Initial Evaluation Of The Patient With Substance Use Disorders

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Obtaining a substance use history is essential when evaluating all patients with HIV/AIDS. Some clinicians may have negative feelings about working with patients who exhibit self-destructive behaviors such as substance abuse and dependence. It is important to be aware of these feelings and realize that patients respond better when a working alliance can be established by approaching them in a nonthreatening and nonjudgmental manner. It is also important to reassure the patient that the information they provide will be kept confidential to those outside of the treatment table 8.2. DSM IV Substance-Induced Disorders

Intoxication Withdrawal

Mood disorders (depressive or manic) Psychosis with delusions Psychosis with hallucinations Anxiety

Sleep disorders Sexual dysfunction Delirium Dementia Amnestic disorders team and be used to develop the safest possible treatment plan. The clinician should ask about specific illicit substances such as heroin, cocaine, marijuana, and the club drugs (see below). For taking a history of alcohol use, some clinicians have suggested the use of the CAGE questionnaire (Ewing, 1984): 1. Can you cut down on your drinking? 2. Are you annoyed when asked to stop? 3. Do you feel guilty about your drinking? 4. Do you need an eye-opener when you wake up in the morning? One should also ask about sedative or stimulant use, whether prescribed or nonprescribed, and any dietary supplements or herbs the patient may be taking. A substance abuse review of systems, focusing on renal, cardiac, gastrointestinal, and, for HIV patients especially, neurological symptoms, is essential. Other points of inquiry are the date the substance was first used; patterns, amount, and frequency of use; and routes of administration and reactions to the use. The time of last use is important to know to determine if the patient is suffering from a substance-induced disorder or is at risk for withdrawal. If the patient has had past substance use treatment it is useful to know the response to this treatment. With the patient's permission, a urine toxicology screen should be obtained, in addition to routine blood tests. Finally, whenever possible, the clinician should try to obtain collateral information about the patient's substance use, since denial is a common defense mechanism in this population.

ally begins crossing the blood-brain barrier within 15-20 seconds. Physical signs of acute opiate intoxication include euphoria and tranquility, sedation, slurred speech, problems with memory and attention, and miosis. Signs and symptoms of opioid withdrawal can be both objective (rhinorrhea and lacrimation, nausea and vomiting, diarrhea, piloerection, mydria-sis, yawning, and muscle spasms) and subjective (body aches, insomnia, craving, dysphoria, anxiety, hot and cold flashes, and anorexia). Heroin withdrawal usually begins within 4 to 8 hours after last use, whereas with methadone, with its longer elimination half-life, withdrawal may not begin until 24 to 48 hours after last use.

Early in the epidemic, heroin addiction led to a rapid spread of HIV and HCV among IDUs in the United States, since few addicts had access to clean needles and syringes. The increase in the purity and availability of heroin along with a decrease in its street price has led to a resurgence in the use of heroin over the past 15 years. There are 600,000 to 800,000 heroin addicts in the United States; however, less than 20% are currently in treatment for their addiction (Community Epidemiologic Work Group, 2000).

The prevalence of HIV appears to be much higher among long-term heroin users who inject, compared with those who have short-term use or other methods of use. Chitwood and colleagues (2003) found an HIV seroprevalence rate of 25% among long-term IDUs and a rate of 13% among new IDUs or heroin sniffers.

SUBSTANCES OF ABUSE Opiates

Injection of heroin may be the most common, though not the only, source of HIV transmission associated with SUD. Opium is one of the oldest medications known, especially for its use in the relief of pain and diarrhea. Morphine and codeine were isolated in the early 1800s and heroin was developed as a semisyn-thetic opium derivative and introduced into medical practice in 1898. The mu opiate receptor is the main one responsible for analgesia, respiratory depression, decreased gastric motility, miosis, euphoria, and dependence. These receptors appear to stimulate release of dopamine from the ventral tegmental area into the nucleus acumbens, the primary reward pathway of the brain. Heroin reaches peak serum concentration within 1 minute when taken intravenously but actu

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