Targeting behavioral therapies to enhance naltrexone treatment of opioid dependence: efficacy of contingency management and significant other involvement.

BACKGROUND: Contingency management (CM) and significant other involvement (SO) were evaluated as strategies to enhance treatment retention, medication compliance, and outcome for naltrexone treatment of opioid dependence. METHODS: One hundred twenty-seven recently detoxified opioid-dependent individuals were randomly assigned to 1 of 3 conditions delivered for 12 weeks: (1) standard naltrexone treatment, given 3 times a week; (2) naltrexone treatment plus contingency management (CM), with delivery of vouchers contingent on naltrexone compliance and drug-free urine specimens; or (3) naltrexone treatment, CM, plus significant other involvement (SO), where a family member was invited to participate in up to 6 family counseling sessions. Principal outcomes were retention in treatment, compliance with naltrexone therapy, and number of drug-free urine specimens. RESULTS: First, CM was associated with significant improvements in treatment retention (7.4 vs 5.6 weeks; P =.05) and in reduction in opioid use (19 vs 14 opioid-free urine specimens; P =.04) compared with standard naltrexone treatment. Second, assignment to SO did not significantly improve retention, compliance, or substance abuse outcomes compared with CM. Significant effects for the SO condition over CM on retention, compliance, and drug use outcomes were seen only for the subgroup who attended at least 1 family counseling session. The SO condition was associated with significant (P =.02) improvements in family functioning. CONCLUSION: Behavioral therapies, such as CM, can be targeted to address weaknesses of specific pharmacotherapies, such as noncompliance, and thus can play a substantial role in broadening the utility of available pharmacotherapies.

Screening for alcohol problems in primary care: a systematic review.

BACKGROUND: Primary care physicians can play a unique role in recognizing and treating patients with alcohol problems. OBJECTIVE: To evaluate the accuracy of screening methods for alcohol problems in primary care. METHODS: We performed a search of MEDLINE for years 1966 through 1998. We included studies that were in English, were performed in primary care, and reported the performance characteristics of screening methods for alcohol problems against a criterion standard. Two reviewers appraised all articles for methodological content and results. RESULTS: Thirty-eight studies were identified. Eleven screened for at-risk, hazardous, or harmful drinking; 27 screened for alcohol abuse and dependence. A variety of screening methods were evaluated. The Alcohol Use Disorders Identification Test (AUDIT) was most effective in identifying subjects with at-risk, hazardous, or harmful drinking (sensitivity, 51%-97%; specificity, 78%-96%), while the CAGE questions proved superior for detecting alcohol abuse and dependence (sensitivity, 43%-94%; specificity, 70%-97%). These 2 formal screening instruments consistently performed better than other methods, including quantity-frequency questions. The studies inconsistently adhered to methodological standards for diagnostic test research: 3 (8%) provided a full description of patient spectrum (demographics and comorbidity), 30 (79%) avoided workup bias, 12 (of 34 studies [35%]) avoided review bias, and 21 (55%) performed an analysis in pertinent clinical subgroups. CONCLUSIONS: Despite methodological limitations, the literature supports the use of formal screening instruments over other clinical measures to increase the recognition of alcohol problems in primary care. Future research in this field will benefit from increased adherence to methodological standards for diagnostic tests.

Hazardous and harmful alcohol consumption in primary care.

Increasing emphasis has been placed on the detection and treatment of hazardous and harmful drinking disorders, particularly among patients who are seen in primary care settings. In this review, we summarize the epidemiology and health-related effects of hazardous and harmful drinking and discuss current methods for their detection and treatment. Hazardous drinking is defined as a quantity or pattern of alcohol consumption that places patients at risk for adverse health events, while harmful drinking is defined as alcohol consumption that results in adverse events (e.g., physical or psychological harm). Prevalence estimates range from 4% to 29% for hazardous drinking and from less than 1% to 10% for harmful drinking. Data from several recent large prospective studies suggest that alcohol consumption in quantities consistent with hazardous or harmful drinking may increase risk for adverse health events, such as hemorrhagic stroke and breast cancer. Existing screening instruments, such as the Michigan Alcoholism Screening Test (MAST) or the CAGE questionnaire, while excellent for detecting alcohol abuse or dependence, should not be used alone to screen for hazardous and harmful drinking. The Alcohol Use Disorders Identification Test (AUDIT) is currently the only instrument specifically designed to identify hazardous and harmful drinking. Treatment of these disorders in the form of brief interventions can be successfully accomplished in primary care settings, as demonstrated by a number of well-conducted randomized trials. Given its proven efficacy in the primary care setting, we recommend routine application of this treatment approach.

