International Association of Physicians in AIDS Care

The Role of Alcohol and Drug Relapse Prevention in the Treatment and Prevention of HIV Disease

by Jan Swanson, DO, FACP and Alan Cooper, PhD

April 1998

Although HIV disease and alcohol and drug abuse are distinct illnesses, each profoundly affects the other. Alcohol and drug abuse have been associated with high-risk sexual behavior such as unprotected sexual activity.^(1-7) Although the data on whether alcohol or drug abuse can accelerate the progression of HIV infection to AIDS have conflicted,^(8-10) some studies have supported such a relationship.^(11-14) One recent study looked at the effects of HIV infection and chronic alcohol use on cerebral white matter concentrations of phosphodiester and phosphocreatine to determine adverse metabolic effects on the brain.⁽¹⁴⁾ The study found that HIV infection and alcohol abuse were additive in their negative effects. Although more research is needed on the relationship between HIV disease progression and drug and alcohol abuse, it is worth asking whether addicts who are HIV-positive will be less compliant with medical treatment as a result of their substance abuse.

Concern for compliance has increased as a result of new complex combination-drug HIV treatments. Some earlier compliance studies that predate protease inhibitors may prove helpful. A 1992 study of zidovudine (ZDV) therapy involving hospital clinic patients with a history of injection drug use found high levels of compliance over a brief study period. Compliance was enhanced when the patient believed that ZDV prolonged life or used a timer for dosing. Surprisingly, patients taking ZDV alone showed lower compliance compared with those taking ZDV plus one to three other nonantiviral drugs.⁽¹⁵⁾

A separate study of compliance with ZDV therapy compared injection drug users (IDUs) with other HIV-positive subjects.⁽¹⁶⁾ The study found that IDUs tended to delay longer than the others in starting the ZDV treatment after it had been proposed to them. However, once the IDUs accepted treatment, they demonstrated as much compliance as the other HIV-positive patients. As one would expect, among the IDUs those who had stopped taking street drugs altogether or took only their prescribed methadone were the most compliant compared with the still active (street) drug users. Good compliance overall may have been the result of the two most compliant subgroups making up most of the IDUs.⁽¹⁶⁾ Whether complex combinations of antiviral medications are taken appropriately by alcohol and drug users is not known, but based on this study it is reasonable to speculate that alcohol or drug users who become abstinent will have superior compliance.

Every physician treating HIV disease would benefit from knowing some basic concepts of addiction medicine, just as every addictionologist needs to know about HIV. Depending on the geographic location, 5 to 60 percent of individuals acquiring HIV disease do so from injection drug use.⁽¹⁷⁾ Injection drug use overall has grown to 37 percent as a likely cause of AIDS among adults in the United States.⁽¹⁸⁾ Several studies have reported elevations in HIV risk behavior and infection among alcoholic inpatients,^(19-22) although no studies to date tell us how many persons have acquired HIV disease while impaired from alcohol. Questions worth investigating further include: How many people continue to drink to excess and use drugs while HIV-positive? How does this contribute to the continual transmission of HIV disease? How does the use of drugs and alcohol affect the immune system and cause the disease to progress?

We do know that many people use alcohol and drugs before becoming HIV-positive and do so afterwards as well. Some of these persons may benefit from relapse prevention training, both in approaching testing and in coping with HIV disease if they test positive, although research is needed in this area. One study examined how patients taking methadone reacted to HIV serostatus notification.⁽²³⁾ Seropositive patients had more disciplinary problems related to greater cocaine use during the year following notification. Cocaine was chosen probably because of its mood-elevating effects and possibly reflected a lack of coping skills in encountering the upsetting news.⁽²³⁾

A chronic relapsing condition

Addiction has been described as a chronic relapsing condition frequently requiring multiple attempts to quit before the addict is able to achieve a sober lifestyle. This may be a result of long-term, possibly irreversible, neurochemical changes that make the addicted brain qualitatively different from a nonaddicted brain. These differences are manifested by global declines in glucose metabolism and intraneuronal changes in gene expression and may explain susceptibility to relapse.⁽²⁴⁾

An alternative but not mutually exclusive explanation looks at the addicted brain as having been differentially conditioned to environmental cues that produce cravings that frequently trigger lapses and eventual relapse. Marlatt and Gordon⁽²⁵⁾ proposed a social learning model of relapse that went beyond conditioning alone and emphasized the presence of high-risk situations, the recall of euphoric experiences, and the availability of coping skills.

