Buprenorphine: Its Role in Preventing HIV Transmission and Improving the Care of HIV-Infected Patients with Opioid Dependence

Buprenorphine misinformation and willingness to treat patients with opioid use disorder among primary care-aligned health care professionals

BACKGROUND

Buprenorphine is a highly effective medication for opioid use disorder that is underused by health care professionals (HCPs). Medications for opioid use disorder (MOUD) misinformation may be an important barrier to buprenorphine access, but most implementation strategies have aimed to reduce negative attitudes towards patients with opioid use disorder (OUD) rather than misinformation specific to buprenorphine use. In this study, we assessed the degree to which HCPs endorsed misinformation related to buprenorphine, and whether this is associated with willingness to provide care to patients with OUD.

METHODS

In September-December of 2022, we surveyed HCPs practicing in Ohio (n = 409). Our primary outcomes included a previously validated 5-item measure of HCP willingness to treat patients with OUD, and three other measures of willingness. Our key independent variable was a study-developed 5-item measure of endorsement of misinformation related to buprenorphine, which assessed beliefs in buprenorphine's efficacy in managing withdrawal symptoms and reducing overdose deaths as well as beliefs about the role of buprenorphine in achieving remission. We computed descriptive and bivariable statistics and fit regression models predicting each outcome of interest.

RESULTS

On average, HCPs scored 2.34 out of 5.00 (SD = 0.80) on the composite measure of buprenorphine misinformation. 48.41% of participants endorsed at least one piece of misinformation. The most endorsed items were that buprenorphine is ineffective at reducing overdose deaths (M = 2.75, SD =0 .98), and that its use substitutes one drug for another (M = 2.41, SD = 1.25). HCP endorsement of buprenorphine misinformation significantly and negatively predicted willingness to work with patients with OUD (b = - 0.34; 95% CI - 0.46, - 0.21); intentions to increase time spent with this patient population (b = - 0.36; 95% CI - 5.86, - 1.28); receipt of an X-waiver (OR = 0.54, 95% CI 0.38, 0.77); and intention to get an X-waiver (OR: 0.56; 95% CI: 0.33-0.94).

CONCLUSIONS

Misinformation is common among HCPs and associated with lower willingness to treat patients with OUD. Implementation strategies to increase MOUD use among HCPs should specifically counter misinformation related to buprenorphine.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov, NCT05505227. Registered 17 August 2022, https://clinicaltrials.gov/ct2/show/NCT05505227.

Differences in buprenorphine prescribing readiness among primary care professionals with and without X-waiver training in the US

BACKGROUND

Medications for opioid use disorder (OUD) are effective at preventing overdose and infectious disease but are vastly under-prescribed in the US. For decades, prescribers faced additional training and regulation to prescribe buprenorphine which stigmatized the medication and lessened support for a harm reduction approach to treating opioid use disorder. The Drug Enforcement Administration removed the X-waiver requirement for prescribing buprenorphine in late 2022, which removed stigma and lessened important barriers to prescribing but also left training at the discretion of individual organizations. Our study aimed to assess differences in knowledge, confidence, and stigma regarding buprenorphine between those who went through the X-waiver training and those who did not, among practicing primary care providers (PCPs).

METHODS

We assessed buprenorphine prescribing readiness among primary care aligned outpatient providers in Ohio, USA. Using survey data, we conducted bivariate and regression analyses predicting primary prescribing outcomes. Primary outcomes measured knowledge of and confidence in buprenorphine, as well as perceived adequacy of one's training. Secondary outcomes were attitudes toward patients with OUD, including bias toward OUD patients, stress when working with them, and empathy toward them. Participants (n = 403) included physicians, nurse practitioners, and physician assistants practicing in primary care aligned disciplines.

RESULTS

Survey data showed that PCPs who received X-waiver training were more likely to understand and have confidence in the mechanism of buprenorphine, and consider their training on treating OUD to be adequate. PCPs with an X-waiver showed more empathy, less negative bias, and experienced less stress when working with patients with OUD.

CONCLUSION

Removing restrictive policies for prescribing buprenorphine is an important step to expanding access and reducing the stigma associated with opioid use disorder treatment. Yet, our findings suggest that the training received alongside regulation may be important for improving prescribing confidence and reducing stigma. Strategies to increase buprenorphine prescribing are unlikely to be effective without also expanding access to prescribing support for primary care providers across the career course.

Awareness, perception and utilization of a mobile health clinic by people who use drugs

INTRODUCTION

People who use drugs (PWUD) face a multitude of barriers to accessing healthcare and other services. Mobile health clinics (MHC) are an innovative, cost-effective health care delivery approach that increases healthcare access to vulnerable populations and medically underserved areas. There is limited understanding, however, of how PWUD perceive and experience MHCs.

METHODS

Semi-structured interviews were conducted with 31 PWUD - 16 who had received care (clients) on an MHC (The Spot) and 15 who had not (non-clients) - to explore their perceptions and utilization of an MHC partnered with a mobile syringe services program in Baltimore, Maryland. Data analysis of the text was conducted using an iterative thematic constant comparison process informed by grounded theory.

RESULTS

Clients and non-clients, once aware of the MHC, had positive perceptions of The Spot and its benefits for their individual health as well as for the wellbeing of their community. These sentiments among clients were largely driven by access to low-barrier buprenorphine and service delivery without stigma around drug use. However, lack of general awareness of the spot and specific service offering were barriers to its use among non-clients.

DISCUSSION

MHCs provide an important opportunity to engage PWUD in healthcare and to expand buprenorphine use; however, even with accessibility near where PWUD access injection equipment, barriers to its use remain. Peer dissemination may be able to facilitate program information sharing and recruitment.KEY MESSAGESPeople who use drugs perceive a mobile health clinic in their neighbourhood as a benefit to their communities and themselves by improving access to healthcare services, providing access to low-threshold buprenorphine dispensation, and offering services without drug use stigma.People who use drugs learned about a mobile health clinic in their neighbourhood largely through word-of-mouth. As a result, people received limited information about the mobile health clinic services creating a barrier to its use.

