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Buprenorphine Treatment in an Urban Community Health Center: What to Expect

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Buprenorphine Treatment in an Urban Community Health Center: What to Expect 500 July-August 2008 Family Medicine Clinical Research and Methods Buprenorphine Treatment in an Urban Community Health Center: What to Expect Chinazo Cunningham, MD, MS; Angela Giovanniello, PharmD; Galit Sacajiu, MD, MPH; Susan Whitley, MD; Pamela Mund, MD; Robert Beil, MD; Nancy Sohler, PhD, MPH Background: Despite new opportunities to expand buprenorphine treatment for opioid dependence, use of this treatment modality has been limited. Physicians may question their ability to success- fully treat opioid-dependent patients with buprenorphine in a primary care setting. We describe a buprenorphine treatment program and treatment outcomes in an urban community health center. Methods: We conducted retrospective chart reviews on the first 41 opioid-dependent patients treated with buprenorphine/naloxone. The primary outcome was 90-day retention in treatment. Results: Patients’ mean age was 46 years, 70.7% were male, 58.8% Hispanic, 31.7% black, 57.5% unemployed, and 70.0% used heroin prior to treatment. Twenty-nine (70.7%) patients were retained in treatment at day 90. Compared to those not retained, patients retained in treatment were more likely to have used street methadone (0% versus 37.9%) and less likely to have used opioid analgesics (54.6% versus 20.7%) and alcohol (50.0% versus 13.8%) prior to treatment. Of the 25 patients with urine toxicology tests, 24% tested positive for opioids. Conclusions: Buprenorphine treatment for opioid dependence in an urban community health center resulted in a 90-day retention rate of 70.7%. Type of substance use prior to treatment appeared to be associated with retention. These findings can help guide program development. (Fam Med 2008;40(7):500-6.) In the United States, the rates of opioid abuse and de- Despite this new treatment opportunity, prescription pendence have increased over the last several years.1-3 of buprenorphine by primary care clinicians has been However, until recently, treatment options for opioid limited.13,14 One potential reason for this limited use dependence have been limited. Although maintenance slow uptake may be physicians’ caution in adopting a pharmacotherapy with opioid agonists reduces adverse new treatment paradigm with drug users. Few studies consequences of opioid dependency,4-10 fewer than have been published that describe the use of buprenor- 20% of opioid-dependent individuals are enrolled in phine for treating opioid dependence outside of sub- substance abuse treatment programs.11,12 Recent legisla- stance abuse treatment settings or clinical trials (with tion and the Food and Drug Administration’s approval strict eligibility criteria and time-intensive treatment of buprenorphine (an oral long-acting partial opioid protocols). As such, physicians may question their abil- agonist) for treatment of opioid dependence have broad- ity to devote sufficient time to treating substance users ened treatment options for opioid-dependent patients. and be skeptical about the potential for buprenoprhine Physicians who obtain waivers to prescribe buprenor- treatment to be successful. Thus, resources that can help phine to treat opioid dependence can now prescribe physicians and health care administrators understand buprenophrine outside of restrictive substance abuse how bupreorphine treatment can be integrated into treatment settings. primary care settings without strict eligibility criteria or time-intensive protocols can be helpful in planning and guiding buprenorphine treatment in primary care settings. In this report, we describe treating opioid-dependent From the Montefiore Medical Center/Albert Einstein College of Medicine (Drs Cunningham, Giovanniello, Sacajiu, Whitley, Mund, and Beil); and patients with buprenorhine in a community health City University of New York Medical School (Dr Sohler). center in the Bronx, NY. Specifically, we describe Clinical Research and Methods Vol. 40, No. 7 501 the buprenorphine treatment program and treatment on-site support groups or substance abuse counselors. outcomes. Limited psychiatric and mental health counseling ser- vices were available; however, because these services Methods were funded by the Ryan White CARE Act, they were The Buprenorphine Treatment Program only offered to HIV-infected patients. Setting. Buprenorphine treatment for opioid depen- dence was initiated in a federally qualifiedcommunity Initial Visit. In the initial visit prior to starting bu- health center in the South Bronx. The neighborhood in prenorphine treatment, patients were educated about which the health center is located is one of the poorest buprenorphine/naloxone, standardized substance abuse in New York City, with 32%–46% of