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Carroll JJ, Cushman PA, Lira MC, Colasanti JA, Del Rio C, Lasser KE, Parker V, Roy PJ, Samet JH, Liebschutz JM. Evidence-Based Interventions to Improve Opioid Prescribing in Primary Care: a Qualitative Assessment of Implementation in Two Studies. J Gen Intern Med 2023; 38:1794-1801. [PMID: 36396881 PMCID: PMC10271994 DOI: 10.1007/s11606-022-07909-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 10/27/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND The TOPCARE and TEACH randomized controlled trials demonstrated the efficacy of a multi-faceted intervention to promote guideline-adherent long-term opioid therapy (LTOT) in primary care settings. Intervention components included a full-time Nurse Care Manager (NCM), an electronic registry, and academic detailing sessions. OBJECTIVE This study sought to identify barriers, facilitators, and other issues germane to the wider implementation of this intervention. DESIGN We conducted a nested, qualitative study at 4 primary care clinics (TOPCARE) and 2 HIV primary care clinics (TEACH), where the trials had been conducted. APPROACH We purposively sampled primary care physicians and advanced practice providers (hereafter: PCPs) who had received the intervention. Semi-structured interviews explored perceptions of the intervention to identify unanticipated barriers to and facilitators of implementation. Interview transcripts were analyzed through iterative deductive and inductive coding exercises. KEY RESULTS We interviewed 32 intervention participants, 30 physicians and 2 advanced practice providers, who were majority White (66%) and female (63%). Acceptability of the intervention was high, with most PCPs valuing didactic and team-based intervention elements, especially co-management of LTOT patients with the NCM. Adoption of new prescribing practices was facilitated by proximity to expertise, available behavioral health care, and the NCM's support. Most participants were enthusiastic about the intervention, though a minority voiced concerns about the appropriateness in their particular clinical environments, threats to the patient-provider relationship, or long-term sustainability. CONCLUSION TOPCARE/TEACH participants found the intervention generally acceptable, appropriate, and easy to adopt in a variety of primary care environments, though some challenges were identified. Careful attention to the practical challenges of implementation and the professional relationships affected by the intervention may facilitate implementation and sustainability.
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Affiliation(s)
- Jennifer J Carroll
- Department of Sociology and Anthropology, North Carolina State University, Raleigh, NC, USA.
- Warren Alpert School of Medicine, Brown University, Providence, RI, USA.
| | - Phoebe A Cushman
- Department of Medicine, UMass Chan Medical School, Worcester, MA, USA
| | - Marlene C Lira
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA, USA
| | - Jonathan A Colasanti
- Division of Infectious Diseases, Emory University, Atlanta, GA, USA
- Grady Health System, Atlanta, GA, USA
| | - Carlos Del Rio
- Division of Infectious Diseases, Emory University, Atlanta, GA, USA
- Grady Health System, Atlanta, GA, USA
| | - Karen E Lasser
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA, USA
- Department of Community Health Sciences, Boston University School of Public Health, Boston, MA, USA
| | - Victoria Parker
- Department of Management, Peter. T. Paul College of Business & Economics, University of New Hampshire, Durham, NH, USA
| | - Payel J Roy
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jeffrey H Samet
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA, USA
| | - Jane M Liebschutz
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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2
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Fujita AW, Ramakrishnan A, Mehta CC, Yusuf OB, Wilson T, Shoptaw S, Carrico AW, Adimora AA, Eaton E, Cohen MH, Cohen J, Adedimeji A, Plankey M, Jones D, Chandran A, Colasanti JA, Sheth AN. Substance Use Treatment Utilization Among Women With and Without Human Immunodeficiency Virus. Open Forum Infect Dis 2023; 10:ofac684. [PMID: 36655189 PMCID: PMC9835749 DOI: 10.1093/ofid/ofac684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
Background Substance use (SU) contributes to poor health outcomes, yet limited data exist to inform strategies to optimize SU treatment among persons with human immunodeficiency virus (HIV). We describe SU and SU treatment utilization among women with and without HIV in the Women's Interagency HIV Study (WIHS). Methods We included data from women enrolled in WIHS from 2013 to 2020. Current SU was self-reported, nonmedical use of drugs in the past year, excluding use of only marijuana. SU treatment utilization was self-reported use of a drug treatment program in the past year. Multivariable regression models were used to investigate associations between participant characteristics and SU treatment. Results Among 2559 women (1802 women living with HIV [WWH], 757 women without HIV), 14% reported current SU. Among those with current SU (n = 367), 71% reported crack/cocaine followed by 40% reporting opioids, and 42% reported any treatment in the past year. The most common treatments were methadone (64%), Narcotics Anonymous (29%), inpatient programs (28%), and outpatient programs (16%). Among women using opioids (n = 147), 67% reported methadone use in the past year compared to 5% using buprenorphine/naloxone. Multivariable analysis showed lower odds of treatment utilization among WWH with concurrent alcohol or marijuana use. Visiting a psychiatrist/counselor was associated with higher odds of treatment. Among WWH, SU treatment was not associated with HIV-related clinical outcomes. Conclusions Treatment utilization was high, especially for methadone use. Our results highlight opportunities for accessing SU treatment for WWH, such as the need to prioritize buprenorphine and comprehensive, wraparound services in HIV care settings.
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Affiliation(s)
- Ayako W Fujita
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Aditi Ramakrishnan
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Division of Infectious Diseases, School of Medicine, Washington University in St Louis, St Louis, Missouri, USA
| | - C Christina Mehta
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Oyindamola B Yusuf
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Tracey Wilson
- Department of Community Health Sciences, School of Public Health, State University of New York Downstate Health Sciences University, Brooklyn, New York, USA
| | - Steven Shoptaw
- Department of Family Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Adam W Carrico
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Adaora A Adimora
- Division of Infectious Diseases, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ellen Eaton
- Division of Infectious Diseases, Department of Medicine, University of Alabama School of Medicine, Birmingham, Alabama, USA
| | - Mardge H Cohen
- Department of Medicine, Stroger Hospital of Cook County, Chicago, Illinois, USA
| | - Jennifer Cohen
- Department of Medicine, Infectious Diseases, University of California, San Francisco, San Francisco, California, USA
| | - Adebola Adedimeji
- Division of Health Behavior Research and Implementation Science, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Michael Plankey
- Division of General Internal Medicine, Department of Medicine, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Deborah Jones
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Aruna Chandran
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Jonathan A Colasanti
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Infectious Disease Program, Grady Health System, Atlanta, Georgia, USA
| | - Anandi N Sheth
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
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Rossom RC, Crain AL, O'Connor PJ, Wright E, Haller IV, Hooker SA, Sperl-Hillen JM, Olson A, Romagnoli K, Solberg L, Dehmer SP, Haapala J, Borgert-Spaniol C, Tusing L, Muegge J, Allen C, Ekstrom H, Huntley K, McCormack J, Bart G. Design of a pragmatic clinical trial to improve screening and treatment for opioid use disorder in primary care. Contemp Clin Trials 2023; 124:107012. [PMID: 36402275 PMCID: PMC9839646 DOI: 10.1016/j.cct.2022.107012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 11/11/2022] [Accepted: 11/14/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Opioid-related deaths continue to rise in the U.S. A shared decision-making (SDM) system to help primary care clinicians (PCCs) identify and treat patients with opioid use disorder (OUD) could help address this crisis. METHODS In this cluster-randomized trial, primary care clinics in three healthcare systems were randomized to receive or not receive access to an OUD-SDM system. The OUD-SDM system alerts PCCs and patients to elevated risk of OUD and supports OUD screening and treatment. It includes guidance on OUD screening and diagnosis, treatment selection, starting and maintaining patients on buprenorphine for waivered clinicians, and screening for common comorbid conditions. The primary study outcome is, of patients at high risk for OUD, the percentage receiving an OUD diagnosis within 30 days of index visit. Additional outcomes are, of patients at high risk for or with a diagnosis of OUD, (a) the percentage receiving a naloxone prescription, or (b) the percentage receiving a medication for OUD (MOUD) prescription or referral to specialty care within 30 days of an index visit, and (c) total days covered by a MOUD prescription within 90 days of an index visit. RESULTS The intervention started in April 2021 and continues through December 2023. PCCs and patients in 90 clinics are included; study results are expected in 2024. CONCLUSION This protocol paper describes the design of a multi-site trial to help PCCs recognize and treat OUD. If effective, this OUD-SDM intervention could improve screening of at-risk patients and rates of OUD treatment for people with OUD.
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Affiliation(s)
- Rebecca C Rossom
- HealthPartners Institute, 8170 33rd Ave S, MS21112R, Minneapolis, MN, 55425, United States of America.
| | - A Lauren Crain
- HealthPartners Institute, 8170 33rd Ave S, MS21112R, Minneapolis, MN, 55425, United States of America.
| | - Patrick J O'Connor
- HealthPartners Institute, 8170 33rd Ave S, MS21112R, Minneapolis, MN, 55425, United States of America.
| | - Eric Wright
- Geisinger Health, 100 North Academy Ave., Danville, PA 17822, United States of America.
| | - Irina V Haller
- Essentia Institute of Rural Health, 502 E 2nd St, Duluth, MN 55805, United States of America.
| | - Stephanie A Hooker
- HealthPartners Institute, 8170 33rd Ave S, MS21112R, Minneapolis, MN, 55425, United States of America.
| | - JoAnn M Sperl-Hillen
- HealthPartners Institute, 8170 33rd Ave S, MS21112R, Minneapolis, MN, 55425, United States of America.
| | - Anthony Olson
- Essentia Institute of Rural Health, 502 E 2nd St, Duluth, MN 55805, United States of America.
| | - Katrina Romagnoli
- Geisinger Health, 100 North Academy Ave., Danville, PA 17822, United States of America.
| | - Leif Solberg
- HealthPartners Institute, 8170 33rd Ave S, MS21112R, Minneapolis, MN, 55425, United States of America.
| | - Steven P Dehmer
- HealthPartners Institute, 8170 33rd Ave S, MS21112R, Minneapolis, MN, 55425, United States of America.
| | - Jacob Haapala
- HealthPartners Institute, 8170 33rd Ave S, MS21112R, Minneapolis, MN, 55425, United States of America.
| | - Caitlin Borgert-Spaniol
- HealthPartners Institute, 8170 33rd Ave S, MS21112R, Minneapolis, MN, 55425, United States of America.
| | - Lorraine Tusing
- Geisinger Health, 100 North Academy Ave., Danville, PA 17822, United States of America.
| | - Jule Muegge
- HealthPartners Institute, 8170 33rd Ave S, MS21112R, Minneapolis, MN, 55425, United States of America.
| | - Clayton Allen
- Essentia Institute of Rural Health, 502 E 2nd St, Duluth, MN 55805, United States of America.
| | - Heidi Ekstrom
- HealthPartners Institute, 8170 33rd Ave S, MS21112R, Minneapolis, MN, 55425, United States of America.
| | - Kristen Huntley
- National Institute on Drug Abuse, Center for the Clinical Trials Network, 16071 Industrial Dr, Gaithersburg, MD 20877, United States of America.
| | - Jennifer McCormack
- The Emmes Company, 401 N Washington St # 700, Rockville, MD 20850, United States of America.
| | - Gavin Bart
- Hennepin Healthcare Research Institute, 825 8th St S, Minneapolis, MN 55404, United States of America.
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4
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Jawa R, Walley AY, Wilson DJ, Green TC, McKenzie M, Hoskinson R, Bratberg J, Ramsey S, Rich JD, Friedmann PD. Prescribe to Save Lives: Improving Buprenorphine Prescribing Among HIV Clinicians. J Acquir Immune Defic Syndr 2022; 90:546-552. [PMID: 35587832 PMCID: PMC9283214 DOI: 10.1097/qai.0000000000003001] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 04/07/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND HIV clinicians are uniquely positioned to treat their patients with opioid use disorder using buprenorphine to prevent overdose death. The Prescribe to Save Lives (PtSL) study aimed to increase HIV clinicians' buprenorphine prescribing via an overdose prevention intervention. METHODS The quasi-experimental stepped-wedge study enrolled 22 Ryan White-funded HIV clinics and delivered a peer-to-peer training to clinicians with follow-up academic detailing that included overdose prevention education and introduced buprenorphine prescribing. Site-aggregated electronic medical record (EMR) data measured with the change in X-waivered clinicians and patients prescribed buprenorphine. Clinicians completed surveys preintervention and at 6- and 12-month postintervention that assessed buprenorphine training, prescribing, and attitudes. Analyses applied generalized estimating equation models, adjusting for time and clustering of repeated measures among individuals and sites. RESULTS Nineteen sites provided EMR prescribing data, and 122 clinicians returned surveys. Of the total patients with HIV across all sites, EMR data showed 0.38% were prescribed buprenorphine pre-intervention and 0.52% were prescribed buprenorphine postintervention. The intervention increased completion of a buprenorphine training course (adjusted odds ratio 2.54, 95% confidence interval: 1.38 to 4.68, P = 0.003) and obtaining an X-waiver (adjusted odds ratio 2.11, 95% confidence interval: 1.12 to 3.95, P = 0.02). There were nonsignificant increases at the clinic level, as well. CONCLUSIONS Although the PtSL intervention resulted in increases in buprenorphine training and prescriber certification, there was no meaningful increase in buprenorphine prescribing. Engaging and teaching HIV clinicians about overdose and naloxone rescue may facilitate training in buprenorphine prescribing but will not result in more treatment with buprenorphine without additional interventions.
