Aims To examine the role of expanded access to opioid agonist treatment as a means to decrease i... more Aims To examine the role of expanded access to opioid agonist treatment as a means to decrease international HIV transmission.Design Review of the English language literature via Medline.Measurements Estimates of prevalence rates for injection drug use, HIV infection and treatment effect sizes for changes in opioid use, opioid injection, needle-sharing, injection-related HIV risk behavior and cost.Findings An estimated 12.6 million injection drug users internationally accounted for 10% of the 4.2 million new HIV infections in 2003. Ninety-three of the 136 countries (68%) that report injection drug use identify HIV infection related to this behavior. Observational studies of methadone treatment demonstrate decreases in opioid use, opioid injection, needle-sharing and lower rates of HIV prevalence and incidence. The effectiveness of buprenorphine in demonstrating similar findings is expected, although implementations and research are still emerging. The cost-effectiveness of opioid agonist treatment has been established. The barriers to international adoption of opioid agonist treatment, despite the research evidence and international guidelines, are discussed.Conclusions Untreated opioid dependence leads to HIV transmission, on an international level. Opioid agonist treatments are associated with reductions in the frequency of opioid use, fewer injections and injection-related HIV risk behaviors and lower rates of HIV prevalence and incidence. Despite international recommendations, treatment for opioid-dependent injection drug users with methadone and buprenorphine is limited. Research, implementation efforts and political strategies to expand access to opioid agonist treatment are needed in order to combat the spread of HIV, especially in the developing world.
BACKGROUND Prescription opioid dependence is increasing, but treatment outcomes with office-based... more BACKGROUND Prescription opioid dependence is increasing, but treatment outcomes with office-based buprenorphine/naloxone among these patients have not been described. METHODS We compared demographic, clinical characteristics and treatment outcomes among 200 patients evaluated for entry into a trial of primary care office-based buprenorphine/naloxone treatment stratifying on those who reported exclusive heroin use (n = 124), heroin and prescription opioid use (n = 47), or only prescription opioid use (n = 29). RESULTS Compared to heroin-only patients, prescription-opioid-only patients were younger, had fewer years of opioid use, and less drug treatment history. They were also more likely to be white, earned more income, and were less likely to have Hepatitis C antibodies. Prescription-opioid-only patients were more likely to complete treatment (59% vs. 30%), remained in treatment longer (21.0 vs. 14.2 weeks), and had a higher percent of opioid-negative urine samples than heroin only patients (56.3% vs. 39.8%), all p values < .05. Patients who used both heroin and prescription opioids had outcomes that were intermediate between heroin-only and prescription-opioid-only patients. CONCLUSIONS Individuals dependent on prescription opioids have an improved treatment response to buprenorphine/naloxone maintenance in an office-based setting compared to those who exclusively or episodically use heroin.
To examine long-term outcomes with primary care office-based buprenorphine/naloxone treatment, we... more To examine long-term outcomes with primary care office-based buprenorphine/naloxone treatment, we followed 53 opioid-dependent patients who had already demonstrated six months of documented clinical stability for 2-5 years. Primary outcomes were retention, illicit drug use, dose, satisfaction, serum transaminases, and adverse events. Thirty-eight percent of enrolled subjects were retained for two years. Ninety-one percent of urine samples had no evidence of opioid use, and patient satisfaction was high. Serum transaminases remained stable from baseline. No serious adverse events related to treatment occurred. We conclude that select opioid-dependent patients exhibit moderate levels of retention in primary care office-based treatment.
The profile of opioid dependence in the United States is changing. Abuse of prescription opioids ... more The profile of opioid dependence in the United States is changing. Abuse of prescription opioids is more common than that of illicit opioids: Recent data indicate that approximately 1.6 million persons abuse or are dependent on prescription opioids, whereas 323,000 abuse or are dependent on heroin. Despite this prevalence, nearly 80% of opioid-dependent persons remain untreated. One option for expanding treatment is the use of buprenorphine and the buprenorphine-naloxone combination. Buprenorphine is a partial opioid agonist that can be prescribed by trained physicians and dispensed at pharmacies. This article addresses the clinical presentation of a patient with opioid dependence and describes the relatively new practice of office-based treatment with buprenorphine-naloxone. The different components of treatment; the role of the physician who provides this treatment; and the logistics of treating this growing, multifaceted patient population are also examined.