Related to drug and alcohol relapse prevention training are approaches that target maintenance of safer sexual behaviors and safer drug injection behaviors such as needle exchange programs and bleach disinfection of needles. Such harm reduction programs attempt to encourage persons at risk to gradually reduce their harmful behaviors in a step-down approach to less dangerous forms, such as replacing heroin use with methadone maintenance.^(26,27)

This article limits itself to drug and alcohol relapse prevention in the treatment and prevention of HIV disease. However, this is not meant to minimize the many different interventions available to limit HIV transmission and disease among alcohol and drug users, from harm reduction to treatments that successfully promote abstinence through extended follow-up.⁽²⁸⁾

Modern medical and social learning explanations of chronic relapsing stand in sharp contrast to the moral approach, which earlier in the century viewed addicted persons as sinners with low moral fiber who lacked self-control over alcohol and drugs. The moral approach attempted to shame these sinners into sobriety with the help of religious conversion, but that approach has fallen into disfavor since the introduction of the disease model of alcoholism in the 1950s.

Marlatt and Gordon have recognized eight high-risk factors that can lead to relapse of alcohol and drug use (Table 1).⁽²⁵⁾ The goal of relapse prevention is for individuals to become aware of their own high-risk situations and to learn effective life-coping skills and cognitive strategies to deal with the situation in which they would have previously used drugs and alcohol. This results in feeling greater self-efficacy and confidence. If individuals lapse, they are asked to look at the lapse and determine what they could have done to avoid it. This allows them to learn from the mistake or slip. Thus, a lapse can be turned into a prolapse. Prolapses occur when individuals understand the cause of their lapse, allowing them to handle the high-risk situation better in the future. Doing this helps keep the recovering individuals from feeling hopelessly addicted or alcoholic. They avoid the abstinence violation effect, a type of thinking pattern in which individuals interpret their slip as a failure and evidence that recovery is not working.⁽²⁵⁾ By learning new coping skills, they learn that change is possible.

Table 1. Eight high-risk factors that can lead to relapse of alcohol and drug abuse ⁽²⁵⁾
High-risk factor	Definition
Negative feelings	Feelings of sadness, fear, guilt, loneliness, worry, etc
Cravings to use	External triggers such as sights, sounds, and smells that provoke a desire for drugs or alcohol
Pleasant emotions	Occasions such as holidays, trips, and times of good fortune that bring about positive feelings
Physical discomfort	Negative physical states such as alcohol or drug withdrawal, insomnia, and chronic pain and illness
Testing personal control	Having "just one" drink, joint, hit, etc, to test will power
Social pressure to use drugs and alcohol	Influence used to make someone else have a drink or use a drug
Having fun with others	Using alcohol or drugs to enhance pleasant times with others, such as during social events
Conflict with others	Arguments and fights with others that result in frustration and anger

Viewing a lapse as a learning situation is helpful for the physician or healthcare professional as well. The physician should not see the addict as hopeless but as a person who is learning from mistakes and who is able to change when given the opportunity. Relapse prevention can thus help a person deal with HIV disease.

An alcoholic numbness or drug buzz is a simple and quick way for individuals to deal with feelings such as fear, shame, and despair brought on by HIV disease. However, when under the influence of alcohol or drugs, individuals are not in control of their lives or disease, which will in turn cause feelings of hopelessness. Learning to deal soberly with the different stages of HIV keeps individuals in control of their life and medical care. See Table 2 for a summary of the five components of relapse prevention.

Table 2. The five components of relapse prevention⁽²⁹⁾
Component	Definition
Assessing high-risk factors	Learning which high-risk situations are of particular concern
Learning effective coping skills	Learning new information and strategies for coping with primary situations
Monitoring high-risk situations	Observing how one thinks, feels, or acts in a given high-risk situation
Developing coping plans to deal with difficult situations	Making prior decisions about how to behave during an anticipated high-risk situation
Evaluating coping plans and skills	Rating confidence to carry out a plan and evaluating how well a plan succeeded in preventing relapse; changes in the plan may be necessary

High-risk relapse stages in HIV disease

Individuals are at risk for relapse at five stages in HIV disease progression. Each stage has its own challenges for the individual. Relapse prevention skills may help to reduce the risk of relapse that accompanies each stage.^(29,30)

Many people are affected by HIV in some way, whether by knowing a celebrity, friend, or family member who has been diagnosed as HIV-positive or has AIDS or by simply making changes in their sexual behavior. Chemically dependent persons in particular have been at greater risk than the rest of the population and have suffered more as a result. This means that recovering persons need to become aware how they may be vulnerable to HIV and how even being tested for HIV can be a high-risk situation that can endanger their sobriety. Certainly, having to live with an HIV-positive diagnosis or developing AIDS-related infections is likely to be a great challenge to recovering individuals' sobriety. How the individuals cope with these dangers will make a big difference to both their recovery and good health.

