JAIDS Journal of Acquired Immune Deficiency Syndromes:
Policy Implications of Integrating Buprenorphine/Naloxone Treatment and HIV Care
Finkelstein, Ruth ScD*; Netherland, Julie MSW, MPhil*; Sylla, Laurie BSW, MHSA†; Gourevitch, Marc N MD, MPH‡; Cajina, Adan MS§; Cheever, Laura MD, ScM§; for the BHIVES Collaborative
From *The New York Academy of Medicine, Division of Health Policy, New York, NY; †Yale University School of Medicine, New Haven, CT; ‡New York University School of Medicine, New York, NY; and §HIV/AIDS Bureau, Health Resources and Services Administration, Rockville, MD.
Supported by grant numbers H97HA03793 from the Health Resources and Services Administration. This grant is funded through the HIV/AIDS Bureau's Special Project of National Significance.
The contents of this publication are solely the responsibility of the authors and do not necessarily represent the views of the funding agencies or the US government.
The BHIVES Collaborative and the National Advisory Committee Members are listed in Appendix 1.
Correspondence to: Ruth Finkelstein, ScD, Vice President for Health Policy, The New York Academy of Medicine, 1216 Fifth Avenue, New York, NY 10029 (e-mail: email@example.com).
Researchers, practitioners, and policymakers have long recognized the potential benefits of providing integrated substance abuse and medical care services, particularly for special populations such as people living with HIV/AIDS. Buprenorphine, an office-based pharmacological treatment for opioid dependence, offers new opportunities for integrating drug treatment into HIV care settings. However, the historical separation between the drug treatment and medical care systems has resulted in a host of policy barriers. The Buprenorphine and HIV Care Evaluation and Support initiative, a multisite demonstration project to assess the feasibility and effectiveness of integrating buprenorphine/naloxone into HIV care settings, provided an opportunity to evaluate if and how policy barriers affect efforts to integrate HIV care and addiction treatment. We found that financing issues, workforce and training issues, and the operational consequences of some conceptual differences between HIV care and addiction treatment are barriers to the full integration of buprenorphine into HIV care. We recommend changes to financing and reimbursement policies, programs to strengthen the addiction treatment skills of physicians, and cross training between the fields of addiction, medicine, drug treatment, and HIV medicine. By addressing some of the policy barriers to integration, this promising new treatment can help the thousands of people living with HIV/AIDS who are also opioid dependent.
Researchers, practitioners, and policymakers have long recognized the potential benefits of providing integrated substance abuse and medical care services, particularly for special populations such as people living with HIV/AIDS. Indeed, different models for integrating substance-abuse treatment and primary care (eg, colocated services, case management, referral networks, increased role of medical providers in screening and intervention) have shown promise in improving engagement in medical care1; facilitating access to drug treatment2; reducing substance use1,3,4; and decreasing medical problems and hospitalizations.1,4,5 In addition, better awareness and understanding of chemical abuse, dependency, and addiction by medical providers may reduce the stigma associated with substance abuse and foster cross-training between medical and substance-abuse professionals.6 Office-based pharmacological treatment of opioid dependence, whether with methadone or buprenorphine, has also been shown to improve client retention and reduce illicit drug use (particularly among stabilized patients and those on higher doses of methadone, LAAM or buprenorphine).2,7-15 Optimally, integration has the potential to increase drug treatment capacity, reduce health care and administrative costs, diminish duplication of services, and improve the health and drug treatment outcomes of vulnerable populations.
