HRSA Offers Guidance on Buprenorphine

By: Ranier Simons, ADAP Blog Guest Contributor

There is a higher prevalence of substance use disorder (SUD) among people living with HIV/AIDS (PLWHA) compared to the population at large.[1] Among PLWHA, nearly 50 percent report a current or past history of substance use disorders (SUD).[2] As such, in May 2023, the HIV/AIDS Bureau of the Health Resources and Services Administration (HRSA) sent a letter to all Ryan White HIV/AIDS Program (RWHAP) Part B Aids Drug Assistance Program (ADAP) recipients encouraging them to include medications used to treat SUD in their formularies. HRSA additionally emphasized adding buprenorphine and naloxone.[3] 

Photo Source: HRSA

Buprenorphine is used to treat opioid addiction as an agonist treatment. It is a long-acting drug compared to the short-acting opioids to which people have addictions, such as heroin and oxycodone. Buprenorphine stays in the blood for 24-36 hours, in contrast to shorter-acting drugs people abuse that require consumption multiple times a day to prevent withdrawal symptoms.[4] Proper dosage of buprenorphine does not cause a euphoric high, and it allows substance abusers to stabilize their lives and gain control. Any drug can be abused and overdosed. However, an overdose of buprenorphine is less likely than an overdose of methadone, another medication used for agonist treatment. Naloxone is a drug that can temporarily reverse the effects of an opioid overdose giving a person time to allow medical assistance to arrive.

Roughly 40 percent of ADAPs do not have buprenorphine or naloxone on their formularies.[3] While most health insurance plans cover medications to treat SUD, 37.4 percent of ADAP patients have no health coverage.[3] Each ADAP determines the composition of its formulary. They use advisory boards of professionals to examine their populations and determine the cost/benefit analysis of including certain medications. ADAP clients without health insurance who also have SUD are left without the means to obtain SUD drugs that could drastically improve their lives.

PLWHA dealing with substance use addictions have poorer health outcomes than those without addictions. Drug abuse causes inconsistent antiretroviral adherence resulting in lower rates of viral suppression. SUD causes people to not engage in behaviors necessary for a productive, stable existence. Additionally, substance abuse can result in dangerous drug interactions between therapeutic medications and the drugs being abused, in addition to excessive wear on organs such as the liver and kidneys. To effectively fight the HIV/AIDS epidemic, it is vital to treat PLWHA wholistically. This means dealing with their mental and physical co-morbidities in addition to their HIV.

Photo Source: Baton Rouge Behavioral Hospital

The World Health Organization (WHO) also recognizes the importance of buprenorphine and naloxone. Both are listed on the 2021 22nd WHO model list of essential medicines, which is updated every two years. The essential medicine list are medicines: “that satisfy the priority health care needs of a population…selected with due regard to disease prevalence and public health relevance, evidence of efficacy and safety and comparative cost-effectiveness…intended to be available in functioning health systems at all times, in appropriate dosage forms, of assured quality and at prices individuals and health systems can afford…“[5] 

RWHAP's ADAP manual states that ADAPs may include medications used to treat chronic medical and mental health conditions in addition to some of the mandatory requirements, such as including at least one drug from each class of HIV antiretroviral medications.[6] If more ADAPs heed the suggestion of the HRSA letter, more PLWHA with substance addictions can get treatment and relief. Many ADAPs are facing funding challenges. However, including buprenorphine and naloxone would be worthwhile formulary additions as their usage is evidence-based.

[1] Shiau, S., Arpadi, S. M., Yin, M. T., & Martins, S. S. (2017). Patterns of drug use and HIV infection among adults in a nationally representative sample. Addictive behaviors, 68, 39–44. https://doi.org/10.1016/j.addbeh.2017.01.015

[2] Durvasula, R., & Miller, T. R. (2014). Substance abuse treatment in persons with HIV/AIDS: challenges in managing triple diagnosis. Behavioral medicine (Washington, D.C.), 40(2), 43–52. https://doi.org/10.1080/08964289.2013.866540

[3] HRSA. (2023, May 11). Ryan White Letter. Retrieved from https://ryanwhite.hrsa.gov/sites/default/files/ryanwhite/grants/rwhap-partb-aids-drug-assistance.pdf

[4] Centre for Addiction and Mental Health. (2023). Buprenorphine. Retrieved from https://www.camh.ca/en/health-info/mental-illness-and-addiction-index/buprenorphine#:~:text=Overview,pain%20relief%20for%20seven%20days

[5] World Health Organization. (2023). WHO model list of essential medicines - 22nd list, 2021. Retrieved from https://www.who.int/publications/i/item/WHO-MHP-HPS-EML-2021.02

[6] HRSA. (2016). AIDS Drug Assistance Program Manual. Retrieved from https://ryanwhite.hrsa.gov/sites/default/files/ryanwhite/resources/adap-manual.pdf

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates.