Substance Abuse Treatment/Counseling

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1 Substance Abuse Treatment/Counseling Pg Service Category Definition - Part A 1 Patients With HIV More Likely to Smoke, Less Likely to Quit Medscape.com, March Recreational Drugs and HIV - AIDSinfonet.org, December HIV and Substance Use - HIV Mental Health Treatment Issues, American Psychiatric Association, May J:\Committees\Quality Assurance\FY16 How To Best\Workgroups\Workgroup 2\TOC - WG2.doc

2 Page 1 of 8 FY 2015 Houston EMA/HSDA Ryan White Part A Service Definition Substance Abuse Services - Outpatient (Revision Date: 06/03/14) HRSA Service Category Substance Abuse Services Outpatient Title: Local Service Category Substance Abuse Treatment/Counseling Title: Budget Type: Fee-for-Service Budget Requirements or Minimum group session length is 2 hours Restrictions: HRSA Service Category Definition: Local Service Category Definition: Target Population (age, gender, geographic, race, ethnicity, etc.): Services to be Provided: Service Unit Definition(s): Financial Eligibility: Client Eligibility: Agency Requirements: Substance abuse services outpatient is the provision of medical or other treatment and/or counseling to address substance abuse problems (i.e., alcohol and/or legal and illegal drugs) in an outpatient setting, rendered by a physician or under the supervision of a physician, or by other qualified personnel. Treatment and/or counseling HIV-infected individuals with substance abuse disorders delivered in accordance with State licensing guidelines. HIV-infected individuals with substance abuse disorders, residing in the Houston Eligible Metropolitan Area (EMA/HSDA). Services for all eligible HIV/AIDS patients with substance abuse disorders. Services provided must be integrated with HIV-related issues that trigger relapse. All services must be provided in accordance with the Texas Department of Health Services/Substance Abuse Services (TDSHS/SAS) Chemical Dependency Treatment Facility Licensure Standards. Service provision must comply with the applicable treatment standards. Individual Counseling: One unit of service = one individual counseling session of at least 45 minutes in length with one (1) eligible client. A single session lasting longer than 45 minutes qualifies as only a single unit no fractional units are allowed. Two (2) units are allowed for initial assessment/orientation session. Group Counseling: One unit of service = one session of group treatment for one eligible client. A single session must last a minimum of 2 hours. A maximum of one unit may be billed per person per group session. Support Groups are defined as professionally led groups that are comprised of HIV-positive individuals, family members, or significant others for the purpose of providing Substance Abuse therapy. Refer to the RWPC s approved FY 2015 Financial Eligibility for Houston EMA/HSDA Services. HIV-infected individuals with substance abuse comorbidities/disorders. Agency must be appropriately licensed by the State. All services must be provided in accordance with applicable Texas Department of State

3 Page 2 of 8 Staff Requirements: Special Requirements: Health Services/Substance Abuse Services (TDSHS/SAS) Chemical Dependency Treatment Facility Licensure Standards. Client must not be eligible for services from other programs or providers (i.e. MHMRA of Harris County) or any other reimbursement source (i.e. Medicaid, Medicare, Private Insurance) unless the client is in crisis and cannot be provided immediate services from the other programs/providers. In this case, clients may be provided services, as long as the client applies for the other programs/providers, until the other programs/providers can take over services. All services must be provided in accordance with the TDSHS/SAS Chemical Dependency Treatment Facility Licensure Standards. Specifically, regarding service provision, services must comply with the most current version of the applicable Rules for Licensed Chemical Dependency Treatment. Services provided must be integrated with HIV-related issues that trigger relapse. Provider must provide a written plan no later than 3/30/13 documenting coordination with local TDSHS/SAS HIV Early Intervention funded programs if such programs are currently funded in the Houston EMA. Must meet all applicable State licensing requirements and Houston EMA/HSDA Part A/B Standards of Care. Not Applicable.

4 Page 3 of 8 FY 2016 RWPC How to Best Meet the Need Decision Process Step in Process: Council Recommendations: Approved: Y: No: Approved With Changes: Date: 06/11/2015 If approved with changes list changes below: Step in Process: Steering Committee Recommendations: 1. Approved: Y: No: Approved With Changes: Date: 06/07/2015 If approved with changes list changes below: Step in Process: Quality Assurance Committee Recommendations: 1. Approved: Y: No: Approved With Changes: Date: 05/21/2015 If approved with changes list changes below: Step in Process: HTBMTN Workgroup Recommendations: Financial Eligibility: Date: 04/14/

