Aaron D. Fox

A Description of an Urban Transitions Clinic Serving Formerly Incarcerated People

Chronic health conditions are overrepresented among jail or prison inmates but often go untreated during incarceration and following release. We describe the Bronx Transitions Clinic, a partnership between a community-based organization and an academic medical center, which facilitates connections to medical care for formerly incarcerated people.

Pain is not associated with worse office-based buprenorphine treatment outcomes.

Physical pain is common among individuals seeking treatment for opioid dependence. Pain may negatively impact addiction treatment. The authors prospectively studied opioid-dependent individuals initiating office-based buprenorphine treatment, comparing buprenorphine treatment outcomes (treatment retention and opioid use) among participants with and without pain (baseline pain or persistent pain). Among 82 participants, 60% reported baseline pain and 38% reported persistent pain. Overall, treatment retention was 56% and opioid use decreased from 89% to 26% over 6 months. In multivariable analyses, the authors found no association between pain and buprenorphine treatment outcomes. Opioid-dependent individuals with and without pain can achieve similar success with buprenorphine treatment.

Buprenorphine Treatment Outcomes among Opioid-Dependent Cocaine Users and Non-users

BACKGROUND AND OBJECTIVES National treatment guidelines state that polysubstance users, including cocaine users, may not be appropriate candidates for office-based buprenorphine treatment. However, data to support this recommendation are sparse and conflicting, and the implications of this recommendation may include limiting the usefulness of buprenorphine treatment, as cocaine use is common among opioid-dependent individuals seeking buprenorphine treatment. We compared buprenorphine treatment outcomes (6-month treatment retention and self-reported opioid use over 6 months) in opioid-dependent cocaine users versus non-users who initiated buprenorphine treatment at an urban community health center. METHODS We followed 87 participants over 6 months, collecting interview and medical record data. We used logistic regression models to test whether baseline cocaine use was associated with treatment retention and mixed effects nonlinear models to test whether baseline cocaine use was associated with self-reported opioid use. RESULTS At baseline, 39.1% reported cocaine use. In all participants, self-reported opioid use decreased from 89.7% to 27.4% over 6 months, and 6-month treatment retention was 54.5%. We found no significant difference in 6-month treatment retention (AOR = 1.56, 95% CI: .58-4.17, p = .38) or self-reported opioid use (AOR = .89, 95% CI: .26-3.07, p = .85) between cocaine users and non-users. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE This study demonstrates that buprenorphine treatment retention is not worse in cocaine users than non-users, with clinically meaningful improvements in self-reported opioid use. These findings suggest that opioid-dependent cocaine users attain considerable benefits from office-based buprenorphine treatment and argue for the inclusion of these patients in office-based buprenorphine treatment programs.

“I Kicked the Hard Way. I Got Incarcerated.” Withdrawal from Methadone During Incarceration and Subsequent Aversion to Medication Assisted Treatments

Incarceration is a common experience for individuals with opioid use disorder, including those receiving medication assisted treatments (MAT), such as buprenorphine or methadone. In the United States, MAT is rarely available during incarceration. We were interested in whether challenges with methadone maintenance treatment during incarceration affected subsequent attitudes toward MAT following release. We conducted semi-structured interviews with 21 formerly incarcerated individuals with opioid use disorder in community substance abuse treatment settings. Interviews were audio recorded, transcribed, and analyzed using a grounded theory approach. Themes that emerged upon iterative readings of transcripts were discussed by the research team. The three main themes relating to methadone were: 1) rapid dose reduction during incarceration; 2) discontinuity of methadone during incarceration; and 3) post incarceration aversion to methadone. Participants who received methadone maintenance treatment prior to incarceration reported severe and prolonged withdrawal symptoms from rapid dose reductions or disruption of their methadone treatment during incarceration. The severe withdrawal during incarceration contributed to a subsequent aversion to methadone and adversely affected future decisions regarding reengagement in MAT. Though MAT is the most efficacious treatment for opioid use disorder, current penal policy, which typically requires cessation of MAT during incarceration, may dissuade individuals with opioid use disorder from considering and engaging in MAT after release from incarceration.

The Hepatitis C virus treatment cascade at an urban postincarceration transitions clinic.

