Background

Persons living with HIV and unhealthy substance use are often less engaged in HIV care, have higher morbidity and mortality and are at increased risk of transmitting HIV to uninfected partners. We developed a quality-improvement tracking system at an urban methadone clinic to monitor patients along the HIV care continuum and identify patients needing intervention.

Objective

To evaluate patient outcomes along the HIV Care Continuum at an urban methadone clinic and explore the relationship of HIV primary care site and patient demographic characteristics with retention in HIV treatment and viral suppression.

Methods

We reviewed electronic medical record data from 2015 for all methadone clinic patients with known HIV disease, including age, gender, race, HIV care sites, HIV care visit dates and HIV viral load. Patients received either HIV primary care at the methadone clinic, an HIV specialty clinic located in the adjacent building, or a community clinic. Retention was defined as an HIV primary care visit in both halves of the year. Viral suppression was defined as an HIV viral load <40 copies/ml at the last lab draw.

Results

The population (n = 65) was 63% male, 82% age 45 or older and 60% non-Caucasian. Of these 65 patients 77% (n = 50) were retained in care and 80% (n = 52) were virologically suppressed. Viral suppression was significantly higher for women (p = .022) and patients 45 years or older (p = .034). There was a trend towards greater retention in care and viral suppression among patients receiving HIV care at the methadone clinic (93, 93%) compared to the HIV clinic (74, 79%) or community clinics (62, 62%).

Conclusions

Retention in HIV care and viral suppression are high in an urban methadone clinic providing integrated HIV services. This quality improvement analysis supports integrating HIV primary care with methadone treatment services for this at-risk population.

OBJECTIVES: Many cisgender women affected by homelessness and substance use desire pregnancy and parenthood. Provider discomfort with patient-centered counseling about reproductive choices and supporting reproductive decisions of these women poses barriers to reproductive healthcare access. METHODS: We used participatory research methods to develop a half-day workshop for San Francisco-based medical and social service providers to improve reproductive counseling of women experiencing homelessness and/or who use substances. Guided by a stakeholder group comprising cisgender women with lived experience and providers, goals of the workshop included increasing provider empathy, advancing patient-centered reproductive health communication, and eliminating extraneous questions in care settings that perpetuate stigma. We used pre/post surveys to evaluate acceptability and effects of the workshop on participants attitudes and confidence in providing reproductive health counseling. We repeated surveys one month post-event to investigate lasting effects. RESULTS: Forty-two San Francisco-based medical and social service providers participated in the workshop. Compared to pre-test, post-test scores indicated reduced biases about: childbearing among unhoused women (p < 0.01), parenting intentions of pregnant women using substances (p = 0.03), and women not using contraception while using substances (p < 0.01). Participants also expressed increased confidence in how and when to discuss reproductive aspirations (p < 0.01) with clients. At one month, 90% of respondents reported the workshop was somewhat or very beneficial to their work, and 65% reported increased awareness of personal biases when working with this patient population. CONCLUSIONS FOR PRACTICE: A half-day workshop increased provider empathy and improved provider confidence in reproductive health counseling of women affected by homelessness and substance use.

Background

Concomitant use of opioids and promethazine has been reported in various subpopulations, including methadone maintenance patients, injection drug users, and at-risk teenagers. Promethazine is thought to potentiate the "high" from opioids. However, to date, the prevalence of promethazine use has not been determined among patients prescribed opioids for chronic pain.

Methods

Urine samples from 921 patients prescribed opioids for chronic pain were analyzed for promethazine. Demographic data, toxicology results, and opioid prescription information were obtained through medical record abstraction. We assessed the prevalence and factors associated with promethazine use with bivariable and multivariable statistics.

Results

The prevalence of promethazine-positive urine samples among chronic pain patients was 9%. Only 50% of promethazine-positive patients had an active prescription for promethazine. Having benzodiazepine-positive urine with no prescription for a benzodiazepine was statistically associated with promethazine use. Also, having a prescription for methadone for pain or being in methadone maintenance for the treatment of opioid dependence were both statistically associated with promethazine use. Chronic pain patients prescribed only a long-acting opioid were more likely to have promethazine-positive urines than patients prescribed a short-acting opioid.

Conclusions

The study provides compelling evidence of significant promethazine use in chronic pain patients. Promethazine should be considered as a potential drug of abuse that could cause increased morbidity in opioid-using populations.

30-60% of patients receiving methadone for opioid use disorder (OUD) actively use cocaine. Cocaine use disorder (CUD) has no FDA-approved pharmacological treatment; existing psychosocial treatments are inadequate. Oxytocin, a social neuropeptide, has preclinical promise as an adjunctive treatment for both OUD and CUD. Twenty-two individuals receiving methadone for OUD with co-occurring CUD were randomized to receive oxytocin or placebo intranasally 40 IU twice daily for two weeks. A priori aims were feasibility and safety. Exploratory effectiveness aims included laboratory-based measures of drug craving, drug-related implicit cognition, and drug use. High retention rates (93.5%), the absence of study-related adverse events, and the fact that oxytocin was well tolerated in this population support the feasibility of larger trials. Two weeks of oxytocin (but not placebo) significantly reduced cocaine craving at day 15 compared to baseline (mean change±SD: OT=-0.23±0.19, p=0.004; PL=-0.16±0.29, p=0.114). For heroin craving, the placebo group reported a trend-level increase over time while the oxytocin group remained unchanged - with medium to large effect sizes between the groups (Cohen's d=0.71-0.90). Oxytocin led to a significant switch from implicit self-association with drugs to implicitly associating drugs with others (mean change±SD: 0.25±0.35, p=0.037) and a trend-level reduction in self-reported cocaine use over time (Z=-1.78, p=0.075). Furthermore, oxytocin significantly increased the accuracy of self-reported cocaine use when correlated with quantitative urine levels of cocaine metabolite. This proof-of-concept study provides promising early evidence that oxytocin may be an effective adjunct to the treatment of co-occurring CUD and OUD. Further investigation with larger trials is warranted.