Active Substance Abuse Research Articles

The rate of treatment of chronic hepatitis C in patients co‐infected with HIV in an urban medical centre

Hepatitis C virus (HCV) and human immunodeficiency virus (HIV) co-infection is common. HIV co-infection results in a higher rate of histologic progression and shorter interval to HCV-related cirrhosis. Successful treatment of HCV with interferon-based therapy reduces the morbidity and mortality of patients. Significant factors may limit the availability of treatment in co-infected patients. The rate of treatment of HCV and limiting factors to treatment in a co-infected population in an urban setting were determined. A retrospective review of co-infected patients was conducted at our liver and gastrointestinal (GI) clinics for treatment of HCV from July 2001 to June 2002. Treatment of HCV and reasons for nontreatment were recorded. A total of 104 HCV/HIV co-infected patients were identified. Seventy-two per cent were males. Mean age was 47.2 years (32-72). Seventy-four of the 82 (90%) with identifiable risk factors for HCV infection had a history of intravenous drug use (IVDU). Twenty per cent (21/104) of the total underwent a liver biopsy. Sixty-seven per cent who had a liver biopsy were treated. Overall, sixteen patients were treated. Eighty-eight (85%) patients were not treated for the following reasons: 13 refused treatment, and 75 were ineligible. Of the ineligible patients, 40% were noncompliant with visits, 15% were active substance abusers, 13% had decompensated cirrhosis, 8% had significant active psychiatric conditions and 24% had significant co-morbid disease. A majority of patients co-infected with HCV/HIV had a IVDU history. Most co-infected patients were not eligible for HCV treatment. A majority of noncandidates had potentially modifiable psychosocial factors leading to nontreatment.

Hepatitis C treatment eligibility in an urban population with and without HIV coinfection.

In an urban referral clinic, 182 hepatitis C-infected adults including 110 (60%) with HIV coinfection were evaluated for pegylated interferon and ribavirin therapy. Overall, only 33% were eligible for treatment. Considering all patients together, the major barriers to treatment were nonadherence with the evaluation process (23%), refusal of treatment (10%), active substance abuse (9%), and medical contraindication (8%). There was a trend toward a higher rate of treatment eligibility in HIV coinfected patients (39% vs. 25%; p = 0.07), who were significantly more likely to be adherent with the evaluation process compared to those with hepatitis C alone (86% vs. 63%; p = <0.001). Acceptance of antiviral therapy for hepatitis C was similar between eligible persons with and without HIV. These findings highlight the need to develop interventions to improve adherence and to manage substance abuse and other comorbidities in order to maximize the impact of interferon and ribavirin therapy on urban patients with hepatitis C.

Hospitalized HIV-infected patients in the HAART era: a view from the inner city.

To evaluate hospitalizations of HIV-infected patients in the highly active antiretroviral therapy (HAART) era, we analyzed 2736 admissions of 1562 HIV-infected patients to Cook County Hospital from September 20, 1999 to July 10, 2002. Patients were predominantly African American (81%), male (72%), and active substance abusers (74%). Only 48% of patients with a prior HIV diagnosis were taking HAART and 37% of them had a viral load less than 1000 copies per milliliter. Patients on protease inhibitor (PI)-sparing regimens more frequently achieved a viral load less than 1000 copies per milliliter than those on a PI-containing regimens (41% vs. 34% p = 0.036). For patients with CD4 cell counts less than 200 cells per milliliter, those not taking HAART were more likely African American (83% vs. 76%, p < 0.031), homeless (13% vs. 5%, p < 0.001), active substance abusers (79% vs. 65%, p < 0.001), female (28% vs. 22%, p = 0.001), new to the hospital system (19% vs. 6%, p < 0.001), or not recently seen in the outpatient clinic (42% vs. 17%, p < 0.001). In our population, active substance abuse was prevalent and only a minority of patients was taking HAART. Women were receiving HAART less often, independent of race and substance abuse. Aggressive programs are needed in high-risk populations to address substance abuse issues and to improve patient use of HAART.

