Barriers and facilitators to primary care or human immunodeficiency virus clinics providing methadone or buprenorphine for the management of opioid dependence

BACKGROUND: Federal initiatives aim to increase office-based treatment of opioid dependence, but, to our knowledge, factors associated with willingness to deliver this care have not been defined. The objective of this study was to describe clinics' willingness to provide methadone hydrochloride or buprenorphine hydrochloride for opioid dependence. METHODS: The design of the study was a survey conducted in New York State. Two hundred sixty-one directors of primary care and/or human immunodeficiency virus specialty clinics (response rate, 61.1%) that serve Medicaid enrollees were questioned. Outcomes were willingness to provide methadone and buprenorphine. Predictors included clinic characteristics, attitudes about drug users and their treatment, and reported barriers and facilitators to treatment. RESULTS: Clinics were more willing to provide buprenorphine than methadone treatment (59.8% vs 32.6%; P < .001). Clinics offering human immunodeficiency virus specialty care (adjusted odds ratio [AOR], 2.16; 95% confidence interval [CI], 1.18-3.95) or a safe location to store narcotics (AOR, 2.99; 95% CI, 1.57-5.70) were more willing to prescribe buprenorphine and more willing to provide methadone. Willingness was positively associated with continuing medical education credits for training, but negatively associated with greater concern about medication abuse. Immediate telephone access to an addiction expert was associated with willingness to provide buprenorphine (AOR, 2.08; 95% CI, 1.15-3.76). Greater willingness to provide methadone was associated with a belief that methadone-treated patients should be seen along with other patients (AOR, 6.20; 95% CI, 1.78-21.64), methadone program affiliation (AOR, 4.76; 95% CI, 1.64-13.82), and having more patients with chronic pain in the clinic (AOR, 2.80; 95% CI, 1.44-5.44). CONCLUSIONS: These clinics serving Medicaid enrollees were more receptive to buprenorphine than methadone treatment. Willingness to provide this care was greater in clinics offering human immunodeficiency virus services, treating more chronic pain, or affiliated with methadone programs. Accessible addiction experts and continuing medical education for training may facilitate adoption of this care.     

Office-Based Management of Opioid Dependence with Buprenorphine: Clinical Practices and Barriers

Background  Buprenorphine is a safe, effective and underutilized treatment for opioid dependence that requires special credentialing, known as a waiver, to prescribe in the United States. Objective  To describe buprenorphine clinical practices and barriers among office-based physicians. Design  Cross-sectional survey. Participants  Two hundred thirty-five office-based physicians waivered to prescribe buprenorphine in Massachusetts. Measurements  Questionnaires mailed to all waivered physicians in Massachusetts in October and November 2005 included questions on medical specialty, practice setting, clinical practices, and barriers to prescribing. Logistic regression analyses were used to identify factors associated with prescribing. Results  Prescribers were 66% of respondents and prescribed to a median of ten patients. Clinical practices included mandatory counseling (79%), drug screening (82%), observed induction (57%), linkage to methadone maintenance (40%), and storing buprenorphine notes separate from other medical records (33%). Most non-prescribers (54%) reported they would prescribe if barriers were reduced. Being a primary care physician compared to a psychiatrist (AOR: 3.02; 95% CI: 1.48–6.18) and solo practice only compared to group practice (AOR: 3.01; 95% CI: 1.23–7.35) were associated with prescribing, while reporting low patient demand (AOR: 0.043, 95% CI: 0.009–0.21) and insufficient institutional support (AOR: 0.37; 95% CI: 0.15–0.89) were associated with not prescribing. Conclusions  Capacity for increased buprenorphine prescribing exists among physicians who have already obtained a waiver to prescribe. Increased efforts to link waivered physicians with opioid-dependent patients and initiatives to improve institutional support may mitigate barriers to buprenorphine treatment. Several guideline-driven practices have been widely adopted, such as adjunctive counseling and monitoring patients with drug screening.     

Attitudes toward buprenorphine and methadone among opioid-dependent individuals

Attitudes and beliefs about drug abuse treatment have long been known to shape response to that treatment. Two major pharmacological alternatives are available for opioid dependence: methadone, which has been available for the past 40 years, and buprenorphine, a recently introduced medication. This mixed-methods study examined the attitudes of opioid-dependent individuals toward methadone and buprenorphine. A total of 195 participants (n = 140 who were enrolling in one of six Baltimore area methadone programs and n = 55 who were out-of-treatment) were administered the Attitudes toward Methadone and toward Buprenorphine Scales, and a subset (n = 46) received an ethnographic interview. The in-treatment group had significantly more positive attitudes toward methadone than did the out-of-treatment group (p < .001), while they did not differ in their attitudes toward buprenorphine. Both groups had significantly more positive attitudes toward buprenorphine than methadone. Addressing these attitudes may increase treatment entry and retention.     

