1
|
Monroe AK, Happ LP, Rayeed N, Ma Y, Jaurretche MJ, Terzian AS, Trac K, Horberg MA, Greenberg AE, Castel AD. Clinic-Level Factors Associated With Time to Antiretroviral Initiation and Viral Suppression in a Large, Urban Cohort. Clin Infect Dis 2020; 71:e151-e158. [PMID: 31701144 PMCID: PMC7583410 DOI: 10.1093/cid/ciz1098] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 11/06/2019] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Using the results of a site assessment survey performed at clinics throughout Washington, DC, we studied the impact of clinic-level factors on antiretroviral therapy (ART) initiation and viral suppression (VS) among people living with human immunodeficiency virus (HIV; PLWH). METHODS This was a retrospective analysis from the District of Columbia (DC) Cohort, an observational, clinical cohort of PLWH from 2011-2018. We included data from PLWH not on ART and not virally suppressed at enrollment. Outcomes were ART initiation and VS (HIV RNA < 200 copies/mL). A clinic survey captured information on care delivery (eg, clinical services, adherence services, patient monitoring services) and clinic characteristics (eg, types of providers, availability of evenings/weekends sessions). Multivariate marginal Cox regression models were generated to identify those factors associated with the time to ART initiation and VS. RESULTS Multiple clinic-level factors were associated with ART initiation, including retention in care monitoring and medication dispensing reviews (adjusted hazard ratios [aHRs], 1.34 to 1.40; P values < .05 for both). Furthermore, multiple factors were associated with VS, including retention in HIV care monitoring, medication dispensing reviews, and the presence of a peer interventionist (aHRs, 1.35 to 1.72; P values < .05 for all). In multivariable models evaluating different combinations of clinic-level factors, enhanced adherence services (aHR, 1.37; 95% confidence interval [CI], 1.18-1.58), medication dispensing reviews (aHR, 1.22; 95% CI, 1.10-1.36), and the availability of opioid treatment (aHR, 1.26; 95% CI, 1.01-1.57) were all associated with the time to VS. CONCLUSIONS The observed association between clinic-level factors and ART initiation/VS suggests that the presence of specific clinic services may facilitate the achievement of HIV treatment goals.
Collapse
Affiliation(s)
- Anne K Monroe
- Department of Epidemiology, Milken Institute School of Public Health, The George Washington University, Washington, DC, USA
| | - Lindsey P Happ
- Department of Epidemiology, Milken Institute School of Public Health, The George Washington University, Washington, DC, USA
| | | | - Yan Ma
- Department of Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, DC, USA
| | - Maria J Jaurretche
- Department of Epidemiology, Milken Institute School of Public Health, The George Washington University, Washington, DC, USA
| | - Arpi S Terzian
- Department of Epidemiology, Milken Institute School of Public Health, The George Washington University, Washington, DC, USA
| | - Kevin Trac
- Department of Epidemiology, Milken Institute School of Public Health, The George Washington University, Washington, DC, USA
| | - Michael A Horberg
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, Maryland, USA
| | - Alan E Greenberg
- Department of Epidemiology, Milken Institute School of Public Health, The George Washington University, Washington, DC, USA
| | - Amanda D Castel
- Department of Epidemiology, Milken Institute School of Public Health, The George Washington University, Washington, DC, USA
| |
Collapse
|
2
|
Thakarar K, Walley AY, Heeren TC, Winter MR, Ventura AS, Sullivan M, Drainoni M, Saitz R. Medication for addiction treatment and acute care utilization in HIV-positive adults with substance use disorders. AIDS Care 2020; 32:1177-1181. [PMID: 31686528 PMCID: PMC7198361 DOI: 10.1080/09540121.2019.1683805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Medication for addiction treatment (MAT) could reduce acute care utilization in HIV-positive individuals with substance use disorders. The study objective was to determine if HIV-positive people with substance use disorders treated with MAT report less acute care utilization than those not receiving MAT. We assessed the association between MAT and acute care utilization among HIV-positive individuals with alcohol or opioid use disorder. Acute care utilization 6 months later was defined as any past 3-month self-reported (1) emergency department (ED) visit and (2) hospitalization. Of 153 participants, 88% had alcohol use disorder, 41% had opioid use disorder, and 48 (31%) were treated with MAT. Fifty-five (36%) participants had an ED visit and 38 (25%) participants had a hospitalization. MAT was not associated with an ED visit (AOR 1.12, 95% CI 0.46-2.75) or hospitalization (AOR 1.09, 95% CI 0.39-3.04). MAT was not associated with acute care utilization. These results highlight the need to increase MAT prescribing in HIV-positive individuals with substance use disorders, and to address the many factors that influence acute care utilization.
