than in the general
population are HIV, other STDs, including hepatitis B and C, and
tuberculosis. Prevention and early treatment of drug abuse and drug-related
diseases are critical public health measures to reduce the spread
of new infections.
- Substance
abuse and addiction involve compulsive drug-seeking behavior that
interferes with an individual's ability to function normally in
many aspects of daily life. Substance abuse and mental health
problems often occur together and, unless treated, can lead to
chronic social and medical consequences.
- Accurate
and reliable diagnosis of substance abuse or dependence is not
a perfect science. Screening techniques, in concert with a thorough
medical history and evaluation, are important in detecting and
correctly diagnosing a substance abuse-related disorder.
- HIV transmission
is preventable in people who use drugs. For drug users and the
community at large, drug addiction treatment is disease prevention.
- Hepatitis
C is extremely common in patients with a past or current history
of injection drug use. All patients with hepatitis C should be
vaccinated against hepatitis A and B if serologic studies show
no prior exposure.
- The clinical
issues to be addressed are to treat comorbid conditions as soon
as possible, treat drug use and HIV aggressively, and be aware
of common drug interactions seen in patients treated for drug
use and HIV simultaneously.
Suggested
Resources
TOP
"Brief
Interventions and Brief Therapies for Substance Abuse."
Treatment Improvement Protocol (TIP) Series 34. Rockville,
MD: Substance Abuse and Mental Health Services Administration Center
for Substance Abuse Treatment; 1999. DHHS Publication No. (SMA)
99-3353. Accessed 1/04.
Klein MB, Lalonde
RG, Suissa S. "The impact of hepatitis C virus coinfection
on HIV progression before and after highly active antiretroviral
therapy." J Acquir Immune Defic Syndr. 2003;33:365-372.
WEBSITES
American
Society of Addiction Medicine. Accessed 11/03.
National
Institute on Drug Abuse. Accessed 11/03.
Erowid
(detailed biochemical and other information on drugs). Accessed
11/03.
Office
on National Drug Control Policy. Accessed 11/03.
Substance
Abuse and Mental Health Services Administration (drug abuse
statistics, clinical treatment information). Accessed 11/03.
References
TOP
American Psychiatric
Association. Diagnostic and Statistical Manual of Mental Disorders.
4th ed. Washington, DC: American Psychiatric Association Press;
1994.
American Society
of Addiction Medicine. "Screening Instruments." In: Graham
AW, Schultz TK, Mayo-Smith MF, Ries RK, Wilford BB, eds. Principles
of Addiction Medicine. Chevy Chase MD: American Society of Addiction
Medicine; 1998:1283-1286.
Chesney MA,
Koblin BA, Barresi PJ, et al. "An individually tailored intervention
for HIV prevention: baseline data from the EXPLORE Study".
Am J Public Health. 2003;93:933-938.
Gourevitch
MN, Friedland GH. "Interactions between methadone and medications
used to treat HIV infection: a review." Mt. Sinai J Med.
2000;67:429-436.
Hyman SE, Malenka
RC. "Addiction and the brain: the neurobiology of compulsion
and its persistence [Review]." Nat Rev Neurosci. 2001;2:695-703.
Johnson RE,
Chutuape MA, Strain EC, Walsh SL, Stitzer ML, Bigelow GE. "A
comparison of levomethadyl acetate, buprenorphine, and methadone
for opioid dependence." New Engl J Med. 2000;343:1290-1697.
Leshner, AL.
"Addiction is a brain disease, and it matters." Science.
1997;278:45-47.
McLellan AT.
"Have we evaluated addiction treatment correctly? Implications
from a chronic care perspective." Addiction. 2002;97:249-252.
O'Brien CP.
"A range of research-based pharmacotherapies for addiction."
Science. 1997;278:66-70.
Principles
of Drug Addiction Treatment: A Research-Based Guide. Bethesda, MD:
National Institute on Drug Abuse; 1999. NIH
Publication 99-4180. Accessed 1/04.
Principles
of HIV Prevention in Drug-Using Populations: A Research-Based Guide.
Bethesda, MD: National Institute on Drug Abuse; 2002. NIH
publication 02-4733. Accessed 1/04.
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