Unfortunately, the historical separation between the drug treatment and medical care systems has resulted in a host of policy barriers, including regulatory, licensing, and financing impediments. These have resulted in workforce and training deficits, organizational obstacles, and underengagement of health professionals in the diagnosis and treatment of substance-use disorders (SUDs), despite their high prevalence. Many doctors do not perceive addiction as within their purview to diagnose and treat.6,16 Only 40% of physicians surveyed include illicit drug use on medical history forms and only 32% administer drug or alcohol screening instruments.17 Lack of training may contribute to this neglect. On average, medical schools devote only 12 hours to alcohol and substance use,16 and only 8% require an addiction medicine component in their curriculum.18 In the absence of adequate training, providers often have a poor understanding of opioid agonist treatment and may struggle with prejudices and negative attitudes.19,20 Importantly, however, research suggests that the attitudes and behavior of medical providers regarding treating addiction are mutable.21,22 Focused training has resulted in improvements in screening and treatment of addiction.16,23-25
Even well-trained providers are likely to face a number of institutional, logistical, and policy barriers in integrating addiction-related pharmacotherapy into primary care settings.26 Administrators or other providers may be resistant to these efforts because of concerns about disruptive patients or a sense that it is outside the mission of the organization and expertise of the providers. Integrated care is also likely to cause apprehension about additional costs associated with the treatment and monitoring of patients.27
Despite the promise of integrated care, the barriers to realizing its potential are numerous, including in HIV care settings. HIV-infected individuals who use substances often lack the resources, skills, or motivation to effectively utilize available health care; indeed, 38% of Ryan White Part-A funded programs surveyed expressed difficulty retaining individuals with SUD in medical care.28 Once in care, some HIV-infected individuals with SUD may fail to follow treatment recommendations, reflecting long-standing community distrust of health care providers and/or individual negative experiences,29 competing priorities, or chaotic living circumstances. Fearing disapproval30 or loss of public assistance, drug users are often unwilling to disclose their substance use to providers.31
The passage of the Drug Addiction Treatment Act of 2000 (DATA 2000) was meant to address some of these barriers by facilitating integration of addiction treatment into medical care settings. Based on the recognition that opioid dependence is a medical disorder amenable to pharmacological treatment, DATA 2000 explicitly sought to increase the role of the medical profession in providing addiction treatment. Buprenorphine and the buprenorphine/naloxone (bup/nx) combination were the first medications approved by the Food and Drug Administration (under the brand names Subutex and Suboxone, respectively) for office-based treatment of opioid dependence. Under DATA 2000, bup/nx is exempt from many of the regulatory requirements of methadone, which, with some limited exceptions, must be prescribed through a certified Opioid Treatment Program when used for the treatment of opioid dependence. Unlike methadone treatment, bup/nx treatment can take place in any clinical care setting and does not require daily attendance. The availability of bup/nx in primary care settings thus has the potential to overcome traditional barriers to integrating medical care and addiction treatment, to expand addiction treatment capacity, and to reach new patients who are unlikely to seek traditional addiction treatment.
From 2004 to 2009, the HIV/AIDS Bureau of the Health Resources and Services Administration (HRSA) funded, through its Special Projects of National Significance, the development of demonstration programs that integrated HIV care and bup/nx treatment for opioid dependence at 10 sites across the United States. HRSA also funded an Evaluation and Technical Assistance Center (the “Center”) to coordinate the multisite mixed method evaluation, provide clinical and evaluation support and technical assistance, and promote dissemination of findings. Data from 9 of the 10 sites were included in the multisite evaluation. Known as the Buprenorphine and HIV Care Evaluation and Support initiative (BHIVES), this study offered an opportunity to assess the feasibility and effectiveness of integrating bup/nx into HIV care settings and provided an opportunity to evaluate if and how policy barriers affect efforts to integrate HIV care and addiction treatment. The range of institutional settings and the distribution of the programs across a variety of states allowed us to examine how setting and state financing policies facilitated or impeded efforts to provide addiction treatment in HIV care settings. In this article, we discuss financing issues, workforce and training issues, and the operational consequences of some conceptual differences between HIV care and addiction treatment. We also discuss a number of policy issues that we had hypothesized would emerge as barriers to integrating care but did not. We conclude with a discussion of how the BHIVES project has already had an impact on policy as well as policy recommendations for improving the integration of HIV care and bup/nx treatment.
As described in Weiss et al32 in this issue, the BHIVES project is multisite national evaluation of 10 demonstration projects, each of which developed a program to integrate bup/nx treatment into HIV care settings. In addition to client-level data, the BHIVES project involved the collection of provider and site-level data to assess the feasibility of implementing these programs and to identify institutional and policy levels barriers to integration. Over the course of the 5-year project, each program received a minimum of 2 site visits-1 at the beginning of the project and 1 at the end. Site visits involved a team of 2-5 staff who visited each site for 2 days to observe the setting, speak with program staff, and conduct qualitative interviews with Principal Investigators, program administrators, medical directors, nursing and counseling staff, doctors prescribing bup/nx, and any other personnel involved in providing bup/nx-related care. Staff from all 10 sites met together with the Evaluation and Support Center staff 7 times over the project period, and we have reviewed notes from these meetings to identify other policy issues that arose. In addition, a National Advisory Committee comprised of technical, policy and clinical experts in HIV care and addiction medicine1 advised the project; their insights on policy opportunities and barriers also inform this work. Finally, we conducted a baseline and follow-up survey of providers at each of the study sites that focused on barriers to providing bup/nx. The methods and results from that survey have been previously published33 and also inform our findings here.
In some ways, HIV care settings-many of which have access to HIV-specific categorical funding streams (principally from the different parts of the Ryan White HIV/AIDS Program)-are well positioned to provide bup/nx treatment. Many of the larger HIV care clinics provide or have effective linkages with mental health, case management, drug treatment, and other ancillary services that can greatly benefit people with HIV and addiction disorders. Nonetheless, because integrated bup/nx and HIV care crosses both medical and behavioral health, payment issues for integrated care are complicated and vary widely from state to state. Bup/nx services for people living with HIV/AIDS can theoretically be covered by Medicaid, Medicare, AIDS Drug Assistance Program (ADAP), other Ryan White-funded programs, private insurance, Medicaid behavioral health carve-outs, and substance-abuse treatment state block grants. Despite, or perhaps because of, the myriad possible funding streams, payment was identified by providers as one of the biggest barriers to providing integrated bup/nx and HIV care. During the study, staffing costs could be covered by grant funds and medication costs covered by grant funds or the manufacturer of Suboxone (Reckitt Benckiser Pharmaceuticals, Inc), but providers were clear that navigating payment systems would pose a major impediment to offering bup/nx going forward. Although Reckitt Benckiser donated free medication for uncovered study participants, this kind of coverage is obviously limited in “real world” settings. Payment barriers fell into 3 basic categories: payment mechanisms, the scope of coverage, and the duration of coverage.