Stage I: Awareness of HIV as a personal risk factor

Individuals often are afraid to face their personal risks and use denial. They may continue to engage in unsafe sexual practices or avoid being tested because they do not believe that they or their partners are at risk of contracting HIV disease. Alcohol and drugs can aid their denial by allowing them to ignore knowledge of risk with an alcohol or drug fog.

Challenge: Responsibility vs harm.

Harm: John was a 35-year-old businessman who was a recovering prescription drug user. Since he dated only professional women, he never bothered with condoms. He believed, These women are too smart, too classy, to be HIV-positive. Only homosexuals get AIDS anyway. I am not in any risk.

Responsibility: John's sponsor confronted him with his self-destructive behavior. After John learned more about HIV disease and safer sex, he decided that he was at risk for becoming HIV-positive unless he changed his behavior. By taking better care of himself, he reduced his risks for relapse as well. He also learned that it is not possible to know whether a potential partner is HIV-positive based on appearance alone.

Coping plan to prevent relapse:

Learn about HIV disease and accept personal vulnerability. It's what you do that counts.
Learn about safer sex and practice this in your sexual life.
Consider that sexual addiction may be a problem if you are unable to carry out the above tasks and get help.
Commit to sobriety to avoid risky behavior.

Stage II: Deciding to get tested and interpreting the results

Individuals may know that they are at risk but refuse to be tested because they are afraid they might be positive and believe that they could not emotionally handle the test results, or they may falsely believe that after testing positive nothing can be done to maintain their health.

Challenge: Courage vs avoidance.

Avoidance: Marty was a 35-year-old recovering cocaine addict and gay man. He thought that being gay doomed him to be HIV-positive. When sober, he always practiced safer sex. However, when high on cocaine, he had often not been aware of who was with him or what he was doing. He was now feeling very depressed and hopeless about his probable HIV disease. As a result, he craved cocaine, hoping to lift his spirits.

Courage: Marty's sponsor told him that avoiding testing was putting him at risk for relapse. He agreed to be tested, and much to his surprise, the test was negative. Marty decided to remain this way by renewing his commitment to sobriety and safer sex.

Coping plan to prevent relapse:

Assess your personal risk of HIV infection.
Understand the test results by consulting reliable sources.
Deal with shame and healthy guilt over your past high-risk behaviors.
Deal with anxiety about being tested.
Find a place to be tested and get pre- and post-test counseling.
Renew your commitment to change high-risk behaviors and stay sober.
Develop a coping plan before learning the results to prevent relapse.

Stage III: Learning to live with an HIV-positive diagnosis

Most physicians know patients who have tested positive but waited years before being evaluated and thus missed the benefits of early medical intervention. Individuals may be afraid to find out about their disease status.

Challenge: Taking charge vs denial.

Denial: Tom was a 50-year-old engineer and recovering alcoholic. He had probably become positive when he had a blood transfusion for a bleeding ulcer caused by his drinking. He learned that he was positive in his treatment program. At that time, he was advised to seek medical help but did not, thinking, What's the use? I am going to die anyway. He also disliked seeing doctors, whom he felt invaded his privacy by poking and prodding him. He felt he could handle the disease on his own. However, his denial was not allowing him to face his emotions honestly, and this put him in danger of relapse.

Taking charge: Tom's treatment counselor encouraged him to read about HIV disease and take charge of his life. Tom learned that being HIV-positive did not mean he had AIDS. He found a doctor he liked. The doctor explained to Tom that laboratory tests and a physical examination would help him devise a good medical care plan with which he could live. Tom discovered he had a high T-cell count and a low viral load and was physically in good shape. He began to feel in charge of his life again, and his relapse risk went down as a result.

Coping plan to prevent relapse:

Learn about potential triggers for relapse, such as negative emotions.
Educate yourself about HIV and your body.
Find a qualified doctor and work out a partnership.
Reassess priorities in your life.
Develop a support system.
Follow a healthy lifestyle, cope with lapses, and learn from them if they occur.

Stage IV: Encountering opportunistic infections, a falling CD4+ count, or a rising viral load

A falling CD4+ count or rising viral load can cause fear about the unknown.

Challenge: Hope vs despair.

Despair: Mary's husband had been a hemophiliac who died of AIDS. She was HIV-positive as a consequence of sexual relations with him. Unable to cope with the loss of her husband, she had become an alcoholic. She did well physically and never thought much about being HIV-positive until she learned her CD4+ count was only 100/mm³. All of a sudden she became afraid and angry. She even started going to bars and having unprotected sex. She thought, Why not? If a man doesn't want to use condoms, he can get AIDS. I'm not going to live long anyway. Why not have fun?