Buprenorphine versus methadone maintenance therapy: a randomized double-blind trial with 405 opioid-dependent patients

Aims To assess the efficacy of buprenorphine compared with methadone maintenance therapy for opioid dependence in a large sample using a flexible dosing regime and the marketed buprenorphine tablet. Design Patients were randomized to receive buprenorphine or methadone over a 13‐week treatment period in a double‐blind, double‐dummy trial. Setting Three methadone clinics in Australia. Participants Four hundred and five opioid‐dependent patients seeking treatment. Intervention Patients received buprenorphine or methadone as indicated clinically using a flexible dosage regime. During weeks 1–6, patients were dosed daily. From weeks 7–13, buprenorphine patients received double their week 6 dose on alternate days. Measurements Retention in treatment, and illicit opioid use as determined by urinalysis. Self‐reported drug use, psychological functioning, HIV‐risk behaviour, general health and subjective ratings were secondary outcomes. Findings Intention‐to‐treat analyses revealed no significant difference in completion rates at 13 weeks. Methadone was superior to buprenorphine in time to termination over the 13‐week period (Wald χ² = 4.371, df = 1, P = 0.037), but not separately for the single‐day or alternate‐day dosing phases. There were no significant between‐group differences in morphine‐positive urines, or in self‐reported heroin or other illicit drug use. The majority (85%) of the buprenorphine patients transferred to alternate‐day dosing were maintained in alternate‐day dosing. Conclusions Buprenorphine did not differ from methadone in its ability to suppress heroin use, but retained approximately 10% fewer patients. This poorer retention was due possibly to too‐slow induction onto buprenorphine. For the majority of patients, buprenorphine can be administered on alternate days.     

Assessment and management of opioid withdrawal symptoms in buprenorphine-dependent subjects

The spontaneous physical dependence of buprenorphine was assessed in opioid addicts who switched from heroin to sublingual or intravenous buprenorphine. Twenty-two patients were randomly assigned to double-blind administration of methadone (n = 11) or placebo (n=11) for 13 days after abrupt withdrawal of buprenorphine. Methadone was administered according to four pre-established dosing schedules depending on the previous amount of daily consumed buprenorphine. No methadone-treated patient required modification of the therapeutic regimen, whereas eight of eleven placebo-treated patients needed treatment with methadone. Buprenorphine withdrawal syndrome was of opioid type, began somewhat more slowly, and showed a peak until day 5. The occurrence, time-course and characteristics of buprenorphine withdrawal syndrome make it necessary to reconsider the abuse potential of this analgesic.     

Barriers to Obtaining Waivers to Prescribe Buprenorphine for Opioid Addiction Treatment Among HIV Physicians

Background Illicit drug use is common among HIV-infected individuals. Buprenorphine enables physicians to simultaneously treat HIV and opioid dependence, offering opportunities to improve health outcomes. Despite this, few physicians prescribe buprenorphine. Objective To examine barriers to obtaining waivers to prescribe buprenorphine. Design Cross-sectional survey study. Participants 375 physicians attending HIV educational conferences in six cities in 2006. Approach Anonymous questionnaires were distributed and analyzed to test whether confidence addressing drug problems and perceived barriers to prescribing buprenorphine were associated with having a buprenorphine waiver, using chi-square, t tests, and logistic regression. Results 25.1% of HIV physicians had waivers to prescribe buprenorphine. In bivariate analyses, physicians with waivers versus those without waivers were less likely to be male (51.1 vs 63.7%, p < .05), more likely to be in New York (51.1 vs 29.5%, p < .01), less likely to be infectious disease specialists (25.5 vs 41.6%, p < .05), and more likely to be general internists (43.6 vs 33.5%, p < .05). Adjusting for physician characteristics, confidence addressing drug problems (adjusted odds ratio [AOR] = 2.05, 95% confidence interval [95% CI] = 1.08–3.88) and concern about lack of access to addiction experts (AOR = 0.56, 95% CI = 0.32–0.97) were significantly associated with having a buprenorphine waiver. Conclusions Among HIV physicians attending educational conferences, confidence addressing drug problems was positively associated with having a buprenorphine waiver, and concern about lack of access to addiction experts was negatively associated with it. HIV physicians are uniquely positioned to provide opioid addiction treatment in the HIV primary care setting. Understanding and remediating barriers HIV physicians face may lead to new opportunities to improve outcomes for opioid-dependent HIV-infected patients.     