Collapse
Affiliation(s)
- K Thakarar
- Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, ME, USA.,Tufts University School of Medicine, Boston, MA, USA
| | - A Y Walley
- Boston Medical Center, Boston, MA, USA.,Boston University School of Medicine, Boston, MA, USA
| | - T C Heeren
- Boston University School of Public Health, Boston, MA, USA
| | - M R Winter
- Boston University School of Public Health, Boston, MA, USA
| | | | | | - M Drainoni
- Boston University School of Medicine, Boston, MA, USA.,Boston University School of Public Health, Boston, MA, USA.,Center for Healthcare Organization and Implementation Research, ENRM Memorial VA Hospital, Bedford, MA, USA
| | - R Saitz
- Boston Medical Center, Boston, MA, USA.,Boston University School of Medicine, Boston, MA, USA.,Boston University School of Public Health, Boston, MA, USA.,Clinical Research and Education Unit, Section of General Internal Medicine, Boston, MA, USA
| |
Collapse
|
3
|
Opioid-Related Diagnoses and Concurrent Claims for HIV, HBV, or HCV among Medicare Beneficiaries, United States, 2015. J Clin Med 2019; 8:jcm8111768. [PMID: 31652928 PMCID: PMC6912616 DOI: 10.3390/jcm8111768] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 10/17/2019] [Accepted: 10/21/2019] [Indexed: 01/10/2023] Open
Abstract
Unsterile opioid injection increases risk for infection transmission, including HIV, hepatitis B virus (HBV), or hepatitis C virus (HCV). We assess prevalence of and risk factors associated with opioid overdose and infections with HIV, HBV, or HCV among Medicare beneficiaries with opioid-related fee-for-service claims during 2015. We conducted a cross-sectional analysis to estimate claims for opioid use and overdose and HIV, HBV, or HCV infections, using data from US Medicare fee-for-service claims. Beneficiaries with opioid-related claims had increased odds for HIV (2.3; 95% confidence interval (CI), 2.3–2.4), acute HBV (6.7; 95% CI, 6.3–7.1), chronic HBV (5.0; 95% CI, 4.7–5.4), acute HCV (9.6; 95% CI, 9.2–10.0), and chronic HCV (8.9; 95% CI, 8.7–9.1). Beneficiaries with opioid-related claims and for HIV, HBV, or HCV infection, respectively, had a 1.1–1.9-fold odds for having a claim for opioid overdose. Independent risk factors for opioid overdose and each selected infection outcome included age, sex, race/ethnicity, region, and residence in a high-vulnerability county. Having opioid-related claims and selected demographic attributes were independent, significant risk factors for having HIV, HBV, or HCV claims among US Medicare beneficiaries. These results might help guide interventions intended to reduce incidences of HIV, HCV, and HBV infections among beneficiaries with opioid-related claims.