The Centers for Disease Control and Prevention&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;am... more The Centers for Disease Control and Prevention&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s HIV Prevention Strategic Plan Through 2005 advocated for increasing the proportion of persons with human immunodeficiency virus (HIV) infection and in need of substance abuse treatment who are successfully linked to services for these 2 conditions. There is evidence that integrating care for HIV infection and substance abuse optimizes outcomes for patients with both disorders. Buprenorphine, a recently approved medication for the treatment of opioid dependence in physicians&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; offices, provides the opportunity to integrate the treatment of HIV infection and substance abuse in one clinical setting, yet little information exists on the models of care that will most successfully facilitate this integration. To promote the uptake of this type of integrated care, the current review provides a description of 4 recently implemented models for combining buprenorphine treatment with HIV primary care: (1) an on-site addiction/HIV specialist treatment model; (2) a HIV primary care physician model; (3) a nonphysician health professional model; and (4) a community outreach model.
Background Factors associated with satisfaction among patients receiving primary care–based bupre... more Background Factors associated with satisfaction among patients receiving primary care–based buprenorphine/naloxone are unknown. Objective To identify factors related to patient satisfaction in patients receiving primary care–based buprenorphine/naloxone that varied in counseling intensity (20 vs 45 minutes) and office visit frequency (weekly vs thrice weekly). Design and Participants One hundred and forty-two opioid-dependent subjects. Measurements Demographics, drug treatment history, and substance use status at baseline and during treatment were collected. The primary outcome was patient satisfaction at 12 weeks. Results Patients’ mean overall satisfaction score was 4.4 (out of 5). Patients were most satisfied with the medication and ancillary services and indicated strong willingness to refer a substance-abusing friend for the same treatment. Patients were least satisfied with their interactions with other opioid-dependent patients, referrals to Narcotics Anonymous, and the inconvenience of the treatment location. Female gender (β = .17, P = .04) and non-White ethnicity/race (β = .17, P = .04) independently predicted patient satisfaction. Patients who received briefer counseling and buprenorphine/naloxone dispensed weekly had greater satisfaction than those whose medication was dispensed thrice weekly (mean difference 4.9, 95% confidence interval 0.08 to 9.80, P = .03). Conclusions Patients are satisfied with primary care office-based buprenorphine/naloxone. Providers should consider the identified barriers to patient satisfaction.
BACKGROUND Despite the availability and demonstrated effectiveness of office-based buprenorphine ... more BACKGROUND Despite the availability and demonstrated effectiveness of office-based buprenorphine maintenance treatment (BMT), the systematic examination of physicians’ attitudes towards this new medical practice has been largely neglected. OBJECTIVE To identify facilitators and barriers to the potential or actual implementation of BMT by office-based medical providers. DESIGN Qualitative study using individual and group semi-structured interviews. PARTICIPANTS Twenty-three practicing office-based physicians in New England. APPROACH Interviews were audiotaped, transcribed, and entered into a qualitative software program. The transcripts were thematically coded using the constant comparative method by a multidisciplinary team. RESULTS Eighty percent of the physicians were white; 55% were women. The mean number of years since graduating medical school was 14 (SD = 10). The primary areas of clinical specialization were internal medicine (50%), infectious disease (20%), and addiction medicine (15%). Physicians identified physician, patient, and logistical factors that would either facilitate or serve as a barrier to their integration of BMT into clinical practice. Physician facilitators included promoting continuity of patient care, positive perceptions of BMT, and viewing BMT as a positive alternative to methadone maintenance. Physician barriers included competing activities, lack of interest, and lack of expertise in addiction treatment. Physicians’ perceptions of patient-related barriers included concerns about confidentiality and cost, and low motivation for treatment. Perceived logistical barriers included lack of remuneration for BMT, limited ancillary support for physicians, not enough time, and a perceived low prevalence of opioid dependence in physicians’ practices. CONCLUSIONS Addressing physicians’ perceptions of facilitators and barriers to BMT is crucial to supporting the further expansion of BMT into primary care and office-based practices.
