Marc N Gourevitch, M.D., M.P.H.

Buprenorphine-naloxone maintenance following release from jail
Lee, Joshua D; Grossman, Ellie; Truncali, Andrea; Rotrosen, John; Rosenblum, Andrew; Magura, Stephen; Gourevitch, Marc N
2012 Jan;33(1):40-47, Substance abuse
ABSTRACT Primary care is understudied as a reentry drug and alcohol treatment setting. This study compared treatment retention and opioid misuse among opioid-dependent adults seeking buprenorphine/naloxone maintenance in an urban primary care clinic following release from jail versus community referrals. Postrelease patients were either (a) induced to buprenorphine in-jail as part of a clinical trial, or (b) seeking buprenorphine induction post release. From 2007 to 2008, N = 142 patients were new to primary care buprenorphine: n = 32 postrelease; n = 110 induced after community referral and without recent incarceration. Jail-released patients were more likely African American or Hispanic and uninsured. Treatment retention rates for postrelease (37%) versus community (30%) referrals were similar at 48 weeks. Rates of opioid positive urines and self-reported opioid misuse were also similar between groups. Postrelease patients in primary care buprenorphine treatment had equal treatment retention and rates of opioid abstinence versus community-referred patients
— id: 150570, year: 2012, vol: 33, page: 40, stat: Journal Article,

HIV treatment outcomes among HIV-infected, opioid-dependent patients receiving buprenorphine/naloxone treatment within HIV clinical care settings: results from a multisite study
Altice, Frederick L; Bruce, R Douglas; Lucas, Gregory M; Lum, Paula J; Korthuis, P Todd; Flanigan, Timothy P; Cunningham, Chinazo O; Sullivan, Lynn E; Vergara-Rodriguez, Pamela; Fiellin, David A; Cajina, Adan; Botsko, Michael; Nandi, Vijay; Gourevitch, Marc N; Finkelstein, Ruth
2011 Mar 1;56 Suppl 1:S22-S32, Journal of acquired immune deficiency syndromes. JAIDS
BACKGROUND: Having opioid dependence and HIV infection are associated with poor HIV-related treatment outcomes. METHODS: HIV-infected, opioid-dependent subjects (N = 295) recruited from 10 clinical sites initiated buprenorphine/naloxone (BUP/NX) and were assessed at baseline and quarterly for 12 months. Primary outcomes included receiving antiretroviral therapy (ART), HIV-1 RNA suppression, and mean changes in CD4 lymphocyte count. Analyses were stratified for the 119 subjects not on ART at baseline. Generalized estimating equations were deployed to examine time-dependent correlates for each outcome. RESULTS: At baseline, subjects on ART (N = 176) were more likely than those not on ART (N = 119) to be older, heterosexual, have lower alcohol addiction severity scores, and lower HIV-1 RNA levels; they were less likely to be homeless and report sexual risk behaviors. Subjects initiating BUP/NX (N = 295) were significantly more likely to initiate or remain on ART and improve CD4 counts over time compared with baseline; however, these improvements were not significantly improved by longer retention on BUP/NX. Retention on BUP/NX for three or more quarters was, however, significantly associated with increased likelihood of initiating ART (beta = 1.34 [1.18, 1.53]) and achieve viral suppression (beta = 1.25 [1.10, 1.42]) for the 64 of 119 (54%) subjects not on ART at baseline compared with the 55 subjects not retained on BUP/NX. In longitudinal analyses, being on ART was positively associated with increasing time of observation from baseline and higher mental health quality of life scores (beta = 1.25 [1.06, 1.46]) and negatively associated with being homo- or bisexual (beta = 0.55 [0.35, 0.97]), homeless (beta = 0.58 [0.34, 0.98]), and increasing levels of alcohol addiction severity (beta = 0.17 [0.03, 0.88]). The strongest correlate of achieving viral suppression was being on ART (beta = 10.27 [5.79, 18.23]). Female gender (beta = 1.91 [1.07, 3.41]), Hispanic ethnicity (beta = 2.82 [1.44, 5.49]), and increased general health quality of life (beta = 1.02 [1.00,1.04]) were also independently correlated with viral suppression. Improvements in CD4 lymphocyte count were significantly associated with being on ART and increased over time. CONCLUSIONS: Initiating BUP/NX in HIV clinical care settings is feasible and correlated with initiation of ART and improved CD4 lymphocyte counts. Longer retention on BPN/NX was not associated with improved prescription of ART, viral suppression, or CD4 lymphocyte counts for the overall sample in which the majority was already prescribed ART at baseline. Among those retained on BUP/NX, HIV treatment outcomes did not worsen and were sustained. Increasing time on BUP/NX, however, was especially important for improving HIV treatment outcomes for those not on ART at baseline, the group at highest risk for clinical deterioration. Retaining subjects on BUP/NX is an important goal for sustaining HIV treatment outcomes for those on ART and improving them for those who are not. Comorbid substance use disorders (especially alcohol), mental health problems, and quality-of-life indicators independently contributed to HIV treatment outcomes among HIV-infected persons with opioid dependence, suggesting the need for multidisciplinary treatment strategies for this population
— id: 134129, year: 2011, vol: 56 Suppl 1, page: S22, stat: Journal Article,

Screening for Substance Abuse: Good Idea or Not Ready for Prime Time?
Andrea Truncali, Andrea; McNeely, Jennifer; Kerr, David; Gourevitch, Marc; Huben, Laura; Naegle, Madeline
2011;:- [Web Site], Oct 4, 2011, MedEdPORTAL
This web-based module introduces the practice of screening for substance abuse in healthcare settings and considers the question of when to implement a screening program. It reviews existing standards of screening for substance abuse and asks whether health systems should expand current practices to ask about use of drugs besides alcohol and tobacco. In addition, the module provides in-depth teaching on the key concepts of sensitivity, specificity and predictive values
— id: 150922, year: 2011, vol: , page: , stat: Web Site,

Factors associated with frequent utilization of crisis substance use detoxification services
Carrier, Emily; McNeely, Jennifer; Lobach, Iryna; Tay, Shane; Gourevitch, Marc N; Raven, Maria C
2011 Apr;30(2):116-122, Journal of addictive diseases
Previous research suggests that some substance users have multiple crisis detoxification visits and never access rehabilitation care. This care-seeking pattern leads to poorer outcomes and higher costs. The authors aimed to identify predictors of repeat detoxification visits by analyzing state-level data routinely collected at the time of substances use services admission. Repeat detoxification clients were more likely to be homeless, city-dwelling fee-for-service Medicaid recipients. Repeat detoxification clients were less likely than those with one admission to enter rehabilitation within 3 days. Treatment providers should aim for rapid transfer to rehabilitation and consider expanding detoxification intake data to improve risk stratification
— id: 130918, year: 2011, vol: 30, page: 116, stat: Journal Article,

Drug treatment outcomes among HIV-infected opioid-dependent patients receiving buprenorphine/naloxone
Fiellin, David A; Weiss, Linda; Botsko, Michael; Egan, James E; Altice, Frederick L; Bazerman, Lauri B; Chaudhry, Amina; Cunningham, Chinazo O; Gourevitch, Marc N; Lum, Paula J; Sullivan, Lynn E; Schottenfeld, Richard S; O'Connor, Patrick G
2011 Mar 1;56 Suppl 1:S33-S38, Journal of acquired immune deficiency syndromes. JAIDS
BACKGROUND: Buprenorphine/naloxone allows the integration of opioid dependence and HIV treatment. METHODS: We conducted a prospective study in HIV-infected opioid-dependent patients to investigate the impact of buprenorphine/naloxone treatment on drug use. Self-report and chart review assessments were conducted every 3 months (quarters 1-4) for 1 year. Outcomes were buprenorphine/naloxone treatment retention, drug use, and addiction treatment processes. RESULTS: Among 303 patients enrolled between July 2005 and December 2007, retention in buprenorphine/naloxone treatment was 74%, 67%, 59%, and 49% during Quarters 1, 2, 3, and 4, respectively. Past 30-day illicit opioid use decreased from 84% of patients at baseline to 42% in retained patients over the year. Patients were 52% less likely to use illicit opioids for each quarter in treatment (Odds ratio = 0.66; 95% CI: 0.61 to 0.72). Buprenorphine/naloxone doses and office visits approximated guidelines published by the United States Department of Health and Human Services. Urine toxicology monitoring was less frequent than recommended. CONCLUSIONS: Buprenorphine/naloxone provided in HIV treatment settings can decrease opioid use. Strategies are needed to improve retention and address ongoing drug use in this treatment population
— id: 134128, year: 2011, vol: 56 Suppl 1, page: S33, stat: Journal Article,

Policy implications of integrating buprenorphine/naloxone treatment and HIV care
Finkelstein, Ruth; Netherland, Julie; Sylla, Laurie; Gourevitch, Marc N; Cajina, Adan; Cheever, Laura
2011 Mar 1;56 Suppl 1:S98-S104, Journal of acquired immune deficiency syndromes. JAIDS
Researchers, practitioners, and policymakers have long recognized the potential benefits of providing integrated substance abuse and medical care services, particularly for special populations such as people living with HIV/AIDS. Buprenorphine, an office-based pharmacological treatment for opioid dependence, offers new opportunities for integrating drug treatment into HIV care settings. However, the historical separation between the drug treatment and medical care systems has resulted in a host of policy barriers. The Buprenorphine and HIV Care Evaluation and Support initiative, a multisite demonstration project to assess the feasibility and effectiveness of integrating buprenorphine/naloxone into HIV care settings, provided an opportunity to evaluate if and how policy barriers affect efforts to integrate HIV care and addiction treatment. We found that financing issues, workforce and training issues, and the operational consequences of some conceptual differences between HIV care and addiction treatment are barriers to the full integration of buprenorphine into HIV care. We recommend changes to financing and reimbursement policies, programs to strengthen the addiction treatment skills of physicians, and cross training between the fields of addiction, medicine, drug treatment, and HIV medicine. By addressing some of the policy barriers to integration, this promising new treatment can help the thousands of people living with HIV/AIDS who are also opioid dependent
— id: 134126, year: 2011, vol: 56 Suppl 1, page: S98, stat: Journal Article,

Improved quality of life for opioid-dependent patients receiving buprenorphine treatment in HIV clinics
Korthuis, P Todd; Tozzi, Mary Jo; Nandi, Vijay; Fiellin, David A; Weiss, Linda; Egan, James E; Botsko, Michael; Acosta, Angela; Gourevitch, Marc N; Hersh, David; Hsu, Jeffrey; Boverman, Joshua; Altice, Frederick L
2011 Mar 1;56 Suppl 1:S39-S45, Journal of acquired immune deficiency syndromes. JAIDS
BACKGROUND: Opioid dependence and HIV infection are associated with poor health-related quality of life (HRQOL). Buprenorphine/naloxone (bup/nx) provided in HIV care settings may improve HRQOL. METHODS: We surveyed 289 HIV-infected opioid-dependent persons treated with clinic-based bup/nx about HRQOL using the Short Form Health Survey (SF-12) administered at baseline, 3, 6, 9, and 12 months. We used normalized SF-12 scores, which correspond to a mean HRQOL of 50 for the general US population (SD 10, possible range 0-100). We compared mean normalized mental and physical composite and component scores in quarters 1, 2, 3, and 4 with baseline scores using generalized estimating equation models. We assessed the effect of clinic-based bup/nx prescription on HRQOL composite scores using mixed effects regression with site as random effect and time as repeated effect. RESULTS: Baseline normalized SF-12 scores were lower than the general US population for all HRQOL domains. Average composite mental HRQOL improved from 38.3 (SE 12.5) to 43.4 (SE 13.2) [beta 1.13 (95% CI: 0.72 to 1.54)] and composite physical HRQOL remained unchanged [beta 0.21 (95% CI: -0.16 to 0.57)] over 12 months follow-up. Continued bup/nx treatment across all 4 quarters was associated with improvements in both physical [beta 2.38 (95% CI: 0.63 to 4.12)] and mental [beta 2.51 (95% CI: 0.42 to 4.60)] HRQOL after adjusting for other contributors to HRQOL. CONCLUSIONS: Clinic-based bup/nx maintenance therapy is potentially effective in ameliorating some of the adverse effects of opioid dependence on HRQOL for HIV-infected populations
— id: 134127, year: 2011, vol: 56 Suppl 1, page: S39, stat: Journal Article,

Undergraduate medical education in substance abuse: a review of the quality of the literature
Kothari, Devyani; Gourevitch, Marc N; Lee, Joshua D; Grossman, Ellie; Truncali, Andrea; Ark, Tavinder K; Kalet, Adina L
2011 Jan;86(1):98-112, Academic medicine
PURPOSE: To prepare to develop a medical school curriculum on substance abuse disorders (SADs), the authors conducted a review of the quality of the sparse published literature. METHOD: The authors searched MEDLINE (1950 through December 2008) using OVID, PsycINFO, and PubMed to identify all studies of SAD interventions targeted toward undergraduate medical students. Of the 1,084 studies identified initially, 31 reported sufficient data to allow the authors to evaluate quality using Medical Education Research Study Quality Instrument (MERSQI) scores. The authors also determined the impact of the studies by considering three-year citation rate and journal impact factor. A detailed review of the literature provided data on contact hours and intervention content. RESULTS: The three-rater intraclass correlation coefficient for total MERSQI score was 0.82 (95% confidence interval: 0.70-0.90). The mean MERSQI score was 10.42 of a possible 18 (SD 2.59; range: 6.33-14.83). MERSQI scores were higher for more recently published studies and correlated with three-year citation rate but not impact factor. The mean contact time for 26 studies was 29.25 hours (range: 0.83-200 hours). CONCLUSIONS: The literature provides a variety of educational methods to train medical students in SAD detection and intervention skills. This literature is of variable quality and provides limited guidance for development of curricula and medical education policy. Better methods of curriculum evaluation and publication guidelines would help ensure that this literature has a positive impact on educational practice and public health
— id: 119230, year: 2011, vol: 86, page: 98, stat: Journal Article,

Substance use prevalence and screening instrument comparisons in urban primary care
Lee, Joshua D; Delbanco, Benjamin; Wu, Edward; Gourevitch, Marc N
2011 Jul;32(3):128-134, Substance abuse
Substance use screening in a primary care setting compared the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST version 3.0), Two-Item Conjoint Screen (TICS), National Institute on Alcohol Abuse and Alcoholism (NIAAA) daily limit single item, and electronic medical record (EMR). Among 236 consecutive adults, ASSIST moderate- to high-risk substance use prevalence was tobacco, 15.3%; alcohol, 8.5%; cannabis, 5.1%; cocaine, 2.5%; and opioids, 2.5%. Compared to ASSIST, a positive TICS was 45% (95% confidence interval [CI], 27-64%) sensitive, 99% (95-100%) specific; the NIAAA single-item screen was 80% (56-94%) sensitive, 87% (82-91%) specific. The NIAAA single item correlated closely with alcohol ASSIST. TICS and EMR were less sensitive for any nontobacco substance use
— id: 134457, year: 2011, vol: 32, page: 128, stat: Journal Article,

Substance Use in the Bathhouses: Misuse of Prescription and Sex Enhancing Drugs is On Par with Sexual Behavior as an HIV Risk Factor
McNeely, J.; Silvera, R.; Ramos, M.; Bernstein, K.; Gourevitch, M. N.; Aberg, J.; Daskalakis, D. D.
2011 ;32(1):56-57, Substance abuse
— id: 128811, year: 2011, vol: 32, page: 56, stat: Journal Article,

A Web-Based Module on Neurobiology to Engage Students in Substance Abuse Research
Truncali, A.; Lee, J. D.; Gillespie, C.; Ross, S.; Kerr, D.; Huben, L.; Kalet, A. L.; Moore, F.; Naegle, M.; Gourevitch, M. N.
2011 ;32(1):53-54, Substance abuse
— id: 128810, year: 2011, vol: 32, page: 53, stat: Journal Article,

Teaching physicians to address unhealthy alcohol use: a randomized controlled trial assessing the effect of a Web-based module on medical student performance
Truncali, Andrea; Lee, Joshua D; Ark, Tavinder K; Gillespie, Colleen; Triola, Marc; Hanley, Kathleen; Gourevitch, Marc N; Kalet, Adina L
2011 Mar;40(2):203-213, Journal of substance abuse treatment
BACKGROUND: The authors developed and evaluated an interactive, Web-based module to train medical students in screening and brief intervention (SBI) for unhealthy alcohol use. METHODS: First-year students were randomized to module versus lecture. Change in knowledge, attitudes, and confidence were compared. Performance was assessed by objective structured clinical examination (OSCE) and analyzed by intention to treat and treatment received. RESULTS: Of 141 consenting students, 64% (n = 90) completed an intervention (54% lecture vs. 70% Web assigned). Knowledge, confidence, and attitudes improved in both groups, with more improvement in Advise-Assist knowledge for Web students (14% vs. -3%, p = .003). Web students outperformed their lecture peers in both general communication (65% vs. 51% items well done, p = .004) and alcohol-specific tasks (54% vs. 41%, p = .021) on OSCE. Analysis by treatment received enhanced between-group differences. CONCLUSION: Use of a Web-based module to teach SBI is associated with greater knowledge gain and skills performance compared with a lecture covering similar content. The module provides an efficient means for training in this area
— id: 138090, year: 2011, vol: 40, page: 203, stat: Journal Article,

