Identifying HIV care enrollees at-risk for cannabis use disorder.

Increased scientific attention given to cannabis in the United States has particular relevance for its domestic HIV care population, given that evidence exists for both cannabis as a therapeutic agent and cannabis use disorder (CUD) as a barrier to antiretroviral medication adherence. It is critical to identify relative risk for CUD among demographic subgroups of HIV patients, as this will inform detection and intervention efforts. A Center For AIDS Research Network of Integrated Clinical Systems cohort (N = 10,652) of HIV-positive adults linked to care at seven United State sites was examined for this purpose. Based on a patient-report instrument with validated diagnostic threshold for CUD, the prevalence of recent cannabis use and corresponding conditional probabilities for CUD were calculated for the aggregate sample and demographic subgroups. Generalized estimating equations then tested models directly examining patient demographic indices as predictors of CUD, while controlling for history and geography. Conditional probability of CUD among cannabis-using patients was 49%, with the highest conditional probabilities among demographic subgroups of young adults and those with non-specified sexual orientation (67-69%) and the lowest conditional probability among females and those 50+ years of age (42% apiece). Similarly, youthful age and male gender emerged as robust multivariate model predictors of CUD. In the context of increasingly lenient policies for use of cannabis as a therapeutic agent for chronic conditions like HIV/AIDS, current study findings offer needed direction in terms of specifying targeted patient groups in HIV care on whom resources for enhanced surveillance and intervention efforts will be most impactful.

Antiretroviral medication treatment for all HIV-infected individuals: a protocol using innovative multilevel methodologies to evaluate New York City's universal ART policy among problem substance users.

BACKGROUND: The intersection of HIV-related health outcomes and problem substance use has been well documented. New York City continues to be a focal point of the U.S. HIV epidemic. In 2011, the NYC Department of Health and Mental Hygiene (NYC DOHMH) issued a recommendation that all HIV infected individuals should be offered antiretroviral therapy (ART) regardless of CD4 cell count or other indicators of disease progression. This policy is based in the concept of "treatment as prevention," in which providing ART to people living with HIV (PLWH) greatly reduces the likelihood of HIV transmission, while also improving individual health. The "ART for ALL" (AFA) study was designed to inform modifications to and identify gaps in the implementation of universal ART, and specifically to help guide allocation of resources to obtain local policy goals for increasing viral suppression among PLWH who have problem substance use. METHODS/DESIGN: The AFA Study is informed by two complementary frameworks: Glasgow and colleagues' RE-AIM model, a multi-level framework developed to guide the evaluation of implementation of new policies, and Bronfrenbrenner's ecological systems model, which conceptualizes the bi-directional interplay between people and their environment. Using multi-level data and mixed methods, the primary aims of the AFA Study are to assess rates of viral load suppression, using the NYC HIV Surveillance Registry, within 12 months of HIV diagnosis with (a) yearly cohorts of high-risk-to-transmit, difficult-to-treat, substance using patients recruited from NYC Sexually Transmitted Disease clinics and a large detoxification unit and (b) yearly cohorts of all newly HIV diagnosed people in NYC. Further goals include (c) recruiting cross-sectional samples of HIV/AIDS service providers to assess ART initiation with problem substance users and d) examining geographic factors that influence rates of viral load suppression. An Implementation Collaborative Board meets regularly to guide study procedures and interpret results. DISCUSSION: The AFA Study has the unique strength of accessing and analyzing data at multiple levels using mixed methodology, taking advantage of NYC DOHMH biomedical surveillance data. If successful, others may benefit from lessons learned to inform local and state policies to improve the health of PLWH and further reduce HIV transmission.

The interaction of active substance use, depression, and antiretroviral adherence in methadone maintenance.

BACKGROUND: Adherence to highly active antiretroviral therapy (HAART) remains crucial in successfully treating HIV. While active substance use and depression are both associated with each other and with HAART nonadherence, little is known about their interaction. An understanding of the interaction of substance use and depressive symptoms on HAART adherence can inform adherence-enhancing interventions as well as interventions that target substance use and depression. PURPOSE: We tested an interaction between substance use and depression on HAART adherence among methadone maintenance patients. METHOD: We assessed substance use, depressive symptoms, and HAART adherence among 100 HIV-infected individuals receiving methadone maintenance in The Bronx, New York. Regressions were performed on adherence using an interaction term comprised of substance use and depressive symptoms. MODPROBE was used to assess significant interactions. RESULTS: Any use of illicit substances was associated with HAART nonadherence (p = 0.043). Cannabis was the single substance of abuse most strongly associated with nonadherence (p = 0.003). Depressive symptoms approached significance in bivariate analysis (p = 0.066). In regression analysis, a significant interaction was found between illicit substance use and depressive symptoms [OR (95% CI) 1.23 (1.06-1.44), p = 0.007], where illicit substance use was associated with nonadherence in individuals with lower depressive symptoms, but not among those with depressive symptoms at higher levels. No individual substances interacted with depressive symptoms on adherence. CONCLUSION: Though substance use and depressive symptoms interacted on HAART adherence, they did not have a synergistic effect. Continued substance use (51% of the sample) suggests an unmet need for treatment, even in methadone maintenance. Further examinations of the interplay of substance use and depression on HAART adherence are warranted.

