Primary Care Management for the HIV/AIDS Provider

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Primary Care Management for the HIV/AIDS Provider

Date: 08/18/2005
Source: AETC National Resource Center

Presenters: Jeffrey Beal, MD; Marshall Glesby, MD; Debra Trimble, MS, RN, FNP-C, AACRN; Ronald Wilcox, MD; Dianne Weyer, RN, MS, CFNP; John Blevins, ThD and Milton Wainberg, MD

Description: The AETC Primary Care Management for the HIV/AIDS Provider Workgroup, in collaboration with the AETC Mental Health and HIV/AIDS Workgroup, has developed a set of clinician support tools for the HIV/AIDS provider to address emerging concerns in the field of primary care management for patients with HIV infection. The two AETC workgroups presented five clinical management tools to support the assessment and management of the following topics in the context of HIV infection:

	Chronic pain

	Depression

	Dyslipidemia

	Hepatitis B & C coinfection

	Substance abuse

Download slides and tools

Linda Podhurst:

Hi, everyone. Welcome to the training exchange. This is Linda Podhurst. I'm happy to let you know that we have more than 80 participants registered for this training exchange, most of whom are front line providers. And I just want to acknowledge the work of the Primary Care Management for the HIV/AIDs Provider workgroup. They have accomplished an incredible amount of work which we're sharing with you today.

I would particularly like to acknowledge that Dr. Jeffrey Beal, Clinical Director of the Florida/Caribbean AIDS Education and Training Center, has been a phenomenal leader coordinating a tremendous amount of work.

And I also want to acknowledge the work of Rianna Stefanakis, the workgroup and training exchange coordinator, here at the AETC NRC.

And with that, I'd like to turn this program over to the chair of the workgroup, Dr. Jeffrey Beal.

Jeffrey Beal:

Thank you, Linda. It has really been a privilege to work with so many of our excellent AETC faculty. My job was certainly made easier by the level of commitment shown by each of the leaders of the subgroups and their group participants. The dialogue has really been great fun.

And each group has a desire to commend the assistance we received from the AETC National Resource Center, with a special thanks for all of the hard work of Rianna Stefanakis, who kept our fingers on the keyboards, kept us on an email trail of communication that was organized and really assisted us in maintaining our focus on a collective end product. We really couldn't have done it without her.

I welcome each of you today as well to this training exchange. I want to remind you to have the tools either printed or readily available for opening on your desktop. Each speaker will kind of prompt you when you need to look at the tool so that you can go from your handout with the speaker notes to the individual tools that we're asking you to review.

Slide 2 please.

Now we begin by just giving you a little background that this is a collaborative effort in this training exchange done by two groups. The one group was the Primary Care Management for the HIV/AIDS Provider and then the Mental Health and HIV/AIDS Workgroup assisted us in collaboration on our mental health substance abuse tools.

Slide 3 -- You'll see the array of AIDS Education and Training Centers across the United States that collectively worked together to bring a product to fruition.

Slide 4 -- You will see the individual leaders of the subgroups. Dr. Glesby led the group on dyslipidemia; Deborah Trimble the chronic pain group, Ronald Wilcox the Hepatitis A, B and C co-infection section group, Dianne Weyer the substance abuse and Milton Wainberg the depression group.

Slide 5 -- The purpose of our training today is to showcase the work of the AETC National Workgroups to the larger AETC network. This year's three workgroups were Primary Care Management for HIV/AIDS Provider, Mental Health and HIV/AIDS, which was in its second year, and the third group was Technology in Training.

During this training exchange we'll discuss how the primary care group and the mental health group worked together collaboratively on the development of five clinician support tools.

Slide 6 -- In about the next 90 minutes we hope to introduce you to the new tools that were designed to assist in the outpatient management of co-morbidities that emerge during the care of our HIV patients and most importantly, we hope to obtain your feedback prior to the finalization of each of these tools.

Slide 7 -- Each of the presenters is going to have about 5 to 10 minutes to present the tools that were made by the group and if time allows, at the end of each of their presentations we'll try to take one or two questions to respect those that may have to leave the call before completion of all the presentations. But there is a 20-minute question and answer session at the end of all five presentations as well as you can email at any time at info@aidsetc.org any questions or comments that you may have as we proceed.

Slide 8 -- The evaluation is available online. It's critically important. It was devised to be very short, taking less than a minute of your time to complete. As an incentive for all of you to complete it we hope that we get 100% response. There's also a nice comment section where you can make any notes that you have that you would like to bring to our attention.

Slide 9 -- As we stated earlier, the AETC National Resource Center coordinated three national workgroups this year. The workgroup topics are decided based upon results from AETC network-wide needs assessments. The purpose of the workgroups is to foster collaboration among the AETCs on a national level. Each workgroup is led by a content area expert and is composed of AETC-affiliated experts on the topic.

The workgroups are charged with the task of identifying, developing and disseminating materials. Now throughout the year the workgroups discuss how to meet gaps and existing resources.

Slide 10 -- The first task was to assess what materials were available to the workgroup members so that an inventory of educational materials already in existence could be made. Now from reviewing all of those collected works, the workgroups then assessed the needs that need to be met. These documents are all posted and available for download in the AETC-only area of the NRC Web site on each workgroup's individual page.

This year the primary care group also was introduced to the online collaboration tool called SharePoint. With the assistance of hosting from the Florida Caribbean AETC, the group was able to post working documents online and all provide input in one location. It really greatly helped with the efficiency of material development and workgroup coordination.

Slide 11 -- For the primary care HIV workgroup, the AETC nation-wide survey identified five priority topics which are displayed on this slide.

Slide 12 -- Our group then divided into five topic groups, each group again examining materials available, identifying what gaps existed and then trying to devise tools to help fill those resource gaps. The mental health workgroup, a separate workgroup, collaborated with us on the topics of depression and substance abuse.

Slide 13 -- All tools have been developed with the HIV/AIDS provider in mind who is working in a resource setting where sub-specialty consultation is not always available in order to provide the higher level of need of their patients.

Slide 14 -- We do want to stress that the materials that you're seeing today are in draft form. We are really hoping to receive additional feedback to close the gaps of any missing information that you see and we ask you to make notes of your comments so that you can add them in the evaluation section if you do not have an opportunity to verbally present them to us.

And if you or someone you know would like to review any of these tools and provide additional suggestions after the training exchange is over, please note that on your evaluation as well.

Slide 15 -- As the tools are presented keep in mind that they're meant to be a practical guide assisting the providers in the primary care of their HIV patients.

Slide 16 -- Our first speaker today is going to be Dr. Marshall Glesby. As an associate professor of medicine in public health and the co-director of the Cornell Clinical Trials Unit, Dr. Glesby has been investigating the metabolic complications in HIV-infected patients including lipid elevations that may lead to accelerated cardiovascular disease and disorders of glucose metabolism.

Dr. Glesby conducts epidemiologic studies and has been an active contributor to our AETC program. Marshall.

Marshall Glesby:

Thank you very much, Jeff. So we'll be starting with the slide set that says Dyslipidemia and HIV/AIDS and we'll start with slide number 24.

I just wanted to say a few brief points in the way of background about why we feel that dyslipidemia is an important clinical problem in HIV-infected patients and relate to recent epidemiological studies that I think fairly strongly suggests that HIV-infected patients are at increased long-term risk of coronary heart disease, probably because of a number of different risk factors, some of which are modifiable like smoking, blood pressure, lipid abnormalities, and some of which are not modifiable, like aging.