The substance-using human immunodeficiency virus patient: approaches to outpatient management.

Individuals with a substance use disorder who are infected with human immunodeficiency virus (HIV) provide physicians with challenging issues for both medical management and drug treatment. Using a case presentation format, we present an overview of some of the major issues involved in delivering effective primary care for these individuals. A detailed medical and substance use history is critical to sort common complaints that can be seen both in HIV infection and with drug use. Physicians must be able to recognize withdrawal syndromes and differentiate those signs and symptoms that may be attributed to specific drugs. A two-phase model of drug abuse treatment takes into account both detoxification and maintenance of abstinence. Primary care physicians should be able to initiate the process of substance abuse treatment and refer the patient to appropriate substance abuse programs when necessary. Pharmacological approaches to long-term abstinence with heroin addiction include methadone, LAAM, and naltrexone. While clinically challenging, HIV-infected substance users can be successfully managed using the general principles of primary care.

Alcohol abusers in primary care: readiness to change behavior.

PURPOSE: Assessing readiness to address alcohol problems is an important early step in managing the alcohol abusing patient. We assessed readiness for behavioral change in primary care of patients who screen positive for alcohol abuse based on the CAGE questionnaire. Our hypothesis was that these patients would be predominantly in the contemplation stage, an opportune stage for physicians to facilitate their movement into substance abuse treatment. PATIENTS AND METHODS: We administered the CAGE questionnaire, a well-validated screening tool for detecting alcohol abuse, to 1,211 of 1,335 patients (91%) who attended two urban primary care clinics. Patients who responded positively to one or more CAGE questions were administered two validated instruments that assessed readiness to change alcohol use. We also measured quantity and frequency of alcohol use. RESULTS: Seventeen percent of patients gave a positive response to one or more CAGE questions (209 of 1,211) and were eligible for further evaluation; 92% (192 of 209) agreed to participate. These subjects' mean age was 50 years and the majority (58%) were African American. Of these patients, 23% were in the precontemplative (denial) stage, 14% were in the contemplative stage, and 63% were in the action stage of behavior change, indicating that they were in early or long-term recovery. Stage of readiness to change results were similar for those with one positive response and two or more positive responses to CAGE questions. CONCLUSIONS: Most patients in whom alcohol abuse is detected in primary care using the CAGE questionnaire are either actively addressing their substance abuse or are in recovery. Contrary to our hypothesis, only a minority of patients are in the contemplation stage. Assessment of stage of change is not apparent from the CAGE questionnaire alone. Our results suggest that clinical skills to facilitate relapse prevention would be particularly valuable for clinicians addressing alcohol abuse in the primary care setting.

Management of hospitalized intravenous drug users: role of the internist.

Intravenous drug users present significant clinical challenges to internists. In this paper, we review common clinical dilemmas faced by internists when managing intravenous drug users in the inpatient hospital setting. Articles were identified through a MEDLINE search and bibliographies of published articles. Studies and reviews were selected for information relevant to the management of hospitalized intravenous drug users. Seventy-three papers were selected for this review. We summarize data and information from the relevant literature concerning common presenting medical problems (fever, musculoskeletal pain, and dyspnea), the importance of knowing patients' HIV status, common behavioral issues, special concerns of women, and the diagnosis and management of drug withdrawal in intravenous drug users. We also offer recommendations for hospital discharge planning. With appropriate knowledge of the epidemiology and management of important medical and substance use problems among intravenous drug users, internists may more effectively care for them in the hospital setting.

New therapies for alcohol problems: application to primary care.

Primary care physicians are frequently involved in the longitudinal care of patients with alcohol problems and in helping patients to decrease their alcohol consumption. Recent clinical trials provide evidence in support of new treatment strategies for these patients. Brief interventions have been used successfully to reduce alcohol consumption in patients with hazardous and harmful drinking. Twelve-step facilitation, cognitive behavioral, and motivational enhancement therapies have produced sustained drinking reductions in patients with alcohol dependence. Pharmacologic therapies, such as naltrexone and acamprosate, have been effective in decreasing alcohol consumption when provided along with psychosocial counseling in patients with alcohol dependence. The current review highlights the application of these new therapies to primary care physicians' efforts on behalf of their patients with alcohol problems.