Chronic peritoneal dialysis patients diagnosed with clinical depression: results of pharmacologic therapy.

Depression has been documented as the most frequently encountered psychological problem in end-stage renal disease (ESRD) patients and has been correlated with both mortality and morbidity in these patients. Previous work by our group has shown that clinical depression is treatable with psychotropic medications in these patients, but that only a limited number of ESRD patients with depression will successfully complete a course of pharmacologic therapy. From July 1997 to October 2002, all chronic peritoneal dialysis (PD) patients in our facility were encouraged to be screened for depression utilizing the self-administered Beck Depression Inventory (BDI) questionnaire. Based on previous work, a score > or =11 on this questionnaire was used to indicate a possible diagnosis of clinical depression; patients with BDI scores > or =11 were encouraged to complete a more formal evaluation for the presence of clinical depression. A total of 320 BDI questionnaires were completed during the study period: 134 patients. (42%) scored > or =11 on the BDI, 69 of the 134 patients (51%) with BDI scores > or =11 agreed to further evaluation. Sixty of these 69 patients (87%) were diagnosed with clinical depression based on scores > or =18 on the Hamilton Depression Scale and standard Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria. Forty-four patients with clinical depression agreed to pharmacologic treatment. However, only 23 of the 44 patients (52%) successfully completed a 12-week course of drug therapy. Two unit social work reviewers systematically reviewed the records of these 21 patients who did not complete therapy and assessed the reasons for their inability to complete treatment. Reasons identified included eight patients who experienced acute medical problems, three who were active substance abusers, and two who reported medication side effects. The remaining eight patients who did not complete the 12 weeks of therapy were examined by applying the axis 1 and axis 2 DSM-IV criteria. Axis 1 is used to diagnose clinical disorders and axis 2 is used to diagnose personality disorders. While all these patients met the DSM-IV axis 1 criteria for clinical depression, eight of these patients met axis 2 criteria for personality disorders; five patients had borderline personality disorders, one had a narcissistic personality disorder, one had a factitious disorder, and one had features of avoidant personality disorder. While some chronic PD patients can be successfully treated for clinical depression with psychotropic medication prescribed by the dialysis medical team, not all patients will agree to be evaluated for clinical depression and accept pharmacologic treatment. Others cannot or will not complete treatment when additional psychiatric disorders exist. These patients may require additional intervention when diagnosed with clinical depression and a personality disorder. Further trials are warranted.

A volunteer community mental health clinic.

A volunteer community mental health clinic.

Pneumocystis carinii pneumonia in HIV-infected patients in the HAART era.

Since the advent of highly active antiretroviral therapy (HAART), the incidence of opportunistic infections (OI) in patients with HIV has markedly decreased. Despite this, there are still large numbers of Pneumocystis carinii pneumonia (PCP) cases at Cook County Hospital (CCH). To better understand this patient group, we performed a retrospective chart review of 120 pathologically proven cases of PCP from January 1998 to June 2001. One hundred four patients were included in the study. Sixty-nine percent of our patients were active substance abusers and 50% had previous knowledge of HIV disease. Of our patients, fewer than 5% were on HAART or PCP prophylaxis on study admission. The overall mortality rate was 14%. Of discharged patients, 65% were placed on HAART therapy and 59% of these achieved a viral load of less than 1000 copies per milliliter in the year postdischarge. Patients who failed to achieve a viral load less than 1000 copies per milliliter were more likely active substance abusers or had a viral load greater than 100,000 copies per milliliter prior to study admission. Our study shows that patients are still being admitted with PCP in the HAART era. Active substance abuse and failure to recognize HIV status contributed heavily to this late presentation of HIV disease. An aggressive approach toward HIV identification and substance abuse treatment may decrease admissions to the hospital for PCP and improve response to HAART therapy.