Buprenorphine Pharmacology Review: Update on Transmucosal and Long-acting Formulations

: Buprenorphine is an effective treatment for opioid use disorder. As a high-affinity, partial agonist for the mu-opioid receptor, buprenorphine suppresses opioid withdrawal and craving, reduces illicit opioid use, and blocks exogenous opioid effects including respiratory depression. Other pharmacologic benefits of buprenorphine are its superior safety profile compared with full opioid agonists and its long half-life that allows daily or less-than-daily dosing. New and innovative buprenorphine formulations, with pharmacokinetic profiles that differ from the original tablet formulation, continue to be developed. These include higher bioavailability transmucosal tablets and films and also 6-month implantable and monthly injectable products. This growing array of available formulations allows more choices for patients and increased opportunity for clinicians to individualize treatment; thus, it is important for buprenorphine prescribers to understand these differences.

Identification and Management of Opioid Use Disorder in Primary Care: an Update

PURPOSE OF REVIEW

The rising prevalence of opioid use disorder (OUD) and related complications in North America coupled with limited numbers of specialists in addiction medicine has led to large gaps in treatment. Primary care providers (PCPs) are ideally suited to diagnose and care for people with OUD and are increasingly being called upon to improve access to care. This review will highlight the recent literature pertaining to the care of patients with OUD by PCPs.

RECENT FINDINGS

The prevalence of patients with OUD in primary care practice is increasing, and models of office-based opioid treatment (OBOT) are evolving to meet local needs of both ambulatory practices and patients. OBOT has been shown to increase access to care and demonstrates comparable outcomes when compared to more specialty-driven care. OBOT is an effective means of increasing access to care for patients with OUD. The ideal structure of OBOT depends on local factors. Future research must explore ways to increase the identification and diagnosis of patients with OUD, improve treatment retention rates, reduce stigma, and promote interdisciplinary approaches to care.

Risky Sexual Behavior Among Individuals Receiving Buprenorphine/Naloxone Opiate Dependency Treatment: HIV Prevention Trials Network (HPTN) 058

INTRODUCTION

Understanding the role of opiate dependency treatment in risky sexual behavior could help optimize interventions for people who inject drugs (PWID).

OBJECTIVES

We evaluated whether long-term medication-assisted treatment (LT-MAT) of opiate dependency with buprenorphine/naloxone influenced risky sexual behavior among HIV-uninfected PWID and identified predictors of risky sexual behavior.

METHODS

We used data from HPTN 058, a randomized controlled trial of LT-MAT vs. short-term medication-assisted treatment among PWID in China and Thailand. We evaluated associations between randomized opiate dependency treatment group and self-reported risky sexual behaviors within the past month: condomless sex with primary partner, condomless sex with nonprimary partner, multiple partners, and more than 3 sexual acts. We used generalized estimating equations to conduct intention-to-treat, as-treated, and exploratory analyses of these associations.

RESULTS

Of 1250 participants included in the analysis, 92% were male, with median age of 34 years (interquartile range 28-39). At baseline, referring to the past month, 36% of participants reported condomless sex with primary partner, 4% reported condomless sex with nonprimary partner, 6% reported multiple sex partners, and 30% reported more than 3 sexual acts. Risky sexual behaviors did not differ significantly between treatment groups at any point. Significant predictors (P < 0.05) of condomless sex with nonprimary partner were history of incarceration and noninjection drug use. Number of needle-sharing partners, noninjection drug use, and higher income were predictors for multiple sexual partners.

CONCLUSIONS

LT-MAT did not significantly modify risky sexual behavior among HIV-uninfected PWID. Interventions that reduce sexual risk should target PWID with history of incarceration, alcohol use, and needle sharing.

Infectious Diseases Physicians' Perspectives Regarding Injection Drug Use and Related Infections, United States, 2017

Background

In the context of the opioid epidemic, injection drug use (IDU)-related infections are an escalating health issue for infectious diseases (ID) physicians in the United States.

Methods

We conducted a mixed methods survey of the Infectious Diseases Society of America's Emerging Infections Network between February and April 2017 to evaluate perspectives relating to care of persons who inject drugs (PWID). Topics included the frequency of and management strategies for IDU-related infection, the availability of addiction services, and the evolving role of ID physicians in substance use disorder (SUD) management.

Results

More than half (53%, n = 672) of 1273 network members participated. Of these, 78% (n = 526) reported treating PWID. Infections frequently encountered included skin and soft tissue (62%, n = 324), bacteremia/fungemia (54%, n = 281), and endocarditis (50%, n = 263). In the past year, 79% (n = 416) reported that most IDU-related infections required ≥2 weeks of parenteral antibiotics; strategies frequently employed for prolonged treatment included completion of the entire course in the inpatient unit (41%, n = 218) or at another supervised facility (35%, n = 182). Only 35% (n = 184) of respondents agreed/strongly agreed that their health system offered comprehensive SUD management; 46% (n = 242) felt that ID providers should actively manage SUD.

Conclusions

The majority of physicians surveyed treated PWID and reported myriad obstacles to providing care. Public health and health care systems should consider ways to support ID physicians caring for PWID, including (1) guidelines for providing complex care, including safe provision of multiweek parenteral antibiotics; (2) improved access to SUD management; and (3) strategies to assist those interested in roles in SUD management.

Abuse liability of intravenous buprenorphine vs. buprenorphine/naloxone: Importance of absolute naloxone amount

BACKGROUND

This study sought to determine the relative importance of a range of Bup/Nx doses compared to Bup alone in producing subjective and reinforcing effects.

METHODS

Heroin-using volunteers (n=13) were transitioned onto daily oral hydromorphone (40mg). Laboratory sessions assessed the reinforcing and subjective effects of intravenous (IV) doses of Bup (1.51, 2.16, 6.15, and 8.64mg) and Bup/Nx (1.51/0.44, 2.16/0.61, 6.15/1.71, and 8.64/2.44mg). Placebo (Pbo), heroin (25mg) and Nx (0.3mg) were tested as neutral, positive, and negative controls, respectively.

RESULTS

IV Bup alone was self-administered substantially less than IV heroin, though the two largest doses of Bup produced positive subjective effects, drug "Liking" (0-100mm), which were comparable to heroin (mean difference: Heroin vs Bup 6.15mg: -3.4mm, Heroin vs Bup 8.64mg: -11.3mm). All indicators of abuse potential seen with IV Bup alone were substantially decreased with the addition of Nx. All Bup/Nx combinations produced ratings of aversive effects, "Bad", which were comparable to, or greater than IV, Nx. On three of the four measures of aversive effects, the largest difference is seen with the 8.64 vs 8.64/2.44 condition.

