Case Studies in Managing People with HIV Who Have Substance Use Disorder (Web)

A. Harm reduction is passive and enables people to continue unhealthy behaviors.B. Harm reduction is all about syringe exchange.C. You use harm reduction approaches when the patient is hopeless to progress clinically.D. Harm reduction utilizes active engagement to set realistic patient-centered goals to reduce harm from unhealthy behaviors.

Congratulations. The best choice is D. Harm reduction “meets where people are”. Instead of using prescriptive and paternalistic approaches, it identifies the harms associated with substance use and tries to reduce harms. Abstinence from substance is not a precondition. Patients need to engage with care providers to make it meaningful. Both parties identify realistic patient-centered goals and work toward achieving them. For example, to reduce risk with injection but not stopping using substances, or gradual reducing use to eventual abstinence from substance. Therefore, this is not a passive or enabling approach. Its application can be used in many non-addiction health conditions and not limited to syringe exchange. Many people do achieve goals that are meaningful to them, and the approach is by no means hopeless.
References:
Hawk M, Coulter RWS, Egan JE, et al. Harm reduction principles for healthcare settings. Harm Reduct J 2017; 14(1): 70. 15.
Sue KL, Fiellin DA. Bringing Harm Reduction into Health Policy - Combating the Overdose Crisis. N Engl J Med 2021; 384(19): 1781-3.

Sorry, the correct answer is D. Harm reduction “meets where people are”. Instead of using prescriptive and paternalistic approaches, it identifies the harms associated with substance use and tries to reduce harms. Abstinence from substance is not a precondition. Patients need to engage with care providers to make it meaningful. Both parties identify realistic patient-centered goals and work toward achieving them. For example, to reduce risk with injection but not stopping using substances, or gradual reducing use to eventual abstinence from substance. Therefore, this is not a passive or enabling approach. Its application can be used in many non-addiction health conditions and not limited to syringe exchange. Many people do achieve goals that are meaningful to them, and the approach is by no means hopeless.
References:
Hawk M, Coulter RWS, Egan JE, et al. Harm reduction principles for healthcare settings. Harm Reduct J 2017; 14(1): 70. 15.
Sue KL, Fiellin DA. Bringing Harm Reduction into Health Policy - Combating the Overdose Crisis. N Engl J Med 2021; 384(19): 1781-3.

A. Full agonist opioid prescribed to prevent opioid overdose or opioid useB. A “x-waiver” from the DEA is required to prescribe for patients with opioid use disorder.C. Partial agonist opioid properties result in a favorable safety profile when compared to full agonist opioids, including decreased risk of respiratory depression.D. It can be taken PO, or given as SQ injection.

Congratulations. The best answer is C. Buprenorphine is a partial agonist where drugs produce increasing receptor activity at lower doses, but at higher doses even when drug is completely bound to the receptors, the maximum opioid effect is never achieved. Safety concerns which occur with full agonist opioids at higher doses including respiratory depression occur above this plateau. Answer A is incorrect: buprenorphine is not a full agonist opioid. Answer B is incorrect: As of 2022, the “W-waiver” is no longer required from the DEA to prescribe buprenorphine. Following the MAT Act in 2023, any prescriber with a standard DEA registration for Schedule III substances is able to prescribe buprenorphine for opioid use disorder. An 8-hour training in addiction is now required for all DEA holders. Answer D is incorrect: Buprenorphine formulation is not available as a PO medication. It is a sublingual medication. It is also available as SQ injection.
References:
The ASAM National Practice Guideline for the Treatment of Opioid Use Disorder: 2020 Focused Update. J Addict Med. 2020 Mar/Apr;14(2S Suppl 1):1-91. doi: 10.1097/ADM.0000000000000633. Erratum in: J Addict Med. 2020 May/Jun;14(3):267. doi: 10.1097/ADM.0000000000000683. PMID: 32511106.
https://www.samhsa.gov/substance-use/treatment/statutes-regulations-guidelines/mat-act

