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Integrating Suboxone Treatment into an HIV Primary Care Clinic

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					 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
  study.
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
                treatment…

• 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
  problems.
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.

				
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