Integrating Medical and Substance Abuse Treatment for Addicts Living with HIV/AIDS: Evidence‐Based Nursing Practice Model

Forty‐five active substance abusers with HIV/AIDS voluntarily participated in a substance abuse treatment research study with interviews at intake, 6 months and 12 months. These participants were engaged in treatment for a minimum of 45 days and a maximum of 90 days. The study used a nursing model of care, The Personalized Nursing LIGHT model, to integrate treatment for HIV/AIDS with substance abuse treatment. The LIGHT model seeks to enhance patient well being directly and thereby to support interventions that decrease substance use and improve management of chronic disease. The substance abuse treatment team included a nurse who used the LIGHT model and coordinated an integrated care protocol. The nurse accompanied clients on visits to their physicians for HIV treatment and facilitated the integration of medical recommendations with the substance abuse treatment. Six‐month posttest data were gathered on all 45 participants and 12‐month posttest interviews were accomplished with 29 of them. At 6 months, 78% of the respondents (35/45) reported no drug use in the past 30 days, and, at 12 months, 79% (23/29) were drug free for the past month. Significant decreases from intake to 6 months were detected on Addiction Severity Index (ASI) composite scores for drug use (p < 0.01), alcohol use (p < 0.04), medical severity (p < 0.02), psychiatric severity (p < 0.01), legal problems (p < 0.04), and employment difficulty (p < 0.01). Improvement of 6‐month drug use composite scores was related significantly to treatment duration (R = 0.42; p < 0.01). Significant decreases in ASI measures of drug use (p < 0.01), alcohol use (p < 0.01), employment difficulty (p < 0.01), and family/social problems (p < 0.01) also occurred at 12 months. Well being, as measured by a Global Well Being Index, was found to improve significantly at 6 months (p < 0.02) and 12 months (p < 0.07). Concurrently, significant improvement was observed on Medical Outcomes Study‐36‐Item Short‐Form Health Survey (SF‐36) measures of general health and health functioning. These changes were noted at 6 months in the general health (p < 0.02), mental health (p < 0.01), social functioning (p < 0.01), role/emotional status (p < 0.04), and vitality (p < 0.01) subscales. At 12 months, the social functioning (p < 0.01) subscale responses were further decreased.

Human Immunodeficiency Virus: The Initial Physician-Patient Encounter

Human Immunodeficiency Virus: The Initial Physician-Patient Encounter

Outpatient Treatment Entry and Health Care Utilization After a Combined Medical/Substance Abuse Intervention for Hospitalized Medical Patients

Drug-abusing patients utilize extensive amounts of health services resources, yet the acute medical hospitalization has typically not been used effectively to engage patients in substance abuse treatment. To assess the effect of an integrated substance abuse/acute medical care day hospital (DH) intervention. Prospective, consecutive chart review of patients referred to a day hospital program from the medicine service at an urban tertiary care teaching hospital. From the referral cohort, a comparison group receiving usual care was identified. One hundred twenty adult medicine inpatients with active substance abuse and self-identified motivation to enter treatment. Outpatient substance abuse treatment entry and post-intervention health services utilization. Following DH treatment, 50.6% entered further outpatient substance abuse treatment (vs 2.4% comparison patients; P <.001). There was a significant increase in ambulatory medical visits for DH patients (pre-6 month 0.49 vs post-6 month 3.46; P <.001), greater than the change noted for comparison patients. However, there was no difference noted in pre-post hospitalization or emergency department utilization following the DH intervention. A DH program for substance abusing hospitalized medicine patients that introduces substance abuse treatment during treatment for an acute medical illness does appear to improve outpatient substance abuse treatment entry and ambulatory care utilization after hospital discharge.

Characteristics of suicide attempts in a large urban jail system with an established suicide prevention program.