Sorry, the best answer is C. Buprenorphine is a partial agonist where drugs produce increasing receptor activity at lower doses, but at higher doses even when drug is completely bound to the receptors, the maximum opioid effect is never achieved. Safety concerns which occur with full agonist opioids at higher doses including respiratory depression occur above this plateau. Answer A is incorrect: buprenorphine is not a full agonist opioid. Answer B is incorrect: As of 2022, the “W-waiver” is no longer required from the DEA to prescribe buprenorphine. Following the MAT Act in 2023, any prescriber with a standard DEA registration for Schedule III substances is able to prescribe buprenorphine for opioid use disorder. An 8-hour training in addiction is now required for all DEA holders. Answer D is incorrect: Buprenorphine formulation is not available as a PO medication. It is a sublingual medication. It is also available as SQ injection.
References:
The ASAM National Practice Guideline for the Treatment of Opioid Use Disorder: 2020 Focused Update. J Addict Med. 2020 Mar/Apr;14(2S Suppl 1):1-91. doi: 10.1097/ADM.0000000000000633. Erratum in: J Addict Med. 2020 May/Jun;14(3):267. doi: 10.1097/ADM.0000000000000683. PMID: 32511106.
https://www.samhsa.gov/substance-use/treatment/statutes-regulations-guidelines/mat-act

A. Methadone is a great treatment option but is associated with stigma and rigid regulations which can greatly limit its access.B. Injectable buprenorphine is a strategy to overcome challenges to store medications or concerns for buprenorphine/methadone diversion.C. Peer navigation and low-barrier and collocated care help increase compliance and viral suppression.D. All of the above.

Congratulations. The best answer is D. Methadone clinics historically are in Black neighborhoods and are associated with systemic violence. The federal regulations of methadone are outdated and pose challenges to access. Injectable buprenorphine bypasses the issues of diversion or storage because it is given in the office by providers. Studies show that even in PWH with active injection and high degree of housing insecurity, peer navigation, low-barrier care, and injectable buprenorphine and ART together achieved durable viral suppression.
References:
C. Simon, L. Vincent, A. Coulter, Z. Salazar, N. Voyles, L. Roberts, et al. The Methadone Manifesto: Treatment Experiences and Policy Recommendations From Methadone Patient Activists. Am J Public Health. 2022;112(S2):S117-S122.
A. Perez, S. Nieves and J. Meisner. Implementation of Injectable Cabotegravir/Rilpivirine for Treatment of Human Immunodeficiency Virus in Patients With Substance Use Disorders at a Syringe Exchange Clinic. Open Forum Infect Dis 2024. 11(11):ofae640.

Sorry, the best answer is D. Methadone clinics historically are in Black neighborhoods and are associated with systemic violence. The federal regulations of methadone are outdated and pose challenges to access. Injectable buprenorphine bypasses the issues of diversion or storage because it is given in the office by providers. Studies show that even in PWH with active injection and high degree of housing insecurity, peer navigation, low-barrier care, and injectable buprenorphine and ART together achieved durable viral suppression.
References:
C. Simon, L. Vincent, A. Coulter, Z. Salazar, N. Voyles, L. Roberts, et al. The Methadone Manifesto: Treatment Experiences and Policy Recommendations From Methadone Patient Activists. Am J Public Health. 2022;112(S2):S117-S122.
A. Perez, S. Nieves and J. Meisner. Implementation of Injectable Cabotegravir/Rilpivirine for Treatment of Human Immunodeficiency Virus in Patients With Substance Use Disorders at a Syringe Exchange Clinic. Open Forum Infect Dis 2024. 11(11):ofae640.

YesNoRemained the same

	Strongly Agree (5)	Agree (4)	Neutral (3)	Disagree (2)	Strongly Disagree (1)
The content covered was useful and relevant to my current or future scope of practice.
The activity was fair, balanced, and free of bias.
The activity improved my knowledge of this clinical issue.
The learning objectives for this activity were achieved.
I am better able to: Communicate/collaborate with other members of the care team on this issue.
I am better able to: Improve access to care and treatment for underrepresented patient groups or geographies because of what I learned.
The information learned during this activity will help improve my skills or judgment within the next six months.
The content was presented clearly.
The educational activity was well planned and presented.

	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree
I intend to: Modify/change my practice or the practice of my team based on this educational activity.
I intend to: Work with my team to create/revise protocols, policies, and/or procedures with my care team.
I intended to: Share what I learned with other members of my care team.
I intend to: Make changes in how I communicate with/educate my patients.
I intend to: Seek additional information on topics discussed during the activity.
On average, I utilized the patient treatment strategies described in this educational activity prior to my participation.

	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree
My office and practice systems can accommodate the above changes.
My patients can accommodate the above changes.
Patient access to the treatments provided will be a barrier to implementing the above changes.

	Excellent (5)	Good (4)	Acceptable (3)	Poor (2)	Very Poor (1)
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Case Studies in Managing People with HIV Who Have Substance Use Disorder

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