Chapter 3: SPNS Initiative: Findings From the Field
Chapter 3: SPNS Initiative: Findings From the Field
In this chapter
- Buprenorphine Treatment Models
- Other Treatment Models
- Patient Experience: The SPNS Buprenorphine Initiative
- Key Findings: SPNS in the Spotlight
“For many years, the Health Resources and Services Administration's (HRSA) HIV/ AIDS Bureau (HAB) sought to improve services for HIV-infected substance abusers seeking care in Ryan White-funded programs. It has remained a HAB priority.” 10
- Dr. Laura Cheever,
Deputy Director and Chief Medical Officer of HAB
Buprenorphine is becoming increasingly available, and thanks to DATA 2000 guidelines it can now be integrated within general medical settings. This allows for more streamlined and comprehensive services for opioid-dependent people living with HIV disease. Ryan White-funded clinics are uniquely situated to address this range of patient needs.
To study opioid treatment among the HIV-infected population, HRSA’s HIV/AIDS Bureau (HAB) funded an SPNS project entitled, An Evaluation of Innovative Methods for Integrating Buprenorphine Opioid Abuse Treatment in HIV Primary Care (Buprenorphine Initiative). This 5-year, national, multisite study involved 10 HIV primary care sites and more than 300 HIV-positive opioid-dependent patients. All sites used Suboxone tablets in the study, as Suboxone film was not yet available during the project period. All grantees were supported by a technical assistance and evaluation center.2 (To read more about the study, see also the monograph Integrating Buprenorphine Therapy Into HIV Primary Care Settings produced at the study's conclusion.)
SPNS grantee sites were:
- community neighborhood health centers,
- university medical centers, and
- hospital centers.
Clinicians, whether at large institutions or at small clinic sites, can take on this work as proven by SPNS grantees.
The Buprenorphine Initiative represents “the largest study addressing substance abuse among people living with HIV to date.” 68
This landmark project helps pave the way for more HIV primary care physicians to better integrate services and offer ever more comprehensive care.
Currently, many Ryan White-funded providers are treating HIV disease among substance users. The promise in promoting opioid treatment within the context of the Ryan White HIV/AIDS Program is that it helps diminish opportunities for miscommunication between health care providers and reduction of drug–drug interactions.10 Similar strategies that HIV primary care providers are already employing in regard to motivational interviewing, harm reduction, and offering nonjudgmental care are all strategies that should continue as providers enter into opioid abuse treatment with patients.
Existing programs for integrating buprenorphine treatment models include community health centers, hospital-based settings, and mobile health units.45
The "HIV primary care model involves the same physician administering HIV treatment and buprenorphine.42 This has been the most widely adopted model in the SPNS Buprenorphine Initiative.
This model is particularly attractive for rural settings, community health centers, and clinical settings where addiction specialists are difficult to access. This model also lends itself to adoption in clinical settings where patients may be distrustful of new providers, as it allows patients to access opioid treatment by their same physician.42
The HIV primary care model approach may help decrease stigma associated with substance abuse treatment and may involve greater oversight on the part of the physician monitoring drug-drug interactions.42 Physicians may fear that if patients perform poorly in adhering to buprenorphine, it may put their relationship--and HIV care--in jeopardy.42 Based on SPNS Buprenorphine Initiative findings, this fear is, on the whole, unfounded. In contrast, patients felt they could open up about their substance abuse more readily and they received the same nonjudgmental harm reduction approach characteristic of Ryan White clinics.69
Though HIV primary care physicians in the SPNS Buprenorphine Initiative were handling buprenorphine administration, they certainly accessed mentorship opportunities and utilized staff such as the glue person to assist in many aspects of care support. In many grantee sites, the HIV primary care physician was responsible for induction of buprenorphine and writing prescriptions, but the glue person was responsible for many other aspects of care, such as counseling, assessments, maintenance, etc.69 (To read a template introduction of the care coordinator glue person to prospective patients, visit CORE Buprenorphine Project Program Tools and see The Glue Person in Chapter 4.
Research has shown that medication-assisted addiction therapy decreases illicit opioid use while increasing retention in HIV primary care and adherence to HIV antiretrovirals.30,70-73 The SPNS project adds to the field of research supporting these findings.
The SPNS Buprenorphine Initiative found that "among the group who was at highest risk for an adverse clinical outcome--those not on ART at baseline--longer retention on [Suboxone] was significantly associated with higher rates of ART initiation and viral suppression. 74 The greatest retention on ART was among subjects maintained on Suboxone for 3 or 4 quarters (9 to 12 months).4
"Buprenorphine is facilitating highly active antiretroviral therapy; it stabilizes patients, and we see their HIV RNA decline and their CD4 cell count rise," explains Dr. Lynn Taylor, from Miriam Hospital, who participated in the SPNS Buprenorphine Initiative.35
HIV clinicians at the majority of SPNS Buprenorphine Initiative sites had limited or no prior experience providing Suboxone to opioid-dependent patients before project initiation. According to Linda Weiss, evaluator of the SPNS Buprenorphine Initiative, physicians across sites found Suboxone treatment to be a good service to provide to their patients and found administration easier than expected and no harder than anything else they were currently overseeing within their clinics.