Transitions clinics, which provide medical care to individuals who have been released from incarceration, reach a population at high risk for hepatitis C Virus (HCV) infection. We used the HCV treatment cascade to describe HCV care at an urban postincarceration transitions clinic, identifying gaps in care and determining reasons for lapses in care. In this retrospective cohort study, we reviewed electronic health records for all formerly incarcerated individuals receiving care at the Bronx Transitions Clinic. HCV treatment cascade measures included the following: detection of HCV antibodies, confirmation of chronic infection, specialist referral, specialist evaluation, initiation of treatment, completion of treatment and achievement of SVR. We recorded reasons for lapses in care. Of 451 patients accessing care, 317 (70%) were screened for HCV antibodies, and 106 (33%) tested positive. Of the 106 antibody‐positive patients, 93 (88%) were evaluated for HCV viremia and 84 (79%) were confirmed to have chronic HCV infection; 19% of the total sample had chronic HCV infection. Of these 84 with chronic HCV, 48 (57%) received specialist referral, 30 (36%) were evaluated, 8 (10%) initiated treatment, and 5 (6%) completed treatment and achieved SVR. Some treatment lapses occurred because patients were deemed unstable for treatment (12%) or were re‐incarcerated (5%). Chronic HCV infection was common among transitions clinic patients. Few were treated and cured. Patients lost contact with providers before consideration for antiviral therapy. Referral to specialty providers was a gap in care. Increasing HCV treatment in this population will likely require intensive delivery models.

Harm Reduction Agencies as a Potential Site for Buprenorphine Treatment

BACKGROUND Harm reduction agencies complement addiction treatment by providing diverse services that improve the health of people who use drugs. Buprenorphine maintenance treatment (BMT) is an effective opioid addiction treatment that may be provided from flexible settings, potentially including harm reduction agencies. This study investigated attitudes toward different potential sites for BMT (harm reduction agencies, general medical clinics, and drug treatment programs) among harm reduction clients. METHODS Using computer-based interviews, participants indicated preferred potential site for BMT (harm reduction agency, drug treatment program, or general medical clinic), interest in BMT by potential site, motivation for treatment, and barriers to BMT. Multivariable logistic regression was used to determine factors associated with harm reduction agency preference. RESULTS Of 102 opioid users, the most preferred potential site for BMT was a harm reduction agency (51%), whereas fewer preferred general medical clinics (13%), drug treatment programs (12%), or were not interested in BMT (25%). In multivariable analysis, experiencing ≥1 barrier to BMT was strongly associated with preferring harm reduction agencies (adjusted odds ratio [aOR] = 3.39, 95% confidence interval [CI]: 1.00-11.43). CONCLUSIONS The potential to initiate BMT at harm reduction agencies is highly favorable among harm reduction clients, especially among those experiencing barriers to BMT. Offering BMT at harm reduction agencies could improve access to treatment, but studies are needed to determine safety and efficacy of this approach.

History of Solitary Confinement Is Associated with Post-Traumatic Stress Disorder Symptoms among Individuals Recently Released from Prison

This study assessed the relationship between solitary confinement and post-traumatic stress disorder (PTSD) symptoms in a cohort of recently released former prisoners. The cross-sectional design utilized baseline data from the Transitions Clinic Network, a multi-site prospective longitudinal cohort study of post-incarceration medical care. Our main independent variable was self-reported solitary confinement during the participants’ most recent incarceration; the dependent variable was the presence of PTSD symptoms determined by primary care (PC)-PTSD screening when participants initiated primary care in the community. We used multivariable logistic regression to adjust for potential confounders, such as prior mental health conditions, age, and gender. Among 119 participants, 43% had a history of solitary confinement and 28% screened positive for PTSD symptoms. Those who reported a history of solitary confinement were more likely to report PTSD symptoms than those without solitary confinement (43 vs. 16%, p < 0.01). In multivariable logistic regression, a history of solitary confinement (OR = 3.93, 95% CI 1.57–9.83) and chronic mental health conditions (OR = 4.04, 95% CI 1.52–10.68) were significantly associated with a positive PTSD screen after adjustment for the potential confounders. Experiencing solitary confinement was significantly associated with PTSD symptoms among individuals accessing primary care following release from prison. Larger studies should confirm these findings.