Hope: Mary's therapist told her that she was acting out of anger and was risking her health, sobriety, and the well-being of others. She encouraged her to explore the anger in therapy instead and to see her physician. Mary went to her physician who prescribed medicine to prevent some likely diseases, such as Pneumocystis carinii pneumonia and Mycobacterium avium-intracellulare complex. He changed her antiviral medicines. Importantly, she learned she was still healthy. This gave her needed hope and her anger lessened, as did her potential for relapse.

Coping plan to prevent relapse:

Identify opportunistic infections early.
Prevent other opportunistic infections as much as possible.
Cope with depression and anger to avoid relapse.
Deal with your fear of dependency and loss of control.
Cope with a changing body image.
Remain hopeful. You can still avoid getting worse and may still get better.

Stage V: Dealing with multiple chronic illnesses and the possibility of death

Dealing with illness, possible disability, and death is hard for anyone.

Challenge: Self-determination vs loss of control.

Loss of control: Susan, a recovering prescription drug user, was a flight attendant. She contracted HIV from her former husband. As a single parent, she prided herself in working and taking care of her daughter without giving into her AIDS diagnosis. After having had P carinii pneumonia twice, she went back to work. She had even developed cytomegalovirus retinitis and worked while receiving intravenous treatment. However, the medicine was not helping and she was losing her sight. At work, she was told she had to take medical disability or lose her job. In desperation, she decided to go to her doctor and told him to stop everything. She now felt useless and out of control and thought, I am no longer of any use to anyone. She wanted to drown herself in pain medication and tranquilizers and die.

Self-determination: The doctor diagnosed Susan as clinically depressed. It was true that she could not hold her current job, but she could still do volunteer work and raise her child. He encouraged her to make plans in case she became terminal, such as determining who would care for her child, settling her financial matters, and writing a will. He encouraged her to look into experimental AIDS therapies and become involved with support groups. Susan did these things and started to feel that she was directing her own life again.

Coping plan to prevent relapse:

Accept the unpredictability of late-stage AIDS.
Take pain medications under your physician's direction. Drug and alcohol use is still harmful.
Learn about available treatment options.
Deal with your fear of death.
Deal with the fear of being a burden to others.
Use your circle of support, such as friends and support groups.

Reducing risk for HIV disease

Relapse prevention strategies have been used to help deter HIV disease. A study by Wexler et al⁽³¹⁾ followed 394 parolees (81 percent male and 19 percent female) who were at risk for HIV infection due to drug use after release from prison. Of these, 241 attended the program and 164 people completed it. The researchers used a social learning relapse prevention model that emphasized learning social skills to prevent relapse. The prisoners learned AIDS risk reduction methods in a structured program (ARRIVE: AIDS Risk Reduction for IV Drug Users on Parole). At the end of the one-year program, attendees had a significant reduction in high-risk behavior, used condoms more often, and had decreased drug use more than those who had not attended the program.⁽³¹⁾

Coping skills: the crucial difference

Patients have fears about HIV infection yet respond to fear in different ways. For example, by avoiding people, places, and situations that promote substance use, a recovering addict uses one important coping skill to deal with cravings. Similarly, by asking for support in dealing with the HIV testing process, the recovering addict helps prevent becoming emotionally isolated in facing a potentially overwhelming experience. An addict who lacks such skills is more likely to try to numb fears by using chemicals. When they lack coping skills, patients often find that testing for HIV infection, waiting for the results, and getting the results can be overwhelming triggers for relapse. Sometimes patients who are afraid of testing say to themselves, What's the point? If I'm HIV-positive, I'll just die anyway. This is obviously self-defeating thinking. Patients need to know that HIV infection is not a death sentence, that the sooner they are tested, the sooner they can get medical care, and that doing so will increase their chances for remaining healthy and living longer. If they do not get treated, they need to know that HIV disease can progress faster.^(32,33)

Patients may find it embarrassing to admit that they have acted in ways that put them at high risk for HIV infection. Perhaps these behaviors involved unsafe sex, multiple sex partners, sex with prostitutes, or sharing needles. If they are prone to shame, they may see such behaviors as proof that they are basically worthless human beings. Such feelings can lead them to withdraw from other people so that no one will know about their behaviors.

There is another option. Patients can hang on to their self-esteem. They can view chemical dependency as a disease that impaired their judgment. What's more, they can distance themselves from their disease. They are not their disease. Their judgment can improve along with their increasing sobriety.