CONCLUSIONS

This study further demonstrates the ability of the Bup/Nx combination to deter IV use. Although none of the Bup/Nx combinations showed indications of abuse potential, formulations with larger absolute Nx, may be less abusable as they precipitate a greater degree of withdrawal.

A mixed methods study of HIV-related services in buprenorphine treatment

BACKGROUND

Opioid use disorder (OUD) is a major risk factor in the acquisition and transmission of HIV. Clinical practice guidelines call for the integration of HIV services in OUD treatment. This mixed methods study describes the integration of HIV services in buprenorphine treatment and examines whether HIV services vary by prescribers' medical specialty and across practice settings.

METHODS

Data were obtained via qualitative interviews with buprenorphine experts (n = 21) and mailed surveys from US buprenorphine prescribers (n = 1174). Survey measures asked about screening for HIV risk behaviors at intake, offering HIV education, recommending all new patients receive HIV testing, and availability of on-site HIV testing. Prescribers' medical specialty, practice settings, caseload demographics, and physician demographics were measured. Multivariate models of HIV services were estimated, while accounting for the nesting of physicians within states.

RESULTS

Qualitative interviews revealed that physicians often use injection behaviors as the primary indicator for whether a patient should be tested for HIV. Interviews revealed that HIV-related services were often viewed as beyond the scope of practice among general psychiatrists. Surveys indicated that prescribers screened for an average of 3.2 of 5 HIV risk behaviors (SD = 1.6) at intake. About 62.0% of prescribers delivered HIV education to patients and 53.2% recommended HIV testing to all new patients, but only 32.3% offered on-site HIV testing. Addiction specialists and psychiatrists screened for significantly more HIV risk behaviors than physicians in other specialties. Addiction specialists and psychiatrists were significantly less likely than other physicians to offer on-site testing. Physicians in individual medical practice were significantly less likely to recommend HIV testing and to offer onsite testing than physicians in other settings.

CONCLUSIONS

Buprenorphine treatment providers have not uniformly integrated HIV-related screening, education, and testing services for patients. Differences by medical specialty and practice setting suggest an opportunity for targeting efforts to increase implementation.

Advances in the treatment of opioid use disorders

The development of medications for treating persons with opioid use disorders has expanded the number of evidence-based treatment options, particularly for persons with the most severe disorders. It has also improved outcomes compared to psychosocial treatment alone and expanded treatment availability by increasing the number of physicians involved in treatment and the settings where patients can be treated. The medications include methadone, buprenorphine, buprenorphine/naloxone, and extended-release injectable naltrexone. Studies have shown that they are most effective when used over an extended, but as-yet-unspecified, period of time and with counseling and other services, particularly for the many with psychosocial problems. Though controversial in some cultures, well-designed studies in Switzerland, the Netherlands, Germany, and Canada have demonstrated the efficacy of supervised heroin injecting for persons who responded poorly to other treatments, and this treatment option has been approved by Switzerland and a few other E.U. countries. The degree to which medication-assisted therapies are available is dependent on many variables, including national and local regulations, preferences of individual providers and their geographical location, treatment costs, and insurance policies. Greater availability of medication-assisted therapies has become a major focus in the U.S. and Canada, where there has been a marked increase in deaths associated with heroin and prescription opioid use. This paper provides a brief summary of these developments.

Opiate Drugs with Abuse Liability Hijack the Endogenous Opioid System to Disrupt Neuronal and Glial Maturation in the Central Nervous System

The endogenous opioid system, comprised of multiple opioid neuropeptide and receptor gene families, is highly expressed by developing neural cells and can significantly influence neuronal and glial maturation. In many central nervous system (CNS) regions, the expression of opioid peptides and receptors occurs only transiently during development, effectively disappearing with subsequent maturation only to reemerge under pathologic conditions, such as with inflammation or injury. Opiate drugs with abuse liability act to modify growth and development by mimicking the actions of endogenous opioids. Although typically mediated by μ-opioid receptors, opiate drugs can also act through δ- and κ-opioid receptors to modulate growth in a cell-type, region-specific, and developmentally regulated manner. Opioids act as biological response modifiers and their actions are highly contextual, plastic, modifiable, and influenced by other physiological processes or pathophysiological conditions, such as neuro-acquired immunodeficiency syndrome. To date, most studies have considered the acute effects of opiates on cellular maturation. For example, activating opioid receptors typically results in acute growth inhibition in both neurons and glia. However, with sustained opioid exposure, compensatory factors become operative, a concept that has been largely overlooked during CNS maturation. Accordingly, this article surveys prior studies on the effects of opiates on CNS maturation, and also suggests new directions for future research in this area. Identifying the cellular and molecular mechanisms underlying the adaptive responses to chronic opiate exposure (e.g., tolerance) during maturation is crucial toward understanding the consequences of perinatal opiate exposure on the CNS.

Opiate addiction therapies and HIV-1 Tat: interactive effects on glial [Ca²⁺]i, oxyradical and neuroinflammatory chemokine production and correlative neurotoxicity

Few preclinical studies have compared the relative therapeutic efficacy of medications used to treat opiate addiction in relation to neuroAIDS. Here we compare the ability of methadone and buprenorphine, and the prototypic opiate morphine, to potentiate the neurotoxic and proinflammatory ([Ca²⁺]i, ROS, H2O2, chemokines) effects of HIV-1 Tat in neuronal and/or mixed-glial co-cultures. Repeated observations of neurons during 48 h exposure to combinations of Tat, equimolar concentrations (500 nM) of morphine, methadone, or buprenorphine exacerbated neurotoxicity significantly above levels seen with Tat alone. Buprenorphine alone displayed marked neurotoxicity at 500 nM, prompting additional studies of its neurotoxic effects at 5 nM and 50 nM concentrations ± Tat. In combination with Tat, buprenorphine displayed paradoxical, concentration-dependent, neurotoxic and neuroprotective actions. Buprenorphine neurotoxicity coincided with marked elevations in [Ca²⁺]i, but not increases in glial ROS or chemokine release. Tat by itself elevated the production of CCL5/RANTES, CCL4/MIP-1β, and CCL2/MCP-1. Methadone and buprenorphine alone had no effect, but methadone interacted with Tat to further increase production of CCL5/RANTES. In combination with Tat, all drugs significantly increased glial [Ca²⁺]i, but ROS was only significantly increased by co-exposure with morphine. Taken together, the increases in glial [Ca²⁺]i, ROS, and neuroinflammatory chemokines were not especially accurate predictors of neurotoxicity. Despite similarities, opiates displayed differences in their neurotoxic and neuroinflammatory interactions with Tat. Buprenorphine, in particular, was partially neuroprotective at a low concentration, which may result from its unique pharmacological profile at multiple opioid receptors. Overall, the results reveal differences among addiction medications that may impact neuroAIDS.

