Managing Hard-to-Manage Patients Sharon Stancliff, MD Medical Consultant New York State Department of Health AIDS Institute New York, NY

Drug Users n IDU directly accounts for 44% of AIDS case reported by June 2000 n Ongoing drug users often perceived of as hard to engage, poorly adherent, and difficult n Education can help to bridge the gap

Syringe Access n Pharmacy access: those over 18 may purchase up to 10 syringes at registered pharmacies n Clinic access: article 28 facilities may register to sell or furnish up to 10 syringes n Syringe exchange programs: 13 in NYS

Goals n Public health: primary and secondary prevention n Health promotion: open the door for honesty and education n Sanitation: promote proper disposal

Drug Treatment n “Do you want to stop or reduce use?” n Treatment alternatives and limitations —Few treatments have solid track records —We know little about how people stop abusing drugs —Users know this on some level

LTRSTRODFMMTP Pre Post LTR: long-term resident. ODF: outpatient, drug-free. MMTP: methadone maintenance treatment program. STI: short-term inpatient. Adapted from Hubbard: Overview of 1-year follow-up outcomes in the (DATOS).g Weekly Cocaine Use Before Treatment and at Month 12 Follow-Up Patients (%)

Methadone Maintenance n Given a high enough dose, the majority will stop heroin use 1 n At lower doses, risky behavior is reduced with significantly lower risk of seroconversion to HIV positive 2 1 Ball 1991, Leavitt Drucker 1998.

MMTPs n Require frequent attendance n Concerns about diversion create an atmosphere of mistrust n Education about true risks and benefits is often lacking

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