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An Evaluation of Innovation Methods for Integrating Buprenorphine Opiod Abuse Treatment in HIV Primary Care Settings

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Background
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Journal Articles
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Background 

Based on new legislation and the availability of buprenorphine treatment, the Buprenorphine Initiative was designed to determine the effectiveness of integrating buprenorphine opioid abuse treatment into HIV primary care settings. This initiative began in September 2004 and is comprised of 10 demonstration sites coordinated by a technical assistance/evaluation center.

The initiative is directed towards persons with HIV in the primary care setting who also have substance abuse issues. As a demonstration project, this initiative seeks to determine the feasibility and/or effectiveness of integrating buprenorphine opioid abuse treatment into HIV primary care settings. The ultimate goal is to improve the health of HIV substance abusers.

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Grantees 

HRSA awarded grants under its Special Projects of National Significance program to the applicants listed below. 

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Evaluation Center Website
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Brown University, Miriam Hospital Immunology Center (Providence, RI): Integrating Buprenorphine Opioid Treatment with HIV Primary Care

Target Population: HIV infected patients with a focus on women, substance abusers, and persons being released from prison

Goal:
1. To evaluate the effectiveness of integrating buprenorphine treatment into HIV primary care
2. To decrease HIV risk behaviors, increase adherence to HIV medications and/or substance abuse treatment, and improve quality of life

Strategies:
1. Initiation of an opioid use/abuse screening program
2. Educational session on all forms of opioid treatment in addition to individualized evaluation for development of a treatment plan
3. Buprenorphine team to include a nurse who will dispense buprenorphine and clinic staff who will provide comprehensive HIV and substance abuse care
4. Near-peer outreach worker to work with participants in the community to improve substance abuse treatment adherence

Evaluation: Assessment of substance abuse, HIV risk behaviors, adherence to HIV medications, quality of life, patient satisfaction, and follow-up with primary care and substance abuse treatment visits will take place at one, three, six, and 12 months; HIV viral load and CD4 data will also be obtained through chart review.

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El Rio Santa Cruz Neighborhood Health Center (Tucson, AZ): Buprenorphine Opioid Abuse Treatment

Target Population: Opioid dependent HIV patients in a primary care setting

Goal:
1. Improve patient adherence with primary HIV treatment including HAART therapy
2. Reduce substance abuse behaviors including syringe-mediated risks
3. Maintain or enhance health status of individuals
4. Improve quality of life for individuals receiving the buprenorphine intervention

Strategies:
1. Training and certification of primary care providers in buprenorphine administration and management in the treatment of opioid abuse, dependence, and addiction
2. Office-based nutritional, mental health, and substance abuse counseling

Evaluation: Measure data related to the goals stated above in addition to HIV health status markers including patients' CD4 counts and Viral Loads.

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The Hektoen Institute, LLC/CORE Center (Chicago, IL): Buprenorphine at CORE: An HIV Primary Care Program Demonstration

Target Population: Opioid dependent HIV positive patients

Goal: To determine the effectiveness of a clinical/psychiatric model including buprenorphine treatment, as indicated by patient acceptance, improved health outcomes, and/or retention in care

Strategies:
1. Identification of opioid dependent patients during assessment in primary care clinics
2. A clinical/psychiatric model consisting of a tightly linked team of a psychiatrist and a chemical dependency counselor who will be able to administer buprenorphine treatment to appropriate patients

Evaluation: Comparison of subjects enrolled the current model of care (HIV/Cognitive-Behavioral Model including detox, residential treatment, and/or methadone) with those in the new clinical/psychiatric model, with respect to health outcomes and retention in care

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Johns Hopkins School of Medicine (Baltimore, MD): Randomized Trial of HIV Clinic Based Buprenorphine versus Referred Substance Abuse Care

Target Population: Treatment-seeking opioid-dependent patients who receive primary medical care in the Johns Hopkins HIV Clinic

Goal: The determine the impact of clinic-based buprenorphine treatment on HIV care utilization, changes in health status and immunological markers, and HIV transmission risk behaviors

Strategies: Incorporation of a clinic-based buprenorphine substance abuse treatment model

Evaluation: A randomized controlled trial of clinic-based buprenorphine treatment versus traditional substance abuse care, with a focus on evaluating the variables stated above in addition to patient characteristics associated with positive outcomes; costs, administrative changes, and acceptance of the new model will also be evaluated