Human immunodeficiency virus infection in intravenous drug users: a model for primary care.

PURPOSE: Intravenous drug users (IVDUs) often encounter barriers to primary care. To improve access, we developed a primary care clinic--Central Medical Unit (CMU)--for substance abusers in drug treatment. We report outcomes for services offered to IVDUs with human immunodeficiency virus (HIV) infection. PATIENTS AND METHODS: During 1990, 24% (120 of 509) of IVDUs eligible for CMU were HIV positive. Diagnostic therapeutic and preventive goals for IVDUs with HIV infection were evaluated for acceptance and compliance by chart review for these 120 patients. RESULTS: On admission, 65% (78 of 120) of patients reported having no source of primary care, 64% (77 of 120) were male, and 77% (92 of 120) were in methadone maintenance. All were screened for tuberculosis, syphilis, and hepatitis; 94% (15 of 16) of eligible patients accepted tuberculosis prophylaxis and 83% (5 of 6) accepted syphilis treatment, but only 36% (5 of 14) accepted hepatitis B vaccine. Of those who accepted therapy, 87% (13 of 15) were compliant with tuberculosis prophylaxis, and 100% (5 of 5) were compliant with syphilis treatment. Influenza vaccine was accepted by 49% (59 of 120) and pneumococcal vaccine by 81% (97 of 120). Ninety-eight percent (118 of 120) accepted T-cell testing: 61% had T-helper counts less than 500/mm3 and 25% were less than 200/mm3. Of those eligible, 89% (70 of 79) accepted antiretroviral therapy, and 100% (35 of 35) accepted Pneumocystis carinii pneumonia prophylaxis. Six-month compliance rates for these therapies were 84% (59 of 70) and 77% (27 of 35), respectively. CONCLUSION: By offering primary care services with drug treatment, the CMU model may be an effective way of providing access to primary care for HIV-infected IVDUs and for facilitating compliance.

A preliminary investigation of the management of alcohol dependence with naltrexone by primary care providers.

PURPOSE: To describe a preliminary investigation of a model of naltrexone therapy and counselling for use by primary care providers and evaluate its impact on drinking behaviors in a cohort of alcohol-dependent subjects. PATIENTS AND METHODS: The subjects enrolled in this study were 29 alcohol-dependent individuals. They were managed within a primary care treatment model located at a university-affiliated substance research program in New Haven, Connecticut. Subjects were assigned to a primary care provider for treatment of their alcohol dependence and were placed on naltrexone at a dose of 50 mg per day. They were seen for an initial "new patient" visit and 7 "brief" follow-up visits during the 10-week study. The primary outcomes for this study were completion of treatment, change in drinking behaviors from baseline, change in liver enzymes from baseline, provider ratings of improvement, and patient ratings of improvement and satisfaction with treatment. RESULTS: Of the 29 subjects: 21 (72%) completed treatment, and 10 (35%) relapsed to heavy drinking. All drinking behaviors improved significantly from baseline: percent of days abstinent increased from 36.6% to 88.8% (P < 0.0001), percent days abstinent from heavy drinking increased from 48.7% to 97.3% (P < 0.0001), and mean number of drinks per occasion decreased from 9.5 to 2.5 (P < 0.0001). The mean serum gamma glutamyl transferase (GGT) for the group decreased from 67.1 U/L to 45.3 U/L (P < 0.0001). CONCLUSIONS: In this preliminary investigation, treatment of alcohol dependence with our model of naltrexone and counselling by primary care providers appeared to be both feasible and effective.

A randomized trial of buprenorphine maintenance for heroin dependence in a primary care clinic for substance users versus a methadone clinic.

