Psychiatric Disorders, Drug Use, and Medical Status in Injection Drug Users With HIV Disease

Income level and drug related harm among people who use injection drugs in a Canadian setting

BACKGROUND

Higher income is generally associated with better health outcomes; however, among people who inject drugs (IDU) income generation frequently involves activities, such as sex work and drug dealing, which pose significant health risks. Therefore, we sought to examine the relationship between level of income and specific drug use patterns and related health risks.

METHODS

This study involved IDU participating in a prospective cohort study in Vancouver, Canada. Monthly income was categorized based on non-fixed quartiles at each follow-up with the lowest level serving as the reference category in generalized linear mixed-effects regression.

RESULTS

Among our sample of 1032 IDU, the median average monthly income over the study follow-up was $1050 [interquartile range=785-2000]. In multivariate analysis, the highest income category was significantly associated with sex work (adjusted odds ratio [AOR]=7.65), drug dealing (AOR=5.06), daily heroin injection (AOR=2.97), daily cocaine injection (AOR=1.65), daily crack smoking (AOR=2.48), binge drug use (AOR=1.57) and unstable housing (AOR=1.67). The high income category was negatively associated with being female (AOR=0.61) and accessing addiction treatment (AOR=0.64), (all p<0.05). In addition, higher income was strongly associated with higher monthly expenditure on drugs (>$400) (OR=97.8).

CONCLUSION

Among IDU in Vancouver, average monthly income levels were low and higher total monthly income was linked to high-risk income generation strategies as well as a range of drug use patterns characteristic of higher intensity addiction and HIV risk. These findings underscore the need for interventions that provide economic empowerment and address high intensity addiction, especially for female IDU.

The relationship between self-reported substance use and psychiatric symptoms in low-threshold methadone maintenance treatment clients

Background

Ongoing psychiatric symptoms and substance use are common difficulties experienced by clients enrolled in methadone maintenance treatment (MMT). However, little research to date has evaluated if specific types of current substance use are related to specific types of current psychiatric symptoms. The present study investigated these relationships with a sample of clients enrolled in a low-threshold MMT program (i.e., clients are not expelled if they continue to use substances). Some clients enrolled in low-threshold programs may never achieve complete abstinence from all substances. Thus, understanding the possibly perpetuating relationships between concurrent substance use and psychiatric symptoms is important. Understanding such relationships may aid in developing possible target areas of treatment to reduce substance use and/or related harms in this population.

Methods

Seventy-seven individuals were interviewed regarding methadone usage and current and past substance use. Current psychiatric symptoms were assessed using a modified version of the Psychiatric Diagnostic Screening Questionnaire (PDSQ). Relationships between types of substances used in the past 30 days and the types and number of psychiatric symptoms experienced in the same timeframe were examined.

Results

The majority of participants (87.0%) reported using alcohol, illicit substances, non-prescribed prescription opioids, or non-prescribed benzodiazepines in the past 30 days and 77.9% of participants reported currently experiencing psychiatric symptoms at levels that would likely warrant diagnosis. Current non-prescribed benzodiazepine use was a predictor for increased severity (i.e., symptom count) of almost all anxiety and mood disorders assessed. Conversely, number and presence of generalized anxiety symptoms and presence of social phobia symptoms predicted current non-prescribed benzodiazepine and alcohol use, respectively.

Conclusions

Individuals enrolled in the present low-threshold MMT program experience a wide variety of psychiatric symptoms and continue to use a variety of substances, including opioids. There was a particularly consistent pattern of associations between non-prescribed benzodiazepine use and a variety of psychiatric symptoms (particularly anxiety) suggesting that addressing concurrent illicit benzodiazepine use and anxiety symptoms in MMT clients warrants further clinical attention and research.

Psychopharmacologic treatment of patients with HIV/AIDS

Psychiatric disorders are common among patients with HIV/AIDS, and psychopharmacologic treatment is a cornerstone of management. The efficacy of psychopharmacologic treatment for depression in HIV/AIDS is relatively well established. However, literature on the treatment of other disorders is limited, which means that we still must determine how standard treatment guidelines may need to be modified in consideration of several key aspects of HIV illness. These include the broad differential diagnosis for psychiatric symptoms and the potential for interactions between psychotropic medications and antiretroviral medications. This paper reviews the literature on psychopharmacologic treatments of key psychiatric disorders in HIV/AIDS as well as differential diagnosis and drug-drug interactions.

The prevalence of mental and physical health disorders among older methadone patients

OBJECTIVES

The aging opioid-addicted cohort from the 1970s has begun to alter the demographic characteristics of individuals in need of services for heroin addiction. Yet, despite clear trends that indicate the population of older methadone patients is increasing, little is known about their well-being and service needs. The goal of this study was to assess the physical and mental health status of older methadone patients.

DESIGN

Face-to-face interviews were conducted with study participants.

SETTING

This study was conducted at a free-standing methadone clinic in a Midwestern industrial city.

PARTICIPANTS

A clinic sample of 140 adult methadone patients over the age of 50 was recruited for face-to-face interviews.