HIV risk reduction with buprenorphine-naloxone or methadone: findings from a randomized trial

OBJECTIVES

Compare HIV injecting and sex risk in patients being treated with methadone (MET) or buprenorphine-naloxone (BUP).

METHODS

Secondary analysis from a study of liver enzyme changes in patients randomized to MET or BUP who completed 24 weeks of treatment and had 4 or more blood draws. The initial 1:1 randomization was changed to 2:1 (BUP:MET) after 18 months due to higher dropout in BUP. The Risk Behavior Survey measured HIV risk before 30 days at baseline and weeks 12 and 24.

RESULTS

Among 529 patients randomized to MET, 391 (74%) were completers; among 740 randomized to BUP, 340 (46%) were completers; 700 completed the Risk Behavior Survey. There were significant reductions in injecting risk (P < 0.0008) with no differences between groups in mean number of times reported injecting heroin, speedball, other opiates, and number of injections; or percent who shared needles; did not clean shared needles with bleach; shared cookers; or engaged in front/back loading of syringes. The percent having multiple sex partners decreased equally in both groups (P < 0.03). For males on BUP, the sex risk composite increased; for males on MET, the sex risk decreased resulting in significant group differences over time (P < 0.03). For females, there was a significant reduction in sex risk (P < 0.02) with no group differences.

CONCLUSIONS

Among MET and BUP patients who remained in treatment, HIV injecting risk was equally and markedly reduced; however, MET retained more patients. Sex risk was equally and significantly reduced among females in both treatment conditions, but it increased for males on BUP and decreased for males on MET.

HIV testing and sexual risk reduction counseling in office-based buprenorphine/naloxone treatment

OBJECTIVES

We assessed the feasibility and preliminary efficacy of human immunodeficiency virus (HIV) testing with sexual risk reduction counseling for opioid-dependent patients initiating office-based buprenorphine/naloxone treatment.

METHODS

We conducted a 14-week randomized, controlled trial with 30 patients (original target of 114) assigned to receive buprenorphine/naloxone induction/stabilization and HIV testing with Brief Sexual Risk Management (BSRM) or Enhanced Sexual Risk Management (ESRM). We evaluated process measures and compared outcomes at baseline and during the 3-month follow-up.

RESULTS

Similar proportions of patients receiving BSRM and ESRM underwent HIV testing (93% vs 80%; P = 0.28) and completed counseling sessions (80% vs 67%; P = 0.40). Brief Sexual Risk Management sessions were shorter than ESRM sessions (15.4 vs 23.4 minutes), with comparable manual adherence (P = 0.80). Outcomes did not vary by BSRM versus ESRM.

CONCLUSIONS

Although the recruitment of opioid-dependent patients with sexual risk behaviors is challenging, HIV testing with sexual risk reduction counseling in office-based buprenorphine/naloxone treatment practice is feasible. Interventions to decrease sexual risk behaviors among a segment of this population are necessary.

Adherence to HIV treatment and care among previously homeless jail detainees

HIV-infected persons entering the criminal justice system (CJS) often experience suboptimal healthcare system engagement and social instability, including homelessness. We evaluated surveys from a multisite study of 743 HIV-infected jail detainees prescribed or eligible for antiretroviral therapy (ART) to understand correlates of healthcare engagement prior to incarceration, focusing on differences by housing status. Dependent variables of healthcare engagement were: (1) having an HIV provider, (2) taking ART, and (3) being adherent (≥95% of prescribed doses) to ART during the week before incarceration. Homeless subjects, compared to their housed counterparts, were significantly less likely to be engaged in healthcare using any measure. Despite Ryan White funding availability, insurance coverage remains insufficient among those entering jails, and having health insurance was the most significant factor correlated with having an HIV provider and taking ART. Individuals interfacing with the CJS, especially those unstably housed, need innovative interventions to facilitate healthcare access and retention.

Retention in methadone and buprenorphine treatment among African Americans

Methadone has been the most commonly used pharmacotherapy for the treatment of opioid dependence in U.S. public sector treatment, but availability of buprenorphine as an alternative medication continues to increase. Drawing data from two community-based clinical trials that were conducted nearly contemporaneously, this study examined retention in methadone versus buprenorphine treatment over 6 months among urban African Americans receiving treatment in one of four publicly-funded programs (N=478; 178 methadone; 300 buprenorphine). Adjusting for confounds related to medication selection, survival analysis revealed that buprenorphine patients are at substantially higher risk of dropout compared to methadone patients (HR=2.43; p<.001). Buprenorphine's retention disadvantage appears to be concentrated in the earlier phases of treatment (approximately the first 50 days), after which risk of subsequent dropout becomes similar for the two medications. These findings confirm a retention disparity between methadone and buprenorphine in this population, and suggest potential avenues for future research to enhance retention in buprenorphine treatment.

Buprenorphine for human immunodeficiency virus/hepatitis C virus-coinfected patients: does it serve as a bridge to hepatitis C virus therapy?

OBJECTIVES

Buprenorphine is associated with enhanced human immunodeficiency virus (HIV) treatment outcomes including increased antiretroviral therapy initiation rates, adherence, and CD4 cell counts among HIV-infected opioid-dependent individuals. Buprenorphine facilitates hepatitis C virus (HCV) treatment in opioid-dependent patients with HCV monoinfection. Less is known about buprenorphine's role in HIV/HCV coinfection.

METHODS

We conducted a retrospective chart review to evaluate HCV care for HIV-infected buprenorphine patients in the first 4 years of buprenorphine's integration into a Rhode Island HIV clinic.

