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

500 July-August 2008 Family Medicine Clinical Research and Methods

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 services 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 dependence 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 identified 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 community pharmacies to obtain prescrip- Flow Chart of Buprenorphine Program tions. We considered treatment success to be retention in buprenorphine treatment at day 90 as confirmed by medical records.

Data We conducted retrospective chart reviews extracting demographic and clinical information on patients who received at least one dose of buprenorphine/naloxone between November 2004 and January 2007 at our community health center. Data were extracted from standardized substance abuse history forms, clinic visits, and laboratory tests. Because of our small sample size, we present frequencies of our variables and make inferences based on observed trends rather than relying on formal statistical significance testing.

Results Over the study period, 74 people in- quired about buprenorphine treatment. Four people were ineligible—one was not opioid dependent, one was taking >30 mg of methadone (prior to Novem- ber 2006), and two were taking >60mg of methadone (after November 2006). Twenty-nine eligible patients never returned for a full assessment or buprenorphine induction. The remaining 41 patients took at least one dose of buprenorphine/naloxone and are included in this report. The mean age of the patients was 46 years, and the majority of the patients were male (70.7%), Hispanic (58.8%) or black (31.7%), unemployed (57.5%), and had public health insurance (78.1%) (Table 1). The most common referral source for patients was providers within COWS—Clinical Opiate Withdrawal Scale19 our community health center (29.3%), followed by a nearby community-based * Buprenorphine Consensus Statement and unpublished data from VA/NIDA #1018 trial indicates organization/syringe exchange program that a first day dose of up to 16 mg can be administered. (19.5%), other sites within our affiliated For comprehensive guidelines on buprenorphine treatment, see: Center for Susstance Abuse academic medical center (17.1%), and Treatment. Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opoid Addiction. self-referral (17.1%). Treatment Improvement Protocol (TIP) Series 40. Available at http://buprenorphine.samhsa.gov/ Bup%20Guidelines.pdf. The majority of patients (70.0%) reported using heroin within 30 days prior to their initial visit. Other opioids used within 30 days prior to treatment in- Clinical Research and Methods Vol. 40, No. 7 503

cluded prescribed and street opioid analgesics (30.0%), street methadone (29.9%), and prescribed methadone Table 1 (27.5%). Other substances used prior to treatment included crack/cocaine (42.5%) and any alcohol (23.1%). Baseline and Treatment Characteristics of 41 The majority of patients had a history of injection drug Patients in the Buprenorphine Treatment Program use (56.4%) and positive antibodies to hepatitis C virus (52.5%). Thirteen (31.7%) were infected with HIV. Total Of the 41 patients who took at least one dose of bu- Baseline Characteristics n (%) Age (mean years + SD) 46.4 + 8.7 prenorphine/naloxone, 29 (70.7%) were induced at our Male 29 (70.7) community health center, and 12 were induced else- Race/ethnicity where (eg, in a hospital or drug treatment program). Of Hispanic 24 (58.5) those induced in our health center, the median number Non-Hispanic black 13 (31.7) of visits during the induction and stabilization period Non-Hispanic white 4 (9.8) (days 1–7) was three visits. For all patients, the median Insurance number of visits during the maintenance period (days Public insurance 32 (78.1) 8–90) was six visits. Private insurance 8 (19.5) The dosing of buprenorphine varied among patients. None 1 (2.4) In general, however, the majority of patients required Employed 17 (42.5) doses that were in the middle range of approved doses Referral source (maximum buprenorphine/naloxone dose recommend- Community health center 12 (29.3) ed is 32 mg/day). On day 1 of induction the median Community-based organization 8 (19.5) buprenorphine/naloxone dose was 8 mg, with 73.2% Affiliated academic health center 7 (17.1) of patients