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There Is No Better Time: Integrating Opioid Use Disorder Treatment in HCV and HIV Care

Chinazo Cunningham, MD, MS

Professor of Medicine
Department of Medicine
Albert Einstein College of Medicine
Attending Physician
Department of Medicine
Montefiore Health System
Bronx, New York

Chinazo Cunningham, MD, MS, has no relevant conflicts of interest to report.

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Tiffany Lu, MD, MS

Assistant Professor of Medicine
Division of General Internal Medicine
Department of Medicine
Albert Einstein College of Medicine
Attending Physician
Comprehensive Family Care Center
Montefiore Medical Center
Bronx, New York

Tiffany Lu, MD, MS, has no relevant conflicts of interest to report.

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Released: October 22, 2020

Treatment for opioid use disorder (OUD) saves lives. In parallel with the opioid epidemic, hepatitis C virus (HCV) and HIV outbreaks have ravaged through communities with high rates of opioid overdose. More recently, during the COVID-19 pandemic, spikes in opioid overdoses have been reported in at least 30 states. HCV and HIV clinicians have been on the frontlines of these colliding epidemics—we routinely care for patients with comorbid HCV, HIV, and OUD. How do we begin to integrate life-saving treatment for OUD in our practices?

The first step to integrating OUD treatment into HCV and HIV care is to understand the treatment options that can be effectively delivered in outpatient care. There are 3 FDA-approved medications that treat OUD: methadone, buprenorphine, and naltrexone. These medications are the cornerstone of OUD treatment because they act on the neurobiologic circuits that underlie the chronic illness of OUD. In particular, methadone and buprenorphine are opioid agonist medications that have been rigorously evaluated in clinical trials and real-world settings to decrease overdose mortality, reduce OUD-related complications, and improve quality of life. Moreover, providing methadone or buprenorphine treatment for people with HCV and/or HIV is associated with improved HCV/HIV treatment outcomes as well as OUD outcomes. Offering medication treatment for OUD is, therefore, a win–win for HCV and HIV care.

In most clinical settings, buprenorphine is the main treatment option that should be offered for patients with OUD. Unlike methadone treatment (which can only be delivered in specialized opioid treatment programs), buprenorphine treatment can be delivered with minimal regulatory barriers. To prescribe buprenorphine, clinicians only need to complete required training and apply to the DEA for a waiver. Buprenorphine waiver trainings are free and can be easily accessed online, with either live in-person or virtual components. Naltrexone treatment, on the other hand, does not require clinicians to obtain a waiver. However, widespread use of this opioid antagonist medication for OUD treatment is limited by its pharmacologic properties. To start extended-release naltrexone for OUD, patients need to be completely abstinent from opioids, which can significantly complicate the treatment initiation process. Therefore, clinicians should be mindful of regulations around treatment delivery and differences in pharmacology when offering OUD treatment.

The next step is to take an inventory of OUD treatment resources within and outside of your treatment setting; it is not necessary to start from scratch when integrating OUD treatment. HCV and HIV clinicians should take advantage of comprehensive treatment guidelines and high-yield clinical tools that support OUD treatment. For example, the New York State Department of Health AIDS Institute has put forth treatment guidelines on substance use disorder treatment and harm reduction with a focus on primary care and outpatient settings. Implementation guides and other clinical tools such as buprenorphine treatment visit templates, treatment agreements, and urine drug testing guides are also available online. Substance use disorder treatment programs located in our communities can also be identified by tapping into local referral systems or through public directories. Intensive psychosocial counseling should not be a prerequisite for patients to receive OUD treatment. However, some patients, particularly those with unstable social conditions or co-occurring substance use disorders, may benefit from participation in counseling. Adapting existing guidelines and tools while leveraging community referral resources is essential.

Finally, clinicians would do well to remember that harm reduction is at the core of why we provide HCV and HIV care—and providing OUD treatment is no different. Engaging patients with OUD to discuss their individual treatment goals and map out steps toward reducing or stopping illicit opioid use takes time and rapport. Because OUD is a chronic disease, most patients will encounter setbacks during the course of their treatment; it is not uncommon for people to drop out of OUD treatment only to re-engage at another time in their lives. Offering to initiate medication treatment for OUD is a concrete first step all clinicians can take, especially when weighing the risks of overdose mortality. In the long run, keeping the door open for transparent and supportive treatment discussions is the key to treating OUD. This is, after all, in our wheelhouse as HCV and HIV clinicians who are already engaging patients in harm reduction for risk behaviors. There is no better time than now for us to step up and integrate OUD treatment into our clinical practices.

Your Thoughts
What are your thoughts about integrating OUD care into your HCV and/or HIV practice? Are there specific barriers that have made this process challenging and how have you overcome them? Please join the conversation and share your experiences in the comments box.

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