Relationship of axis II pathology to sex- and drug-related risk behaviors among patients in HIV primary care.

Some HIV+ patients continue to engage in high-risk behaviors post-diagnosis. To tailor risk reduction interventions for "positives," it is necessary to understand contributing factors. We recently showed that HIV+ patients with co-morbid Axis I psychiatric and substance use disorders had the highest rates of ongoing risk behavior and those without diagnoses the lowest; substance dependence was more impactful than psychiatric disorders. In this companion paper, we provide complementary information about Axis II pathology based on data obtained from the same sample of 179 patients receiving HIV primary care. Patients were categorized as sub-threshold or as having personality traits/disorders (BR ≥ 75) on any of the 14 personality scales of the Millon Multiaxial Personality Inventory (MCMI-III). HIV risk behaviors assessed included (1) the number of sexual partners; (2) any sex without a condom; (3) lifetime and recent injection drug use (IDU); and (4) sharing of injection equipment. After controlling for a diagnosis of alcohol or drug dependence, borderline patients were more likely to have multiple sexual partners and to use condoms irregularly. Trends for multiple sex partners also were observed among patients with antisocial and depressive personality traits/disorders. Antisocial patients also were more likely to be current IDUs. Positives with personalities characterized by risk-taking tendencies and/or decreased capacity to engage in good self-care may benefit from risk reduction interventions that take their feelings of power/invincibility or (conversely) powerlessness/helplessness into account. For patients with antisocial and/or borderline traits/disorders, a "one size fits all" intervention focusing primarily on skills training is likely to fail because the underlying factors driving behavior are not being adequately addressed.

Clinician-assessed depression and HAART adherence in HIV-infected individuals in methadone maintenance treatment.

BACKGROUND: The impact of measurement methods on the relationship between depression and HIV treatment adherence has not been adequately examined. PURPOSE: The purpose of this paper is to examine the relationship between clinician- and patient-rated depression and HIV medication adherence. METHODS: The participants were 91 HIV-infected individuals in methadone maintenance. Depression was assessed via clinician ratings (Clinical Global Impression Scale and Montgomery Asberg Depression Rating Scale) and self-report (Beck Depression Inventory-Short Form). Clinicians rated substance abuse using the Clinical Global Impression Scale and a structured interview. HIV medication adherence was measured over the following 2 weeks using electronic caps. RESULTS: Each unit increase in the Clinical Global Impression Scale was associated with 75% increased odds of nonadherence (OR=1.75, p=0.002, 95% CI=1.23-2.48). Similarly, for each standard deviation Montgomery Asberg Depression Rating Scale increase, there was a 2.6-fold increased odds of nonadherence (OR=2.60, p=0.001, 95% CI=1.45-4.67). Substance abuse and self-reported depression severity were not significantly related to adherence. CONCLUSIONS: Clinician-rated depression severity was a strong predictor of nonadherence. Assessment methods may influence the relationship between depression and HIV nonadherence.

Psychopathology and transmission risk behaviors in patients with HIV/AIDS.

The role of psychiatric and substance use disorders in HIV transmission has not been fully elucidated, particularly among those living with the virus. We compared sex and drug risk behaviors for 228 HIV+ patients in four diagnostic groups: (1) no diagnosis; (2) psychiatric only; (3) substance dependence only; and (4) co-morbid psychiatric and substance dependence. Significant group differences were observed for having multiple sex partners, condom use, and injection drug use (IDU), but not for sharing of injection equipment. Patients with co-morbid psychiatric and substance disorders reported multiple sex partners most frequently, while substance dependence contributed to irregular condom use and IDU. Analysis by substance use subgroup (no dependence, alcohol dependence only, drug dependence only, co-morbid alcohol, and drug dependence) showed that alcohol dependence contributed to having multiple sex partners, while alcohol and drug dependence both contributed to irregular condom use. Meanwhile, only drug dependence contributed to drug risk. HIV+ patients should be screened for psychopathology, with risk reduction interventions tailored to diagnostic group to achieve maximum effect.

Self-efficacy and depression as mediators of the relationship between pain and antiretroviral adherence.