Aims Gender differences exist regarding alcohol and illicit drug use disorders in the United Sta... more Aims Gender differences exist regarding alcohol and illicit drug use disorders in the United States. Little is known about the gender-related factors associated with non-medical use of prescription opioids.Design Using data from the 2003 National Survey on Drug Use and Health, we examined risk factors for past-year non-medical use of prescription opioids stratified by gender.Setting Non-institutionalized US residences.Participants Civilian, non-institutionalized US citizens aged 12 years and older.Measurements Self-reported alcohol and drug use, focusing specifically on past-year non-medical use of prescription opioids.Findings Among 55 023 respondents, 4.8% reported past-year, non-medical use of prescription opioids. For both women and men, alcohol abuse/dependence and marijuana, hallucinogen, cocaine, non-medical stimulant and sedative/tranquilizer use were associated with past-year non-medical use of prescription opioids. Among women but not men, first use of illicit drugs beginning at 24 years or older [adjusted odds ratios (AOR) 1.90, 95% CI 1.05–3.44], serious mental illness (AOR 1.67, 95% CI 1.29–2.17) and cigarette smoking (AOR 1.33, 95% CI 1.05–1.68) were associated with past-year non-medical use of prescription opioids. Among men but not women, past-year inhalant use (AOR 1.93, 95% CI 1.28–2.92) was associated with the outcome.Conclusions For both women and men, illicit drug use is associated with the non-medical use of prescription opioids. Additionally, certain factors associated with the non-medical use of prescription opioids are notably gender-specific. Clinicians should recognize that patients with a history of illicit substance use or misuse of other prescription medications are at increased risk for non-medical use of prescription opioids, and that gender-specific factors can help to identify individuals at greatest risk.
OBJECTIVE: To assess the effects of oral substitution treatment for opioid-dependent injecting dr... more OBJECTIVE: To assess the effects of oral substitution treatment for opioid-dependent injecting drug users on HIV risk behaviors and infections. DATA SOURCES: Multiple electronic databases were searched. Reference lists of retrieved articles were checked. METHODS: Because of varying methodologies of available studies, this systematic review was limited to a descriptive summary, looking at consistency of outcomes across studies. RESULTS: Twenty-eight studies involving methadone treatment were included in the review. Methadone maintenance treatment is associated with statistically significant reductions in injecting use and sharing of injecting equipment. It is also associated with reductions in numbers of injecting drug users reporting multiple sex partners or exchanges of sex for drugs or money, but has little effect on condom use. It appears that the reductions in risk behaviors do translate into fewer cases of HIV infection. CONCLUSIONS: Methadone maintenance treatment for injecting drug users significantly reduces the risk of transmission of HIV and should be provided as a component of a strategic approach to the prevention and control of HIV infection. There is insufficient evidence to determine whether other forms of oral substitution treatment also reduce the risk of HIV transmission.
Aims To examine the role of expanded access to opioid agonist treatment as a means to decrease i... more Aims To examine the role of expanded access to opioid agonist treatment as a means to decrease international HIV transmission.Design Review of the English language literature via Medline.Measurements Estimates of prevalence rates for injection drug use, HIV infection and treatment effect sizes for changes in opioid use, opioid injection, needle-sharing, injection-related HIV risk behavior and cost.Findings An estimated 12.6 million injection drug users internationally accounted for 10% of the 4.2 million new HIV infections in 2003. Ninety-three of the 136 countries (68%) that report injection drug use identify HIV infection related to this behavior. Observational studies of methadone treatment demonstrate decreases in opioid use, opioid injection, needle-sharing and lower rates of HIV prevalence and incidence. The effectiveness of buprenorphine in demonstrating similar findings is expected, although implementations and research are still emerging. The cost-effectiveness of opioid agonist treatment has been established. The barriers to international adoption of opioid agonist treatment, despite the research evidence and international guidelines, are discussed.Conclusions Untreated opioid dependence leads to HIV transmission, on an international level. Opioid agonist treatments are associated with reductions in the frequency of opioid use, fewer injections and injection-related HIV risk behaviors and lower rates of HIV prevalence and incidence. Despite international recommendations, treatment for opioid-dependent injection drug users with methadone and buprenorphine is limited. Research, implementation efforts and political strategies to expand access to opioid agonist treatment are needed in order to combat the spread of HIV, especially in the developing world.
BACKGROUND Prescription opioid dependence is increasing, but treatment outcomes with office-based... more BACKGROUND Prescription opioid dependence is increasing, but treatment outcomes with office-based buprenorphine/naloxone among these patients have not been described. METHODS We compared demographic, clinical characteristics and treatment outcomes among 200 patients evaluated for entry into a trial of primary care office-based buprenorphine/naloxone treatment stratifying on those who reported exclusive heroin use (n = 124), heroin and prescription opioid use (n = 47), or only prescription opioid use (n = 29). RESULTS Compared to heroin-only patients, prescription-opioid-only patients were younger, had fewer years of opioid use, and less drug treatment history. They were also more likely to be white, earned more income, and were less likely to have Hepatitis C antibodies. Prescription-opioid-only patients were more likely to complete treatment (59% vs. 30%), remained in treatment longer (21.0 vs. 14.2 weeks), and had a higher percent of opioid-negative urine samples than heroin only patients (56.3% vs. 39.8%), all p values < .05. Patients who used both heroin and prescription opioids had outcomes that were intermediate between heroin-only and prescription-opioid-only patients. CONCLUSIONS Individuals dependent on prescription opioids have an improved treatment response to buprenorphine/naloxone maintenance in an office-based setting compared to those who exclusively or episodically use heroin.