Collapse
|
4
|
Cooke A, Saleem H, Hassan S, Mushi D, Mbwambo J, Lambdin B. Patient and provider perspectives on implementation barriers and facilitators of an integrated opioid treatment and HIV care intervention. Addict Sci Clin Pract 2019; 14:3. [PMID: 30691511 PMCID: PMC6350287 DOI: 10.1186/s13722-019-0133-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 01/18/2019] [Indexed: 01/22/2023] Open
Abstract
Background In Dar es Salaam Tanzania, the first opioid treatment program (OTP) in Sub-Saharan Africa, had very high rates of enrollment of people who use drugs (PWUD) but low rates of antiretroviral therapy (ART) initiation among HIV-positive patients. The integrated methadone and anti-retroviral therapy (IMAT) intervention was developed to integrate HIV services into the OTP clinic. The objective of this paper is to better understand the contextual factors that influence the effectiveness of IMAT implementation using the consolidated framework for implementation research (CFIR). Methods Semi-structured, in-depth interviews were conducted with 35 HIV-positive OTP patients and 8 OTP providers at the Muhimbili National Hospital OTP clinic 6-months after IMAT implementation. Providers were asked about their reactions to and opinions of the IMAT intervention including its implementation, their role in patient education, intervention procedures, and ART dispensing. Interviews with patients focused on their experiences with the IMAT intervention and adapting to the new protocol. Analysis of interview data was guided by the CFIR. Results The CFIR constructs found to be driving forces behind facilitating or impeding IMAT implementation were: intervention characteristics (e.g. complexity, adaptability and evidence related to IMAT), outer setting (e.g. patient needs and resources), and inner setting (e.g. compatibility of IMAT and available resources for IMAT). The most significant barrier to implementation identified in interviews was availability of resources, including workforce limitations and lack of space given patient load. OTP providers and patients felt the design of the IMAT intervention allowed for adaptability to meet the needs of providers and patients. Conclusions Understanding the contextual factors that influence implementation is critical to the success of interventions that seek to integrate HIV services into existing programs for key populations such as PWUD. Approximately 4 months after IMAT implementation, the OTP clinic adopted a ‘test-and-treat’ model for HIV-positive PWUD, which significantly impacted clinic workload as well as the care context. In this study we highlight the importance of intervention characteristics and resources, as key facilitators and barriers to implementation, that should be actively integrated into intervention protocols to increase implementation success. Similar interventions in other low-resource settings should address the ways intervention characteristics and contextual factors, such as adaptability, complexity and available resources impact implementation in specific care contexts.
Collapse
Affiliation(s)
- Alexis Cooke
- Department of Psychiatry, University of California, San Francisco, 3333 California Street, Suite 485, San Francisco, CA, 94118, USA.
| | - Haneefa Saleem
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Dorothy Mushi
- Department of Psychiatry, Muhimbili University of Health and Allied Sciences, Dar-es-Salaam, Tanzania
| | - Jessie Mbwambo
- Department of Psychiatry, Muhimbili University of Health and Allied Sciences, Dar-es-Salaam, Tanzania
| | | |
Collapse
|
5
|
Voon P, Joe R, Fairgrieve C, Ahamad K. Treatment of opioid use disorder in an innovative community-based setting after multiple treatment attempts in a woman with untreated HIV. BMJ Case Rep 2016; 2016:bcr-2016-215557. [PMID: 27402654 DOI: 10.1136/bcr-2016-215557] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Opioid use disorder is associated with significant health and social harms. Various evidence-based interventions have proven successful in mitigating these harms, including harm reduction strategies and pharmacological treatment such as methadone. We present a case of a 35-year-old HIV-positive woman who was off antiretroviral therapy due to untreated opioid use disorder, and had a history of frequently self-discharging from hospital against medical advice. During the most recent hospital admission, the patient was transferred to an innovative community-based clinical support residence that supported harm reduction. Initially, she received methadone to only manage the withdrawal symptoms rather than for long-term maintenance therapy. However, with gradual dose increases to treat cravings and withdrawal, she ultimately discontinued all drug use and reinitiated antiretroviral therapy. This case highlights that patients whose goal is not abstinence can be successfully treated for acute medical illnesses and comorbid substance use disorders using harm reduction approaches, including appropriate dosing of pharmacotherapy.