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Affiliation(s)
- Raagini Jawa
- Section of Infectious Diseases, Boston Medical Center, 801 Massachusetts Avenue, 2 Floor, Boston, MA, 02118
- Grayken Center for Addiction, Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Boston Medical Center, 801 Massachusetts Avenue, 2 Floor, Boston, MA, 02118
- Boston University School of Medicine, Boston, MA, USA
| | - Alexander Y. Walley
- Grayken Center for Addiction, Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Boston Medical Center, 801 Massachusetts Avenue, 2 Floor, Boston, MA, 02118
- Boston University School of Medicine, Boston, MA, USA
| | - Donna J. Wilson
- University of Massachusetts Medical School- Baystate and Baystate Health, 3601 Main Street, 3 Floor, Springfield, MA
| | - Traci C. Green
- Opioid Policy Research Collaborative, The Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA 02453
- The Warren Alpert Medical School of Brown University, Providence, RI
| | - Michelle McKenzie
- The Center for Health + Justice Transformation, The Miriam and Rhode Island Hospitals, 164 Summit Avenue, Providence, RI 02906
- The Warren Alpert Medical School of Brown University, Providence, RI
| | - Randall Hoskinson
- University of Massachusetts Medical School- Baystate and Baystate Health, 3601 Main Street, 3 Floor, Springfield, MA
| | - Jeffrey Bratberg
- University of Rhode Island College of Pharmacy, 7 Greenhouse Rd, Kingston, RI 02881
| | - Susan Ramsey
- The Warren Alpert Medical School of Brown University, Providence, RI
| | - Josiah D. Rich
- The Center for Health + Justice Transformation, The Miriam and Rhode Island Hospitals, 164 Summit Avenue, Providence, RI 02906
- The Warren Alpert Medical School of Brown University, Providence, RI
| | - Peter D. Friedmann
- University of Massachusetts Medical School- Baystate and Baystate Health, 3601 Main Street, 3 Floor, Springfield, MA
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5
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Fujita AW, Wilson JD, Kennedy AJ. A Call to Action: Integration of Buprenorphine Prescribing into the Care of Persons with HIV and Opioid Use Disorder. Open Forum Infect Dis 2022; 9:ofac400. [PMID: 36039099 PMCID: PMC9384664 DOI: 10.1093/ofid/ofac400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 07/02/2022] [Indexed: 11/12/2022] Open
Abstract
During the coronavirus disease 2019 (COVID-19) pandemic, we also experienced a worsening opioid overdose epidemic. Untreated opioid use disorder (OUD) in persons with human immunodeficiency virus (HIV) is associated with worse HIV-related outcomes. Buprenorphine is a safe, evidence-based medication for OUD and is effective in reducing opioid craving and overdose and improving outcomes along the HIV care continuum. Despite the longstanding evidence supporting the benefits of buprenorphine, there remains an implementation gap in the uptake of buprenorphine prescribing in HIV care settings. To improve integration of OUD care and HIV primary care, we recommend (1) all HIV clinicians obtain a buprenorphine waiver, (2) teaching on OUD should be integrated into infectious diseases and HIV continuing medical education, and (3) previously validated models of integrated care should be leveraged to urgently expand access to buprenorphine for persons with HIV and OUD.
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Affiliation(s)
- A Wendy Fujita
- Division of Infectious Diseases, Emory University Department of Medicine , Atlanta, GA , USA
| | - J Deanna Wilson
- Division of General Internal Medicine, University of Pittsburgh School of Medicine , Pittsburgh, PA , USA
| | - Amy J Kennedy
- Division of General Internal Medicine, University of Washington School of Medicine , VA Puget Sound Healthcare System, Seattle, WA , USA
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Haldane V, Jung AS, De Foo C, Shrestha P, Urdaneta E, Turk E, Gaviria JI, Boadas J, Buse K, Miranda JJ, Strathdee SA, Barratt A, Kazatchkine M, McKee M, Legido-Quigley H. Integrating HIV and substance misuse services: a person-centred approach grounded in human rights. Lancet Psychiatry 2022; 9:676-688. [PMID: 35750060 DOI: 10.1016/s2215-0366(22)00159-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 04/19/2022] [Accepted: 04/19/2022] [Indexed: 12/13/2022]
Abstract
Integrating HIV-related care with treatment for substance use disorder provides an opportunity to better meet the needs of people living with these conditions. People with substance use disorder are rendered especially vulnerable by prevailing policies, structural inequalities, and stigmatisation. In this Series paper we analyse existing literature and empirical evidence from scoping reviews on integration designs for the treatment of HIV and substance use disorder, to understand barriers to and facilitators of care integration and to map ways forward. We discuss how approaches to integration address two core gaps in current models: a failure to consider human rights when incorporating the perspectives of people living with HIV and people who use drugs, and a failure to reflect critically on structural factors that determine risk, vulnerability, health-care seeking, and health equity. We argue that successful integration requires a person-centred approach, which is grounded in human rights, treats both concerns holistically, and reconnects with underlying social, economic, and political inequalities.
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Affiliation(s)
- Victoria Haldane
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Anne-Sophie Jung
- School of Politics and International Studies, University of Leeds, Leeds, UK.
| | - Chuan De Foo
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore; National University Health System, Singapore
| | - Pami Shrestha
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore; National University Health System, Singapore
| | | | - Eva Turk
- Institute for Health and Society, University of Oslo, Oslo, Norway; Medical Faculty, University of Maribor, Maribor, Slovenia
| | - Juan I Gaviria
- Coordinación de Vigilancia Epidemiologica e Infectologia, Hospital del Instituto Ecuatoriano del Seguro Social (IESS) Sur de Quito, Quito, Ecuador
| | - Jesus Boadas
- Centro de Rehabilitación Mental ANSALUD, Santo Domingo, Dominican Republic
| | - Kent Buse
- The George Institute for Global Health, Imperial College London, London, UK
| | - J Jaime Miranda
- Universidad Peruana Cayetano Heredia, Lima, Peru; The George Institute for Global Health, UNSW, Sydney, NSW, Australia
| | | | - Ashley Barratt
- Positive21, London, UK; ReShape/International HIV Partnerships-European Chemsex Forum, London, UK
| | | | - Martin McKee
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Helena Legido-Quigley
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore; National University Health System, Singapore; Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
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7
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Jakubowski A, Rath C, Harocopos A, Wright M, Welch A, Kattan J, Navos Behrends C, Lopez-Castro T, Fox AD. Implementation of buprenorphine services in NYC syringe services programs: a qualitative process evaluation. Harm Reduct J 2022; 19:75. [PMID: 35818071 PMCID: PMC9275037 DOI: 10.1186/s12954-022-00654-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 06/22/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Syringe services programs (SSPs) hold promise for providing buprenorphine treatment access to people with opioid use disorder (OUD) who are reluctant to seek care elsewhere. In 2017, the New York City Department of Health and Mental Hygiene (DOHMH) provided funding and technical assistance to nine SSPs to develop "low-threshold" buprenorphine services as part of a multipronged initiative to lower opioid-related overdose rates. The aim of this study was to identify barriers to and facilitators of implementing SSP-based buprenorphine services. METHODS We conducted 26 semi-structured qualitative interviews from April 2019 to November 2019 at eight SSPs in NYC that received funding and technical assistance from DOHMH. Interviews were conducted with three categories of staff: leadership (i.e., buprenorphine program management or leadership, eight interviews), staff (i.e., buprenorphine coordinators or other staff, eleven interviews), and buprenorphine providers (six interviews). We identified themes related to barriers and facilitators to program implementation using thematic analysis. We make recommendations for implementation based on our findings. RESULTS Programs differed in their stage of development, location of services provided, and provider type, availability, and practices. Barriers to providing buprenorphine services at SSPs included gaps in staff knowledge and comfort communicating with participants about buprenorphine, difficulty hiring buprenorphine providers, managing tension between harm reduction and traditional OUD treatment philosophies, and financial constraints. Challenges also arose from serving a population with unmet psychosocial needs. Implementation facilitators included technical assistance from DOHMH, designated buprenorphine coordinators, offering other supportive services to participants, and telehealth to bridge gaps in provider availability. Key recommendations include: (1) health departments should provide support for SSPs in training staff, building health service infrastructure and developing policies and procedures, (2) SSPs should designate a buprenorphine coordinator and ensure regular training on buprenorphine for frontline staff, and (3) buprenorphine providers should be selected or supported to use a harm reduction approach to buprenorphine treatment. CONCLUSIONS Despite encountering challenges, SSPs implemented buprenorphine services outside of conventional OUD treatment settings. Our findings have implications for health departments, SSPs, and other community organizations implementing buprenorphine services. Expansion of low-threshold buprenorphine services is a promising strategy to address the opioid overdose epidemic.
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Affiliation(s)
- Andrea Jakubowski
- Division of General Internal Medicine, Department of Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, 3300 Kossuth Avenue, Bronx, NY, 10467, USA.
| | - Caroline Rath
- grid.238477.d0000 0001 0320 6731Bureau of Alcohol, Drug Use, Care, Prevention and Treatment, New York City Department of Health and Mental Hygiene, 42-09 28th Street Queens, Long Island City, NY 11101 USA
| | - Alex Harocopos
- grid.238477.d0000 0001 0320 6731Bureau of Alcohol, Drug Use, Care, Prevention and Treatment, New York City Department of Health and Mental Hygiene, 42-09 28th Street Queens, Long Island City, NY 11101 USA
| | - Monique Wright
- grid.238477.d0000 0001 0320 6731Bureau of Alcohol, Drug Use, Care, Prevention and Treatment, New York City Department of Health and Mental Hygiene, 42-09 28th Street Queens, Long Island City, NY 11101 USA
| | - Alice Welch
- grid.238477.d0000 0001 0320 6731Bureau of Alcohol, Drug Use, Care, Prevention and Treatment, New York City Department of Health and Mental Hygiene, 42-09 28th Street Queens, Long Island City, NY 11101 USA
| | - Jessica Kattan
- grid.238477.d0000 0001 0320 6731Bureau of Alcohol, Drug Use, Care, Prevention and Treatment, New York City Department of Health and Mental Hygiene, 42-09 28th Street Queens, Long Island City, NY 11101 USA
| | - Czarina Navos Behrends
- grid.5386.8000000041936877XDepartment of Population Health Sciences, Weill Cornell Medical College, 402 E. 67th St, New York, NY 10065 USA
| | - Teresa Lopez-Castro
- grid.254250.40000 0001 2264 7145Department of Psychology, The City College of New York, 160 Convent Avenue, New York, NY 10031 USA
| | - Aaron D. Fox
- grid.251993.50000000121791997Division of General Internal Medicine, Department of Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, 3300 Kossuth Avenue, Bronx, NY 10467 USA
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8
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Bold KW, Deng Y, Dziura J, Porter E, Sigel KM, Yager JE, Ledgerwood DM, Bernstein SL, Edelman EJ. Practices, attitudes, and confidence related to tobacco treatment interventions in HIV clinics: a multisite cross-sectional survey. Transl Behav Med 2022; 12:726-733. [PMID: 35608982 PMCID: PMC9260059 DOI: 10.1093/tbm/ibac022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Tobacco use disorder (TUD) is a major threat to health among people with HIV (PWH), but it is often untreated. Among HIV clinicians and staff, we sought to characterize practices, attitudes, and confidence addressing TUD among PWH to identify potential opportunities to enhance provision of care. Cross-sectional deidentified, web-based surveys were administered from November 4, 2020 through December 15, 2020 in HIV clinics in three health systems in the United States Northeast. Surveys assessed provider characteristics and experience, reported practices addressing tobacco use, and knowledge and attitudes regarding medications for TUD. Chi-square tests or Fisher's exact tests were used to examine differences in responses between clinicians and staff who were prescribers versus nonprescribers and to examine factors associated with frequency of prescribing TUD medications. Among 118 survey respondents (56% prescribers), only 50% reported receiving prior training on brief smoking cessation interventions. Examining reported practices identified gaps in the delivery of TUD care, including counseling patients on the impact of smoking on HIV, knowledge of clinical practice guidelines, and implementation of assessment and brief interventions for smoking. Among prescribers, first-line medications for TUD were infrequently prescribed and concerns about medication side effects and interaction with antiretroviral treatments were associated with low frequency of prescribing. HIV clinicians and staff reported addressable gaps in their knowledge, understanding, and practices related to tobacco treatment. Additional work is needed to identify ways to ensure adequate training for providers to enhance the delivery of TUD treatment in HIV clinic settings.
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Affiliation(s)
- Krysten W Bold
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Yanhong Deng
- Yale Center for Analytic Sciences, Yale School of Public Health, New Haven, CT, USA
| | - James Dziura
- Yale Center for Analytic Sciences, Yale School of Public Health, New Haven, CT, USA
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Elizabeth Porter
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Keith M Sigel
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jessica E Yager
- State University of New York Downstate Health Sciences University, Brooklyn, NY, USA
| | - David M Ledgerwood
- Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine, Detroit, MI, USA
| | - Steven L Bernstein
- Department of Emergency Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - E Jennifer Edelman
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Program in Addiction Medicine, Yale School of Medicine, New Haven, CT, USA
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, USA
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9
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Garner BR, Knudsen HK, Zulkiewicz BA, Tueller SJ, Gotham HJ, Martin EG, Donohoe T, Toro AK, Loyd K, Gordon T. The Setting-Intervention Fit of Nine Evidence-Based Interventions for Substance Use Disorders Within HIV Service Organizations Across the United States: Results of a National Stakeholder-Engaged Real-Time Delphi Study. J Acquir Immune Defic Syndr 2022; 90:S206-S214. [PMID: 35703773 PMCID: PMC9204782 DOI: 10.1097/qai.0000000000002981] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Given substance use disorders (SUDs) among people with HIV are highly prevalent, integrating SUD services within HIV service settings is needed to help end the HIV epidemic. In this study, we assessed the setting-intervention fit (SIF) of 9 evidence-based SUD interventions: acamprosate, disulfiram, oral naltrexone, injectable naltrexone, oral buprenorphine, injectable buprenorphine, contingency management, motivational interviewing, and cognitive behavioral therapy (CBT). SETTING Clinical and nonclinical HIV service organizations (HSOs) in the United States. METHODS In May 2020, a stakeholder-engaged real-time Delphi was completed with 202 HSOs. HSO respondents rated the extent to which each SUD intervention was fundable, implementable, retainable, sustainable, scalable, and timely for their HSO, and these 6 items were summed into an SIF score (possible range of 0-18). RESULTS Motivational interviewing had the highest average SIF score (11.42), with SIF scores above the midpoint (9.5) for clinical (11.51) and nonclinical HSOs (11.36). For nonclinical HSOs, none of the other interventions were above the midpoint. For clinical HSOs, the average SIF scores were above the midpoint for CBT (10.97) and oral buprenorphine (9.51). Multivariate regression analyses, which controlled for characteristics of the HSO respondent, revealed geographic region of the United States and whether the HSO currently offered any substance use services as 2 of the best predictors of SIF scores. CONCLUSIONS Notwithstanding the need to improve the SIF for the other evidence-based SUD interventions, motivational interviewing, CBT, and oral buprenorphine are currently the evidence-based SUD interventions with greatest perceived fit for integration within HSOs in the United States.
