1. ACCREDITATION STATEMENT: University of California, San Diego School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The University of California, San Diego School of Medicine designates this educational activity for a maximum of one credit per hour AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity. 1 Didactic Series Screening for Alcohol and Substance Abuse in HIV-infected Patients Chris Mathews, M.D., MSPH UCSD Owen Clinic Pacific AETC June 12, 2014

2. 2 Learning Objectives 1)Review prevalence of substance use and substance use disorders (SUDs) in HIV- infected patients under care 2)Review impact of active substance use and SUDs on HIV-related health outcomes 3)Summarize the rationale for & limitations of substance abuse screening tools in HIV- infected patients 4)Describe available screening tools, how to get them and how to use them

3. 3 Self-Reported Substance Abuse Prevalence at Owen Clinic Entry (n=1,682)

4. Poll Question 1 How often you use any self report substance use screening tools on new HIV patients in your practice? −Always −Most of the time −Sometimes −Rarely −Never 4

5. Poll Question 2 When should urine drug screening be performed on HIV patients in your practice? (select as many as apply) −Routinely on all new patients −Routinely on all patients prescribed opiates −Only when abuse or diversion is suspected −As part of a work-up for altered mental status 5

6. Consequences of Unrecognized and Untreated Substance Use Disorders (SUDs) for HIV Care Poorer engagement in care Less likely to be prescribed antiretroviral therapy Worse adherence More likely to be treated at advanced stages of HIV disease More rapid disease progression More likely to have worse treatment outcomes Risk behavior disinhibition Chitsaz et al. AIDS Behav (2013) 17:S118–S127 6

7. Conceptual Model of HIV-related Health Behaviors Chitsaz et al. AIDS Behav (2013) 17:S118–S127 7

8. Consequences of Unrecognized and Untreated Substance Use Disorders (SUDs) for HIV Care Chitsaz et al. AIDS Behav (2013) 17:S118–S127 8

9. Consequences of Unrecognized and Untreated Substance Use Disorders (SUDs) for HIV Care Drug use severity was negatively and independently correlated with three outcomes just before incarceration: (1)having an HIV care provider AOR = 0.28 (2) being prescribed antiretroviral therapy AOR = 0.12 (3) high levels (> 95 %) of antiretroviral medication adherence AOR = 0.18 Chitsaz et al. AIDS Behav (2013) 17:S118–S127 9

10. Consequences of Recent Substance Use for ART Adherence Rosen et al. AIDS Behav. 2013 Jan;17(1):142-7AIDS Behav. 10

11. Consequences of Recent Substance Use for ART Adherence (ACTG 362) Cohn et al. AIDS Care. 2011 Jun;23(6):775-85AIDS Care. 11

12. Consequences of Recent Substance Use for Mortality (ACTG 362) Cohn et al. AIDS Care. 2011 Jun;23(6):775-85AIDS Care. 12

13. ASAM Definition of Addiction 13 Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social, and spiritual manifestations. This revised definition of addiction is characterized by: –Inability to consistently abstain –Impairment in behavioral control –Craving –Diminished recognition of significant problems with one’s behaviors and interpersonal relationships –A dysfunctional emotional response http://www.asam.org/research-treatment/definition-of-addiction

14. Substance Use Disorders and DSM-5 The term addiction is not applied in DSM-5 The more neutral term of substance use disorder (SUD)used to describe a wide range of disorder, from mild to severe, chronically relapsing, compulsive drug taking –SUD includes the previous DSM-4 categories of substance abuse and substance dependence –2 defined criteria necessary for SUD diagnosis (DSM- 4 required only 1) Distinction made between SUD and substance- induced disorders (intoxication and withdrawal) 14

15. The Screening Process Is defined as a range of evaluation procedures and techniques Does not enable treatment personnel to make a clinical diagnosis Indicates whether a probability exists that the condition sought is present Is a preliminary assessment to determine whether key features of a targeted problem are present in an individual. Limitations of self-report associated with stigma SAMHSA TIP 11 15