Adjunctive counseling during brief and extended buprenorphine-naloxone treatment for prescription opioid dependence: a 2-phase randomized controlled trial
Weiss, Roger D; Potter, Jennifer Sharpe; Fiellin, David A; Byrne, Marilyn; Connery, Hilary S; Dickinson, William; Gardin, John; Griffin, Margaret L; Gourevitch, Marc N; Haller, Deborah L; Hasson, Albert L; Huang, Zhen; Jacobs, Petra; Kosinski, Andrzej S; Lindblad, Robert; McCance-Katz, Elinore F; Provost, Scott E; Selzer, Jeffrey; Somoza, Eugene C; Sonne, Susan C; Ling, Walter
2011 Dec;68(12):1238-1246, Archives of general psychiatry
CONTEXT: No randomized trials have examined treatments for prescription opioid dependence, despite its increasing prevalence. OBJECTIVE: To evaluate the efficacy of brief and extended buprenorphine hydrochloride-naloxone hydrochloride treatment, with different counseling intensities, for patients dependent on prescription opioids. DESIGN: Multisite, randomized clinical trial using a 2-phase adaptive treatment research design. Brief treatment (phase 1) included 2-week buprenorphine-naloxone stabilization, 2-week taper, and 8-week postmedication follow-up. Patients with successful opioid use outcomes exited the study; unsuccessful patients entered phase 2: extended (12-week) buprenorphine-naloxone treatment, 4-week taper, and 8-week postmedication follow-up. SETTING: Ten US sites. Patients A total of 653 treatment-seeking outpatients dependent on prescription opioids. INTERVENTIONS: In both phases, patients were randomized to standard medical management (SMM) or SMM plus opioid dependence counseling; all received buprenorphine-naloxone. MAIN OUTCOME MEASURES: Predefined 'successful outcome' in each phase: composite measures indicating minimal or no opioid use based on urine test-confirmed self-reports. RESULTS: During phase 1, only 6.6% (43 of 653) of patients had successful outcomes, with no difference between SMM and SMM plus opioid dependence counseling. In contrast, 49.2% (177 of 360) attained successful outcomes in phase 2 during extended buprenorphine-naloxone treatment (week 12), with no difference between counseling conditions. Success rates 8 weeks after completing the buprenorphine-naloxone taper (phase 2, week 24) dropped to 8.6% (31 of 360), again with no counseling difference. In secondary analyses, successful phase 2 outcomes were more common while taking buprenorphine-naloxone than 8 weeks after taper (49.2% [177 of 360] vs 8.6% [31 of 360], P < .001). Chronic pain did not affect opioid use outcomes; a history of ever using heroin was associated with lower phase 2 success rates while taking buprenorphine-naloxone. CONCLUSIONS: Prescription opioid-dependent patients are most likely to reduce opioid use during buprenorphine-naloxone treatment; if tapered off buprenorphine-naloxone, even after 12 weeks of treatment, the likelihood of an unsuccessful outcome is high, even in patients receiving counseling in addition to SMM. Trial Registration clinicaltrials.gov Identifier: NCT00316277
— id: 149734, year: 2011, vol: 68, page: 1238, stat: Journal Article,

New measures to establish the evidence base for medical education: identifying educationally sensitive patient outcomes
Kalet, Adina L; Gillespie, Colleen C; Schwartz, Mark D; Holmboe, Eric S; Ark, Tavinder K; Jay, Melanie; Paik, Steve; Truncali, Andrea; Hyland Bruno, Julia; Zabar, Sondra R; Gourevitch, Marc N
2010 May;85(5):844-851, Academic medicine
Researchers lack the rich evidence base and benchmark patient outcomes needed to evaluate the effectiveness of medical education practice and guide policy. The authors offer a framework for medical education research that focuses on physician-influenced patient outcomes that are potentially sensitive to medical education. Adapting the concept of ambulatory care sensitive conditions, which provided traction to health services research by defining benchmark patient outcomes to measure health system performance, the authors introduce the concept and propose the adoption of educationally sensitive patient outcomes and suggest two measures: patient activation and clinical microsystem activation. They assert that the ultimate goal of medical education is to ensure that measurement of future physicians' competence and skills is based not only on biomedical knowledge and critical clinical skills but also on the ability to translate these competencies into effective patient- and systems-level outcomes. The authors consider methodological approaches and challenges to measuring such outcomes and argue for large, multiinstitutional, prospective cohort studies and the development of a national Database for Research in Education in Academic Medicine to provide the needed infrastructure. They advocate taking the next steps to establish an educational evidence base to guide the academic medical centers of the 21st century in aligning medical education practice with health care delivery that meets the needs of individuals and populations
— id: 110111, year: 2010, vol: 85, page: 844, stat: Journal Article,

Extended-release naltrexone for treatment of alcohol dependence in primary care
Lee, Joshua D; Grossman, Ellie; DiRocco, Danae; Truncali, Andrea; Hanley, Kathleen; Stevens, David; Rotrosen, John; Gourevitch, Marc N
2010 Jul;39(1):14-21, Journal of substance abuse treatment
The feasibility of using extended-release injectable naltrexone (XR-NTX) to treat alcohol dependence in routine primary care settings is unknown. An open-label, observational cohort study evaluated 3-month treatment retention, patient satisfaction, and alcohol use among alcohol-dependent patients in two urban public hospital medical clinics. Adults seeking treatment were offered monthly medical management (MM) and three XR-NTX injections (380 mg, intramuscular). Physician-delivered MM emphasized alcohol abstinence, medication effects, and accessing mutual help and counseling resources. Seventy-two alcohol-dependent patients were enrolled; 90% (65 of 72) of eligible subjects received the first XR-NTX injection; 75% (49 of 65) initiating treatment received the second XR-NTX injection; 62% (40 of 65), the third. Among the 56% (n = 40) receiving three injections, median drinks per day decreased from 4.1 (95% confidence interval = 2.9-6) at baseline to 0.5 (0-1.7) during Month 3. Extended-release naltrexone delivered in a primary care MM model appears a feasible and acceptable treatment for alcohol dependence
— id: 111657, year: 2010, vol: 39, page: 14, stat: Journal Article,

CURRENT SUBSTANCE MISUSE AND HIV RISK BEHAVIOR AMONG HIGHLY SEXUALLY ACTIVE MEN WHO HAVE SEX WITH MEN (MSM) ATTENDING COMMERCIAL SEX VENUES, EVENTS AND PARTIES (CSVEP) IN NEW YORK CITY
McNeely, J; Silvera, R; Torres, K; Bernstein, K; Aberg, J; Gourevitch, M; Daskalakis, D
2010 JUN ;25(9):250-250, Journal of general internal medicine
— id: 111910, year: 2010, vol: 25, page: 250, stat: Journal Article,

Substance use treatment barriers for patients with frequent hospital admissions
Raven, Maria C; Carrier, Emily R; Lee, Joshua; Billings, John C; Marr, Mollie; Gourevitch, Marc N
2010 Jan;38(1):22-30, Journal of substance abuse treatment
Substance use (SU) disorders adversely impact health status and contribute to inappropriate health services use. This qualitative study sought to determine SU-related factors contributing to repeated hospitalizations and to identify opportunities for preventive interventions. Fifty Medicaid-insured inpatients identified by a validated statistical algorithm as being at high-risk for frequent hospitalizations were interviewed at an urban public hospital. Patient drug/alcohol history, experiences with medical, psychiatric and addiction treatment, and social factors contributing to readmission were evaluated. Three themes related to SU and frequent hospitalizations emerged: (a) barriers during hospitalization to planning long-term treatment and follow-up, (b) use of the hospital as a temporary solution to housing/family problems, and (c) unsuccessful SU aftercare following discharge. These data indicate that homelessness, brief lengths of stay complicating discharge planning, patient ambivalence regarding long-term treatment, and inadequate detox-to-rehab transfer resources compromise substance-using patients' likelihood of avoiding repeat hospitalization. Intervention targets included supportive housing, detox-to-rehab transportation, and postdischarge patient support
— id: 105642, year: 2010, vol: 38, page: 22, stat: Journal Article,

Medical homes: challenges in translating theory into practice
Carrier, Emily; Gourevitch, Marc N; Shah, Nirav R
2009 Jul;47(7):714-722, Medical care
The concept of the medical home has existed since the 1960s, but has recently become a focus for discussion and innovation in the health care system. The most prominent definitions of the medical home are those presented by the Patient-Centered Primary Care Collaborative, the National Committee for Quality Assurance, and the Commonwealth Fund. These definitions share: adoption of health information technology and decision support systems, modification of clinical practice patterns, and ensuring continuity of care. Each of these components is a complex undertaking, and there is scant evidence to guide assessment of diverse strategies for achieving their integration into a medical home. Without a shared vocabulary and common definitions, policy-makers seeking to encourage the development of medical homes, providers seeking to improve patient care, and payers seeking to develop appropriate systems of reimbursement will face challenges in evaluating and disseminating the medical home model
— id: 100611, year: 2009, vol: 47, page: 714, stat: Journal Article,

FRAGMENTATION AND CONTINUITY OF CARE AMONG DIABETIC MEDICAID BENEFICIARIES SEEKING CARE AT SAFETY-NET HOSPITALS AND CLINICS
Carrier, ER; Gourevitch, MN; Raven, M; Capponi, LJ; Lobach, I; Tay, S; Billings, J; Shah, NR
2009 APR ;24(10):78-79, Journal of general internal medicine
— id: 99165, year: 2009, vol: 24, page: 78, stat: Journal Article,

FACTORS ASSOCIATED WITH REPEAT USE OF CRISIS SUBSTANCE-USE DETOXIFICATION SERVICES
Carrier, ER; Raven, M; Mcneely, J; Tay, S; Lobach, I; Gourevitch, MN
2009 APR ;24(10):74-74, Journal of general internal medicine
— id: 99164, year: 2009, vol: 24, page: 74, stat: Journal Article,

First Do No Harm ... Reduction?
Gourevitch, Marc N
2009 Mar 17;150(6):417-418, Annals of internal medicine
— id: 96480, year: 2009, vol: 150, page: 417, stat: Journal Article,

Extended-Release Naltrexone Injectable Suspension for Treatment of Alcohol Dependence in Urban Primary Care
Lee, J. D.; Grossman, E.; DiRocco, D.; Truncali, A.; Rotrosen, J.; Stevens, D.; Gourevitch, M. N.
2009 OCT ;30(1):85-85, Substance abuse
— id: 114203, year: 2009, vol: 30, page: 85, stat: Journal Article,

At-Home Buprenorphine Induction in Urban Primary Care
Lee, J.; DiRocco, D.; Grossman, E.; Gourevitch, M. N.
2009 OCT ;30(2):191-191, Substance abuse
— id: 114206, year: 2009, vol: 30, page: 191, stat: Journal Article,

Impact of a Web-Based Alcohol Screening and Brief Intervention Module
Lee, J.; Gillespie, C.; Gourevitch, M. N.; Hanley, K.; Jay, M.; Paik, S.; Richter, R.; Triola, M.; Zabar, S.; Kalet, A.
2009 OCT ;30(2):204-204, Substance abuse
— id: 114207, year: 2009, vol: 30, page: 204, stat: Journal Article,

Effectiveness of Buprenorphine vs. Methadone Maintenance in Jail and Post-Release: A Pilot Study
Lee, J.; Gourevitch, M. N.; Joseph, H.; Herschberger, J.; Marsch, L.; Rosenblum, A.; Magura, S.
2009 OCT ;30(2):204-205, Substance abuse
— id: 114208, year: 2009, vol: 30, page: 204, stat: Journal Article,

Home Buprenorphine/Naloxone Induction in Primary Care
Lee, Joshua D; Grossman, Ellie; DiRocco, Danae; Gourevitch, Marc N
2009 Feb;24(2):226-232, Journal of general internal medicine
BACKGROUND: Buprenorphine can be used for the treatment of opioid dependence in primary care settings. National guidelines recommend directly observed initial dosing followed by multiple in-clinic visits during the induction week. We offered buprenorphine treatment at a public hospital primary care clinic using a home, unobserved induction protocol. METHODS: Participants were opioid-dependent adults eligible for office-based buprenorphine treatment. The initial physician visit included assessment, education, induction telephone support instructions, an illustrated home induction pamphlet, and a 1-week buprenorphine/naloxone prescription. Patients initiated dosing off-site at a later time. Follow-up with urine toxicology testing occurred at day 7 and thereafter at varying intervals. Primary outcomes were treatment status at week 1 and induction-related events: severe precipitated withdrawal, other buprenorphine-prompted withdrawal symptoms, prolonged unrelieved withdrawal, and serious adverse events (SAEs). RESULTS: Patients (N = 103) were predominantly heroin users (68%), but also prescription opioid misusers (18%) and methadone maintenance patients (14%). At the end of week 1, 73% were retained, 17% provided induction data but did not return to the clinic, and 11% were lost to follow-up with no induction data available. No cases of severe precipitated withdrawal and no SAEs were observed. Five cases (5%) of mild-to-moderate buprenorphine-prompted withdrawal and eight cases of prolonged unrelieved withdrawal symptoms (8% overall, 21% of methadone-to-buprenorphine inductions) were reported. Buprenorphine-prompted withdrawal and prolonged unrelieved withdrawal symptoms were not associated with treatment status at week 1. CONCLUSIONS: Home buprenorphine induction was feasible and appeared safe. Induction complications occurred at expected rates and were not associated with short-term treatment drop-out
— id: 91325, year: 2009, vol: 24, page: 226, stat: Journal Article,

Successful treatment of chronic hepatitis C with pegylated interferon in combination with ribavirin in a methadone maintenance treatment program
Litwin, Alain H; Harris, Kenneth A Jr; Nahvi, Shadi; Zamor, Philippe J; Soloway, Irene J; Tenore, Peter L; Kaswan, Daniel; Gourevitch, Marc N; Arnsten, Julia H
2009 Jul;37(1):32-40, Journal of substance abuse treatment
Injection drug users constitute 60% of the more than 4 million people in the United States with hepatitis C virus (HCV), including many methadone maintenance patients. Few data exist describing clinical outcomes for patients receiving HCV treatment on-site in methadone maintenance settings. In this retrospective study, we describe clinical outcomes for 73 patients receiving HCV treatment on-site in a methadone maintenance treatment program. Fifty-five percent of patients achieved end-of-treatment response, and 45% achieved sustained viral response. These treatment response rates are nearly equivalent to previously published HCV treatment response rates, despite high prevalences of ongoing drug use (49%), psychiatric comorbidity (67%), and HIV coinfection (32%). These data show that on-site HCV treatment with pegylated interferon and ribavirin is effective in methadone-maintained patients, many of whom are active drug users, psychiatrically ill, or HIV coinfected, and that methadone maintenance treatment programs represent an opportunity to safely treat chronic hepatitis C
— id: 96481, year: 2009, vol: 37, page: 32, stat: Journal Article,

MISMATCH BETWEEN TREATMENT ENROLLMENT AND DRUG USE PATTERNS AMONG HEROIN AND PRESCRIPTION OPIOID USERS IN NEW YORK CITY
Mcneely, J; Gourevitch, MN
2009 APR ;24(10):123-123, Journal of general internal medicine
— id: 99167, year: 2009, vol: 24, page: 123, stat: Journal Article,

Factors affecting willingness to provide buprenorphine treatment
Netherland, Julie; Botsko, Michael; Egan, James E; Saxon, Andrew J; Cunningham, Chinazo O; Finkelstein, Ruth; Gourevitch, Mark N; Renner, John A; Sohler, Nancy; Sullivan, Lynn E; Weiss, Linda; Fiellin, David A
2009 Apr;36(3):244-251, Journal of substance abuse treatment
Buprenorphine is an effective long-term opioid agonist treatment. As the only pharmacological treatment for opioid dependence readily available in office-based settings, buprenorphine may facilitate a historic shift in addiction treatment from treatment facilities to general medical practices. Although many patients have benefited from the availability of buprenorphine in the United States, almost half of current prescribers are addiction specialists suggesting that buprenorphine treatment has not yet fully penetrated general practice settings. We examined factors affecting willingness to offer buprenorphine treatment among physicians with different levels of prescribing experience. Based on their prescribing practices, physicians were classified as experienced, novice, or as a nonprescriber and asked to assess the extent to which a list of factors impacted their prescription of buprenorphine. Several factors affected willingness to prescribe buprenorphine for all physicians: staff training; access to counseling and alternate treatment; visit time; buprenorphine availability; and pain medications concerns. Compared with other physicians, experienced prescribers were less concerned about induction logistics and access to expert consultation, clinical guidelines, and mental health services. They were more concerned with reimbursement. These data provide important insight into physician concerns about buprenorphine and have implications for practice, education, and policy change that may effectively support widespread adoption of buprenorphine
— id: 149779, year: 2009, vol: 36, page: 244, stat: Journal Article,

Impact of an Office-Based Opioid Treatment (OBOT) Workshop
Phillips, K. A.; Chaudhry, A.; Nahvi, S.; Kunins, H.; Gourevitch, M.; Alford, D. P.
2009 OCT ;30(1):92-93, Substance abuse
— id: 114204, year: 2009, vol: 30, page: 92, stat: Journal Article,

Medicaid patients at high risk for frequent hospital admission: real-time identification and remediable risks
Raven, Maria C; Billings, John C; Goldfrank, Lewis R; Manheimer, Eric D; Gourevitch, Marc N
2009 Mar;86(2):230-241, Journal of urban health
Patients with frequent hospitalizations generate a disproportionate share of hospital visits and costs. Accurate determination of patients who might benefit from interventions is challenging: most patients with frequent admissions in 1 year would not continue to have them in the next. Our objective was to employ a validated regression algorithm to case-find Medicaid patients at high-risk for hospitalization in the next 12 months and identify intervention-amenable characteristics to reduce hospitalization risk. We obtained encounter data for 36,457 Medicaid patients with any visit to an urban public hospital from 2001 to 2006 and generated an algorithm-based score for hospitalization risk in the subsequent 12 months for each patient (0 = lowest, 100 = highest). To determine medical and social contributors to the current admission, we conducted in-depth interviews with high-risk hospitalized patients (scores >50) and analyzed associated Medicaid claims data. An algorithm-based risk score >50 was attained in 2,618 (7.2%) patients. The algorithm's positive predictive value was equal to 0.67. During the study period, 139 high-risk patients were admitted: 60 met inclusion criteria and 50 were interviewed. Fifty-six percent cited the Emergency Department as their usual source of care or had none. Sixty-eight percent had >1 chronic medical conditions, and 42% were admitted for conditions related to substance use. Sixty percent were homeless or precariously housed. Mean Medicaid expenditures for the interviewed patients were $39,188 and $84,040 per patient for the years immediately prior to and following study participation, respectively. Findings including high rates of substance use, homelessness, social isolation, and lack of a medical home will inform the design of interventions to improve community-based care and reduce hospitalizations and associated costs
— id: 94377, year: 2009, vol: 86, page: 230, stat: Journal Article,