Nationally, only half of those with opioid-use disorders are covered by private or military insurance. The remainder are covered by Medicaid (15.4%), other public insurance (2.9%), or are uninsured (26.4%).34 About one-third of private insurers exclude bup/nx and over half place it in the highest cost-sharing tier.35 Coverage for bup/nx by Medicaid varies widely by state. In the BHIVES project, some sites, like the CORE Center in Cook County, Illinois, were able to get Medicaid coverage for bup/nx routinely, although others had to go through a preauthorization process.
The ADAP is another potential source of public funding for bup/nx for those who are uninsured, ineligible for Medicaid or Medicare, and/or waiting for enrollment into Medicaid. ADAP formularies are different for every state, range widely, and change from year to year. ADAP formularies cover bup/nx only in Washington, DC, Maryland, and Michigan. Some states, such as Massachusetts, do not include bup/nx on a formulary but will cocover the medication if it is covered by the patient's primary insurance. New Jersey has an open formulary that covers all Food and Drug Administration-approved medications.36 According to the National ADAP Monitoring report for 2009, only 3% of all ADAP expenditures went toward drug treatment, suggesting that coverage for bup/nx is limited at best.37 During the period of the BHIVES study, only 2 sites had coverage for bup/nx through ADAP. Increasing pressure on the ability of ADAP programs to meet basic HIV treatment need and growing ADAP waiting lists in a number of states limit the likelihood of this resource expanding significantly to cover bup/nx treatment.
Finally, the financing split between medical care and behavioral health created complications for some sites. For example, in 1 site, all behavioral health services for Medicaid-enrolled patients are overseen by a separate managed care organization. This organization will only allow patients to receive substance-abuse treatment through the managed care company's own psychiatrists and counselors. Therefore, even if a patients' HIV care was covered at this site, their bup/nx treatment from their HIV physicians was not. In some sites, existing payment incentives posed challenges (even those originally intended to enhance access to drug treatment for people living with HIV/AIDS). For instance, in San Francisco and New York, people living with HIV/AIDS are given priority slots in methadone maintenance. Payment for these services is well reimbursed creating financial incentives for providers to enroll patients in methadone. Treatment decisions may be based on ease of reimbursement rather than on patient preference or need.
In addition to problems with payment mechanisms, sites encountered problems with the scope of coverage offered. Ideally, bup/nx treatment involves the prescription of the medication, supervised induction, periodic physician visits, and ongoing counseling or support. Other desirable components of care include recovery support, psychiatric services, case management, urine toxicology, and laboratory analyses. Unfortunately, coverage for all of these components is rarely available through public or private payers. Currently, providing these services through a centralized staff person, like the bup/nx coordinator that our study identified as critical for high needs populations in this demonstration,32 requires individual programs to identify grant or other sources of funding. Although the professional background and credentialing of this person varied from site to site, each site had one person who played a central role in coordinating services, assisting with entitlements, and, in most instances, providing counseling. In general, this position was paid for by the HRSA grant that funded the BHIVES study. Clearly, without this funding, medical care settings will be challenged to find a way to pay for these services for these high needs patients.
The services provided through this study were more comprehensive than those that might be offered in the absence of grant support, but the incremental costs of providing bup/nx itself were relatively low. Compared with other HIV patients with opioid dependence, we found incremental HIV clinic costs were $21 per patient per month.38 With the cost of the bup/nx included, the total additional cost of $231 per patient month still compares favorably with monthly per patient costs reported elsewhere for methadone maintenance services provided in an office ($238), or methadone clinic ($159-$377).39,40 The main driver of costs in this study was the number of physician encounters. Models of integrated care within the BHIVES study that required fewer physician encounters, relying instead on nonphysician bup/nx coordinators for some of the care realize significant costs savings over what we have reported here.38 This suggests that costs may be reduced by using mid-level providers for more patient management and/or amending prescribing regulations to allow mid-level providers to prescribe bup/nx. However, these potential cost savings must be weighed against the role that physicians can and should play in the care and treatment of bup/nx patients and the important role physicians can play in bringing addiction treatment into the medical mainstream.