RESULTS

Sixty-one patients initiated buprenorphine. All had HCV antibody testing; 57 (93%) were antibody-positive. All antibody-positive patients underwent HCV RNA testing; 48 (84%) were RNA-positive. Of these, 15 (31%) were not referred to HCV care. Among chronically infected patients, 3 received HCV treatment after buprenorphine; all had cirrhosis and none achieved viral eradication. At buprenorphine induction, most patients had inadequately controlled HIV infection, with detectable HIV RNA (59%) or CD4 cell count less than or equal to 350/μL (38%).

CONCLUSIONS

Buprenorphine has shown limited success to date as a bridge to HCV treatment within an HIV clinic. Buprenorphine's stabilization of opioid dependence and HIV disease may permit the use of HCV therapy over time.

Opioid maintenance treatment as a harm reduction tool for opioid-dependent individuals in New York City: the need to expand access to buprenorphine/naloxone in marginalized populations

The aim of this pilot study was to assess the effectiveness of buprenorphine/naloxone (BUP/NX) among marginalized, opioid-dependent individuals in terms of retention in and cycling into and out of a harm-reduction program. This pilot study enrolled 100 participants and followed them from November 2005 to July 2008. The overall proportion of patients retained in the program at the end of 3, 6, 9, and 12 months was 68%, 63%, 56%, and 42%, respectively. This pilot study demonstrated that BUP/NX could be successfully used to treat marginalized heroin users.

Predictors of abstinence: National Institute of Drug Abuse multisite buprenorphine/naloxone treatment trial in opioid-dependent youth

OBJECTIVE

To examine predictors of opioid abstinence in buprenorphine/naloxone (Bup/Nal)-assisted psychosocial treatment for opioid-dependent youth.

METHOD

Secondary analyses were performed of data from 152 youth (15-21 years old) randomly assigned to 12 weeks of extended Bup/Nal therapy or up to 2 weeks of Bup/Nal detoxification with weekly individual and group drug counseling. Logistic regression models were constructed to identify baseline and during-treatment predictors of opioid-positive urine (OPU) at week 12. Predictors were selected based on significance or trend toward significance (i.e., p < .1), and backward stepwise selection was used, controlling for treatment group, to produce final independent predictors at p ≤ .05.

RESULTS

Youth presenting to treatment with previous 30-day injection drug use and more active medical/psychiatric problems were less likely to have a week-12 OPU. Those with early treatment opioid abstinence (i.e., weeks 1 and 2) and those who received additional nonstudy treatments during the study were less likely to have a week-12 OPU and those not completing 12 weeks of treatment were more likely to have an OPU.

CONCLUSIONS

Youth with advanced illness (i.e., reporting injection drug use and additional health problems) and those receiving ancillary treatments to augment study treatment were more likely to have lower opioid use. Treatment success in the first 2 weeks and completion of 12 weeks of treatment were associated with lower rates of OPU. These findings suggest that youth with advanced illness respond well to Bup/Nal treatment and identify options for tailoring treatment for opioid-dependent youth presenting at community-based settings.

CLINICAL TRIAL REGISTRATION INFORMATION

Buprenorphine/Naloxone-Facilitated Rehabilitation for Opioid Dependent Adolescents; http://www.clinicaltrials.gov; NCT00078130.

Therapeutic drug monitoring of protease inhibitors and efavirenz in HIV-infected individuals with active substance-related disorders

BACKGROUND

Achieving targeted antiretroviral (ARV) plasma concentrations during long-term treatment in human immunodeficiency virus (HIV)-infected patients with substance-related disorders (SRDs) may be challenging due to a number of factors, including medication adherence, coinfection with hepatitis B or C virus, medication intolerance, and drug interactions. One approach to investigate these factors is to conduct therapeutic drug monitoring to measure ARV exposure during treatment. The objective of this study was to utilize therapeutic drug monitoring to compare efavirenz (EFV) and protease inhibitor pharmacokinetics in patients with and without SRDs.

METHODS

This was a multicenter, cross-sectional open-label study in patients with HIV-1 infection receiving antiretroviral therapy (ART), with active (n=129) or without (n=146) SRD according to National Institute on Drug Abuse criteria. Two hundred seventy-five subjects who were receiving either protease inhibitor-based or EFV-based ART regimens for >6 months were enrolled at 4 HIV treatment centers with an equal distribution of SRD and non-SRD at each site. The patients were instructed during enrollment visits with regard to the importance of adherence before and after study visits. Demographics and routine clinical laboratory tests were recorded.

RESULTS

Among the 275 patients, 47% had SRD with at least 1 substance. There were no significant differences between SRD and non-SRD groups for race, gender, age, or CD4 count at entry. A significantly higher proportion of patients with SRD had an entry HIV RNA plasma concentration>75 copies per milliliter compared with patients without SRD (40% vs 28%, P=0.044). Logistic regression modeling revealed an association between HIV RNA plasma concentration and African American race (P=0.017). A significantly higher proportion of SRDs also had an EFV or protease inhibitor trough concentration below the desired range (23% vs 9%, P=0.048). Significantly lower trough concentrations were noted in patients with SRDs receiving atazanavir (0.290 vs 0.976 μg/mL) or lopinavir (3.75 vs 5.30 μg/mL).

CONCLUSIONS

The pharmacokinetic data indicate differences between HIV-infected patients with and without SRDs that may influence viral load suppression during long-term ART. These findings require additional investigation in a randomized design with more intensive pharmacokinetic assessment to identify individual factors that are contributing to suboptimal ARV exposure in patients with SRDs.

Patient perspectives on buprenorphine/naloxone treatment in the context of HIV care

BACKGROUND

Research has shown that buprenorphine/naloxone (bup/nx) is a safe and effective treatment for opioid dependence. Few reports, however, describe the patient perspective on bup/nx treatment and its integration into HIV care settings.

METHODS

We conducted qualitative interviews with 33 patients to further investigate patient satisfaction and experience with bup/nx treatment and integrated care. Interviews focused on drug use/cessation history; attitudes toward and satisfaction with bup/nx treatment; and perspectives on integrated bup/nx treatment and HIV care.

RESULTS

Patients were overwhelmingly satisfied with the pharmacologic effects and treatment outcomes of bup/nx, including effectiveness in blocking cravings and controlling opioid use; decreased fear of withdrawal and/or missing doses; and an overall improvement in quality of life. Patients also described being more engaged with both their substance abuse treatment and HIV care, including greater ability to manage their own treatment, keep, appointments, and adhere to antiretroviral medication regimes. Counseling was seen by some patients as an important component of bup/nx treatment. Nearly all were positive about their experience with integrated care, appreciative of an improved drug treatment environment, convenience, and quality of care.