PURPOSE: Buprenorphine is an alternative to methadone for the maintenance treatment of heroine dependence and may be effective on a thrice weekly basis. Our objective was to evaluate the effect of thrice weekly buprenorphine maintenance for the treatment of heroin dependence in a primary care clinic on retention in treatment and illicit opioid use. SUBJECTS AND METHODS: Opioid-dependent patients were randomly assigned to receive thrice weekly buprenorphine maintenance in a primary care clinic that was affiliated with a drug treatment program (n = 23) or in a traditional drug treatment program (n = 23) in a 12-week clinical trial. Primary outcomes were retention in treatment and urine toxicology for opioids; secondary outcomes were opioid withdrawal symptoms and toxicology for cocaine. RESULTS: Retention during the 12-week study was higher in the primary care setting (78%, 18 of 23) than in the drug treatment setting (52%, 12 of 23; P = 0.06). Patients admitted to primary care had lower rates of opioid use based on overall urine toxicology (63% versus 85%, P < 0.01) and were more likely to achieve 3 or more consecutive weeks of abstinence (43% versus 13%, P = 0.02). Cocaine use was similar in both settings. CONCLUSIONS: Buprenorphine maintenance is an effective treatment for heroin dependence in a primary care setting.

Measurement of compliance with naltrexone in the treatment of alcohol dependence: research and clinical implications.

BACKGROUND: Medication compliance is a critical issue in pharmacotherapy. This study evaluated the clinical utility of the Medication Event Monitoring System (MEMS), a newer method for monitoring medication compliance, compared with pill count, a traditional measure, in a sample of patients treated for alcohol dependence with naltrexone. METHOD: Ninety-three outpatients meeting DSM-III-R criteria for alcohol dependence participated in a 10-week open-label study of naltrexone. They were provided with naltrexone, 50 mg daily, and concurrent counseling. Measures of medication compliance and drinking during treatment were collected every 2 weeks. RESULTS: Pill count yielded a significantly (p < .001) higher estimate of compliance (87.6%+/-18.1%) than the MEMS (80.4%+/-20.6%). However, the estimate of compliance obtained with the MEMS was more consistently correlated with treatment outcome (percentage of days abstinent, percentage of heavy drinking days, and mean alcohol amount consumed per drinking occasion) than the pill count compliance rate. In addition, classification of the sample into compliant and less compliant groups using the MEMS data yielded groups that differed more clearly on drinking outcomes than did stratification on the basis of pill count. CONCLUSION: In pharmacotherapy research, the MEMS may provide more reliable and valid information about subjects' medication compliance than pill count. Clinically, information obtained with the MEMS could be used to provide feedback to patients about their pill-taking behavior to enhance compliance and overall outcome of therapy.

AIDS oncology.

Kaposi's sarcoma, non-Hodgkin's lymphoma, Hodgkin's disease, and squamous cell carcinoma are among the malignancies seen with increased frequency in patients infected with HIV. The outlook for patients with these malignancies has improved significantly with the utilization of highly active antiretroviral therapy (HAART) and more aggressive cytotoxic therapies. Novel biologic therapies with lesser side effects are currently being evaluated. This article reviews the current knowledge about HIV malignancies, their epidemiology, pathogenesis, clinical manifestations, and treatment.

Risk factors for and knowledge of Mycobacterium tuberculosis infection among drug users in substance abuse treatment.

OBJECTIVE: To determine the prevalence, incidence and risk factors for Mycobacterium tuberculosis infection, as well as to assess TB knowledge and attitudes, among a group of known drug users in a city with low TB incidence (11.3 per 100,000 in 1995). METHODS: Patients of an urban drug treatment facility enrolled in opioid substitution, opioid antagonist and other drug treatment programs were screened for TB, including tuberculin skin testing and standardized data collection on TB risk factors. A subsample of clients was interviewed about TB knowledge and attitudes. RESULTS: Between 1 June 1995 and 31 May 1996, 1055 individuals were screened. The prevalence of infection was 15.7% (CI: 13.2-18.2%). PPD positivity was associated with older age (per annum, OR = 1.08, CI: 1.05-1.11), non-white race (OR = 2.81, CI: 1.72-4.60), foreign birth (OR = 4.24, CI: 2.35-7.62) and a history of injecting drug use (OR = 1.89, CI: 1.14, 3.12). The incidence of infection was 2.9 per 100 person-years (CI: 1.8-4.7). Thirty-two per cent of 79 drug users interviewed about TB knowledge and attitudes thought TB could be prevented by bleaching or not sharing needles/syringes. Fifty-one per cent thought anyone with a positive TB skin test was contagious. CONCLUSION: M. tuberculosis infection was common in this population and associated with injecting drugs and several demographic factors. The incidence of new infection was relatively low. In this non-endemic environment, the detection and treatment of latent infection are important aspects of TB control. Misconceptions about TB transmission were also widespread in this population. Drug treatment programs can play a key role by undertaking screening programs that educate about TB and identify infected subjects who would benefit from preventive therapy.