Several sites also reported concerns related to the duration of coverage for bup/nx treatment. Like methadone, bup/nx can be used for either detoxification or as a maintenance therapy. For individuals with chronic opioid dependence problems, most specialists recommend ongoing treatment with a replacement therapy.41-43 However, some payers are reluctant to cover bup/nx beyond the initial detoxification period or, they cap the total number of days or total costs allowed for drug treatment. Other problems emerged in getting timely coverage for the induction period. For example, uninsured patients who wish to be induced on bup/nx may be required to wait long periods while their Medicaid applications are processed (which can take up 90 days). Often individuals with substance-abuse problems have narrow windows of readiness to start treatment, and delays can mean that a critical opportunity to engage someone in treatment is lost. Potential harm, such as death from overdose or new HIV or HCV infection may occur during this treatment delay. For HIV medications, like antiretrovirals, ADAP is often used to cover this gap. However, given the limited coverage of bup/nx by ADAP, this is not currently a viable solution in most states.
Workforce and Training Issues
As discussed above, researchers have suggested that physician training in and the identification and treatment of substance-abuse disorders is limited. To partially address that shortcoming, DATA 2000 includes a requirement for physicians not trained in addiction medicine who wish to prescribe bup/nx to participate in an 8-hour training course. Once this training is completed, a physician can submit a waiver to the Center for Substance Abuse Treatment to obtain a unique Drug Enforcement Agency registration to prescribe bup/nx. Although several of the physicians in the BHIVES study felt the training was helpful and important, others noted that these requirements set bup/nx apart from all of the other new medications and treatment technologies they were asked to incorporate into their practices. In fact, many reported that the training requirement actually raised their apprehension about prescribing bup/nx.32 Several physicians stated that they could prescribe methadone and other controlled substances for pain without special training and that the rationale for treating bup/nx differently was not evident. Although attitudes toward the training requirement were mixed, nearly all the physicians involved in the study wanted and appreciated mentoring for difficult issues, including precipitated withdrawal and pain management.44 They were also interested in connecting to other HIV physicians with experience prescribing bup/nx.32,45
The prohibition against nonphysicians prescribing bup/nx was universally cited as a problem in the BHIVES study. In the large academic medical centers, many HIV clinics include physicians who see patients only a half-day a week. These part-time HIV physicians may be hesitant to take on bup/nx prescribing because they are unlikely to be able to accommodate the more frequent visits needed during the induction period.32 In addition, because they are only in clinic 1 day a week, adjusting dosages and accommodating drop-in visits can be difficult. Nurse practitioners and physician assistants, on the other hand, often have controlled substance prescribing privileges, tend to be in the clinic much more often, and play a central role in many HIV care settings. In fact, in some settings, they handle much of the HIV and primary care and most of the related prescribing. In the BHIVES study, at some sites, the role of bup/nx prescribing physician was somewhat limited (eg, initial physical exam, occasional monitoring visits, and writing prescriptions), whereas nonphysician staff provided much of the ongoing bup/nx care. Both physicians and nonphysicians interviewed felt the regulations restricting nurse practitioners and physician assistants from prescribing bup/nx were arbitrary restrictions that set bup/nx apart from other medications and created unnecessary logistical burdens and access barriers. Given the relatively slow diffusion of bup/nx prescribing among physicians in the BHIVES study,32 lifting the restriction on nonphysician prescribing might facilitate broader access to bup/nx in HIV care settings. Nonphysician prescribing is likely to be well received by patients because few patients distinguish between the person who writes the prescription for their bup/nx and the provider with whom they have the most face-to-face contact.46 However, physicians, particularly those with expertise in addiction and/or ongoing patient relationships, can play a critical role in bup/nx treatment.
Conceptual and Operational Differences Between HIV Care and Drug Treatment
Despite the high rates of comorbidity between HIV and substance-abuse disorders, the worlds of HIV care and drug treatment have developed fairly independently and are guided by different sets of assumptions and different measures of success. These differences come to the fore as participating programs work to integrate HIV care and bup/nx treatment. The majority of physicians participating in the BHIVES initiative articulated harm reduction approaches to care that emphasized patient autonomy, a non-judgmental acceptance of some patient behaviors (including certain levels of drug use), and an overwhelming focus on retaining clients in care to improve their medical outcomes. They perceived addiction medicine and drug treatment providers as having a more regimented and punitive approach that was often focused exclusively on achieving abstinence from drugs. Those providers with more background and experience in drug treatment settings, on the other hand, perceived the HIV clinics as unstructured and HIV clinicians as vulnerable to manipulation by patients. These conceptual differences had operational consequences. For instance, several HIV-oriented prescribing physicians reported surprise and dismay at their difficulty placing their bup/nx patients in “drug-free” treatment programs that viewed bup/nx as a drug rather than a medication. Those more experienced in drug treatment are familiar with the frequent polarization between “drug-free” and medication-assisted treatment, and many have been able to intervene successfully with a range of treatment modalities. Moreover, as noted in elsewhere in this issue,32,47 many HIV providers used urine toxicology screens less frequently than recommended by addiction specialists, citing tensions between wanting to monitor clinical outcomes and fearing that that toxicology screens would seem judgmental or punitive by patients, ultimately having a negative impact on the treatment. Some HIV providers were also initially reluctant to establish consequences for patients who persisted in their drug use, fearing that setting limits might deter patients from returning for HIV care. Many providers expressed the sentiment that any reduction in drug use, however limited, was good for their patients' health. Finally, a few providers acknowledged that opioid analgesics were sometimes knowingly prescribed to patients with addiction problems. Before the availability of office-based bup/nx, prescription opioids were viewed by a few as a better option for their addicted patients than street drugs. Over the course of the study, many HIV providers learned from and adopted the recommendations of addiction medicine experts, such as routine use of toxicology screens.