individuals living histories were taken, and laboratory tests were obtained. below the poverty line.15 Additionally, in this neighbor- The substance abuse history included questions about hood, deaths and hospitalizations from drug use and onset of drug use, heaviest drug use, route of drug use, HIV are among the highest in New York City.16 Of the and amount and frequency of drug use in the previous 15,000 patients at the community health center, the 30 days for heroin, opioid analgesics, “street” metha- majority are female and black or Hispanic. The study done, prescribed methadone, benzodiazepines, crack/ was approved by the Montefiore Medical Center insti- cocaine, marijuana, alcohol, and other drugs if appli- tutional review board. cable. Patients were asked about current and previous drug treatment, mental health diagnoses and treatment, Patients. Adult patients who presented to the health and social indicators. Laboratory tests included liver center between November 2004 and January 2007 function tests, a urine toxicology test, and a urine with opioid dependence (as defined by DSM-IV cri- pregnancy test if applicable. Eligible patients were teria17) were considered candidates for treatment with scheduled for induction with buprenorphine/naloxone buprenorphine and are included in this report. Patients within 1–2 days after the initial visit. from within and outside of the health center were iden- tified by health care providers, referred from outside Buprenorphine Induction and Stabilization. Bu- organizations, or self-identified. Self-referred patients prenorphine induction and stabilization occurred may have been informed about our program through through a joint effort between the physicians and word of mouth, Internet sites that provide information pharmacist. Providers monitored signs of opioid with- about buprenorphine treatment providers, or flyers/ drawal using a standardized clinical tool (the Clinical brochures placed in the community. In accordance Opiate Withdrawal Scale19) and adjusted buprenor- with the Center for Substance Abuse Treatment (CSAT) phine/naloxone doses accordingly (Figure 1). Because Guidelines,18 patients with certain conditions were of our team approach, visits and phone calls occurred considered to not be appropriate for buprenorphine with the physician only, the pharmacist only, or both treatment at the health center and were referred to a providers. Explicit counseling sessions were not of- substance abuse treatment center. These conditions in- fered at our health center, but psychosocial counseling cluded (1) pregnancy, (2) alcohol dependency as defined techniques (eg, motivational interviewing) were often by DSM-IV criteria, (3) benzodiazepine dependency as incorporated into medical visits. During the induction defined by DSM-IV criteria, (4) serum transaminase and stabilization process, buprenorphine/naloxone was levels more than five times the upper limit of normal, provided on-site by the pharmacist, who dispensed (5) current suicidal ideation, and (6) taking more than enough medication until the following visit. Patients 30 mg of methadone daily in a methadone maintenance were provided the physician’s and pharmacist’s after- program in the past 30 days. In November 2006, the hours contact information to facilitate ongoing commu- last criterion was changed to taking more than 60 mg nication during the induction and stabilization process. of methadone daily in a methadone program in the The induction period typically occurred on days 1–3 past 14 days. (day 1 represents the first day on which buprenorphine/ naloxone was taken), with patients reaching a stable Staffing. Four general internists worked closely with dose of buprenorphine/naloxone on days 4–7. a clinical pharmacist to screen, assess, induce, and maintain patients with buprenorphine treatment. Each Buprenorphine Maintenance. Once patients’ doses general internist was available in the health center on were stable, the frequency of their contacts with the a part-time basis, each providing care for 1–4 half days physician and pharmacist decreased. The use of urine per week. The clinical pharmacist was available 4 half toxicology tests varied between physicians and was days per week. Physicians were supported by routine guided by clinical judgment. Buprenorphine treat- patient care/billing, while the pharmacist was partially ment was never terminated because of results of urine supported by a grant. Although one social worker was toxicology tests. Early in the program, all maintenance available for all health center patients, there were no doses of buprenorphine/naloxone were dispensed by our 502 July-August 2008 Family Medicine pharmacist, but after physicians became more comfortable with buprenorphine Figure 1 treatment, they referred patients to com- munity pharmacies to obtain prescrip- Flow Chart of Buprenorphine
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