receiving a dose between 4–8 mg. On day Self 7 (17.1) 7 after stabilization, the median dose was 10 mg, with Methadone maintenance program 4 (9.8) 63.2% of patients receiving a dose between 8–16 mg. Other 3 (7.3) On day 90 (or last day of treatment if not retained), the Substance use* median dose was 12 mg, with 68.6% of patients receiv- Heroin 28 (70.0) ing a dose between 8–16 mg. Opioid analgesics 12 (30.0) Twenty-nine (70.7%) patients were retained in treat- Prescribed methadone 11 (27.5) ment at day 90. Twenty-five (61.0%) patients had at “Street” methadone 11 (29.0) least one urine toxicology test performed after starting Crack/cocaine 17 (42.5) buprenorphine treatment. Physicians’ practices varied Any alcohol 9 (23.1) with regard to urine toxicology tests: one tested 100% Ever injected drugs 22 (56.4) of patients, one tested 75.0%, one tested 41.2%, and one HIV infection 13 (31.7) tested no patients (but had treated only one patient). Of Hepatitis C Virus antibody positive 21 (52.5) these 25 patients with tests, most had two or more tests, with tests occurring at various intervals ranging from Buprenorphine Treatment Median number of visits day 2 to day 90. Of those with tests, 24% had at least Induction and stabilization (days 1-7) 3 (range=1–5) one test positive for opioids, and 64% had at least one Maintenance (days 8-90) 6 (range=0–17) test positive for any drug (opioids, cocaine, cannabi- Median buprenorphine/naloxone dose noids, benzodiazepines, barbiturates, phencyclidine). Induction (day 1) 8 mg (range=2–18 mg) The most common drugs present in positive tests were Stabilization (day 7) 10 mg (range=2–32 mg) cocaine (32.0%) and cannabinoids (28.0%). Maintenance† (day 90) 12 mg (range=1–32 mg) Compared to those not retained, patients retained Retained in treatment at day 90 29 (70.7) in treatment were more likely to have used street Urine toxicology test performed 25 (61.0) methadone (0% versus 37.9%, P<.05) and less likely Positive for opioids 6 (24.0) to have used opioid analgesics (54.6% versus 20.7%, Positive for any drug‡ 16 (64.0) P<.05) and alcohol (50.0% versus 13.8%, P<.05) prior to treatment (Table 2). Because of a few missing data points for some variables, denominators reflect the number of valid responses. * Self-reported substance use 30 days prior to initiation of buprenorphine Discussion treatment In an urban community health center, patients who † If patients were not in treatment at 90 days, then the last known dose sought treatment for opioid dependence with buprenor- after day 7 was recorded. ‡ Drugs tested included opioids, cocaine, cannabinoids, benzodiazepines, phine were predominantly male, from racial/ethnic mi- barbiturates, and phencyclidine. norities, and heroin users. Overall, the 90-day retention rate was 71%. Our data suggest that compared to those 504 July-August 2008 Family Medicine

16–28 contacts per person with the nurse case manager in the first month of treatment. Our Table 2 retention rate is a bit lower than those reported in clinical trials conducted in primary care Baseline and Treatment Characteristics settings.22-24 These studies had strict eligibility of 41 Patients Not Retained and Retained criteria (eg, no cocaine use), on-site dispens- in Buprenorphine Treatment ing of buprenorphine up to thrice weekly, and required one–three weekly counseling sessions. Not Retained in Retained in Retention rates in these trials were 78%–81% Buprenorphine Buprenorphine Treatment (n=12) Treatment (n=29) at 10–13 weeks. These types of programs with Baseline Characteristics n (%) n (%) strict eligibilty criteria and intense protocols Male 9 (75.0) 20 (69.0) may be difficult to implement in many primary Hispanic ethnicity 6 (50.0) 18 (62.1) care settings. Employed 2 (18.2) 15 (51.7) Our data suggest that retention rates may dif- Substance use* fer by type of substance use prior to initiating Heroin 9 (81.8) 19 (65.5) buprenorphine treatment. We found that reten- Opioid analgesics 6 (54.6) 6 (20.7) † tion rates were higher among those using street Prescribed methadone 3 (27.3) 8 (27.6) methadone and lower among those using opioid “Street” methadone 0 (0) 11 (37.9) † analgesics and any alcohol prior to starting bu- Crack/cocaine 6 (54.6) 11 (37.9) prenorphine. Based on our clinical experience, Any alcohol 5 (50.0) 4 (13.8) † we hypothesize that patients who were