CONCLUSIONS

Findings suggest that patients report bup/nx to be a viable treatment and many prefer it to other opioid replacement therapies.

Advances in the prevention of heterosexual transmission of HIV/AIDS among women in the United States

Despite recent advances in testing and treatment, the incidence of HIV/AIDS in the United States has remained stagnant with an estimated 56,300 new infections every year. Women account for an increasing proportion of the epidemic. The vulnerability of women to HIV stems from both increased biologic susceptibility to heterosexual transmission and also the social, economic, and structural disadvantages they often confront. This review describes the main reasons for the increased vulnerability of U.S. women to HIV transmission with particular emphasis on specific highrisk groups including: non-Hispanic blacks, women who use drugs, women with a history of incarceration, and victims of intimate partner violence. Although behavioral approaches to HIV prevention may be effective, pragmatic implementation is often difficult, especially for women who lack sociocultural capital to negotiate condoms with their male partners. Recent advances in HIV prevention show promise in terms of female-initiated interventions. These notably include female condoms, non-specific vaginal microbicides, and antiretroviral oral and vaginal pre-exposure prophylaxis. In this review, we will present evidence in support of these new female-initiated interventions while also emphasizing the importance of advocacy and the political support for these scientific advances to be successful.

Drug treatment as HIV prevention: expanding treatment options

Research conducted during the first 20 years of the AIDS epidemic provided a solid foundation of data supporting methadone treatment as HIV prevention. Drug users in methadone treatment were consistently found to reduce the frequency of drug use, risk behaviors, and infections. These data have been consistent over time and across cultural settings and have been used to promote the expansion of drug treatment as a prevention intervention. More recently, data have emerged suggesting the prevention potential of medication-assisted treatments other than methadone (buprenorphine/naloxone and naltrexone). Still, with a few notable exceptions, global drug treatment coverage for opiate injectors remains remarkably low and only a few treatment interventions for stimulant use have shown efficacy in reducing HIV risk. Importantly, more recent data provide support for the role of drug treatment programs in improving access and adherence to antiretroviral treatment and that injection drug users in substance abuse treatment are more likely to achieve sustained viral suppression. While important challenges remain in maximizing its impact, the scientific literature provides strong evidence of the efficacy of drug treatment as an HIV prevention strategy.

Drug treatment as HIV prevention: a research update

Drug use continues to be a major factor fueling the global epidemic of HIV infection. This article reviews the current literature on the ability of drug treatment programs to reduce HIV transmission among injection and noninjection drug users. Most data come from research on the treatment of opiate dependence and provide strong evidence on the effectiveness of medication-assisted treatment for reducing the frequency of drug use, risk behaviors, and HIV infections. This has been a consistent finding since the epidemic began among diverse populations and cultural settings. Use of medications other than methadone (such as buprenorphine/naloxone and naltrexone) has increased in recent years with promising data on their effectiveness as HIV prevention and as new treatment options for communities heavily affected by opiate use and HIV infection. However, few treatment interventions for stimulant abuse and dependence have shown efficacy in reducing HIV risk. The cumulative literature provides strong support of drug treatment programs for improving access and adherence to antiretroviral treatment. Drug users in substance abuse treatment are significantly more likely to achieve sustained viral suppression, making viral transmission less likely. Although there are challenges to implementing drug treatment programs for maximum impact, the scientific literature leaves no doubt about the effectiveness of drug treatment as an HIV prevention strategy.

The Physician Clinical Support System-Buprenorphine (PCSS-B): a novel project to expand/improve buprenorphine treatment

Opioid dependence is largely an undertreated medical condition in the United States. The introduction of buprenorphine has created the potential to expand access to and use of opioid agonist treatment in generalist settings. Physicians, however, often have limited training and experience providing this type of care. Some physicians believe having a mentoring relationship with an experienced provider during their initial introduction to the use of buprenorphine would ease implementation. Our goal was to describe the development, implementation, resources, and evaluation of the Physician Clinical Support System-Buprenorphine (PCSS-B), a federally funded program to improve access to and quality of treatment with buprenorphine. We provide a description of the PCSS-B, a national network of 88 trained physician mentors with expertise in buprenorphine treatment and skills in clinical education. We provide information regarding the use the PCSS-B core services including telephone, email and in-person support, a website, clinical guidances, a warmline and outreach to primary care and specialty organizations. Between July 2005 and July 2009, 67 mentors and 4 clinical experts reported providing mentoring services to 632 participants in 48 states, Washington DC and Puerto Rico. A total of 1,455 contacts were provided through email (45%), telephone (34%) and in-person visits (20%). Seventy-six percent of contacts addressed a clinical issue. Eighteen percent of contacts addressed a logistical issue. The number of contacts per participant ranged from 1-125. Between August 2005 and April 2009 there were 72,822 visits to the PCSS-B website with 179,678 pages viewed. Seven guidances were downloaded more than 1000 times. The warmline averaged more than 100 calls per month. The PCSS-B model provides support for a mentorship program to assist non-specialty physicians in the provision of buprenorphine and may serve as a model for dissemination of other types of care.

Prevention of HIV infection for people who inject drugs: why individual, structural, and combination approaches are needed

HIV can spread rapidly between people who inject drugs (through injections and sexual transmission), and potentially the virus can pass to the wider community (by sexual transmission). Here, we summarise evidence on the effectiveness of individual-level approaches to prevention of HIV infection; review global and regional coverage of opioid substitution treatment, needle and syringe programmes, and antiretroviral treatment; model the effect of increased coverage and a combination of these three approaches on HIV transmission and prevalence in injecting drug users; and discuss evidence for structural-level interventions. Each intervention alone will achieve modest reductions in HIV transmission, and prevention of HIV transmission necessitates high-coverage and combined approaches. Social and structural changes are potentially beneficial components in a combined-intervention strategy, especially when scale-up is difficult or reductions in HIV transmission and injection risk are difficult to achieve. Although further evidence is needed on how to optimise combinations of interventions in different settings and epidemics, we know enough now about which actions are effective: the challenge is to deliver these well and to scale.