Patients should try to take responsibility for actions that harmed others, to make amends, and to learn from their mistakes. At the same time, patients will need to always look at themselves with compassion. Admitting mistakes and making amends does not mean admitting to badness but rather that they, like all of us, are fallible human beings.

Patients avoid testing for a variety of reasons, especially when they falsely believe that finding out that they are HIV-positive is getting a death sentence or that even if they know their HIV status there is nothing they can do to prevent their getting AIDS. Patients may need help in overcoming such beliefs.

Use of relapse prevention in a medical setting

Physicians who treat HIV-positive patients will encounter psychiatric disorders and active substance abuse disorders in these patients at rates considerably higher than those in HIV-negative patients. One study at the John Hopkins Hospital General HIV Clinic found that 54 percent of consecutive patients seen suffered from a psychiatric disorder, while another 22 percent suffered from a chemical dependency problem.⁽³⁴⁾ Physicians can respond to these related disorders in a number of ways. They can use screening and referral procedures. They can read relevant literature.^(29,34-37) They can attend conferences, such as those offered by the American Society of Addiction Medicine, to learn to identify chemical dependency problems as well as to provide brief interventions that enhance motivation in patients⁽³⁵⁾ or help prevent relapses that complicate HIV treatment. In general, physicians with the proper training should follow these recommendations:

At the initial visit, assess patients' current and past use of drugs and alcohol. This can be done in the medical history or by using assessment tools such as the Alcohol Use Disorders Identification Test (AUDIT) developed by the World Health Organization.⁽³⁸⁾ If patients are currently using drugs and alcohol, the physician may need to medically detoxify them or refer them to a medical facility that can.
If patients are in recovery, assess their relapse risk at this stage of their HIV disease. Nonjudgmentally find out how they coped with illnesses and negative emotions such as fear and anxiety in the past. If they coped by using alcohol and drugs, help them to develop a plan to deal with their current healthcare status without using drugs or alcohol. If they are at high risk that day for relapse, have them call their sponsor or stay with a sober friend or relative. You can suggest that they read literature on relapse or refer them to a social service agency that has relapse prevention training.
With each medical visit, do not forget to find out about the status of your patients' sobriety. Are they tempted to use drugs or alcohol? Are they expecting to be exposed to one of their high-risk situations? Will today's medical diagnosis or laboratory result put them at risk for lapsing? A diagnosis such as cytomegalovirus retinitis or a high viral load is discouraging. How will your patients deal with it? Help the patients write an effective coping plan that does not involve alcohol or drugs.
If your patients lapse, help them to evaluate the lapse and develop a coping plan for that specific situation (eg, depression) so the lapse will not recur.
Medicines such as disulfiram (Antabuse) and naltrexone hydrochloride (Revia) can be helpful. Individuals who are depressed or anxious often benefit from antidepressants. Buspirone hydrochloride (Buspar) can also help reduce anxiety.
Be sure to praise patients' desires and attempts to be sober; look for successful coping so you can praise it and increase patients' self-confidence.

Conclusion

Seventy-five percent of recovering individuals relapse in the first year.⁽³⁹⁾ Relapse prevention can reduce this number and therefore has a place in the care of the HIV-infected population. Individuals abstaining from drugs and alcohol may benefit from a stronger immune system and may be less likely to engage in unsafe sexual behavior that would allow them to contract sexually transmitted diseases or expose others to HIV disease.

It is hoped that more studies such as the ARRIVE program will be done to evaluate relapse prevention in the HIV-infected population. Additional questions that need to be resolved include what behavioral and cognitive skills are most useful for the person living with HIV; what stages of HIV disease are most likely to be greater relapse risks; and how relapse prevention material can be presented most effectively.

Individuals who are HIV-positive could benefit from assessment of drug and alcohol use, drug and alcohol detoxification, and training in relapse prevention skills. Relapse prevention is a tool that is available to physicians and can be applied in an outpatient medical setting. When this is not possible on site, brief intervention aimed at increasing motivation to get help and referral to chemical dependency practitioners are recommended.

Jan Swanson, DO, FACP, is an internist specializing in HIV disease and an addiction medicine physician based in Texas. Alan Cooper, PhD, is a licensed clinical psychologist based in Texas.

A list of US alcohol and drug dependency resources is on the IAPAC web site at www.iapac.org. Information is requested on simliar resources in other countries. Please e-mail resource information to gordon@ iapac.org.

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This article was provided by International Association of Physicians in AIDS Care. It is a part of the publication Journal of the International Association of Physicians in AIDS Care.