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.

Awareness of hepatitis C diagnosis is associated with less alcohol use among persons co-infected with HIV.

BACKGROUND AND OBJECTIVE: It is unknown whether testing HIV-infected individuals for hepatitis C virus (HCV) and informing them of their HCV status impacts subsequent alcohol use. We hypothesized that HIV-infected individuals with current or past alcohol problems who reported being told they had HCV were more likely to 1) abstain from alcohol and 2) not drink unhealthy amounts compared to individuals who had not been told. DESIGN, PARTICIPANTS, AND MEASUREMENTS: Data from a prospective, observational cohort study (HIV-Longitudinal Interrelationships of Viruses and Ethanol) were used to assess the association between awareness of having HCV at baseline and subsequent abstinence and not drinking unhealthy amounts as reported at 6-month follow-up intervals. General estimating equations logistic regression was used to account for the correlation from using repeated observations from the same subject over time. We adjusted for age, sex, race, homelessness, injection drug use, depressive symptoms, and having abnormal liver tests. RESULTS: Participants who reported being told they had HCV were more likely to report abstaining from alcohol (AOR = 1.60; 95% CI: 1.13 to 2.27) and not drinking unhealthy amounts (AOR = 1.46; 95% CI: 1.01 to 2.11). CONCLUSIONS: Among patients infected with HIV who had a history of alcohol problems, reporting being told one had HCV was associated with greater abstinence from alcohol and less unhealthy amounts of drinking.

Substance abuse treatment and receipt of liver specialty care among persons coinfected with HIV/HCV who have alcohol problems.

We examined the association of substance abuse treatment with access to liver specialty care among 231 persons coinfected with HIV and hepatitis C virus (HCV) with a history of alcohol problems who were recruited and followed up in the HIV-Longitudinal Interrelationships of Viruses and Ethanol cohort study from 2001 to 2004. Variables regarding demographics, substance use, health service use, clinical variables, and substance abuse treatment were from a standardized research questionnaire administered biannually. We defined substance abuse treatment services as any of the following in the previous 6 months: 12 weeks in a halfway house or residential facility, 12 visits to a substance abuse counselor or mental health professional, day treatment for at least 30 days, or any participation in a methadone maintenance program. Liver specialty care was defined as a visit to a liver doctor, a hepatologist, or a specialist in treating hepatitis C in the past 6 months. At study entry, most of the 231 subjects (89%, n = 205) had seen a primary care physician, 50% had been exposed to substance abuse treatment, and 50 subjects (22%) had received liver specialty care. An additional 33 subjects (14%) reported receiving liver specialty care during the follow-up period. In the multivariable model, we observed a clinically important although not statistically significant association between having been in substance abuse treatment and receiving liver specialty care (adjusted odds ratio = 1.38; 95% confidence interval = 0.9-2.11). Substance abuse treatment systems should give attention to the need of patients to receive care for prevalent treatable diseases such as HIV/HCV coinfection and facilitate its medical care to improve the quality of care for individuals with substance use disorders. The data illustrate the need for clinical care models that give explicit attention to the coordination of primary health care with addiction and hepatitis C specialty care while providing ongoing support to engage and retain these patients with complex health needs.

Following young people with perinatal HIV infection from adolescence into adulthood: the protocol for PHACS AMP Up, a prospective cohort study.