5 4/1/ Page 4 of 8 Patients With HIV More Likely to Smoke, Less Likely to Quit Diana Swift March 03, Of the estimated 419,945 US adults receiving medical care for HIV infection, more than 4 in 10 are current smokers, almost twice as many as in the general population, according to a survey based Centers for Disease Control and Prevention (CDC) analysis. Furthermore, patients with HIV are less likely to quit smoking than their general population counterparts, notes the study, published in the March 3 issue of the Annals of Internal Medicine. Smoking's negative synergistic effects with HIV substantially reduce the benefits of effective antiviral treatment and increase the risk for illness and death. There is clearly a role for professionals treating this population. "For persons with HIV who receive care regularly, providers have a unique opportunity to promote smoking cessation interventions during visits," write Rennatus Mdodo, DrPH, from the Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Office of Infectious Diseases, CDC, Atlanta, Georgia, and colleagues. To estimate smoking prevalence in adults with HIV vs the general population, the authors used data collected in 2009 by the Medical Monitoring Project, an HIV surveillance system, and data from the 2009 National Health Interview Study, a cross sectional household survey. Results for patients with HIV were based on face to face interviews plus medical record abstractions from 461 responding Medical Monitoring Project facilities in which 4217 individuals completed interviews linked with medical record abstractions. The researchers compared data, which included several sociodemographic and behavioral variables, with information from 27,731 National Health Interview Study participants. HIV adults were predominantly male (71.2%), older than 40 years (75.4%), and non Hispanic black (41.4%). Half had more than a high school education (50.6%), and 54.3% lived at or above the federal poverty level. In the HIV group, 42.4% (95% confidence interval [CI], 39.7% 45.1%) were current smokers compared with 20.6% (95% CI, 19.9% 21.3%) of the National Health Interview Study adults. Fewer participants in the HIV group were never smokers (37.3% [95% CI, 34.9% 39.6%] vs 57.5% [95% CI, 56.6% 58.4%]). About one in five participants in both groups were former smokers. In the HIV group, the smoking rate was lowest in among Hispanics and Latinos (35.0%) and highest among persons incarcerated in the 12 months before interviewing (67.8%). Factors, some of which are modifiable, independently associated with current smoking included male sex, age 40 to 49 years, non Hispanic white/black ethnicity, having no more than a high school education, living below the poverty level, and homelessness or incarceration in the last 12 months. Other factors fuelling smoking likelihood were noninjectable drug use, binge drinking, and failure to achieve viral suppression. In the general population as well, male sex, older age, non Hispanic white/black ethnicity, and low education levels were associated with smoking. 1/2

6 4/1/ Page 5 of 8 As for cessation, the HIV group was also less likely than the general adult population to quit: 32.4% (95% CI, 29.6% 35.3%) of ever smokers vs 51.7% (95% CI, 50.3% 53.0%) of all adults. Although evidence based smoking cessation interventions and clinical guidelines have been developed for the population at large, they have not been fully implemented for HIV infected persons, who may face additional challenges such as substance abuse and poverty. The CDC has recently launched a national antismoking campaign for smokers with HIV. The authors recommend that smoking cessation programs be a routine component of healthcare for patients with HIV. "Provider initiated quitting discussions and expanded access to evidence based smoking cessation interventions for adults with HIV may help increase quit rates and reduce morbidity and mortality rates associated with smoking," they write. This work was supported by the CDC under an agreement with the Medical Monitoring Project. The CDC had no input into the study design and execution but approved the final version. The authors have disclosed no relevant financial relationships. Ann Intern Med. 2015;162: Abstract Medscape Medical News 2015 WebMD, LLC Send comments and news tips to news@medscape.net. Cite this article: Patients With HIV More Likely to Smoke, Less Likely to Quit. Medscape. Mar 03, /2