The King County Department of Adult and Juvenile Detention in Washington State, like many jail systems across the nation, implemented a suicide prevention program in response to high suicide rates. A review committee was formed to prospectively study the patterns of suicide attempts that occurred in the system after the program was implemented and to make recommendations for improvements. All first suicide attempts per jail booking over a 33-month period in two of the department's jails were studied. For each attempt, characteristics of the individual and of the attempt were abstracted by trained staff. A total of 132 first suicide attempts were made by 124 individual inmates during the study period. The prevalence of mental illness among inmates who attempted suicide was 77 percent, compared with 15 percent in the general jail population. Seventy-five percent of the inmates who attempted suicide had received a mental health evaluation from jail personnel before the attempt. Suicide attempts that were made in observation units for suicidal inmates (42 percent of all attempts), particularly those made in group observation units, necessitated fewer visits to an emergency department than those that occurred in general areas of the jail. On the basis of these findings, the jails implemented interventions such as more suicide screening and treatment for inmates who have active substance abuse, greater consensus building in decisions about housing, and structural changes such as greater use of group-housing units and the use of barriers to prevent the inmates from jumping from balconies.

Pancreas after kidney transplantation.

After three decades of controversy surrounding the therapeutic validity of pancreas transplantation, the procedure has become accepted as the preferred treatment for patients with insulin-dependent diabetes mellitus (IDDM) and advanced diabetic nephropathy with end-stage renal disease (ESRD) and for

Substance abuse in heart transplant recipients: a 10-year follow-up study.

Active substance abuse is widely accepted as a contraindication for heart transplantation because of the theory that relapse would occur after transplantation and result in compromise of graft function, lowering long-term survival. Listing "recovering" substance abusers for heart transplantation has been controversial. To determine if substance abuse plays an unfavorable role in the outcome of heart transplantation. The medical records of all patients at our center who received a heart transplant more than 10 years ago were retrospectively reviewed for history of substance abuse. From a pool of 189 transplant recipients, 47 patients had a definite history of substance abuse (group 1) and were considered in recovery, whereas 142 patients were clearly without any history of substance abuse (group 2). Group 1 had a significantly greater percentage of patients with a pretransplantation diagnosis of idiopathic cardiomyopathy (P = .003), a higher occurrence of heart-related cause of death (P = .017), and a significant prevalence of noncompliance (P = .0001) and death because of noncompliance (P = .0004). In contrast, group 2 surprisingly had a significantly higher incidence of death related to infection (P = .0062), which is unexplained. Despite higher incidence of noncompliance in group 1, there was no significant difference in the overall survival rate between the 2 groups. These results suggest that patients with a history of substance abuse can undergo successful heart transplantation with acceptable long-term survival, though they are at greater risk for substance abuse relapse and resulting noncompliance with the treatment regimen. The extent to which relapse of substance abuse and its consequences affect the cost of posttransplantation care remains to be determined.

Substance abuse in heart transplant recipients: a 10-year follow-up study

Active substance abuse is widely accepted as a contraindication for heart transplantation because of the theory that relapse would occur after transplantation and result in compromise of graft function, lowering long-term survival. Listing "recovering" substance abusers for heart transplantation has been controversial. To determine if substance abuse plays an unfavorable role in the outcome of heart transplantation. The medical records of all patients at our center who received a heart transplant more than 10 years ago were retrospectively reviewed for history of substance abuse. From a pool of 189 transplant recipients, 47 patients had a definite history of substance abuse (group 1) and were considered in recovery, whereas 142 patients were clearly without any history of substance abuse (group 2). Group 1 had a significantly greater percentage of patients with a pretransplantation diagnosis of idiopathic cardiomyopathy (P = .003), a higher occurrence of heart-related cause of death (P = .017), and a significant prevalence of noncompliance (P = .0001) and death because of noncompliance (P = .0004). In contrast, group 2 surprisingly had a significantly higher incidence of death related to infection (P = .0062), which is unexplained. Despite higher incidence of noncompliance in group 1, there was no significant difference in the overall survival rate between the 2 groups. These results suggest that patients with a history of substance abuse can undergo successful heart transplantation with acceptable long-term survival, though they are at greater risk for substance abuse relapse and resulting noncompliance with the treatment regimen. The extent to which relapse of substance abuse and its consequences affect the cost of posttransplantation care remains to be determined.