Prior to patient enrollment, providers attended an 8-hour training in conjunction with the American Society of Addiction Medicine (ASAM). In addition, each site had access to affiliated personnel with some experience in the use of Suboxone, underscoring the importance of a mentor with some addiction experience.64 All sites stressed the importance of a care coordinator, or "glue person. According to Weiss, to adequately address the needs of PLWHA and fully implement opioid abuse treatment, SPNS grantee physicians found they needed someone to assist in coordinating support services, address mental health issues, and work on any unforeseen psychosocial aspects that arose. This glue person was a mainstay, and the glue person's work cannot be overstated. (See "Determine Staffing" section in Chapter 4 to learn more.)
SPNS research supports integrating MAT--specifically Suboxone--into HIV primary care. According to one grantee site study among 93 HIV-positive, opioid-dependent patients who were assigned either to clinic-based buprenorphine and individual counseling or to case management with referral to drug treatment, people in the buprenorphine group were significantly more likely to participate in treatment for opioid dependence (74 percent versus 41 percent), less likely to use opioids and cocaine, and more likely to attend their HIV primary care visits than were people in the group referred to drug treatment.75
The SPNS Buprenorphine Initiative findings should provide encouragement to sites considering integrating opioid treatment into their HIV primary care clinics.64 (To read SPNS grantee site case studies, see the monograph, Integrating Buprenorphine Therapy Into HIV Primary Care Settings.)
While the HIV primary care model was adopted by the bulk of SPNS Buprenorphine Initiative grantees, success has been found through initiation of other treatment models, too. These include the following:
Onsite Addiction Specialist Model
This model includes a partnership between an HIV physician and an addiction specialist. The addiction specialist oversees induction, stabilization, and maintenance. Care is only "integrated" in the sense that patients receive both substance abuse treatment and HIV care within the same clinical setting.
It takes advantage of onsite specialized care and integrated electronic medical records within a single facility, and allows patients to continue to receive the full spectrum of care needs addressed under one roof. This model, however, requires patients to coordinate appointments through two separate physicians, which may add another barrier to care receipt.
This model was most applicable in HIV treatment centers within teaching hospitals where addiction care was easily accessible and HIV physicians had rotations only a few hours a week within the clinic.
This model utilizes an addiction specialist skilled in buprenorphine administration to handle the induction and stabilization phases and work with the HIV physician during the maintenance phase. The appeal of this model is that HIV physicians with reservations about full oversight of buprenorphine have increased support.
Conversely, this hybrid model initially fragments care and may require more coordination between physicians. Also, patients may need to schedule and adhere to appointments with two providers rather than one.
Community Outreach Model
This model taps into the work being done by community health care mobile van units, particularly among marginalized populations. The van brings care services and treatment into the community to offer directly observed HIV treatment and buprenorphine therapy. This model may be helpful to individuals with difficulty keeping appointments and who are homeless.
However, this model requires an enormous amount of flexibility. It may create barriers to patients seeking care within the clinic setting and the community outreach van, and it offers less structure and potentially less autonomy than a clinic setting.
Drug Treatment Model
This model has been utilized in locations where substance abuse clinics offer HIV services onsite. Since patients are accessing buprenorphine therapy within the constructs of a substance abuse clinic, it offers easier transition to methadone therapy for those patients who need to be transferred to this more structured environment.
Disadvantages include the continued segregation of buprenorphine therapy from the patient's traditional HIV physician (as patients would be referred to this new setting to address their HIV and opioid addiction). Substance abuse clinics are also often overburdened and may not be available in certain geographic locations. In addition, not all substance abuse clinics are well versed in HIV care, so this model is highly specific to a particular type of care setting.
The SPNS Buprenorphine Initiative found that:
"Patients were overwhelmingly satisfied with the pharmacologic effects and treatment outcomes of Suboxone, including effectiveness in blocking cravings and controlling opioid use; decreased fear of withdrawal and/or missed doses; and an overall improvement in quality of life. Patients also described being more engaged with both their substance abuse treatment and HIV care, including greater ability to manage their own treatment, keep appointments, and adhere to antiretroviral medication regimes. . . . Nearly all were positive about their experience with integrated care, appreciative of an improved drug treatment environment, convenience, and quality of care.
"Patients often described themselves as feeling 'normal' on buprenorphine, like how they used to feel before they started using opioids. There was improved quality of life not only in health care outcomes but improved social status, too. Cravings for opioids were dramatically reduced.
"As one patient described, '[I]f it wasn’t for Suboxone, I think I’d be dead, truly. . . . [Instead] it got me back to working. . . . I got my apartment, my son. He’s always loved me [but now] he respects me a lot more. . . . I start seeing hope for myself. And I start feeling I could fight HIV and there’s nothing that I can’t accomplish.'"
Patients and providers were overwhelmingly satisfied with the treatment and its results. The Buprenorphine Initiative:
- Allowed for integration--rather than fragmentation--of services, resulting in improved retention in care.
- Allowed initiation of ARVs among patients not previously on treatment.
- Improved drug and HIV treatment outcomes, particularly among those not previously on ARVs.
- Improved CD4 counts among patients participating in the project.
- Resulted in decreased heroin and other opioid use.
- Increased social stability.
- Decreased HIV transmission risk behaviors.
- Decreased stigma associated with substance abuse treatment.
- Was associated with improved mental and physical health-related quality of life.