Lipid problems can be multi-factorial in origin in HIV-infected patients and may be partly related to the underlying HIV infection, the drugs used to treat HIV, other metabolic problems such as lipodystrophy, as well as other factors.

So in summary then, dyslipidemia we feel is an important modifiable risk factor for coronary heart disease.

Slide number 25 -- Some of the challenges I think clinicians are faced with in terms of managing lipid abnormalities in HIV-infected patients are listed on this slide and they include the fact that many patients will have mixed lipid disorders, that is, elevations in both LDL cholesterol -- the bad type of cholesterol -- as well as triglycerides. And frequently the HDL cholesterol -- the good type of cholesterol -- is also low.

There are well-known pharmacokinetic drug/drug interactions between some of the drugs used to treat lipid abnormalities, specifically the statin drugs, as well as some of the antiretrovirals. In some cases, the statin levels are increased; in others, they're actually decreased depending on the concurrent medications that are used.

And lastly I think many of us, many physicians in particular, I think are not well trained to get a dietary history and to counsel patients about dietary interventions.

Slide 26 -- We've attempted to try to address these challenges by first providing what we feel is a comprehensive management guideline for lipid abnormalities in the context of HIV infection and its therapy. And as Jeffrey mentioned, our focus is really on settings in which expert consultation may not be readily available, although the tool should also be valuable for people who do have access to consultation.

And with regard to the dietary interventions, since not all providers will have access to a dietician, we have included, as you'll see, a diet information sheet. This diet information sheet was produced by AIDS Project Los Angeles and they kindly allowed us to reproduce it in our tool.

Slide number 27 -- The overall objective of this tool is to provide a framework or algorithm for assessing and managing dyslipidemia in HIV-infected patients.

Next slide, slide number 28 -- if you could please turn your attention to the actual tool now, I will not be going through it in any detail but just giving you kind of an overview of the different components of it. And certainly during the question and answer period at the end I'd be happy to address any specific questions that people have.

Slide number 29 -- The major components to the lipid tool are a patient assessment algorithm; that is on the first page; a patient management algorithm on the second page, and we've also included two support tools.

One is a risk calculation worksheet from the Framingham Study as part of the National Cholesterol Education Program Adult Treatment Panel 3 Guidelines published in JAMA in 2001. And this is particularly for people who are going to have Web access where you can actually access an online calculator.

And the second is the patient education tool that I've already mentioned -- the diet information sheet.

I'd like to acknowledge the efforts of the collaborators that are listed on the bottom of slide 29 -- (Laura Armas), Jeffrey Beal for his incredible leadership, (Karl Finkenbaum) and Daniel Lee, as well as Rianna, for all of her help.

Slide 30 -- The tool, as are all the other tools that you'll see today, are currently in draft form and we certainly, as Jeffrey mentioned, welcome your input both at the end of the presentations or through follow up emails to info@aidsetc.org.

Slide 31 -- The tool is intended to be a practical guide and it is primarily based on the cardiovascular subcommittee of the AIDS Clinical Trials Group and HIV Medicine Association of the Infectious Disease Society of America joint guidelines for managing dyslipidemia in HIV-infected patients and its reference in the actual tool published in Clinical Infectious Diseases a couple of years ago now.

And the tool itself was developed through the contributions of the people I've already mentioned who are HIV specialists either with expertise in metabolic complications and/or extensive experience in HIV primary care and education and all of whom are AETC faculty.

Slide 32 -- So turning just to the first major part of the tool, as I mentioned, the risk assessment or patient assessment part where the focus is on determining a person's lipid profile and performing what's called a risk stratification to determine their level of risk of having a coronary heart disease event over a 10-year period, and that's based again on the Framingham Cohort Study data.

So there is a reference in the tool to the web site at the National Heart, Lung and Blood Institute where you can access a simple online calculator. Or for those who are not able to access the internet easily, there are also the tables provided at the end of the document.

Slide number 33 -- For the management section, the two major approaches are lifestyle changes and the option of changing antiretrovirals for those whose treatment histories permit. And the second is pharmacologic management of lipid abnormalities, which is divided into two big categories: whether LDL or non-HDL cholesterol elevation is the primary abnormality, or whether elevated triglycerides are the major problem.

Slide 34 -- The other components of the tool are a fact box on rhabdomyolysis which is an uncommon but very clinically important potential side effect of the statin drugs and the nutrition fact sheet that I've already mentioned a couple of times.

Slide number 35 -- We acknowledge that the tool is not, you know, entirely comprehensive. We made it as comprehensive as possible given the space constraints but there are certain situations; for example, patients who may experience (unintelligible) toxicities on certain medications where the algorithm may just sort of end and may not direct you to other option.

So you can keep that in mind as you're using the tool or looking at it and you can give us feedback on that if there are any major areas that you think we've overlooked.

So lastly on slide 36 -- Again we encourage your feedback and please consider pilot testing this tool in your clinical settings and letting us know how it works.

So at this time I think we have time to take one or two quick questions.

Operator:

At this time we would like to remind everyone in order to ask a question simply press star then the number 1 on your telephone keypad.

Your first question comes from the line of Jonathan Rodnick.

Jonathan Rodnick:

Hi, great algorithms. A couple of things I might mention. I end up using the same Framingham assessment and ATP things are on a palm, and I end up using it all the time. I think you might make a reference , or I can send you that if you don't have it -- where to download the palm things.

Another one is the use of high sensitivity CRP has become a very important guideline at least for me about whether treating people, most of the newer things, most of the things don't put that in. I don't know if you want to mention it but I know that recent review -- I think it was in JAMA or New England Journal -- it said that it's the same level factor as LDL or certainly probably the best measure of cholesterol risk is in the what's called non-HDL cholesterol and that with high sensitivity CRP is probably the key ones.

The last thing that I want to mention, I really like the handouts for lowering cholesterol and triglycerides, but one of things that's missing that you mentioned in your prologue is the patient with a low HDL and not necessarily triglycerides over 500. And probably this is the most common thing we all struggle with -- whether it's with the HIV patient or non-HIV patient. And there are some things that directly address what to do with a patient with a low HDL.

That's it. Those are my comments. But overall -- outside of that it looks great.

Marshall Glesby:

Thank you very much for your feedback and you make some excellent points. We can certainly add information about the risk calculator for palm devices, and I think we'll have to think a little bit about the low HDL issue. I think it's not, you know, even in the general population I think at least at this point, although there are some new drugs coming down the pipeline, it can often be a hard problem to address.

Regarding the C-reactive protein I think that's a very good point and one I think that our group can discuss further. I think it's a little complicated by the fact that there are at least some data suggesting that HIV infection or people with HIV infection tend to have relatively higher levels of C-reactive protein and whether it will pan out to be a similar predictor in this population I think is unclear in my mind at this point. But thank you for raising those points.

Operator:

At this time there are no further questions.

Jeffrey Beal:

ll right, thank you very much. Our next presentation is on the chronic pain tool and will be given by Deborah Trimble. Deborah is the nurse practitioner with the Texas/Oklahoma AETC. She provides primary care for patients with HIV and AIDS and has been involved in the establishment of a pain management center within the Thomas Street Clinic in Houston Texas. She is also an instructor on pain management and HIV/AIDS for the Texas/Oklahoma AETC. Thank you.