Self‐reported side effects in buprenorphine and methadone patients receiving antiretroviral therapy: results from the MANIF 2000 cohort study

Aims The aim of the study was to investigate the relationship between methadone and buprenorphine treatment and self‐reported symptoms in HIV‐infected opioid dependent individuals receiving antiretroviral therapy (ART). Design Longitudinal study. Setting The French MANIF2000 cohort was used to compare self‐reported symptoms in buprenorphine and methadone patients also receiving ART. Participants We selected individuals receiving ART and OAT (342 visits among 106 patients). Measurements Symptoms were self‐reported using a list of 14 symptoms (e.g. nausea, fatigue, fever) perceived during the previous 4 weeks, including three painful symptoms (abdominal or muscular pain, headaches). A two‐step Heckman approach enabled us to account for the non‐random assignment of OAT: a probit model identified predictors of starting either buprenorphine or methadone. A Poisson regression based on generalized estimating equations (GEE) was then used to identify predictors of the number of symptoms while adjusting for the non‐random assignment of OAT. Findings The median (interquartile range) number of symptoms was 4 (1–6) and 2 (1–6) among buprenorphine and methadone patients, respectively. After adjustment for non‐random assignment of OAT type, depressive and opioid withdrawal symptoms, anxiolytics consumption and daily cannabis use, methadone patients were more likely to report a lower number of symptoms than those receiving buprenorphine. Conclusions Methadone patients on ART report fewer symptoms than buprenorphine patients on ART under current treatment conditions in France. Further experimental research is still needed to identify an OAT–ART strategy which would minimize the burden of self‐reported symptoms and potential interactions, while assuring sustainability and response to both treatments.     

Effects of Practice Setting on Quality of Lipid-Lowering Management in Patients With Coronary Artery Disease

We undertook a study to determine whether there were differences in the quality of lipid management in patients with coronary artery disease (CAD) in 2 different practice settings (which represent different socioeconomic classes), and to determine the level of compliance with the National Cholesterol Education Program guidelines by academic physicians in managing patients with CAD. A retrospective cross-sectional study was performed using a systematic chart review of 270 medical records (131 from the cardiology clinic, 139 from the cardiology private practice) of patients with known CAD at an academic tertiary care center in New York City. The total proportion of patients with CAD having a lipid profile ordered in the clinic and private suite was 43%. Of these people, 22% had a low-density lipoprotein cholesterol (LDL) ≤100 mg/dl and 54% had an LDL ≤130 mg/dl (10% and 23% of the total population, respectively). The total proportion of patients taking lipid-lowering medications was 29%. When comparing the quality of treatment between the 2 settings, there were no statistically significant differences in the percentages of patients who had lipid profiles measured (40% clinic vs 47% private suite, p >0.10), in the percentage of patients with LDL ≤130 mg/dl (50% clinic vs 57% private suite, p >0.10) or in the weighted percentage of patients taking lipid-lowering medications (29% clinic vs 48% private suite, p = 0.099). The performances of individual physicians, however, varied widely. The percentages of patients with lipid profiles measured by individual physicians ranged from 0% to 83%, while the percentages of patients on drug treatment by a physician ranged between 10% and 88%. These findings indicate that socioeconomic differences, represented by different practice settings, do not account for differences in the screening for, control of, or use of medications in managing hyperlipidemia. Rather, individual physicians are accountable for differences in lipid management.     

Ten Years of Methadone Maintenance Treatment: Some Clinical Observations

Ten years of methadone maintenance were reviewed in all 547 patients admitted to one clinic in New York City. High retention rates, reduced but still high mortality rates, increased employment, and minor degrees of recognized opiate abuse characterized those remaining in treatment. The treated patients appeared to evolve into a unique social and economic class, partly in the drug subculture and partly outside the drug world. Many were dependent on public assistance for living expenses, methadone treatment, and medical care. An interesting finding was their heavy demands for inpatient hospital care, often for drug-related reasons. A segment of New York City narcotic addicts was sequestered in an open-ended treatment process with considerable benefits to themselves and to society. Only a small fraction appeared to gravitate toward full economic support, to discontinuation of methadone, and to an enduring narcotic-free state.     