An Intervention to Improve Care & Reduce Costs for Medicaid Patients with Frequent Hospital Admissions
Raven, Maria; Elbel, Brian; Kostrowski, Shannon; Gillespie, Colleen; Gourevitch, Marc; Billings, John
2009 ;2009:487-488, Abstracts (AcademyHealth)
Research Objective: For a subset of fee-for-service Medicaid patients with frequent hospital admissions, contact with the health care system remains acute and episodic at high cost to Medicaid, while less costly outpatient primary and preventive care services are underutilized. Previous work validated the accuracy of a predictive case-finding algorithm to identify complex Medicaid patients at risk for future high costs who might benefit from more intensive services, and identified remediable risk factors such as substance use, homelessness, and lack of social support associated with frequent hospital admissions. We aimed to pilot an intervention for a limited number of high-cost patients to address unmet health and social needs in both the hospital and community, to improve care while reducing hospital admissions and associated costs in this population. Our intention was to expand the program based on pilot success. Study Design: Community and hospital-based care management intervention with process and implementation evaluation, and pre-post cost analysis. Eligible patients were offered intervention enrollment during an admission to an urban public hospital. Patients underwent in-depth psychosocial interviews by study social workers to identify immediate and long-term needs such as housing, primary care, transportation to and advocacy during appointments, medication management, entitlements enrollment, improved connections to psychiatric and substance use treatment, and home visits. Patients who met criteria for chronic homelessness were evaluated in-hospital by a community-housing partner who initiated housing applications based on a housing first model. Pre-paid cell phones were provided to patients when needed to maintain close contact with study staff for reminder calls and crisis management. Study staff worked closely with inpatient providers to facilitate appropriate discharge planning and follow-up. Population Studied: Consecutive English-speaking Medicaid fee-for-service patients aged 18-64 identified as high-cost and high-risk for readmission in the following 12 months by a validated predictive case-finding algorithm. Principal Findings: Over the past year, 19 patients have enrolled. 100% are male. 17/19 were chronic substance users at enrollment. 5/19 were lost to follow-up. Of the remaining patients, 8 met criteria for chronic homelessness that would facilitate expedited placement into permanent housing. Of these 8, 2 were placed in nursing homes and 2 died. The remaining 4 chronically homeless patients are now in transitional or permanent housing. Hospitalizations and ED visits have decreased, while establishment of an outpatient medical home has increased. Comparing the 9-12 months after the intervention to the 12 months before intervention revealed a decrease in average monthly inpatient Medicaid costs per patient ranging from $1205-$2881. This resulted in an average annual inpatient cost reduction from $14,464 to $34,568.52. Prior research indicates without intervention, Medicaid costs for these patients in the following 12 months will increase. Conclusion: A pilot intervention to improve care for medically, socially complex high-cost Medicaid patients shows savings to Medicaid and decreased hospitalizations and ED visits by addressing issues that are challenging for the traditional health care system to manage. Implications for Policy, Delivery or Practice: Our model will be expanded to serve a greater number of patients across additional hospitals to determine if the success of our pilot can be replicated, and will include a more detailed cost analysis. Funding Source(s): The United Hospital Fund
— id: 107294, year: 2009, vol: 2009, page: 487, stat: Journal Article,

Housing insecurity and lack of public assistance are risk factors for tuberculin skin test conversion among persons who use illicit drugs in New York City
Sivapalasingam, Sumathi; Klein, Robert S; Howard, Andrea; Qin, Angie; Tseng, Chi-Hong; Gourevitch, Marc N
2009 Sep;3(3):172-177, Journal of addiction medicine : JAM
BACKGROUND: Persons who use illicit drugs are at increased risk of new tuberculosis (TB) infection. We conducted a prospective cohort study to assess rates and risk factors for tuberculin skin test (TST) conversion among persons with a history of illicit drug use, who were enrolled in a methadone program and had a negative baseline 2-step TST (eligible participants). METHODS: TST and standardized interviews were administered to 401 eligible participants from 1995 through 1999, every 6 months for a 2-year follow-up time. Analyses were conducted in 2006. RESULTS: A total of 1,447 repeat TSTs were performed during 843 person-years of follow-up (median: 2.0 years). The TST conversion rate was 3.7 per 100 person-years. In multivariate analysis, participants who converted were more likely to report ever having been homeless (HR, 2.4; 95% CI, 1.2-5.0) or ever having lived in a homeless shelter (HR, 2.4; 95% CI, 1.2-4.9) at the baseline interview, and less likely to have reported receiving public assistance since the last study visit (RR, 0.15; 95% CI, 0.07-0.32). CONCLUSIONS: This is the first study utilizing 2-step TST at baseline to measure the incidence of TST conversion among persons who use illicit drugs. Controlling for homelessness, persons with a lack of current public assistance was identified as a risk factor for TST conversion. These individuals may most benefit from annual tuberculin skin testing
— id: 138364, year: 2009, vol: 3, page: 172, stat: Journal Article,

Validation of the Spanish translation of the Patient Assessment of Chronic Illness Care (PACIC) survey
Aragones, Abraham; Schaefer, Eric W; Stevens, David; Gourevitch, Marc N; Glasgow, Russell E; Shah, Nirav R
2008 Oct;5(4):A113-A113, Preventing chronic disease
INTRODUCTION: The Patient Assessment of Chronic Illness Care (PACIC) survey is a patient-centered instrument for evaluating the quality and patient-centeredness of chronic illness care received according to the Chronic Care Model paradigm. This study validates the Spanish translation of the PACIC in an urban, Spanish-speaking population. METHODS: One hundred Spanish-speaking patients with diabetes completed the translated PACIC and sociodemographic and cultural questionnaires. Test-retest reliability was assessed in a subset of 20 patients who completed the questionnaire 2 to 4 months later. Internal consistency was evaluated with Cronbach alpha. PACIC score and subscale associations with sociodemographic characteristics were examined. RESULTS: Test-retest reliability for the overall translated PACIC scale was 0.77. Scores were not associated with patient sociodemographic characteristics, including age, country of birth, years living in the United States, or education level (P >.05). CONCLUSION: The Spanish translation of the PACIC survey demonstrated high reliability, internal consistency, and test-retest reliability. Scores showed no association with sociodemographic or cultural characteristics. The Spanish version can reliably be used to assess care delivered according to the Chronic Care Model in a heterogeneous Spanish-speaking population
— id: 92143, year: 2008, vol: 5, page: A113, stat: Journal Article,

Update in addiction medicine for the primary care clinician
Gordon, Adam J; Fiellin, David A; Friedmann, Peter D; Gourevitch, Marc N; Kraemer, Kevin L; Arnsten, Julia H; Saitz, Richard
2008 Dec;23(12):2112-2116, Journal of general internal medicine
— id: 96482, year: 2008, vol: 23, page: 2112, stat: Journal Article,

The Public Hospital in American Medical Education
Gourevitch, Marc N; Malaspina, Dolores; Weitzman, Michael; Goldfrank, Lewis R
2008 Sep;85(5):779-786, Journal of urban health
The importance of the public hospital system to medical education is often absent from the debate about its value. Best known as a core provider of services to the underserved, the safety net hospital system also plays a critical role in the education of future physicians. Particular strengths include its ability to imbue physicians in training with core professional values, to reveal through the enormous range of clinical experience provided many of the social forces shaping health, and to foster interest in and commitment to advancing population health. Faculty teaching in the public hospital system has unusual opportunities to reveal to learners the broader meanings of their diverse and rich experiences. Now, as an alarming array of pressures bearing down on the safety net system threaten its stability, the potential negative impact on medical education, were it to shrink or be forced to change its essential mission, must be considered. As advocates of the safety net system marshal forces to rationalize its funding and support, its tremendous contribution to the training of physicians and other health care professionals must be clearly set forth to ensure that support for the public hospital system's health is appropriately broad based
— id: 80970, year: 2008, vol: 85, page: 779, stat: Journal Article,

Working with patients with alcohol problems: a controlled trial of the impact of a rich media web module on medical student performance
Lee, Joshua D; Triola, Marc; Gillespie, Colleen; Gourevitch, Marc N; Hanley, Kathleen; Truncali, Andrea; Zabar, Sondra; Kalet, Adina
2008 Jul;23(7):1006-1009, Journal of general internal medicine
INTRODUCTION/AIMS: We designed an interactive web module to improve medical student competence in screening and interventions for hazardous drinking. We assessed its impact on performance with a standardized patient (SP) vs. traditional lecture. SETTING: First year medical school curriculum. PROGRAM DESCRIPTION: The web module included pre/posttests, Flash(c), and text didactics. It centered on videos of two alcohol cases, each contrasting a novice with an experienced physician interviewer. The learner free-text critiqued each clip then reviewed expert analysis. PROGRAM EVALUATION: First year medical students conveniently assigned to voluntarily complete a web module (N = 82) or lecture (N = 81) were rated by a SP in a later alcohol case. Participation trended higher (82% vs. 72%, p < .07) among web students, with an additional 4 lecture-assigned students crossing to the web module. The web group had higher mean scores on scales of individual components of brief intervention (assessment and decisional balance) and a brief intervention composite score (1-13 pt.; 9 vs. 7.8, p < .02) and self-reported as better prepared for the SP case. CONCLUSIONS: A web module for alcohol use interview skills reached a greater proportion of voluntary learners and was associated with equivalent overall performance scores and higher brief intervention skills scores on a standardized patient encounter
— id: 82918, year: 2008, vol: 23, page: 1006, stat: Journal Article,

Factors associated with antiretroviral therapy adherence and medication errors among HIV-infected injection drug users
Arnsten, Julia H; Li, Xuan; Mizuno, Yuko; Knowlton, Amy R; Gourevitch, Marc N; Handley, Kathleen; Knight, Kelly R; Metsch, Lisa R
2007 Nov 1;46 Suppl 2:S64-S71, Journal of acquired immune deficiency syndromes. JAIDS
BACKGROUND: Active drug use is often associated with poor adherence, but few studies have determined psychosocial correlates of adherence in injection drug users (IDUs). METHODS: Of 1161 Intervention for Seropositive Injectors-Research and Evaluation study enrollees, 636 were taking antiretrovirals. We assessed self-reported adherence to self-reported antiretroviral regimens and medication errors, which we defined as daily doses that were inconsistent with standard or alternative antiretroviral prescriptions. RESULTS: Most subjects (75%, n=477) self-reported good (>or=90%) adherence, which was strongly associated with an undetectable viral load. Good adherence was independently associated with being a high school graduate, not sharing injection equipment, fewer depressive symptoms, positive attitudes toward antiretrovirals, higher self-efficacy for taking antiretrovirals as prescribed, and greater sense of responsibility to protect others from HIV. Medication errors were made by 54% (n=346) and were strongly associated with a detectable viral load and fewer CD4 cells. Errors were independently associated with nonwhite race and with depressive symptoms, poorer self-efficacy for safer drug use, and worse attitudes toward HIV medications. CONCLUSIONS: Modifiable factors associated with poor adherence, including depressive symptoms and poor self-efficacy, should be targeted for intervention. Because medication errors are prevalent and associated with a detectable viral load and fewer CD4 cells, interventions should include particular efforts to identify medication taking inconsistent with antiretroviral prescriptions
— id: 96483, year: 2007, vol: 46 Suppl 2, page: S64, stat: Journal Article,

Effects of pegylated interferon alfa-2b on the pharmacokinetic and pharmacodynamic properties of methadone: a prospective, nonrandomized, crossover study in patients coinfected with hepatitis C and HIV receiving methadone maintenance treatment
Berk, Steven I; Litwin, Alain H; Arnsten, Julia H; Du, Evelyn; Soloway, Irene; Gourevitch, Marc N
2007 Jan;29(1):131-138, Clinical therapeutics
BACKGROUND: Hepatitis C virus (HCV) infection is common among methadone-maintained HIV-positive individuals. Pegylated interferon (pegIFN) used in combination with ribavirin is conventional treatment for HCV. However, pegIFN has been associated with adverse effects (AEs) that may simulate opioid withdrawal and be confused with insufficient methadone dosage. OBJECTIVE: The aim of this study was to determine, using methadone pharmacokinetic properties, whether methadone dosage adjustments are needed on initiation of treatment with pegIFN alfa-2b for HCV in methadone-maintained HIV-positive patients. METHODS: This prospective, nonrandomized, crossover study was conducted at the Albert Einstein College of Medicine and Montefiore Medical Center (Bronx, New York). Patients who were aged > or =18 years, coinfected with chronic HCV and HIV, and had been receiving methadone maintenance treatment (dosage, 40-200 mg/d PO) for at least 8 weeks prior to enrollment were eligible. We determined mean methadone C(max), T(max), Cn,in, AUC, and oral clearance (CL/F) values over a 24-hour period before (baseline) and after the administration of pegIFN alfa-2b 1.5 microg/kg SC (2 doses given 1 week apart). To determine differences in opiate withdrawal symptoms, one of the primary investigators administered the Subjective Opiate Withdrawal Scale (SOWS) and Objective Opiate Withdrawal Scale (OOWS) at baseline and 7, 14, and 21 days after the administration of the first dose. Study participants underwent weekly clinical evaluation for signs and symptoms of methadone withdrawal and for AEs of pegIFN. RESULTS: Nine patients were included in the study (7 men, 2 women; 7 Hispanic, 2 black; mean [SD] age, 41 [8.3] years; mean [SD] weight, 75.0 [12.3] kg). We did not observe any significant changes from baseline in mean C(max), T(max), C(min), AUC, and CL/F values despite 80% power to detect a 30% change in either direction. Changes from baseline in SOWS and OOWS scores were not statistically significant. The only AEs reported were mild and consistent with those expected after pegIFN alfa-2b administration, such as inflammation at the injection site and mild, brief, flu-like symptoms. CONCLUSION: Based on the results of this small, prospective, nonrandomized study, pegIFN alfa-2b did not appear to precipitate opioid withdrawal in this sample of methadone-maintained persons with HIV and chronic HCV coinfection; methadone dosage adjustments were unlikely to be needed
— id: 96490, year: 2007, vol: 29, page: 131, stat: Journal Article,

Safe Syringe Disposal is Related to Safe Syringe Access among HIV-positive Injection Drug Users
Coffin, Phillip O; Latka, Mary H; Latkin, Carl; Wu, Yingfeng; Purcell, David W; Metsch, Lisa; Gomez, Cynthia; Gourevitch, Marc N
2007 Sep;11(5):652-662, AIDS & behavior
We evaluated the effect of syringe acquisition on syringe disposal among HIV-positive injection drug users (IDUs) in Baltimore, New York City, and San Francisco (N = 680; mean age 42 years, 62% male, 59% African-American, 21% Hispanic, 12% White). Independent predictors of safe disposal were acquiring syringes through a safe source and ever visiting a syringe exchange program. Weaker predictors included living in San Francisco, living in the area longer, less frequent binge drinking, injecting with an HIV+ partner, peer norms supporting safe injection, and self-empowerment. Independent predictors of safe 'handling'-both acquiring and disposing of syringes safely-also included being from New York and being older. HIV-positive IDUs who obtain syringes from a safe source are more likely to safely dispose; peer norms contribute to both acquisition and disposal. Interventions to improve disposal should include expanding sites of safe syringe acquisition while enhancing disposal messages, alternatives, and convenience
— id: 73926, year: 2007, vol: 11, page: 652, stat: Journal Article,

Update in addiction medicine for the generalist
Gordon, Adam J; Sullivan, Lynn E; Alford, Daniel P; Arnsten, Julia H; Gourevitch, Marc N; Kertesz, Stefan G; Kunins, Hillary V; Merrill, Joseph O; Samet, Jeffrey H; Fiellin, David A
2007 Aug;22(8):1190-1194, Journal of general internal medicine
— id: 96488, year: 2007, vol: 22, page: 1190, stat: Journal Article,

On-site medical care in methadone maintenance: associations with health care use and expenditures
Gourevitch, Marc N; Chatterji, Pinka; Deb, Nandini; Schoenbaum, Ellie E; Turner, Barbara J
2007 Mar;32(2):143-151, Journal of substance abuse treatment
To evaluate whether long-term drug treatment with on-site medical care is associated with diminished inpatient and outpatient service use and expenditures, we linked prospective interview data to concurrent Medicaid claims of drug users in a methadone program with comprehensive medical services. Patient care was classified as follows: long-term (>/=6 months) drug treatment with on-site usual source of medical care (linked care), long-term drug treatment only, or neither. Multivariate analyses adjusted for visit clustering within patients (n = 423, with 1,161 person-years of observation). After adjustment, linked care participants had more outpatient visits (p < .001), fewer emergency department (ED) visits (24% vs. 33%, p = .02) and fewer hospitalizations (27% vs. 40%, p = .002) than the 'neither' group. Ambulatory care expenditures in the linked group were increased, whereas expenditures for other services were similar or reduced. Long-term drug treatment with on-site medical care was associated with increased ambulatory care, less ED and inpatient care, and no net increase in expenditures
— id: 71928, year: 2007, vol: 32, page: 143, stat: Journal Article,