To examine long-term outcomes with primary care office-based buprenorphine/naloxone treatment, we... more To examine long-term outcomes with primary care office-based buprenorphine/naloxone treatment, we followed 53 opioid-dependent patients who had already demonstrated six months of documented clinical stability for 2-5 years. Primary outcomes were retention, illicit drug use, dose, satisfaction, serum transaminases, and adverse events. Thirty-eight percent of enrolled subjects were retained for two years. Ninety-one percent of urine samples had no evidence of opioid use, and patient satisfaction was high. Serum transaminases remained stable from baseline. No serious adverse events related to treatment occurred. We conclude that select opioid-dependent patients exhibit moderate levels of retention in primary care office-based treatment.
The profile of opioid dependence in the United States is changing. Abuse of prescription opioids ... more The profile of opioid dependence in the United States is changing. Abuse of prescription opioids is more common than that of illicit opioids: Recent data indicate that approximately 1.6 million persons abuse or are dependent on prescription opioids, whereas 323,000 abuse or are dependent on heroin. Despite this prevalence, nearly 80% of opioid-dependent persons remain untreated. One option for expanding treatment is the use of buprenorphine and the buprenorphine-naloxone combination. Buprenorphine is a partial opioid agonist that can be prescribed by trained physicians and dispensed at pharmacies. This article addresses the clinical presentation of a patient with opioid dependence and describes the relatively new practice of office-based treatment with buprenorphine-naloxone. The different components of treatment; the role of the physician who provides this treatment; and the logistics of treating this growing, multifaceted patient population are also examined.
The Centers for Disease Control and Prevention&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;am... more The Centers for Disease Control and Prevention&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s HIV Prevention Strategic Plan Through 2005 advocated for increasing the proportion of persons with human immunodeficiency virus (HIV) infection and in need of substance abuse treatment who are successfully linked to services for these 2 conditions. There is evidence that integrating care for HIV infection and substance abuse optimizes outcomes for patients with both disorders. Buprenorphine, a recently approved medication for the treatment of opioid dependence in physicians&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; offices, provides the opportunity to integrate the treatment of HIV infection and substance abuse in one clinical setting, yet little information exists on the models of care that will most successfully facilitate this integration. To promote the uptake of this type of integrated care, the current review provides a description of 4 recently implemented models for combining buprenorphine treatment with HIV primary care: (1) an on-site addiction/HIV specialist treatment model; (2) a HIV primary care physician model; (3) a nonphysician health professional model; and (4) a community outreach model.
Background Factors associated with satisfaction among patients receiving primary care–based bupre... more Background Factors associated with satisfaction among patients receiving primary care–based buprenorphine/naloxone are unknown. Objective To identify factors related to patient satisfaction in patients receiving primary care–based buprenorphine/naloxone that varied in counseling intensity (20 vs 45 minutes) and office visit frequency (weekly vs thrice weekly). Design and Participants One hundred and forty-two opioid-dependent subjects. Measurements Demographics, drug treatment history, and substance use status at baseline and during treatment were collected. The primary outcome was patient satisfaction at 12 weeks. Results Patients’ mean overall satisfaction score was 4.4 (out of 5). Patients were most satisfied with the medication and ancillary services and indicated strong willingness to refer a substance-abusing friend for the same treatment. Patients were least satisfied with their interactions with other opioid-dependent patients, referrals to Narcotics Anonymous, and the inconvenience of the treatment location. Female gender (β = .17, P = .04) and non-White ethnicity/race (β = .17, P = .04) independently predicted patient satisfaction. Patients who received briefer counseling and buprenorphine/naloxone dispensed weekly had greater satisfaction than those whose medication was dispensed thrice weekly (mean difference 4.9, 95% confidence interval 0.08 to 9.80, P = .03). Conclusions Patients are satisfied with primary care office-based buprenorphine/naloxone. Providers should consider the identified barriers to patient satisfaction.