Collapse
Affiliation(s)
- Pauline Voon
- Urban Health Research Initiative, BC Centre for Excellence in HIV/AIDS, UBC, Vancouver, British Columbia, Canada Faculty of Medicine, School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ronald Joe
- Department of Vancouver Community, Vancouver Coastal Health, Vancouver, British Columbia, Canada Faculty of Medicine, Department of Family Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Christopher Fairgrieve
- Urban Health Research Initiative, BC Centre for Excellence in HIV/AIDS, UBC, Vancouver, British Columbia, Canada
| | - Keith Ahamad
- Urban Health Research Initiative, BC Centre for Excellence in HIV/AIDS, UBC, Vancouver, British Columbia, Canada
| |
Collapse
|
6
|
Lee J, Kresina TF, Campopiano M, Lubran R, Clark HW. Use of pharmacotherapies in the treatment of alcohol use disorders and opioid dependence in primary care. BIOMED RESEARCH INTERNATIONAL 2015; 2015:137020. [PMID: 25629034 PMCID: PMC4299453 DOI: 10.1155/2015/137020] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Revised: 08/22/2014] [Accepted: 09/10/2014] [Indexed: 01/10/2023]
Abstract
Substance-related and addictive disorders are chronic relapsing conditions that substantially impact public health. Effective treatments for these disorders require addressing substance use/dependence comprehensively as well as other associated comorbidities. Comprehensive addressing of substance use in a medical setting involves screening for substance use, addressing substance use directly with the patient, and formulating an appropriate intervention. For alcohol dependence and opioid dependence, pharmacotherapies are available that are safe and effective when utilized in a comprehensive treatment paradigm, such as medication assisted treatment. In primary care, substance use disorders involving alcohol, illicit opioids, and prescription opioid abuse are common among patients who seek primary care services. Primary care providers report low levels of preparedness and confidence in identifying substance-related and addictive disorders and providing appropriate care and treatment. However, new models of service delivery in primary care for individuals with substance-related and addictive disorders are being developed to promote screening, care and treatment, and relapse prevention. The education and training of primary care providers utilizing approved medications for the treatment of alcohol use disorders and opioid dependence in a primary care setting would have important public health impact and reduce the burden of alcohol abuse and opioid dependence.
Collapse
Affiliation(s)
- Jinhee Lee
- Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, Rockville, MD 20857, USA
- Division of Pharmacologic Therapies, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 1 Choke Cherry Road, Rockville, MD 20857, USA
| | - Thomas F. Kresina
- Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, Rockville, MD 20857, USA
- Division of Pharmacologic Therapies, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 1 Choke Cherry Road, Rockville, MD 20857, USA
| | - Melinda Campopiano
- Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, Rockville, MD 20857, USA
- Division of Pharmacologic Therapies, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 1 Choke Cherry Road, Rockville, MD 20857, USA
| | - Robert Lubran
- Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, Rockville, MD 20857, USA
- Division of Pharmacologic Therapies, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 1 Choke Cherry Road, Rockville, MD 20857, USA
| | - H. Westley Clark
- Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, Rockville, MD 20857, USA
| |
Collapse
|
7
|
Meyer JP, Althoff AL, Altice FL. Optimizing care for HIV-infected people who use drugs: evidence-based approaches to overcoming healthcare disparities. Clin Infect Dis 2013; 57:1309-17. [PMID: 23797288 PMCID: PMC3792721 DOI: 10.1093/cid/cit427] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2013] [Accepted: 06/14/2013] [Indexed: 12/12/2022] Open
Abstract
Substance use disorders (SUDs) and human immunodeficiency virus (HIV) are pervasive epidemics that synergize, resulting in negative outcomes for HIV-infected people who use drugs (PWUDs). The expanding epidemiology of substance use demands a parallel evolution of the HIV specialist-beyond HIV to diagnosis and management of comorbid SUDs. The purpose of this paper is to describe healthcare disparities for HIV-infected PWUDs along each point of a continuum of care, and to suggest evidence-based strategies for overcoming these healthcare disparities. Despite extensive dedicated resources and availability of antiretroviral therapy (ART) in the United States, PWUDs continue to experience delayed HIV diagnosis, reduced entry into and retention in HIV care, delayed initiation of ART, and inferior HIV treatment outcomes. Overcoming these healthcare disparities requires integrated packages of clinical, pharmacological, behavioral, and social services, delivered in ways that are cost-effective and convenient and include, at a minimum, screening for and treatment of underlying SUDs.