buying Ever injected drugs 6 (60.0) 16 (55.2) street methadone may have been “self-treating” HIV infection 6 (50.0) 7 (24.1) their opioid dependence. We believe this self- Buprenorphine treatment treatment signified the desire to reduce or stop Median buprenorphine/naloxone dose illicit opioid use but without guidance of health Induction (day 1) 8 mg 8 mg care providers. These patients who self-treated Stabilization (day 7) 10 mg 9 mg with street methadone may have been more Maintenance‡ (day 90) 12 mg 12 mg motivated than others to remain in a treatment Urine toxicology tests performed 5 (41.7) 20 (69.0) program that was specifically not a methadone Positive for opioids 1 (20.0) 5 (25.0) maintenance treatment program. Positive for any drug§ 4 (80.0) 12 (60.0) Our finding that individuals who used opioid analgesics prior to starting treatment were less All percentages signify column percentages. Because of a few missing data points for likely to be retained in treatment conflicts with some variables, denominators reflect the number of valid responses. findings of a few other studies.24-26 In these stud- * Self-reported substance use 30 days prior to initiation of buprenorphine treatment ies, opioid analgesic users differed from heroin † P<.05 users in demographic characteristics and drug ‡ If patients were not in treatment at 90 days, then the last known dose after day 7 was recorded treatment histories. Opioid analgesic users may § Drugs tested included opioids, cocaine, cannabinoids, benzodiazepines, barbiturates, represent a different type of opioid-dependent and phencyclidine. patient than heroin users. In our clinical experience, many patients who take opioid analgesics do not view their use as problematic, even with DSM-IV diagnoses of opioid dependence. not retained in buprenorphine treatment, those retained Although alcohol dependence was an exclusion crite- may be more likely to have used street methadone and rion, no patients were excluded for this reason. Howev- less likely to have used opioid analgesics and alcohol er, any alcohol use was associated with poor retention. prior to starting treatment. Of those with urine toxicol- With only nine patients who reported alcohol use, we ogy tests, 24% had evidence of ongoing opioid use. were unable to separately analyze those with heavy, Our 90-day retention rate of 71% is comparable to frequent, or binge drinking. Thus, alcohol use and its that in the few primary care-based buprenorphine treat- associated consequences should be further explored in ment programs previously described. Despite having research focusing on buprenorphine treatment. patients with a higher socioeconomic status, one bu- Although urine toxicology tests were performed prenorhpine program in Rhode Island reported a reten- in only 61% of patients after starting buprenorphine tion rate of 59% at 24 weeks.20 Another buprenorphine treatment, 24% tested positive for opioids. However, program treating homeless and primary care patients 64% of those tested had evidence of other drug use, in Boston had retention rates of 77%–93% at 3 months, the most common being cocaine and cannibinoids. Of respectively.21 However, in that program patients had the 16 individuals without urine toxicology tests, nine Clinical Research and Methods Vol. 40, No. 7 505 were retained in treatment and seven were not. Clearly, similar role with a nurse, nurse practitioner, or phar- we cannot be certain whether patients who did not macist may not be feasible. Despite these limitations, have urine toxicology tests used drugs or not. If all 16 our findings add to the scant literature published on patients continued using opioids, then the proportion of buprenophrine treatment outside of substance abuse patients with continued opioid use would be 54% (22 treatment settings and outside of strict, time-intensive of 41) instead of 24% (6 of 25). Thus, in a worst-case clinical trials. scenerio, we would still consider buprenorphine treatment moderately successful. Conclusions Although not ideal for our evaluation, the lack of sys- Buprenorphine treatment for opioid dependence in tematic collection of urine toxicology tests reflects pa- an urban community health center resulted in a 90-day tient care provided by different health care providers in retention rate of 71%. Type of substance use prior to the community. While