Deborah.

Deborah Trimble:

Thank you, Jeff.

Thank you all for joining us this afternoon. I will start with a brief introduction and say just briefly that it's very difficult to combine the amount of information into a tool on a few pages and that certainly was one of the challenges that we faced in addressing chronic pain.

Let's start with slide 38. The challenges in treating patients that are living with AIDS and HIV are many, as those of you who do provide primary realize. In some of the research, it says that up to 80% of our HIV/AIDS patients are living with chronic pain syndromes, especially those with late disease.

If you've done any research yourself, you've found that you have not been able to find any standardized, evidence-based guidelines for treating your patients with chronic pain. There has been limited research done in chronic pain for patients with HIV. There's been quite a bit on cancer and most of our treatment guidelines or treatment processes are based on patients with cancer. As we all know, our patients are not like cancer patients in that they are now living a very long time and we have to address this problem in a different way.

Treating chronic pain in our patients is a time-intensive thing and it limits a lot of providers from doing it. They just don't want to be involved in it because of the amount of time that's going to be involved as well as the liability of providing long-term narcotics should their patients require that.

Slide number 39 -- There are complications that are specific to HIV/AIDS that contribute to chronic pain. One, of course, is that many of our medications and early treatments led to and continue to lead to irreversible chronic pain. We found, as you probably have, that surgeons often are reluctant to intervene in our immuno-compromised patients when there might be a surgical intervention that would actually help alleviate their chronic pain.

And rehab or physical therapy can be quite helpful but there are some patients who are unable to participate in this type of activity due to their problems with incontinence, sedation from certain medications, their psychiatric disorders.

Slide number 40 -- You can turn to the chronic pain management tools that have been developed. They are a number of algorithms as well as guide boxes and information tools to help you and hopefully will address the challenges that you face when you're treating your patients with HIV and chronic pain.

The first page assumes that the diagnosis of chronic pain is already present; that acute pain has been treated adequately -- the symptom or the problem has gone but chronic pain continues. And the most important thing in evaluating how your management is going to be affecting a patient is that you need to establish a baseline chronic pain level for them using some type of a scale -- the Likert Scale is one of the easiest things to do.

And then if you go on to page 2, this is mostly based on the cancer steps which are based on the WHO pain ladder. We're not going to go through all of this page-by-page, but I do want to draw your attention to the second page. There is a list of education and counseling for patients who are going to be receiving chronic pain treatment. Of course these are not extensive or all-inclusive but they are guidelines and tips that might help you.

The third page is specifically for patients who have substance abuse issues. We have a copy of the pain ladder for your reference.

And let's go ahead and go on to slide 41. At the end there are some guidelines in the tool that will help you with opioid choices and non-opioid choices for medications, as well as a contract for long-term narcotic treatment which is something that is invaluable and helpful in your documentation.

Okay, slide 41. These three algorithms are meant to address this in a general manner. Of course, all instances of chronic pain in situations cannot be addressed specifically. The algorithm addresses ongoing long-term chronic pain management, and also as I said, in the case of substance abuse issues, as many patients who have either past or current substance abuse still may experience chronic pain and, of course, have the right to have that pain addressed and taken care of so that they have quality of life.

There are also supplementary support materials and references found in the tool.

Slide 42 -- Our objective was to provide a generalized framework for chronic pain management and hopefully to address some of the barriers to effective pain management for our patients and to increase your comfort level in providing chronic pain management for your patients who are experiencing it.

Slide 43 -- The algorithms are based on literature, as I said, general pain guidelines that have been developed mostly for cancer pain treatment. They are outlined in an outline structure approach for different management options and delineate the different levels of opioid and non-opioid treatment.

We recommend a treatment based on specific clinical situations, and as you can see from the algorithm, based on the amount of pain that you're able to decrease with a treatment. If it hasn't reached a certain level then you go ahead and you move on to the next step of the pain ladder and the type of medication that you're going to be using.

Slide 44 -- Hopefully these have been formatted for easy reference for you. We worked very hard at trying to do that with the busy primary care provider in mind. But hopefully they are comprehensive enough to help guide your general decision-making in treating your chronic pain patients.

We've also listed adjunct complementary and alternative therapies for you to investigate further as some of them are quite beneficial in aiding the non-opioid and opioid treatments.

Slide number 45 -- The challenges in developing a tool such as this of course are that there are lots of materials out there, but trying to translate them into a comprehensive guide that's easy to use was our biggest task.

There are limited expertise and resources, as I said earlier, on chronic pain management in patients with HIV. One other thing I wanted to point out is that the algorithm and guides do not include interventional therapies or parenteral therapies because we have assumed that you would agree the benefit for these patients would be to be referred to a specialist who does that type of therapy.

Slide number 46 -- Our next steps, of course, are to encourage you to utilize the tool, pilot it in your clinical setting and hopefully do some research on it, investigate components such as specific drug choices that might be optimum for HIV patients. And comprehensive literature review or med analysis of any of the information would be helpful as well.

At this time we can take a couple of questions and once those questions are answered you can email follow up questions to the NRC at aidsetc.org. Thank you for your attention.

Operator:

As a reminder, if you would like to ask a question simply press star then the number 1 on your telephone keypad.

At this time there are no questions.

Jeffrey Beal:

Deborah, thank you very much.

Deborah Trimble:

Thank you

Jeffrey Beal:

Our next presentation is on Hepatitis B and C co-infection and will be given by Dr. Ronald Wilcox of the Delta Regional AIDS Education and Training Center. Dr. Wilcox is the Medical Director of the Delta AETC and is an associate professor at the Louisiana State University School of Medicine. His infectious disease research focuses on Hepatitis and investigating therapeutic approaches to HIV and AIDS.

Ron?

Ronald Wilcox:

Good afternoon, everyone. I'm on my cell phone so if there's some static or anything let me know, okay?

We're going to start off on slide 48 and I just want to acknowledge first the people who worked with me on this project. It was Susanne Jed from the Mountain Plains AETC, Rianna Stefanakis from the AETC NRC, and myself, and we developed three different tools as part of this workgroup. And we'll be covering each other's tool.

On slide 49 there are five different things that we as a group decided were some of the challenges in managing mainly Hepatitis B and C co-infection but also touching on Hepatitis A.

One of the things that can be confusing, especially with Hepatitis B, is what kind of screening test you should do and what the meaning of the screening tests are. So we tried to develop a tool so that addressed appropriate screening; we'll go over that more.

Also patient education regarding disease -- what are some of the things that it's important to teach the patient about side effect management for patients who are on therapy for Hepatitis B; and then the other two, determining appropriateness or need for HCV therapy and appropriate workup in preparation for treatment are things that we plan on working on in the future. So we have not had time just yet to develop those tools.

On slide 50 -- So our main thing was a tool for the provider and it's to cover the different screens that you would use for Hepatitis A, B and C and then need for immunization looking at the results for those screenings.

In terms of helping clinicians care for the patients, we developed two patient information tools; one on living with chronic Hepatitis C or B and the other on how to deal with the treatment side effects.

So, on slide 51 is a picture of the first tool and this is the Hepatitis A, B and C screening and it goes over things like with the Hepatitis A, how to screen for Hepatitis A and what it means with the positive test. Hepatitis B -- there's the chart showing you the results -- if you have these results with the basic screening lab, what further screening labs you would need to get as well as the way to interpret the results of the screening lab. And then at the bottom it's Hepatitis C, what kind of basic screening lab you do and then if that's positive, what further studies you may want to do.