BACKGROUND Despite the availability and demonstrated effectiveness of office-based buprenorphine ... more BACKGROUND Despite the availability and demonstrated effectiveness of office-based buprenorphine maintenance treatment (BMT), the systematic examination of physicians’ attitudes towards this new medical practice has been largely neglected. OBJECTIVE To identify facilitators and barriers to the potential or actual implementation of BMT by office-based medical providers. DESIGN Qualitative study using individual and group semi-structured interviews. PARTICIPANTS Twenty-three practicing office-based physicians in New England. APPROACH Interviews were audiotaped, transcribed, and entered into a qualitative software program. The transcripts were thematically coded using the constant comparative method by a multidisciplinary team. RESULTS Eighty percent of the physicians were white; 55% were women. The mean number of years since graduating medical school was 14 (SD = 10). The primary areas of clinical specialization were internal medicine (50%), infectious disease (20%), and addiction medicine (15%). Physicians identified physician, patient, and logistical factors that would either facilitate or serve as a barrier to their integration of BMT into clinical practice. Physician facilitators included promoting continuity of patient care, positive perceptions of BMT, and viewing BMT as a positive alternative to methadone maintenance. Physician barriers included competing activities, lack of interest, and lack of expertise in addiction treatment. Physicians’ perceptions of patient-related barriers included concerns about confidentiality and cost, and low motivation for treatment. Perceived logistical barriers included lack of remuneration for BMT, limited ancillary support for physicians, not enough time, and a perceived low prevalence of opioid dependence in physicians’ practices. CONCLUSIONS Addressing physicians’ perceptions of facilitators and barriers to BMT is crucial to supporting the further expansion of BMT into primary care and office-based practices.
Aims Gender differences exist regarding alcohol and illicit drug use disorders in the United Sta... more Aims Gender differences exist regarding alcohol and illicit drug use disorders in the United States. Little is known about the gender-related factors associated with non-medical use of prescription opioids.Design Using data from the 2003 National Survey on Drug Use and Health, we examined risk factors for past-year non-medical use of prescription opioids stratified by gender.Setting Non-institutionalized US residences.Participants Civilian, non-institutionalized US citizens aged 12 years and older.Measurements Self-reported alcohol and drug use, focusing specifically on past-year non-medical use of prescription opioids.Findings Among 55 023 respondents, 4.8% reported past-year, non-medical use of prescription opioids. For both women and men, alcohol abuse/dependence and marijuana, hallucinogen, cocaine, non-medical stimulant and sedative/tranquilizer use were associated with past-year non-medical use of prescription opioids. Among women but not men, first use of illicit drugs beginning at 24 years or older [adjusted odds ratios (AOR) 1.90, 95% CI 1.05–3.44], serious mental illness (AOR 1.67, 95% CI 1.29–2.17) and cigarette smoking (AOR 1.33, 95% CI 1.05–1.68) were associated with past-year non-medical use of prescription opioids. Among men but not women, past-year inhalant use (AOR 1.93, 95% CI 1.28–2.92) was associated with the outcome.Conclusions For both women and men, illicit drug use is associated with the non-medical use of prescription opioids. Additionally, certain factors associated with the non-medical use of prescription opioids are notably gender-specific. Clinicians should recognize that patients with a history of illicit substance use or misuse of other prescription medications are at increased risk for non-medical use of prescription opioids, and that gender-specific factors can help to identify individuals at greatest risk.
OBJECTIVE: To assess the effects of oral substitution treatment for opioid-dependent injecting dr... more OBJECTIVE: To assess the effects of oral substitution treatment for opioid-dependent injecting drug users on HIV risk behaviors and infections. DATA SOURCES: Multiple electronic databases were searched. Reference lists of retrieved articles were checked. METHODS: Because of varying methodologies of available studies, this systematic review was limited to a descriptive summary, looking at consistency of outcomes across studies. RESULTS: Twenty-eight studies involving methadone treatment were included in the review. Methadone maintenance treatment is associated with statistically significant reductions in injecting use and sharing of injecting equipment. It is also associated with reductions in numbers of injecting drug users reporting multiple sex partners or exchanges of sex for drugs or money, but has little effect on condom use. It appears that the reductions in risk behaviors do translate into fewer cases of HIV infection. CONCLUSIONS: Methadone maintenance treatment for injecting drug users significantly reduces the risk of transmission of HIV and should be provided as a component of a strategic approach to the prevention and control of HIV infection. There is insufficient evidence to determine whether other forms of oral substitution treatment also reduce the risk of HIV transmission.
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