7 Page 6 of 8 AIDS InfoNet Fact Sheet Number 154 HOW DOES DRUG USE RELATE TO HIV? Injection drug and alcohol use are major factors in the spread of HIV infection. Outside of Africa, injection drug use now accounts for 1 in 3 new HIV infections. Shared equipment for using drugs can carry HIV and hepatitis viruses, and drug and alcohol use is linked with unsafe sexual activity. Drug and alcohol use can also be dangerous for people who are taking antiretroviral medications (ARVs). Drug users are less likely to be adherent to their medications, and street drugs may have dangerous interactions with ARVs. Fact sheet 494 has more information on individual drugs and HIV. Drug and alcohol treatment to stop drug use can lower your risk of HIV infection. INJECTION AND INFECTION HIV infection spreads easily when people share equipment to inject drugs. Sharing equipment also spreads hepatitis B, hepatitis C, and other serious diseases. Infected blood can be drawn up into a syringe and then get injected along with the drug by the next user of the syringe. This is the easiest way to transmit HIV during drug use because infected blood goes directly into someone s bloodstream. To reduce the risk of HIV and hepatitis infection, never share any equipment used with drugs, and keep washing your hands. Carefully clean your cookers and the site you will use for injection. See fact sheet 155 for more information on ways to reduce the harm of drug use. A recent study showed that HIV can survive in a used syringe for at least 4 weeks. If you have to re-use equipment, you can reduce the risk of infection by cleaning it between users. If possible, re-use your own syringe. It still should be cleaned because bacteria can grow in it. The most effective way to clean a syringe is to use water first, then bleach and a final water rinse. Try to get all blood out of the syringe by shaking vigorously for 30 seconds. Use cold water because hot water can make the blood form clots. To kill most HIV and hepatitis C virus, leave bleach in the syringe for two full minutes. Cleaning does not always kill HIV or hepatitis. Always use a new syringe if possible. DRUG USE AND HIV ACCESS TO CLEAN NEEDLES Access to clean needles and syringes reduces the spread of HIV and viral hepatitis. In some states, adults can purchase new syringes in pharmacies without a prescription. Some communities have started needle exchange programs to give free, clean syringes to people so they won t need to share. Programs that provide easier access to new syringes are controversial because some people think they promote drug use. However, research on needle exchange shows that this is not true. Rates of HIV infection go down where there are needle exchange programs, and more drug users sign up for treatment programs. The North American Syringe Exchange Network has a web page listing several needle exchange programs at DRUG USE AND UNSAFE SEX For a lot of people, drugs and sex go together. Drug users might trade sex for drugs or for money to buy drugs. Some people connect having unsafe sex with their drug use. Research shows that sexual behavior is the main HIV risk factor for injection drug users. Drug use, including methamphetamine or alcohol, increases the chance that people will not protect themselves during sexual activity. Someone who is trading sex for drugs might find it difficult to set limits on what they are willing to do. Drug and alcohol use may reduce condom use and safer sex practices. Often, substance users have multiple sexual partners. This increases their risk of becoming infected with HIV or another sexually transmitted disease. Also, substance users may have an increased risk of carrying sexually transmitted diseases. This can increase their risk of becoming infected with HIV, or of transmitting HIV infection. MEDICATIONS AND DRUGS It is very important to take every dose of ARVs. People who are not adherent (miss doses) are more likely to have higher levels of HIV in their blood, and to develop resistance to ARV medications. Drug use is linked with poor adherence, which can lead to treatment failure and disease worsening. Some street drugs interact with ARVs. The liver breaks down some medications used to fight HIV, especially the protease inhibitors and the non-nucleoside reverse transcriptase inhibitors. It also breaks down some recreational drugs, including alcohol. When drugs and medications are both in line to use the liver, they might both be processed much more slowly. This can lead to a serious overdose of the medication or of the recreational drug. An overdose of a medication can cause serious side effects. An overdose of a recreational drug can be deadly. At least one death of a person with HIV has been blamed on mixing a protease inhibitor with the recreational drug Ecstasy. Some ARVs can change the amount of methadone in the bloodstream. It may be necessary to adjust the dosage of methadone in some cases. See the fact sheets for each of the medications you are taking, and discuss your HIV medications with your methadone counselor and your HIV health care provider. THE BOTTOM LINE Drug use is a major cause of new HIV infections. Shared equipment can spread HIV, hepatitis, and other diseases. Alcohol and drug use, even when just used recreationally, contribute to unsafe sexual activities and an increase in sexually transmitted infections. To protect yourself from infection, never reuse any equipment for using drugs. Even if you re-use your own syringes, clean them thoroughly between times. Cleaning is only partly effective. In some communities, new syringes can be bought without a prescription. Also, needle exchange programs in some areas provide free, new syringes. These programs reduce the rate of new HIV infections. Drug use can lead to missed doses of ARVs. This increases the chances of treatment failure and resistance to medications. Mixing recreational drugs and ARVs can be dangerous. Drug interactions can cause serious side effects or dangerous overdoses. Reviewed September 30, 2014 A Project of the International Association of Providers of AIDS Care. Fact Sheets can be downloaded from the Internet at