On slide 52, this acknowledges that some of the information that was taken or that was used in the development of this tool was from different algorithms that were developed by the Hepatitis Resource Network. There were multiple pages for those algorithms and we tried to condense it into a single page. Ideally, we see this to be either shrunk into a pocket-sized card that could be laminated and kept in your lab coat or as a single page that could be laminated as an easy reference.

Okay, on slide 53 is the chronic Hepatitis C and B tool. As you can see, it was designed as two-sided tool. It goes over first, you can tell the patient whether they have B, C or both. You can write down what their (unintelligible) are and if they have Hepatitis B you can put down what the genotype is.

But then in the boxed section, it talks about what chronic Hepatitis does to your body. It also talks about transmission and the basic workup of what we do for someone with chronic Hepatitis.

On the back of the sheet then would be to emphasize ways that the patient could protect themselves if they have chronic Hepatitis, emphasizing the fact that they should not drink alcohol as well as touching on other things.

On slide 54 it kind of explains the tool. So in terms of the chronic Hepatitis tool, we kind of perceive that as a front/back page thing that may be put on a pad of paper that you can rip off and give to the patient each time you see the patient for the initial work up for the Hepatitis B or C.

And the third tool, on slide 55, is the managing side effects of Hepatitis B therapy and with this, we really tried to emphasize first, what is Hepatitis B therapy and ways that the patient can really address a lot of side effects. We also tried to emphasize on there some of the more important side effects that the patient needs to be aware of to alert their provider that they're having those kinds of problems.

On slide 56, it's more information about exactly what we were trying to develop with that tool and once again, like that previous tool, they kind of foresee this as a two-sided tear-away sheet. And that could be used in your office (unintelligible).

On slide 57, some of the challenges that we faced in development was with our patients, especially if you work in the public hospital system, you always want to try developing your tool about something on the level of a sixth grade reading level and that can be understood by patients. And it's kind of difficult to write about Hepatitis on that level, but we tried to. And we really tried to create user-friendly materials that were basic enough but helpful.

Slide 58: we would really like any kind of feedback on these tools as to ways we could improve them. Consider pilot testing them in your setting and let us know through the NRC web site about your experiences using the tool and whether you felt they were helpful.

So that's the end of my presentation. We have time for one or two questions if there's any questions at this time.

Operator:

Once again we would like to remind everyone if you would like to ask a question simply press star and the number 1 on your telephone keypad.

And at this time there are no questions.

Ronald Wilcox:

Thank you very much.

Jeffrey Beal:

Ron, thank you.

All right, we're doing very well time-wise. Our next presentation will be on substance abuse and this will be a shared presentation with John Blevins and Dianne Weyer of the Southeast AIDS Education and Training Center. Dianne is a family nurse practitioner who works in a rural area of Georgia providing care for patients. She's a clinical instructor at the Southeast AIDS Education and Training Center and has had many years of experience with our AETCs.

John Blevins is has been greatly involved with the Minority AIDS Initiative (MAI) project at SEATEC and has a strong background as a mental health and HIV specialist. Dianne and John?

Dianne Weyer:

Hello, this is Dianne and I want to welcome everyone for joining us. John and I had the wonderful task of trying to design a substance abuse assessment tool addressing those tough issues of substance abuse in HIV care in a primary care setting. We did have the opportunity for our draft tool to be reviewed by members of the AETC Mental Health Group as well as members of our sister AETCs.

Slide 61 -- The tool was designed with the primary care clinician in mind versus the mental health or substance abuse clinician practicing in a specialty or referral setting.

John provided the mental health/substance abuse expertise and I offered the perspective of an HIV primary care clinician. Our intent was to provide a user-friendly algorithm appropriate for all levels of mental health and substance abuse level of knowledge.

We have provided a number of supplementary tools that can be utilized to enhance the primary care clinician's familiarity with substance abuse as well as the complex issue of behavior change which hopefully will result when we're working with our patients with this problem.

Slide 62 -- Aspects of this tool have been used primarily in the addiction treatment world to the best of our knowledge but less if any in the HIV care setting world. And we're excited to be able to provide some sort of tool for the primary care clinician, given the limited resources that so many of us struggle with.

Slide 63 -- The tool will support the HIV clinician by offering, hopefully, a simple screening or assessment process to identify those HIV patients who have a substance abuse diagnosis in addition to their chronic immune compromised condition. Hopefully, the tool will provide a process that is general and broad enough to be used in a time-limited environment and also transferable to other specialty settings such as family practice, infectious disease, ob/gyn.

Tools and resources that will assist the clinician in managing those individuals who are dually or triply diagnosed are very important as we see more and more of our primary care clinicians with less educational preparation in the field of substance abuse and mental health.

Slide 64 -- Objectives are to help those providers identify HIV-infected individuals whose substance abuse may compromise an already struggling immune system by interfering in their overall health as well as impacting their ability to adhere to their HAART regimen.

Another objective of the tool is to guide the HIV primary care clinician to manage substance abuse, including behavior change, using the behavior change model. And as you will see in our supplemental information, we have provided some additional tools and resources for the clinician.

Slide 65 -- I hope you were able to download the tool that is on this slide. I'd like to point out a few specifics on the next couple of slides so if we could go on to slide 66.

We recognize the challenge of identifying those individuals who are dually and sometimes even triply diagnosed in the primary HIV care setting. For many of us this is a new territory and for some of us we have the opportunity to get specialized care by our mental health substance abuse colleagues. Unfortunately, for the rest of us that's not an option so the assessment and management falls on the shoulders of the primary care professional in their setting.

The tool begins with a needs assessment or evaluation if you will be asking the patient a few important questions that many of us are familiar with by using a similar tool to determine alcohol use.

The CAGE screening tool is simple to use, and provides an opportunity for the patient as well as the clinician to recognize his or her substance abuse use.

The frames that are the second part of the tool are additional resources that allow the clinician to consider some different interventions based on their setting, based on where the patient is at. There are rating scales the clinician can access quite easily while using the tool to add to the assessment process and possible intervention.

Slide 67 -- We have provided a number of supplemental materials for the primary care clinician as we have them listed here -- the DAST and the AUDIT and SOCRATES and certainly stages of change with a little bit more information and some other materials that perhaps some of you may be able to utilize and may not be appropriate for others. We're trying to give a clinician who may not be trained in substance abuse or mental health as much information as possible or at least have access to it.

Slide 68 -- Our challenge was to develop a tool that was broad enough to encompass all settings with a variety of available resources and at the same time creating a tool specific enough to help the individual clinician. Similar to the other presenters today, the challenge is very, very much out there.

Another important challenge was to develop a short tool, knowing that all of us have way too much paper stuff in our office and exam room. So we tried to keep that in mind as well.

You're welcome.

Any other questions from the general audience? You would be welcome to ask while we're waiting just a minute for Dr. Wainberg to join us.

Operator:

Your next question comes from the line of Tonia Poteat.

Tonia Poteat:

Jonathan Rodnick:

Hi. I have been struggling a little bit with the issues of methamphetamine obviously and it's effect on patients and it seems to be obviously the drug of choice, the substance abuse of choice. And I wondered about both urine screening for it. I was wondering and it's kind of a dual question is one, should we ever mention the role of urine screening and is there anything specific for some of the other substance abuses?

