Lawrence, MA
Ponce, PR
Buprenorphine Treatment for Opioid Use Disorder in HIV Primary Care (Integrated Buprenorphine Treatment) is an integrated care approach designed to reduce opioid use and overdose while improving client engagement in HIV care. Greater Lawrence Family Health Center and Med Centro, Inc. implemented this integrated care approach as part of Using Evidence-Informed Interventions to Improve Health Outcomes among People Living with HIV (E2i), an initiative funded by the Ryan White HIV/AIDS Program (RWHAP) Part F Special Projects of National Significance (SPNS) program from 2017–2021. Clients who participated in this intervention received integrated care—treatment for opioid use disorder (OUD) and HIV in a single setting—to improve retention in care, viral suppression, and engagement in OUD treatment.
People with untreated OUD may have difficulty remaining in HIV care and with HIV medication adherence.1 People who are in treatment for both OUD and HIV may receive fragmented care and inconsistent clinical visits, and will benefit from integration of OUD treatment with HIV care.2,3 Integrated Buprenorphine Treatment is an evidence-informed intervention developed by HIV experts in collaboration with community members to improve health outcomes among people with HIV. In this intervention, clients receive treatment for OUD and HIV in a single setting, with the goals of reducing opioid use and overdose while improving client engagement in HIV care.
Recognizing that many people with HIV use opioids to manage pain, that people with chronic pain may experience OUD, and that injection drug use is a common route of HIV transmission, the intersection of the HIV and opioid epidemics can be addressed by integrating buprenorphine treatment into HIV primary care.
The goal of buprenorphine treatment is to reduce the harm of opioid misuse and minimize the experience of withdrawal or cravings. The three main stages of treatment are:
- Induction: medically monitored initiation of buprenorphine treatment
- Stabilization: increasing medication dosage until a client no longer has withdrawal or cravings and has not developed symptoms of opioid excess
- Maintenance: regular visits to the clinic to help clients maintain stability
Based on preference and previous experiences, clients began buprenorphine treatment at the care site—clinic or mobile unit—or at home. As an adjunct to buprenorphine treatment, provision of counseling and mental health services by behavioral health staff is recommended but not required.
Integrated Buprenorphine Treatment offers more than medication. The intervention requires organizations to assess and adapt their staffing, equipment, and procedures. Organizations need to identify community needs, establish or strengthen partnerships with other organizations (such as pharmacies, laboratories, and mental health and substance use disorder treatment providers for referral purposes), and follow federal and state buprenorphine policies.
Across the two sites, a total of 20 clients received services through this intervention. All measured outcomes improved from enrollment to 12 months; the increases in engagement and retention in care were statistically significant.
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Source: Buprenorphine Treatment for Opioid Use Disorder in HIV Primary Care: E2i Implementation Guide. Rockville, MD: U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau; 2021.
“As a professional, I am grateful to see the evolution and progress of our clients as they stabilize from opioid addiction and increase adherence to their HIV treatment.”
- Staff Training. All prescribing providers obtained a buprenorphine prescription waiver. Rules regarding training, certifications, and waivers are subject to change. For up-to-date information, see the SAMHSA Medication for Substance Use Disorders website. All treatment team members must have experience or training in the assessment and management of SUDs. For national training opportunities, see the Center of Excellence for Integrated Health Solutions and the American Society for Addiction Medicine (ASAM).
- All clinical staff can benefit from training on the basic features of SUDs, medication supported recovery, urine toxicology testing, confidentiality, motivational interviewing, polysubstance use disorders, and buprenorphine-specific subjects (e.g., client selection, induction, stabilization, documentation, forms, regulations, and case studies). In addition, all organizational staff, including front desk staff, can benefit from training on cultural responsiveness to reduce stigma and build trusting relationships with clients.
- Integration of psychiatric and counseling services within the program. Services may include individual therapy, group therapy, psychiatric medication management, peer support, etc. If full integration of behavioral health services is not possible, create a network of recovery support services with partnering agencies.