Tuberculosis chemoprophylaxis using a liquid isoniazid-methadone admixture for drug users in methadone maintenance.

BACKGROUND: Tuberculosis is common in drug users, although compliance with therapy may be difficult in this population. OBJECTIVE: To evaluate an approach to enhancing compliance with tuberculosis chemoprophylaxis in drug users enrolled on methadone maintenance utilizing an isoniazid (INH)-methadone admixture. DESIGN: A prospective cohort study. SETTING: A drug treatment program in New Haven, Connecticut, USA. PATIENTS: Opioid-dependent drug users enrolled in methadone maintenance. INTERVENTION: Liquid isoniazid was mixed into subjects' daily dose of methadone. Vitamin B6 was given to subjects for self-administration. MEASUREMENTS AND MAIN RESULTS: Number of eligible subjects, reasons for not starting therapy, number starting therapy, proportion completing therapy and median duration of INH therapy were calculated. Thirty-nine subjects were eligible for INH chemoprophylaxis: 34 (87%) received INH mixed directly in their methadone and five (13%) had their INH consumption supervised by a nurse. Among these subjects, 72% (28/39) completed therapy. Among the 11 subjects who discontinued INH, discharge from the methadone maintenance program was the most common reason--73% (8/11). Thus, among the 31 subjects who were not discharged from methadone maintenance, 90% (28/31) successfully completed INH prophylaxis. The median duration of therapy was 182 days. CONCLUSIONS: Tuberculosis chemoprophylaxis using a liquid isoniazid-methadone admixture appears to be an effective approach to enhancing compliance with this therapy in methadone-maintained drug users.

Physician impairment by substance abuse.

Physician impairment by substance abuse represents a significant challenge to physicians, patients, and society as a whole. Although data is sparse, the prevalence of alcohol and illicit drug abuse among physicians is probably similar to that of the general population, while abuse of prescription drugs may be more prevalent. From a medicolegal standpoint, these issues are managed mostly at the state level and substance abuse is of increasing interest to credentialling organizations such as hospitals and managed care organizations. A variety of concrete steps can be taken to identify physicians with substance abuse problems and treatment approaches have been designed specifically for impaired physicians. With improved attention to the problem of physician impairment by substance abuse, the well-being of both physicians and their patients can be enhanced.

Pharmacotherapy for opioid and cocaine abuse.

The need for continued development of medications to address opioid and cocaine addiction is unequivocal. Methadone maintenance, despite its limitations, remains the best-established pharmacologic treatment for opioid dependence. Continued participation in methadone programs is associated with decreased risk of acquiring HIV infection. Clonidine alone or combined with naltrexone may be used for opioid detoxification in the office practice. At the present time, no proven pharmacologic therapy for cocaine addiction exists.

HIV infection and cocaine use in methadone maintained and untreated intravenous drug users.

In a survey of 424 intravenous drug users (IVDUs) of whom 107 were currently enrolled in a methadone maintenance program (MMP), we assessed risk behaviors for Human Immunodeficiency Virus (HIV) transmission and conducted HIV testing. We found that African Americans were over-represented in the HIV infected group and under-represented in the methadone maintenance treatment group. Furthermore, subjects in current methadone maintenance treatment reported fewer drug injections in the last 30 days, a reduced speedball (a heroin/cocaine mixture) injection frequency and reduced total cocaine and injected cocaine use. HIV infected subjects reported 20% more cocaine use and injected cocaine use than HIV negatives. However, this difference was due to African Americans reporting more cocaine use and at the same time being over-represented in the HIV infected group. Stratified analysis by ethnicity found significant MMP effects for all ethnic groups, but only one significant HIV status effect, and this was limited to African Americans. Cocaine injection frequency in African Americans was significantly higher for the HIV infected versus non-infected subjects. We conclude that i.v. cocaine use is a risk factor associated with HIV infection and that methadone maintenance treatment is associated with reducing this risk factor. Furthermore, African American cocaine users are at great risk for HIV infection, and increased efforts for engagement in treatment are necessary.

Plasma concentrations of buprenorphine 24 to 72 hours after dosing.

