Substance use Disorders
Stephen J. Ferrando
Steven L. Batki
The connection between human immunodeficiency virus (HIV) and substance use has been recognized since the early stages of the epidemic. In the United States, it is estimated that more than 800,000 persons have been diagnosed with acquired immunodeficiency syndrome (AIDS).1 Men who have sex with men (MSM) and injection drug users (IDUs) have been the predominant HIV risk groups. Of men living with AIDS, 32% were IDUs or MSM who were also IDUs.1 Women, ethnic minority groups, and children have been particularly hard hit by injection drug–related and heterosexual transmission of HIV. Since the epidemic began, 57% of AIDS cases among women have been attributed to injection drug use or sex with partners who inject drugs. Of new AIDS cases reported in 2000, IDU-associated AIDS accounted for 26% of cases among African American and 31% among Hispanic adults and adolescents, compared with 19% of all cases among whites.1 Noninjection drugs, such as crack cocaine, and alcohol are also associated with HIV risk via unsafe sexual behaviors.2
Practitioners in HIV treatment settings routinely face the clinical problems associated with substance use disorders. The treatment of individuals with the “triple diagnosis” of HIV, substance abuse, and psychiatric disorders has multiple levels of complexity, including ongoing substance use, increased psychological distress, and potentially poor adherence to medical treatment regimens. These co-occurring disorders may be associated with greater morbidity and mortality and have led to the development of integrated HIV, drug abuse, and psychiatric treatment services.3
In this chapter, we begin by reviewing the potential association between substance use, psychiatric disorders, and HIV risk behaviors. We then discuss the prevalence of psychiatric and substance use disorders among HIV-infected individuals in various treatment settings and research cohorts. Next, we discuss the medical, psychiatric, and substance abuse treatment of individuals with a triple diagnosis of psychiatric disorder, substance use, and HIV infection.
Substance use, Psychiatric Disorders, and HIV Disease: Scope of the Problem
Evidence for a connection between psychiatric disorders, substance use, and HIV can be derived from four sources: (a) data concerning HIV risk behaviors of individuals with psychiatric and/or substance use disorders, (b) HIV seroprevalence studies in psychiatric and
substance abuse treatment settings, (c) clinical samples of patients with HIV in various treatment settings, and (d) cohort studies of psychopathology among homosexual/bisexual men and IDUs with HIV infection.
substance abuse treatment settings, (c) clinical samples of patients with HIV in various treatment settings, and (d) cohort studies of psychopathology among homosexual/bisexual men and IDUs with HIV infection.
HIV Risk Behaviors of Individuals with Psychiatric and Substance use Disorders
Injection and noninjection drug use, as well as alcohol use, are associated with HIV risk behaviors.4 Both psychiatric inpatients and outpatients have revealed high rates of HIV risk behaviors associated with substance use.5 For example, Cournos et al.5 found that 44% of inpatients with schizophrenia were sexually active in the previous 6 months, more than half of whom had multiple sexual partners. Among the sexually active group, consistent condom use was infrequent, nearly half used alcohol or drugs during sex, and half had exchanged sex for money or drugs.5
To date, evidence that presence of a dual diagnosis confers higher risk for HIV infection than presence of a substance use or psychiatric disorder alone is largely indirect. An inferential link between dual diagnosis and HIV risk can be derived from the knowledge that psychiatric and substance use disorders frequently co-occur, that injection and noninjection drug use are known risk factors for HIV infection, and that psychiatric symptoms may magnify HIV risk by producing impaired knowledge, judgment, and interpersonal skills regarding sexual and drug use behavior.6
HIV Seroprevalence in Psychiatric and Substance Abuse Treatment Settings
Among drug users entering treatment, the prevalence of HIV varies greatly by geographic region and ranges from 0 to 35%.7 Among psychiatric patients, studies in the United States—mostly from the New York City area—using discarded blood samples, revealed rates of HIV infection between 4.0% and 22.9% among inpatients.8 Factors associated with HIV-positive serostatus in studies of psychiatric inpatients have included younger age, ethnic minority status, poor reality testing, hypersexuality, childhood and adult sexual victimization, and homelessness, but the most prevalent risk factors have consistently been homosexual/bisexual activity among men and history of injection drug use.8 Males and females in these studies have generally had equal HIV infection rates. Information on specific psychiatric and substance use disorders, and their combinations, has been limited in these studies.
Psychopathology and Substance Abuse in Clinical Samples of Patients with HIV
The triple diagnosis of HIV infection, psychiatric disorder, and substance use disorder is commonly described in studies of HIV-positive patients seen in integrated methadone maintenance treatment (MMT) programs and HIV medical clinics. Clinical samples of IDUs with HIV infection entering MMT reveal high rates of prior psychiatric morbidity, current distress, and suicidal ideation. Further, while in MMT, up to 80% of these patients require psychiatric consultation for the treatment of depression, psychotic symptoms, anxiety, insomnia, cognitive impairment, and behavioral disinhibition, often with concurrent substance abuse (cocaine, amphetamine, alcohol, and/or sedative-hypnotics).9
Reports describing HIV-positive patients seen in specialized HIV medical clinics document the frequent occurrence of psychiatric and substance use disorders, which complicate the manifestations and treatment of HIV infection. Lyketsos et al.10 found that more than 50%
of individuals in their HIV clinic had a psychiatric diagnosis, most of them had a concurrent psychiatric and substance use disorder, and those with a triple diagnosis had the highest mean scores on the Beck Depression Inventory (BDI) and the General Health Questionnaire compared to individuals with no diagnosis or a psychiatric or substance use disorder alone. The collective data from clinical studies underscore the importance of psychiatric and substance abuse screening in HIV medical clinics.
of individuals in their HIV clinic had a psychiatric diagnosis, most of them had a concurrent psychiatric and substance use disorder, and those with a triple diagnosis had the highest mean scores on the Beck Depression Inventory (BDI) and the General Health Questionnaire compared to individuals with no diagnosis or a psychiatric or substance use disorder alone. The collective data from clinical studies underscore the importance of psychiatric and substance abuse screening in HIV medical clinics.