Microsocial environmental influences on highly active antiretroviral therapy outcomes among active injection drug users: the role of informal caregiving and household factors
Knowlton, Amy R; Arnsten, Julia H; Gourevitch, Marc N; Eldred, Lois; Wilkinson, James D; Rose, Carol Dawson; Buchanan, Amy; Purcell, David W
2007 Nov 1;46 Suppl 2:S110-S119, Journal of acquired immune deficiency syndromes. JAIDS
Active injection drug users (IDUs) are at high risk of unsuccessful highly active antiretroviral therapy (HAART). We sought to identify baseline factors differentiating IDUs' treatment success versus treatment failure over time among those taking HAART. Interventions for Seropositive Injectors-Research and Evaluation (INSPIRE) study participants were assessed at baseline and at 6- and 12-month follow-ups. Multinominal regression determined baseline predictors of achieving or maintaining viral suppression relative to maintaining detectable viral loads over 12 months. Of 199 participants who were retained and remained on HAART, 133 (67%) had viral load change patterns included in the analysis. At follow-up, 66% maintained detectable viral loads and 15% achieved and 19% maintained viral suppression. Results indicated that those having informal care (instrumental or emotional support) were 4.6 times more likely to achieve or maintain viral suppression relative to experiencing treatment failure. Those who maintained viral suppression were 3.5 times less likely to live alone or to report social discomfort in taking HAART. Study results underscore the importance of microsocial factors of social network support, social isolation, and social stigma for successful HAART outcomes among IDUs. The findings suggest that adherence interventions for IDUs should promote existing informal HIV caregiving, living with supportive others, and positive medication-taking norms among social networks
— id: 96486, year: 2007, vol: 46 Suppl 2, page: S110, stat: Journal Article,

Hepatitis C management by addiction medicine physicians: results from a national survey
Litwin, Alain H; Kunins, Hillary V; Berg, Karina M; Federman, Alex D; Heavner, Karyn K; Gourevitch, Marc N; Arnsten, Julia H
2007 Jul;33(1):99-105, Journal of substance abuse treatment
Drug users are disproportionately affected by hepatitis C virus (HCV), yet they face barriers to health care that place them at risk for levels of HCV-related care that are lower than those of nondrug users. Substance abuse treatment physicians may treat more HCV-infected persons than other generalist physicians, yet little is known about how such physicians facilitate HCV-related care. We conducted a nationwide survey of American Society of Addiction Medicine physicians (n = 320) to determine substance abuse physicians' HCV-related management practices and to describe factors associated with these practices. We found that substance abuse treatment physicians promote several elements of HCV-related care, including screening for HCV antibodies, recommending vaccinations against hepatitis A and B, and referring patients to subspecialists for HCV treatment. Substance abuse physicians who also provide primary medical or HIV-related care were most likely to facilitate HCV-related care. A significant minority of physicians were either providing HCV antiviral treatment or willing to provide HCV antiviral treatment
— id: 96489, year: 2007, vol: 33, page: 99, stat: Journal Article,

Results from a randomized controlled trial of a peer-mentoring intervention to reduce HIV transmission and increase access to care and adherence to HIV medications among HIV-seropositive injection drug users
Purcell, David W; Latka, Mary H; Metsch, Lisa R; Latkin, Carl A; Gomez, Cynthia A; Mizuno, Yuko; Arnsten, Julia H; Wilkinson, James D; Knight, Kelly R; Knowlton, Amy R; Santibanez, Scott; Tobin, Karin E; Rose, Carol Dawson; Valverde, Eduardo E; Gourevitch, Marc N; Eldred, Lois; Borkowf, Craig B
2007 Nov 1;46 Suppl 2:S35-S47, Journal of acquired immune deficiency syndromes. JAIDS
BACKGROUND: There is a lack of effective behavioral interventions for HIV-positive injection drug users (IDUs). We sought to evaluate the efficacy of an intervention to reduce sexual and injection transmission risk behaviors and to increase utilization of medical care and adherence to HIV medications among this population. METHODS: HIV-positive IDUs (n=966) recruited in 4 US cities were randomly assigned to a 10-session peer mentoring intervention or to an 8-session video discussion intervention (control condition). Participants completed audio computer-assisted self-interviews and had their blood drawn to measure CD4 cell count and viral load at baseline and at 3-month (no blood), 6-month, and 12-month follow-ups. RESULTS: Overall retention rates for randomized participants were 87%, 83%, and 85% at 3, 6, and 12 months, respectively. Participants in both conditions reported significant reductions from baseline in injection and sexual transmission risk behaviors, but there were no significant differences between conditions. Participants in both conditions reported no change in medical care and adherence, and there were no significant differences between conditions. CONCLUSIONS: Both interventions led to decreases in risk behaviors but no changes in medical outcomes. The characteristics of the trial that may have contributed to these results are examined, and directions for future research are identified
— id: 96484, year: 2007, vol: 46 Suppl 2, page: S35, stat: Journal Article,

Two-step tuberculin skin testing in drug users
Swaminathan, Shobha; Schoenbaum, Ellie E; Klein, Robert S; Howard, Andrea A; Lo, Yungtai; Gourevitch, Marc N
2007 ;26(2):71-79, Journal of addictive diseases
To assess the utility of booster testing and to identify factors associated with a positive booster test, two-step tuberculin testing was performed in drug users recruited from methadone treatment. Participants also received a standardized interview on demographics and testing for HIV and CD4+ lymphocyte count. Of 619 enrollees completing the protocol, 174 (28%) had a positive PPD and 24 of the remaining 445 (5%) had a positive booster test. On multivariate analysis, boosting was associated with older age (adjusted odds ratio [ORadj] 2.38/decade, 95% confidence interval [CI] 1.34-4.22), history of using crack cocaine (ORadj 2.61, 95% CI 1.10-6.18) and a history of working as a home health aide (ORadj 4.23, 95% CI 1.39-12.86). Two-step tuberculin skin testing increased the proportion of participants with latent tuberculosis infection from 22% to 25%. Given the effectiveness of chemoprophylaxis, booster testing should be considered when drug users are screened for tuberculosis infection
— id: 96487, year: 2007, vol: 26, page: 71, stat: Journal Article,

Colocating buprenorphine with methadone maintenance and outpatient chemical dependency services
Whitley, Susan D; Kunins, Hillary V; Arnsten, Julia H; Gourevitch, Marc N
2007 Jul;33(1):85-90, Journal of substance abuse treatment
Buprenorphine may be used to treat opioid dependence in office-based settings, but treatment models are needed to ensure access to psychosocial services needed by many patients. We describe a novel buprenorphine treatment program colocated with methadone maintenance and outpatient chemical dependency services. We conducted a retrospective chart review of the first 40 consecutive patients initiating buprenorphine treatment in this program to determine characteristics associated with treatment retention. Exclusion criteria were current alcohol or benzodiazepine dependence. Secondary drug users and patients who were psychiatrically or medically ill were included. At 6 months, 60% (n = 24) were retained, 13% (n = 5) tested positive for opiates, and 25% (n = 10) tested positive for secondary substances. Patients who were older (odds ratio [OR] per year of age = 1.1, confidence interval [CI] = 1.0-1.2) and those who were employed (OR = 9.8, CI = 1.8-53.1) were more likely to remain in treatment, but other variables were not associated with retention. Our experience demonstrates that buprenorphine can be successfully integrated into outpatient substance abuse treatment
— id: 89582, year: 2007, vol: 33, page: 85, stat: Journal Article,

Longitudinal correlates of health care-seeking behaviors among HIV-seropositive injection drug users: how can we intervene to improve health care utilization?
Wilkinson, James D; Zhao, Wei; Arnsten, Julia H; Knowlton, Amy R; Mizuno, Yuko; Shade, Starley B; Gourevitch, Marc N; Santibanez, Scott; Metsch, Lisa R
2007 Nov 1;46 Suppl 2:S120-S126, Journal of acquired immune deficiency syndromes. JAIDS
OBJECTIVE: To identify modifiable factors associated with health care utilization by HIV-negative seropositive injection drug users (IDUs). METHODS: We analyzed longitudinal data from 966 participants in a randomized controlled trial of a behavioral intervention designed to address medical care, adherence, and risk reduction. The outcomes of this study were usual place for care (clinic vs. emergency room) and frequency of primary care visits. RESULTS: Results of multiple logistic regression analysis showed that increase in 'importance of HIV care scale' score (odds ratio [OR]=2.99; P<0.001), empowerment (OR=3.53; P<0.001), utilization of case management (OR=3.07; P=0.007), and having a stable residence (OR=2.63; P=0.008) were significantly associated with participants being 'clinic users.' Increase in importance of HIV care scale score (OR=5.65; P=0.01) increased empowerment (OR=2.42; P=0.005), taking greater control of one's health (OR=2.17; P=0.001), having health insurance (OR=2.58; P=0.003), utilization of case management (OR=3.14; P=0.027), and CD4 count>or=200 cells/mm (OR=2.09; P=0.007) were significantly associated with reporting 2 or more primary HIV care visits in the past 6 months. CONCLUSIONS: Future interventions for this population may be strengthened by addressing the importance of HIV primary care; empowering participants with respect to the health care system; and promoting linkages to case management, health insurance, and local housing programs
— id: 96485, year: 2007, vol: 46 Suppl 2, page: S120, stat: Journal Article,

False reduction in serum methadone concentrations by BD Vacutainer serum separator tubes (SSTTM)
Berk, Steven I; Litwin, Alain H; Du, Yunling; Cruikshank, Greg; Gourevitch, Marc N; Arnsten, Julia H
2006 Oct;52(10):1972-1974, Clinical chemistry
— id: 97797, year: 2006, vol: 52, page: 1972, stat: Journal Article,

Pharmacokinetic drug interactions between opioid agonist therapy and antiretroviral medications: implications and management for clinical practice
Bruce, R Douglas; Altice, Frederick L; Gourevitch, Marc N; Friedland, Gerald H
2006 Apr 15;41(5):563-572, Journal of acquired immune deficiency syndromes. JAIDS
BACKGROUND: Opioid dependence and HIV/AIDS are 2 of the most serious yet treatable diseases worldwide. Global access to opioid agonist therapy and HIV treatment is expanding but when concurrently used, problematic pharmacokinetic drug interactions can occur. METHODS: We reviewed English, Spanish, French, and Italian language articles from 1966 to 2005 in Medline using the following keywords: HIV, AIDS, HIV therapy, antiretroviral therapy, HAART, drug interactions, methadone, and buprenorphine. Additionally, we reviewed abstracts from national and international meetings and conference proceedings. Selected references from these articles were reviewed as well. RESULTS: Clinical case series and carefully controlled pharmacokinetic interaction studies have been conducted between methadone and most approved antiretroviral therapies. Important pharmacokinetic drug interactions have been demonstrated within each class of agents, affecting either methadone or antiretroviral agents. Few studies, however, have been conducted with buprenorphine. The metabolism of both therapies, description of the known interactions, and clinical implications and management of these interactions are reviewed. CONCLUSIONS: Certain interactions between methadone and antiretroviral medications are known and may have important clinical consequences. To optimize care, clinicians must be alert to these interactions and have a basic knowledge regarding their management
— id: 66132, year: 2006, vol: 41, page: 563, stat: Journal Article,

Opioid dependence: rationale for and efficacy of existing and new treatments
Fiellin, David A; Friedland, Gerald H; Gourevitch, Marc N
2006 Dec 15;43 Suppl 4:S173-S177, Clinical infectious diseases
Opioid dependence is a chronic and relapsing medical disorder with a well-established neurobiological basis. Opioid agonist treatments, such as methadone and the recently approved buprenorphine, stabilize opioid receptors and the intracellular processes that lead to opioid withdrawal and craving. Both methadone and buprenorphine have been proven effective for the treatment of opioid dependence and can contribute to a decreased risk of human immunodeficiency virus (HIV) transmission. In addition, a buprenorphine/naloxone combination appears to have a decreased potential for abuse or diversion, compared with that associated with methadone. Largely because of these properties, recent legislation now affords an unprecedented opportunity for general physicians to offer opioid agonist treatment through their offices. This review focuses on the neurobiological basis of opioid dependence, the rationale for methadone and buprenorphine treatments, and issues in prescribing these medications to patients with HIV infection
— id: 96491, year: 2006, vol: 43 Suppl 4, page: S173, stat: Journal Article,

A 5-year evaluation of a methadone medical maintenance program
Harris, Kenneth A Jr; Arnsten, Julia H; Joseph, Herman; Hecht, Joe; Marion, Ira; Juliana, Patti; Gourevitch, Marc N
2006 Dec;31(4):433-438, Journal of substance abuse treatment
Methadone medical maintenance (MMM) is a model for the treatment of opioid dependence in which a monthly supply of methadone is distributed in an office setting, in contrast to more highly regulated settings where daily observed dosing is the norm. We assessed patient characteristics and treatment outcomes of an MMM program initiated in the Bronx, New York, in 1999 by conducting a retrospective chart review. Participant characteristics were compared with those of patients enrolled in affiliated conventional methadone maintenance treatment programs. Patients had diverse ethnicities, occupations, educational backgrounds, and income levels. Urine toxicology testing detected illicit opiate and cocaine use in 0.8% and 0.4% of aggregate samples, respectively. The retention rate was 98%, which compares favorably with the four other MMM programs that have been reported in the medical literature. This study demonstrates that selected patients from a socioeconomically disadvantaged population remained clinically stable and engaged in treatment in a far less intensive setting than traditional methadone maintenance
— id: 96492, year: 2006, vol: 31, page: 433, stat: Journal Article,

Individual, interpersonal, and structural correlates of effective HAART use among urban active injection drug users
Knowlton, Amy; Arnsten, Julia; Eldred, Lois; Wilkinson, James; Gourevitch, Marc; Shade, Starley; Dowling, Krista; Purcell, David
2006 Apr 1;41(4):486-492, Journal of acquired immune deficiency syndromes. JAIDS
Among individuals receiving highly active antiretroviral therapy (HAART), injection drug users (IDUs) are less likely to achieve HIV suppression. The present study examined individual-level, interpersonal, and structural factors associated with achieving undetectable plasma viral load (UVL) among US IDUs receiving recommended HAART. Data were from baseline assessments of the INSPIRE (Interventions for Seropositive Injectors-Research and Evaluation) study, a 4-site, secondary HIV prevention intervention for heterosexually active IDUs. Of 1113 study participants at baseline, 42% (n = 466) were currently taking recommended HAART (34% were female, 69% non-Hispanic black, 26% recently homeless; median age was 43 years), of whom 132 (28%) had a UVL. Logistic regression revealed that among those on recommended HAART, adjusted odds of UVL were at least 3 times higher among those with high social support, stable housing, and CD4 > 200; UVL was approximately 60% higher among those reporting better patient-provider communication. Outpatient drug treatment and non-Hispanic black race and an interaction between current drug use and social support were marginally negatively significant. Among those with high perceived support, noncurrent drug users compared with current drug users had a greater likelihood of UVL; current drug use was not associated with UVL among those with low support. Depressive symptoms (Brief Symptom Inventory) were not significant. Results suggest the major role of social support in facilitating effective HAART use in this population and suggest that active drug use may interfere with HAART use by adversely affecting social support. Interventions promoting social support functioning, patient-provider communication, stable housing, and drug abuse treatment may facilitate effective HAART use in this vulnerable population
— id: 66131, year: 2006, vol: 41, page: 486, stat: Journal Article,

Unprotected sex among HIV-positive injection drug-using women and their serodiscordant male partners: role of personal and partnership influences
Latka, Mary H; Metsch, Lisa R; Mizuno, Yulo; Tobin, Karin; Mackenzie, Sonia; Arnsten, Julia H; Gourevitch, Marc N
2006 Jun;42(2):222-228, Journal of acquired immune deficiency syndromes. JAIDS
We investigated the characteristics of human immunodeficiency virus (HIV)-positive injection drug-using women who reported unprotected vaginal and/or anal sex with HIV-negative or unknown serostatus (serodiscordant) male partners. Of 426 female study participants, 370 were sexually active. Of these women, 39% (144/370) and 40% (148/370) reported vaginal and/or anal sex with serodiscordant main and casual partners, respectively. Sixty percent of women inconsistently used condoms with their serodiscordant main partners, whereas 53% did so with casual partners. In multivariate analysis, during sex with main partners, inconsistent condom users were less likely to feel confident about achieving safe sex (self-efficacy), personal responsibility for limiting HIV transmission, and that their partner supported safe sex. Inconsistent condom use was also more likely among women who held negative beliefs about condoms and in couplings without mutual disclosure of HIV status. Regarding sex with casual partners, inconsistent condom users were more likely to experience psychologic distress, engage in sex trading, but they were less likely to feel confident about achieving safe sex. These findings suggest that there are widespread opportunities for the sexual transmission of HIV from drug-using women to HIV-uninfected men, and that reasons vary by type of partnership. Multifaceted interventions that address personal, dyadic, and addiction problems are needed for HIV-positive injection drug-using women
— id: 66130, year: 2006, vol: 42, page: 222, stat: Journal Article,

Drug interactions between opioids and antiretroviral medications: interaction between methadone, LAAM, and delavirdine
McCance-Katz, Elinore F; Rainey, Petrie M; Smith, Patrick; Morse, Gene D; Friedland, Gerald; Boyarsky, Beth; Gourevitch, Marc; Jatlow, Peter
2006 Jan-Feb;15(1):23-34, American journal on addictions
Understanding the drug interactions between antiretrovirals and opioid therapies may decrease toxicities and enhance adherence with improved HIV outcomes in opioid-dependent individuals. The authors report the results of a clinical pharmacology study designed to determine whether significant pharmacokinetic and/or pharmacodynamic interactions occur between the non-nucleoside reverse transcriptase inhibitor, delavirdine (DLV), and either methadone or levo-alpha acetyl methadol (LAAM) (n = 40). DLV significantly decreased methadone clearance (p = .018) and increased the methadone elimination half-life (p < .001) with a resultant increase in AUC of 19% and C(min)of 29%. The combined effect of DLV on the total concentration of LAAM and its active metabolites, norLAAM and dinorLAAM, was to significantly increase AUC by 43% (p < .001), C(max) by 30% (p = .013), and C(min) by 59% (p = .004) while decreasing T(max) (p = .05). Cognitive deficits over the seven-day study period as measured by the Mini-Mental State Examination, opioid withdrawal symptoms as measured by the Objective Opioid Withdrawal Scale, or complaints of adverse symptoms were not observed. Methadone and LAAM did not affect DLV concentrations. The findings from this study show that DLV treatment in methadone- or LAAM-maintained individuals results in altered opioid pharmacokinetics with an increased exposure and potential risk for opioid toxicity with methadone or LAAM treatment and an increased risk of cardiac toxicity with concomitant LAAM and DLV administration
— id: 66135, year: 2006, vol: 15, page: 23, stat: Journal Article,

