Treatment And Management Of Substance Use Disorders

To address the unique needs of the HIV patient who is addicted to substances, it is necessary to find the balance between addiction treatment and harm reduction. A greater level of tolerance and flexibility is required than might otherwise be expected in a formalized addiction treatment program that stresses abstinence and the use of 12-step groups. This includes tolerance of ongoing substance use during the course of treatment.

The initial phase of addiction treatment is usually concerned with providing safe and humane detoxification from the substance of abuse. Benzodiazepines are recommended as the treatment of choice in management of alcohol or sedative/hypnotic withdrawal (Mayo-Smith, 1997), although some clinicians have also advocated the use of anticonvulsants (Pages and Ries, 1998; Malcolm et al., 2001). Detoxification can generally be done at the same dosages as those for seronegative patients until the later stages of HIV illness, when lower doses may be necessary.

Methadone detoxification is the preferred method of managing opioid withdrawal. Schedules using bu-prenorphine and/or clonidine for opioid detoxification are also available (NIH Consensus Development Conference, 1998). Detoxification from cocaine and stimulants is not done pharmacologically.

After medical stabilization and detoxification, the goals of treatment should include maintenance of abstinence when possible and rapid treatment of relapse. Substance abuse treatment is usually provided on an outpatient basis, though treatment communities afford a higher level of care for those with a more severe and refractory SUD. Adjunctive anticraving agents may be used by HIV-positive patients with severe addictive disorders to aid in abstinence. Disulfu-ram, acamprosate, and naltrexone have all been used to curb alcohol craving. Methadone maintenance therapy has been shown to be effective in managing abstinence from opiates, and recently buprenorphine has been approved for the office management of opiate dependence.

Harm reduction is a strategy that is particularly applicable to the addicted, HIV-positive patient (Fer-

rando and Batki, 2000). In harm reduction, many individuals in recovery will not maintain abstinence and that treatment strategies should therefore focus on reducing behavior that has potentially harmful consequences, such as the sharing of needles or illicit activities to pay for substance use. Sterile needle-exchange programs have not only been effective in decreasing risk-taking behaviors, but some studies and meta-analyses indicate that they may have contributed to a significant decrease in HIV seroconversion among the IDU population (Cochrane Collaborative Review Group, 2004; Des Jarlais et al., 2005).

Motivational interviewing is a useful method for managing patients with SUD (Miller and Rollnick, 1991). In this process, the practitioner assesses a patient's readiness to change and facilitates movement along a continuum of change (Prochaska and DiClemente, 1986). One goal is to engage the patient in a manner that creates a disparity in wants expressed by the patient and their current reality. In this process the clinician should try to avoid eliciting the patient's defense mechanisms through the expression of empathy, avoid argumentation, create discrepancy, roll with the resistance, and support and reframe the patient's desires, all of which will effectively serve to create an environment that facilitates behavioral change.

Network therapy is an office-based treatment of SUD advocated by Galanter and colleagues (Galanter and Brook, 2001) that employs both psychodynamic and cognitive-behavioral approaches. The treatment includes a therapeutic network of non-abusing family members, significant others, and peers who actively participate with the therapist to provide cohesiveness and support, undermine denial, and promote compliance with treatment. Studies have demonstrated significantly less illicit substance use among patients receiving this treatment for cocaine and opiate abuse. (Galanter et al., 1997, 2004)

Two meta-analyses looking at the outcomes of psychosocial interventions upon risk-taking behavior among IDUs showed that simply undergoing a screening to enroll in the studies seemed to have a beneficial effect of reducing risky behavior in both experimental and comparison groups; there were no significant differences based on the length of time of the interventions (Gibson et al., 1998; Semaan et al., 2002). These studies stress the importance of including information about HIV infection and HIV risk reduction and access to condoms and HIV testing along with other components of any drug intervention pro gram. For those patients with comorbid SUD and mental disorder, successful treatment approaches stress the integration of mental health care and substance abuse treatment along with medical care. Patients receiving ancillary services are more likely to link up with medical care (Klinkenberg and Sacks, 2004).

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