Psychopathology and Substance Abuse in Research Cohorts
Data derived from controlled studies of mostly asymptomatic HIV-positive gay men have shown very high lifetime rates and generally much lower current rates of major depressive, drug use, and alcohol use disorders.11 In recent years, there have been resurgences of HIV risk behavior among young gay men and men of color in association with the use of methylenedeoxymethamphetamine (MDMA, “Ecstasy”) and methamphetamine.
In a cross-sectional study of psychopathology among IDUs with HIV infection, Lipsitz et al.12 reported relatively high rates of current depressive disorders among both male and female IDUs. The rates of current depressive disorders they found were comparable to those found in in-treatment IDU populations studied before the HIV epidemic, but much higher than the rates found in studies of homosexual men.11 When these investigators compared rates of current depressive disorders among HIV-positive IDUs versus HIV-negative IDUs, HIV-positive men (but not HIV-positive women) were more depressed than their HIV-negative counterparts. Longitudinal follow-up of this cohort over 3 years revealed that HIV serostatus and baseline major depressive disorder (MDD) independently predicted persistent or recurrent episodes of MDD after sociodemographic and other factors were controlled statistically.13
Personality disorders are associated with substance abuse, HIV risk behavior, distress, and mal- adaptive coping with HIV infection. In a study of individuals from various risk groups presenting for HIV testing and counseling, Jacobsberg et al.14 found higher rates of antisocial personality disorder among individuals who were seropositive compared with those who were seronegative. Among 100 IDUs tested for HIV, individuals with antisocial personality disorder (ASPD), 36% engaged in more needle sharing with more drug use partners than IDUs without ASPD.
Cognitive dysfunction is an important aspect of psychopathology in HIV infection. Studies on neuropsychological performance in HIV-positive drug and alcohol users reveal that up to 88% of patients have impairment in one or more cognitive domains.15 In comparing asymptomatic HIV-positive IDUs with HIV-negative IDUs, investigators found that drug use is a more important factor in producing neuropsychological impairment than HIV itself. In addition to drug use, independent predictors of poor neuropsychological test performance among HIV-positive IDUs include HIV viral load, low educational attainment, and premorbid medical and psychiatric problems.15 Furthermore, increasing evidence suggests that individuals with HIV and comorbid methamphetamine, cocaine, heroin, or alcohol abuse may experience more rapid deterioration in cognitive function than individuals without such comorbidity.16 This may be due to the propensity for HIV and these substances to induce neuropathologic changes in striatal and other dopaminergic systems.
Medical Aspects of HIV Infection in Substance Users
Common HIV-Associated and Other Medical Problems in Substance Users
The course and complications of HIV disease may be different for substance users than individuals in other HIV risk groups. Once substance users enter medical treatment, the secondary complications of continued drug and alcohol use (e.g., decreased self-care, pneumonia, skin
abscesses, sexually transmitted diseases) and behavioral disturbances secondary to psychiatric distress or disorders may complicate the course and treatment of HIV infection. Longitudinal epidemiologic evidence suggests that alcohol and illicit drug use accelerates progression of HIV infection.17
abscesses, sexually transmitted diseases) and behavioral disturbances secondary to psychiatric distress or disorders may complicate the course and treatment of HIV infection. Longitudinal epidemiologic evidence suggests that alcohol and illicit drug use accelerates progression of HIV infection.17
Severe bacterial infections, including pneumonias, endocarditis, and sepsis are common in IDUs and may be mistaken for other complications of HIV disease (e.g., bacterial pneumonia may be presumed secondary to Pneumocystis jiroveci (formerly carinii) infection (i.e., PCP). In addition, Mycobacterium tuberculosis (TB), including drug-resistant strains, may be seen in drug users with HIV and homeless individuals living in shelters; however, the incidence of TB has declined in epicenter cities in the United States, likely because of better HIV treatment and TB control strategies.18 Primary sexually transmitted diseases are common among IDUs with HIV infection because many HIV-infected drug users continue to practice unsafe sex and risky drug use practices.19 In addition, reactivation of old infections, such as with the development of neurosyphilis, may occur in drug users with advanced immunosuppression and may be difficult to diagnose because of the broad differential diagnosis for encephalopathy (see Chapters 12 and 19).
Hepatitis C virus (HCV) infection is increasingly recognized as a significant comorbid condition that affects the clinical outcome of patients with substance use disorders and HIV disease. Coinfection is common because both HIV and HCV share routes of transmission, notably injection.7 HIV is a risk factor for accelerating the course of HCV, and HCV can worsen the outcome of HIV disease. HCV treatment involves the use of inter- feron alpha, which is associated with numerous neuropsychiatric adverse effects, most notably the onset or exacerbation of depression and other dysphoric symptoms. These psychiatric adverse effects can be successfully treated with antidepressant medications such as selective serotonin reuptake inhibitors (SSRIs).20,21 Alcohol use is a highly significant cofactor in further increasing the morbidity and mortality associated with HCV infection, making abstinence from alcohol an important treatment goal in the individual with HCV infection.
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