Portland, Ore.
Five-year effort calls for Portland HIV clinics to offer buprenorphine therapy, counseling
Portland Integrates Care for Opioid-Dependent HIV/AIDS Patients, or PICODAP, is a collaboration of state and local agencies to test the integration of opiate dependency treatment, including substance abuse counseling and treatment with the drug buprenorphine, with HIV care for opiate-addicted patients. The U.S. Department of Health and Human Services' Health Resources and Services Administration HIV/AIDS Bureau is providing the grant over five years as a Special Projects of National Significance program.
"Addiction to opiates like heroin and prescription pain medicines, remains a critical problem in Portland, like most cities, and folks who are struggling with this addiction are the least likely to be in a position to have their medical needs met by the current health care system," said P. Todd Korthuis, M.D., M.P.H., assistant professor of medicine (general internal medicine and geriatrics), OHSU School of Medicine.
PICODAP offers "a way to treat a very complex, difficult illness in a patient-friendly environment," said Korthuis, director of the OHSU HIV Program. "It's a movement away from compartmentalizing treatment and a move toward integrated, holistic health care."
David Pollack, M.D., professor of psychiatry, OHSU School of Medicine, and medical director of the Office of Mental Health & Addiction Services, Oregon Department of Human Services, one of PICOCAP's partner agencies, said the project will respond to demand among local and state substance abuse service agencies for an expansion in the use of buprenorphine for treating opiate addiction.
"This project has particular appeal since it focuses on a very difficult group to treat, persons with HIV who are also opiate dependent, for whom harm reduction and rehabilitation would be very important to improve health and quality of life, as well as to reduce overall medical costs for their care," Pollack said.
Two models of opiate care will be tested at three Portland clinics: an integrated model, in which patients receive buprenorphine treatment and substance abuse counseling at either the OHSU HIV Clinic or the Multnomah County HIV Health Services Center; and a traditional model, in which patients are given buprenorphine and counseling at CODA Inc., a nonprofit drug and alcohol abuse treatment and prevention organization, but receive HIV care at OHSU or Multnomah County.
Researchers will measure patient outcomes, including medication adherence, attendance in substance abuse counseling, and health outcomes. They also will examine staff perceptions, policy changes and challenges of integrating buprenorphine treatment into the clinic. Each site will have a "change team" comprised of a physician, a nurse, a counselor and a patient advocate that will be in charge of integrating the buprenorphine program into each clinic.
CODA, which offers a methadone program, will distribute buprenorphine according to federal guidelines for methadone.
Korthuis and other investigators want to curb a steady rise in the numbers of Portland-area residents living with HIV and AIDS, to which opiate addiction is closely linked, Korthuis said.
Persons with a history of intravenous drug use represent the Portland-metro area's second-largest group of people living with AIDS or HIV. They accounted for 22.7 percent of new HIV-AIDS cases through 2002. While intravenous drug use is prevalent in all counties in the metropolitan area, it is most prevalent in Multnomah County: .9 percent of the county's 18-and-older residents - 4,456 people - abuse or are addicted to opiates, according to a 2000 state DHS report.
Between 1999 and 2002, AIDS cases increased 21.6 percent. According to the Oregon Department of Human Services, by Dec. 31, 2002, an estimated 1,969 individuals in the Portland-metropolitan area were living with AIDS and 2,281 individuals had HIV infection without AIDS.
Suboxone (buprenorphine combined with naloxone), manufactured by Reckitt Benckiser PLC of Berkshire, United Kingdom, received U.S. Food and Drug Administration approval in 2002. It is the first drug approved for treatment of opiate dependency by primary care doctors. Methadone, which also is effective for treating opiate dependence, must be given under strict supervision in approved substance abuse treatment centers.
At low doses, buprenorphine produces an opiate-like effect that enables opioid-addicted individuals to discontinue the misuse of heroin or prescription narcotics without experiencing withdrawal symptoms. The effects reach a plateau at moderate doses, leading to lower risk of abuse, addiction and side effects compared to methadone.
"Buprenorphine offers a powerful tool to everyday doctors to help patients with addiction," Korthuis said. "Our hope is that by integrating substance abuse treatment with primary care, patients will experience the best of both worlds."
And there are other, more societal benefits to buprenorphine therapy, Pollack said.
"There is much less stigma associated with getting care for opiate addiction as compared with the traditional methadone clinics, as well as less exposure to more hard-core addicts and dealers, leading to potential reductions in relapse and/or exploitation by others," he said.