MEASURES

Mental health status was assessed by the Composite International Diagnostic Interview. The SF-12v2 was administered to measure a range of physical health issues. Participants were also asked about a variety of chronic conditions. In addition, respondents provided access to their drug screen results from monthly urine tests for illegal drug use for 1 year before and 1 year after the interview.

RESULTS

Findings revealed that over half (57.1%) of respondents had at least one mental health disorder in the past year. In the year before the interview, the most prevalent mental health disorder experienced by older adult patients was major depressive episode (32.9%). The most prevalent anxiety disorders were posttraumatic stress disorder (27.8%) and generalized anxiety disorder (29.7%). Additionally, women experienced significantly higher levels of depression than males (43.8% versus 27.2%), and nearly twice the prevalence rate of agoraphobia and panic disorders. Regarding physical health, respondents reported high rates of health problems in the past year, including arthritis (54.3%) and hypertension (44.9%). The majority of respondents reported having fair to poor physical health (57.7%). When examining the entire 24-month period during which urine data were collected, three quarters (76.4%) of the respondents had at least 1 month where the urine screen detected illegal drug use.

CONCLUSIONS

In the next decade, the growing and aging substance abusing population will require clinicians trained in both geriatrics and substance abuse. Health and mental health professionals have the opportunity to address the specialized needs of this population and prepare for the shifting service needs these older patients will require.

A program evaluation study of a nursing home operated as a modified therapeutic community for chemically dependent persons with AIDS. Project Samaritan AIDS Services, Inc.'s Residential Health Care Facility, Highbridge Section, Bronx, NY

An interagency evaluation of the treatment effectiveness of a speciality nursing home (NH) run as a therapeutic community (TC) for residents diagnosed with acquired immunodeficiency syndrome (AIDS) and substance abuse/dependence (SA/D) was conducted. A total of 79 chemically dependent men and women with AIDS were: (a) administered the Tennessee Self-Concept Scale (TSCS; Roid & Fitts, 1991) at initial testing (T(1)) and 8 months after their initial testing (T(2)); and (b) assessed on specific physical health indicators (i.e. , weight, CD-4 count, and viral load) and other treatment outcomes (e.g., abstinence) over the same two time periods. The TSCS results identified a valid and invalid TSCS test group and further distinguished among three subgroups of invalid responders. Significant improvements were observed from T(1) testing to T(2) testing on the TSCS, on the physical health indicators, and on other treatment outcomes. The need for additional and continued mental health services for this population was noted.

Selective serotonin reuptake inhibitor treatment of depression in symptomatic HIV infection and AIDS. Improvements in affective and somatic symptoms

Somatic symptoms often complicate the diagnosis and psychopharmacological treatment of depression in HIV illness. We treated 33 depressed HIV-positive men and women with medically symptomatic HIV or AIDS (CDC stages 2B, 2C, 3B, or 3C) in a 6 week open-label trial with sertraline, paroxetine, or fluoxetine, to assess their effectiveness and tolerability. We further assessed whether treatment of depression resulted in a reduction in both affective and somatic symptoms in this medically ill population. Twenty-four subjects (73%) completed the trial (7 on sertraline, 7 on paroxetine, 10 on fluoxetine), 20 (83%) of whom were clinical responders. Nine dropped out within 1-3 weeks of treatment because of adverse effects, mostly agitation, anxiety, and insomnia. Subjects who completed 6 weeks of SSRI treatment experienced significant reductions in both affective and somatic symptoms, many of the latter having been attributed to HIV rather than depression. These results suggest that, even in later stages of HIV illness, the contribution of depression to perceived somatic symptoms may be significant, and that these symptoms may improve with antidepressant treatment.

Psychiatric morbidity, illicit drug use and adherence to zidovudine (AZT) among injection drug users with HIV disease

This study describes the relationship between the need for psychiatric consultation, illicit drug use, and zidovudine (AZT) adherence in HIV-infected injection drug users (IDUs) in methadone maintenance treatment (MMT). The treatment records of 57 IDUs in MMT who had been prescribed AZT between May and August of 1991 were reviewed. Those who required psychiatric consultation (P+, N = 46, 81%) were compared with those who did not require psychiatric consultation (P-, N = 11, 19%) on adherence to AZT treatment (using the mean corpuscular volume [MCV] as a biological marker), on recent illicit drug use, and on CD4 lymphocyte (T cell) count changes from the beginning to the end of AZT treatment. The P+ subjects were less likely than P- subjects to adhere to AZT treatment: fewer in the P+ group had an MCV outside of the normal range, and P+ subjects had a lower average monthly increase in MCV since the beginning of AZT treatment. Recent illicit drug use and CD4 lymphocyte count changes from the beginning to the end of AZT treatment did not show group differences. Psychiatric morbidity among HIV-infected IDUs in MMT is common, and may contribute to poor adherence to AZT treatment. Psychiatric screening and adherence-enhancing interventions should be targeted to IDUs entering drug treatment programs.