INTRODUCTION: The first generation of adolescents born with HIV infection has reached young adulthood due to advances in treatment. It is important to continue follow-up of these individuals to assess their long-term medical, behavioural and mental health and ability to successfully transition to adulthood while coping with a chronic, potentially stigmatising condition. To accomplish this, and to maintain their interest in long-term research participation, we need to accommodate the changing lifestyles and interests of young adult study participants while ensuring valid data collection. We report the protocol for Pediatric HIV/AIDS Cohort Study (PHACS) Adolescent Master Protocol (AMP) Up, a prospective cohort study enrolling young adult participants for long-term follow-up. METHODS AND ANALYSIS: AMP Up is recruiting 850 young men and women 18 years of age and older-600 perinatally HIV-infected and a comparison group of 250 perinatally HIV-exposed, uninfected-at 14 clinical research sites in the USA and Puerto Rico. Recruitment began in April 2014 and is ongoing, with 305 participants currently enrolled. Planned follow-up is ≥6 years. Data are collected with a flexible hybrid of online and in-person methods. Outcomes include: transition to adult clinical care and retention in care; end-organ diseases; malignancies; metabolic complications; sexually transmitted infections; reproductive health; mental health and neurocognitive functioning; adherence to antiretroviral treatment; sexual behaviour and substance use; hearing and language impairments; and employment and educational achievement. ETHICS AND DISSEMINATION: The study received ethical approval from the Harvard T.H. Chan School of Public Health's institutional review board (IRB), and from the IRBs of each clinical research site. All participants provide written informed consent; for cognitively impaired individuals with legally authorised representatives, legal guardian permission and participant assent is obtained. Findings will be disseminated through peer-reviewed journals, conference presentations and participant summaries.

Prevalence of and risk factors for substance use among perinatally human immunodeficiency virus-infected and perinatally exposed but uninfected youth.

PURPOSE: This study examined risk factors associated with recent substance use (SU) among perinatally human immunodeficiency virus (HIV)-infected (PHIV+) and perinatally exposed, uninfected (PHEU) youth and compared SU lifetime prevalence with the general population of United States (U.S.) adolescents. METHODS: We conducted cross-sectional and longitudinal analyses of 511 PHIV+ and PHEU youth (mean age at study entry, 13.2 years; 51% female; 69% PHIV+; and 72% African-American) enrolled in a U.S. multisite prospective cohort study between 2007 and 2009. Substance use data were collected by audio computer-assisted self-interview. Youth Risk Behavior Surveillance System and Monitoring the Future data were used to compare SU lifetime prevalence with U.S. samples. RESULTS: Perinatal HIV infection was not a statistically significant risk factor for alcohol or marijuana use. Risk factors for alcohol use among PHIV+ youth included higher severity of emotional and conduct problems and alcohol and marijuana use in the home by the caregiver or others. Risk factors for marijuana use among PHIV+ youth included marijuana use in the home, higher severity of conduct problems, and stressful life events. Similar SU risk factors among PHEU youth included SU in the home and higher severity of conduct and emotional problems. Overall lifetime prevalence of SU by age was similar to that in national surveys. CONCLUSIONS: Although SU lifetime prevalence and risk factors for PHIV+ and PHEU adolescents were similar to national norms, the negative consequences are potentially greater for PHIV+ youth. Prevention efforts should begin before SU initiation and address the family and social environment and youth mental health status.

Alcohol consumption and HIV disease progression.

OBJECTIVE: To assess the relation between alcohol consumption and laboratory markers of HIV disease progression. METHODS: We prospectively assessed CD4 cell counts, HIV RNA levels, and alcohol consumption for up to 7 years in 595 HIV-infected persons with alcohol problems recruited between 1997 and 2003. We investigated the relation of these markers of HIV disease progression to alcohol consumption using longitudinal regression models controlling for known prognostic factors, including adherence and depressive symptoms, and stratified by antiretroviral therapy (ART) use. RESULTS: Among subjects who were not on ART, heavy alcohol consumption was associated with a lower CD4 cell count (adjusted mean decrease of 48.6 cells/microL compared with abstinence; P = 0.03) but not with higher log(10) HIV RNA. Among subjects who were on ART, heavy alcohol consumption was not associated with a lower CD4 cell count or higher log(10) HIV RNA. CONCLUSIONS: Heavy alcohol consumption has a negative impact on the CD4 cell count in HIV-infected persons not receiving ART. In addition to the known deleterious effects of alcohol on ART adherence, these findings suggest that avoiding heavy alcohol consumption in patients not on ART may have a beneficial effect on HIV disease progression.

Impact of hepatitis C on HIV progression in adults with alcohol problems.