BACKGROUND: This study evaluated plasma buprenorphine concentrations 24-72 h following sublingual administration of a dose of buprenorphine solution, ranging from 16 mg/70 kg to 44 mg/70 kg, administered on a daily or thrice-weekly schedule. Additionally, this study evaluated the effects of different thrice-weekly buprenorphine dose schedules on opiate use and withdrawal symptoms. METHODS: Opiate dependent subjects (n = 10) were maintained in an outpatient clinic for two 3-week periods at each of three thrice-weekly buprenorphine dose schedules (providing a weekly total buprenorphine dose of 64, 84 and 112 mg) and for 1 week of a daily buprenorphine dose of 16 mg/70 kg. Plasma samples were obtained 24, 48 and 72 h following administration of buprenorphine. Urine samples were also collected and opiate withdrawal symptoms, agonist effects and the use of heroin, cocaine, alcohol and other drugs, were assessed. RESULTS: Plasma levels showed a wide range of intra- and inter-subject variability. Nonetheless, higher doses of buprenorphine resulted in higher plasma concentrations at each time point and plasma concentration decreased with time. There were no significant differences in heroin use across dosing. Rates of withdrawal symptoms were low and did not differ across dosing schedules. CONCLUSIONS: In the two highest dose schedules, plasma levels 72 h following the administration of the highest dose and at 48 h after the lower dose, were comparable to plasma concentrations at 24 h following daily administration of 16 mg/70 kg of buprenorphine.

SPECT regional cerebral blood flow alterations in naltrexone-precipitated withdrawal from buprenorphine.

The effects of naltrexone-precipitated withdrawal from buprenorphine on behavior and regional cerebral blood flow (rCBF) were studied in 11 opiate-dependent patients. Patients initially received buprenorphine, 2 mg sublingually, every day for 7 days. They were then challenged sequentially with placebo and naltrexone, 25 mg orally, before single photon emission computed tomography with technetium-99m-d,l-hexamethyl-propylene amine oxime as tracer. Behavioral ratings of withdrawal severity were made before and after naltrexone/placebo administration. Naltrexone produced significantly greater signs and symptoms of opiate withdrawal than placebo. Analysis of variance revealed no significant regionally specific effect of naltrexone on rCBF ratios. Severity of withdrawal, however, showed a significant negative correlation with rCBF in the anterior cingulate cortex following naltrexone. These results are interesting as the anterior cingulate region has been implicated in the emotional component of pain and in opiate-induced analgesia.

HIV post-exposure therapy for drug users in treatment.

The purpose of this study was to evaluate the attitudes of drug treatment program providers concerning human immunodeficiency virus (HIV) post-exposure therapy (PET) for drug users enrolled in drug treatment. This was a cross-sectional evaluation of drug treatment program providers in four methadone maintenance programs (MMPs) in New Haven, Connecticut. Thirty-five MMP providers including: 29 MMP treatment staff (physicians, nurses, counselors) and 6 primary care provider staff (physicians, nurse practitioners, and nurses) participated in the study. The providers were presented with four case vignettes of individuals exposed to HIV through a needle stick ("stick"): a phlebotomist with occupational exposure (Case A) and three drug users with nonoccupational exposure to HIV (Cases B, C, and D). Case B had the same estimated future risk as Case A (three sticks/4 years) and the other cases had increased risk: Case C (four to six sticks/year) and Case D (monthly "sticks"). For each vignette, providers were asked whether they would offer HIV PET ("yes" or "no"). In addition, focus groups were held within each group of providers who were asked: "What role should drug treatment programs play in the implementation of PET?" All MMP staff (29/29) and primary care providers (6/6) felt that the phlebotomist with occupational exposure should be offered PET. The percent of MMP and Primary care provider staff recommending PET for the other cases were: Case B (MMP staff: 86% [25/29], PCPs: 100% [6/6]), Case C (MMP staff: 69% [20/29], PCPs: 33% [2/6]), and Case D (MMP staff: 59% [17/29], PCPs: 17% [1/6]). The "common themes" that were identified in the focus groups included: concern that MMPs lack resources to provide PET, the ethics of withholding PET, the "limit" on the number of times PET should be offered, and the role of PET in the overall HIV prevention message. Both MMP staff and PCPs felt that MMPs should have an "indirect" role in providing HIV PET by providing education and referral only. MMP staff and PCPs differed in their likelihood of offering HIV PET to drug users enrolled in MMPs. The possibility of HIV PET for drug users in treatment raises significant implementation issues for MMPs that will require further study if HIV PET becomes widely used in drug users.