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Montefiore Medical Center (Bronx, NY): The Development and Evaluation of Integration of Buprenorphine into HIV Primary Care in Bronx Community Health Centers

Target Population: Patients of Bronx HIV primary care community health centers

Goal: 
1. To integrate buprenorphine substance abuse treatment into the primary care setting
2. To improve access to and retention in treatment

Strategies: 
1. Develop formal linkages between primary care providers and substance abuse/buprenorphine treatment experts and providers and community pharmacies dispensing buprenorphine
2. Help facilitate certification of providers in buprenorphine treatment administration
3. A substance abuse treatment team (HIV primary care physicians, substance abuse expert physicians, an HIV pharmacist, and a nurse clinical coordinator) to provide education and training, support, and consultation for providers

Evaluation:
The evaluation will focus on clinical and psychosocial changes among participants treated with buprenorphine in comparison to those receiving usual care; the analysis will focus on drug use, HIV-related health status, mental and physical health and well-being, health service utilization, and patient satisfaction

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OASIS (Oakland, CA) 

Target Population: HIV-exposed heroin users in the Oakland region

Goal: To improve medical, psychosocial, and addiction outcomes

Strategies: Integration of buprenorphine therapy into medical services at an existing site of HIV primary care

Evaluation: Evaluation will compare the impact of a 2-year enhanced group intervention for HIV-exposed heroin users referred for outside substance abuse treatment to a similar enhanced intervention combined with 2-years of medically integrated buprenorphine

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Oregon Health and Science University (Portland, OR): Portland Integrates Care for Opioid Dependent AIDS Patients

Target Population: Opioid addicted patients in primary care HIV clinics

Goal: To integrate buprenorphine treatment and substance abuse counseling with HIV care, with anticipated improvements in medication adherence, attendance in substance abuse counseling, and health outcomes

Strategies:
1. Establishing teams composed of a physician, nurse, physician assistant, counselor and patient advocate to both coordinate and make decisions about buprenorphine integration at their clinic
2. This team will also monitor patients and assure that individual services provided for them are appropriate

Evaluation: The evaluation will compare outcomes of participants involved in the model where buprenorphine treatment is integrated with HIV care, to those of participants who receive buprenorphine treatment according to federal guidelines for methadone

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UCSF Positive Health Program (San Francisco, CA): Integrating Buprenorphine into the SFGH AIDS Program

Target Population: Patients in a comprehensive HIV primary care setting in San Francisco

Goal: To deliver new services for HIV-infected patients by enabling primary care providers to integrate substance abuse treatment into their existing clinical services

Strategies: A multidisciplinary collaboration with the Division of Substance Abuse and Addiction Medicine and the Community Behavioral Health Services agency to:
1. Provide physician education and training on addiction treatment, integrated services, and the use of buprenorphine
2. Develop the policies and procedures to deliver buprenorphine treatment in HIV clinical settings

Evaluation: Process and outcome evaluation will focus on the efficacy of the buprenorphine treatment intervention with a diverse, low income, and often homeless population of persons living with HIV/AIDS

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University of Miami AIDS Clinical Research Unit (Miami, FL): Miami Integration Project

Target Population: HIV-positive opioid users

Goal: To determine the feasibility and effectiveness of integrating buprenorphine substance abuse treatment with HIV primary care

Strategies: Subjects will be randomized to receive the new integrated treatment or the current standard of care

Evaluation: Baseline and follow-up measures will document demographics as well as changes in health, psychiatric needs, support and legal status, family health, social relationships, drug/alcohol use, ART use, and treatment adherence among the two groups

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Yale University AIDS Program (New Haven, CT): Integrating Buprenorphine into HIV Clinical Care Settings

Target Population: HIV-infected opioid dependent patients in an HIV treatment setting

Goal: To determine the best model of substance abuse treatment for HIV-infected patients, with a focus on the site of induction and stabilization, the type of counseling, adherence and health outcomes, and cost effectiveness

Strategies: Three separate models will be implemented, which include:
1. On-site Addiction Treatment Model comparing standard and enhanced levels of counseling by a trained addiction specialist team
2. HIV Primary Care Model with induction and stabilization performed on-site by the patients' primary care providers
3. Induction/Stabilization Model with induction and 8 week stabilization performed in an off-site substance abuse treatment facility

Evaluation: A control group of HIV-infected patients enrolled in a methadone treatment clinic will be used as the comparison for each of the models, and evaluation will be conducted with respect to retention in therapy, illicit drug use, adherence to HAART, and the impact on HIV transmission behaviors