Recent incarceration and buprenorphine maintenance treatment outcomes among human immunodeficiency virus–positive patients

ABSTRACT Background: Opioid use disorder is a common cause of morbidity and mortality among people living with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS). Buprenorphine maintenance treatment (BMT) is an effective means of therapy, but patients with recent criminal justice involvement may need more support during BMT than other patients. The authors hypothesized that recently incarcerated BMT patients who initiated treatment in primary care would have poorer treatment outcomes than those who were not recently incarcerated. Methods: Investigators analyzed data from a multisite cohort study of BMT integrated into HIV care. Patients were stratified by self-reported incarceration in the 30 days before initiation of BMT. The outcomes of interest were 6- and 12-month treatment retention and self-reported opioid use. Investigators used multivariable logistic regression and hierarchical linear model, respectively, to evaluate the association between recent incarceration and these outcomes while adjusting for potential confounding variables. Results: Among 305 BMT patients living with HIV/AIDS, 39 (13%) reported recent incarceration. Patients with recent incarceration (vs. without) were more likely to be homeless, unemployed, and previously diagnosed with mental illness. Recent incarceration was not significantly associated with differences in 6-month (odds ratio [OR] = 0.95; 95% confidence interval [CI] = 0.46–1.98) and 12-month (OR = 0.57; 95% CI = 0.27–1.18) treatment retention or in self-reported opioid use (OR = 0.99; 95% CI = 0.51–1.92) after adjustment for potential confounding variables. Conclusions: Those with incarceration in the 30 days prior to BMT initiation were more likely to be homeless, unemployed, and previously diagnosed with mental illness than those without recent incarceration. However, no significant difference in self-reported opioid use or 6-month or 12-month retention in treatment was detected between those with and without recent incarceration. Future studies should confirm these findings with larger sample sizes. Encouraging formerly incarcerated individuals with opioid use disorder to initiate evidence-based treatments, including BMT, should be part of efforts to confront the opioid addiction epidemic in the United States.

Development and evaluation of a community-based buprenorphine treatment intervention

BackgroundThe majority of Americans with opioid use disorder remain out of treatment. Operating in 33 states, Washington DC, and Puerto Rico, harm reduction agencies, which provide sterile syringes and other health services to people who inject drugs, are a key venue to reach out-of-treatment opioid users. Aiming to link out-of-treatment individuals with opioid use disorder to buprenorphine treatment, we developed a community-based buprenorphine treatment (CBBT) intervention in collaboration with New York City harm reduction agencies.MethodsIntervention development included formative data collection, feasibility testing at one harm reduction agency, and pilot testing for preliminary effectiveness at a second harm reduction agency. We used a pre-post design for both feasibility and pilot testing. In the CBBT intervention, we trained harm reduction agency staff to provide (1) buprenorphine education, (2) motivational interviewing, (3) referrals to buprenorphine-prescribing doctors, and (4) treatment retention support. We assessed feasibility by measuring staff satisfaction with the intervention and changes in knowledge about buprenorphine. We assessed preliminary effectiveness by comparing rates of buprenorphine initiation among groups of harm reduction agency clients before and after intervention implementation.ResultsAmong staff members at the first harm reduction agency, knowledge increased from 52% correct answers pre-intervention to 79% correct post-intervention. Among clients at the second harm reduction agency, initiation of buprenorphine treatment was low and did not differ between pre- and post-intervention groups.ConclusionsThe CBBT intervention was feasible and well-received, but initiation of buprenorphine treatment among harm reduction agency clients was low. More robust interventions may be necessary to increase initiation of buprenorphine treatment.

Optimizing psychosocial support during office-based buprenorphine treatment in primary care: Patients' experiences and preferences

BACKGROUND Buprenorphine maintenance treatment is effective and has been successfully integrated into human immunodeficiency virus (HIV) and primary care settings. However, one key barrier to providers prescribing buprenorphine is their perception that they are unable to provide adequate counseling or psychosocial support to patients with opioid addiction. This qualitative study investigated supportive elements of office-based buprenorphine treatment that patients perceived to be most valuable. METHODS The authors conducted five focus groups with 33 buprenorphine treatment-experienced participants. Focus groups were audio-recorded and transcribed. Iterative readings of transcripts and grounded theory analysis revealed common themes. RESULTS Overall, participants perceived that buprenorphine treatment helped them to achieve their treatment goals and valued the flexibility, accessibility, and privacy of treatment. Participants identified interpersonal and structural elements of buprenorphine treatment that provided psychosocial support. Participants desired good physician-patient relationships, but also valued care delivery models that were patient-centered, created a safe place for self-disclosure, and utilized coordinated team-based care. CONCLUSIONS Participants derived psychosocial support from their prescribing physician, but were also open to collaborative or team-based models of care, as long as they were voluntary and confidential. Buprenorphine-prescribing physicians without access to referral options for psychosocial counseling could focus on maintaining nonjudgmental attitudes and shared decision-making during patient encounters. Adding structure and psychosocial support to buprenorphine treatment through coordinated team-based care also seems to have great promise.