Obviously I think it's important to focus on alcohol but like meth and cocaine, other ones that are kind of street drugs? I know you have that one questionnaire in there but it doesn't seem specific to those kinds of things.

Dianne Weyer:

This is Dianne. Actually we agree and we were trying to keep the algorithm to one page as I'm sure you could appreciate. But we do have at the very top where it says occurrence of alcohol or drug use, some markers -- either the family reporting a change or the clinician noticing some change as well as some positive toxicology screens. So we could certainly maybe enhance that to include what you're talking about.

I'm actually sitting in Salt Lake City getting ready to attend a crystal meth and HIV conference so I'm hopeful that perhaps I'll pick something up here that maybe we'd be able to incorporate in the tool as well.

John Blevins:

I would also point you towards -- I'm going to need help from folks on the mental health working group -- but it's the methamphetamine intervention developed at UCLA day treatment program. Is this ringing a bell with anybody?

I will work to get information on that protocol which showed some encouraging results about day treatment for crystal methamphetamine and that treatment as usual can be helpful for methamphetamine addiction and for treatment for it.

But I'm not at a place where I can access the name of the protocol or the intervention itself but I can certainly get that for you if you could also remember to write on your evaluation and request about that a little bit more information on methamphetamine.

Operator:

Your next question comes from the line of Thomas Donohoe.

Thomas Donohoe:

I actually wanted to follow up with Jack Rodnick's comment about methamphetamine. There's an addition to the New York/New Jersey pocket guide which does include stimulants. I believe just today the Midwest AETC put out a fact sheet for HIV providers on stimulants. They included crack and crystal meth. That went out through the HAB email today.

And we're going to have -- actually Rianna has the draft of it -- and I apologize to Rianna. I didn't finish it by this call but we have a tips sheet for HIV clinicians working with meth users and (unintelligible) shops. I was going to review that, to the person that someone just made reference to in LA with the day programs.

And Neal Flynn who's going to give the medical update at the meth conference is reviewing that as well and we're going to pilot it at our Asilomar Faculty Development Retreat. So we'll have that by the end of September.

Operator:

Your next question comes from the line of Keith Crawford.

Keith Crawford:

Yes. I just wanted to make a comment. The National Clinician's Consultation Center actually did an outstanding training last week on crystal meth and they have a team of experts and a number of resources as well that some of you may want to tap into, some of their tools and also some very good data on treatment outcomes -- so that's a possible source of additional information.

Operator:

At this time there are no further questions.

Jeffrey Beal:

Jack, I'm going to ask you to go ahead and introduce yourself for me to the group and this is the presentation then. We will interrupt if and when Milton Wainberg joins the call. It's on the last of our topics before our formal Q&A session. It's on depression.

Jack Rodnick:

Okay. Well, I'm Jack Rodnick. I'm a family physician in San Francisco and I have really not much specific expertise but about a year ago we in our practice introduced using a depression screen which is part of the algorithm and it's certainly opened up a lot of issues that I find discussing with patients.

So let's see, let me go through whatever the slides are and see if there's anything other in the background that we should mention.

The algorithm and the materials had primarily to do specifically with depression -- both major depression and more situational depression. It does not specifically address manic depression. One of the things I've been struggling with as we all think about these things is whether to put in perhaps at least a reference to a questionnaire on manic depression which is obviously common but not specifically addressed here.

If you want to turn to the depression diagnostic algorithm which is divided -- at this point there are three pages of it.

The diagnostic one uses the PHQ9 form after an initial two-question screen and I think this has been evidence-based medicine kind of tested fairly well, this two-question screen. And at least it works in adults. It's not quite clear in adolescents and children what this screen should be but being adults, this gives you a way of a bit like using the CAGE for alcohol. And if you get two or more responses then use the full nine-question questionnaire which is downloadable and also available. I have it on the palm.

And then the decision-making is based on using the score off of this PHQ9 which is basically nine questions that ask the common things that happen with depression with trouble with sleeping to lack of energy, obviously sadness, hopelessness and suicide things. One of the things we did want to mention is that people would ask for about suicide risk would be referred directly on the algorithm.

The next page goes on to the treatment algorithm and although it doesn't give specific medications on this, on the last page we have references to these medications. One of the things I've been scratching my beard about is whether to mention specific medications on this algorithm because it assumes pretty much people are going to be using SSRIs in primary care and then how to monitor this.

And then the last page of the tools for providers are hyperlinks to many other resources -- primarily chapters or articles as well as the drug interaction resource from the New York AIDS Institute. There's also obviously the drug interactions from the New Jersey/New York AETC, another monograph on managing SSRI side effects.

So basically the tool was designed so that people could use that and hyperlink to the source if they wanted additional documentation about where to go. And that's I think a quick introduction.

Jeffrey Beal:

Okay. Thank you for pinch-hitting and joining in. Let me make a few other comments. We think the depression -- this is Dr. Beal again -- has Milton joined us? If he does, interrupt me.

We think that depression came up on the list, of course, because of the fact that we are linking in HIV care (unintelligible) the fact that depressed patients also are patients who have the most trouble with medication and medication adherence along with the effect on their quality of life.

And basically this tool was put together by the group to try to be a venue for the primary care physicians, all of us doing HIV primary care, to work on the education, counseling and more importantly, the proper screening of depression and trying to encourage us in conjunction with the mental health group, trying to find what are the short questions that can be answered, knowing that none of us have time to do lengthy, long discussion, but trying to find two key questions.

And that was probably one of the most interesting things that this group did in conjunction with our co-group in mental health, trying to identify simply two questions to start with that could lead you on the track as to whether or not you need to go further down the road in evaluating depression.

So it's a concise tool; it's a brief tool. There are references there for you on drug/drug interaction, as Jack mentioned. There's support information for dialoguing with the patient. They've tried to highlight the importance of the providers and doing screens on a regular basis.

The next step for this tool is going to be in getting feedback and I have to say as the chair of this entire group, I do have an interest in seeing this tool be developed further because I think we get in a rut in sometimes the drugs that we prescribe for primary care and I'll certainly speak for myself. I will get in a rut of prescribing the same drug for the same patient every time and I don't think I understand the nuances of the experts in mental health as to why they may choose one over the other.

So we really looking for some consultants to assist in furthering this tool down around maybe giving us some guidance on what drugs to start with what patients and why based upon the evaluation of the tool.

Operator:

Once again as a reminder if you would like to ask a question or make a comment simply press star 1 on your telephone keypad.

Your first question or comment comes from the line of Keith Crawford.

Keith Crawford:

Yes, hi. I'm looking at this patient health questionnaire. I'm wondering how closely this compares with other tools like the Hamilton Depression System. Has this been validated and are you primarily using this because it's obviously a shorter survey and probably easier for the clinician to use?

Jack Rodnick:

Yeah, this is Jack Rodnick. Can you hear me?

Keith Crawford:

Yes, I can.

Jack Rodnick:

Okay, good. I believe this has been validated, this short questionnaire and as a good screen and I've tried to find some references to that. Most of these things, some of the ideas that came out of this for me were put together -- there was a big depression project in primary care that didn't specifically mention HIV, funded by the MacArthur Foundation and I hopefully, I can't see where I put my references at this point but most of the things, this was a large, large project.

All their lines are muted. You'll start on slide 70 for anyone who's looking for a page.

Milton Wainberg

Correct. Thank you so much.