Problems We Expected But Did Not Find
Over the course of the study, several anticipated difficulties failed to materialize. Because of the complicated financing and the Drug Enforcement Agency regulations governing the handling, dispensing and record-keeping surrounding bup/nx, we expected the study sites to have problems finding pharmacies willing to dispense the medication. This was not borne out over the 5-year study period. Each site was able to easily find one or more pharmacies able and willing to dispense the medication. In addition, providers' concerns about the record-keeping requirements for bup/nx proved to be unfounded. None of the sites reported the record keeping to be unduly burdensome. We also hypothesized that patients who relapsed might be reluctant to return to their HIV providers for care, feeling guilty or ashamed. We probed this question extensively in interviews with both patients and providers, and most felt that this rarely, if ever, happened. Rather, most patients welcomed the opportunity to discuss their drug use openly with their physicians (which discussion of the bup/nx offered) and did not feel judged or unwelcome to return when they relapsed.46 Finally, when bup/nx first came on the market, regulators were concerned about diversion; in fact, they initially limited each physician to 30 bup/nx patients. We found very little evidence of diversion among the BHIVES study patients or their peers. As described in more detail in Egan et al46 in this issue, most “misuse” of the medication was limited to keeping doses in reserve for one's own use later, sharing (not selling to) with friends, and preventing withdrawal among peers.
Policy Impact of the BHIVES Initiative
The BHIVES initiative was both an evaluation and a service delivery project. As such, the study sites actively engaged with and sought to ameliorate the policy barriers they encountered in implementing their programs. Several initiated successful efforts to expand the availability of bup/nx in HIV care settings. One program, for example, used its residency program to train new physicians to use bp/nx with patients. Three sites were actively involved in ensuring the bup/nx was included in their states' Medicaid programs, and the site in Oregon was also instrumental in insuring that bup/nx is not excluded by ADAP in that state. One of the sites got a large public hospital system to include bup/nx in its formulary for all patients prescribed this treatment so that patients on bup/nx admitted to the hospital could continue to receive treatment. Finally, another site based in a large academic medical center is developing a protocol for nurses to oversee bup/nx treatment, which may provide a model strategy for effectively using nonphysicians in bup/nx treatment.
Several models for integrating drug treatment into medical care have been developed and evaluated over the years. However, significant financing, workforce, and conceptual barriers persist. The increasing availability of medication-assisted drug treatment demands creative solutions to these historical and systemic barriers, particularly for populations like people living with HIV/AIDS who have high rates of substance use disorders. The BHIVES initiative demonstrates that implementing integrated HIV and bup/nx care programs is feasible in a variety of settings.32 It also demonstrates that such programs have the potential to reduce drug use,47 improve the quality of HIV care,48 improve HIV-related outcomes,49 and improve health-related quality of life.50,46 Moreover, the cost of providing bup/nx in HIV care settings is comparable with methadone.38 By addressing some of the policy barriers to integration, this promising program model can help the thousands of people living with HIV/AIDS who are also opioid dependent.
We must address the complex and difficult problem of financing bup/nx care within medical settings. A 2008 survey found that 38 states offered some kind of Medicaid coverage for office-based bup/nx, but only 2 states used Substance Abuse Prevention and Treatment block grant funding to pay for bup/nx.51 There are also inconsistencies in what is covered and how coverage is accessed, and many states have barriers to and restrictions on coverage, such as requiring pre-authorization; covering the medication but not physician or counseling visits; covering counseling but not the medication; and/or limits of the number of days or total cost of treatment. In fact, the rules governing Medicaid coverage of medication-assisted drug treatment are so complex that tables from a National Council of State Legislatures survey on Medicaid coverage include 190 explanatory footnotes.52 Expanding the coverage of bup/nx through Medicaid, Medicare, and ADAP without requiring preauthorization is an important first step. Recent reforms to the health care system will expand the number of people covered by insurance and include substance abuse and mental health services as part of the benefits package. This will not only help provide needed services directly but should also relieve some of the financial pressure on the ADAP system, making the coverage of bup/nx more feasible.