- Pre-implementation preparation. Before implementation, sites reviewed federal, state, and local laws and regulations to see what services were allowable in their jurisdiction. For example, some states have more restrictive rules around prescribing buprenorphine.
- Prior to implementation, sites—whether clinic-based, or a mobile unit—needed to arrange dedicated space for induction visits, and secure supplies, such as drug screening kits, and computer software for securing client logs and records. Mobile units may require retrofitting to ensure appropriate treatment space and lab station capacity.
- Before integrating buprenorphine treatment into HIV care, the treatment team developed an internal communication plan for meeting regularly to discuss clients and program flow.
- Visit flow and sequence. The exact timing and structure of initial and follow-up visits depended on each site’s current capabilities as well as a client’s needs. Staff used existing resources, checklists, and other materials that made sense for their program. They also tailored educational materials and created organizational policies and procedures to guide clients through the intervention.
- Referral network. Staff assessed the existing opportunities in their communities for medication for OUD, substance use treatment, and wraparound services, and built partnerships and referral relationships to ensure that their clients had access to comprehensive care.
Two sites participated in the E2i initiative. Learn more about their implementations below.
Greater Lawrence Family Health Center (Lawrence, MA)
Med Centro, Inc. (Ponce, PR)
“This program is an unbelievable benefit for clients. [Use of the mobile unit] removes the barrier of a brick-and-mortar site, with no appointments or wait times, and allows us to provide low-barrier and client-centered care.”
- Outpatient substance use treatment can be provided with RWHAP funds. Additional providers can be recruited and/or trained as demand for buprenorphine treatment grows. Meeting with administration twice a year to discuss needs, budget, and outcomes can be effective in facilitating integration and improving sustainability.
- A large amount of effort was required at the start of treatment for staff to contact clients; however, this helped to build relationships between staff and clients, and contacting clients became easier over time.
- Costs incurred by the sites were related to planning and implementation, including hiring new personnel, training, supplies, incentives, and outreach activities. For more information on costs, see the implementation guide.
- Many clients struggled and relapsed or fell out of care during the intervention; relapse is expected during the substance use recovery process. It is important to meet clients where they are and to welcome them back into treatment without judgment.
- It is challenging for clients to attend appointments when they experience scheduling and/or transportation barriers. RWHAP funds were used to support transportation services, expanded clinic hours, and at-home services.
- Having an onsite pharmacy and/or using a courier service for medications can be effective strategies for improving access to medications.
- Many clients have co-occurring needs, such as treatment for polysubstance use and psychiatric disorders, which require intensive engagement. The clinic-based site scheduled weekly appointments with case managers and psychologists to support clients throughout the intervention. Pacing enrollments and creating alternate clinic schedules helped staff to even out and sustain their caseloads.
- Clients with Medicaid health care coverage should pay close attention to Medicaid expiration dates—one site created a log to remind clients a month before they needed to renew health care coverage. Other payer sources may be needed for clients whose health care coverage will not cover treatment.
Implementation Resources
- Buprenorphine Treatment for Opioid Use Disorder in HIV Primary Care: E2i Toolkit
- Buprenorphine Treatment for Opioid Use Disorder in HIV Primary Care: E2i Implementation Guide
- Tratamiento con buprenorfina para el trastorno por consumo de opioides en el cuidado primario del VIH: Guía de implementación de E2i
- Cunningham CO. Opioids and HIV infection: From pain management to addiction treatment. Top Antivir Med. 2018;25(4):143-146.
- Lucas GM, Chaudhry A, Hsu J, et al. Clinic-based treatment of opioid-dependent HIV-infected patients versus referral to an opioid treatment program: A randomized trial. Ann Intern Med. 2010;152(11):704-711.
- Altice FL, Bruce RD, Lucas GM, et al. HIV treatment outcomes among HIV-infected, opioid-dependent patients receiving buprenorphine/naloxone treatment within HIV clinical care settings: Results from a multisite study. J Acquir Immune Defic Syndr. 2011;56 Suppl 1:S22-32.