16. The Screening Process A comprehensive assessment is a thorough evaluation to establish the presence or absence of a disorder or disease. Once screening results are known, one of the following three conclusions can be drawn: –The individual is likely to benefit from referral for a comprehensive assessment. –Further assessment is unwarranted. –Screening should be repeated at a later time. SAMHSA TIP 11 16

17. Screening tools: Options to Consider Single item vs. multi-item Alcohol, other substances, or combined Self-administered vs. interviewer administered vs. computer-assisted 17

18. Substance Screening Tools: Examples Alcohol Screening CAGE MAST AUDIT Maximum drinks screener Frequency of 5+/4+ drinking screener Combined substance screening DAST NIDA-ASSIST CRAFFT (for adolescents) CAGE-AID Single question screener for drug abuse 18

19. SBIRT Recommended Screening Tools: CAGE Agerwala et al. J Psychoactive Drugs. 2012 Sep-Oct;44(4):307-17J Psychoactive Drugs. 19

20. SBIRT Recommended Screening Tools: CRAFFT Agerwala et al. J Psychoactive Drugs. 2012 Sep-Oct;44(4):307-17J Psychoactive Drugs. 20

21. SBIRT Recommended Screening Tools: AUDIT Agerwala et al. J Psychoactive Drugs. 2012 Sep-Oct;44(4):307-17J Psychoactive Drugs. 21

22. SBIRT Recommended Screening Tools: ASSIST Agerwala et al. J Psychoactive Drugs. 2012 Sep-Oct;44(4):307-17J Psychoactive Drugs. 22

23. SBIRT Recommended Screening Tools: Single Item Tools Agerwala et al. J Psychoactive Drugs. 2012 Sep-Oct;44(4):307-17J Psychoactive Drugs. 23

24. Screening Resources SAMHSA screening tools URL –http://www.integration.samhsa.gov/clinical-practice/screening- tools#drugshttp://www.integration.samhsa.gov/clinical-practice/screening- tools#drugs SAMHSA SBIRT (Screening, Brief Intervention, Referral, Treatment) –http://beta.samhsa.gov/sbirthttp://beta.samhsa.gov/sbirt CRAFFT –http://www.ceasar-boston.org/CRAFFT/http://www.ceasar-boston.org/CRAFFT/ AUDIT –http://www.integration.samhsa.gov/AUDIT_screener_for_alcohol. pdfhttp://www.integration.samhsa.gov/AUDIT_screener_for_alcohol. pdf DAST –http://www.emcdda.europa.eu/attachements.cfm/att_61480_EN_ DAST%202008.pdfhttp://www.emcdda.europa.eu/attachements.cfm/att_61480_EN_ DAST%202008.pdf 24

25. Screening Resources AUDIT-C –http://www.integration.samhsa.gov/images/res/tool_a uditc.pdfhttp://www.integration.samhsa.gov/images/res/tool_a uditc.pdf CAGE-AID –http://www.integration.samhsa.gov/images/res/CAGE AID.pdfhttp://www.integration.samhsa.gov/images/res/CAGE AID.pdf NIDAMED (resources for health professionals) –http://www.drugabuse.gov/nidamed-medical-health- professionalshttp://www.drugabuse.gov/nidamed-medical-health- professionals NIDA Drug Screening Tool (online) –http://www.drugabuse.gov/nmassist/http://www.drugabuse.gov/nmassist/ 25

26. NIDA-ASSIST Online 26 http://www.drugabuse.gov/nmassist/

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35. Poll Question 3 How likely are you to implement in the next 3 months routine substance abuse screening using a standardized tool on new HIV patients? −Very likely −Somewhat likely −Possible −Unlikely −Very unlikely 35

36. Poll Question 4 How likely are you to implement in the next 3 months routine substance abuse screening using a standardized tool on follow-up HIV patients? −Very likely −Somewhat likely −Possible −Unlikely −Very unlikely 36