Thinking Beyond the Role of a Dental Health Provider Meth HIV and Mental Health

Thinking Beyond the Role of a Dental Health Provider: Meth, HIV and Mental Health Wednesday, October 17, 2007 Bloomington, IL Linda Kaste, DDS, PhD UIC College of Dentistry Lisa Rassano, PhD UIC College of Medicine, Department of Psychiatry Mona Van Kanegan, DDS, MS Midwest AIDS Training and Education Center Heartland Health Outreach Objectives 1) What are the basic distributions for Meth, HIV and Mental Health, and their interactions? 2) What happens to people who take Methamphetamines? What are the basic interactions of Meth with HIV and Mental Health? 3) What are the implications for the dental workforce? Distributions of Meth, HIV and Mental Health Meth at the National Level Meth at the National Level Past Month Use of Selected Drugs amg Persons 12+, 2006 9 8 7 6 5 4 3 2 1 0 an a s s er s ts ics ge n er ain ts ha lan Re lie v qu iliz Co c ul an iju ut Ma r pe St im Ha llu c io er a Pa in ot h Ps y ch Tr an http://oas.samhsa.gov/ Male Female In Me t h e Meth at the National Level  An estimated 731,000 current Meth users in the US, age 12 or older (slight decline from 1.3M seen in 2005)  45% of the primary admissions to substance use treatment for Meth use were for women (vs 26% women for alcohol abuse or marijuana use) http://oas.samhsa.gov/ Meth at the National Level (2002-2005) 1.2 1 0.8 0.6 0.4 0.2 0 Non-Metro Small Metro Large Metro http://oas.samhsa.gov The National Survey on Drug use and Health/ Meth at the National Level: Meth at the National Level: Past Year Methamphetamine Use among Persons Aged 12 or Older, by Geographic Region: 2006 http://oas.samhsa.gov/ Meth at the National Level: Past Year Methamphetamine Initiates among Persons Aged 12 or Older and Mean Age at First Use of Methamphetamine among Past Year Methamphetamine Initiates Aged 12 to 49: 2002-2006 1Mean-age-at-first-use estimates are for recent initiates aged 12 to 49. http://oas.samhsa.gov/ Meth and HIV at the National Level Meth and HIV at the National Level Approximately 4 out of 10 U.S. AIDS deaths are related to drug abuse. www.drugabuse.gov Meth and HIV at the National Level Concerns from rural Colorado “6 key elements identified that may increase risk of HIV/STD transmissions amg rural Meth users: 1) A belief that HIV is not present in rural areas 2) Prolonged unprotected sex while high 3) Deciding to inject Meth 4) Mental confusion resulting from chronic use of binging 5) Injecting in a chaotic drug environment, and 6) Rural structural factors such as HIV stigma, marginalization, inadequate tx services, and limited HIV testing and prevention” Fact Sheet No 18, 2006, Rural Center for AIDS/STD Prevention Meth and Mental Health at the National Level Meth and Serious Psychological Distress at the National Level 4.5 x more Meth use among persons with Serious Psychological Distress (1.8%) than those without (0.4%) 3.4 x more Serious Psychological Distress among Meth users (38.2%) than non-Meth users (11.2%) http://oas.samhsa.gov 2005 statistics for adults 18+ Meth in Illinois Meth in Illinois  “2 Prong” • Drug trafficking from Mexico & California thru Chicago • Small labs – major drug in central and south Illinois http://www.usdoj.gov/dea/pubs/states/illinois.html Meth in Illinois Primary methamphetamine/amphetamine admissions Aged 12 and over For Illinois: TEDS 1992-2002 1600 1400 1200 1000 800 600 400 200 0 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 http://wwwdasis.samhsa.gov/teds02/2002_teds_rpt.pdf HIV in Illinois HIV in Illinois Number of HIV and AIDS Cases Total and Collar Counties 7000 6000 5000 4000 3000 2000 1000 0 2006 2007 HIV Cases Total HIV Cases Collar AIDS Cases Total AIDS Cases Collar Illinois DPH as of August 2007 Mental Health in Illinois Mental Health in Illinois  Prevalence of Poor Mental Health 33.6%  29th among the 50 states 2004 BRFSS Thinking Beyond the Role of a Dental Provider: Meth, HIV, & Mental Health Lisa A. Razzano, Ph.D. Center for Mental Health Services Research & Policy University of Illinois at Chicago Illinois State Oral Health Conference Bloomington, IL 17 October 2007 Mental illnesses . . . . Are Brain Disorders Disrupt a person’s thinking, feeling, moods, and ability to relate to others. Often result in a diminished capacity for coping with the ordinary demands of life. The precise cause of mental disorders is not known. According to the Surgeon General, mental health and mental illness are a product of the interplay or interaction between biological, psychological, and sociocultural factors. Diverse effects in the brain:  Anatomical– size and structure  Chemical – changing the effects of neurotransmitters