Insuring that our existing payment mechanisms can address service systems that integrate HIV care and bup/nx may also mean revisiting separate financing systems for medical care and behavioral health care. The historical separation of health care and drug treatment results in nonpatient centered health care. It has never made sense and makes even less sense as office-based medical treatments for addiction become more available. The HIV field is probably among the most advanced in its efforts to bring together medical, mental health, and addiction treatment, but significant structural barriers to integrated care remain. In the meantime, the Ryan White HIV/AIDS Program, which has focused increasing attention on substance abuse services in recent years, may provide the best opportunity to cover the costs of the bup/nx coordinator and other assets to successful integration. HRSA is the unique position to encourage its grantees to use Ryan White HIV/AIDS Program funds to increase access to bup/nx services.
Efforts to address workforce issues are already underway. In addition to their promotion of screening, brief intervention, and referral to treatment, the Substance Abuse and Mental Health Administration's has also supported the Physician Clinical Support System,45 which links experienced bup/nx prescribers with less experienced ones. The BHIVES study fostered a network of HIV clinicians who shared their experiences and expertise in prescribing bup/nx to HIV-infected patients,32 and this informal network of mentoring will now be formalized through the Physician Clinical Support System, which can match HIV specialists with one another. We also recommend that more training on addiction medicine and treatment be included in medical education curricula and in curricula for training programs for physician assistants, nurse practitioners, and nurses and that HIV specialists, in particular, be given additional training in the management of chronic pain conditions. Although there has been little movement to change the regulations that prohibit nonphysicians from prescribing bup/nx, as mentioned above, one study site has begun to establish protocols through which HIV clinic nurses can oversee bup/nx treatment under the standing orders of a qualified physician. The prohibition on mid-level prescribing of bup/nx should be lifted. Easing restrictions on the number of patients who may be prescribed bup/nx by a single provider would also help increase availability of treatment, as uptake by providers has been slow, and in some regions, only a limited number of providers are available to provide bup/nx or integrated treatment.
Addressing the conceptual differences between HIV medicine and drug treatment providers will require ongoing communication and cross training between the 2 fields. One framework that seemed to mitigate different understandings was viewing addiction as a chronic, relapsing condition. Cross-training between HIV and drug treatment providers could, not only address some their philosophical differences, but also create concrete networks for referrals and collaborative practice. In general, the BHIVES study suggested that HIV providers could serve their patients better if they had a deeper understanding of addiction, the variety of drug treatment modalities available, and how to match patient needs with these different modalities. HRSA is uniquely positioned to take leadership educating HIV providers and promoting cross-training between HIV and drug treatment providers.53 The Substance Abuse and Mental Health Administration is also well positioned to promote and support diffusion of bup/nx prescribing among clinicians and acceptance of medication-assisted treatment of opioid addiction among drug treatment providers.
People living with HIV/AIDS and their service providers have been innovators throughout the epidemic. The Ryan White HIV/AIDS Program-as implemented by HRSA-was designed to foster that innovation. With the leadership of HRSA and support from the Ryan White HIV/AIDS Program, the time is right to fully integrate drug treatment into HIV care. Models pioneered in the HIV setting, such as patient-doctor partnerships and community-based clinical trials, have repeatedly transformed and improve the delivery of health care. We have demonstrated that integration of primary HIV care and office-based drug treatment is feasible and desirable from the perspectives of both patient and providers. Policies and practices that support this integration should be rapidly adopted to facilitate this integration as the next common sense advance in improving the treatment and care of people living with HIV/AIDS.
1. Willenbring ML, Olson DH. A randomized trial of integrated outpatient treatment for medically ill alcoholic men. Arch Intern Med
2. Fiellin DA, Rosenheck RA, Kosten TR. Office-based treatment for opioid dependence: reaching new patient populations. Am J Psychiatry
3. Weisner C, Mertens J, Parthasarathy S, et al. Integrating primary medical care with addiction treatment: a randomized controlled trial. JAMA
4. Merrill JO. Policy progress for physician treatment of opiate addiction. J Gen Intern Med
5. Lago M, Levin S, Pharham D. Linkage solutions between primary care, HIV/AIDS, substance abuse and mental health services in non-governmental health care organizations. Paper presented at: International AIDS Conference; 1998; Geneva, Switzerland.