Improving access to sterile syringes and safe syringe disposal for injection drug users in methadone maintenance treatment
McNeely, Jennifer; Arnsten, Julia H; Gourevitch, Marc N
2006 Jul;31(1):51-57, Journal of substance abuse treatment
We evaluated a novel intervention designed to improve access to sterile syringes and safe syringe disposal for injection drug users (IDUs) newly enrolled in methadone maintenance, through interviews with two sequential cohorts of 100 recent entrants into a methadone program in the Bronx, NY. A substantial number of participants had injected in the previous 6 months, and most continued injecting during the early weeks of treatment. The intervention was associated with significant behavior changes among IDUs, including increased use of pharmacies as a primary source of syringes (11% vs. 37%, p < .05) and decreases in both purchasing of syringes on the street (51% vs. 27%, p < .05) and needle sharing (40% vs. 7%, p < .01). The intervention had no impact on the prevalence of injection or on syringe disposal practices. Our findings suggest that drug treatment programs can serve an important role in reducing injection-related risk behavior by facilitating access to sterile syringes
— id: 66129, year: 2006, vol: 31, page: 51, stat: Journal Article,

Sterile syringe access and disposal among injection drug users newly enrolled in methadone maintenance treatment: a cross-sectional survey
McNeely, Jennifer; Arnsten, Julia H; Gourevitch, Marc N
2006 ;3:8-8, Harm reduction journal
ABSTRACT : BACKGROUND : We sought to assess injection practices, means of acquiring and disposing of syringes, and utilization and knowledge of harm reduction resources among injection drug users (IDUs) entering methadone maintenance treatment (MMT). METHODS : Interviews with 100 consecutive patients, including 35 IDUs, entering a MMT program in the Bronx, NY. RESULTS : Utilization of unsafe syringe sources was reported by 69% of IDUs in our sample. Most (80%) IDUs reused syringes, and syringe sharing was also common. Fewer than half knew that non-prescription pharmacy purchase of syringes was possible. The most common means of disposing of injecting equipment were the trash (63%) and syringe exchange programs (49%). CONCLUSIONS : These findings indicate that drug users entering treatment under-utilize sanctioned venues to obtain sterile syringes or safely dispose of used injection equipment. Programs providing services to drug users should adopt a proactive stance to address the safety and health issues faced by injectors
— id: 66134, year: 2006, vol: 3, page: 8, stat: Journal Article,

Correlates of health care utilization among HIV-seropositive injection drug users
Mizuno, Y; Wilkinson, J D; Santibanez, S; Dawson Rose, C; Knowlton, A; Handley, K; Gourevitch, M N
2006 Jul;18(5):417-425, AIDS Care
This study sought to identify correlates of poor health care utilization among HIV-positive injection drug users (IDUs) using Andersen's behavioural health model. We used baseline data from INSPIRE, a study of HIV-positive IDUs (n=1161) to identify predisposing, enabling, and need factors related to poor utilization (defined as fewer than two outpatient visits in the past six months, or identification of emergency room (ER) as the usual place for care). Using bivariate and multivariate models, we found a number of enabling factors that could facilitate the use of health care services such as having health insurance, having seen a case manager, and better engagement with health care providers. These enabling factors could be modified through interventions targeting HIV-positive IDUs. In addition, health insurance and case management appear to be important factors to address because they contributed in making other factors (e.g. lower education, lack of stable housing) non-significant barriers to outpatient care utilization. In the future, these findings may be used to inform the development of interventions that maximize use of scarce HIV resources and improve health care utilization among HIV-positive IDUs
— id: 66146, year: 2006, vol: 18, page: 417, stat: Journal Article,

Agreement between Mantoux skin testing and QuantiFERON-TB assay using dual mycobacterial antigens in current and former injection drug users
Shah, Sanjiv S; McGowan, Joseph P; Klein, Robert S; Converse, Paul J; Blum, Steve; Gourevitch, Marc N
2006 Apr;12(4):MT11-MT16, Medical science monitor
BACKGROUND: Individuals infected with non-tuberculous mycobacteria may elicit false-positive reactions on tuberculin skin testing. The QuantiFERON-TB (QFT) assay utilizes tuberculin and M. avium antigens and, therefore, may be more specific for latent tuberculosis infection. The objective of this study was to investigate the agreement between the QFT and single and dual antigen skin testing for detecting latent M. tuberculosis and assess the impact of cross-reactions from latent infection with other mycobacteria in inner-city injection drug users, a population at high risk for tuberculosis. MATERIAL/METHODS: We studied the agreement of results from skin testing using tuberculin and purified protein derivative-Battey (PPD-B) with the QFT test using tuberculin and Mycobacterium avium sensitin (MAS) in 48 HIV-seronegative injection drug users. RESULTS: The agreement between skin testing and the QFT assay for tuberculin was 73% (kappa = 0.45) and for PPD-B/MAS was 63% (kappa = 0.12). Agreement between skin test tuberculin dominance (tuberculin reaction > or =5 mm greater than PPD-B) and QFT tuberculin dominance (proportional difference between MAS and tuberculin reaction of > or =10%) was 75% (kappa = 0.53). All subjects tuberculin dominant by skin test were also QFT positive for tuberculin. Agreement between skin test Battey dominance and QFT avium dominance was 83% (kappa = 0.12). CONCLUSIONS: Results from the QFT assay and skin testing demonstrated moderate concordance in identifying subjects with latent tuberculous infection, and use of dual antigens did not appreciably improve the agreement between the two methods
— id: 66133, year: 2006, vol: 12, page: MT11, stat: Journal Article,

Overcoming barriers to prevention, care, and treatment of hepatitis C in illicit drug users
Edlin, Brian R; Kresina, Thomas F; Raymond, Daniel B; Carden, Michael R; Gourevitch, Marc N; Rich, Josiah D; Cheever, Laura W; Cargill, Victoria A
2005 Apr 15;40 Suppl 5:S276-S285, Clinical infectious diseases
Injection drug use accounts for most of the incident infections with hepatitis C virus (HCV) in the United States and other developed countries. HCV infection is a complex and challenging medical condition in injection drug users (IDUs). Elements of care for hepatitis C in illicit drug users include prevention counseling and education; screening for transmission risk behavior; testing for HCV and human immunodeficiency virus infection; vaccination against hepatitis A and B viruses; evaluation for comorbidities; coordination of substance-abuse treatment services, psychiatric care, and social support; evaluation of liver disease; and interferon-based treatment for HCV infection. Caring for patients who use illicit drugs presents challenges to the health-care team that require patience, experience, and an understanding of the dynamics of substance use and addiction. Nonetheless, programs are successfully integrating hepatitis C care for IDUs into health-care settings, including primary care, methadone treatment and other substance-abuse treatment programs, infectious disease clinics, and clinics in correctional facilities
— id: 66141, year: 2005, vol: 40 Suppl 5, page: S276, stat: Journal Article,

Medical complications of drug use
Gourevitch, Marc N; Arnsten, Julia H
Substance abuse : a comprehensive textbook Philadelphia : Lippincott Williams & Wilkins, 2005,
— id: 5488, year: 2005, vol: , page: ?, stat: Chapter,

Effects of methadone on QT-interval dispersion
Krantz, Mori J; Lowery, Christopher M; Martell, Bridget A; Gourevitch, Marc N; Arnsten, Julia H
2005 Nov;25(11):1523-1529, Pharmacotherapy
STUDY OBJECTIVE: To evaluate the effects of methadone on QT-interval dispersion. DESIGN: Single-center, prospective, cohort study. SETTING: Methadone maintenance treatment facility. PATIENTS: One hundred eighteen patients who were newly admitted to the facility. Intervention. Twelve-lead electrocardiograms (ECGs) were performed in patients at both baseline and 6 months after the start of methadone therapy. MEASUREMENTS AND MAIN RESULTS: The ECGs were manually interpreted, and investigators were blinded to time interval and methadone dose. At least eight discernible ECG leads were required for study inclusion. Mean differences between baseline and follow-up rate-corrected QT (QTc) interval and QT dispersion were compared. Multivariate associations between clinical characteristics and magnitude of change in QT dispersion were assessed using linear regression. Mean +/- SD baseline QT dispersion was 32.9 +/- 12 msec, which increased to 42.4 +/- 15 msec (+9.5 +/- 18.6 msec, p<0.0001) after 6 months of therapy. The QTc increased by a similar magnitude (+14.1 msec, p<0.0001). No QT dispersion value exceeded 100 msec. The only variable associated with a greater increase in QT dispersion was antidepressant therapy (20 vs 8.5 msec, p=0.04). CONCLUSION: Methadone modestly increased both QTc interval and QT dispersion. Increased QT dispersion reflects heterogeneous cardiac repolarization and occurs with nonantiarrhythmic agents, such as synthetic opioids. However, the magnitude of this effect appears to be substantially less with methadone than with antiarrhythmic drugs
— id: 66136, year: 2005, vol: 25, page: 1523, stat: Journal Article,

Integrating services for injection drug users infected with hepatitis C virus with methadone maintenance treatment: challenges and opportunities
Litwin, Alain H; Soloway, Irene; Gourevitch, Marc N
2005 Apr 15;40 Suppl 5:S339-S345, Clinical infectious diseases
Despite the high prevalence of hepatitis C virus (HCV) infection among drug users enrolled in methadone maintenance treatment programs, few drug users are being treated with combination therapy. The most significant barrier to treatment is lack of access to comprehensive HCV-related care. We describe a pilot program to integrate care for HCV infection with substance abuse treatment in a setting of maintenance treatment with methadone. This on-site, multidisciplinary model of care includes comprehensive screening and treatment for HCV infection, assessment of eligibility, counseling with regard to substance abuse, psychiatric services, HCV support groups, directly observed therapy, and enhanced linkages to a tertiary care system for diagnostic procedures. Our approach has led to high levels of adherence, with liver biopsy and substantial rates of initiation of antiviral therapy. Two cases illustrate the successful application of this model to patients with HCV infection complicated by active substance abuse and psychiatric comorbidity
— id: 66140, year: 2005, vol: 40 Suppl 5, page: S339, stat: Journal Article,

Impact of methadone treatment on cardiac repolarization and conduction in opioid users
Martell, Bridget A; Arnsten, Julia H; Krantz, Mori J; Gourevitch, Marc N
2005 Apr 1;95(7):915-918, American journal of cardiology
We prospectively assessed the effect of oral methadone on the corrected QT interval (QTc) among 160 patients free of structural heart disease and measured serum methadone concentrations and simultaneous QTc intervals in a subset of 44 participants. Mean +/- SD QTc increased by 12.4 +/- 23 ms (p <0.001) at 6 months, by 10.7 +/- 30 ms (p <0.001) at 12 months, and the QTc change from baseline to 12 months correlated with the trough (r = 0.37, p = 0.008) and peak (r = 0.32, p = 0.03) serum methadone concentrations
— id: 66139, year: 2005, vol: 95, page: 915, stat: Journal Article,

The impact of barriers to hepatitis C virus treatment in recovering heroin users maintained on methadone
Sylvestre, Diana L; Litwin, Alain H; Clements, Barry J; Gourevitch, Marc N
2005 Oct;29(3):159-165, Journal of substance abuse treatment
Although most cases of hepatitis C virus (HCV) infection are associated with injection drug use, there are few data regarding the impact of putative barriers such as psychiatric disease and intercurrent drug use on HCV treatment outcomes. To define the impact of characteristics often cited as reasons for withholding HCV treatment, we studied HCV treatment in a real world sample of 76 recovering heroin users maintained on methadone. Overall, 21 (28%) had a sustained virological response and 18 (24%) discontinued treatment early. Although there was a modest decrement in response rates in patients reporting a preexisting psychiatric history (p = .01), neither intercurrent drug use nor short duration of pretreatment drug abstinence led to significant reductions in virological outcomes (p = .09 and p = .18, respectively.) We conclude that injection drug users can be safely and effectively treated for HCV despite multiple barriers to treatment when they are treated in a setting that can address their special needs
— id: 66138, year: 2005, vol: 29, page: 159, stat: Journal Article,

Economic evaluation of an HIV prevention intervention for seropositive injection drug users
Tuli, Karunesh; Sansom, Stephanie; Purcell, David W; Metsch, Lisa R; Latkin, Carl A; Gourevitch, Marc N; Gomez, Cynthia A
2005 Nov-Dec;11(6):508-515, Journal of public health management & practice
OBJECTIVE: To assess the cost-effectiveness of Intervention for HIV-Seropositive injection drug users--Research and Evaluation (INSPIRE), designed to reduce risky sexual and needle-sharing behaviors in research sites in four US cities (2001-2003). METHODS: We collected data on program and participant costs. We used a mathematical model to estimate the number of sex partners of injection drug users expected to become infected with human immunodeficiency virus (HIV) (with and without intervention), cost of treatment for sex partners who became infected, and the effect of infection on partners' quality-adjusted life expectancy. We determined the minimum effect that INSPIRE must have on condom use among participants for the intervention to be cost-saving (intervention cost less than savings from averted HIV infections) or cost-effective (net cost per quality-adjusted life year saved less than $50,000). RESULTS: The intervention cost was $870 per participant. It would be cost-saving if it led to 53 percent reduction in the proportion of participants who had any unprotected sex in 1 year and cost-effective with 17 percent reduction. If behavior change lasted 3 months, the cost-effectiveness threshold was 66 percent; if 3 years, the threshold was 6 percent. CONCLUSIONS: Although cost-saving thresholds may not be achievable by the intervention, we anticipate that cost-effectiveness thresholds will be attained
— id: 66137, year: 2005, vol: 11, page: 508, stat: Journal Article,

Gender differences in factors associated with adherence to antiretroviral therapy
Berg, Karina M; Demas, Penelope A; Howard, Andrea A; Schoenbaum, Ellie E; Gourevitch, Marc N; Arnsten, Julia H
2004 Nov;19(11):1111-1117, Journal of general internal medicine
OBJECTIVE: To identify gender differences in social and behavioral factors associated with antiretroviral adherence. DESIGN: Prospective cohort study. SETTING: Methadone maintenance program. PARTICIPANTS: One hundred thirteen HIV-seropositive current or former opioid users. MEASUREMENTS AND MAIN RESULTS: Participants were surveyed at baseline about social and behavioral characteristics and at monthly research visits about drug and alcohol use and medication side effects. Electronic monitors (MEMS) were used to measure antiretroviral adherence. Median adherence among women was 27% lower than among men (46% vs. 73%; P < .05). In gender-stratified multivariate models, factors associated with worse adherence in men included not belonging to an HIV support group (P < .0001), crack/cocaine use (P < .005), and medication side effects (P = .01). Among women, alcohol use (P = .005), heroin use (P < .05), and significant medication side effects (P < .005) were independently associated with worse adherence. In a model including both men and women, worse adherence was associated with lack of long-term housing (P < .005), not belonging to any HIV support groups (P < .0005), crack or cocaine use (P < .01), and medication side effects (P < .0005). In addition, worse adherence was associated with the interaction between female gender and alcohol use (P < or = .05). CONCLUSIONS: In this cohort of current and former opioid users, gender-stratified analysis demonstrated that different social and behavioral factors are associated with adherence in men and women. Among both men and women, worse adherence was associated with lack of long-term housing, not belonging to an HIV support group, crack/cocaine use, and medication side effects. Among women only, alcohol use was associated with worse adherence
— id: 66142, year: 2004, vol: 19, page: 1111, stat: Journal Article,

Factors associated with successful referral for clinical care of drug users with chronic hepatitis C who have or are at risk for HIV infection
Fishbein, Dawn A; Lo, Yungtai; Reinus, John F; Gourevitch, Marc N; Klein, Robert S
2004 Nov 1;37(3):1367-1375, Journal of acquired immune deficiency syndromes. JAIDS
The objective of this study was to determine outcomes of referring drug users (DUs) with chronic hepatitis C for clinical evaluation and care. Two hundred twenty-eight persons with detectable hepatitis C virus RNA were given expedited referrals for evaluation and possible treatment of hepatitis C from a prospective study cohort of current and former opiate-addicted DUs. Four outcomes were analyzed: accepted referral, arrived for clinical evaluation, had liver biopsy, and received treatment. One hundred twenty-seven participants (56%) accepted referral, of whom 54 (43%) arrived for evaluation. Of these participants, 12 (22%) had liver biopsy, and 4 (7%) were treated. Multivariate logistic regression revealed that HIV-infected DUs were significantly less likely to accept referral (adjusted odds ratio [O(Radj)], 0.51; 95% confidence interval [CI], 0.30-0.88), and older participants were more likely to keep an appointment (O(Radj), 1.06/y; 95% CI, 1.00-1.12). Of HIV-seropositive participants, those with a history of injection were more likely to accept referral (O(Radj), 3.60; 95% CI, 1.08-11.96), and those with higher HIV load (O(Radj), 0.50/log10; 95% CI, 0.26-0.94) and Hispanic ethnicity (O(Radj), 0.26; 95% CI, 0.07-0.89) were less likely to keep an appointment. Despite expedited referrals for hepatitis C care, only a few participants received an evaluation, and even far fewer were treated. Because increasingly effective treatment is available, better methods are urgently needed to improve evaluation and treatment of HCV-infected DUs, including those coinfected with HIV
— id: 66144, year: 2004, vol: 37, page: 1367, stat: Journal Article,