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Affiliation(s)
| | | | | | | | | | - Erika G Martin
- Rockefeller College of Public Affairs and Policy at the University at Albany, Both Part of the State University of New York, Albany
| | - Tom Donohoe
- University of California Los Angeles, Pacific AIDS Education and Training Center, Los Angeles, CA 90024 and
| | | | - Katie Loyd
- RTI International, Research Triangle Park, NC
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10
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Wyse JJ, McGinnis KA, Edelman EJ, Gordon AJ, Manhapra A, Fiellin DA, Moore BA, Korthuis PT, Kennedy AJ, Oldfield BJ, Gaither JR, Gordon KS, Skanderson M, Barry DT, Bryant K, Crystal S, Justice AC, Kraemer KL. Twelve-Month Retention in Opioid Agonist Treatment for Opioid Use Disorder Among Patients With and Without HIV. AIDS Behav 2022; 26:975-985. [PMID: 34495424 PMCID: PMC8840957 DOI: 10.1007/s10461-021-03452-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2021] [Indexed: 12/22/2022]
Abstract
Although opioid agonist therapy (OAT) is associated with positive health outcomes, including improved HIV management, long-term retention in OAT remains low among patients with opioid use disorder (OUD). Using data from the Veterans Aging Cohort Study (VACS), we identify variables independently associated with OAT retention overall and by HIV status. Among 7,334 patients with OUD, 13.7% initiated OAT, and 27.8% were retained 12-months later. Likelihood of initiation and retention did not vary by HIV status. Variables associated with improved likelihood of retention included receiving buprenorphine (relative to methadone), receiving both buprenorphine and methadone at some point over the 12-month period, or diagnosis of HCV. History of homelessness was associated with a lower likelihood of retention. Predictors of retention were largely distinct between patients with HIV and patients without HIV. Findings highlight the need for clinical, systems, and research initiatives to better understand and improve OAT retention.
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Affiliation(s)
- Jessica J Wyse
- VA Portland Health Care System, Portland, OR, USA.
- School of Public Health, Oregon Health & Science University, Portland, OR, USA.
| | | | - E Jennifer Edelman
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, USA
| | - Adam J Gordon
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Ajay Manhapra
- Integrative Pain Recovery Service, Hampton VA Medical Center, Hampton, VA, USA
- APT Foundation, Pain Treatment Services, New Haven, CT, USA
| | - David A Fiellin
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, USA
| | - Brent A Moore
- VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - P Todd Korthuis
- Section of Addiction Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Amy J Kennedy
- Los Angeles County Department of Health Services, Los Angeles, CA, USA
| | - Benjamin J Oldfield
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Julie R Gaither
- Department of Pediatrics, Yale School of Medicine, New Haven, CT, USA
| | - Kirsha S Gordon
- VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | | | - Declan T Barry
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
- APT Foundation, Pain Treatment Services, New Haven, CT, USA
| | - Kendall Bryant
- National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, USA
| | - Stephen Crystal
- Center for Health Services Research, Institute for Health, Rutgers University, New Brunswick, NJ, USA
| | - Amy C Justice
- VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, USA
| | - Kevin L Kraemer
- Center for Research on Health Care, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
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11
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Rossom RC, Sperl-Hillen JM, O'Connor PJ, Crain AL, Nightingale L, Pylkas A, Huntley KV, Bart G. A pilot study of the functionality and clinician acceptance of a clinical decision support tool to improve primary care of opioid use disorder. Addict Sci Clin Pract 2021; 16:37. [PMID: 34130758 PMCID: PMC8207778 DOI: 10.1186/s13722-021-00245-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 06/03/2021] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE Most Americans with opioid use disorder (OUD) do not receive indicated medical care. A clinical decision support (CDS) tool for primary care providers (PCPs) could address this treatment gap. Our primary objective was to build OUD-CDS tool and demonstrate its functionality and accuracy. Secondary objectives were to achieve high use and approval rates and improve PCP confidence in diagnosing and treating OUD. METHODS A convenience sample of 55 PCPs participated. Buprenorphine-waivered PCPs (n = 8) were assigned to the intervention. Non-waivered PCPs (n = 47) were randomized to intervention (n = 24) or control (n = 23). Intervention PCPs received access to the OUD-CDS, which alerted them to patients at potentially increased risk for OUD or overdose and guided diagnosis and treatment. Control PCPs provided care as usual. RESULTS The OUD-CDS was functional and accurate following extensive multi-phased testing. PCPs used the OUD-CDS in 5% of encounters with at-risk patients, far less than the goal of 60%. OUD screening confidence increased for all intervention PCPs and OUD diagnosis increased for non-waivered intervention PCPs. Most PCPs (65%) would recommend the OUD-CDS and found it helpful with screening for OUD and discussing and prescribing OUD medications. DISCUSSION PCPs generally liked the OUD-CDS, but use rates were low, suggesting the need to modify CDS design, implementation strategies and integration with existing primary care workflows. CONCLUSION The OUD-CDS tool was functional and accurate, but PCP use rates were low. Despite low use, the OUD-CDS improved confidence in OUD screening, diagnosis and use of buprenorphine. NIH Trial registration NCT03559179. Date of registration: 06/18/2018. URL: https://clinicaltrials.gov/ct2/show/NCT03559179.
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Affiliation(s)
- Rebecca C Rossom
- HealthPartners Institute, Minneapolis, MN, USA. .,University of Minnesota School of Medicine, Minneapolis, MN, USA.
| | | | | | | | | | - Anne Pylkas
- HealthPartners Medical Group, Minneapolis, MN, USA.,Sage Prairie Clinic, Eagan, MN, USA
| | - Kristen V Huntley
- Center for the Clinical Trials Network, National Institute on Drug Abuse, Bethesda, MA, USA
| | - Gavin Bart
- University of Minnesota School of Medicine, Minneapolis, MN, USA.,Hennepin Healthcare, Minneapolis, MN, USA
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12
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Abstract
Opioid use disorder (OUD) is a common, treatable chronic disease that can be effectively managed in primary care settings. Untreated OUD is associated with considerable morbidity and mortality-notably, overdose, infectious complications of injecting drug use, and profoundly diminished quality of life. Withdrawal management and medication tapers are ineffective and are associated with increased rates of relapse and death. Pharmacotherapy is the evidence based mainstay of OUD treatment, and many studies support its integration into primary care settings. Evidence is strongest for the opioid agonists buprenorphine and methadone, which randomized controlled trials have shown to decrease illicit opioid use and mortality. Discontinuation of opioid agonist therapy is associated with increased rates of relapse and mortality. Less evidence is available for the opioid antagonist extended release naltrexone, with a meta-analysis of randomized controlled trials showing decreased illicit opioid use but no effect on mortality. Treating OUD in primary care settings is cost effective, improves outcomes for both OUD and other medical comorbidities, and is highly acceptable to patients. Evidence on whether behavioral interventions improve outcomes for patients receiving pharmacotherapy is mixed, with guidelines promoting voluntary engagement in psychosocial supports, including counseling. Further work is needed to promote the integration of OUD treatment into primary care and to overcome regulatory barriers to integrating methadone into primary care treatment in the US.
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Affiliation(s)
- Megan Buresh
- Department of Addiction Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Robert Stern
- Department of Addiction Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Darius Rastegar
- Department of Addiction Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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13
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Nguemo Djiometio JB, Djiadeu P, Mbuagbaw L, Njoroge I, Nelson LE, Kahan M. Individuals' experiences of the integration of substance use/addiction and HIV/AIDS services in community settings: a qualitative systematic review protocol. JBI Evid Synth 2021; 18:2687-2693. [PMID: 32740031 DOI: 10.11124/jbisrir-d-19-00391] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE The objectives of this systematic review are: i) to identify, appraise, and synthesize the best available evidence on individuals' experiences of the integration of substance use/addiction and HIV/AIDS services in community settings, and ii) to identify barriers to and facilitators of the integration of the services. INTRODUCTION The integration of drug use treatment and HIV services has shown to improve HIV prevention, decrease HIV infection and progression, while improving access to social and support services among substance users. Combined pharmacological and behavioral drug use treatments have been proven to diminish behaviors that increase HIV risk, decrease incidence of the disease, and improve adherence to antiretroviral therapy among individuals who use drugs and are HIV-positive. INCLUSION CRITERIA The populations of interest in this review include patients who have experienced integrated substance use/addiction and HIV services, as well as health care professionals and policy makers who have been involved in developing or implementing integrated substance use/addiction and HIV/AIDS services. Eligible studies will focus on the views, attitudes, understandings, and perceptions of patients, health care professionals, and policy makers resulting from experience in developing or implementing strategies that have or could inform the integration of substance use/addiction and HIV/AIDS services in community settings. METHODS Searches will be conducted in MEDLINE, Embase, PsycINFO, and CINHAL. The search for unpublished studies will include OpenGrey, Grey Matters, New York Academy of Medicine's Grey Literature Report, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform. Selected studies will be critically appraised by two independent reviewers for methodological quality. Data will be extracted and then synthesized following the JBI meta-aggregative approach. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO CRD42020185858.
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Affiliation(s)
- Joseph B Nguemo Djiometio
- Daphne Cockwell School of Nursing, Faculty of Community Services, Ryerson University, Toronto, ON, Canada.,Substance Use Service/META:PHI, Women's College Hospital, Toronto, ON, Canada
| | - Pascal Djiadeu
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Irene Njoroge
- Substance Use Service/META:PHI, Women's College Hospital, Toronto, ON, Canada
| | - LaRon E Nelson
- Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, ON, Canada.,School of Nursing, Yale University, New Haven, CT, USA
| | - Meldon Kahan
- Substance Use Service/META:PHI, Women's College Hospital, Toronto, ON, Canada
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14
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Seval N, Frank CA, Litwin AH, Roth P, Schade MA, Pavlicova M, Levin FR, Brady KT, Nunes EV, Springer SA. Design and methods of a multi-site randomized controlled trial of an integrated care model of long-acting injectable buprenorphine with infectious disease treatment among persons hospitalized with infections and opioid use disorder. Contemp Clin Trials 2021; 105:106394. [PMID: 33838307 DOI: 10.1016/j.cct.2021.106394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 03/29/2021] [Accepted: 03/31/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Hospitalization with co-occurring opioid use disorder (OUD) and infections presents a critical time to intervene to improve outcomes for these intertwined epidemics that are typically managed separately. A surge in life-threatening infectious diseases associated with injection drug use, including bacterial and fungal infections, HIV, and HCV accounts for substantial healthcare utilization, morbidity, and mortality. Infectious Disease (ID) specialists manage severe infections that require hospitalization and are a logical resource to engage patients in medication treatment for OUD (MOUD). An injectable long-acting monthly formulation of buprenorphine (LAB) has a potential advantage for initiating MOUD within hospital settings and bridging to treatment after discharge. METHODS A randomized multi-site trial tests a new model of care (ID/LAB) in which OUD and infections are managed by ID specialists and hospitalists using LAB coupled with referrals to community resources for long-term MOUD. A sample of 200 adults admitted to three U.S. hospitals for OUD and infections are randomly assigned 1:1 to ID/LAB or treatment as usual (TAU). The primary outcome measure is the proportion of patients enrolled in effective MOUD at 12 weeks after randomization. Secondary outcomes include relapse to opioid use, adherence to infectious disease treatment, infection morbidity and mortality, and drug overdose. RESULTS We describe the design, procedures, statistical analysis, and early implementation issues of this randomized trial. CONCLUSIONS Study findings will provide insight into the feasibility and effectiveness of integrated treatment of OUD and serious infections and have the potential to reduce morbidity and mortality in this vulnerable population.
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Affiliation(s)
- Nikhil Seval
- Yale School of Medicine, Department of Internal Medicine, Section of Infectious Disease, Yale AIDS Program, New Haven, CT, USA
| | - Cynthia A Frank
- Yale School of Medicine, Department of Internal Medicine, Section of Infectious Disease, Yale AIDS Program, New Haven, CT, USA
| | - Alain H Litwin
- University of South Carolina School of Medicine Greenville, Prisma Health: Upstate Affiliate, Department of Infectious Disease, Greenville, SC, USA; Department of Medicine, University of South Carolina School of Medicine- Greenville, Greenville, SC, USA
| | - Prerana Roth
- University of South Carolina School of Medicine Greenville, Prisma Health: Upstate Affiliate, Department of Infectious Disease, Greenville, SC, USA
| | - Meredith A Schade
- Penn State Milton S. Hershey Medical Center, Department of Medicine, Division of Infectious Diseases, Hershey, PA, USA
| | - Martina Pavlicova
- Columbia University Mailman School of Public Health, Department of Biostatistics, New York, NY, USA
| | - Frances R Levin
- College of Physicians and Surgeons of Columbia University, New York State Psychiatric Institute/Division on Substance Use Disorders, New York, NY, USA
| | - Kathleen T Brady
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Edward V Nunes
- College of Physicians and Surgeons of Columbia University, New York State Psychiatric Institute/Division on Substance Use Disorders, New York, NY, USA
| | - Sandra A Springer
- Yale School of Medicine, Department of Internal Medicine, Section of Infectious Disease, Yale AIDS Program, New Haven, CT, USA.