Comparison of costs and utilization among buprenorphine and methadone patients

AIMS

Buprenorphine is an effective alternative to methadone for treatment of opioid dependence, but economic concerns represent a barrier to implementation. The economic impacts of buprenorphine adoption by the US Veterans Health Administration (VHA) were examined.

DESIGN

Prescriptions of buprenorphine, methadone treatment visits, health-care utilization and cost, and diagnostic data were obtained for 2005.

FINDINGS

VHA dispensed buprenorphine to 606 patients and methadone to 8191 other patients during the study year. An analysis that controlled for age and diagnosis found that the mean cost of care for the 6 months after treatment initiation was $11,597 for buprenorphine and $14,921 for methadone (P < 0.001). Cost was not significantly different in subsequent months. The first 6 months of buprenorphine treatment included an average of 66 ambulatory care visits, significantly fewer than the 137 visits in methadone treatment (P < 0.001). In subsequent months, buprenorphine patients had 8.4 visits, significantly fewer than the 21.0 visits of methadone patients (P < 0.001). Compared to new methadone episodes, new buprenorphine episodes had 0.634 times the risk of ending [95% confidence interval 0.547-0.736]. Implementation of buprenorphine treatment was not associated with an influx of new opioid-dependent patients.

CONCLUSION

Despite the higher cost of medication, buprenorphine treatment was no more expensive than methadone treatment. VHA methadone treatment costs were higher than reported by other providers. Although new buprenorphine treatment episodes lasted longer than new methadone episodes, buprenorphine is recommended for more adherent patients.

Factors affecting willingness to provide buprenorphine treatment

Buprenorphine is an effective long-term opioid agonist treatment. As the only pharmacological treatment for opioid dependence readily available in office-based settings, buprenorphine may facilitate a historic shift in addiction treatment from treatment facilities to general medical practices. Although many patients have benefited from the availability of buprenorphine in the United States, almost half of current prescribers are addiction specialists suggesting that buprenorphine treatment has not yet fully penetrated general practice settings. We examined factors affecting willingness to offer buprenorphine treatment among physicians with different levels of prescribing experience. Based on their prescribing practices, physicians were classified as experienced, novice, or as a nonprescriber and asked to assess the extent to which a list of factors impacted their prescription of buprenorphine. Several factors affected willingness to prescribe buprenorphine for all physicians: staff training; access to counseling and alternate treatment; visit time; buprenorphine availability; and pain medications concerns. Compared with other physicians, experienced prescribers were less concerned about induction logistics and access to expert consultation, clinical guidelines, and mental health services. They were more concerned with reimbursement. These data provide important insight into physician concerns about buprenorphine and have implications for practice, education, and policy change that may effectively support widespread adoption of buprenorphine.

Nurse practitioner and physician assistant interest in prescribing buprenorphine

Office-based buprenorphine places health care providers in a unique position to combine HIV and drug treatment in the primary care setting. However, federal legislation restricts nurse practitioners (NPs) and physician assistants (PAs) from prescribing buprenorphine, which may limit its potential for uptake and inhibit the role of these nonphysician providers in delivering drug addiction treatment to patients with HIV. This study aimed to examine the level of interest in prescribing buprenorphine among nonphysician providers. We anonymously surveyed providers attending HIV educational conferences in six large U.S. cities about their interest in prescribing buprenorphine. Overall, 48.6% (n = 92) of nonphysician providers were interested in prescribing buprenorphine. Compared to infectious disease specialists, nonphysician providers (adjusted odds ratio [AOR] = 2.89, 95% confidence interval [CI] = 1.22-6.83) and generalist physicians (AOR = 2.04, 95% CI = 1.09-3.84) were significantly more likely to be interested in prescribing buprenorphine. NPs and PAs are interested in prescribing buprenorphine. To improve uptake of buprenorphine in HIV settings, the implications of permitting nonphysician providers to prescribe buprenorphine should be further explored.

Integration and co-location of HIV/AIDS, tuberculosis and drug treatment services

Injection drug use (IDU) plays a critical role in the HIV epidemic in several countries throughout the world. In these countries, injection drug users are at significant risk for both HIV and tuberculosis, and active IDU negatively impacts treatment access, adherence and retention. Comprehensive strategies are therefore needed to effectively deliver preventive, diagnostic and curative services to these complex patient populations. We propose that developing co-located integrated care delivery systems should become the focus of national programmes as they continue to scale-up access to antiretroviral medications for drug users. Existing data suggest that such a programme will expand services for each of these diseases; increase detection of tuberculosis (TB) and HIV; improve medication adherence; increase entry into substance use treatment; decrease the likelihood of adverse drug events; and improve the effectiveness of prevention interventions. Key aspects of integration programmes include: co-location of services convenient to the patient; provision of effective substance use treatment, including pharmacotherapies; cross-training of generalist and specialist care providers; and provision of enhanced monitoring of drug-drug interactions and adverse side effects. Central to implementing this agenda will be fostering the political will to fund infrastructure and service delivery, expanding street-level outreach to IDUs, and training community health workers capable of cost effectively delivering these services.

Initial strategies for integrating buprenorphine into HIV care settings in the United States

The Centers for Disease Control and Prevention's HIV Prevention Strategic Plan Through 2005 advocated for increasing the proportion of persons with human immunodeficiency virus (HIV) infection and in need of substance abuse treatment who are successfully linked to services for these 2 conditions. There is evidence that integrating care for HIV infection and substance abuse optimizes outcomes for patients with both disorders. Buprenorphine, a recently approved medication for the treatment of opioid dependence in physicians' offices, provides the opportunity to integrate the treatment of HIV infection and substance abuse in one clinical setting, yet little information exists on the models of care that will most successfully facilitate this integration. To promote the uptake of this type of integrated care, the current review provides a description of 4 recently implemented models for combining buprenorphine treatment with HIV primary care: (1) an on-site addiction/HIV specialist treatment model; (2) a HIV primary care physician model; (3) a nonphysician health professional model; and (4) a community outreach model.