Effect of alcohol consumption on diabetes mellitus: a systematic review
Howard, Andrea A; Arnsten, Julia H; Gourevitch, Marc N
2004 Feb 3;140(3):211-219, Annals of internal medicine
BACKGROUND: Both diabetes mellitus and alcohol consumption are prevalent in the United States, yet physicians are poorly informed about how alcohol use affects risk for or management of diabetes. PURPOSE: To conduct a systematic review assessing the effect of alcohol use on the incidence, management, and complications of diabetes mellitus in adults. DATA SOURCES: English-language studies in persons 19 years of age or older that were identified by searching the MEDLINE database from 1966 to the third week of August 2003 and the reference lists of key articles. STUDY SELECTION: Two independent assessors reviewed 974 retrieved citations to identify all experimental, cohort, or case-control studies that assessed the effect of alcohol use on diabetes risk, control, self-management, adverse drug events, or complications. DATA EXTRACTION: Two independent reviewers extracted data and evaluated study quality on the basis of established criteria. DATA SYNTHESIS: Thirty-two studies that met inclusion criteria were reviewed. Compared with no alcohol use, moderate consumption (one to 3 drinks/d) is associated with a 33% to 56% lower incidence of diabetes and a 34% to 55% lower incidence of diabetes-related coronary heart disease. Compared with moderate consumption, heavy consumption (>3 drinks/d) may be associated with up to a 43% increased incidence of diabetes. Moderate alcohol consumption does not acutely impair glycemic control in persons with diabetes. CONCLUSIONS: Moderate alcohol consumption is associated with a decreased incidence of diabetes mellitus and a decreased incidence of heart disease in persons with diabetes. Further studies are needed to assess the long-term effects of alcohol consumption on glycemic control and noncardiac complications in persons with diabetes
— id: 43552, year: 2004, vol: 140, page: 211, stat: Journal Article,

The experience of chronic severe pain in patients undergoing methadone maintenance treatment
Karasz, Alison; Zallman, Leah; Berg, Karina; Gourevitch, Marc; Selwyn, Peter; Arnsten, Julia H
2004 Nov;28(5):517-525, Journal of pain & symptom management
Recent studies indicate that severe chronic pain is common among patients in methadone maintenance treatment (MMT), but no qualitative studies have examined such patients' experiences of pain and pain treatment. This study used qualitative methods to explore the experiences of MMT patients with chronic pain. Twelve patients screening positive for chronic severe pain on the Brief Pain Inventory were interviewed for the study. Results suggest that chronic severe pain has major consequences in the lives of methadone maintenance patients and may be linked to illegal drug use, social isolation, and role failure. A variety of barriers limited access to effective treatment. A common complaint with care was providers' lack of concern or inability to 'listen.' Patients who were satisfied with treatment focuses on the psychosocial dimensions of care. These preliminary results suggest that treatment approaches should emphasize emotional support, negotiation of explanatory models, and an emphasis on the psychosocial sequelae of pain. However, more research is needed to guide the development of effective treatment strategies
— id: 66143, year: 2004, vol: 28, page: 517, stat: Journal Article,

Validity of a self-reported history of a positive tuberculin skin test. A prospective study of drug users
Kunins, Hillary V; Howard, Andrea A; Klein, Robert S; Arnsten, Julia H; Litwin, Alain H; Schoenbaum, Ellie E; Gourevitch, Marc N
2004 Oct;19(10):1039-1044, Journal of general internal medicine
OBJECTIVE: To define the prevalence of and factors associated with having a negative purified protein derivative (PPD) among persons who self-report a prior positive PPD and to define the safety of repeat testing in such persons. DESIGN: Observational cohort study. SETTING: Methadone maintenance program with onsite primary care. PATIENTS/PARTICIPANTS: Current or former drug users enrolled in methadone maintenance treatment. INTERVENTIONS: Structured interview, tuberculin skin testing regardless of self-reported PPD status, and anergy testing. MEASUREMENTS AND MAIN RESULTS: Nearly one third (31%) of participants who self-reported a prior positive PPD had a negative measured PPD, despite receipt of a 'booster' PPD. A single participant (0.5%) blistered in response to the PPD without lasting ill effect. Participants with PPD results discordant from their history were more likely to be HIV-seropositive and nonreactive to the anergy panel. The discordance rate among HIV-infected participants was 43%, and was largely attributable to immune dysfunction. Among HIV-seronegative participants, the discordance rate was 27%. Recent crack-cocaine use was independently associated with discordance in the absence of HIV infection. CONCLUSIONS: We confirmed that planting a PPD in patients who self-report a positive PPD history confers minimal risk. Substantial rates of discordance exist between self-reported history of a positive PPD and measured PPD status. Further research is needed to define the optimal management of PPD-negative patients who self-report a prior positive PPD and who have not received prior treatment for latent tuberculosis
— id: 62313, year: 2004, vol: 19, page: 1039, stat: Journal Article,

Drug interactions between opioids and antiretroviral medications: interaction between methadone, LAAM, and nelfinavir
McCance-Katz, Elinore F; Rainey, Petrie M; Smith, Patrick; Morse, Gene; Friedland, Gerald; Gourevitch, Marc; Jatlow, Peter
2004 Mar-Apr;13(2):163-180, American journal on addictions
Understanding drug interactions between antiretrovirals and opiate therapies may decrease toxicities and enhance adherence, with improved HIV outcomes in injection drug users. We report results of a clinical pharmacology study designed to examine the interaction of the protease inhibitor, nelfinavir, with methadone and LAAM (N = 48). Nelfinavir decreased methadone exposure, but no withdrawal was observed over the five day study period. LAAM and dinorLAAM concentrations were decreased, while norLAAM concentrations were increased, with minimal overall change in LAAM/metabolite exposure. Methadone and LAAM did not affect nelfinavir concentrations, but methadone decreased M8 metabolite exposure. While no toxicities were observed, clinicians should be aware of the potential for drug interactions when patients require treatment with nelfinavir and these opiate medications
— id: 66145, year: 2004, vol: 13, page: 163, stat: Journal Article,

Gender and hospitalization patterns among HIV-infected drug users before and after the availability of highly active antiretroviral therapy
Floris-Moore, Michelle; Lo, Yungtai; Klein, Robert S; Budner, Nancy; Gourevitch, Marc N; Moskaleva, Galina; Schoenbaum, Ellie E
2003 Nov 1;34(3):331-337, Journal of acquired immune deficiency syndromes. JAIDS
We examined highly active antiretroviral therapy (HAART) era and pre-HAART era hospitalization rates among 604 HIV-infected drug users in a prospective study in Bronx, New York. Medical history and risk behaviors were elicited by semiannual interviews. Standardized medical record review abstracted discharge diagnoses for all hospitalizations. Hospitalization rates from January 1997 to December 2000 were compared with rates from January 1992 to December 1996. The rate of hospitalizations per 100 patient-years in the HAART era was 49.3 compared with 44.1 in the pre-HAART era (P = 0.13). Among women, the rate was significantly higher in the HAART era than in the pre-HAART era (68.1 vs. 49.4 hospitalizations per 100 patient-years, respectively; P = 0.01). In the second era, HAART users had lower rates than those who did not use HAART (37.2 vs. 83.4 hospitalizations per 100 patient-years, respectively; P < 0.001) for both HIV-associated and non-HIV-associated illnesses. Multivariate analysis revealed that in the HAART era, female gender (relative risk ratio = 1.72, P = 0.03) and not using HAART (relative risk ratio = 1.82, P = 0.02) independently predicted increased hospitalization risk. In the pre-HAART era, women were at independently higher risk of hospitalization (relative risk ratio = 1.36, P = 0.05). Among HIV-infected drug users, those who use HAART have a decreased risk of hospitalization; those who do not use HAART remain at high risk of continuing morbidity from both HIV-related and non-HIV-related illness and have high hospitalization rates
— id: 43554, year: 2003, vol: 34, page: 331, stat: Journal Article,

Medications that prolong the QT interval
Krantz, Mori J; Martell, Bridget A; Arnsten, Julia H; Gourevitch, Marc N
2003 Aug 27;290(8):1025-1025, JAMA
— id: 105895, year: 2003, vol: 290, page: 1025, stat: Journal Article,

The impact of methadone induction on cardiac conduction in opiate users
Martell, Bridget A; Arnsten, Julia H; Ray, Beevash; Gourevitch, Marc N
2003 Jul 15;139(2):154-155, Annals of internal medicine
— id: 43555, year: 2003, vol: 139, page: 154, stat: Journal Article,

Effectiveness of isoniazid treatment for latent tuberculosis infection among human immunodeficiency virus (HIV)-infected and HIV-uninfected injection drug users in methadone programs
Scholten, Jerod N; Driver, Cynthia R; Munsiff, Sonal S; Kaye, Katherine; Rubino, Mary Ann; Gourevitch, Marc N; Trim, Caroline; Amofa, James; Seewald, Randy; Highley, Esther; Fujiwara, Paula I
2003 Dec 15;37(12):1686-1692, Clinical infectious diseases
Injection drug users (IDUs) were heavily affected by the tuberculosis (TB) resurgence in New York City in the 1990s. We assessed the effectiveness of screening for latent TB infection in methadone users and of selective treatment with isoniazid. Risk for future TB was classified as low or high on the basis of tuberculin, anergy, and HIV test results. The cohort of 2212 IDUs was followed up for a median of 4.2 years; 25 IDUs, of whom 20 (80%) were infected with human immunodeficiency virus (HIV), developed TB. In an adjusted Cox proportional hazards model of high-risk IDUs, the risk of TB was associated with HIV infection (HR 10.3; 95% CI, 3.4-31.3); receipt of <6 months of isoniazid therapy (HR 7.6; 95% CI, 1.02-57.1); a CD4+ T lymphocyte count of <200 cells/mm3 (HR 6.6; 95% CI, 1.7-25.9); and tuberculin positivity (HR 4.0; 95% CI, 1.6-10.2). Treatment with isoniazid was beneficial in HIV-infected, tuberculin-positive IDUs
— id: 43553, year: 2003, vol: 37, page: 1686, stat: Journal Article,

Analysis of a population-based Pneumocystis carinii pneumonia index as an outcome measure of access and quality of care for the treatment of HIV disease
Arno, Peter S; Gourevitch, Marc N; Drucker, Ernest; Fang, Jing; Goldberg, Clara; Memmott, Margaret; Bonuck, Karen; Deb, Nandini; Schoenbaum, Ellie
2002 Mar;92(3):395-398, American journal of public health. AJPH
OBJECTIVES: A population-based Pneumocystis carinii pneumonia (PCP) Index was developed in New York City to identify geographic areas and subpopulations at increased risk for PCP. METHODS: A zip code-level PCP Index was created from AIDS surveillance and hospital discharge records and defined as (number of PCP-related hospitalizations)/(number of persons living with AIDS). RESULTS: In 1997, there were 2262 hospitalizations for PCP among 39 740 persons living with AIDS in New York City (PCP Index =.05691). PCP Index values varied widely across neighborhoods with high AIDS prevalence (West Village =.02532 vs Central Harlem =.08696). Some neighborhoods with moderate AIDS prevalence had strikingly high rates (Staten Island =.14035; northern Manhattan =.08756). CONCLUSIONS: The PCP Index highlights communities in particular need of public health interventions to improve HIV-related service delivery
— id: 43559, year: 2002, vol: 92, page: 395, stat: Journal Article,

Impact of active drug use on antiretroviral therapy adherence and viral suppression in HIV-infected drug users
Arnsten, Julia H; Demas, Penelope A; Grant, Richard W; Gourevitch, Marc N; Farzadegan, Homayoon; Howard, Andrea A; Schoenbaum, Ellie E
2002 May;17(5):377-381, Journal of general internal medicine
Despite a burgeoning literature on adherence to HIV therapies, few studies have examined the impact of ongoing drug use on adherence and viral suppression, and none of these have utilized electronic monitors to quantify adherence among drug users. We used 262 electronic monitors to measure adherence with all antiretrovirals in 85 HIV-infected current and former drug users, and found that active cocaine use, female gender, not receiving Social Security benefits, not being married, screening positive for depression, and the tendency to use alcohol or drugs to cope with stress were all significantly associated with poor adherence. The strongest predictor of poor adherence and, in turn, failure to maintain viral suppression, was active cocaine use. Overall adherence among active cocaine users was 27%, compared to 68% among subjects who reported no cocaine use during the 6-month study period. Consequently, 13% of active cocaine users maintained viral suppression, compared to 46% of nonusers. Interventions to improve adherence should focus on reducing cocaine use, developing adaptive coping skills, and identifying and treating depression
— id: 43558, year: 2002, vol: 17, page: 377, stat: Journal Article,

Crack cocaine use and other risk factors for tuberculin positivity in drug users
Howard, Andrea A; Klein, Robert S; Schoenbaum, Ellie E; Gourevitch, Marc N
2002 Nov 15;35(10):1183-1190, Clinical infectious diseases
Two-step tuberculin testing and standardized interviews of 793 current and former drug users were performed to determine the risk factors for tuberculin positivity. The prevalence of tuberculin positivity was 25%. Factors independently associated with tuberculin positivity among participants seronegative for human immunodeficiency virus (HIV) included crack cocaine use (adjusted odds ratio [OR], 1.6; 95% confidence interval [CI], 1.0-2.5), employment as a home health aide (adjusted OR, 2.1; 95% CI, 1.0-4.1), birth in Puerto Rico (adjusted OR, 2.2; 95% CI, 1.3-3.6), foreign birthplace (adjusted OR, 4.7; 95% CI, 1.6-13.6), African American race (adjusted OR, 2.5; 95% CI, 1.2-5.0), reported tuberculosis exposure (adjusted OR, 2.3; 95% CI, 1.2-4.4), and older age (adjusted OR, 2.9; 95% CI, 1.2-6.7). Additional risk factors among HIV-infected participants included alcoholism (adjusted OR, 2.4; 95% CI, 1.0-5.8) and high CD4(+) lymphocyte count. Identification of and administration of appropriate chemoprophylaxis to drug users with these risk factors should be given high priority
— id: 43557, year: 2002, vol: 35, page: 1183, stat: Journal Article,

Modified directly observed therapy (MDOT) for injection drug users with HIV disease
McCance-Katz, Elinore F; Gourevitch, Marc N; Arnsten, Julia; Sarlo, Julie; Rainey, Petrie; Jatlow, Peter
2002 Fall;11(4):271-278, American journal on addictions
Injection drug use is an important factor in the spread of HIV infection, and strategies to enhance adherence to HIV therapeutics are critically important to controlling viral transmission and improving clinical outcomes. To this end, the authors sought (1) to enhance adherence to highly active antiretroviral therapy (HAART) among methadone-maintained injection drug users (IDUs) using modified directly observed therapy (MDOT), and (2) to define interactions between methadone and HAART and the potential contribution of drug interactions to adherence and HIV outcomes in this population. Adherence was explored here through a pilot, unblinded, 24-week study in a methadone maintenance program in which simplified HAART (efavirenz and didanosine [one daily] and a second nucleoside [twice daily]) was administered 6 days/week by clinic staff to HIV-infected IDUs (n = 5) with their methadone. Evening doses of riboflavin-tagged nucleoside and one full day of medication weekly were given as take home doses. As a result of HAART administration, four of five participants with mean viral load at baseline of 10(5) copies/ml had undetectable viral load by 8 weeks of treatment (p = .043). Methadone area under the curve (AUC) decreased by 55% (p = .007) within 2 weeks of initiating this HAART regimen, and a mean methadone dose increase of 52% was required. The authors conclude that MDOT is a promising intervention for the treatment of IDUs with HIV disease, though significant drug interactions must be monitored for carefully and rapidly addressed
— id: 43556, year: 2002, vol: 11, page: 271, stat: Journal Article,

Antiretroviral therapy adherence and viral suppression in HIV-infected drug users: comparison of self-report and electronic monitoring
Arnsten JH; Demas PA; Farzadegan H; Grant RW; Gourevitch MN; Chang CJ; Buono D; Eckholdt H; Howard AA; Schoenbaum EE
2001 Oct 15;33(8):1417-1423, Clinical infectious diseases
To compare electronically monitored (MEMS) with self-reported adherence in drug users, including the impact of adherence on HIV load, we conducted a 6-month observational study of 67 antiretroviral-experienced current and former drug users. Adherence (percentage of doses taken as prescribed) was calculated for both the day and the week preceding each of 6 research visits. Mean self-reported 1-day adherence was 79% (median, 86%), and mean self-reported 1-week adherence was 78% (median, 85%). Mean MEMS 1-day adherence was 57% (median, 52%), and mean MEMS 1-week adherence was 53% (median, 49%). One-day and 1-week estimates were highly correlated (r>.8 for both measures). Both self-reported and MEMS adherence were correlated with concurrent HIV load (r=.43-.60), but the likelihood of achieving virologic suppression was greater if MEMS adherence was high than if self-reported adherence was high. We conclude that self-reported adherence is higher than MEMS adherence, but a strong relationship exists between both measures and virus load. However, electronic monitoring is more sensitive than self-report for the detection of nonadherence and should be used in adherence intervention studies
— id: 43561, year: 2001, vol: 33, page: 1417, stat: Journal Article,

Interactions between HIV-related medications and methadone: an overview. Updated March 2001
Gourevitch MN
2001 May;68(3):227-228, Mount Sinai journal of medicine
— id: 43563, year: 2001, vol: 68, page: 227, stat: Journal Article,