So going to slide 71, I'm going to talk a little bit about the depression diagnostic algorithm, the depression treatment algorithm. There's a reference page and the PHQ questionnaire that we've been talking so much about.

I need to report that this work has been put first by Jonathan Rodnick from the Pacific AETC and then reviewed by some of us at the mental health and HIV/AIDS workgroup including people from all parts of the country.

Slide 72 -- It is in draft so we absolutely welcome input from others. It has been reviewed by several mental health care providers and HIV experts but please do not hesitate to help us more with this.

Slide 73 -- So what are the challenges in managing depression and HIV and AIDS? Number one, we know that depression is very common in people living with HIV and AIDS. In clinics you can have anywhere from 40% to 60% of patients reporting or having depression. (Unintelligible) because by medications, complications of HIV or psychiatric as disorders. What we do know is that depression increases morbidity and mortality in HIV-infected patients.

It impacts on adherence in a dramatic way and it's important to pay attention to drug interactions and side effects once we're working with people who have depression and taking medications and if we're going to add a psychiatric medication to that.

In slide 74 -- addressing the challenges for providers and their patients is of course a very important issue to take care of. We need to facilitate a routine screening and treatment which can improve their overall quality of life. If we improve depression then we can improve the quality of life.

It's important to delineate drug-to-drug interactions and overlapping toxicities. Whenever we add a new medication we need to find out not only how it interacts with others but what side effects we add for the quality of life of the person and provide additional resources. We wanted to provide additional resources to support HIV and AIDS providers.

Slide 75 -- So what are the objectives of the tools that we are trying to present to you today? We want to emphasize a critical nature of diagnosing and treating depression in people living with HIV and AIDS. Why do we say that? It's because (unintelligible) shown that even though about 60% of people in clinics may have depression, half of them get their diagnosis and half of them get treated so it is a problem.

And as I said in previous slides, it impacts on quality of life, adherence, morbidity and morality.

We want to provide a framework for assessment and treatment and we want to (unintelligible) recognize in patients I have at risk for suicide. So let me take you to slide 76 which is basically the tool of the depression diagnostic algorithm.

We know that it impacts adherence, risk reduction, morbidity and mortality. We have a definition of depression, some of the symptoms reported by family members of the patient; some of the key questions to ask which is for depression there always has to be sadness, depression or hopelessness and/or loss of interest in things that you usually enjoy.

And according to those responses you can use the PHQ9 that we have attached for you to review later and according to the PHQ9, according to the scores, there are different severities and we give (unintelligible) in how to progress with regards to referral, with regards to what to discuss with the patient and what things to watch for and what to educate.

We in the bottom have a little bit of suicidal screen because we want to make sure that we address suicidal thoughts prior to becoming actions. And some things to consider on the right side before initiating treatment, that what looks like depression not necessarily is always depression and it's important to assess other possibilities before deciding that somebody had depression.

Going to slide 77, this diagnostic algorithm is a one-page training in the context of HIV and AIDS complications including suicidality. The emphasis is education, counseling and proper screening to insure comprehensive assessment and he demonstrates that HIV/AIDS providers cannot (unintelligible) depression with proper support materials.

Going to the next slide, 78, this is a treatment algorithm. It offers concise instructions for monitoring and management, makes special emphasis on drug to drug interactions, and we have support materials to provide existing information on depression in the context of HIV and AIDS.

And in this algorithm the idea is to offer providers with a single way of determining monitoring elements of medication and what education needs to be done before prescribing these medications. And also in the same algorithm we provide some drug-to-drug interactions of antidepressants with HIV antiretroviral medication.

Slide 79 -- So how will this support HIV and AIDS providers? The idea is to provide a framework for accurately assessing or screening patients, encourage providers to initiate treatment when depression has been diagnosed or refer to additional interventions if the patient is at high risk for suicide, highlight side effects and toxicities that are especially relevant for people living with AIDS and HIV.

Of course some people have access mental health providers very close to them; some people do not. According to your capacities surrounding you, if there's somebody that you can refer to, we don't need to wait just for suicide; we can wait for moderate to severe depressions to happen and maybe mild depressions can be treated by family providers.

Slide 80 -- Challenges faced in the development process. Adapting existing resources to support the need of HIV providers is important, provide clear assessment and treatment plan for depression in the context of HIV and AIDS including appropriate support materials to support providers understand and initiate an initiative to diagnose and treat depression.

Slide 81 -- So what are the next steps? We encourage your feedback to support modifications of the tools and please pilot test in your clinical settings and share your experiences with us. And you can address the questions at the email that is presented there.

If people have one or two questions I'll be happy to answer them.

Jeffrey Beal:

Dr. Wainberg, thank you very much. I didn't get to introduce and I want to let the audience know that you are a psychiatrist based at Columbia University's College of Physicians and Surgeons. Dr. Wainberg works with us in the New York/New Jersey AIDS Education and Training Center. He's also the director of the HIV Mental Health Training project which is a New York/ New Jersey AETC partner since 2001.

Thank you very much.

We have time now for questions of the general audience again.

Operator:

Thank you. Once again we would like to remind everyone, in order to ask a question simply press star then the number 1 on your telephone keypad.

Your next question comes from the line of Mona Bernstein.

Mona Bernstein:

This is Mona Bernstein. I'm with the Pacific AETC and actually this is a general question that I was going to ask before this presentation which is, do you have a timeframe for when you would like to confirm these assessments tools and finalize them? I was thinking to give them out at our Asilomar Faculty Development Conference to everybody and giving them an opportunity to provide feedback. And that conference is in the middle of September. So I was wondering about the timeline.

Jeffrey Beal:

I certainly would love to meet that timeline. This is Dr. Beal and I think that if they are not all ready, certainly what is ready -- I can't speak for Linda but I think that's a great opportunity for a review.

Is Linda still there?

Linda Podhurst:

Yes, I'm still on the line and that's fine. We anticipated that it would a month or two months while we were receiving feedback from people. We'll take feedback indefinitely so that we can continually modify them.

Mona Bernstein:

Okay, great. Thank you.

Linda Podhurst:

Thank you, Mona.

Operator:

At this time there are no further questions.

Jeffrey Beal:

I'd like to ask just one question if I may as the chair which is to Dr. Rodnick. When you look at the mental health PHQ-9, at the questionnaire and the two questions on the questionnaire, how frequently would you recommend in primary care practice that those be asked; every visit, once a quarter? What's your expectation?

Jack Rodnick:

That's an excellent question. We recommend that they ask it every visit at this point because I don't think the data is out there. Obviously most people don't. I think most people are going to ask it at an initial visit and then probably periodically thereafter particularly if usually done on kind of diagnosis of 20 feet of how sad the patient looks I think it'll be triggered.

But the answer is it's not known how often this should be done, which is true of so many of the screening things we do. But I think particularly when dealing with issues of HIV towards either early on or when starting medicines, I think it would be important to ask it every visit.

Jeffrey Beal:

Dr. Wainberg, would you like to comment?

Milton Wainberg:

I certainly agree. I think that definitely the first assessment one has to assess both things including depression and other psychiatric symptoms and, you know, they're people that you see once a month or once every two months or once every three months according to how stable they are and sometimes weekly according to other issues. I would screen any time that I can and if possible, every time. So I'm in agreement with him. It doesn't take that long because you need to have only two questions to start if you think about it. And if one of those two are positive that means that you need to address it.

Jeffrey Beal:

Any other general questions?