8 HIV MENTAL HEALTH TREATMENT ISSUES HIV and Substance Use Page 7 of 8 A strong link between HIV and substance abuse. Substance abuse has been associated with HIV/AIDS since the beginning of the pandemic. It is well known that sharing injection equipment is a leading cause of HIV transmission among those who inject drugs. But drug and alcohol use also put people at higher HIV risk by disinhibiting them and making it more likely they will engage in unprotected sex. The National Institute on Drug Abuse (NIDA) reports that from 2005 to 2009, 64 percent of HIV+ people in the U.S. had used an illicit drug, but not intravenously; only 19 percent had never used an illicit drug. A 2009 study found one in four of those living with HIV reported alcohol or drug use at a level warranting treatment. Besides injection drugs, other substances associated with HIV risk include cocaine ( coke, crack ), amphetamines ( speed ), alcohol, inhaled nitrates ( poppers ), and party or club drugs, such as crystal methamphetamine (meth) or MDMA ( ecstasy ). NIDA further reports that drug abuse and addiction can worsen the progression of HIV and its consequences, especially in the brain. Animal studies have shown that stimulants can increase HIV viral replication. A human study found HIV caused greater neuronal injury and cognitive impairment in drug users than non-users. How does substance abuse complicate HIV treatment? Concurrent (or dual) diagnoses of HIV, substance use, and mental health disorders may affect one another, complicating the course of HIV infection. Problematic drug and alcohol use can undermine both prevention and treatment adherence. A substance-using patient is less likely to adhere to antiretroviral medications, increasing the risk for viral resistance. Needle-exchange programs and information about cleaning injection equipment has reduced new HIV infections among injection drug users. But injection drug users, often with limited access to care, don t tend to seek medical care for HIV until the disease has progressed, complicating treatment. Drugs such as heroin, cocaine, and alcohol can suppress the immune system. Drugs can also interfere with HIV medications, and vice versa. Amphetamines, ketamine ( Special K ) and heroin can interact with specific antiretrovirals, while Ritonavir can increase the potency of MDMA to a fatal degree. HIV+ patients who are injection drug users are more likely to have comorbid psychiatric conditions. Studies have found that between 70-90% had a psychiatric condition before being diagnosed with HIV. These patients also have high rates of prior suicidal behavior. The multifaceted symptoms of psychiatric conditions can sometimes mask the signs of substance abuse, and vice versa. When there is a comorbid psychiatric disorder, the treating physician should carefully prescribe medications, particularly those that tend to be habit-forming. Medical complications are also a serious concern when treating an HIV+ patient who has a substance use disorder. A treating clinician must be aware of the risk of severe bacterial infections including tuberculosis, hepatitis C and sexually transmitted diseases. How is substance abuse treated? Effective treatment for substance abuse improves the quality of life for HIV+ patients, and reduces the spread of HIV infection. Substance abuse treatment can also make it more likely that patients will adhere to their HIV treatment. Clincians need to screen all HIV+ patients for ongoing or recurrent drug and alcohol use and abuse. There are a variety of screening tools that can be used to identify these problems. Most important to a good history is for the clinician to use a nonjudgmental attitude in asking questions. The main goal of substance abuse treatment is to reduce or stop drug use, followed by a sustained reduction of high-risk behaviors. A longer-term goal is to develop the ability to quickly control relapse or relapse behaviors, and to maintain the positive behaviors learned in treatment. The ideal treatment setting for an HIV+ person with a substance use disorder treats both diseases in an integrated fashion. Even when this is not possible, treating physicians and other health care professionals must communicate with one another to ensure a successful outcome. Outpatient substance abuse treatment is the most common method, and can be quite effective. If the outpatient method is unable to help an individual stay off drugs, residential treatment should be considered. Twelve-step programs can be helpful in the recovery process, especially meetings where discussion of HIV is welcome or accepted. The pharmacological treatments that are a standard part of substance abuse rehabilitation (e.g. disulfiram, naltrexone, acamprosate, buprenorphine, and methodone) can be administered to HIV+ patients as long as care is taken to monitor

9 Page 8 of 8 reactions to the medications. Long-term Methodone Maintenance Therapy (MMT) is recommended for severe addicts. Drug-drug interactions should be carefully monitored for those on methodone. A number of medications used to treat HIV and related conditions may raise or lower the levels of methodone in a patient s bloodstream. Naltrexone may not be the right treatment for patients who require pain management with opiods. References Chaffee, Barbara, Screening and Ongoing Assessment for Substance Abuse in HIV: Guideline for Care (April 5, 2011): National Institute on Drug Abuse ( related-topics/hivaids) About this Fact Sheet This fact sheet was revised by John-Manuel Andriote, based on an earlier version by Kerry Flynn Roy in collaboration with the APA Commission on AIDS. For more information contact American Psychiatric Association, Office of HIV Psychiatry, 1000 Wilson Blvd., Suite 1825, Arlington, VA 22209; phone: ; fax: ; or AIDS@psych.org. Visit our web site at