BACKGROUND: Coinfection of human immunodeficiency virus (HIV) and hepatitis C virus (HCV) is a substantial medical and public health concern due to its increasing prevalence and complex patient management. Alcohol use may worsen HCV-related liver disease and interfere with adherence to antiretroviral therapy (ART) and medical care. We therefore studied the association between HCV infection and markers of HIV disease progression in adults with alcohol problems. METHODS: This is a longitudinal study of 396 HIV-infected persons with alcohol problems, 199 (50%) of whom were coinfected with HCV (positive HCV RNA test). CD4 cell counts and HIV RNA levels were assessed at baseline and then every 6 months for up to 42 months. Hepatitis C virus RNA status was determined at study enrollment. We examined the relationship between HCV infection and laboratory markers of HIV progression (CD4 cell count and log10 HIV RNA) by fitting multivariable longitudinal regression models for each outcome. RESULTS: Among subjects who were adherent to ART, the presence of HCV infection was associated with a lower CD4 cell count (adjusted mean difference -46.0 cells/microL, p=0.03). There was no association observed between HCV infection and CD4 cell count among those not adherent to ART or those not taking ART. No significant association was observed between HCV infection and HIV RNA regardless of ART status. CONCLUSIONS: Hepatitis C virus infection has an adverse effect on CD4 cell count in patients with alcohol problems who are adherent to ART. Addressing HCV coinfection among these patients may confer additional immunologic benefit for this patient population.

Hepatitis C infection is associated with depressive symptoms in HIV-infected adults with alcohol problems.

OBJECTIVES: Depression is common in persons with HIV infection and with alcohol problems, and it has important prognostic implications. Neurocognitive dysfunction has been reported with chronic hepatitis C virus (HCV) infection. We hypothesized that HCV infection is associated with more depressive symptoms in HIV-infected persons with a history of alcohol problems. METHODS: We performed a cross-sectional analysis of baseline data from a prospective cohort study of 391 HIV-infected subjects with a history of alcohol problems, of whom 59% were HCV antibody (Ab) positive and 49% were HCV RNA-positive. We assessed depressive symptoms (Center for Epidemiologic Studies Depression [CES-D]) and past month alcohol consumption. In the primary analysis, we evaluated whether there were more depressive symptoms in HCV Ab-positive and RNA-positive subjects in unadjusted analyses and adjusting for alcohol consumption, gender, age, race, CD4 count, homelessness, drug dependence, and medical comorbidity. RESULTS: Mean CES-D scores were higher in subjects who were HCV Ab-positive compared with those who were HCV Ab-negative (24.3 vs 19.0; p < 0.001). In adjusted analyses, the difference in CES-D scores between HCV Ab-positive and Ab-negative subjects persisted (24.0 vs 19.0; p < 0.001). Unadjusted mean CES-D scores were also significantly higher in HCV RNA-positive subjects compared with those who were RNA-negative, and the difference remained significant (24.6 vs 19.3; p < 0.001) in adjusted analyses. CONCLUSIONS: HCV/HIV coinfected persons with a history of alcohol problems have more depressive symptoms than those without HCV, and this association is unexplained by a variety of population characteristics. These data suggest that HCV may have a direct effect on neuropsychiatric function.

Why do WIC participants fail to pick up their checks? An urban study in the wake of welfare reform.

OBJECTIVES: This study explored whether work or immigration concerns affect women's participation in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). METHODS: The sample included women who had withdrawn from the WIC program and current WIC clients from 1 center in New York City. Logistic regression analyses were used to predict noncollection of checks; demographic characteristics, program participation, and problems with the WIC program were independent variables. RESULTS: Strong predictors of noncollection of checks were job conflicts, transportation or illness problems, and WIC receipt by the woman herself (rather than by her children). CONCLUSIONS: Employment conflicts were related to failure to pick up WIC checks; immigration concerns were not. As a means of enhancing WIC participation, flexibility is recommended in terms of center hours, locations, and staffing and program check distribution policies.