Management of high blood cholesterol by primary care physicians

Objective:To study knowledge of and adherence to National Cholesterol Education Program Adult Treatment Panel (ATP) guidelines among primary care physicians. Design:Cross-sectional telephone survey. Setting:New York State primary care practitioners; survey conducted November 1988-January 1989. Participants:Physicians in general practice, family practice, internal medicine without subspecialty, and cardiology who reported ≥10 bours/week of clinical practice (n=329; response rate = 63%). Interventions:None. Measurements and main results:While 84% of physicians bad beard of the ATP guidelines, gaps in knowledge and inconsistencies between ATP recommendations and clinical practices were found. Although the ATP guidelines recommend six months of dietary therapy before starting drug treatment, 41% of physicians would initiate drug treatment for a healthy 40-year-old man with total cbolesterol of 7.8 mmol/L (300 mg/dl) either at the initial visit or after one month of lipid-lowering diet. Multivariate analysis of a 24-item knowledge scale revealed that less knowledgeable physicians were more likely to be older, lack board certification, and have a specialty other than cardiology (p<0.01). Less knowledgeable physicians were also more likely to consider drug company literature and drug company representatives very useful sources of information about cholesterol (p=0.02). Conclusion:This study suggests that bard-to-reach physician groups may require special efforts to communicate consensus guidelines of major importance to clinical practice. Received from the Department of Medicine and the Division of Epidemiology and Sociomedical Sciences, School of Public Health, Columbia University Health Sciences Division, New York, New York. Supported in part by a Grant-in-aid from the American Heart Association, New York City Affiliate.     

Ten years of methadone maintenance treatment: some clinical observations

Ten years of methadone maintenance were reviewed in all 547 patients admitted to one clinic in New York City. High retention rates, reduced but still high mortality rates, increased employment, and minor degrees of recognized opiate abuse characterized those remaining in treatment. The treated patients appeared to evolve into a unique social and economic class, partly in the drug subculture and partly outside the drug world. Many were dependent on public assistance for living expenses, methadone treatment, and medical care. An interesting finding was their heavy demands for inpatient hospital care, often for drug-related reasons. A segment of New York City narcotic addicts was sequestered in an open-ended treatment process with considerable benefits to themselves and to society. Only a small fraction appeared to gravitate toward full economic support, to discontinuation of methadone, and to an enduring narcotic-free state.     

Methadone Treatment of Opiate Dependence in Canada

Although methadone has been used in Canada for the treatment of opiate-dependent persons since 1959, information concerning its use in Canada is limited. Methadone treatment in Canada is discussed with respect to national and provincial drug laws, public and professional support for the treatment, patient characteristics, and the sources and types of illicit and licit opiates abused. The paper also reports on the results of a survey of the physicians in Canada who were authorized during 1981–82 to prescribe methadone to opiate-dependent persons. These physicians were asked to provide information on the number of patients they treated with methadone during the previous 12 months, their indications) for the use of methadone, the dosages used and duration of treatment, and the auxiliary treatments provided. Information concerning specific provincial methadone treatment programmes is also presented.     

Quality of Life Among Heroin Users on Buprenorphine versus Methadone Maintenance

Objectives: To assess the quality of life (QoL) of heroin users starting and following 4 and 8 months of maintenance treatment program using buprenorphine vs. methadone. Methods: Participants received maintenance treatment with oral methadone or sublingual buprenorphine for the treatment of heroin dependence. Participants' QoL was measured using the Quality of Life Enjoyment and Satisfaction Questionnaire completed before treatment and at 1-, 4-, and 8-month follow-up. Baseline data from 304 heroin-dependent participants starting maintenance treatment, and 4-month and 8-month follow-up data for the 180 and 129 participants, respectively, retained in trial treatment are presented. Results: For the participants retained in treatment, statistically significant improvements in QoL and all specific life domains were observed in 4 and 8 months. However, for users who were maintained on methadone, this improvement was observed during the first month of treatment. Conclusions: The results show the beneficial effects of the maintenance treatment programs using both buprenorphine and methadone with regard to satisfaction with QoL and all specific life domains among heroin-dependent outpatients, with methadone having an earlier onset than buprenorphine. Further studies are needed to identify the factors linked to these benefits and their time course.     