6. Samet JH, Friedmann P, Saitz R. Benefits of linking primary medical care and substance abuse services: patient, provider, and societal perspectives. Arch Intern Med
7. Rhoades H, Creson D, Elk R, et al. Retention, HIV risk and illicit drug use during treatment: methadone dose and visit frequency. Am J Pub Health
8. Weinrich M, Stuart M. Provision of methadone treatment in primary care medical practices: review of the Scottish experience and implications for US policy. JAMA
9. King VL, Stoller KB, Hayes M, et al. A multicenter randomized evaluation of methadone medical maintenance. Drug Alcohol Depend
10. Novick DM, Joseph H. Medical maintenance: the treatment of chronic opiate dependence in general medical practice. J Subst Abuse Treat
11. Gossop M, Marsden J, Stewart D, et al. Methadone treatment practices and outcome for opiate addicts treated in drug clinics and in general practice: results from the National Treatment Outcome Research Study. Br J Gen Pract
12. Keen J, Oliver P, Rowse G, et al. Does methadone maintenance treatment based on the new national guidelines work in a primary care setting? Br J Gen Pract
13. Wilson P, Watson R, Ralston GE. Methadone maintenance in general practice: patients, workload, and outcomes. BMJ
14. Novick DM, Joseph H, Salsitz EA, et al. Outcomes of treatment of socially rehabilitated methadone maintenance patients in physicians' offices (medical maintenance): follow-up at three and a half to nine and a fourth years. J Gen Intern Med
. 1994; 9:127-130.
15. Fiellin DA, O'Connor PG, Chawarski M, et al. Methadone maintenance in primary care: a randomized controlled trial. JAMA
16. Miller NS, Sheppard LM, Colenda CC, et al. Why physicians are unprepared to treat patients who have alcohol- and drug-related disorders. Acad Med
17. Missed Opportunity: National Survey of Primary are Physicians and Patients on Substance Abuse
. New York, NY: Center On Addiction and Substance Abuse; April 2000.
18. Position Paper on Drug Policy
. Providence, RI: Physician Leadership on National Drug Control Policy; January 2000.
19. Gerbert B, Maguire BT, Bleecker T, et al. Primary care physicians and AIDS: attitudinal and structural barriers to care. JAMA
20. Merrill JO, Rhodes LA, Deyo RA, et al. Mutual mistrust in the medical care of drug users: the keys to the “narc” cabinet. J Gen Intern Med
21. Moatti JP, Souville M, Escaffre N, et al. French general practitioners' attitudes toward maintenance drug abuse treatment with buprenorphine. Addiction
22. Saitz R, Horton NJ, Sullivan LM, et al. Addressing alcohol problems in primary care: a cluster randomized, controlled trial of a systems intervention. The screening and intervention in primary care (SIP) study. Ann Intern Med
23. Erickson CK, Wilcox RE, Miller GW, et al. Effectiveness of addiction science presentations to treatment professionals, using a modified Solomon study design. J Drug Educ
24. Christison GW, Haviland MG. Requiring a one-week addiction treatment experience in a six-week psychiatry clerkship: effects on attitudes toward substance-abusing patients. Teach Learn Med
25. Karam-Hage M, Nerenberg L, Brower KJ. Modifying residents' professional attitudes about substance abuse treatment and training. Am J Addict
26. Fiellin DA, O'Connor P, Chawarski M, et al. Process of care during a randomized trial of office-based treatment of opioid dependence in primary care. Am J Addict
. 2004;13(Suppl 1):S67-S78.
27. Elliott V. Link between primary care, addiction services may help treatment. amednews.com
28. Tobias C, Drainoni M. Title I Survey: Services for HIV Positive Substance Users
. Boston, MA: Heatlh and Disability Working Group, Boston University School of Public Health; September 8, 2001.
29. Mantell J, Cassidy T. Unpublished Data From 100 Interviews With Patients in HIV Medication Adherence Programs Across the US. New York, NY: The New York Academy of Medicine; 2001.
30. Weiss L, Kluger M, McCoy K. Health Care Accessibility and Acceptability Among People That Inject Drugs or Use Crack Cocaine
. New York City, NY: Office of Special Populations, The New York Academy of Medicine; 2000.
31. Stancliff S, Myers J, Steiner S, et al. Beliefs about methadone in an inner-city methadone clinic. J Urban Health
32. Weiss L, Egan J, Botsko M, et al. A multi-site evaluation of integrated buprenorphine/naloxone and HIV treatment: overview of the BHIVES collaborative. J Acquir Immune Defic Syndr
. 2011;56(Suppl 1):S1-S2.
33. Netherland J, Botsko M, Egan JE, et al. Factors affecting willingness to provide buprenorphine treatment. J Subst Abuse Treat
34. Becker WC, Fiellin DA, Merrill JO, et al. Opioid use disorder in the United States: insurance status and treatment access. Drug Alcohol Depend
35. Horgan CM, Reif S, Hodgkin D, et al. Availability of addiction medications in private health plans. J Subst Abuse Treat
38. Schackman B, Leff J, Botsko M, et al. The cost of integrated HIV care and buprenorphine/naloxone treatment: results of a cross-site evaluation. J Acquir Immune Defic Syndr
. 2011;56(Suppl 1):S76-S82.