obtaining urine toxicology tests starting buprenorphine treatment appeared to be associ- is mandatory for methadone maintenance treatment, it ated with retention rates. High retention was associated is not required for buprenorphine treatment. Physicians’ with street methadone use, and low retention was as- decisions on whether to obtain urine toxicology tests sociated with opioid analgesic and alcohol use prior to is complex and beyond the scope of this discussion. treatment. Of patients with urine toxicology tests, less Some may argue that ordering urine toxicology tests than one fourth had tests positive for opioids. Findings may undermine the patient-provider relationship due to from this evaluation can help physicians and health care confrontation and distrust. However, we believe that if administrators guide program development. handled in a sensitive way, obtaining urine toxicology tests can be one additional piece of important clinical Acknowledgments: This study was supported by the Health Resources and Services Administration, HIV/AIDS Bureau, Special Projects of National information that can help improve patient-provider Significance, Grant #6H97HA00247-04, and the Center for AIDS Research communication and patient care. at the Albert Einstein College of Medicine and Montefiore Medical Center While the clinical goal for many patients is to eventu- funded by the National Institutes of Health (NIH AI-51519). Dr Cunning- ham is supported by the Robert Wood Johnson Foundation’s Harold Amos ally achieve abstinence from opioid addiction, providers Medical Faculty Development Program. treating opioid addiction in the primary care setting These findings were presented, in part, at the 6th International Conference must recognize that reduction in opioid use should be on Urban Health, Amsterdam, Holland, October 2006. Conflicts of interest: Dr Whitley gives talks sponsored by Reckitt Benck- considered a positive outcome, even if abstinence is iser. All other authors have no conflicts of interest. not immediately achieved. In line with harm reduction principles, appropriate outcomes for many patients Corresponding Author: Address correspondence to Dr Cunningham, Mon- might include less opioid use, less injection drug use, tefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467. 718-944-3860. Fax: 718-944-3841. ccunning@ less criminal activity, and more engagment with the montefiore.org. health care system. Bringing opioid-dependent patients into primary care settings allows for more opportunities to treat or prevent associated chronic diseases such as Re f e r e n c e s HIV and/or hepatitis C virus infections. Further exa- 1. Crane E. Narcotic analgesics. The Drug Abuse Warning Network mation into the potential benefits of related outcomes (DAWN) Report, 2003. http://oas.samhsa.gov/2k3/pain/DAWNpain. pdf. Accessed November 18, 2007. of buprenorphine treatment in the primary care setting 2. Office of National Drug Control Policy (ONDCP). Drug Policy Infor- is warranted. mation Clearinghouse. Heroin fact sheet, 2003. www.streetdrugs.org/ pdf/Heroin2.pdf. Accessed November 18, 2007. 3. Substance Abuse and Mental Health Services Administration. Office of Limitations Applied Studies. Emergency department trends from the Drug Abuse There are limitations to our evaluation. Our sample Warning Network, final estimates 1995–2002. Rockville, Md: DAWN size is small, which reflects the slow uptake of bu- Series: D-24, DHHS publication no. (SMA) 03-3780, 2003. http:// 13,14 dawninfo.samhsa.gov/old_dawn/pubs_94_02/edpubs/2002final/files/ prenorphine noted in previous studies. Because of EDTrendFinal02AllText.pdf. Accessed November 18, 2007. this we were unable to fully examine factors associated 4. Kakko J, Svanborg KD, Kreek MJ, Heilig M. One-year retention and with retention in treatment due to limited power. In social function after buprenorphine-assisted relapse prevention treatment for heroin dependence in Sweden: a randomised, placebo-controlled addition, because our study was a retrospective chart trial. Lancet 2003;361(9358):662-8. review, we were unable to collect data that were not 5. Effective medical treatment of opiate addiction. National Consensus systematically recorded in medical records, which may Development Panel on Effective Medical Treatment of Opiate Addic- tion. JAMA 1998;280(22):1936-43. be associated with treatment retention. Finally, similar 6. Ball JC, Ross A. The effectiveness of methadone maintenance treatment: to other buprenorhpine treatment models based in pri- patients, programs, services, and outcome. New York: Springer-Verlag, mary care settings,25,26 a critical part of our program 1991. 