The incidence of tuberculosis in drug users with small tuberculin reaction sizes
Klein RS; Gourevitch MN; Teeter R; Schoenbaum EE
2001 Aug;5(8):707-711, International journal of tuberculosis & lung disease
SETTING: In persons infected with the human immunodeficiency virus (HIV), a decreased tuberculin reaction cut-point of > or = 5 mm induration is recommended. OBJECTIVE: To determine tuberculosis risk in non-anergic HIV-infected persons with 5-9 mm tuberculin reactions. DESIGN: A prospective study with semi-annual tuberculin and anergy testing, HIV antibody and T cell subset assays, and active surveillance for tuberculosis. RESULTS: Participants were 572 HIV-seronegative and 241 HIV-seropositive non-anergic drug users. No tuberculosis occurred in HIV-seronegative persons. Tuberculosis incidence among HIV-seropositive drug users was 3.3, 7.7, 0, and 0.34 per 100 person-years in those with tuberculin reaction sizes of > or = 10 mm, 5-9 mm, 1-4 mm, and 0 mm, respectively, and was significantly increased in persons with 5-9 mm induration compared with those with 0-4 mm induration (rate ratio 27.7, 95%CI 2.9-268). Among persons with reaction sizes of 5-9 mm, tuberculosis occurred exclusively in those with CD4+ lymphocyte counts <500/mm3 at the time of their 5-9 mm tuberculin reactions. CONCLUSION: HIV-infected persons with tuberculin reaction sizes of 5-9 mm are at increased risk for tuberculosis compared to non-anergic persons with smaller (0-4 mm) reaction sizes. However, this increased risk may be limited to those with low CD4+ lymphocyte counts at the time of tuberculin testing
— id: 43562, year: 2001, vol: 5, page: 707, stat: Journal Article,

Regular outpatient medical and drug abuse care and subsequent hospitalization of persons who use illicit drugs
Laine C; Hauck WW; Gourevitch MN; Rothman J; Cohen A; Turner BJ
2001 May 9;285(18):2355-2362, JAMA
CONTEXT: Patients and the public could benefit from identification of factors that prevent drug users' heavy reliance on inpatient care; however, optimal health care delivery models for illicit drug users remain ill-defined. OBJECTIVE: To evaluate associations of outpatient medical and drug abuse care with drug users' subsequent hospitalization rates. DESIGN AND SETTING: Retrospective cohort study of data from longitudinally linked claims for all ambulatory physician/clinic services and drug abuse services covered by the New York State Medicaid program. SUBJECTS: A total of 11 556 human immunodeficiency virus (HIV)-positive and 46 687 HIV-negative drug users. MAIN OUTCOME MEASURES: Hospitalization in federal fiscal year (FFY) 1997 compared by 4 patterns of care in FFY 1996: regular drug abuse care (>/=6 months in 1 program), regular medical care (>35% of care from 1 clinic, group practice, or individual physician), both, or neither. RESULTS: Hospitalization occurred in 55.6% of HIV-positive and 37.5% of HIV-negative drug users, with a mean of 27.5 and 24.5 inpatient days, respectively. In HIV-positive drug users, the adjusted odds ratio (AOR) for hospitalization was lowest among those with both regular medical and drug abuse care (AOR, 0.76; 95% confidence interval [CI], 0.67-0.85) followed by those with regular medical care alone (AOR, 0.82; 95% CI, 0.74-0.91) and regular drug abuse care alone (AOR, 0.85; 95% CI, 0.76-0.96) vs those with neither. In HIV-negative drug users, the AOR of hospitalization was lower for those with regular medical and drug abuse care (AOR, 0.73; 95% CI, 0.68-0.79), regular drug abuse care alone (AOR, 0.71; 95% CI, 0.66-0.76), and regular medical care (AOR, 0.91; 95% CI, 0.86-0.95) vs those with neither. Both types of care showed favorable effects for all but drug abuse-related hospitalizations. CONCLUSION: Our data indicate that regular drug abuse care with regular medical care for drug users is associated with less subsequent hospitalization
— id: 43566, year: 2001, vol: 285, page: 2355, stat: Journal Article,

Cost-effectiveness of tuberculosis screening and observed preventive therapy for active drug injectors at a syringe-exchange program
Perlman DC; Gourevitch MN; Trinh C; Salomon N; Horn L; Des Jarlais DC
2001 Sep;78(3):550-567, Journal of urban health
This study examined whether costs associated with tuberculosis (TB) screening and directly observed preventive therapy (DOPT) among drug injectors attending a syringe exchange are justified by cases and costs of active TB cases prevented and examined the impact of monetary incentives to promote adherence on cost-effectiveness. We examined program costs and projected savings using observed adherence and prevalence rates and literature estimates of isoniazid (INH) preventive therapy efficacy, expected INH hepatoxicity rates, and TB treatment costs; we conducted sensitivity analyses for a range of INH effectiveness, chest X-ray (CXR) referral adherence, and different strategies regarding anergy among persons affected with human immunodeficiency virus (HIV). For 1,000 patients offered screening, incorporating real observed program adherence rates, the program would avert $179,934 in TB treatment costs, for a net savings of $123,081. Assuming a modest risk of TB among HIV-infected anergic persons, all strategies with regard to anergy were cost saving, and the strategy of not screening for anergy and not providing DOPT to HIV-infected anergic persons resulted in the greatest cost savings. If an incentive of $25 per person increased CXR adherence from the observed 31% to 50% or 100%, over a 5-year follow-up the net cost savings would increase to $170,054 and $414,856, respectively. In this model, TB screening and DOPT at a syringe exchange is a cost-effective intervention and is cost-saving compared to costs of treating active TB cases that would have occurred in the absence of the intervention. This model is useful in evaluating the cost impact of planned program refinements, which can then be tested. Monetary incentives for those referred for screening CXRs would be justified on a cost basis if they had even a modest beneficial impact on adherence
— id: 43560, year: 2001, vol: 78, page: 550, stat: Journal Article,

Interactions between methadone and medications used to treat HIV infection: a review
Gourevitch MN; Friedland GH
2000 Oct-Nov;67(5-6):429-436, Mount Sinai journal of medicine
BACKGROUND: It is critical for providers caring for HIV-positive methadone recipients to have accurate information on pharmacologic interactions between methadone and antiretroviral therapy. If providers do not have these data, symptoms of narcotic withdrawal or excess due to medication interactions may be mismanaged, and antiretroviral regimens may be suboptimal in efficacy or associated with increased side effects and toxicities. This review was undertaken to clarify what is known about interactions between pharmacotherapies of opiate dependence and HIV-related medications, to suggest clinically useful approaches to these issues, and to outline areas which need further study. METHOD: A search for relevant published papers and abstracts presented at scientific meetings was conducted using electronic databases. These documents were obtained and reviewed, and additional publications referenced in them were also reviewed. RESULTS: Pharmacokinetic interactions between methadone and zidovudine, didanosine, stavudine, abacavir, nevirapine, efavirenz and nelfinavir have been documented. The mechanisms, clinical implications and management of these interactions are reviewed. CONCLUSIONS: Interactions between methadone and some HIV-related medications are known to occur, yet their characteristics cannot reliably be predicted based on current understanding of metabolic enzyme induction and inhibition, or through in vitro studies. Only carefully designed and conducted pharmacologic studies involving human subjects can help us define the nature of the interactions between methadone (and other pharmacotherapies for opiate dependence) and specific HIV-related medications. Clinicians must be aware of known interactions and be alert to the possibility that interactions which are still undocumented may be present among their patients
— id: 43567, year: 2000, vol: 67, page: 429, stat: Journal Article,

Prevalence of peripheral neuropathy in injection drug users
Berger AR; Schaumburg HH; Gourevitch MN; Freeman K; Herskovitz S; Arezzo JC
1999 Aug 11;53(3):592-597, Neurology
BACKGROUND: Nucleoside analogue reverse transcriptase inhibitors are a critical component of antiretroviral therapy in HIV-infected persons. Several of these medications cause painful, dose-limiting peripheral neuropathy (PN), which may develop earlier and more intensely in persons with preexisting neuropathy. The prevalence of baseline peripheral neuropathy in injection drug users (IDUs), one of the largest populations of HIV-infected persons, has not been described, yet has important implications for the selection of antiretroviral therapy. METHODS: The authors performed a cross-sectional study of PN in 212 HIV-seronegative and HIV-seropositive IDUs using detailed neurologic histories, physical examinations, quantitative electrophysiologic study, and quantitative sensory testing. Data were used to assign patients to one of four positive categories of PN or one of two negative categories. RESULTS: PN was present in 24.5% of HIV-seronegative IDUs, three to four times the reported frequency for HIV-seronegative persons in the general or male homosexual population. PN was present in 32.1% of HIV-seropositive patients. PN was axonal in nature and associated with increased age and alcohol use. PN was asymptomatic in 81% of HIV-seronegative and 71% of HIV-seropositive patients with PN. CONCLUSIONS: There is a high prevalence of PN in HIV-seronegative IDUs. Although these PNs do not seem to predispose HIV-seropositive IDUs to HIV-related PN, they may increase the likelihood of iatrogenic neuropathy. Intravenous drug users may need more diligent monitoring when administered nucleoside analogues than patients in risk groups with lower endemic rates of PN
— id: 43570, year: 1999, vol: 53, page: 592, stat: Journal Article,

Methadone and antiretroviral medications, part I
Gourevitch MN; Friedland GH
1999 Apr;11(4):30-1 contd, AIDS clinical care
AIDS: The interactions of Methadone with NRTIs and NNRTIs are presented in the first of a two-part article. Methadone is an effective treatment for heroin addiction; however, insufficient information is available on its interactions with HAART. Methadone is metabolized by the cytochrome P450 system, and NRTIs do not appear to be inducers or inhibitors of the cytochrome P450 system. Pharmacokinetics between Methadone and AZT have been studied in detail, and AZT appears to have no effect on plasma Methadone levels. However, NNRTIs do share metabolic pathways with Methadone, indicating that important interactions between Methadone and these drugs are possible, but formal study is still needed. A table of current information is presented on NRTI and NNRTI interactions with Methadone. EDAT- 2001/05/22 10:00 MHDA- 2001/05/22 10:01 P
— id: 43565, year: 1999, vol: 11, page: 30, stat: Journal Article,

Methadone and antiretroviral medications, part II
Gourevitch MN; Friedland GH
1999 May;11(5):37, 43, 45-6, AIDS clinical care
AIDS: The second installment in a two-part series on Methadone and antiretroviral medications is presented. The use of methadone and potential drug interactions between Methadone and anti-HIV medications are reviewed. Several studies about drug interactions, other substance-abuse therapies and opiates, and the future direction of antiretroviral and opiate interaction studies are discussed. Physicians are advised to consider the potential effects of Methadone on HIV-related medications when designing a treatment regimen. EDAT- 2001/05/22 10:00 MHDA- 2001/05/22 10:01 P
— id: 43564, year: 1999, vol: 11, page: 37, 43, 45, stat: Journal Article,

Effectiveness of isoniazid chemoprophylaxis for HIV-infected drug users at high risk for active tuberculosis
Gourevitch MN; Hartel D; Selwyn PA; Schoenbaum EE; Klein RS
1999 Oct 22;13(15):2069-2074, AIDS
OBJECTIVE: To define the effectiveness of chemoprophylaxis, outside of a clinical trial setting, in preventing tuberculosis among tuberculin-reactive and anergic HIV-infected drug users at high risk of developing active tuberculosis. DESIGN: An observational cohort study. SETTING: Methadone maintenance treatment program with on-site primary care. PARTICIPANTS: Current or former drug users enrolled in methadone treatment. INTERVENTIONS: Annual skin testing for tuberculosis infection and anergy was performed, and eligible patients were offered daily isoniazid for 12 months and followed prospectively. MAIN OUTCOME MEASURE: The development of active tuberculosis. RESULTS: A total of 155 persons commenced chemoprophylaxis. Among tuberculin reactors, tuberculosis rates were 0.51 and 2.07/100 person-years in those completing 12 months versus those not taking prophylaxis [rate ratio 0.25, 95% confidence interval (CI) 0.06-1.01]. Among anergic individuals, comparable rates were 0 and 1.44/100 person-years. Lower tuberculosis rates among completers were not attributable to differences in immune status between the treated and untreated groups. CONCLUSION: The completion of isoniazid chemoprophylaxis was associated with a marked reduction in tuberculosis risk among tuberculin reactors and anergic persons in this high-risk population. These data support aggressive efforts to provide a complete course of preventative therapy to HIV-infected tuberculin reactors, and lend weight to the findings of others that isoniazid can reduce the rate of tuberculosis in high-risk anergic HIV-infected persons
— id: 43568, year: 1999, vol: 13, page: 2069, stat: Journal Article,

Three oral formulations of methadone. A clinical and pharmacodynamic comparison
Gourevitch MN; Hartel D; Tenore P; Freeman K; Marion I; Hecht J; Lowinson J
1999 Oct;17(3):237-241, Journal of substance abuse treatment
This study was done to determine whether there were any differences in subjective symptoms of opiate withdrawal or methadone pharmacodynamics among patients as they were switched between three different oral formulations of methadone. Patients enrolled in a three-way double-blind crossover trial of three methadone formulations. Subjective symptoms and pharmacodynamic measures were assessed throughout the study period. Eighteen patients were enrolled the study. No statistically significant differences in any of the pharmacodynamic parameters studied were found among the three methadone preparations. There was no significant difference among preparations in the rate and extent of rise and fall in plasma methadone levels during a 24-hour intensive sampling period. Subjective symptoms also did not correlate with methadone formulation. Intolerance to changes in methadone formulation, often observed clinically, do not appear to have a pharmacodynamic basis. Our findings support the notion that such change intolerance reflects factors other than the pharmacologic properties of the different formulations of methadone
— id: 43569, year: 1999, vol: 17, page: 237, stat: Journal Article,

Self-assessment of tuberculin skin test reactions by drug users with or at risk for human immunodeficiency virus infection
Gourevitch MN; Teeter R; Schoenbaum EE; Klein RS
1999 Apr;3(4):321-325, International journal of tuberculosis & lung disease
SETTING: Self-assessment of tuberculin test results, if accurate, could enhance tuberculosis screening efforts by reducing the need for follow-up visits for skin test reading. We investigated tuberculin test self-assessment in a longitudinal study of tuberculosis infection among drug users. OBJECTIVE: To determine the accuracy of tuberculin reaction self-assessment by drug users at high risk for tuberculosis infection. DESIGN: Two readings were compared of the same skin test, performed 48-72 hours after placement: 1) self-assessment using a simple yes-no approach to induration, versus 2) trained examiner reading. Self-assessments were performed immediately prior to trained examiner readings. RESULTS: Participants were 137 human immunodeficiency virus (HIV) seropositive and 344 HIV-seronegative current and former drug users. Ten per cent (35/344) of reactions read by participants as 'flat' were read by trained examiners as > or =5 mm (54% of which were > or =10 mm). Twenty-three per cent (19/82) of reactions read by trained examiners as > or =10 mm and 32% (35/110) of reactions read by trained examiners as being > or =5 mm were self-read by participants as 'flat'. Sensitivity (0.68) and specificity (0.83) of self-read tuberculin reactions were sub-optimal. Inter-reader reliability was poorer between participants and trained examiners than between trained examiners. CONCLUSION: Self-assessments of tuberculin skin test responses by drug users with or at risk for HIV infection are not reliable
— id: 43571, year: 1999, vol: 3, page: 321, stat: Journal Article,

A prospective study of HIV disease progression in female and male drug users
Webber MP; Schoenbaum EE; Gourevitch MN; Buono D; Klein RS
1999 Feb 4;13(2):257-262, AIDS
OBJECTIVE: To compare HIV disease progression and mortality in a cohort of female and male drug users. DESIGN: A prospective cohort study of 222 HIV-seropositive women and 302 HIV-seropositive men who attended a hospital-affiliated methadone maintenance program with on-site primary care. METHODS: Regression slopes of CD4+ cell decline were compared using the two sample t-test, and the distribution of AIDS-defining illnesses evaluated by Mantel-Haenszel chi2 test. Time to AIDS-defining clinical conditions and death were compared using the Kaplan-Meier log-rank test. Multivariate estimates of progression to clinical AIDS or death, for all participants, stratified by sex, were derived from Cox proportional hazards models. RESULTS: Ninety-five persons (43 women and 52 men) developed AIDS-defining conditions. Analyses of the rates of CD4+ cell decline, the distribution of first AIDS-defining illnesses, and the time to clinical AIDS did not differ by sex. In the multivariate model, sex was not associated with an AIDS outcome, whereas crack-cocaine use [hazards ratio (HR), 1.815; 95% confidence interval (CI), 1.151-2.863], CD4+ cell count (100 x 10(6)/l; HR, 0.589; 95% CI, 0.511-0.679), and two or more HIV-related symptoms (HR, 1.702; 95% CI, 1.125-2.576) were associated. Mortality rates (8.71 per 100 person-years in women and 9.85 per 100 person-years in men) were similar, using univariate or multivariate methods. CONCLUSIONS: There was little difference in clinical outcomes or mortality between HIV-seropositive female and male drug users with access to primary care. However, crack-cocaine use was independently associated with progression to clinical AIDS
— id: 43572, year: 1999, vol: 13, page: 257, stat: Journal Article,