Buprenorphine Use: The International Experience

The confluence of the heroin injection epidemic and the human immunodeficiency virus (HIV) infection epidemic has increased the call for expanded access to effective treatments for both conditions. Buprenorphine and methadone are now listed on the World Health Organization's Model Essential Drugs List. In France, which has the most extensive experience, buprenorphine has been associated with a dramatic decrease in deaths due to overdose, and buprenorphine diversion appears to be associated with inadequate dosage, social vulnerability, and prescriptions from multiple providers. Other treatment models (in the United States, Australia, Germany, and Italy) and buprenorphine use in specific populations are also reviewed in the present article. In countries experiencing a dual epidemic of heroin use and HIV infection, such as former states of the Soviet Union and other eastern European and Asian countries, access to buprenorphine and methadone may be one potential tool for reducing the spread of HIV infection among injection drug users and for better engaging them in medical care.

Opioid Dependence: Rationale for and Efficacy of Existing and New Treatments

Opioid dependence is a chronic and relapsing medical disorder with a well-established neurobiological basis. Opioid agonist treatments, such as methadone and the recently approved buprenorphine, stabilize opioid receptors and the intracellular processes that lead to opioid withdrawal and craving. Both methadone and buprenorphine have been proven effective for the treatment of opioid dependence and can contribute to a decreased risk of human immunodeficiency virus (HIV) transmission. In addition, a buprenorphine/naloxone combination appears to have a decreased potential for abuse or diversion, compared with that associated with methadone. Largely because of these properties, recent legislation now affords an unprecedented opportunity for general physicians to offer opioid agonist treatment through their offices. This review focuses on the neurobiological basis of opioid dependence, the rationale for methadone and buprenorphine treatments, and issues in prescribing these medications to patients with HIV infection.

Pharmacokinetic Interactions between Buprenorphine and Antiretroviral Medications

Buprenorphine is used for the treatment of opioid dependence. As the number of persons receiving buprenorphine treatment and antiretroviral therapy continues to grow, so too does the existence and clinical impact of drug interactions between buprenorphine and medications for treating human immunodeficiency virus (HIV) infection. Awareness that such interactions exist may deter some patients and physicians from initiating potentially lifesaving therapy or lead to complications among patients whose treatment is already under way. Complications include nonadherence to antiretroviral therapy and the development of viral resistance. Illicit drug use is a frequent consequence of adverse drug effects experienced by injection drug users. The occurrence of unrecognized drug interactions can lead to unsuccessful therapy for HIV infection and the treatment of substance dependence. The present review is organized to provide a working background of buprenorphine pharmacology. Review of the current state of knowledge regarding specific interactions between buprenorphine and antiretrovirals is followed by a review of the clinical applicability of these interactions.

A Trial of Integrated Buprenorphine/Naloxone and HIV Clinical Care

BACKGROUND

Untreated opioid dependence adversely affects the care of human immunodeficiency virus (HIV)-positive patients. Buprenorphine, a partial opioid agonist, is available for maintenance treatment of opioid dependence in HIV specialty settings. We investigated the feasibility and efficacy of integrating buprenorphine, along with 2 levels of counseling, into HIV clinical care.

METHODS

HIV-positive, opioid-dependent patients were enrolled in a 12-week pilot study and randomized to receive daily buprenorphine/naloxone treatment along with either brief physician management or physician management combined with nurse-administered drug counseling and adherence management. Primary outcomes included treatment retention; illicit drug use, assessed by urine toxicology test and self-report; CD4 lymphocyte counts; and log(10) HIV type 1 (HIV-1) RNA levels.

RESULTS

Of the 16 patients who received at least 1 dose of buprenorphine, 13 (81%) completed 12 weeks of treatment. The proportion of opioid-positive weekly urine test results decreased from 100% at baseline to 32% (month 1), 20% (month 2), and 16% (month 3). Only 4 patients reported any opioid use (in the prior 7 days) during the 12-week study. CD4 lymphocyte counts remained stable over the course of the study. The mean log(10) HIV-1 RNA level (+/- standard deviation) declined significantly, from 3.66+/-1.06 log(10) HIV-1 RNA copies/mL at baseline to 3.0+/-0.57 log(10) HIV-1 RNA copies/mL at month 3 (P<.05). No significant differences based on counseling intervention were detected. All 13 patients who completed the study continued to receive treatment in an extension phase of at least 0-15 months' duration.

CONCLUSIONS

We conclude that it is feasible to integrate buprenorphine into HIV clinical care for the treatment of opioid dependence. Patients experienced good treatment retention and reductions in their opioid use. HIV biological markers remained stable or improved during buprenorphine/naloxone treatment.

Directly administered antiretroviral therapy in methadone clinics is associated with improved HIV treatment outcomes, compared with outcomes among concurrent comparison groups

BACKGROUND

Directly administered antiretroviral therapy (DAART) in methadone clinics has the potential to improve treatment outcomes for human immunodeficiency virus (HIV)-infected injection drug users (IDUs).

METHODS

DAART was provided at 3 urban methadone clinics. Eighty-two participants who were initiating or reinitiating highly active antiretroviral therapy (HAART) received supervised doses of therapy at the clinic on the mornings on which they received methadone. Treatment outcomes in the DAART group were compared with outcomes in 3 groups of concurrent comparison patients, who were drawn from the Johns Hopkins HIV Cohort. The concurrent comparison patients were taking HAART on a self-administered basis. The 3 groups of concurrent comparison patients were as follows: patients with a history of IDU who were receiving methadone at the time HAART was used (the IDU-methadone group; 75 patients), patients with a history of IDU who were not receiving methadone at the time that HAART was used (the IDU-nonmethadone group; 244 patients), and patients with no history of IDU (the non-IDU group; 490 patients).

RESULTS

At 12 months, 56% of DAART participants achieved an HIV type 1 RNA level <400 copies/mL, compared with 32% of participants in the IDU-methadone group (P=.009), 33% of those in the IDU-nonmethadone group (P=.001), and 44% of those in the non-IDU group (P=.077). The DAART group experienced a median increase in the CD4 cell count of 74 cells/mm3, compared with 21 cells/mm3 in the IDU-methadone group (P=.04), 33 cells/mm3 in the IDU-nonmethadone group (P=.09), and 84 cells/mm3 in the non-IDU group (P=.98). After adjustment for other covariates in a logistic regression model, DAART participants were significantly more likely to achieve viral suppression than were patients in each of the 3 comparison groups.

CONCLUSIONS

These results suggest that methadone clinic-based DAART has the potential to provide substantial clinical benefit for HIV-infected IDUs.