Addressing Structural Barriers to HIV Care among Triply Diagnosed Adults: Project Bridge Oakland

People who are "triply diagnosed" with HIV, mental health issues, and substance-related disorders face tremendous barriers connecting to and remaining in HIV care. Authors of this article implemented Project Bridge Oakland (PBO), an intervention based on harm reduction and trauma-informed care, to help maintain continuity of care for triply diagnosed adults through cycles of criminal justice involvement. From August 2011 to December 2014, a clinical social worker and an HIV physician provided intensive case management for 19 clients living in Oakland, California. By working with clients across a multitude of community, clinic, and correctional spaces while maintaining a low threshold for services, the social worker was able to engage a severely marginalized population in HIV care. This article details the PBO strategies for assisting with a wide range of services needed for community stabilization, navigating criminal justice involvement, and establishing a therapeutic relationship through mundane practices such as eating and waiting for appointments. This article illustrates how programs aimed at stabilizing triply diagnosed clients in the community and connecting them to HIV care require coordination among providers, outreach to engage clients, ample time to work with them, and flexibility to account for the complexities of their day-to-day lives and experiences.

Physicians Practicing in Methadone Treatment Programs

OBJECTIVE

This study examines the characteristics and roles of physicians practicing in methadone maintenance treatment programs (MTPs).

METHODS

Physicians and clinic directors at 172 MTPs in the United States completed surveys. MTPs were selected for study participation based on their locations (large urban, urban, or nonurban area) ownership status (for profit and non-profit), and size (patient capacity of 1-100, 101-300, and 300+). Weighted data were analyzed with descriptive and multivariate methods. RESULTS. Physicians were primarily white males aged 45 or older; 44% had 10 or more years of experience working in methadone treatment. Physicians reported spending 26% of their time completing administrative tasks. Most reported that they determine dosing levels on an individual patient basis. Average maintenance dose was 69 mg/day.

CONCLUSIONS

Physicians' treatment practices play a major role in overall treatment, treatment retention, and outcomes. Physicians at for-profit and large urban MTPs reported spending the most time in direct patient contact.

Buprenorphine: "field trials" of a new drug

Buprenorphine is being introduced as a new treatment drug for narcotics addiction in the United States. The authors were asked by the National Institute on Drug Abuse to conduct a field trial to determine if buprenorphine might play a role in street markets. Because no street use of the drug existed in the United States, the authors used three sources of information: (a) "street readings" of clinical studies, (b) Internet discussion lists, and (c) research in other countries. By using an emergent style of analysis that relies on replication of patterns across disparate data sources, it was determined that buprenorphine has desirable characteristics from a street addict point of view. An evaluation of the field trial 5 years later evaluates its accuracy.

Heroin Addict Habit Size in Three Cities: Context and Variation

The field of heroin addiction research has never had a reliable figure for the size of the average heroin habit. Four ethnographers were asked to conduct research in three U.S. cities to explore this question. While they were able to calculate averages that fit well with a standard pharmacology reference, they found the high variance around the estimates more significant. Each ethnographer constructed a model to show how the dynamics and contexts of the street markets suggest that any average is more an artifact of statistical calculation rather than a reflection of an addict's actual situation at any given point in time.