Sarah Dolgonos:

Hi, this is Sarah Dolgonos from the AETC National Resource Center and I'm a research associate and I have a question directed towards the Substance Abuse team.

A question about part of the approach is (unintelligible) is to talk about helping the primary care clinician address behavior change methods and modifications for helping the patient improve on that level and I wanted to hear you talk about how that works and whether the tools you're supplying, if you've seen that to be effective and whether it's straightforward in that it works well with substance abuse and whether there are other approaches and what other methods substance specialists might use if behavior change methods do not prove successful in the initial (unintelligible)?

John Blevins:

Okay. Dianne is a primary care clinician, I'm a mental health clinician and faculty at SEATEC.. Neither of us has used in our own clinical practices with any regularity the assessment tools that we have chosen for the algorithm. We chose them because we had information that they were effective and reliable and they come from a motivational interviewing, stages of change kind of perspective, that guiding philosophy that underwrote what we presented.

We had initially come up with a different kind of tool which focused much more on assessing behavior change and readiness for change and realized we had fallen back a bit in terms of what would be helpful for primary care providers. What we tried to provide in the assessment tool is something very short for primary care providers to begin a very time-limited conversation with patients about their drug and alcohol use knowing that if drug and alcohol use is problematic, ideally if resources are available in their community, they'll be able to refer to a clinician.

In terms of other kind of interventions that I think work, my own thought is, is that in an ideal world communities would have access to a wide variety of treatment approaches. We know that's not the case but ideally I would hope that clinicians could tailor an intervention or a referral for more intensive treatment to the particular needs and circumstances in context of their patient as much as that's possible. When it's not possible they have to utilize their resources in their own community.

But if we could provide a spectrum of intervention not necessarily the primary care provider doing that but mental health and substance abuse treatment providers being able to provide a number of programs from residential to day treatment to abstinence only to risk reduction, I think we'd be in much better shape.

Milton Wainberg:

Can I make a comment? This is Milton Wainberg. I think that one of the wonderful things about what we're trying to do today is try to cover some bases that have not been covered through research. And part of the problem is that let's think for a second in mental health, in how many researchers of mental health and HIV are there trying to do work in this area.

The answer is that there are not too many and therefore for us, you know, when the questions are asked which I think are perfectly valid questions and I'm one of the persons who ask these questions all the time, you know, have these tools been validated research-wise. And having the answer, not yet, is a very good one for the time being. And part of what I think we're trying to do here is to try to put in practice things that have been used in other settings and get feedback and perhaps then try to figure out how to do a validation of some of these screening tools.

The reality is that many of us are working out there and are looking for these tools and are never finding them because there has never been the proper exactly well done research to validate some of these tools for HIV affected or infected populations.

And this is a wonderful opportunity to start doing something, get some feedback and maybe stimulate that somebody will do a validation of one of these tools. That's what I wanted to offer.

Dianne Weyer:

This is Dianne. I have a couple of comments. Thank you, Milton, I agree wholeheartedly. We have to start somewhere. And I think as an HIV clinician, one of my agendas is just for primary care clinicians to start thinking about the patients in a way that they haven't been thinking about them previously sometimes which is many, many of our patients are substance users. And I think that we get so wrapped up in the HIV clinical part of it that we sometimes forget, at least I do because it's a busy, busy world we practice in, to ask these very, very simple questions to even identify those individuals who might benefit from some intervention.

I think that, as John mentioned, resources vary from site to site and that we can't and by no means do we want to suggest that our patients who are being seen by primary care should not access specialty addiction centers or personnel if those are available. Many of us practice in very rural settings where we have very limited resources and so it falls back on the primary care clinician to do the best they can first to see if there is a problem, help the patient identify that there's a problem and then try to go from there.

In terms of the stages of change I think this is, as John mentioned, something that's relatively new in primary care and probably has not been utilized to the extent that it could.

Jeffrey Beal:

Thank you. Are there other questions, comments?

Deborah Trimble:

Hi, this is Deb Trimble. I have a question for the substance abuse group and perhaps mental health experts that are in the audience. One of the questions that I have asked to me often by other providers who don't want to get involved in chronic pain management is, you know, how do you tell the difference between somebody who truly has pain and somebody who is drug seeking?

And in my research I was not able to find any sort of tools that could really tell a provider, a clinician that. Has anyone come across anything that might be able to be used?

John Blevins:

This is John Blevins. I don't know of anything. It's a very good question. I don't know -- I'm not aware of any tools

Milton Wainberg:

This is Milton Wainberg. I'm not aware of any tool and I don't think that we will ever find one.

Deborah Trimble:

Probably not.

Milton Wainberg:

I'm sorry to say that. I actually -- the way that I think, you know, for all of our clinicians out there is that it's okay to make mistakes. In other words I think that the best way to handle it is if I'm always going to be worried that whoever is coming to you is just coming to get prescriptions out of me, then I'm never going to treat the ones that are having the problem or the pain that I need to treat. And there are some clinical simple techniques in working with somebody to address how to prescribe pain medications without having to be the perfect judge if they're having pain and/or substance abuse because by the way, both of them can be present.

And basically assess as time passes how to do it, maybe initially seeing the person a little bit more regularly, talking openly about how many prescriptions -- how many tablets you're giving and having some control over that and determining the needs and how many times you will replace medications that get lost and establishing a relationship and determine what's happening. And sometimes we, you know, our legs get pulled 20 times and sometimes they don't but hopefully we will be treating also those that are having a lot of pain.

Deborah Trimble:

Thanks. That's helpful.

Jeffrey Beal:

Operator:

You have a question from the line of Andrea Garwood.

Andrea Garwood:

Hi, I'm with the Hug Me Program in Orlando, Florida. I'm a licensed mental health service. I think something that we're fortunate here to have RNPs and other clinicians who work hand in hand with us and something that we've had to use many times when we believe that someone is drug seeking is pretty much both of us confronting the client.

We're not sure if this is what's happening but we're concerned this is the pattern that we will take and sort of what the doctor was just saying is, you know, letting them know how many pills we're willing to give at this time and it should last you until this time. And this is our way of in good conscience treating you for what we believe is pain but also not abusing it.

So I don't know if that helps anyone. That's something that we generally do here as a team.

Milton Wainberg:

And how do you find it when you use it?

Andrea Garwood:

Usually very effective but it also weeds out the ones that are drug-seekers because almost always we have them come back prior to the time it should last, saying something has happened, you know, lost, stolen purse, any of those kinds of things. And in those cases we then said, you know, as we explained to you, we are compassionate but we are unable to do that at this time. In a week or in two weeks when, you know, our next turn to really give you another prescription we'll be glad to give it to you at that time but until then.

So we usually stick to that pretty well.

Milton Wainberg:

Any time that you find that you are able (sic) to treat the people who have pain?

Andrea Garwood:

Difficult. We do work with pain management centers as well but I have one woman in particular now that she continues to be in pain no matter what we have tried to do to help here and she appears to be drug seeking all the time. And obviously I don't know if she really is just drug seeking or is she really in pain and those are the ones that we don't know.

Milton Wainberg:

You know what's wonderful about our communication right now? I'm just so happy that you remembered only the bad one patient that you're having difficulty with. And what I'm exercising with that is the reality is that there probably other 25 or 40 or 50 that you've been able to manage and you're working well. You know, we always have this tendency to remember the one that we're having a hard time and that we're still not sure that, you know, is it drug seeking or is it pain? Let it be one and the 400 others get what they need to get (unintelligible). A good yield. It's actually a better yield than many of the screening tools that have been validated in the world.