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15
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Edelman EJ, Dziura J, Esserman D, Porter E, Becker WC, Chan PA, Cornman DH, Rebick G, Yager J, Morford K, Muvvala SB, Fiellin DA. Working with HIV clinics to adopt addiction treatment using implementation facilitation (WHAT-IF?): Rationale and design for a hybrid type 3 effectiveness-implementation study. Contemp Clin Trials 2020; 98:106156. [PMID: 32976995 PMCID: PMC7511156 DOI: 10.1016/j.cct.2020.106156] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 09/16/2020] [Accepted: 09/17/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Tobacco, alcohol and opioid misuse are associated with substantial morbidity and mortality among people with HIV (PWH). Despite existence of evidence-based counseling and medications for addiction, these treatments are infrequently offered in HIV clinics. The Working with HIV clinics to adopt Addiction Treatment using Implementation Facilitation (WHAT-IF?) study was conducted to address this implementation challenge. The study's goals were to conduct a formative evaluation of barriers to and facilitators of implementing addiction treatment for PWH followed by an evaluation of the impact of Implementation Facilitation (IF) on promoting adoption of addiction treatments and clinical outcomes. METHODS The study was conducted at four HIV clinics in the northeast United States, using a hybrid type 3 effectiveness-implementation stepped wedge design and guided by the Promoting Action on Research Implementation in Health Services Research (PARiHS) framework. A mixed-methods approach was used to identify evidence, context, and facilitation-related barriers to and facilitators of integration of addiction treatments into HIV clinics and to help tailor IF for each clinic. An evaluation was then conducted of the impact of IF on implementation outcomes, including provision of addiction treatment (primary outcome), organizational and clinician and staff readiness to adopt addiction treatment, and changes in organizational models of care used to deliver addiction treatment. The evaluation also included IF's impact on effectiveness outcomes, specifically HIV-related outcomes among patients eligible for addiction treatment. CONCLUSIONS Results will generate important information regarding the impact of IF as a reproducible strategy to promote addiction treatment in HIV clinics.
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Affiliation(s)
- E Jennifer Edelman
- Program in Addiction Medicine, Yale School of Medicine, New Haven, CT, United States of America; Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States of America; Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, United States of America.
| | - James Dziura
- Yale Center for Analytic Sciences, Yale School of Public Health, New Haven, CT, United States of America; Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, United States of America
| | - Denise Esserman
- Yale Center for Analytic Sciences, Yale School of Public Health, New Haven, CT, United States of America; Department of Biostatistics, Yale School of Public Health, New Haven, CT, United States of America
| | - Elizabeth Porter
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States of America
| | - William C Becker
- Program in Addiction Medicine, Yale School of Medicine, New Haven, CT, United States of America; Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States of America; VA Connecticut Healthcare System, West Haven, CT, United States of America
| | - Philip A Chan
- Department of Medicine, Brown University, Providence, RI, United States of America
| | - Deborah H Cornman
- Institute for Collaboration on Health, Intervention, and Policy (InCHIP), University of Connecticut, Storrs, CT, United States of America
| | - Gabriel Rebick
- New York University, New York, NY, United States of America
| | - Jessica Yager
- SUNY Downstate, Brooklyn, NY, United States of America
| | - Kenneth Morford
- Program in Addiction Medicine, Yale School of Medicine, New Haven, CT, United States of America; Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States of America
| | - Srinivas B Muvvala
- Program in Addiction Medicine, Yale School of Medicine, New Haven, CT, United States of America; Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States of America
| | - David A Fiellin
- Program in Addiction Medicine, Yale School of Medicine, New Haven, CT, United States of America; Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States of America; Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, United States of America; Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, United States of America
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16
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Parcesepe AM, Lancaster K, Edelman EJ, DeBoni R, Ross J, Atwoli L, Tlali M, Althoff K, Tine J, Duda SN, Wester CW, Nash D. Substance use service availability in HIV treatment programs: Data from the global IeDEA consortium, 2014-2015 and 2017. PLoS One 2020; 15:e0237772. [PMID: 32853246 PMCID: PMC7451518 DOI: 10.1371/journal.pone.0237772] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 08/02/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Substance use is common among people living with HIV and has been associated with suboptimal HIV treatment outcomes. Integrating substance use services into HIV care is a promising strategy to improve patient outcomes. METHODS We report on substance use education, screening, and referral practices from two surveys of HIV care and treatment sites participating in the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium. HIV care and treatment sites participating in IeDEA are primarily public-sector health facilities and include both academic and community-based hospitals and health facilities. A total of 286 sites in 45 countries participated in the 2014-2015 survey and 237 sites in 44 countries participated in the 2017 survey. We compared changes over time for 147 sites that participated in both surveys. RESULTS In 2014-2015, most sites (75%) reported providing substance use-related education on-site (i.e., at the HIV clinic or the same health facility). Approximately half reported on-site screening for substance use (52%) or referrals for substance use treatment (51%). In 2017, the proportion of sites providing on-site substance use-related education, screening, or referrals increased by 9%, 16%, and 8%, respectively. In 2017, on-site substance use screening and referral were most commonly reported at sites serving only adults (compared to only children/adolescents or adults and children/adolescents; screening: 86%, 37%, and 59%, respectively; referral: 76%, 47%, and 46%, respectively) and at sites in high-income countries (compared to upper middle income, lower middle income or low-income countries; screening: 89%, 76%, 68%, and 45%, respectively; referral: 82%, 71%, 57%, and 34%, respectively). CONCLUSION Although there have been increases in the proportion of sites reporting substance use education, screening, and referral services across IeDEA sites, gaps persist in the integration of substance use services into HIV care, particularly in relation to screening and referral practices, with reduced availability for children/adolescents and those receiving care within resource-constrained settings.
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Affiliation(s)
- Angela M Parcesepe
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Kathryn Lancaster
- Department of Epidemiology, The Ohio State University, Columbus, Ohio, United States of America
| | - E Jennifer Edelman
- Yale School of Medicine, New Haven, Connecticut, United States of America
- Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Raquel DeBoni
- National Institute of Infectology, Evandro Chagas, Fiocruz, Brazil
| | - Jeremy Ross
- TREAT Asia/amfAR, The Foundation for AIDS Research, Bangkok, Thailand
| | - Lukoye Atwoli
- Department of Mental Health, Moi University School of Medicine, Eldoret, Kenya
| | - Mpho Tlali
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Keri Althoff
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Judicaël Tine
- Maladies Infectieuses du Centre Hospitalier, National Universitaire de FANN, Dakar, Senegal
| | - Stephany N Duda
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - C William Wester
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Vanderbilt Institute for Global Health (VIGH), Nashville, Tennessee, United States of America
| | - Denis Nash
- Institute for Implementation Science in Population Health, City University of New York, New York, New York, United States of America
- Department of Epidemiology and Biostatistics, City University of New York, New York, New York, United States of America
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17
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Rieb LM, Samaan Z, Furlan AD, Rabheru K, Feldman S, Hung L, Budd G, Coleman D. Canadian Guidelines on Opioid Use Disorder Among Older Adults. Can Geriatr J 2020; 23:123-134. [PMID: 32226571 PMCID: PMC7067148 DOI: 10.5770/cgj.23.420] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background In Canada, rates of hospital admission from opioid overdose are higher for older adults (≥ 65) than younger adults, and opioid use disorder (OUD) is a growing concern. In response, Health Canada commissioned the Canadian Coalition of Seniors’ Mental Health to create guidelines for the prevention, screening, assessment, and treatment of OUD in older adults. Methods A systematic review of English language literature from 2008–2018 regarding OUD in adults was conducted. Previously published guidelines were evaluated using AGREE II, and key guidelines updated using ADAPTE method, by drawing on current literature. Recommendations were created and assessed using the GRADE method. Results Thirty-two recommendations were created. Prevention recommendations: it is key to prioritize non-pharmacological and non-opioid strategies to treat acute and chronic noncancer pain. Assessment recommendations: a comprehensive assessment is important to help discern contributions of other medical conditions. Treatment recommendations: buprenorphine is first line for both withdrawal management and maintenance therapy, while methadone, slow-release oral morphine, or naltrexone can be used as alternatives under certain circumstances; non-pharmacological treatments should be offered as an integrated part of care. Conclusion These guidelines provide practical and timely clinical recommendations on the prevention, assessment, and treatment of OUD in older adults within the Canadian context.
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Affiliation(s)
- Launette M Rieb
- Department of Family Practice, University of British Columbia, Vancouver, BC
| | - Zainab Samaan
- Department of Psychiatry, McMaster University, Hamilton, ON
| | | | - Kiran Rabheru
- Department of Psychiatry, University of Ottawa, Ottawa, ON
| | - Sid Feldman
- Department of Family and Community Medicine, University of Toronto, Toronto, ON
| | - Lillian Hung
- Canadian Gerontological Nurses Association, Toronto, ON
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Edelman EJ, Moore BA, Calabrese SK, Berkenblit G, Cunningham CO, Ogbuagu O, Patel VV, Phillips KA, Tetrault JM, Shah M, Blackstock O. Preferences for implementation of HIV pre-exposure prophylaxis (PrEP): Results from a survey of primary care providers. Prev Med Rep 2019; 17:101012. [PMID: 31890474 PMCID: PMC6926349 DOI: 10.1016/j.pmedr.2019.101012] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 08/15/2019] [Accepted: 10/20/2019] [Indexed: 12/11/2022] Open
Abstract
PrEP implementation in primary care has been slow. Primary care providers equally favor training all vs. having a PrEP specialist. Efforts to promote knowledge of clinical guidelines may enhance PrEP implementation.
Primary care physicians (PCPs) are critical for promoting HIV prevention by prescribing pre-exposure prophylaxis (PrEP). Yet, there are limited data regarding PCP’s preferred approaches for PrEP implementation. In 2015, we conducted an online survey of PCPs’ PrEP prescribing and implementation. Participants were general internists recruited from a national professional organization. We examined provider and practice characteristics and perceived implementation barriers and facilitators associated with preferred models for PrEP implementation. Among 240 participants, the majority (85%) favored integrating PrEP into primary care, either by training all providers (“all trained”) (42%) or having an onsite PrEP specialist (“on-site specialist”) (43%). Only 15% preferred referring patients out of the practice to a specialist (“refer out”). Compared to those who preferred to “refer out,” participants who preferred the “all trained” model were more likely to spend most of their time delivering direct patient care and to practice in the Northeast. Compared to participants who preferred the “refer out” or on-site specialist” models, PCPs preferring the all trained model were less likely to perceive lack of clinic PrEP guidelines/protocols as a barrier to PrEP. Most PCPs favored integrating PrEP into primary care by either training all providers or having an on-site specialist. Time devoted to clinical care and geography may influence preferences for PrEP implementation. Establishing clinic-specific PrEP protocols may promote on-site PrEP implementation. Future studies should focus on evaluating the effectiveness of different PrEP implementation models on PrEP delivery.
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Affiliation(s)
- E. Jennifer Edelman
- Yale, New Haven, CT, United States
- Corresponding author at: Yale University, School of Medicine and Public Health, 367 Cedar Street, E.S. Harkness Memorial Hall, Building A, Suite 401, New Haven, CT 06510 203.737.7115, United States.
| | | | - Sarah K. Calabrese
- Yale, New Haven, CT, United States
- George Washington University, Washington, DC, United States
| | | | - Chinazo O. Cunningham
- Albert Einstein College of Medicine, Montefiore Health System, Bronx, NY, United States
| | | | - Viraj V. Patel
- Albert Einstein College of Medicine, Montefiore Health System, Bronx, NY, United States
| | | | | | | | - Oni Blackstock
- Albert Einstein College of Medicine, Montefiore Health System, Bronx, NY, United States
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Perspectives on the HIV continuum of care among adult opioid users in New York City: a qualitative study. Harm Reduct J 2019; 16:58. [PMID: 31606048 PMCID: PMC6790030 DOI: 10.1186/s12954-019-0329-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 09/15/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Engagement in the HIV care continuum combined with office-based opioid treatment remains a cornerstone in addressing the intertwined epidemics of opioid use disorder (OUD) and HIV/AIDS. Factors influencing patient engagement with OUD and HIV care are complex and require further study. METHODS In this qualitative study, in-depth interviews were conducted among 23 adult patients who use drugs (PWUD) in an inpatient detoxification program in New York City. The semi-structured interview guide elicited participant experiences with various phases of the HIV care continuum, including factors influencing access to HIV care, interactions with HIV and primary care providers, preferences around integrated care approaches for OUD and HIV, and barriers experienced beyond clinical settings which affected access to HIV care (e.g., insurance issues, transportation, cost, retrieving prescriptions from their pharmacy). Data collection and thematic analysis took place concurrently using an iterative process-based established qualitative research method. RESULTS Respondents elicited high acceptability for integrated or co-located care for HIV and OUD in primary care. Factors influencing engagement in HIV care included (1) access to rapid point-of-care HIV testing and counseling services, (2) insurance coverage and costs related to HIV testing and receipt of antiretroviral therapy (ART), (3) primary care providers offering HIV care and buprenorphine, (4) illicit ART sales to pharmacies, (5) disruption in supplies of ART following admissions to inpatient detoxification or residential treatment programs, (6) in-person and telephone contact with peer support networks and clinic staff, (7) stigma, and (8) access to administrative support in primary care to facilitate reengagement with care following relapse, behavioral health services, transportation vouchers, and relocation from subsidized housing exposing patients to actively using peers. CONCLUSION These findings suggest expanding clinical and administrative support in primary care for PWUDs with patient navigators, case managers, mobile health interventions, and peer support networks to promote linkage and retention in care.
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Addressing unhealthy alcohol use among people living with HIV: recent advances and research directions. Curr Opin Infect Dis 2019; 31:1-7. [PMID: 29176446 DOI: 10.1097/qco.0000000000000422] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Unhealthy alcohol use is prevalent among people living with HIV (PLWH). We sought to identify the most current literature examining the impact of unhealthy alcohol on health outcomes and latest developments on how to best intervene. RECENT FINDINGS New research shows that PLWH have heightened morbidity and mortality at lower levels of alcohol consumption compared with HIV-uninfected persons. Studies published since 2016 have further elucidated the effects of persistent unhealthy alcohol use on HIV treatment outcomes over time. Screening and brief interventions, as well as pharmacologic treatment, can reduce unhealthy alcohol use among PLWH. SUMMARY Unhealthy alcohol use is an important and modifiable risk factor for poor health and HIV treatment outcomes among PLWH. More research is needed to encourage and maintain engagement in alcohol-related interventions and improve implementation.
