Treatment into an HIV
Primary Care Clinic
Scope of Problem
• Of 1200 HIV patients in our HIV Primary Care
clinic, 10-20 % are believed to be opiate
dependent and not in active treatment.
• Pain syndromes (sometimes ill-defined) account
for some of these patients and they may be
receiving prescribed narcotics…
• …but many live along the fault lines, opiate
dependent, socially unstable, with a tenuous
link to health care.
Identifying Potential Patients
• Referrals through PCPs at Immunology Clinic
• “On the spot” education sessions by a member
of the study team to review treatment options.
• Rapid referral to the patient‟s desired form of
treatment: methadone, Suboxone, self-help,
counseling (usually a combination).
• Patients may choose to enroll in our evaluation
And then the patient decides what road
they want to travel.
• If they choose Suboxone, the treatment nurse
meets with them and plans in detail for further
evaluation and induction, if appropriate.
Specific features of Suboxone treatment are
explained in risk/benefit terms. Alternative
treatment options are offered.
• A treatment plan is initiated based on patient-
If they choose another form of
• They are referred to one of the in-house
addiction service programs or directly to
• They always have the option to discuss
Suboxone treatment at a later date.
Nurse facilitates completion of:
in-depth education re:Suboxone treatment
DSM-IV criteria evaluation
substance abuse history
labs (including tox screen)
reading/discussion/signing of pt. agreement
releases of information
Active engagement with patient to plan details
of induction, including last use of opioid and
typical withdrawal symptoms for patient.
Patient discusses plan with physician,
treatment nurse and, if possible, supportive
person in patient‟s life.
Day of Induction
• Pt. presents in withdrawal to facilitate
therapeutic action of Suboxone.
• Two to three hour visit allows reversal of
• Thereafter, doses are titrated to give optimal
effect of blocking craving for opiates, as well as
blocking opiate euphoria.
• Most patients try street opiates while in
treatment, needing to prove to themselves that
opiate „high‟ is blocked by Suboxone.
• Induction, stabilization and maintenance
phases of treatment. May require multiple
inductions due to relapse.
• Outreach workers provide motivational
enhancement and community follow-up.
• If dose tapering desired after period of stable
functioning, increase frequency of visits while
dose is slowly tapered.
• Ongoing education, referral, and support
• Linkage to care
Elements of Successful Treatment
Developing a therapeutic relationship that
encourages the growth of trust and self-efficacy
A focus on the individual‟s personal struggle
with addiction that acknowledges the strengths
that they bring to treatment
A willingness to examine patterns of self-
defeating behavior, including the provider‟s
unwitting reinforcement of same
• Persisting in identifying an additional
treatment mode to support Suboxone‟s effect
• Creatively supporting patient to find and
utilize effective counseling, case management,
self-help groups or any other avenues for
addressing unmet needs.
• Timely identification and aggressive treatment
of depression and other mental health
And, most importantly…
And a sense of humor
happily married to
a sense of perspective.
Arthur Pina, Jr.
He has been in our Suboxone
treatment program for one year.
He would like to share his story