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Associate Professor of Medicine
Division of Infectious Disease
Department of Internal Medicine
Yale School of Medicine
New Haven, Connecticut
Section of Infectious Disease
Department of Internal
Veterans Administration Connecticut Healthcare Services
West Haven, Connecticut
Sandra Springer, MD, has disclosed that she has received consulting fees from Alkermes and DKB Med and fees for non-CME/CE services from DKB Med.
The ongoing opioid epidemic in the United States has driven multiple HIV outbreaks, as illustrated by the infamous 2015 outbreak of 181 new HIV infections linked to oxymorphone injection in Indiana. Among people without HIV infection, substance use increases the risk of acquiring HIV through condomless sex and using contaminated injection equipment. Among people with HIV, substance use is associated with decreased ART adherence and increased HIV-1 RNA, thereby increasing risk of HIV transmission.
Medication treatment for opioid use disorder (OUD) reduces the risks of HIV transmission, improves virologic suppression, and decreases the rates of opioid use, overdose, and death. Below, I offer guidance drawn from my clinical experience and recent recommendations from the National Academies of Sciences, Engineering, and Medicine on how to integrate screening, diagnosis, and medication treatment of OUD into routine infectious disease services.
Integrating OUD Management Into Infectious Disease Practice
Take the Initiative
First, be a champion by taking the lead to incorporate OUD management into your practice. Recall the example set by clinicians caring for those affected by the early HIV epidemic in the United States. In both epidemics, stigma presents a huge barrier to patients and clinicians. By providing leadership, you can inform others in your practice, provide support for those who are interested but unsure of how to proceed, and obtain buy-in from key stakeholders (eg, hospital directors).
Screen for OUD
Second, select one of the multiple free screening tools for OUD. My colleagues and I have developed the Rapid Opioid Dependency Screen that screens for moderate to severe OUD. Others include the NIDA Quick Screen with a reflex to NIDA-Modified ASSIST.
Select Treatment to Offer
Although there are no specific guidelines on tailoring medication treatment to patient characteristics, general guidelines are available from the American Society of Addiction Medicine (ASAM) and the Substance Abuse and Mental Health Services Administration (SAMHSA). However, there are legal restrictions on what you can provide in certain settings. Of the 3 key medications for OUD, only extended-release naltrexone requires no special licensing or waiver. Prescribing buprenorphine requires special training outside postgraduate programs and a waiver from the DEA, whereas methadone can only be administered in a federally licensed methadone clinic.
Extended-release naltrexone and buprenorphine are, thus, the most amenable to use in a primary care or infectious disease clinic. Along with considerations about training and waivers, deciding between these 2 treatments depends on underlying comorbidities, patient characteristics, and dosing considerations. For example, buprenorphine, as a partial μ agonist and partial κ antagonist, would be an option if the patient has chronic pain. Naltrexone, a full μ antagonist, would not be appropriate for pain conditions. The treatments also differ in how they are administered, with the formulations for buprenorphine including daily sublingual tablets/films, monthly injections, or implants lasting 6 months. Extended-release naltrexone is only available as a monthly injection.
Obtain a Waiver
Clinicians electing to provide buprenorphine should obtain buprenorphine X-waiver training. Training requires 8 hours for physicians and 24 hours for physician assistants and nurse practitioners; training can be obtained for free and conducted at your own pace online through the Providers Clinical Support System (PCSS) or ASAM.
Integrate OUD Management
When integrating OUD management into practice, many clinicians are concerned that they may cause a patient to go into withdrawal or that patients may divert their medication rather than taking it. Both SAMHSA and PCSS offer step-by-step guidance on assessing whether a patient is able to safely start medication at home, best practices for buprenorphine dosing during induction, and insights on comorbid pain management in a person with OUD. My colleagues and I have also published guidelines for comanagement of OUD and infectious diseases.
SAMHSA also offers free technical assistance to providers who want to treat OUD through the State Targeted Response Technical Assistance program, also known as the Opioid Response Network. This program provides education and training in evidence-based practices using local expertise in communities.
It is not clinically difficult to manage OUD; clinicians routinely manage more challenging conditions, from diabetes mellitus to chronic liver disease. In my own practice, I find that OUD is one of the most satisfying diseases I have ever managed. Not only can you make a difference in patients’ lives by reducing their risk of overdose, but by treating patients’ underlying OUD, you help them stabilize their lives to obtain employment, go to school, and reunify with family—all while successfully comanaging their HIV, HCV, and other infectious diseases.