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Rich KM, Bia J, Altice FL, Feinberg J. Integrated Models of Care for Individuals with Opioid Use Disorder: How Do We Prevent HIV and HCV? Curr HIV/AIDS Rep 2019; 15:266-275. [PMID: 29774442 PMCID: PMC6003996 DOI: 10.1007/s11904-018-0396-x] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Purpose of Review To describe models of integrated and co-located care for opioid use disorder (OUD), hepatitis C (HCV), and HIV. Recent Findings The design and scale-up of multidisciplinary care models that engage, retain, and treat individuals with HIV, HCV, and OUD are critical to preventing continued spread of HIV and HCV. We identified 17 models within primary care (N = 3), HIV specialty care (N = 5), opioid treatment programs (N = 6), transitional clinics (N = 2), and community-based harm reduction programs (N = 1), as well as two emerging models. Summary Key components of such models are the provision of (1) medication-assisted treatment for OUD, (2) HIV and HCV treatment, (3) HIV pre-exposure prophylaxis, and (4) behavioral health services. Research is needed to understand differences in effectiveness between co-located and fully integrated care, combat the deleterious racial and ethnic legacies of the “War on Drugs,” and inform the delivery of psychiatric care. Increased access to harm reduction services is crucial. Electronic supplementary material The online version of this article (10.1007/s11904-018-0396-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Katherine M Rich
- Section of Infectious Diseases, AIDS Program, Yale School of Medicine, New Haven, CT, USA
| | - Joshua Bia
- Frank H. Netter School of Medicine, Quinnipiac University, North Haven, CT, USA
| | - Frederick L Altice
- Section of Infectious Diseases, AIDS Program, Yale School of Medicine, New Haven, CT, USA.,Centre of Excellence on Research in AIDS (CERIA), University of Malaya, Kuala Lumpur, Malaysia
| | - Judith Feinberg
- Departments of Behavioral Medicine & Psychiatry and Medicine, West Virginia University School of Medicine, Morgantown, WV, USA.
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"Someone who is in this thing that I am suffering from": The role of peers and other facilitators for task sharing substance use treatment in South African HIV care. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 70:61-69. [PMID: 31082664 DOI: 10.1016/j.drugpo.2018.11.004] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 11/07/2018] [Accepted: 11/19/2018] [Indexed: 11/20/2022]
Abstract
South Africa is home to the largest number of people living with HIV/AIDS in the world. Alongside the HIV/AIDS epidemic, problematic alcohol and other drug (AOD) use is prevalent and associated with poor HIV treatment and secondary HIV prevention outcomes. International guidelines and local policy both support the integration of mental health care and AOD treatment into HIV care, yet barriers exist to implementation. This study aimed to explore patient and provider perspectives on the integration of HIV and AOD treatment services in Cape Town, South Africa. This included barriers and facilitators to task sharing AOD treatment in HIV care and preferences for a task shared approach to integrating AOD treatment in HIV care, including who should deliver the behavioural intervention. We conducted thirty semi-structured qualitative interviews with HIV and AOD treatment staff, providers, and people living with HIV/AIDS (PLWH) with moderate, problematic AOD use and difficulties (personal or structural) adhering to HIV treatment. Findings illustrated several key themes: (1) the separation between AOD and HIV services (a "siloed treatment experience"), even in the context of geographic co-location; (2) low AOD treatment literacy among HIV patients and providers, including a low awareness of existing AOD use services, even when co-located; (3) substance use stigma as a barrier to HIV and AOD treatment integration; (4) a strong patient preference for peer interventionists; and (5) the role of community health workers (CHWs) in detecting AOD use among some PLWH who had not followed up in HIV care. These findings will inform a future type 1 hybrid effectiveness-implementation trial, guided by the RE-AIM framework, to evaluate a task shared, evidence-based intervention to address problematic AOD use and improve HIV medication adherence in this setting.
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Abstract
OBJECTIVE We sought to identify optimal strategies for integrating HIV- and opioid use disorder-(OUD) screening and treatment in diverse settings. DESIGN Systematic review. METHODS We searched Ovid MEDLINE, PubMed, Embase, PsycINFO and preidentified websites. Studies were included if they were published in English on or after 2002 through May 2017, and evaluated interventions that integrated, at an organizational level, screening and/or treatment for HIV and OUD in any care setting in any country. RESULTS Twenty-nine articles met criteria for inclusion, including 23 unique studies: six took place in HIV care settings, 12 in opioid treatment settings, and five elsewhere. Eight involved screening strategies, 22 involved treatment strategies, and seven involved strategies that encompassed screening and treatment. Randomized controlled studies demonstrated low-to-moderate risk of bias and observational studies demonstrated fair to good quality. Studies in HIV care settings (n = 6) identified HIV-related and OUD-related clinical benefits with the use of buprenorphine/naloxone for OUD. No studies in HIV care settings focused on screening for OUD. Studies in opioid treatment settings (n = 12) identified improving HIV screening uptake and clinical benefits with antiretroviral therapy when provided on-site. Counseling intensity for OUD medication adherence or HIV-related risk reduction was not associated with clinical benefits. CONCLUSION Screening for HIV can be effectively delivered in opioid treatment settings, yet there is a need to identify optimal OUD screening strategies in HIV care settings. Strategies integrating the provision of medications for HIV and for OUD should be expanded and should not be contingent on resources available for behavioral interventions. REGISTRATION A protocol for record eligibility was developed a priori and was registered in the PROSPERO database of systematic reviews (registration number CRD42017069314).
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Oldfield BJ, Muñoz N, Boshnack N, Leavitt R, McGovern MP, Villanueva M, Tetrault JM, Edelman EJ. "No more falling through the cracks": A qualitative study to inform measurement of integration of care of HIV and opioid use disorder. J Subst Abuse Treat 2019; 97:28-40. [PMID: 30577897 DOI: 10.1016/j.jsat.2018.11.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 11/06/2018] [Accepted: 11/19/2018] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Integration of HIV- and opioid use disorder (OUD)-related care is associated with improved patient outcomes. Our goal was to develop a novel instrument for measuring quality of integration of HIV and OUD-related care that would be applicable across diverse care settings. METHODS Grounded in community-based participatory research principles, we conducted a qualitative study from August through November 2017 to inform modification of the Behavioral Health Integration in Medical Care (BHIMC) instrument, a validated measure of quality of integration of behavioral health in primary care. We conducted semi-structured interviews of patients (n = 22), focus groups with clinical staff (n = 24), and semi-structured interviews of clinic leadership (n = 5) in two urban centers in Connecticut. RESULTS We identified three themes that characterize optimal integration of HIV- and OUD-related care: (1) importance of mitigating mismatches in resources and knowledge, particularly resources to address social risks and knowledge gaps about evidence-based treatments for OUD; (2) need for patient-centered policies and inter-organization communication, and (3) importance of meeting people where they are, geographically and at their stage of change. These themes highlighted aspects of integrated care for HIV and OUD not captured in the original BHIMC. CONCLUSIONS Patients, clinical staff, and organization leadership perceive that addressing social risks, communication across agencies, and meeting patients in their psychosocial and structural context are important for optimizing integration of HIV and OUD-related care. Our proposed, novel instrument is a step towards measuring and improving service delivery locally and nationally for this vulnerable population.
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Affiliation(s)
- Benjamin J Oldfield
- National Clinician Scholars Program, Yale School of Medicine, New Haven, CT, United States of America; Department of Medicine, Yale School of Medicine, New Haven, CT, United States of America; Department of Pediatrics, Yale School of Medicine, New Haven, CT, United States of America.
| | - Nicolas Muñoz
- Department of Medicine, Yale School of Medicine, New Haven, CT, United States of America
| | | | - Robert Leavitt
- AIDS Project New Haven, New Haven, CT, United States of America
| | - Mark P McGovern
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, United States of America
| | - Merceditas Villanueva
- Department of Medicine, Yale School of Medicine, New Haven, CT, United States of America; Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, United States of America
| | - Jeanette M Tetrault
- Department of Medicine, Yale School of Medicine, New Haven, CT, United States of America
| | - E Jennifer Edelman
- Department of Medicine, Yale School of Medicine, New Haven, CT, United States of America; Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, United States of America
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25
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Abstract
The worsening opioid epidemic ignites infectious disease development and transmission as opioids abused by insufflation and/or injection establish a pathway for infection to the user and propagate vulnerability to diseases. The phenomenon of the synergistic collision of epidemics intensifying the load of disease constitutes a syndemic. Merrill Signer (1994) voiced the term "syndemic" to characterize the complex nexus of politics, economics, psychosocial/environmental factors, and health disparities resulting in the inner-city AIDS crisis of the 1990s. Today, the surge of opioid use puts individuals at risk for disease transmission and living the catastrophic clash wrought by the epidemics. By following a case study caught in the crossfire of epidemics, this article prompts to underscore recognition of the at-risk patient for HIV infection and to embolden care integration of prevention and treatment strategies nurses are qualified to execute.
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26
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Slawek DE, Lu TY, Hayes B, Fox AD. Caring for Patients With Opioid Use Disorder: What Clinicians Should Know About Comorbid Medical Conditions. PSYCHIATRIC RESEARCH AND CLINICAL PRACTICE 2018. [PMCID: PMC9175890 DOI: 10.1176/appi.prcp.20180005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Opioid use disorder (OUD) is a growing problem, with opioid‐involved overdose deaths quadrupling since 1999 in the United States. This article reviews comorbid medical conditions related to OUD, starting with complications of behaviors associated with opioid use (e.g., injection drug use), followed by conditions stemming from the direct effects of opioids (e.g., hypogonadism). HIV and hepatitis C virus (HCV) are common infections in people with OUD, and treatment for these conditions can be safely provided regardless of ongoing substance use. Complications of drug injection, such as HIV, HCV, skin and soft tissue infections, and infective endocarditis, may be prevented through provision of sterile syringes and supervised injection facilities. Rare, life‐threatening bacterial infections may present with signs and symptoms that mimic intoxication, such as malaise or stupor, and should be assessed in patients with fever or positive blood cultures. In addition, chronic opioid exposure can lead to hypogonadism, opioid‐induced hyperalgesia, sleep‐disordered breathing, and potentially increased risk of cardiovascular disease and neurocognitive impairment. Pharmacotherapies for OUD (buprenorphine, methadone, and naltrexone) are safe and effective and their adverse opioid effects can be managed in clinical practice. Awareness of OUD‐associated medical conditions and their treatments is an important step in improving the health and wellness of people with OUD.
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Affiliation(s)
| | - Tiffany Y. Lu
- Department of MedicineAlbert Einstein College of MedicineBronxNY
| | - Benjamin Hayes
- Department of MedicineAlbert Einstein College of MedicineBronxNY
| | - Aaron D. Fox
- Department of MedicineAlbert Einstein College of MedicineBronxNY
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27
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Vallecillo G, Robles MJ, Durán X, Lerma E, Horcajada JP, Torrens M. Trends in AIDS Mortality, Retention in Opioid Agonist Therapy, and HIV RNA Suppression in HIV-Infected People Who Injected Drugs from 2000 to 2015. AIDS Behav 2018; 22:2766-2772. [PMID: 29372455 DOI: 10.1007/s10461-018-2033-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
AIDS is a major cause of preventable mortality in HIV-infected people who inject drugs (HIV-PWID). An observational study was conducted to examine trends in AIDS mortality and related factors among HIV-infected individuals who died between 2000 and 2015 at an urban hospital. Overall HIV-mortality was 6.5% (413/6307) with no changes over time (p 0.76). AIDS mortality dropped in HIV-PWID (p 0.02) although it represented 26.4% at the end of study period. Age (per one-year increase) [odds ratio (OR) 0.95], third study period (2010-2015) (OR 0.54), HIV-PWID on opioid agonist therapy (OAT) (OR 0.39), and HIV RNA suppression (OR 0.15) were associated with AIDS mortality. OAT was reported in 58.3% (161/276) and RNA suppression in 30.9% (85/276) of HIV-PWID. OAT non-retention was due to drop-outs [85.2% (98/115)] and rejection [14.8% (17/115)] in HIV-PWID. Therefore, additional strategies are required to improve OAT retention and HIV RNA suppression to continue reducing AIDS mortality.
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Affiliation(s)
- G Vallecillo
- Institute of Neuropsychiatry and Addictions, Hospital del Mar, Passeig Marítim 25-29, 08003, Barcelona, Spain.
- Addiction Research Group, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain.
| | - M J Robles
- Geriatric Unit, Hospital del Mar, Barcelona, Spain
| | - X Durán
- Department of Methodological Advice in Biomedical Research (AMIB), Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - E Lerma
- Institute of Neuropsychiatry and Addictions, Hospital del Mar, Passeig Marítim 25-29, 08003, Barcelona, Spain
- Addiction Research Group, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - J P Horcajada
- Infectious Disease Department, Hospital del Mar, Barcelona, Spain
| | - M Torrens
- Institute of Neuropsychiatry and Addictions, Hospital del Mar, Passeig Marítim 25-29, 08003, Barcelona, Spain
- Addiction Research Group, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
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Havens JR, Walsh SL, Korthuis PT, Fiellin DA. Implementing Treatment of Opioid-Use Disorder in Rural Settings: a Focus on HIV and Hepatitis C Prevention and Treatment. Curr HIV/AIDS Rep 2018; 15:315-323. [PMID: 29948609 PMCID: PMC6260984 DOI: 10.1007/s11904-018-0402-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
PURPOSE OF REVIEW To describe the epidemiology of opioid-use disorder in the rural United States (U.S.) as it pertains to HIV and hepatitis C transmission and treatment resources. RECENT FINDINGS Heroin and fentanyl analogs have surpassed prescription opioids in their availability in rural opioid markets adding to HIV and hepatitis C (HCV) and overdose risks. Only 18% of rural individuals live in towns with inpatient services which are of limited quality and utility. Opioid treatment programs that provide methadone are not located in rural areas and only 3% of the primary care providers have the ability to prescribe buprenorphine. National models and resources have been established but lack implementation in rural areas leading to ongoing HIV and HCV transmission and overdose. Addressing the adverse impact of opioids in the rural U.S. will require a concerted effort to implement effective treatments according to national standards.
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Affiliation(s)
- Jennifer R Havens
- Department of Behavioral Science and Center on Drug and Alcohol Research, University of Kentucky, 845 Angliana Avenue, Lexington, KY, 40508, USA.
| | - Sharon L Walsh
- Department of Behavioral Science and Center on Drug and Alcohol Research, University of Kentucky, 845 Angliana Avenue, Lexington, KY, 40508, USA
| | - P Todd Korthuis
- Department of Medicine, Section of Addition Medicine, Oregon Health and Science University, Portland, OR, USA
| | - David A Fiellin
- Yale School of Medicine, New Haven, CT, USA
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, USA
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Edelman EJ, Oldfield BJ, Tetrault JM. Office-Based Addiction Treatment in Primary Care: Approaches That Work. Med Clin North Am 2018; 102:635-652. [PMID: 29933820 DOI: 10.1016/j.mcna.2018.02.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Primary care is an important setting for delivering evidence-based treatment to address substance use disorders. To date, effective approaches to treat, care largely incorporate pharmacotherapy with counseling-based interventions and rely on multidisciplinary teams. There is strong support for primary care-based approaches to address alcohol and opioid use disorder with growing data focused on people living with human immunodeficiency virus and those experiencing incarceration. Future work should focus on the implementation of these effective approaches to decrease health disparities among people with substance use and to identify optimal approaches to address substance use in primary care and specialty settings.
