Integrating Suboxone Treatment into an HIV Primary Care Clinic

Document Sample
Integrating Suboxone Treatment into an HIV Primary Care Clinic Powered By Docstoc
					 Integrating Suboxone
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-
  centered goals.
      If they choose another form of

• They are referred to one of the in-house
  addiction service programs or directly to
  methadone clinic.

• They always have the option to discuss
  Suboxone treatment at a later date.
    Suboxone Induction:Prep
 Nurse facilitates completion of:

      in-depth education re:Suboxone treatment
      DSM-IV criteria evaluation
      substance abuse history
      labs (including tox screen)
      physical exam,
      reading/discussion/signing of pt. agreement
      releases of information
            Ongoing preparation

 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
  withdrawal symptoms.
• 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.
           Ongoing treatment
• 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
           with you.