7. Fiellin DA, O’Connor PG. Clinical practice. Office-based treatment of is our partially grant-funded pharmacist. Although opioid-dependent patients. N Engl J Med 2002;347(11):817-23. many buprenorphine treatment models in primary care 8. Fudala PJ, Bridge TP, Herbert S, et al. Office-based treatment of opiate settings have a dedicated nurse in a role similar to our addiction with a sublingual-tablet formulation of buprenorphine and pharmacist, in many primary care settings, filling a naloxone. N Engl J Med 2003;349(10):949-58. 506 July-August 2008 Family Medicine

9. Sees KL, Delucchi KL, Masson C, et al. Methadone maintenance 18. Center for Substance Abuse Treatment. Clinical guidelines for the versus 180-day psychosocially enriched detoxification for treatment use of buprenorphine in the treatment of opioid addiction. Treatment of opioid dependence: a randomized controlled trial. JAMA 2000; Improvement Protocol (TIP) Series 40. DHHS publication no. (SMA) 283(10):1303-10. 04-3939. Rockville, Md: Substance Abuse and Mental Health Services 10. Johnson RE, Chutuape MA, Strain EC, Walsh SL, Stitzer ML, Bigelow Administration, 2004.http://buprenorphine.samhsa.gov/Bup%20Guide- GE. A comparison of levomethadyl acetate, buprenorphine, and metha- lines.pdf. Accessed February 5, 2007. done for opioid dependence. N Engl J Med 2000; 343(18):1290-7. 19. Wesson DR, Ling W. The Clinical Opiate Withdrawal Scale (COWS). 11. O’Connor PG, Fiellin DA. Pharmacologic treatment of heroin-dependent J Psychoactive Drugs 2003;35(2):253-9. patients. Ann Intern Med 2000;133(1):40-54. 20. Stein MD, Cioe P, Friedmann PD. Buprenorphine retention in primary 12. Executive Office of the President, Office of National Drug Control care. J Gen Intern Med 2005;20(11):1038-41. Policy. Consultation document on opioid agonist treatment, 2003. www. 21. Alford DP, LaBelle CT, Richardson JM, et al. Treating homeless opioid whitehousedrugpolicy.gov/science%5Ftech/methadone/metha3.html. dependent patients with buprenorphine in an office-based setting. J Gen Accessed November 18, 2007. Intern Med 2007;22(2):171-6. 13. Kissin W, McLeod C, Sonnefeld J, Stanton A. Experiences of a na- 22. Fiellin DA, Pantalon MV, Pakes JP, O’Connor PG, Chawarski M, tional sample of qualified addiction specialists who have and have not Schottenfeld RS. Treatment of heroin dependence with buprenorphine prescribed buprenorphine for opioid dependence. J Addict Dis 2006; in primary care. Am J Drug Alcohol Abuse 2002;28(2):231-41. 25(4):91-103. 23. O’Connor PG, Oliveto AH, Shi JM, et al. A randomized trial of bu- 14. Cunningham CO, Kunins HV, Roose RJ, Elam RT, Sohler NL. Barriers to prenorphine maintenance for heroin dependence in a primary care obtaining waivers to prescribe buprenorphine for opioid addiction treat- clinic for substance users versus a methadone clinic. Am J Med 1998; ment among HIV physicians. J Gen Intern Med 2007; 22(9):1325-9. 105(2):100-5. 15. Karpati A, Kerker B, Mostashari F, et al. Health disparities in New 24. Sullivan LE, Barry D, Moore BA, et al. A trial of integrated buprenor- York City. New York: New York City Department of Health and Mental phine/naloxone and HIV clinical care. Clin Infect Dis 2006;43(suppl Hygiene, 2004. www.nyc.gov/html/doh/downloads/pdf/epi/dispari- 4):S184-S190. ties-2004.pdf. Accessed November 18, 2007. 25. Basu S, Smith-Rohrberg D, Bruce RD, Altice FL. Models for integrating 16. Olson EC, Van Wye G, Kerker B, Thorpe L, Frieden TR. Take care buprenorphine therapy into the primary HIV care setting. Clin Infect Highbridge and Morrisania. NYC community health profiles, second Dis 2006;42(5):716-21. edition. www.nyc.gov/html/doh/downloads/pdf/data/2006chp-106.pdf. 26. Sullivan LE, Bruce RD, Haltiwanger D, et al. Initial strategies for Accessed February 3, 2007. integrating buprenorphine into HIV care settings in the United States. 17. Diagnostic and statistical manual of mental disorders, fourth edition. Clin Infect Dis 2006;43(suppl 4):S191-S196. Washington, DC: American Psychiatric Association, 1994.