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Affiliation(s)
- E Jennifer Edelman
- Department of Medicine, Yale University School of Medicine and Public Health, 367 Cedar Street, E.S. Harkness Memorial Hall, Building A, Suite 401, New Haven, CT 06510, USA.
| | - Benjamin J Oldfield
- National Clinician Scholars Program, Yale University School of Medicine, PO Box 208088, New Haven, CT 06520, USA
| | - Jeanette M Tetrault
- Department of Internal Medicine, Yale University School of Medicine, 367 Cedar Street, Suite 305, New Haven, CT 06510, USA
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30
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Lagisetty P, Klasa K, Bush C, Heisler M, Chopra V, Bohnert A. Primary care models for treating opioid use disorders: What actually works? A systematic review. PLoS One 2017; 12:e0186315. [PMID: 29040331 PMCID: PMC5645096 DOI: 10.1371/journal.pone.0186315] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 09/28/2017] [Indexed: 12/30/2022] Open
Abstract
Background Primary care-based models for Medication-Assisted Treatment (MAT) have been shown to reduce mortality for Opioid Use Disorder (OUD) and have equivalent efficacy to MAT in specialty substance treatment facilities. Objective The objective of this study is to systematically analyze current evidence-based, primary care OUD MAT interventions and identify program structures and processes associated with improved patient outcomes in order to guide future policy and implementation in primary care settings. Data sources PubMed, EMBASE, CINAHL, and PsychInfo. Methods We included randomized controlled or quasi experimental trials and observational studies evaluating OUD treatment in primary care settings treating adult patient populations and assessed structural domains using an established systems engineering framework. Results We included 35 interventions (10 RCTs and 25 quasi-experimental interventions) that all tested MAT, buprenorphine or methadone, in primary care settings across 8 countries. Most included interventions used joint multi-disciplinary (specialty addiction services combined with primary care) and coordinated care by physician and non-physician provider delivery models to provide MAT. Despite large variability in reported patient outcomes, processes, and tasks/tools used, similar key design factors arose among successful programs including integrated clinical teams with support staff who were often advanced practice clinicians (nurses and pharmacists) as clinical care managers, incorporating patient “agreements,” and using home inductions to make treatment more convenient for patients and providers. Conclusions The findings suggest that multidisciplinary and coordinated care delivery models are an effective strategy to implement OUD treatment and increase MAT access in primary care, but research directly comparing specific structures and processes of care models is still needed.
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Affiliation(s)
- Pooja Lagisetty
- Division of General Internal Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan, United States of America
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, United States of America
- Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, Michigan, United States of America
- * E-mail:
| | - Katarzyna Klasa
- University of Michigan School of Public Health, Ann Arbor, Michigan, United States of America
| | - Christopher Bush
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, North Carolina, United States of America
| | - Michele Heisler
- Division of General Internal Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan, United States of America
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, United States of America
- Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Vineet Chopra
- Division of General Internal Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan, United States of America
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, United States of America
| | - Amy Bohnert
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, United States of America
- Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, Michigan, United States of America
- Division of Psychiatry, University of Michigan School of Medicine, Ann Arbor, Michigan, United States of America
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31
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Riggins DP, Cunningham CO, Ning Y, Fox AD. Recent incarceration and buprenorphine maintenance treatment outcomes among human immunodeficiency virus-positive patients. Subst Abus 2017; 38:297-302. [PMID: 27715904 PMCID: PMC5303565 DOI: 10.1080/08897077.2016.1220443] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Opioid use disorder is a common cause of morbidity and mortality among people living with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS). Buprenorphine maintenance treatment (BMT) is an effective means of therapy, but patients with recent criminal justice involvement may need more support during BMT than other patients. The authors hypothesized that recently incarcerated BMT patients who initiated treatment in primary care would have poorer treatment outcomes than those who were not recently incarcerated. METHODS Investigators analyzed data from a multisite cohort study of BMT integrated into HIV care. Patients were stratified by self-reported incarceration in the 30 days before initiation of BMT. The outcomes of interest were 6- and 12-month treatment retention and self-reported opioid use. Investigators used multivariable logistic regression and hierarchical linear model, respectively, to evaluate the association between recent incarceration and these outcomes while adjusting for potential confounding variables. RESULTS Among 305 BMT patients living with HIV/AIDS, 39 (13%) reported recent incarceration. Patients with recent incarceration (vs. without) were more likely to be homeless, unemployed, and previously diagnosed with mental illness. Recent incarceration was not significantly associated with differences in 6-month (odds ratio [OR] = 0.95; 95% confidence interval [CI] = 0.46-1.98) and 12-month (OR = 0.57; 95% CI = 0.27-1.18) treatment retention or in self-reported opioid use (OR = 0.99; 95% CI = 0.51-1.92) after adjustment for potential confounding variables. CONCLUSIONS Those with incarceration in the 30 days prior to BMT initiation were more likely to be homeless, unemployed, and previously diagnosed with mental illness than those without recent incarceration. However, no significant difference in self-reported opioid use or 6-month or 12-month retention in treatment was detected between those with and without recent incarceration. Future studies should confirm these findings with larger sample sizes. Encouraging formerly incarcerated individuals with opioid use disorder to initiate evidence-based treatments, including BMT, should be part of efforts to confront the opioid addiction epidemic in the United States.
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Affiliation(s)
| | - Chinazo O. Cunningham
- Albert Einstein College of Medicine, Bronx, New York, USA
- Montefiore Medical Center, Bronx, New York, USA
| | - Yuming Ning
- Albert Einstein College of Medicine, Bronx, New York, USA
- Montefiore Medical Center, Bronx, New York, USA
| | - Aaron D. Fox
- Albert Einstein College of Medicine, Bronx, New York, USA
- Montefiore Medical Center, Bronx, New York, USA
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Haldane V, Cervero-Liceras F, Chuah FLH, Ong SE, Murphy G, Sigfrid L, Watt N, Balabanova D, Hogarth S, Maimaris W, Buse K, Piot P, McKee M, Perel P, Legido-Quigley H. Integrating HIV and substance use services: a systematic review. J Int AIDS Soc 2017; 20:21585. [PMID: 28692211 PMCID: PMC5515016 DOI: 10.7448/ias.20.1.21585] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 04/25/2017] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Substance use is an important risk factor for HIV, with both concentrated in certain vulnerable and marginalized populations. Although their management differs, there may be opportunities to integrate services for substance use and HIV. In this paper we systematically review evidence from studies that sought to integrate care for people living with HIV and substance use problems. METHODS Studies were included if they evaluated service integration for substance use and HIV. We searched multiple databases from inception until October 2015. Articles were screened independently by two reviewers and assessed for risk of bias. RESULTS AND DISCUSSION 11,057 records were identified, with 7616 after removal of duplicates. After screening titles and abstracts, 51 met the inclusion criteria. Integration models were categorized by location (HIV, substance use and other facilities), level of integration from mirco (integrated care delivered to individuals) to macro (system level integrations) and degree of integration from least (screening and counselling only) to most (care for HIV, substance use and/or other illnesses at the same facility). Most reported descriptive or cohort studies; in four randomized control trials integrated activities improved patient outcomes. There is potential for integrating services at all facility types, including mobile health services. While services offering screening only can achieve synergies, there are benefits from delivering integrated treatment for HIV and substance use, including ease of referral to other mental health and social services. CONCLUSIONS Our review used a wide range of databases and conference archives to increase representation of papers from low- and middle-income countries. Limitations include the overrepresentation of studies from the United States, and the descriptive nature of the majority of papers. The evidence reviewed shows that greater integration offers important benefits in both patient and service outcomes but further research and outcome reporting is needed to better understand innovative and holistic care models at the complex intersection of substance use and HIV services.
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Affiliation(s)
- Victoria Haldane
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | | | - Fiona LH Chuah
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Suan Ee Ong
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Georgina Murphy
- Centre for Tropical Medicine and Global Health, Nuffield Dept. of Clinical Medicine, University of Oxford, Oxford, UK
| | - Louise Sigfrid
- Centre for Tropical Medicine and Global Health, Nuffield Dept. of Clinical Medicine, University of Oxford, Oxford, UK
| | - Nicola Watt
- The Centre for Health and Social Change (ECOHOST), London School of Hygiene and Tropical Medicine, London, UK
| | - Dina Balabanova
- Department of Global Health & Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Sue Hogarth
- London School of Hygiene and Tropical Medicine, London, UK
- London Borough of Waltham Forest, London, UK
| | - Will Maimaris
- London School of Hygiene and Tropical Medicine, London, UK
- Haringey Council, London, UK
| | - Kent Buse
- London Borough of Waltham Forest, London, UK
- UNAIDS, Geneva, Switzerland
| | - Peter Piot
- London School of Hygiene and Tropical Medicine, London, UK
| | - Martin McKee
- The Centre for Health and Social Change (ECOHOST), London School of Hygiene and Tropical Medicine, London, UK
| | - Pablo Perel
- London School of Hygiene and Tropical Medicine, London, UK
- The World Heart Foundation, Geneva, Switzerland
| | - Helena Legido-Quigley
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
- London School of Hygiene and Tropical Medicine, London, UK
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Guise A, Seguin M, Mburu G, McLean S, Grenfell P, Islam Z, Filippovych S, Assan H, Low A, Vickerman P, Rhodes T. Integrated opioid substitution therapy and HIV care: a qualitative systematic review and synthesis of client and provider experiences. AIDS Care 2017; 29:1119-1128. [PMID: 28281354 DOI: 10.1080/09540121.2017.1300634] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
People who use drugs in many contexts have limited access to opioid substitution therapy and HIV care. Service integration is one strategy identified to support increased access. We reviewed and synthesized literature exploring client and provider experiences of integrated opioid substitution therapy and HIV care to identify acceptable approaches to care delivery. We systematically reviewed qualitative literature. We searched nine bibliographic databases, supplemented by manual searches of reference lists of articles from the database search, relevant journals, conferences, key organizations and consultation with experts. Thematic synthesis was used to develop descriptive themes in client and provider experiences. The search yielded 11 articles for inclusion, along with 8 expert and policy reports. We identify five descriptive themes: the convenience and comprehensive nature of co-located care, contrasting care philosophies and their role in shaping integration, the limits to disclosure and communication between clients and providers, opioid substitution therapy enabling HIV care access and engagement, and health system challenges to delivering integrated services. The discussion explores how integrated opioid substitution therapy and HIV care needs to adapt to specific social conditions, rather than following universal approaches. We identify priorities for future research. Acceptable integrated opioid substitution therapy and HIV care for people who use drugs and providers is most likely through co-located care and relies upon attention to stigma, supportive relationships and client centred cultures of delivery. Further research is needed to understand experiences of integrated care, particularly delivery in low and middle income settings and models of care focused on community and non-clinic based delivery.
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Affiliation(s)
- Andy Guise
- a Department of Global Public Health , University of California San Diego , San Diego , USA.,b Department of Public Health and Policy , London School of Hygiene and Tropical Medicine , London , UK
| | - Maureen Seguin
- c Centre for Research on Drugs and Health Behaviour , London School of Hygiene and Tropical Medicine , London , UK
| | - Gitau Mburu
- d Program Impact Unit , International HIV/AIDS Alliance , Brighton , UK.,e Department of Health Research , University of Lancaster , Lancaster , UK
| | - Susie McLean
- d Program Impact Unit , International HIV/AIDS Alliance , Brighton , UK
| | - Pippa Grenfell
- c Centre for Research on Drugs and Health Behaviour , London School of Hygiene and Tropical Medicine , London , UK
| | - Zahed Islam
- f Management Sciences for Health , Dhaka , Bangladesh
| | - Sergii Filippovych
- g Treatment, Procurement and Supply Management Department , International HIV/AIDS Alliance Ukraine , Kyiv , Ukraine
| | - Happy Assan
- h Tanzanian Network of People who Use Drugs , MDM Drop in centre , Dar es Salaam , Tanzania
| | - Andrea Low
- i International Center for AIDS Care and Treatment Programs , Columbia University , New York , USA
| | - Peter Vickerman
- j School of Social and Community Medicine , University of Bristol , Bristol , UK
| | - Tim Rhodes
- c Centre for Research on Drugs and Health Behaviour , London School of Hygiene and Tropical Medicine , London , UK
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Korthuis PT, McCarty D, Weimer M, Bougatsos C, Blazina I, Zakher B, Grusing S, Devine B, Chou R. Primary Care-Based Models for the Treatment of Opioid Use Disorder: A Scoping Review. Ann Intern Med 2017; 166:268-278. [PMID: 27919103 PMCID: PMC5504692 DOI: 10.7326/m16-2149] [Citation(s) in RCA: 192] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Greater integration of medication-assisted treatment (MAT) for opioid use disorder (OUD) in U.S. primary care settings would expand access to treatment for this condition. Models for integrating MAT into primary care vary in structure. This article summarizes findings of a technical report for the Agency for Healthcare Research and Quality describing MAT models of care for OUD, based on a literature review and interviews with key informants in the field. The report describes 12 representative models of care for integrating MAT into primary care settings that could be considered for adaptation across diverse health care settings. Common components of existing care models include pharmacotherapy with buprenorphine or naltrexone, provider and community education, coordination and integration of OUD treatment with other medical and psychological needs, and psychosocial services and interventions. Models vary in how each component is implemented. Decisions about adopting MAT models of care should be individualized to address the unique milieu of each implementation setting.