and electrochemical connections  Organic – changes in overall function, e.g., executive function – like memory or concentration, sensations and perceptions, etc. What are some of the factors in relationship between mental health and HIV/AIDS? Specific mental health symptoms affect participation in high risk behaviors; Among those with living with mental illnesses and HIV, symptoms of HIV-illness progression often are “masked” as reoccurrence of mental health concerns; & Mental health symptoms are directly related to morbidity and mortality among people with HIV/AIDS. HIV Infection Rates Among Clients with Severe Mental illnesses Study N Cournos et al. (1991) 451 Volavka et al. (1991) 515 Sacks et al. (1992) 350 Empfield et al. (1993) 203 Susser et al. (1993) 62 Stewart et al. (1994) 533 Cournos et al. (1994) 971 Setting % HIV two state hospitals 5.5 state hospital 8.9 private hospital 7.1 homeless inpatients 6.4 city homeless shelter 19.4 state hospital 5.8 two state hospitals 5.2 These rates can be 8 – 75 times as high as for those individuals among the general population. Co-Occurring Issues for Clients with HIV/AIDS & Mental Health Concerns Poverty & Unstable Housing • higher rates of homelessness • lack of control over where/when have sex; trade sex for money, other resources Previous Trauma & Abuse • as high as 50% in some mental health service settings; strongly correlated with HIV risk behaviors Substance Use • nearly twice rate of general population (14% vs. 28%) • Can vary by Dx, as well as “drugs of choice” Patterns of Co-Existing Substance Use Basic rates among people with mental illnesses, based on one national study of 20,000+ clients: Dx Any AOD Use Alcohol Use Other Drug Use Schizophrenia Affective Disorders Bipolar Disorder Major Depression Anxiety Disorders 47.0% 32.0% 60.7% 27.2% 23.7% 33.7% 21.8% 46.2% 16.5% 17.9% 27.5% 19.4% 40.7% 18.0% 11.9% Impact of Mental Health on Course of HIV/AIDS Studies have demonstrated, that symptoms of depression – even “psychosocial” depression not only Major Depressive Disorder – and symptoms of anxiety directly affect the two most widely monitored biological markers of HIV-illness progression: viral load and CD4 count Depression & Anxiety  Studies have demonstrated that Anxiety and Mood Disorders have become quite prominent among those living with HIV/AIDS.  Both negatively impact medication adherence.  Suicide has become a more common phenomenon – related to symptoms of depression as well as a more “existential” aspect of well-being in stressful life situations.  Avoid dismissing anxiety, hopelessness, and depression as “justified reactions” to life with HIV infection. Methamphetamine  Is defined by the National Institute on Drug Abuse (NIDA) as: “an addictive stimulant that is closely related to amphetamine, but has longer lasting and more toxic effects on the central nervous system. It has a high potential for abuse and addiction.”  Chronic, long-term use can lead to psychotic behavior, paranoia, hallucinations, repetitive motor activities, and stroke  Also creates changes in brain structure and function – like memory loss, aggressive or violent behavior, and mood disturbances Dopamine – “King” of the CNS  In the brain, dopamine plays central role in regulating reward and movement. In the dopamine reward pathway, dopamine is manufactured in nerve cell bodies located within the ventral tegmental area (VTA), and is then released in areas including the prefrontal cortex. It is further linked to motor pathways, as well as executive functions.  Meth creates dopamine release as well as reuptake (e.g., cocaine only affects re-uptake) Dopamine binding to receptors and uptake pumps in the nucleus accumbens Outlook for the Meth User Implications for the Dental Workforce Support Overall Physical Well-being of All Patients  Treat dental disease, eliminate pain, restore function  Support patient compliance with medical care • Reinforce adherence to medications • Screen for medication side effects / toxicities • Tobacco cessation; referral for drug / alcohol abuse • STD prevention / risk reduction  Help identify undiagnosed patients (diabetes, HTN, HIV) and refer them for testing and/or medical care Who is using Meth and Why?  10-40% of prison population have oral evidence of Meth use  Growing problem in teens and young adultsclubs and parties  MSM to initiate or enhance sexual encounters  Men who are HIV+ to overcome fatigue, depression Risk Assessment/Indications of Meth Use  Comprehensive oral exam including medical and dental history  Oral health status– xerostomia, evidence of decay on facial and cervical areas of max and mand teeth, tooth wear due to bruxism or clenching  Accelerated rate of decay not accounted for by other factors Talking to patients about their Meth Use  How did your teeth get to be this way?  