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The New York Academy of Medicine (New York, NY): Center for the Evaluation and Support of Integrated Buprenorphine Treatment and HIV Care

Target Population: Buprenorphine Initiative model demonstration sites serving opioid dependent HIV patients

Goal:
1. To enhance the development of model demonstration programs that integrate buprenorphine treatment and HIV primary care
2. To conduct a multi-site process, outcome, impact and cost evaluation of these programs
3. To disseminate the findings to providers, administrators, and policy makers

Strategies: 
1. Assemble a staff of experts and a National Advisory Committee to provide training and technical support to the demonstration sites
2. Provide ongoing technical assistance and support in program design, clinical training and consultation, and the development of policy and procedures that address regulatory, ethical, and clinical concerns
3. Translate the results of the evaluation into peer-reviewed publications, training materials, briefing papers, reports, and fact sheets

Evaluation: The Center will conduct a multi-site evaluation utilizing client, provider, and program data to determine the processes necessary to develop integrated HIV and buprenorphine programs, and their feasibility, effectiveness, impact, and cost

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Journal Articles 

Cunningham CO, Giovanniello A, Li X, Kunins HV, Roose RJ, & Sohler NL. A comparison of buprenorphine induction strategies: Patient-centered home-based inductions versus standard-of-care office-based inductions. Journal of Substance Abuse Treatment, June 2011; 40(4): 349–356.  PubMed Abstract

Friedland G and Vlahov D. Integration of Buprenorphine for Substance-Abuse Treatment by HIV Care Providers. Journal of Acquired Immune Deficiency Syndromes, March 2011; 56 (Supplement 1): S1-S2. PubMed

Cheever LW, Kresina TF, Cajina A, & Lubran R. A Model Federal Collaborative to Increase Patient Access to Buprenorphine Treatment in HIV Primary Care. Journal of Acquired Immune Deficiency Syndromes, March 2011; 56 (Supplement 1): S3-S6.  PubMed Abstract

Weiss L, Egan JE, Botsko M, Netherland J, Fiellin D, Finkelstein R. The BHIVES Collaborative: Organization and Evaluation of a Multisite Demonstration of Integrated Buprenorphine/Naloxone and HIV Treatment.  Journal of Acquired Immune Deficiency Syndromes, March 2011; 56 (Supplement 1): S7-S13.  PubMed Abstract

Chaudhry AA, Botsko M, Weiss L, Egan JE, Mitty J, Estrada B, Lucas GM, Woodson T, Flanigan TP, & Fiellin DA, for the BHIVES Collaborative. Participant Characteristics and HIV Risk Behaviors Among Individuals Entering Integrated Buprenorphine/Naloxone and HIV Care. Journal of Acquired Immune Deficiency Syndromes, March 2011; 56 (Supplement 1): S14-S21. PubMed Abstract

Altice FL, Bruce RD, Lucas GM, Lum PJ, Korthuis PT, Flanigan TP, Cunningham CO, Sullivan LE, Vergara-Rodriguez P, Fiellin DA, Cajina A, Botsko M, Nandi V, Gourevitch MN, Finkelstein R, and the BHIVES Collaborative (2011) HIV Treatment Outcomes Among HIV-Infected, Opioid-Dependent Patients Receiving Buprenorphine/Naloxone Treatment within HIV Clinical Care Settings: Results From a Multisite Study. Journal of Acquired Immune Deficiency Syndromes, March 2011; 56 (Supplement 1): S22-S32. PubMed Abstract

Fiellin DA, Weiss L, Botsko M, Egan JE, Altice FL, Bazerman LB, Chaudhry A, Cunningham CO, Gourevitch MN, Lum PJ, Sullivan LE, Schottenfeld RS, & O'Connor PG, for the BHIVES Collaborative. Drug Treatment Outcomes Among HIV-Infected Opioid-Dependent Patients Receiving Buprenorphine/Naloxone. Journal of Acquired Immune Deficiency Syndromes, March 2011; 56 (Supplement 1): S33-S38. PubMed Abstract

Korthuis PT, Tozzi MJ, Nandi V, Fiellin DA, Weiss L, Egan JE, Botsko M, Acosta A, Gourevitch MN, Hersh D, Hsu J, Boverman J, & Altice FL, for the BHIVES Collaborative.  Improved Quality of Life for Opioid-Dependent Patients Receiving Buprenorphine Treatment in HIV Clinics. Journal of Acquired Immune Deficiency Syndromes, March 2011; 56 (Supplement 1): S39-S45. PubMed Abstract