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Affiliation(s)
- P Todd Korthuis
- From Oregon Health & Science University, Portland, Oregon, and University of Washington, Seattle, Washington
| | - Dennis McCarty
- From Oregon Health & Science University, Portland, Oregon, and University of Washington, Seattle, Washington
| | - Melissa Weimer
- From Oregon Health & Science University, Portland, Oregon, and University of Washington, Seattle, Washington
| | - Christina Bougatsos
- From Oregon Health & Science University, Portland, Oregon, and University of Washington, Seattle, Washington
| | - Ian Blazina
- From Oregon Health & Science University, Portland, Oregon, and University of Washington, Seattle, Washington
| | - Bernadette Zakher
- From Oregon Health & Science University, Portland, Oregon, and University of Washington, Seattle, Washington
| | - Sara Grusing
- From Oregon Health & Science University, Portland, Oregon, and University of Washington, Seattle, Washington
| | - Beth Devine
- From Oregon Health & Science University, Portland, Oregon, and University of Washington, Seattle, Washington
| | - Roger Chou
- From Oregon Health & Science University, Portland, Oregon, and University of Washington, Seattle, Washington
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Edelman EJ, Maisto SA, Hansen NB, Cutter CJ, Dziura J, Fiellin LE, O'Connor PG, Bedimo R, Gibert C, Marconi VC, Rimland D, Rodriguez-Barradas MC, Simberkoff MS, Justice AC, Bryant KJ, Fiellin DA. The Starting Treatment for Ethanol in Primary care Trials (STEP Trials): Protocol for Three Parallel Multi-Site Stepped Care Effectiveness Studies for Unhealthy Alcohol Use in HIV-Positive Patients. Contemp Clin Trials 2016; 52:80-90. [PMID: 27876616 DOI: 10.1016/j.cct.2016.11.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 11/14/2016] [Accepted: 11/17/2016] [Indexed: 01/20/2023]
Abstract
Unhealthy alcohol use is common among HIV-positive patients, yet effective evidence-based treatments are rarely provided in clinical settings providing HIV care. Further, given patient variability in response to initial treatments, stepped care approaches may be beneficial. We describe the rationale, aims and study design for the current StartingTreatment forEthanol inPrimary care Trials (STEP Trials); three parallel randomized controlled effectiveness trials being conducted in five Infectious Disease Clinics. Participants meeting criteria for: 1) at-risk drinking, 2) moderate alcohol use with liver disease (MALD), or 3) alcohol use disorder (AUD) are randomized to integrated stepped care versus treatment as usual. For those with at-risk drinking or MALD, integrated stepped care starts with a one session brief intervention and follow-up 2-week telephone booster. Based on pre-specified nonresponse criteria, participants may be "stepped up" at week 4 to receive four sessions of motivational enhancement therapy (MET) and "stepped up" again at week 12 for addiction physician management (APM) and consideration of alcohol pharmacotherapy. For those with AUD, integrated stepped care begins with APM. Non-responders may be "stepped up" at week 4 to receive MET and again at week 12 for a higher level of care (e.g. intensive outpatient program). The primary outcome is alcohol consumption assessed at 24weeks, and secondary outcome is the VACS Index, a validated measure of HIV morbidity and mortality risk. Results from the STEP Trials should inform future research and the implementation of interventions to address unhealthy alcohol use among HIV-positive individuals.
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Affiliation(s)
- E Jennifer Edelman
- Yale University School of Medicine, New Haven, CT 06510, United States; Center for Interdisciplinary Research on AIDS, Yale University School of Public Health, New Haven, CT 06510, United States.
| | | | - Nathan B Hansen
- Center for Interdisciplinary Research on AIDS, Yale University School of Public Health, New Haven, CT 06510, United States; College of Public Health, University of Georgia, Athens, GA 30602, United States
| | | | - James Dziura
- Yale Center for Analytic Sciences, Yale University School of Public Health, New Haven, CT 06511, United States
| | - Lynn E Fiellin
- Yale University School of Medicine, New Haven, CT 06510, United States; Center for Interdisciplinary Research on AIDS, Yale University School of Public Health, New Haven, CT 06510, United States
| | | | - Roger Bedimo
- Veterans Affairs North Texas Health Care System and UT Southwestern, Dallas, TX 75216, United States
| | - Cynthia Gibert
- D.C. Veterans Affairs Medical Center and George Washington University School of Medicine and Health Sciences, Washington, D.C. 20422, United States
| | - Vincent C Marconi
- Atlanta Veterans Affairs Medical Center and Emory University School of Medicine, Decatur, GA 30033, United States
| | - David Rimland
- Atlanta Veterans Affairs Medical Center and Emory University School of Medicine, Decatur, GA 30033, United States
| | - Maria C Rodriguez-Barradas
- Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas Houston, TX 77030, United States
| | - Michael S Simberkoff
- VA NY Harbor Healthcare System and New York University School of Medicine, New York, NY 10010, United States
| | - Amy C Justice
- Yale University School of Medicine, New Haven, CT 06510, United States; VA Connecticut Healthcare System, Veterans Aging Cohort Study, West Haven, CT 06516, United States
| | - Kendall J Bryant
- National Institute on Alcohol Abuse and Alcoholism HIV/AIDS Program, Bethesda, MD 20892-7003, United States
| | - David A Fiellin
- Yale University School of Medicine, New Haven, CT 06510, United States; Center for Interdisciplinary Research on AIDS, Yale University School of Public Health, New Haven, CT 06510, United States
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Fox AD, Masyukova M, Cunningham CO. Optimizing psychosocial support during office-based buprenorphine treatment in primary care: Patients' experiences and preferences. Subst Abus 2015; 37:70-5. [PMID: 26566712 PMCID: PMC4801741 DOI: 10.1080/08897077.2015.1088496] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Buprenorphine maintenance treatment is effective and has been successfully integrated into human immunodeficiency virus (HIV) and primary care settings. However, one key barrier to providers prescribing buprenorphine is their perception that they are unable to provide adequate counseling or psychosocial support to patients with opioid addiction. This qualitative study investigated supportive elements of office-based buprenorphine treatment that patients perceived to be most valuable. METHODS The authors conducted five focus groups with 33 buprenorphine treatment-experienced participants. Focus groups were audio-recorded and transcribed. Iterative readings of transcripts and grounded theory analysis revealed common themes. RESULTS Overall, participants perceived that buprenorphine treatment helped them to achieve their treatment goals and valued the flexibility, accessibility, and privacy of treatment. Participants identified interpersonal and structural elements of buprenorphine treatment that provided psychosocial support. Participants desired good physician-patient relationships, but also valued care delivery models that were patient-centered, created a safe place for self-disclosure, and utilized coordinated team-based care. CONCLUSIONS Participants derived psychosocial support from their prescribing physician, but were also open to collaborative or team-based models of care, as long as they were voluntary and confidential. Buprenorphine-prescribing physicians without access to referral options for psychosocial counseling could focus on maintaining nonjudgmental attitudes and shared decision-making during patient encounters. Adding structure and psychosocial support to buprenorphine treatment through coordinated team-based care also seems to have great promise.
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Affiliation(s)
- Aaron D Fox
- a Albert Einstein College of Medicine , Bronx , New York , USA
- b Department of Medicine, Montefiore Medical Center , Bronx , New York , USA
| | | | - Chinazo O Cunningham
- a Albert Einstein College of Medicine , Bronx , New York , USA
- b Department of Medicine, Montefiore Medical Center , Bronx , New York , USA
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Aletraris L, Edmond MB, Paino M, Fields D, Roman PM. Counselor training and attitudes toward pharmacotherapies for opioid use disorder. Subst Abus 2015; 37:47-53. [PMID: 26168816 PMCID: PMC4879956 DOI: 10.1080/08897077.2015.1062457] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Methadone and buprenorphine have been demonstrated to be effective in the treatment of opioid use disorder (OUD), especially when combined with psychosocial treatment. Despite buprenorphine's association with fewer withdrawal symptoms and lessened risk of abuse, compared with methadone, its adoption remains limited. Given the vital role that counselors may play in its successful implementation, their knowledge and perceptions of opioid agonist therapy may be facilitators or barriers to its acceptance. METHODS Informed by diffusion theory, the current study examined perceptions of buprenorphine's and methadone's acceptability among 725 counselors employed in a nationally representative sample of substance use disorder treatment centers. First, we provided descriptive statistics about medication diffusion, extent of training received about the medications, and perceptions of acceptability of each medication. Then, we compared acceptability of opioid agonists with other treatment approaches for OUD. Finally, we conducted 2 ordinary least squares regressions to examine counselor acceptability of buprenorphine and of methadone. RESULTS Descriptive statistics suggested that diffusion of information about buprenorphine and methadone was not complete, and training was not extensive for either medication. Counselors reported greater acceptability and training of buprenorphine compared with methadone. Methadone was rated as the least acceptable among all other treatment approaches. Multivariate analyses indicated regional differences, and that medication-specific training, adaptability, and educational attainment were positively related with perceptions of acceptability of either medication, even after controlling for organizational characteristics. Adherence to a 12-step orientation was negatively associated with acceptability. CONCLUSIONS Dissemination of information about opioid agonist therapy is occurring. Nevertheless, the fact that 20% of counselors admitted not knowing enough about either buprenorphine's or methadone's effectiveness is surprising in light of the extensive literature documenting their effectiveness. Future research should focus upon different types of training that can inform physicians, counselors, and patients about the use of opioid agonist therapy.
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Affiliation(s)
- Lydia Aletraris
- University of Georgia, Owens Institute for Behavioral Research, Athens, GA, USA
| | - Mary Bond Edmond
- University of Georgia, Owens Institute for Behavioral Research, Athens, GA, USA
| | - Maria Paino
- Oakland University, Department of Sociology, Anthropology, Social Work, and Criminal Justice, Rochester, MI, USA
| | - Dail Fields
- University of Georgia, Owens Institute for Behavioral Research, Athens, GA, USA
| | - Paul M. Roman
- University of Georgia, Owens Institute for Behavioral Research, Athens, GA, USA
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Bojko MJ, Mazhnaya A, Makarenko I, Marcus R, Dvoriak S, Islam Z, Altice FL. "Bureaucracy & Beliefs": Assessing the Barriers to Accessing Opioid Substitution Therapy by People Who Inject Drugs in Ukraine. DRUGS-EDUCATION PREVENTION AND POLICY 2015; 22:255-262. [PMID: 27087758 DOI: 10.3109/09687637.2015.1016397] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
AIMS Opioid substitution therapy (OST) is an evidence-based HIV prevention strategy for people who inject drugs (PWIDs). Yet, only 2.7% of Ukraine's estimated 310,000 PWIDs receive it despite free treatment since 2004. The multi-level barriers to entering OST among opioid dependent PWIDs have not been examined in Ukraine. METHODS A multi-year mixed methods implementation science project included focus group discussions with 199 PWIDs in 5 major Ukrainian cities in 2013 covering drug treatment attitudes and beliefs and knowledge of and experiences with OST. Data were transcribed, translated into English and coded. Coded segments related to OST access, entry, knowledge, beliefs and attitudes were analyzed among 41 PWIDs who were eligible for but had never received OST. FINDINGS A number of programmatic and structural barriers were mentioned by participants as barriers to entry to OST, including compulsory drug user registration, waiting lists, and limited number of treatment slots. Participants also voiced strong negative attitudes and beliefs about OST, especially methadone. Their perceptions about methadone's side effects as well as the stigma of being a methadone client were expressed as obstacles to treatment. CONCLUSIONS Despite expressed interest in treatment, Ukrainian OST-naïve PWIDs evade OST for reasons that can be addressed through changes in program-level and governmental policies and social-marketing campaigns. Voiced OST barriers can effectively inform public health and policy directives related to HIV prevention and treatment in Ukraine to improve evidence-based treatment access and availability.
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Affiliation(s)
- Martha J Bojko
- Yale University School of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, Connecticut, USA
| | - Alyona Mazhnaya
- ICF International HIV/AIDS Alliance in Ukraine, Kyiv, Ukraine
| | | | - Ruthanne Marcus
- Yale University School of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, Connecticut, USA
| | - Sergii Dvoriak
- Ukrainian Institute for Public Health Policy, Kyiv, Ukraine
| | - Zahedul Islam
- ICF International HIV/AIDS Alliance in Ukraine, Kyiv, Ukraine
| | - Frederick L Altice
- Yale University School of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, Connecticut, USA; Yale University School of Public Health, Division of Epidemiology of Microbial Diseases, New Haven, Connecticut, USA
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Haddad MS, Zelenev A, Altice FL. Buprenorphine maintenance treatment retention improves nationally recommended preventive primary care screenings when integrated into urban federally qualified health centers. J Urban Health 2015; 92:193-213. [PMID: 25550126 PMCID: PMC4338126 DOI: 10.1007/s11524-014-9924-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Buprenorphine maintenance therapy (BMT) expands treatment access for opioid dependence and can be integrated into primary health-care settings. Treating opioid dependence, however, should ideally improve other aspects of overall health, including preventive services. Therefore, we examined how BMT affects preventive health-care outcomes, specifically nine nationally recommended primary care quality health-care indicators (QHIs), within federally qualified health centers (FQHCs) from an observational cohort study of 266 opioid-dependent patients initiating BMT between 07/01/07 and 11/30/08 within Connecticut's largest FQHC network. Nine nationally recommended preventive QHIs were collected longitudinally from electronic health records, including screening for chronic infections, metabolic conditions, and cancer. A composite QHI score (QHI-S), based on the percentage of eligible QHIs achieved, was categorized as QHI-S ≥80% (recommended) and ≥90% (optimal). The proportion of subjects achieving a composite QHI-S ≥80 and ≥90 % was 57.1 and 28.6%, respectively. Screening was highest for hypertension (91.0%), hepatitis C (80.1%), hepatitis B (76.3%), human immunodeficiency virus (71.4%), and hyperlipidemia (72.9%) and lower for syphilis (49.3%) and cervical (58.5%), breast (44.4%), and colorectal (48.7%) cancer. Achieving QHI-S ≥80% was positively and independently associated with ≥3-month BMT retention (adjusted odds ratio (AOR) = 2.19; 95% confidence interval (CI) = 1.18-4.04) and BMT prescription by primary care providers (PCPs) rather than addiction psychiatric specialists (AOR = 3.38; 95% CI = 1.78-6.37), and negatively with being female (AOR = 0.30; 95% CI = 0.16-0.55). Within primary health-care settings, achieving greater nationally recommended health-care screenings or QHIs was associated with being able to successfully retain patients on buprenorphine longer (3 months or more) and when buprenorphine was prescribed simultaneously by PCPs rather than psychiatric specialists. Decreased preventive screening for opioid-dependent women, however, may require gender-based strategies for achieving health-care parity. When patients can be retained, integrating BMT into urban FQHCs is associated with improved health outcomes including increased multiple preventive health-care screenings.