Point out signs of damage  Use the opportunity to educate  If patient is receptive to receiving help, have phone number available, tell the patient what to expect  Referral to primary care for testing– HIV, HCV etc. Awareness of Serostatus Among Persons With HIV, United States 800,000 diagnosed HIV/AIDS cases 250,000 undiagnosed HIV infections (25%) 40,000 new infections annually Awareness of Serostatus Among People With HIV and Estimates of Transmission  Of the 25% of that are unaware of their HIV infection, they account for 55% of new infections Prevention Intervention  Meth use has been linked with increased numbers of HIV infections in some populations  Meth increases HIV and other STD risk  Meth use suppresses immune response to HIV, forget to take HIV meds development of drug resistance virus, accelerate HIV related dementia and other health problems Oral Health--Prevention Intervention Four fold effect of drug:  Xerostomic effect  Cravings for sugar+carbonated beverages  Tooth grinding, clenching  Long duration of action leading to long periods of poor oral hygiene. Clinical Care  Meth increases heart rate, blood pressure, body temperature and dehydrates the body  Patient may be aggressive, irritable, violent, loss of short term memory, may have to give written post opinstructions Clinical Care  Duration of Meth “high” is 812 hours, if patient reports use in the previous 24 hours, avoid using local anesthesia containing vasoconstrictor  Avoid prescribing opioid analgesics due to their abuse potential and the risk of increased respiratory depression Clinical Care  Initial treatment plan should include prophylaxis, fluoride treatment and caries control to determine tooth restorability  In office and home use of fluorides, OHI, increase/stimulate salivary: switch to water, sugarless gum, pilocarpine, review OHI.  Damage to teeth is so extensive that the only option is extraction and fabrication of dentures Cavity Prevention Cavity Prevention toothpaste & floss rinses proxabrush Xerostomia Aids mouth spray Rx fluoride paste xylitol-based gum Audience Questions For more information: Listing of publications re: mental health www.nimh.nih.gov/publicat/index.cfm Borderline Personality Disorder http://www.bpdcentral.com/faqs.shtml http://www.mayoclinic.com/health/borderline-personalitydisorder/DS00442 http://www.borderlinepersonalitydisorder.com/ Medications www.nimh.nih.gov/publicat/NIMHmedicate.pdf Lisa Razzano, Ph.D., Associate Professor of Psychiatry Razzano@psych.uic.edu Sources:  Klasser, GD, Epstein J. Methamphetamine and Its Impact on Dental Care. JCDA 2005;71:759762.  Goodchild JH, Donaldson M. Methamphetamine abuse in dentistry: A review of the literature and presentation of a clinical case. Quintessence International 2007;38:583-590.  Health Bulletin: Methamphetamine and HIV. Health & Mental Hygiene News 2004;3:3 Sources:  Department of Health and Human Services, Centers for Disease Control and Prevention. Methamphetamine Use and Risk for HIV/AIDS: www.cdc.gov/hiv/resources/factsheets/meth.htm  American Dental Association. Dental topics A-Z Methamphetamine use. www.ada.org/prof/resources/topics/methmouth.asp  American Dental Association. ADA warns of Methamphetamine’s effect on oral health. 2005 www.ada.org/public/meida/releases/0508_release01.as p Clinical HIV Resources AIDS Education and Training Centers Website: www.aidsetc.org Has an extensive information on oral health topics– Treatment planning guidelines Oral Manifestations Slide sets, video presentations, CE Patient information Clinical HIV Resources Clinical Manual for the Management of the HIV Infected Adult 2006 Edition Can print document from the AETC Nat’l Resource Center website: www.aidsetc.org/aetc?page=cm-00-00 Clinical HIV Resources www.ask.hrsa.gov Principles of Oral Health Management for the HIV/AIDS Patient- publication code #HAB00230) call 1-888-275-4772 or Print copies (using Adobe Acrobat) directly from the HRSA website: www.ask.hrsa.gov/ElectronicPublications.cfm?start=29 Clinical Consultation Service MATEC Dental Consultation services are provided for the diagnosis, prevention, and oral health management of HIV patients, as well as policy and system development. Please contact: Mona Van Kanegan, DDS, MS Dental Director Phone: (773) 751-1747 Fax: (773) 275-3689 Email: mvankanegan@heartlandalliance.org Leave a voice message with your question, contact info, and the best time to reach you. Or you can fax or email the same information. You will be contacted in 24-48 hrs.