Collapse
|
8
|
A novel bivalent HIV-1 entry inhibitor reveals fundamental differences in CCR5-μ-opioid receptor interactions between human astroglia and microglia. AIDS 2013; 27:2181-90. [PMID: 23751259 DOI: 10.1097/qad.0b013e3283639804] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We explored whether the opiate, morphine, affects the actions of maraviroc, as well as a recently synthesized bivalent derivative of maraviroc linked to an opioid antagonist, naltrexone, on HIV-1 entry in primary human glia. METHODS HIV-1 entry was monitored in glia transiently transfected with an LTR construct containing a luciferase reporter gene under control of a promoter for the HIV-1 transactivator protein Tat. The effect of maraviroc and the bivalent ligand with or without morphine on CCR5 surface expression and cytokine release was also explored. RESULTS Maraviroc inhibits HIV-1 entry into glial cells, whereas morphine negates the effects of maraviroc leading to a significant increase in viral entry. We also demonstrate that the maraviroc-containing bivalent ligand better inhibits R5-tropic viral entry in astrocytes than microglia compared to maraviroc when coadministered with morphine. Importantly, the inhibitory effects of the bivalent compound in astrocytes were not compromised by morphine. Exposure to maraviroc decreased the release of pro-inflammatory cytokines and restricted HIV-1-dependent increases in CCR5 expression in both astrocytes and microglia, whereas exposure to the bivalent had a similar effect in astrocytes but not in microglia. The CCR5-μ-opioid receptor (MOR) stoichiometric ratio varied among the two cell types with CCR5 expressed at much higher levels than MOR in microglia, which could explain the effectiveness of the bivalent ligand in astrocytes compared to microglia. CONCLUSION A novel bivalent compound reveals fundamental differences in CCR5-MOR interactions and HIV-1 infectivity among glia, and has unique therapeutic potential in opiate abuse-HIV interactive comorbidity.
Collapse
|
9
|
Tran BX, Ohinmaa A, Duong AT, Nguyen LT, Vu PX, Mills S, Houston S, Jacobs P. Cost-effectiveness of integrating methadone maintenance and antiretroviral treatment for HIV-positive drug users in Vietnam's injection-driven HIV epidemics. Drug Alcohol Depend 2012; 125:260-6. [PMID: 22436971 DOI: 10.1016/j.drugalcdep.2012.02.021] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2011] [Revised: 02/26/2012] [Accepted: 02/26/2012] [Indexed: 10/28/2022]
Abstract
Drug use negatively affects adherence to and outcomes of antiretroviral treatment (ART). This study evaluated the cost-effectiveness of integrating methadone maintenance treatment (MMT) with ART for HIV-positive drug users (DUs) in Vietnam. A decision analytical model was developed to compare the costs and consequences of 3 HIV/AIDS treatment strategies for DUs: (1) only ART, (2) providing ART and MMT in separated sites (ART-MMT), and (3) integrating ART and MMT with direct administration (DAART-MMT). The model was parameterized using empirical data of costs and outcomes extracted from the MMT and ART cohort studies in Vietnam, and international published sources. Probabilistic sensitivity analysis was conducted to examine the model's robustness. The base-case analysis showed that the cost-effectiveness ratio of ART, DAART-MMT, and ART-MMT strategies was USD 1358.9, 1118.0 and 1327.1 per 1 Quality-Adjusted Life Year (QALY), equivalent to 1.22, 1.00, and 1.19 times Gross Domestic Product per capita (GDPpc). The incremental cost-effectiveness ratio for DAART-MMT and ART-MMT versus ART strategy was 569.4 and 1227.8, approximately 0.51 and 1.10 times GDPpc/QALY. At the willingness to pay threshold of 3 times GDPpc, the probability of being cost-effective of DAART-MMT versus ART was 86.1%. These findings indicated that providing MMT along with ART for HIV-positive DUs is a cost-effective intervention in Vietnam. Integrating MMT and ART services could facilitate the use of directly observed therapy that supports treatment adherence and brings about clinically important improvements in health outcomes. This approach is also incrementally cost-effective in this large injection-driven HIV epidemic.