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Affiliation(s)
- Marwan S Haddad
- Community Health Center, Inc., 635 Main Street, Middletown, CT, 06457, USA,
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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.
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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
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Morano JP, Zelenev A, Walton MR, Bruce RD, Altice FL. Latent tuberculosis infection screening in foreign-born populations: a successful mobile clinic outreach model. Am J Public Health 2014; 104:1508-15. [PMID: 24922157 DOI: 10.2105/ajph.2014.301897] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVES We evaluated the efficacy of a mobile medical clinic (MMC) screening program for detecting latent tuberculosis infection (LTBI) and active tuberculosis. METHODS A LTBI screening program in a MMC in New Haven, Connecticut, used medical surveys to examine risk factors and tuberculin skin test (TST) screening eligibility. We assessed clinically relevant correlates of total (prevalent; n = 4650) and newly diagnosed (incident; n = 4159) LTBI from 2003 to 2011. RESULTS Among 8322 individuals, 4159 (55.6%) met TST screening eligibility criteria, of which 1325 (31.9%) had TST assessed. Similar to LTBI prevalence (16.8%; 779 of 4650), newly diagnosed LTBI (25.6%; 339 of 1325) was independently correlated with being foreign-born (adjusted odds ratio [AOR] = 8.49; 95% confidence interval [CI] = 5.54, 13.02), Hispanic (AOR = 3.12; 95% CI = 1.88, 5.20), Black (AOR = 2.16; 95% CI = 1.31, 3.55), employed (AOR = 1.61; 95% CI = 1.14, 2.28), and of increased age (AOR = 1.04; 95% CI = 1.02, 1.05). Unstable housing (AOR = 4.95; 95% CI = 3.43, 7.14) and marijuana use (AOR = 1.57; 95% CI = 1.05, 2.37) were significantly correlated with incident LTBI, and being male, heroin use, interpersonal violence, employment, not having health insurance, and not completing high school were significantly correlated with prevalent LTBI. CONCLUSIONS Screening for TST in MMCs successfully identifies high-risk foreign-born, Hispanic, working, and uninsured populations and innovatively identifies LTBI in urban settings.
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Affiliation(s)
- Jamie P Morano
- Jamie P. Morano, Alexei Zelenev, Mary R. Walton, R. Douglas Bruce, and Frederick L. Altice are with the Yale School of Medicine, Department of Infectious Diseases, Yale University AIDS Program, New Haven, CT. R. D. Bruce and F. L. Altice are also affiliated with the Yale School of Public Health, Division of Epidemiology of Microbial Diseases, New Haven. F. L. Altice is also associated with the Centre of Excellence in Research in AIDS, University of Malaya, Kuala Lumpur, Malaysia
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Drainoni ML, Farrell C, Sorensen-Alawad A, Palmisano JN, Chaisson C, Walley AY. Patient perspectives of an integrated program of medical care and substance use treatment. AIDS Patient Care STDS 2014; 28:71-81. [PMID: 24428768 PMCID: PMC3926137 DOI: 10.1089/apc.2013.0179] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The benefits of integrating primary care and substance use disorder treatment are well known, yet true integration is difficult. We developed and evaluated a team-based model of integrated care within the primary care setting for HIV-infected substance users and substance users at risk for contracting HIV. Qualitative data were gathered via focus groups and satisfaction surveys to assess patients' views of the program, evaluate key elements for success, and provide recommendations for other programs. Key themes related to preferences for the convenience and efficiency of integrated care; support for a team-based model of care; a feeling that the program requirements offered needed structure; the importance of counseling and education; and how provision of concrete services improved overall well-being and quality of life. For patients who received buprenorphine/naloxone for opioid dependence, this was viewed as a major benefit. Our results support other studies that theorize integrated care could be of significant value for hard-to-reach populations and indicate that having a clinical team dedicated to providing substance use disorder treatment, HIV risk reduction, and case management services integrated into primary care clinics has the potential to greatly enhance the ability to serve a challenging population with unmet treatment needs.
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Affiliation(s)
- Mari-Lynn Drainoni
- Department of Health Policy and Management, Boston University School of Public Health, Boston, Massachusetts
- Section of Infectious Diseases, Boston University School of Medicine, Boston, Massachusetts
- Center for Health Quality, Outcomes and Economic Research, ENRM Veterans Administration Hospital, Boston, Massachusetts
| | - Caitlin Farrell
- Department of Health Policy and Management, Boston University School of Public Health, Boston, Massachusetts
| | - Amy Sorensen-Alawad
- Department of Geriatrics, Boston University School of Medicine, Boston, Massachusetts
| | - Joseph N. Palmisano
- Department of Data Coordinating Center, Boston University School of Public Health, Boston, Massachusetts
| | - Christine Chaisson
- Department of Data Coordinating Center, Boston University School of Public Health, Boston, Massachusetts
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - Alexander Y. Walley
- Department of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts
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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.
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Morano JP, Walton MR, Zelenev A, Bruce RD, Altice FL. Latent tuberculosis infection: screening and treatment in an urban setting. J Community Health 2013; 38:941-50. [PMID: 23728822 PMCID: PMC3781590 DOI: 10.1007/s10900-013-9704-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Despite its benefit for treating active tuberculosis, directly observed therapy (DOT) for latent tuberculosis infection (LTBI) has been largely understudied among challenging inner city populations. Utilizing questionnaire data from a comprehensive mobile healthcare clinic in New Haven, CT from 2003 to July 2011, a total of 2,523 completed tuberculin skin tests (TSTs) resulted in 356 new LTBIs. Multivariate logistic regression correlated covariates of the two outcomes (a) initiation of isoniazid preventative therapy (IPT) and (b) completion of 9 months of IPT. Of the 357 newly positive TSTs, 86.3 % (n = 308) completed screening chest radiographs (CXRs): 90.3 % (n = 278) were normal, and 0.3 % (n = 1) had active tuberculosis. Of those completing CXR screening, 44.0 % (n = 135) agreed to IPT: 69.6 % (n = 94) selected DOT, and 30.4 % (n = 41) selected self-administered therapy (SAT). Initiating IPT was correlated with undocumented status (AOR = 3.43; p < 0.001) and being born in a country of highest and third highest tuberculosis prevalence (AOR = 14.09; p = 0.017 and AOR = 2.25; p = 0.005, respectively). Those selecting DOT were more likely to be Hispanic (83.0 vs 53.7 %; p < 0.0001), undocumented (57.4 vs 41.5 %; p = 0.012), employed (p < 0.0001), uninsured (p = 0.014), and have stable housing (p = 0.002), no prior cocaine or crack use (p = 0.013) and no recent incarceration (p = 0.001). Completing 9 months of IPT was correlated with no recent incarceration (AOR 5.95; p = 0.036) and younger age (AOR 1.03; p = 0.031). SAT and DOT participants did not significantly differ for IPT duration (6.54 vs 5.68 months; p = 0.216) nor 9-month completion (59.8 vs 46.3 %; p = 0.155). In an urban mobile healthcare sample, screening completion for LTBI was high with nearly half initiating IPT. Undocumented, Hispanic immigrants from high prevalence tuberculosis countries were more likely to self-select DOT at the mobile outreach clinic, potentially because of more culturally, linguistically, and logistically accessible services and self-selection optimization phenomena. Within a diverse, urban environment, DOT and SAT IPT models for LTBI treatment resulted in similar outcomes, yet outcomes were hampered by differential measurement bias between DOT and SAT participants.
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Affiliation(s)
- Jamie P Morano
- Department of Medicine, Section of Infectious Diseases, AIDS Program, Yale University School of Medicine, 135 College Street, Suite 323, New Haven, CT 06510, USA.
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Haddad MS, Zelenev A, Altice FL. Integrating buprenorphine maintenance therapy into federally qualified health centers: real-world substance abuse treatment outcomes. Drug Alcohol Depend 2013; 131:127-35. [PMID: 23332439 PMCID: PMC3674170 DOI: 10.1016/j.drugalcdep.2012.12.008] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2012] [Revised: 12/09/2012] [Accepted: 12/10/2012] [Indexed: 11/25/2022]
Abstract
BACKGROUND Few studies have examined real-world effectiveness of integrated buprenorphine maintenance treatment (BMT) programs in federally qualified health centers (FQHCs). METHODS Opioid dependent patients (N=266) inducted on buprenorphine between July 2007 and December 2008 were retrospectively assessed at Connecticut's largest FQHC network. Six-month BMT retention and opioid-free time were collected longitudinally from electronic health records; 136 (51.1%) of patients were followed for at least 12 months. RESULTS Participants had a mean age of 40.1 years, were primarily male (69.2%) and treated by family practitioners (70.3%). Co-morbidity included HCV infection (59.8%), mood disorders (71.8%) and concomitant cocaine use (59%). Retention on BMT was 56.8% at 6 months and 61.6% at 12 months for the subset observed over 1 year. Not being retained on BMT at 12 months was associated with cocaine use (AOR=2.18; 95% CI=1.35-3.50) while prescription of psychiatric medication (AOR=0.36; 95% CI 0.20-0.62) and receiving on-site substance abuse counseling (AOR=0.34; 95% CI 0.19, 0.59) improved retention. Two thirds of the participants experienced at least one BMT gap of 2 or more weeks with a mean gap length of 116.4 days. CONCLUSIONS Integrating BMT in this large FQHC network resulted in retention rates similarly reported in clinical trials and emphasizes the need for providing substance abuse counseling and screening for and treating psychiatric comorbidity.
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Affiliation(s)
| | | | - Frederick L. Altice
- Yale University School of Medicine, New Haven, CT, USA,Yale University School of Public Health, New Haven, CT, USA
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Sohler NL, Weiss L, Egan JE, López CM, Favaro J, Cordero R, Cunningham CO. Consumer attitudes about opioid addiction treatment: a focus group study in New York City. J Opioid Manag 2013; 9:111-9. [PMID: 23709320 DOI: 10.5055/jom.2013.0152] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2012] [Revised: 12/07/2012] [Accepted: 12/20/2012] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To develop effective programs for people who are opioid dependent and to impact the opioid epidemic in New York City, it is crucial to monitor attitudes about opioid addiction treatments among opioid users who have experienced barriers to engagement and retention in addiction treatment. DESIGN The authors conducted a qualitative study using focus groups. METHODS Six focus groups in three needle exchanges in New York City were audio recorded, transcribed, and systematically coded. The authors report on the main themes related to the study objectives. PARTICIPANTS Participants of each needle exchange who were opioid dependent and had some knowledge of both methadone and buprenorphine were eligible. RESULTS There were four main findings. Participants felt the following: 1) buprenorphine is an appropriate option for those heroin users who are motivated to stop using, 2) they have less control over their addiction treatment with methadone than they would have with buprenorphine, 3) buprenorphine treatment is not accessible to many New York City residents who would benefit from this treatment, and 4) lack of access to buprenorphine treatment is a cause of treatment-related diversion. CONCLUSIONS Both methadone maintenance and buprenorphine treatment opportunities are necessary to address the diverse treatment needs of opioid-dependent people in New York City. However, the current medical model of buprenorphine treatment may be too restrictive for some opioid-dependent people and may be contributing to the use of illicit buprenorphine. New models to deliver buprenorphine treatment may address these problems.
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Affiliation(s)
- Nancy L Sohler
- The City College of New York, Sophie Davis School of Biomedical Education, New York, NY, USA
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The burgeoning HIV/HCV syndemic in the urban Northeast: HCV, HIV, and HIV/HCV coinfection in an urban setting. PLoS One 2013; 8:e64321. [PMID: 23691197 PMCID: PMC3653872 DOI: 10.1371/journal.pone.0064321] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Accepted: 04/14/2013] [Indexed: 01/16/2023] Open
Abstract
Introduction Despite recommendations for generation-based HCV and once lifetime HIV screening, thousands of individuals in the U.S. still remain untested and undiagnosed. This cross-sectional study examines the correlates of HCV and HIV monoinfection and HIV/HCV coinfection in an urban Northeast setting. Methods Utilizing an electronic database from a mobile medical clinic in New Haven, CT from January 2003 to July 2011, 8,311 individuals underwent structured health assessment and screening for HIV and HCV. Results HIV [N = 601 (8.0%)] and HCV [N = 753 (10.1%)] infection were identified, and 197 (26.1%) of the 753 with HCV were coinfected with HIV. Both monoinfection and coinfection status were independently correlated with crack cocaine use and increasing age. HIV/HCV coinfection was correlated with men having sex with men (MSM) (AOR = 38.53, p<0.0080), shooting gallery use (AOR = 3.06, p<0.0070), and not completing high school (AOR = 2.51, p<0.0370). HCV monoinfection correlated with health insurance (AOR = 2.16, p<0.0020), domestic violence (AOR = 1.99, p<0.0070), and being Hispanic (AOR = 2.63, p<0.0001), while HIV monoinfection correlated with having had syphilis (AOR = 2.66, p<0.0001) and being Black (AOR = 1.73, p = 0.0010). Conclusions Though HIV and HCV share common transmission risk behaviors, independent correlates with viral infection status in an urban Northeast setting are distinct and have important implications for surveillance, healthcare delivery, disease prevention, and clinical care.
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Edelman EJ, Fiellin DA. Moving HIV pre-exposure prophylaxis into clinical settings: lessons from buprenorphine. Am J Prev Med 2013; 44:S86-90. [PMID: 23253768 PMCID: PMC3645931 DOI: 10.1016/j.amepre.2012.09.035] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2012] [Revised: 09/04/2012] [Accepted: 09/19/2012] [Indexed: 11/28/2022]
Affiliation(s)
- E Jennifer Edelman
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut 06520-8093, USA
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Brief versus extended counseling along with buprenorphine/naloxone for HIV-infected opioid dependent patients. J Subst Abuse Treat 2012; 43:433-9. [DOI: 10.1016/j.jsat.2012.07.011] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Revised: 06/27/2012] [Accepted: 07/04/2012] [Indexed: 11/18/2022]
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