Substance abuse in bipolar disorder

Background: High rates of substance abuse have been reported in the general population, with males more often affected than females. Although high rates of substance abuse have also been reported in bipolar patients, the relationship between substance abuse and bipolar disorder has not been well characterized. Methods: Substance abuse histories were obtained in 392 patients hospitalized for manic or mixed episodes of bipolar disorder and rates of current and lifetime abuse calculated. Analyses comparing sex, subtype (manic vs. mixed) and clinical history variables were conducted. Results: Rates of lifetime substance abuse were high for both alcohol (48.5%) and drugs (43.9%). Nearly 60% of the cohort had a history of some lifetime substance abuse. Males had higher rates of abuse than females, but no differences in substance abuse were observed between subjects in manic and mixed bipolar states. Rates of active substance abuse were lower in older age cohorts. Subjects with a comorbid diagnosis of lifetime substance abuse had more psychiatric hospitalizations. Conclusions: Substance abuse is a major comorbidity in bipolar patients. Although rates decrease in older age groups, substance abuse is still present at clinically important rates in the elderly. Bipolar patients with comorbid substance abuse may have a more severe course. These data underscore the significance of recognition and treatment of substance abuse in bipolar disorder patients.

Substance abuse in bipolar disorder

High rates of substance abuse have been reported in the general population, with males more often affected than females. Although high rates of substance abuse have also been reported in bipolar patients, the relationship between substance abuse and bipolar disorder has not been well characterized. Substance abuse histories were obtained in 392 patients hospitalized for manic or mixed episodes of bipolar disorder and rates of current and lifetime abuse calculated. Analyses comparing sex, subtype (manic vs. mixed) and clinical history variables were conducted. Rates of lifetime substance abuse were high for both alcohol (48.5%) and drugs (43.9%). Nearly 60% of the cohort had a history of some lifetime substance abuse. Males had higher rates of abuse than females, but no differences in substance abuse were observed between subjects in manic and mixed bipolar states. Rates of active substance abuse were lower in older age cohorts. Subjects with a comorbid diagnosis of lifetime substance abuse had more psychiatric hospitalizations. Substance abuse is a major comorbidity in bipolar patients. Although rates decrease in older age groups, substance abuse is still present at clinically important rates in the elderly. Bipolar patients with comorbid substance abuse may have a more severe course. These data underscore the significance of recognition and treatment of substance abuse in bipolar disorder patients.

Substance Abuse and Health Services Utilization Among Women in a Comprehensive HIV Program

SUMMARY Substance abuse history and treatment needs were assessed in 308 women at a comprehensive HIV program in St. Louis. We found that 229 (74%) women had a history of substance abuse and 38 (12%) had a history of injection drug use. Only 25 (44%) of 57 women requiring substance abuse treatment at enrollment had received treatment. Adherence with quarterly medical follow-up was associated with highly active antiretroviral therapy (HAART) prescription in 1997 and 1998, but not with need for substance abuse treatment. However, women needing substance abuse treatment were less likely to have been prescribed HAART in 1998. We recommend that providers of medical services to women with HIV conduct formal assessments of substance abuse behaviors among their patients and ensure that treatment needs are adequately addressed within the framework of care. Further examination of the use of HAART in women who are active substance abusers is needed.

Epidemiology of Pneumocystis carinii pneumonia in an era of effective prophylaxis: the relative contribution of non-adherence and drug failure