The goals of this study were to examine the association between pain and antiretroviral adherence and to estimate the mediating effect of adherence self-efficacy and depression symptom severity. Surveys using audio computer-assisted self-interview were conducted among 70 HIV-infected current and former drug users enrolled in a methadone program. We assessed antiretroviral adherence and adherence self-efficacy using questions from the Adult Clinical Trials Group survey. We considered participants adherent if they reported taking at least 95% of prescribed antiretrovirals over the past seven days. We assessed depression symptom severity using the depression subscale of the Brief Symptom Inventory. Participants reported pain of any duration in response to a question from the Brief Pain Inventory. Participants reporting pain were 87% less likely to be classified as adherent compared to those without pain (Unadjusted OR = 0.13, 95%CI: 0.03-0.52). When we examined adherence self-efficacy as a mediator of the relationship between pain and adherence, criteria for partial mediation were met. Adjusting for self-efficacy, the beta coefficient for pain decreased by 23% but the independent relationship between pain and antiretroviral adherence was maintained. Mediation criteria were not met when we examined the mediating effect of depression symptom severity on the relationship between pain and adherence. Adjusting for depression symptom severity, the beta coefficient for pain decreased by 9% and the relationship between pain and antiretroviral adherence remained significant. Our results indicate that neither adherence self-efficacy nor depression symptom severity fully mediated the relationship between pain and adherence. HIV providers should recognize the potential impact of pain on antiretroviral adherence among current and former drug users.

Development of a substance abuse consultation and referral service in an academic medical center: challenges, achievements and dissemination.

Approximately 25% of US hospital beds are occupied by individuals with active substance use disorders (SUD). Acute medical hospitalization provides an opportunity to address SUDs and provide patient-centered intervention and referral for treatment. Nationally, some hospitals have developed substance abuse consultation departments to improve the care of hospitalized substance users. In this paper we describe the Addiction Psychiatry Service (APS) in a large urban hospital which provides bed-side SUD consultation, screening, intervention and referral to treatment. APS utilizes the multiple disciplines of psychology, social work and medicine to integrate substance abuse services throughout the hospital and educate future generations of medical and psychology trainees. We conclude with how the APS service is informing the development of similar programs in other academic departments within our hospital and best practice recommendations to further disseminate this service model.

Anxiety disorders in adults treated by hemodialysis: a single-center study.

BACKGROUND: Anxiety is a complicating comorbid diagnosis in many patients with medical illnesses. In patients with end-stage renal disease (ESRD), anxiety disorders often are perceived to represent symptoms of depression rather than independent conditions and therefore have been relatively understudied in this medical population. STUDY DESIGN: To evaluate the psychosocial impact of anxiety disorders on patients with ESRD, we sought to identify the rates of these disorders in a sample of patients receiving hemodialysis at a single center by using a structured clinical interview. We also compared a commonly used screening measure, the Hospital Anxiety and Depression Scale (HADS), with these clinical diagnoses to determine the measure's criterion validity or ability to predict a psychiatric diagnosis in ESRD populations. Finally, we examined the relationship between anxiety diagnosis and perceptions of quality of life (QOL) and health status. SETTING & PARTICIPANTS: A sample of 70 randomly selected hemodialysis patients from an urban metropolitan center. PREDICTOR: Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) Axis I Diagnosis (SCID-I). OUTCOMES: HADS and Kidney Disease Quality of Life Short Form. RESULTS: Using the SCID, 71% of the sample received a DSM-IV Axis I diagnosis, with 45.7% of subjects meeting criteria for an anxiety disorder and 40% meeting criteria for a mood disorder. The concordance between DSM-IV anxiety disorders and anxiety scores acquired by using the HADS was not significant. Thus, although the HADS may provide an acceptable measure of overall "psychic distress" compared against the SCID-I, it has poor predictive power for anxiety diagnoses in patients with ESRD. Additionally, the presence of an anxiety disorder was associated with an overall perceived lower QOL (t = 2.4; P < 0.05). LIMITATIONS: Single-center study and a population not representative of US demographics. CONCLUSIONS: A substantial proportion of participating patients met criteria for an anxiety disorder. The utility of the HADS as a screening tool for anxiety in patients with ESRD should be questioned. The finding that anxiety disorders negatively impact on QOL and are not merely manifestations of depression in patients with ESRD emphasizes the importance of accurate diagnosis and effective treatment. Strategic options are necessary to improve the diagnosis of anxiety disorders, potentially enhancing QOL and medical outcome in patients with ESRD.

Temporal Relationship of Sex Risk Behaviors and Substance Use Severity Among Men in Substance Use Treatment.