Collapse
|
10
|
Abstract
Opioid dependence in the setting of pregnancy provides a distinct set of challenges for providers. Treatment plans must take into consideration psychiatric and medical comorbidities while balancing risks and benefits for the maternal-fetal dyad. Treatment is best offered through a comprehensive treatment program designed to effectively deliver opioid agonist maintenance treatment along with psychosocial and obstetric care. As misuse of prescription analgesics increases in the United States, identification of the problem in pregnancy will become more important because this misuse is expected to lead to an increased prevalence of opioid dependence in pregnancy. Buprenorphine as maintenance treatment of opioid dependence during pregnancy has promise and may offer some benefits, but more research is needed, especially regarding induction of actively addicted women during pregnancy. For the present, methadone maintenance remains the standard of care for agonist treatment of opioid dependence in pregnancy against which other treatments must be compared.
Collapse
Affiliation(s)
- Jessica L Young
- Vanderbilt University Medical Center, Nashville, TN 37232, USA.
| | | |
Collapse
|
11
|
Abstract
Research on the epidemiology of illicit drug use disorders provides continued critical insights into the distribution and determinants of drug use and drug use disorders in the United States. This research serves as a foundation for understanding the etiology of these disorders, helping to disentangle the complex interrelationship of developmental, genetic, and environmental risk and protective factors. Building on an understanding of this research in substance abuse epidemiology, it is important for clinicians to understand the unique trends in drug use in the overall communities that they serve and the unique risk factors for given individuals. The generally high prevalence of substance use disorders, along with their high comorbidity with other psychiatric disorders and with the HIV epidemic, make prevention, evaluation, and referral for treatment for drug abuse an important part of routine clinical practice in a range of clinical settings, including primary care, psychiatric, and emergency department settings. Ongoing efforts to ensure insurance coverage parity for the treatment of mental health and substance use disorders offer the promise of continued improvements in the integration and availability of such services in the broader US health care system.
Collapse
Affiliation(s)
- Jeffrey D Schulden
- Division of Epidemiology, Services, and Prevention Research, National Institute on Drug Abuse (NIDA), Bethesda, MD 20892-9589, USA.
| | | | | |
Collapse
|
12
|
Survey of methadone-drug interactions among patients of methadone maintenance treatment program in Taiwan. SUBSTANCE ABUSE TREATMENT PREVENTION AND POLICY 2012; 7:11. [PMID: 22429858 PMCID: PMC3373376 DOI: 10.1186/1747-597x-7-11] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/08/2011] [Accepted: 03/20/2012] [Indexed: 11/10/2022]
Abstract
BACKGROUND Although methadone has been used for the maintenance treatment of opioid dependence for decades, it was not introduced in China or Taiwan until 2000s. Methadone-drug interactions (MDIs) have been shown to cause many adverse effects. However, such effects have not been scrutinized in the ethnic Chinese community. METHODS The study was performed in two major hospitals in southern Taiwan. A total of 178 non-HIV patients aged ≥ 20 years who had participated in the Methadone Maintenance Treatment Program (MMTP) ≥ 1 month were recruited. An MDI is defined as concurrent use of drug(s) with methadone that may result in an increase or decrease of effectiveness and/or adverse effect of methadone. To determine the prevalence and clinical characteristics of MDIs, credible data sources, including the National Health Insurance (NHI) database, face-to-face interviews, medical records, and methadone computer databases, were linked for analysis. Socio-demographic and clinical factors associated with MDIs and co-medications were also examined. RESULTS 128 (72%) MMTP patients took at least one medication. Clinically significant MDIs included withdrawal symptoms, which were found among MMTP patients co-administered with buprenorphine or tramadol; severe QTc prolongation effect, which might be associated with use of haloperidol or droperidol; and additive CNS and respiratory depression, which could result from use of methadone in combination with chlorpromazine or thioridazine. Past amphetamine use, co-infection with hepatitis C, and a longer retention in the MMTP were associated with increased odds of co-medication. Among patients with co-medication use, significant correlates of MDIs included the male gender and length of co-medication in the MMTP. CONCLUSIONS The results demonstrate clinical evidence of significant MDIs among MMTP patients. Clinicians should check the past medical history of MMTP clients carefully before prescribing medicines. Because combinations of methadone with other psychotropic or opioid medications can affect treatment outcomes or precipitate withdrawal symptoms, clinicians should be cautious when prescribing these medications to MMTP patients and monitor the therapeutic effects and adverse drug reactions. Although it is difficult to interconnect medical data from different sources for the sake of privacy protection, the incumbent agency should develop pharmacovigilant measures to prevent the MDIs from occurring. Physicians are also advised to check more carefully on the medication history of their MMTP patients.