To determine the relative contribution of patient non-adherence, provider failure to prescribe prophylaxis, and drug failure to the continued occurrence of Pneumocystis carinii pneumonia (PCP), and to determine correlates of non-adherence. Retrospective case-control study. Patients with confirmed or presumptive PCP from May 1995 to September 1997 who had at least 6 months of prior HIV care (cases) were compared to controls matched for initial CD4 cell count and date of initial HIV care. The incidence of PCP declined by 85% in the 28 months of the study. Of the 118 cases of PCP identified, 59 (50%) were in HIV care for > 6 months prior to PCP diagnosis. In a multivariate logistic regression model, risk factors for PCP among patients in HIV care were patient non-adherence [odds ratio (OR), 12.4; 95% confidence interval (CI), 6.4-23.5], use of prophylaxis other than trimethoprim-sulfamethoxazole (OR, 27.0; 95% CI, 13.8-52.9), and absence of antiretroviral use (OR, 7.5; 95% CI, 4.5-12.5). Provider non-adherence occurred in one out of 59 cases (2%), and five out of 106 controls (5%). Of the patients who developed PCP on prophylaxis, 18 cases (30%) appeared due to drug failure; there were no cases of apparent drug failure among patients on trimethoprim-sulfamethoxazole. In multivariate analysis, non-adherence was more common among patients of non-white race, those with a history of injecting drug use, and those with active substance abuse or psychiatric illness. Patient non-adherence was the most common reason for the occurrence of PCP among patients in HIV care; provider non-adherence was uncommon. Drug failure occurred only among patients on prophylaxis other than trimethoprim-sulfamethoxazole.

Fixed high dose right unilateral electroconvulsive therapy produced a higher antidepressant response rate than titrated dosing

McCall WV, Reboussin DM, Weiner RD, et al. Titrated moderately suprathreshold vs fixed high-dose right unilateral electroconvulsive therapy: acute antidepressant and cognitive effects . Arch Gen Psychiatry2000 May; 57 :...

Strength in Numbers: The ARISE Method for Mobilizing Family and Network to Engage Substance Abusers in Treatment

The model described in this paper takes into consideration two key findings: (a) In a given year, the vast majority (90–95%) of active substance abusers do not enter treatment or self-help groups, and (b) substance abusers have frequent contact with their families (60–80% either live with a parent or are in daily contact). This paper presents a method for mobilizing and collaborating with families and extended the support system toward working with resistance and getting the substance abuser into treatment. Principles and techniques are provided for convening and structuring intervention network meetings toward that end. This intervention network approach can be used either alone or as part of an overall model, ARISE (A Relational Intervention Sequence for Engagement). The ARISE model addresses both clinical and programmatic issues in treatment engagement for substance abusers.

A 'second life' agenda. Psychiatric research issues raised by protease inhibitor treatments for people with the human immunodeficiency virus or the acquired immunodeficiency syndrome.

Seldom in the history of medicine has an entire generation of patients with an incurable, progressive, and ultimately fatal disease suddenly been offered the prospect of extended survival and even, perhaps, a "second life." The relatively simultaneous appearance of 2 major treatment developments has created profound changes in therapeutic options and outlook. The first development is an assay of serum levels of human immunodeficiency virus viral copies, providing a critical tool for clinical decision making. The second is the marketing between December 1995 and April 1997 of 4 human immunodeficiency virus protease inhibitors that, combined with previously available antiviral medications, achieve a new level of efficacy. With the advent of these changes come multiple psychiatric research and policy issues. These include the development of strategies to establish and maintain medication adherence. This is a critical task, given the complexity of combination therapy regimens and the rapid onset of viral resistance to protease inhibitors within days to weeks of missed or suboptimal dosing. The psychological issues to be studied include the process of restructuring lives and expectations in the event of clinical benefit or managing the distress associated with clinical failure. Other research questions include the effects of restored health on the appraisal of human immunodeficiency virus risk behaviors, assessment of effect of neurocognitive functioning, and unanswered questions about psychotropic or protease inhibitor drug interactions due to their shared metabolic pathways. Behavioral scientists can inform provision of care to patients who may be considered difficult to treat, such as those with severe and persistent mental illness or active substance abuse or the homeless. This includes the provision of empirical data regarding individual and situational characteristics that are likely to promote or impede adherence, as well as innovative provision systems. Psychiatry can make notable contributions during this turning point in human immunodeficiency virus therapeutics and research.