Sex risk behaviors and substance use are intertwined. Many men continue to engage in high-risk sexual behaviors even when enrolled in substance use disorder (SUD) treatment. We hypothesized that changes in sex risk behaviors would coincide with changes in drug/alcohol use severity among men in SUD treatment. During an HIV risk-reduction trial, men in methadone maintenance and outpatient drug-free treatment (N = 359) completed assessments at baseline and six months after. We assessed changes in sex risk and substance use severity, using the Addiction Severity Index-Lite (ASI-Lite), controlling for treatment condition. In multinomial logistic regressions, decreased alcohol severity was significantly associated with decreases in reported sex partners, and increased alcohol severity was significantly associated with increases in reported sex partners. Increasing drug use severity was significantly associated with maintaining and initiating sex with a high-risk partner, while decreasing alcohol use severity was significantly associated with discontinuing sex under the influence. However, changes in drug/alcohol use severity were not associated with changes in unprotected sex. Substance use reductions may decrease HIV risk behaviors among male substance users. Our findings highlight the importance of integrating interventions in SUD treatment settings that address the intersection of sex risk behaviors and substance use.

Prescription medication misuse among HIV-infected individuals taking antiretroviral therapy.

HIV has become a highly treatable disease due to advances in antiretroviral therapy (ART). Additionally, HIV-infected individuals often take opiates, barbiturates, and benzodiazepines to treat co-occurring conditions, including pain and symptoms of HIV. We sought to examine prescription medication misuse by surveying 295 HIV-infected patients receiving ART. Participants answered questions about their demographics, alcohol and other drug use, psychiatric diagnoses, ART adherence and side effects, and quality of life. Eleven percent of our sample acknowledged prescription medication misuse. In regression analysis, prescription medication misusers were more likely to report any drinking to intoxication (OR=4.31, 95% CI: 1.35-13.76, p=0.013), reported greater severity of ART side effects (OR=1.05, 95% CI: 1.01-1.10, p=0.041), and demonstrated poorer cognitive functioning (OR=0.97, 95% CI: 0.94-0.99, p=0.048) compared to those who did not misuse prescription medications. Special care should be taken by medical providers before prescribing medications that may be abused or diverted. Patients should also be screened for aberrant use, even if not prescribed. ART side effects, cognitive deficits, and alcohol abuse may serve as risk factors or indicators of prescription medication misuse, and should be monitored.

The efficacy of a computerized assessment of medication adherence in active substance users.

BACKGROUND: Self-reports of medication adherence are subject to recall errors and social desirability bias. The visual analogue scale (VAS) is a brief measure and minimally burdensome. Its accuracy among substance users needs confirmation. METHODS: We administered the VAS on an audio computer-assisted self-interview (ACASI) to 102 HIV-positive active substance users. Viral load (VL) was obtained via chart review. Cohen κ assessed the overall agreement between VL suppression and adherence, and a receiver-operator characteristic (ROC) curve assessed the diagnostic performance. RESULTS: The VAS estimates of adherence correlated with VL. Various cutoffs for adherence were associated with VL suppression, demonstrating fair to moderate agreement through κ. Area under the curve (AUC) demonstrated that the ACASI-administered VAS strongly predicted VL suppression (AUC = 0.79). DISCUSSION: The VAS administered by ACASI is viable for measuring highly active antiretroviral therapy (HAART) adherence among substance users. Its benefits as a screening instrument may make it useful for both clinical and research purposes.

Confidentiality protections versus collaborative care in the treatment of substance use disorders.

Practitioners in federally-assisted substance use disorder (SUD) treatment programs are faced with increasingly complex decisions when addressing patient confidentiality issues. Recent policy changes, intended to make treatment more available and accessible, are having an impact on delivery of SUD treatment in the United States. The addition of electronic health records provides opportunity for more rapid and comprehensive communication between patients' primary and SUD care providers while promoting a collaborative care environment. This shift toward collaborative care is complicated by the special protections that SUD documentation receives in SUD treatment programs, which vary depending on what care is provided and the setting where the patient is treated. This article explores the special protections for substance abuse documentation, discrepancies in treatment documentation, ways to deal with these issues in clinical practice, and the need for more knowledge about how to harmonize treatment in the SUD and primary care systems.

Trauma healing via cognitive behavior therapy in chronically hospitalized patients.

RATIONALE: This study examines the effect of Skill Training In Affect Regulation (STAIR) on a cohort of 24 inpatients with Schizophrenia with histories of significant trauma and Complex PTSD. METHOD: Using a model of Trauma Healing proposed by the NYS Office of Mental Health, 24 patients underwent 12 weeks of group-based Cognitive Behavior Therapy. Treatment modalities focused on trust, safety, affect-regulation, identification of trauma triggers, and disrupting abuse-driven behaviors. A comparison group of patients received 12 weeks of supportive psychotherapy by therapists unfamiliar with Trauma Management. Treatment outcome was compared using the Modified Impact of Events, and Brief Psychiatric Rating Scales. RESULTS: Following completion of 12 weeks of therapy, only those patients undergoing therapy in Trauma Recovery showed improvement on items such as tension, excitement, hostility, suspiciousness, and anger-control. CONCLUSION: These findings are an encouraging first step in trauma recovery of patients with chronic mental illness, histories of prolonged trauma, and Complex PTSD.