Screening and Ongoing Assessment for Substance Abuse in HIV
Screening and Ongoing Assessment for Substance Abuse in HIV
Recommendations. If the initial drug screening result is positive, or if the patient has a history of substance use, the clinician should re-evaluate the patient's drug use at least quarterly.
Clinicians should ask patients with a history of substance use about their last use of alcohol and substances to help diagnose relapses earlier and refer the patient back into care.
Clinicians should offer patients with active substance use/abuse problems referral to appropriate substance use treatment programs or other substance use services.
Blood alcohol levels and urine drug screens should not be ordered as routine screening tests. When these tests are performed, patient consent should be obtained.
Clinicians should provide positive feedback to patients who are successfully engaged in a recovery program.
A range of substance use treatment referral options is available, and clinicians should be familiar with the alcohol and substance use treatment programs and services in their areas. Patients who are currently using substances or alcohol but have a history of good recovery may need just a simple reminder to return to their previous support systems. Outpatient substance abuse treatment services and Twelve Step programs, such as Alcoholics Anonymous and Narcotics Anonymous, are some of the options available for these patients. Other patients may need referral to inpatient treatment or supportive living. Clinicians who are not addiction specialists should offer referral to programs that can help the patient choose among these options. Active addiction is a complex process and patients often refuse referral for help. See Working With the Active User for guidance in dealing with active users.
Patients with a known history of substance/alcohol dependence are at high risk for relapse, particularly when stressed by a new diagnosis of HIV or its complications. By asking patients who are in early recovery about the date of last use of substances, alcohol, and tobacco at every monitoring visit, clinicians can diagnose relapses earlier and refer patients back into care (see Section IV. B. "Relapse Prevention" in Working With the Active User). Patients who use multiple drugs may succeed at discontinuing the use of one drug while continuing to use others. Clinicians should phrase questions to inquire into the use of other substances as well.
A urine drug screen or blood alcohol level (BAL) should be obtained only with the patient's consent, except under medically indicated conditions, such as suspected drug overdose, where the results would provide clinically significant information for appropriate treatment decisions. The tests are generally not clinically helpful when performed routinely, but may elucidate a clinical scenario in which substance use is suspected. If the urine drug screen or BAL is obtained and results suggest that the patient has been using alcohol or substances, the clinician should gently challenge the patient's statement, express concern, and recommend referral to treatment.
Clinicians should give positive feedback to a patient who is engaged in a recovery program. The question: When did you last drink or use? can be asked in a supportive fashion. For example, asking the patient: So how long have you been sober/straight? Is it 6 months? No sips or slips? Great! can be a simple way to provide support for recovery. Clinicians should also express support for patients who continue to use, but have succeeded in reducing use. If a patient has resumed use after a period of recovery, the clinician should express concern and recommend ways to move back toward recovery.
Ongoing Assessment of Patients With Known Substance/Alcohol Abuse Problems
Recommendations. If the initial drug screening result is positive, or if the patient has a history of substance use, the clinician should re-evaluate the patient's drug use at least quarterly.
Clinicians should ask patients with a history of substance use about their last use of alcohol and substances to help diagnose relapses earlier and refer the patient back into care.
Clinicians should offer patients with active substance use/abuse problems referral to appropriate substance use treatment programs or other substance use services.
Blood alcohol levels and urine drug screens should not be ordered as routine screening tests. When these tests are performed, patient consent should be obtained.
Clinicians should provide positive feedback to patients who are successfully engaged in a recovery program.
A range of substance use treatment referral options is available, and clinicians should be familiar with the alcohol and substance use treatment programs and services in their areas. Patients who are currently using substances or alcohol but have a history of good recovery may need just a simple reminder to return to their previous support systems. Outpatient substance abuse treatment services and Twelve Step programs, such as Alcoholics Anonymous and Narcotics Anonymous, are some of the options available for these patients. Other patients may need referral to inpatient treatment or supportive living. Clinicians who are not addiction specialists should offer referral to programs that can help the patient choose among these options. Active addiction is a complex process and patients often refuse referral for help. See Working With the Active User for guidance in dealing with active users.
Patients with a known history of substance/alcohol dependence are at high risk for relapse, particularly when stressed by a new diagnosis of HIV or its complications. By asking patients who are in early recovery about the date of last use of substances, alcohol, and tobacco at every monitoring visit, clinicians can diagnose relapses earlier and refer patients back into care (see Section IV. B. "Relapse Prevention" in Working With the Active User). Patients who use multiple drugs may succeed at discontinuing the use of one drug while continuing to use others. Clinicians should phrase questions to inquire into the use of other substances as well.
A urine drug screen or blood alcohol level (BAL) should be obtained only with the patient's consent, except under medically indicated conditions, such as suspected drug overdose, where the results would provide clinically significant information for appropriate treatment decisions. The tests are generally not clinically helpful when performed routinely, but may elucidate a clinical scenario in which substance use is suspected. If the urine drug screen or BAL is obtained and results suggest that the patient has been using alcohol or substances, the clinician should gently challenge the patient's statement, express concern, and recommend referral to treatment.
| Key Point A refusal for a urine drug screen or blood alcohol level should raise suspicion that the patient has relapsed. |
Clinicians should give positive feedback to a patient who is engaged in a recovery program. The question: When did you last drink or use? can be asked in a supportive fashion. For example, asking the patient: So how long have you been sober/straight? Is it 6 months? No sips or slips? Great! can be a simple way to provide support for recovery. Clinicians should also express support for patients who continue to use, but have succeeded in reducing use. If a patient has resumed use after a period of recovery, the clinician should express concern and recommend ways to move back toward recovery.