39. Jones ES, Moore BA, Sindelar JL, et al. Cost analysis of clinic and office-based treatment of opioid dependence: results with methadone and buprenorphine in clinically stable patients. Drug Alcohol Depend
40. Zarkin GA, Dunlap LJ, Homsi G. The substance abuse services cost analysis program (SASCAP): a new method for estimating drug treatment services costs. Eval Program Plann
41. Woody GE, Poole SA, Subramaniam G, et al. Extended vs short-term buprenorphine-naloxone for treatment of opioid-addicted youth: a randomized trial. JAMA
42. Kakko J, Svanborg KD, Kreek MJ, et al. 1-year retention and social function after buprenorphine-assisted relapse prevention treatment for heroin dependence in Sweden: a randomised, placebo-controlled trial. Lancet
43. Sees KL, Delucchi KL, Masson C, et al. Methadone maintenance vs 180-day psychosocially enriched detoxification for treatment of opioid dependence: a randomized controlled trial. JAMA
44. Lum P, Little S, Botsko M, et al. Opioid prescribing and provider confidence recognizing opioid abuse in HIV primary care settings. J Acquir Immune Defic Syndr
. 2011;56(Suppl 1):S91-S97.
45. Egan J, Casadonte P, Gartenmann T, et al. The physician clinical support system-buprenorphine (PCSS-B): a novel project to expand/improve buprenorphine treatment. J Gen Intern Med
. In press.
46. Egan J, Netherland J, Gass J, et al. Patient perspectives on buprenorphine/naloxone treatment in the context of HIV care. J Acquir Immune Defic Syndr
. 2011;56(Suppl 1):S46-S53.
47. Fiellin DA, Sullivan LE, Egan JE, et al. Drug treatment outcomes among HIV-infected, opioid-dependent patients receiving buprenorphine/naloxone. J Acquir Immune Defic Syndr
. 2011;56(Suppl 1):S33-S38.
48. Korthuis P, Fiellin D, Rongwei F, et al. Improving adherence to HIV quality of care indicators in persons with opioid dependence: the role of buprenorphine/naloxone. J Acquir Immune Defic Syndr
. 2011;56(Suppl 1):S83-S90.
49. Altice F, Bruce R, Lucas G. HIV treatment outcomes among HIV-infected, opioid-dependent patients receiving buprenorphine/naloxone treatment within HIV clinical care settings: results from a multisite study. J Acquir Immune Defic Syndr
. 2011;56(Suppl 1):S22-S32.
50. Korthuis PT, Tozzi MJ, Nandi V. Improved quality of life for opioid-dependent patients receiving buprenorphine treatment in HIV clinics. J Acquir Immune Defic Syndr
. 2011;56(Suppl 1):S39-S45.
51. Chalk M. Financing Buprenorphine in the Treatment of Opioid Addiction. Buprenorphine Summit
. Bethseda, MD: CSAT; 2010.
52. Rinaldo D. Medicaid Financing of Medication-Assisted Treatment for Opiate Addiction
. Washington, DC: National Conference of State Legislatures; April 1, 2008.
53. Cheever L, Kresina T, Cajina A, et al. A model federal collaborative to increase patient access to buprenorphine treatment in HIV primary care. J Acquir Immune Defic Syndr
. 2011;56(Suppl 1):S3-S6.
The CORE Center (Chicago, IL), El Rio Santa Cruz Neighborhood Health Center (Tucson, AZ), Johns Hopkins University (Baltimore, MD), Miriam Hospital (Providence, RI), Montefiore Medical Center (Bronx, NY), OASIS (Oakland, CA), Oregon Health Sciences University (Portland, OR), University of California San Francisco Positive Health Program at San Francisco General Hospital (San Francisco, CA), University of Miami Medical School (Miami, FL), Yale University School of Medicine (New Haven, CT) and The New York Academy of Medicine (New York, NY).
National Advisory Committee Members
The Members include: Marc Gourevitch, MD, Director, Division of General Internal Medicine, New York University School of Medicine; David Fiellin, MD, Associate Professor of Medicine, Yale University School of Medicine, Department of Internal Medicine; Alan Fleischman, MD, March of Dimes; Gerald Friedland, MD, Director, AIDS Program, Professor of Medicine & Epidemiology & Public Health, Yale University School of Medicine; Colleen Labelle, RN, ACRN, Nurse Manager for Office-based Opioid Treatment Program, Boston Medical Center; Christine Lubinski, MA, Executive Director, HIV Medical Association, Infectious Diseases Society of America; Joseph Merrill, MD, University of Washington, Medicine/Division of General Internal Medicine; Katie O'Neill, Esq., Senior Vice President and Director of HIV/AIDS Projects, Legal Action Center; Sharon Stancliff, MD, Medical Director of the Harm Reduction Coalition; Michael Stein, MD, Professor of Medicine, Brown University School of Medicine; Robert Underwood. Cited Here...
buprenorphine/naloxone; HIV/AIDS; opioid treatment; policy; substance-use treatment
© 2011 Lippincott Williams & Wilkins, Inc.
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