Buprenorphine versus methadone maintenance for the treatment of opioid dependence

Aims. To evaluate the effectiveness of buprenorphine compared with methadone maintenance therapy in opiate addicts over a treatment period of 24 weeks. Design. Subjects were randomized to receive either buprenorphine or methadone in an open, comparative study. Setting. Subjects were recruited and treated at the drug addiction outpatient clinic at the University of Vienna. Participants. Sixty subjects (19 females and 41 males) who met DSM-IV criteria for opioid dependence and were seeking treatment. Intervention. Subjects received either sublingual buprenorphine (2-mg or 8-mg tablets; maximum daily dose 8 mg) or oral methadone (racemic D -/+ L-methadone; maximum daily dose 80 mg). A stable dose was maintained following the 6-day induction phase. Measurement. Assessment of treatment retention and illicit substance use (opiates, cocaine and benzodiazepines) was made by urinalysis. Findings. The retention rate was significantly better in the methadone maintained group (p< 0.05) but subjects completing the study in the buprenorphine group had significantly lower rates of illicit opiate consumption (p = 0.04). Conclusion. The results support the superiority of methadone with respect to retention rate. However, they also confirm previous reports of buprenorphine use as an alternative in maintenance therapy for opiate addiction, suggesting that a specific subgroup may be benefiting from buprenorphine. This is the first comparative trial to use sublingual buprenorphine tablets: previously published comparison studies refer to 30% solutions of buprenorphine in alcohol.     

Drug Interactions of Clinical Importance among the Opioids,Methadone and Buprenorphine,and Other Frequently Prescribed Medications: A Review

Drug interactions are a leading cause of morbidity and mortality. Methadone and buprenorphine are frequently prescribed for the treatment of opioid addiction. Patients needing treatment with these medications often have co‐occurring medical and mental illnesses that require medication treatment. The abuse of illicit substances is also common in opioid‐addicted individuals. These clinical realities place patients being treated with methadone and buprenorphine at risk for potentially toxic drug interactions. A substantial literature has accumulated on drug interactions between either methadone or buprenorphine with other medications when ingested concomitantly by humans. This review summarizes current literature in this area. (Am J Addict 2009;19:4–16)     

French field experience with buprenorphine

In most European countries, methadone treatment is provided to only 20-30% of opiate abusers who need treatment due to regulations and concerns about safety. To address this need in France, all registered medical doctors since 1995 have been allowed to prescribe buprenorphine (BUP) without any special education or licensing. This led to treating approximately 65,000 patients per year with BUP, about ten times more than with more restrictive methadone policies. French physician compensation mechanisms, pharmacy services, and medical insurance funding all minimized barriers to BUP treatment. About 20% of all physicians in France are using BUP to treat about half of the estimated 150,000 problem heroin users. Daily supervised dosing by a pharmacist for the first six months resulted in significantly better treatment retention (80% vs 46%) and lower heroin use. Intravenous diversion of BUP may occur in up to 20% of BUP patients and has led to various infections and relatively rare overdoses in combination with sedatives. Opiate overdose deaths have declined substantially (by 79%) since BUP was introduced in 1995. Newborn opiate withdrawal in mothers treated with buprenorphine compared to methadone was reported to be less frequent, less severe, and of shorter duration. Although some of the public health benefits seen during the time of buprenorphine expansion in France might be contingent upon characteristics of the French health and social services system, the French model raises questions about the value of tight regulations on prescribing BUP imposed by many countries throughout the world.     

Effectiveness and feasibility study of routine HIV rapid testing in an urban methadone maintenance treatment program

Abstract

Background: Universal Human Immunodeficiency Virus (HIV) testing and treatment are strategies to decrease AIDS-related morbidity and mortality and to reduce HIV transmission. Objective: This study examined the feasibility and effectiveness of routine HIV rapid testing implemented in the largest New York City (NYC) Methadone Maintenance Treatment Program (MMTP). Methods: A routine HIV rapid testing program performed by medical providers without pretest counseling or the provision of incentives was compared to HIV rapid testing done by referral to HIV counselors with pretest counseling and incentives over the prior 12 months. Results: Routine HIV rapid testing proved feasible and effective when performed by the medical staff in the setting of a large urban MMTP. The program increased HIV testing in all genders, race/ethnicities, and ages. HIV-positive individuals were diagnosed and successfully linked to care. The elimination of HIV prevention counseling may have facilitated expanded testing. Conclusion: This study confirms that routine HIV rapid testing without HIV-prevention counseling or the provision of incentives for patients is feasible on a large scale in a busy, urban methadone clinic.