Our nation is in the midst of an epidemic of opioid overdose deaths. The common use of opioids among persons living with HIV (PLWH), along with their common use of benzodiazepines, has resulted in high rates of opioid overdose among PLWH.3 Ideally, HIV physicians would provide effective office-based opioid treatment (OBOT) to reduce drug use and overdose mortality,4-6 but HIV physicians have been reluctant to adopt buprenorphine/naloxone (Bup/Nx).7 The current study posits that HIV physicians, who have been battling AIDS-related mortality for years, will find prevention of overdose death through naloxone prescription (NxP) more compelling, more trainable and less complex.8 Beginning with NxP, the current project will utilize academic detailing with motivational interviewing (MI) to encourage HIV physicians to accept a larger role in treating the primary disease (opioid addiction) with office-based Bup/Nx. In a stepped wedge design, the proposed study will implement NxP and OBOT in 20 HIV practice settings that receive Ryan White Funding; treat adults; have 4 or more prescribers; have an electronic medical record (EMR); and come from states in the top half nationally for opioid overdose deaths. The implementation will roll-out sequentially among randomly-selected eligible practices in three 9-month phases. The implementation strategy will include (1) a 1.5-hour, onsite peer-to-peer training with continuing medical education credits provided that will focus on saving lives through NxP and introduce the idea that office-based medication is available to treat the primary disease (opioid addiction) in their office; (2) expert mentoring and technical support for the physicians and practice; (3) academic detailing by a clinician trained in MI at 1, 3, 5 and 7 months after the initial training; and (4) pharmacist peer-to-peer outreach to local pharmacies to ensure that the medications are available. Primary outcomes drawn from implementation science will be feasibility, acceptability, readiness and intent to prescribe naloxone and Bup/Nx from surveys 9, 18, and 27 months into the active implementation phase, and at nine month follow-up; number of clinicians prescribing naloxone and Bup/Nx (i.e. uptake); and number of patients prescribed naloxone or Bup/Nx (i.e. penetration) from EMR data. Formative evaluation will examine implementation facilitators and barriers in qualitative interviews. HIV outpatient practices are promising settins in which to implement naloxone to reduce overdose and Bup/Nx to treat opioid use disorders. Using peer-to-peer physician training, proactive expert support, academic detailing with motivational interviewing, and pharmacy outreach, this innovative proposal will leverage the primary value of saving lives to implement naloxone prescription among HIV physicians and increase their motivation to adopt office-based Bup/Nx treatment.
Our nation is in the midst of an epidemic of opioid overdose deaths, and persons living with HIV have high rates of opioid overdose. This innovative proposal will test peer-to-peer physician training, proactive expert support, academic detailing with motivational interviewing, and pharmacy outreach to implement naloxone prescription and buprenorphine treatment in HIV outpatient settings. If successful, it will provide a model to facilitate access to overdose prevention and effective office-based opioid treatment for persons living with HIV.
|Hunter, Sarah B; Schwartz, Robert P; Friedmann, Peter D (2016) Introduction to the Special Issue on the Studies on the Implementation of Integrated Models of Alcohol, Tobacco, and/or Drug Use Interventions and Medical Care. J Subst Abuse Treat 60:1-5|