Egan JE, Netherland J, Gass J, Finkelstein R, & Weiss L, for the BHIVES Collaborative. Patient Perspectives on Buprenorphine/Naloxone Treatment in the Context of HIV Care. Journal of Acquired Immune Deficiency Syndromes, March 2011; 56 (Supplement 1): S46-S53. PubMed Abstract

Sullivan LE, Botsko M, Cunningham CO, O'Connor PG, Hersh D, Mitty J, Lum PJ, Schottenfeld RS, & Fiellin DA, for the BHIVES Collaborative. The Impact of Cocaine Use on Outcomes in HIV-Infected Patients Receiving Buprenorphine/Naloxone. Journal of Acquired Immune Deficiency Syndromes, March 2011; 56 (Supplement 1): S54-S61. PubMed Abstract

Vergara-Rodriguez P, Tozzi MJ, Botsko M, Nandi V, Altice F, Egan JE, O'Connor PG, Sullivan LE, & Fiellin DA, for the BHIVES Collaborative. Hepatic Safety and Lack of Antiretroviral Interactions With Buprenorphine/Naloxone in HIV-Infected Opioid-Dependent Patients. Journal of Acquired Immune Deficiency Syndromes, March 2011; 56 (Supplement 1): S62-S67. PubMed Abstract

Weiss L, Netherland J, Egan JE, Flanigan TP, Fiellin DA, Finkelstein R, & Altice FL, for the BHIVES Collaborative.  Integration of Buprenorphine/Naloxone Treatment into HIV Clinical Care: Lessons From the BHIVES Collaborative. Journal of Acquired Immune Deficiency Syndromes, March 2011; 56 (Supplement 1): S68-S75. PubMed Abstract

Schackman BR, Leff JA, Botsko M, Fiellin DA, Altice FL, Korthuis PT, Sohler N, Weiss L, Egan JE, Netherland J, Gass J, & Finkelstein R, for the BHIVES Collaborative. The Cost of Integrated HIV Care and Buprenorphine/Naloxone Treatment: Results of a Cross-Site Evaluation. Journal of Acquired Immune Deficiency Syndromes, March 2011; 56 (Supplement 1): S76-S82. PubMed Abstract

Korthuis PT, Fiellin DA, Fu Rongwei, Lum PJ, Altice FL, Sohler N, Tozzi MJ, Asch SM, Botsko M, Fishl M, Flanigan TP, Boverman J, & McCarty D, for the BHIVES Collaborative. Improving Adherence to HIV Quality of Care Indicators in Persons With Opioid Dependence: The Role of Buprenorphine. Journal of Acquired Immune Deficiency Syndromes, March 2011; 56 (Supplement 1): S83-S90. PubMed Abstract

Lum PJ, Little S, Botsko M, Hersh D, Thawley RE, Egan JE, Mitty J, Boverman J, & Fiellin DA, for the BHIVES Collaborative. Opioid-Prescribing Practices and Provider Confidence Recognizing Opioid Analgesic Abuse in HIV Primary Care Settings. Journal of Acquired Immune Deficiency Syndromes, March 2011; 56 (Supplement 1): S91-S97. PubMed Abstract

Finkelstein R, Netherland J, Sylla L, Gourevitch MN, Cajina A, Cheever L, for the BHIVES Collaborative. Policy Implications of Integrating Buprenorphine/Naloxone Treatment and HIV Care. Journal of Acquired Immune Deficiency Syndromes, March 2011; 56 (Supplement 1): S98-S104. PubMed Abstract

Whitley SD, Sohler NL, Kunins HV, Giovanniello A, Li X, Sacajiu G, & Cunningham CO. Factors associated with complicated buprenorphine inductions. Journal of Substance Abuse Treatment, July 2010; 39(1): 51-57. PubMed Abstract

Sohler NL, Li X, Kunins HV, Sacajiu G, Giovanniello A, Whitley S, & Cunningham CO.  Home- versus office-based buprenorphine inductions for opioid-dependent patients. Journal of Substance Abuse Treatment, March 2010; 38(2): 153-159.  PubMed Abstract

Cunningham CO, Giovanniello A, Sacajiu G, Li X, Brisbane M, & Sohler NL. Inquiries about and initiation of buprenorphine treatment in an inner-city clinic. Substance Abuse, July-September 2009; 30(3): 261-262. PubMed Abstract

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