Collapse
|
13
|
Yuan Y, Arnatt CK, Li G, Haney KM, Ding D, Jacob JC, Selley DE, Zhang Y. Design and synthesis of a bivalent ligand to explore the putative heterodimerization of the mu opioid receptor and the chemokine receptor CCR5. Org Biomol Chem 2012; 10:2633-46. [PMID: 22354464 DOI: 10.1039/c2ob06801j] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The bivalent ligand approach has been utilized not only to study the underlying mechanism of G protein-coupled receptors dimerization and/or oligomerization, but also to enhance ligand affinity and/or selectivity for potential treatment of a variety of diseases by targeting this process. Substance abuse and addiction have made both the prevention and the treatment of human immunodeficiency virus (HIV) infection more difficult to tackle. Morphine, a mu opioid receptor (MOR) agonist, can accelerate HIV infection through up-regulating the expression of the chemokine receptor CCR5, a well-known co-receptor for HIV invasion to the host cells and this has been extensively studied. Meanwhile, two research groups have described the putative MOR-CCR5 heterodimers in their independent studies. The purpose of this paper is to report the design and synthesis of a bivalent ligand to explore the biological and pharmacological process of the putative MOR-CCR5 dimerization phenomenon. The developed bivalent ligand thus contains two distinct pharmacophores linked through a spacer; ideally one of which will interact with the MOR and the other with the CCR5. Naltrexone and Maraviroc were selected as the pharmacophores to generate such a bivalent probe. The overall reaction route to prepare this bivalent ligand was convergent and efficient, and involved sixteen steps with moderate to good yields. The preliminary biological characterization showed that the bivalent compound 1 retained the pharmacological characteristics of both pharmacophores towards the MOR and the CCR5 respectively with relatively lower binding affinity, which tentatively validated our original molecular design.
Collapse
Affiliation(s)
- Yunyun Yuan
- Department of Medicinal Chemistry, Virginia Commonwealth University, 800 E. Leigh Street, Richmond, VA 23298, USA
| | | | | | | | | | | | | | | |
Collapse
|
14
|
Granich R, Gupta S, Suthar AB, Smyth C, Hoos D, Vitoria M, Simao M, Hankins C, Schwartlander B, Ridzon R, Bazin B, Williams B, Lo YR, McClure C, Montaner J, Hirnschall G. Antiretroviral therapy in prevention of HIV and TB: update on current research efforts. Curr HIV Res 2011; 9:446-69. [PMID: 21999779 PMCID: PMC3531820 DOI: 10.2174/157016211798038597] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2011] [Revised: 08/14/2011] [Accepted: 08/18/2011] [Indexed: 01/14/2023]
Abstract
There is considerable scientific evidence supporting the use of antiretroviral therapy (ART) in prevention of human immunodeficiency virus (HIV) and tuberculosis (TB) infections. The complex nature of the HIV and TB prevention responses, resource constraints, remaining questions about cost and feasibility, and the need to use a solid evidence base to make policy decisions, and the implementation challenges to translating trial data to operational settings require a well-organised and coordinated response to research in this area. To this end, we aimed to catalogue the ongoing and planned research activities that evaluate the impact of ART plus other interventions on HIV- and/or TB-related morbidity, mortality, risk behaviour, HIV incidence and transmission. Using a limited search methodology, 50 projects were identified examining ART as prevention, representing 5 regions and 52 countries with a global distribution. There are 24 randomised controlled clinical trials with at least 12 large randomised individual or community cluster trials in resource-constrained settings that are in the planning or early implementation stages. There is considerable heterogeneity between studies in terms of methodology, interventions and geographical location. While the identified studies will undoubtedly advance our understanding of the efficacy and effectiveness of ART for prevention, some key questions may remain unanswered or only partially answered. The large number and wide variety of research projects emphasise the importance of this research issue and clearly demonstrate the potential for synergies, partnerships and coordination across funding agencies.