Deborah Trimble:

This is Deborah and I want to thank Dr. Wainberg for his comments because that was what I was trying to draw out is that of course in our setting we're lucky to have a multi-disciplinary pain team and one of the things that we do is that if I'm the primary care provider for a patient for example, I transfer them to somebody else if they're going to become part of our pain program because it is easier if you're not the primary care provider when you are treating your chronic pain.

And we do find that confronting patients together as a team is certainly beneficial but in rural areas like Dianne was talking about, there's not that luxury and oftentimes the primary care provider is going to be the one that has to treat the chronic pain as well as their HIV as well as everything else and it does become a difficult position for them.

But I really appreciate Dr. Wainberg's comments that you do have to just accept it and say, just like we're taught, that you believe what the patient says pain is and yeah, you're probably going to get the wool pulled over your eyes sometimes but hopefully, you know, we're improving the quality of life for a lot of patients who aren't doing that.

That's all I have to say.

Milton Wainberg:

That's great

Operator:

Your next question comes from the line of Mary Baskerville.

Mary Baskerville:

I just have a comment that I want to just point out that I have many, many drug addicts who also have pain and that are not in recovery. And I just want to point out that drug addicts do have pain.

Milton Wainberg:

Absolutely.

Mary Baskerville:

So there are those who are incapable of not seeking drugs that do seek drugs but they are also in pain. So I'd just like to point out that there are ways that we need to point out that we're aware of their addiction but we need to point out to them that we need to make sure that we have boundaries in place so that they don't titrate their drugs to the point that they lethally overdose. And in that sense we have someone onboard, someone on the team like a family member, who is administering their drug, otherwise they're going to administer lethal overdoses.

And I'll get very technical with them and tell them, you know, this drug will suppress your respiration if you take too much of it. But I will also talk about their addiction in the same sense that I will talk about their pain and make them equal diseases rather than talking about the addiction in terms of it being some sort of a devious thing they're hiding from me, making them aware that I'm aware of it and referring to it as a disease that I know about.

It's pretty hard to hide that from a provider who knows the patient well and I think it's rendering primary care, it's impossible to hide that. You can do a drug screen, you can do a lot of things; you may learn it in hindsight, that there is from the amount that they're consuming.

Someone's already mentioned about how many you give them and you can follow up with your diagnosis and say I want to see you again in 10 days to see how you're doing with this and how much you're taken. And if there's no objective signs to see that they're recovering, then you can kind of determine well, there's no real evidence here that you ever were in pain or you are in pain.

So I think that if you have no real hard evidence, there's no hypertension, there's no, you know, it's just all very subjective; then you have a pretty good idea that the patient is using as opposed to treating. And when that happens I'm in favor of addressing the addition as the problem in the same way that I am treating the pain or all the underlying source of the pain. Let's find out what's causing the pain. And I think the addiction is capable causing pain that's just real.

I think in terms of just understanding it as a disease, sometimes we need to look at where we're coming from and do we truly, truly treat it as a disease or do we just treat it as, you know, the behavior problem that that patient is hiding from me?

I think once they really see that we know they're sick, sometimes they are a little more open with us if that makes any sense to anybody.

John Blevins:

Yes, thank you for your comments.

Operator:

Your next question comes from the lines of Carol Dawson-Rose.

Carol Dawson-Rose:

Hi. I've got a question for you. We and some of the people that I've been working with here in San Francisco have been talking a lot about research on the brain that actually tries to work with people that have been traumatized like through PTSD or sexual assault or sexual abuse as a child and how that is exhibited, you know, through mental health, you know, mental health exhibits that behavior or that sign of that and this whole idea that it's somehow connected to pain.

And so the trauma-pain link that I think is related to this topic of mental health and I'm interested in understanding more about it for drug users that I work with (unintelligible) because I think that a lot of people are treating their mental health problems through their own drug use and trying to manage on top of that.

And I'm just wondering if any of the trainers or speakers have any comments about that work and what we know from it. Thank you.

Milton Wainberg:

If I'm understanding correctly you're talking about psychological pain and not physical pain, is that correct?

Carol Dawson-Rose:

I'm talking about people who are trying to treat their psychological pain but a lot of it comes out as a physical pain. They complain of it physically.

Milton Wainberg:

You know, I think -- this is Milton Wainberg and if anybody else wants to answer please do not hesitate after me -- we do know that people who have been exposed to previous trauma have more tendency to have PTSD anxiety and depression so not only post traumatic stress disorder but also depression and anxiety are outcomes of trauma. PTSD is one of them, not the only, you know, diagnosis.

(Unintelligible) is very clear research that shows that substance abuse, people who have substance abuse disorders have prior histories, psychiatric diagnosis; in other words, PTSD, anxiety or depression that they may be treating with the substance abuse so, you know, the second element is also present there.

And when people are depressed, somatization, in other words showing a somatic symptoms, having symptoms that are physical are very connected with depression and even more, when somebody had any medical illness and they also have depression they tend to have more clinic visits, they are seeking for medications more regularly.

So the other good thing about treating depression is not only that they improve the quality of life of the patient but it improves the quality of life of the provider because once people are less depressed, they have less complaints and they bother less their providers. And I'm saying it of course in a funny way but the idea is for everybody to be happier and not burned out.

So I think that everything that you have said is absolutely there and there is research that describes all of those to confirm that it's good to treat the depression and including the substance abuse. One of the concerns of the history of psychiatry was dividing substance abuse separate from psychiatry disorders and it's pretty clear that they're part of the same brain having problems.

And if anybody wants to add anything please do not hesitate.

Carol Dawson-Rose:

I certainly see that in our pain clinic patients, that I don't think there's one patient that does not have a psychiatric diagnosis of either depression or bipolar disorder and many, many, many of them; yes, I can't give you a percentage off the top of my head at this moment but most of them are probably treating psychological pain more so than they are physical pain.

Dianne Weyer:

This is Dianne. I agree also with the patients that I take care of who have substance abuse problems. Many, many of them are dually depressed and particularly my meth users who come from the heterosexual side of the world and particularly maybe the females although it would be interesting to do further research. But I agree, Dr. Wainberg, that you do see many, many patients who are dually diagnosed and triply diagnosed for that matter.

Jeffrey Beal:

Great. I want to remind the listeners to please make certain that you fill out your evaluations. We still have time for questions. Next question please?

Operator:

Once again we would like to remind everyone in order to ask a question press star then the number 1 on your telephone keypad.

And at this time there are no questions.

Jeffrey Beal:

All right, it sounds like we are ending the day here. I want to thank everyone for being a participant. I want to ask listeners again, please fill out your online evaluation form. We really want your feedback to support and your information to help us in the modification of the tools. We hope that you will pilot test them in your clinical settings and then share your experience with us.

As moderator of the call I'd like to thank Linda Podurst and Rianna Stefanakis and the entire AETC NRC staff for everything you did for us in the group. Thank you, Dr. Glesby, Deborah Trimble, Dr. Wilcox, Dianne Weyer, Milton Wainberg and Jack Rodnick for jumping in and I thank you all for your attention and time and look forward to all the feedback.

Thank you very much.

Operator:

This concludes today's conference call. Thank you for your participation. You may now disconnect.

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