Integrated Buprenorphine

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Integrated Buprenorphine HIV Care The BHIVES
Initiative

• Ruth Finkelstein, ScD
• The New York Academy of Medicine
• August 30, 2006

BHIVES is funded through HRSAs HIV/AIDS
Bureau, Special Projects National Significance
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Background

• Patients with HIV/AIDS often have multiple
  co-existing problems such as psychiatric and
  substance use disorders, as well as social
  service needs, like housing, transportation and
  income, that present challenging obstacles to
  successful medical management.
• Programs that integrate medical care and drug
  treatment have shown great promise in improving
  health and substance use outcomes.

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Background

• Buprenorphine represents a unique opportunity to
  integrate drug treatment for opioid dependence
  into office-based care settings.
• HIV-infected drug users are likely to benefit
  from integrated programs, but historical,
  regulatory, and attitudinal barriers have
  prevented the widespread adoption of integrated
  care models in the U.S.

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HRSA SPNS Initiative

• Starting in 2005, HRSA funded 10 sites to design
  and implement programs that integrate primary HIV
  care and the office-based treatment of opioid
  addiction using buprenorphine.
• Sites designed their own integrated interventions
  using best practice models of HIV and
  buprenorphine treatment.
• HRSA also funded an Evaluation and Support Center
  to coordinate a multi-site evaluation, provide
  clinical and evaluation technical assistance, and
  promote dissemination.

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Funded Sites

• Evaluation Support Center (BHIVES)
• The New York Academy of Medicine, Division of
  Health Policy
• Yale University Medical School
• Model Demonstration Sites
• EL Rio Santa Cruz Neighborhood Health Center
  (Tucson, AZ)
• OASIS (Oakland, CA)
• Oregon Health Sciences University (Portland,
  OR)
• Montefiore Medical Center, (New York, NY)
• University of Miami Medical School (Miami, FL)
• The Miriam Hospital (Providence, RI)
• UCSF Positive Health Program (San Francisco, CA)
• Johns Hopkins University (Baltimore, MD)
• CORE Center (Chicago, IL)
• Yale University School of Medicine (New Haven, VT)

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Purpose of the Initiative

• Assess the feasibility and efficacy of
  integrating buprenorphine into the primary care
  treatment of people living with HIV/AIDS and
  addicted to opiates.
• Identify best practice models of integrated care
  that are effective, sustainable, replicable and
  efficient.
• Promote the application of these models in the
  HIV health care community.
• Improve the health and well-being of dually
  diagnosed people.

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Buprenorphine Treatment

• Buprenorphine is an opioid replacement therapy
  approved by the FDA in 2002 for office based
  treatment of addiction, which has proven as
  effective as methadone in reducing illicit opioid
  use.
• General benefits for substance users include
• Facilitated access to drug treatment.
• Improved engagement in medical care.
• Decreased medical problems and hospitalizations.
• Increased patient satisfaction with treatment.

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Potential Benefits of Integrated Buprenorphine
Treatment in HIV Care

• Rapid expansion of treatment capacity.
• Simultaneous treatment of medical and substance
  use co-morbidities.
• Normalization of patient social functioning.
• Removes abstinent patients from settings that may
  trigger relapse.
• Better adherence to drug treatment and/or HIV
  clinical care, including antiretroviral therapy
• Lower probability of HIV disease progression
• Fewer hospitalizations and drug-related medical
  problems (e.g., infections)
• Increase willingness and ability of HIV providers
  to address substance use

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Models of Integrated Care

• 1) Full buprenorphine treatment provided onsite
  in an HIV clinic by psychiatrists or addiction
  medicine specialists.
• Patients see two providers but within the same
  setting.
• Providers coordinate care through electronic
  medical records, case conferences, and/or
  informal communication.
• Care can be more specialized, but fewer providers
  may learn addiction treatment skills.
• Often, most buprenorphine-related services are
  provided by nursing or counseling staff.

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Models of Integrated Care, cont.

• 2) Full buprenorphine treatment provided onsite
  by all or a subset of HIV primary care
  physicians.
• Patients may see one provider for both
  buprenorphine and HIV care
• OR
• May see one provider for buprenorphine and
  another primary care
• Often, most buprenorphine-related services are
  provided by nursing or counseling staff

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Models of Integrated Care, cont.

• 3) Induction and stabilization, considered the
  most challenging aspect of treatment, conducted
  offsite by specialists, with buprenorphine
  maintenance provided by onsite HIV primary care
  physicians.
• May encourage more providers to provide
  buprenorphine.
• Transition from induction to maintenance
  treatment may lead to drop out.

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Preliminary Lessons about Care Models

• Staffing of many HIV clinics make buprenorphine
  treatment challenging
• MDs often at the clinic one half day per week
• E.g., during induction, patient may need to be
  seen every day.
• Staff with more hours and on-site presence in the
  clinic (NPs, PAs, counselors) play a central role
  
• NPs and PAs, who may be primary providers, are
  unable to prescribe buprenorphine

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Lessons learned, cont.

• Many physicians need initial support to overcome
  concerns about induction process
• Use of local clinical experts
• Observation of inductions
• Use of induction clinics
• Help identifying assessing appropriate patients
• Access to mentorship and clinical support
• Most HIV clinics are receptive to buprenorphine
  treatment, once logistical concerns, like space
  and staffing issues, have been addressed.
• Care models are likely to be highly dependent on
  the HIV care setting and its staffing model.

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Project Status

• All sites have IRB approval of clinical and
  evaluation protocols.
• 130 patients are being treated through the
  initiative either in integrated care or
  comparison settings.