Collapse
Affiliation(s)
- Reuben Granich
- Antiretroviral Treatment and HIV Care, Department of HIV/AIDS, Building D, 1st Floor, Room 1005, World Health Organization, Avenue Appia 20, CH-1211, Geneva 27, Switzerland.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
15
|
Brack A, Rittner HL, Stein C. Immunosuppressive effects of opioids--clinical relevance. J Neuroimmune Pharmacol 2011; 6:490-502. [PMID: 21728033 DOI: 10.1007/s11481-011-9290-7] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Accepted: 06/26/2011] [Indexed: 02/06/2023]
Abstract
Opioid-induced immunosuppression has been demonstrated in cell culture experiments and in animal models. This is in striking contrast to the paucity of confirmatory studies in humans. This review describes the basic pharmacokinetics and -dynamics of opioid use in patients. It summarizes the major findings on opioid use and infectious complications in intensive care unit (ICU) patients, in patients with acute or chronic non-malignant pain, and in intravenous drug users (IDU). The limitations of studies in each area are discussed. For example, ethical concerns may complicate randomized placebo-controlled trials (RCT) in acute postoperative pain and for a large part of ICU patients. Importantly, most studies in patients with chronic (non-malignant) pain only inadequately report infectious complications in relation to opioid use since their incidence is usually not considered to be drug related. Infectious complications in IDUs are very frequent but cannot easily be distinguished from risk behavior or risk environment. In summary, convincing clinical evidence is lacking that opioids per se increase the rate of infectious complications in most patient categories. From a clinical standpoint, important unresolved issues are i) selection of relevant animal models, ii) opioid selection and discontinuation, and iii) the role of coexisting diseases and concomitant other medications.
Collapse
Affiliation(s)
- Alexander Brack
- Klinik und Poliklinik für Anästhesiologie, Zentrum Operative Medizin, Universitätsklinikum Würzburg, Oberdürrbacher Straße 6, 97080 Würzburg, Germany.
| | | | | |
Collapse
|
16
|
A Model Federal Collaborative to Increase Patient Access to Buprenorphine Treatment in HIV Primary Care. J Acquir Immune Defic Syndr 2011; 56 Suppl 1:S3-6. [DOI: 10.1097/qai.0b013e318209740f] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
17
|
Proeschold-Bell RJ, Heine A, Pence BW, McAdam K, Quinlivan EB. A cross-site, comparative effectiveness study of an integrated HIV and substance use treatment program. AIDS Patient Care STDS 2010; 24:651-8. [PMID: 20846009 DOI: 10.1089/apc.2010.0073] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Co-occurrence of HIV and substance abuse is associated with poor outcomes for HIV-related health and substance use. Integration of substance use and medical care holds promise for HIV patients, yet few integrated treatment models have been reported. Most of the reported models lack data on treatment outcomes in diverse settings. This study examined the substance use outcomes of an integrated treatment model for patients with both HIV and substance use at three different clinics. Sites differed by type and degree of integration, with one integrated academic medical center, one co-located academic medical center, and one co-located community health center. Participants (n=286) received integrated substance use and HIV treatment for 12 months and were interviewed at 6-month intervals. We used linear generalized estimating equation regression analysis to examine changes in Addiction Severity Index (ASI) alcohol and drug severity scores. To test whether our treatment was differentially effective across sites, we compared a full model including site by time point interaction terms to a reduced model including only site fixed effects. Alcohol severity scores decreased significantly at 6 and 12 months. Drug severity scores decreased significantly at 12 months. Once baseline severity variation was incorporated into the model, there was no evidence of variation in alcohol or drug score changes by site. Substance use outcomes did not differ by age, gender, income, or race. This integrated treatment model offers an option for treating diverse patients with HIV and substance use in a variety of clinic settings. Studies with control groups are needed to confirm these findings.
Collapse
Affiliation(s)
| | - Amy Heine
- Division of Infectious Diseases, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Brian Wells Pence
- Department of Community and Family Medicine, Global Health Institute, Duke University, Durham, North Carolina
| | - Keith McAdam
- Department of Psychiatry, Duke University, Durham, North Carolina
| | - Evelyn Byrd Quinlivan
- Division of Infectious Diseases, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| |
Collapse
|