Effect of prior hepatitis B infection on serum IgE levels in patients with human immunodeficiency virus infection
de Asis ML; Rosenstreich DL; Chang CJ; Gourevitch MN; Small CB
1998 Jan;80(1):35-38, Annals of allergy, asthma & immunology
BACKGROUND: Advanced HIV infection is associated with increased serum IgE levels, which in turn have been associated with a poor prognosis. Our preliminary data revealed that serum IgE levels were significantly elevated in HIV seropositive injection drug users compared with HIV seropositive non-injection drug users. Since viral hepatitis is common among injection drug users and is itself associated with elevated serum IgE levels, we studied whether there was an association between increased serum IgE levels and positive hepatitis serology in HIV-seropositive patients. METHODS: A retrospective cross-sectional analysis was performed. The medical records of ambulatory HIV-infected patients in an ongoing study were reviewed. Forty-five patients had hepatitis A, B, and C serology performed. The associations between serum IgE levels and hepatitis A, B and C antibodies, CD4 and CD8 lymphocyte percentages, injection drug use, and sex were analyzed by univariate and multiple regression analyses. RESULTS: On univariate analyses, hepatitis B antibody was significantly associated with increased serum IgE levels in HIV-infected subjects (P = .013), especially in those with AIDS (P = .015). Multiple regression analyses controlling for CD4 lymphocyte percentages, sex, and drug use, confirmed that hepatitis B antibody status remained significantly associated with increased serum IgE levels (P = .05). There was no association of serum IgE levels with hepatitis A or C serology. CONCLUSION: Prior hepatitis B infection is significantly associated with increased serum IgE levels in advanced HIV infection. The clinical implications of this finding deserve further study
— id: 43578, year: 1998, vol: 80, page: 35, stat: Journal Article,

Cost-effectiveness of directly observed chemoprophylaxis of tuberculosis among drug users at high risk for tuberculosis
Gourevitch MN; Alcabes P; Wasserman WC; Arno PS
1998 Jul;2(7):531-540, International journal of tuberculosis & lung disease
SETTING: A methadone treatment program with on-site medical care in the Bronx, New York. OBJECTIVE: To define whether costs associated with directly observed preventive therapy (DOPT) of tuberculosis are justified by cases and costs of tuberculosis prevented among persons at high risk for active disease. DESIGN: Detailed data were collected on drug users in treatment regarding human immunodeficiency virus (HIV) and tuberculosis infection and disease, and costs of screening, chemoprophylaxis, direct observation and treatment of active disease. The cost-effectiveness of providing DOPT to this population was modeled. RESULTS: We assessed the impact of providing DOPT to 151 eligible persons. Assuming 65% isoniazid effectiveness, and incorporating costs of screening, observed chemoprophylaxis and clinical monitoring, a net savings in tuberculosis-related hospital costs of $285,284 ($563 per person screened) was associated with DOPT ($10,274 per case prevented). Direct observation of chemoprophylaxis proved cost-effective if associated with even a 10% increment in overall isoniazid effectiveness compared with self-administered chemoprophylaxis. DOPT costs per tuberculosis case averted remained below the in-patient costs of a single case of drug-sensitive disease across a range of parameter values. CONCLUSIONS: Providing DOPT is a highly cost-effective intervention for drug users in treatment. Commitment of additional resources required for DOPT should be given priority in this and other populations at high risk for tuberculosis
— id: 43576, year: 1998, vol: 2, page: 531, stat: Journal Article,

Overview of HIV and AIDS: biology and epidemiology of the virus
Klein RS; Gourevitch MN
1998 Oct;8(4):751-767, Gastrointestinal endoscopy clinics of North America
HIV-1 infects mononuclear cells using the CD4+ molecule and the chemical receptors of those cells. After a prolonged clinical latency period, the ability to replace destroyed cells is outpaced by ongoing cellular destruction, leading to the characteristic immunodeficiency of AIDS and its opportunistic infections and neoplasms. In the United States, the number of new cases of AIDS has diminished in recent years, although in some groups, such as women, the number of new cases continues to rise. In the developing world, AIDS remains a pandemic of huge proportions. In the absence of an effective vaccine, culturally appropriate efforts at education and behavior modification offer the best hope of controlling AIDS
— id: 43575, year: 1998, vol: 8, page: 751, stat: Journal Article,

A prospective study of tuberculosis and HIV disease progression
Munsiff SS; Alpert PL; Gourevitch MN; Chang CJ; Klein RS
1998 Dec 1;19(4):361-366, Journal of acquired immune deficiency syndromes & human retrovirology
OBJECTIVE: To determine whether active tuberculosis alters the rate of progression of HIV infection in dually infected patients. METHODS: HIV-seropositive patients at two Bronx, New York hospitals with tuberculosis confirmed by culture from July 1992 to February 1995, who survived the initial hospitalization for tuberculosis, were matched on gender, age, CD4+ percentage, and calendar time with HIV-seropositive patients without tuberculosis participating in a study of the natural history of HIV infection. Patients received follow-up observation prospectively until May 23, 1995 to determine survival rates and development of AIDS-defining opportunistic infections (OIs). RESULTS: 70 patients had tuberculosis; 120 did not. Mean CD4+ percentages were 12.4% and 12.5%, respectively. At study entry, 27% of those with tuberculosis had prior AIDS-defining OIs other than tuberculosis, compared with 10% of those without tuberculosis (p = .004). In multivariate survival analysis, controlling for CD4+ level, tuberculosis was not an independent predictor of increased other causes of AIDS-related mortality. However, in a logistic regression model, independent predictors of subsequent OIs included tuberculosis (hazard ratio, 4.1; 95% confidence intervals [CI], 1.9, 8.7), CD4+ count <100/mm3 (hazard ratio, 2.4; 95% CI, 1.1, 5.0) and prior OIs (hazard ration, 3.3; 95% CI, 1.3, 8.3). CONCLUSIONS: Tuberculosis was not an independent predictor of increased non-tuberculosis-related mortality in HIV-seropositive patients but was associated with increased risk of development of OIs
— id: 43573, year: 1998, vol: 19, page: 361, stat: Journal Article,

Clinical predictors of Pneumocystis carinii pneumonia, bacterial pneumonia and tuberculosis in HIV-infected patients
Selwyn PA; Pumerantz AS; Durante A; Alcabes PG; Gourevitch MN; Boiselle PM; Elmore JG
1998 May 28;12(8):885-893, AIDS
BACKGROUND: Clinicians are frequently faced with the differential diagnosis between Pneumocystis carinii pneumonia (PCP), bacterial pneumonia, and pulmonary tuberculosis in HIV-infected patients. OBJECTIVES: To identify features that could help differentiate these three pneumonia types at presentation by evaluating the clinical characteristics of the three diagnoses among patients at two urban teaching hospitals. DESIGN: Retrospective chart review. METHODS: Cases were HIV-infected patients with a verified hospital discharge diagnosis of PCP (n = 99), bacterial pneumonia (n = 94), or tuberculosis (n = 36). Admitting notes were reviewed in a standardized manner; univariate and multivariate analyses were used to determine clinical predictors of each diagnosis. RESULTS: Combinations of variables with the highest sensitivity, specificity, and odds ratios (OR) were as follows: for PCP, exertional dyspnea plus interstitial infiltrate (sensitivity 58%, specificity 92%; OR, 16.3); for bacterial pneumonia, lobar infiltrate plus fever < or = 7 days duration (sensitivity 48%, specificity 94%; OR, 14.6); and for tuberculosis, cough > 7 days plus night sweats (sensitivity 33%, specificity 86%; OR, 3.1). On regression analysis, independent predictors included interstitial infiltrate (OR, 10.2), exertional dyspnea (OR, 4.9), and oral thrush (OR, 2.9) for PCP; rhonchi on examination (OR, 12.4), a chart mention of 'toxic' appearance (OR, 9.1), fever < or = 7 days (OR, 6.6), and lobar infiltrate (OR, 5.8) for bacterial pneumonia; and cavitary infiltrate (OR, 21.1), fever > 7 days (OR, 3.9), and weight loss (OR, 3.6) for tuberculosis. CONCLUSIONS: Simple clinical variables, all readily available at the time of hospital admission, can help to differentiate these common pneumonia syndromes in HIV-infected patients. These findings can help to inform clinical decision-making regarding choice of therapy, use of invasive diagnostic procedures, and need for respiratory isolation
— id: 43577, year: 1998, vol: 12, page: 885, stat: Journal Article,

Temporal trends in the progression of human immunodeficiency virus disease in a cohort of drug users
Webber MP; Schoenbaum EE; Gourevitch MN; Buono D; Chang CJ; Klein RS
1998 Nov;9(6):613-617, Epidemiology
We evaluated changes over time in rates of progression to AIDS, mortality, and distribution of AIDS-defining illnesses in 524 human immunodeficiency virus (HIV)-seropositive injection drug users enrolled between 1986 and 1995 in a prospective study of HIV infection in the Bronx, NY. At enrollment, participants attended a hospital-affiliated methadone maintenance program with on-site primary care. Using the 1993 clinical definition of AIDS, we found that the hazard ratio (HR) of progression to AIDS declined for enrollees over time in comparison with the referent group of persons enrolled in 1986-1987. For program enrollees in 1988-1989, the HR was 1.0 [95% confidence interval (CI) = 0.6-1.6]; for enrollees in 1990-1991, the HR was 0.3 (95% CI = 0.1-0.9); for enrollees in 1992-1993, the HR was 0.5 (95% CI = 0.3-0.9); and for enrollees in 1994-1995, the HR was 0.2 (95% CI = 0.1-0.7), after controlling on initial CD4+ cell counts and age. Nevertheless, the greater AIDS-free time of later study entrants was not associated with reduced mortality. The study provides evidence that drug users with access to primary care likely benefited from improved management of HIV disease in prolonging AIDS-free time but, through 1996, did not experience greater survival
— id: 43574, year: 1998, vol: 9, page: 613, stat: Journal Article,

A prospective study of tuberculosis and human immunodeficiency virus infection: clinical manifestations and factors associated with survival
Alpert PL; Munsiff SS; Gourevitch MN; Greenberg B; Klein RS
1997 Apr;24(4):661-668, Clinical infectious diseases
We prospectively studied the effect of human immunodeficiency virus (HIV) infection on the presentation and outcome of tuberculosis. A total of 216 patients with tuberculosis were identified; 162 (75%) of these patients were tested for antibodies to HIV; 92 (57%) were seropositive. The patients who were seropositive for HIV were more likely to be male and Hispanic and to have been homeless or incarcerated. Eighty-one percent of these patients had CD4 lymphocyte counts of < or =200/mm3. The seropositive patients had extrapulmonary tuberculosis more often than did the seronegative patients (odds ratio [OR], 2.3; 95% confidence interval [CI], 1.2-4.8). Smears for acid-fast bacilli were positive more often for non-HIV-infected patients with pulmonary tuberculosis (74.5%) than for HIV-infected patients (54.3%) [OR, 2.46; 95% CI, 1.01-6.02]-even those with focal or cavitary disease. A delay in initiating therapy was associated with in-hospital mortality: the median time from admission to the start of treatment was 4 days for patients who survived and 15 days for those who died (P = .02). The median survival was 22.7 months for HIV-infected patients who did not die during the initial hospitalization. Factors independently associated with reduced rates of survival included the severity of immunodeficiency, nonuse of directly observed therapy, infection due to drug-resistant Mycobacterium tuberculosis, and a history of injection drug use
— id: 43579, year: 1997, vol: 24, page: 661, stat: Journal Article,

Integrating primary care and methadone maintenance treatment: implementation issues
Herman M; Gourevitch MN
1997 ;16(1):91-102, Journal of addictive diseases
Linking primary medical care with methadone maintenance treatment brings critical services to drug users, many with HIV/AIDS, tuberculosis and other illnesses. However, a variety of important philosophical, ethical, and systems issues may impede the process of implementing a 'linked' service delivery model. Conflicting paradigms, such as the traditional 'doctor-patient' relationship with its emphasis on continuity of care and the substance abuse treatment model of limit-setting and behavioral consequences, create tension in the treatment system. This article describes these tensions and uses clinical vignettes to demonstrate how to address these implementation issues. In conclusion, solutions are proposed for successfully integrating services for medically ill substance abusers
— id: 43581, year: 1997, vol: 16, page: 91, stat: Journal Article,

Reliability of anergy skin testing in persons with HIV infection
Klein RS; Gourevitch MN
1997 Apr;155(4):1490-1490, American journal of respiratory & critical care medicine
— id: 43580, year: 1997, vol: 155, page: 1490, stat: Journal Article,

The epidemiology of HIV and AIDS. Current trends
Gourevitch MN
1996 Nov;80(6):1223-1238, Medical clinics of North America
Nationally and globally the HIV/AIDS pandemic shows little sign of abating as it arrives at the midpoint of its second decade. In many communities, however, successful steps have been taken to limit its progression. The challenge of the years ahead lies in engaging individuals and communities to join in arresting and ultimately reversing the tide of this plague
— id: 43583, year: 1996, vol: 80, page: 1223, stat: Journal Article,

Lack of association of induration size with HIV infection among drug users reacting to tuberculin
Gourevitch MN; Hartel D; Schoenbaum EE; Klein RS
1996 Oct;154(4 Pt 1):1029-1033, American journal of respiratory & critical care medicine
Smaller tuberculin test induration sizes suggest eligibility for tuberculosis chemoprophylaxis in HIV-seropositive than in HIV-seronegative persons. To determine whether human immunodeficiency virus (HIV) infection is associated with induration size among tuberculin reactors, a cross-sectional study of HIV-seropositive and -seronegative drug users was performed. Twenty-four of 160 (15%) HIV-seropositive and 68 of 284 (24%) HIV-seronegative patients had reactions to purified protein derivative (PPD) of > or = 2 mm (OR = 0.56, 95% CI 0.32 to 0.96). However, the prevalence of tuberculin reactivity was equal among nonanergic subjects with and without HIV infection. Median induration size was similar among HIV-seropositive (20.5 mm) and -seronegative (17.5 mm) reactors. Thus, although HIV-seropositive patients were less likely, due to cutaneous anergy, to be PPD reactors, induration size was not associated with HIV infection among reactors. Although using a reduced cutpoint to determine suitability of chemoprophylaxis in HIV-seropositive persons may be prudent, the logical assumption that the loss of specificity this entails is accompanied by an increase in sensitivity for detecting Mycobacterium tuberculosis infection remains to be proved
— id: 43584, year: 1996, vol: 154, page: 1029, stat: Journal Article,

A prospective study of syphilis and HIV infection among injection drug users receiving methadone in the Bronx, NY
Gourevitch MN; Hartel D; Schoenbaum EE; Selwyn PA; Davenny K; Friedland GH; Klein RS
1996 Aug;86(8 Pt 1):1112-1115, American journal of public health. AJPH
OBJECTIVES. The purpose of this study was to assess the relationship between syphilis and human immunodeficiency virus (HIV) infection in injection drug users. METHODS. A 6-year prospective study of 790 injection drug users receiving methadone maintenance treatment in the Bronx, NY, was conducted. RESULTS. Sixteen percent (4/25) of HIV-seroconverting patients, 4.8% (16/335) of prevalent HIV-seropositive patients, and 3.5% (15/430) of persistently HIV-seronegative patients was diagnosed with syphilis. Incidence rates for early syphilis (cases per 1000 person-years) were 15.9 for HIV-seroconverting patients, 8.9 for prevalent HIV-seropositive patients, and 2.9 for persistently HIV-seronegative patients. Early syphilis incidence was higher among women than men (8.4 vs 3.2 cases per 1000 person-years). Independent risks for early syphilis included multiple sex partners, HIV seroconversion, paid sex, and young age. All HIV seroconverters with syphilis were female. CONCLUSIONS. Diagnosis of syphilis in drug-using women reflects high-risk sexual activity and is associated with acquiring HIV infection. Interventions to reduce the risk of sexually acquired infections are urgently needed among female drug users
— id: 43585, year: 1996, vol: 86, page: 1112, stat: Journal Article,

Successful adherence to observed prophylaxis and treatment of tuberculosis among drug users in a methadone program
Gourevitch MN; Wasserman W; Panero MS; Selwyn PA
1996 ;15(1):93-104, Journal of addictive diseases
Incomplete antituberculous chemoprophylaxis and treatment are major causes of the resurgence of tuberculosis, often drug-resistant, among drug users. We offered directly observed antituberculous chemoprophylaxis (n = 102) or treatment (n = 12) to tuberculous chemoprophylaxis (n = 102) or treatment (n = 12) to eligible methadone maintenance treatment patients. Methadone dosing was not contingent upon ingestion of antituberculous medication(s). No material incentives were provided. Ninety (88%) prophylaxis and 9 (75%) treatment patients were administered > or = 5 weekly doses of antituberculous medications during > or = 80% of 4740 patient-weeks. The majority of patients were HIV-seropositive. Active substance abuse was not associated with diminished adherence. Over 80% of patients completed or were still receiving therapy at the end of the study. Adherence to and completion of directly observed antituberculous therapy can thus be attained by drug users in treatment, despite ongoing drug misuse. Substance abuse treatment programs provide opportunities for enhanced compliance, and should thus be viewed as critical components of strategies to address the tuberculosis epidemic in drug users
— id: 43587, year: 1996, vol: 15, page: 93, stat: Journal Article,

Needle exchange use among a cohort of injecting drug users
Schoenbaum EE; Hartel DM; Gourevitch MN
1996 Dec;10(14):1729-1734, AIDS
OBJECTIVE: To study prospectively injection behavior of injecting drug users (IDU) who did and did not utilize a local needle exchange in the Bronx, New York City. DESIGN: Since 1985, IDU attending a methadone maintenance program have been enrolled in a prospective study of HIV-related risk behaviors. Since 1989, when a needle exchange opened near the methadone program, data have been collected from study participants regarding utilization of the exchange. PARTICIPANTS: Study participants (n = 904) who injected between 1985 and 1993. RESULTS: Of 904 IDU, 21.9% used the needle exchange. Male gender [adjusted odds ratio (AOR), 1.57], HIV seropositivity (AOR, 1.39) and younger age (AOR per 10 years of age, 1.66) were independently associated with needle exchange attendance. The percentage injecting declined each year, preceding the opening of the needle exchange and concurrent with its operation (from 64.6% in 1985 to 43.6% in 1993). Among the 329 participants who injected in the year before the exchange opened, 1988, 53 out of 124 (42.7%) needle exchange users and 168 out of 205 (81.9%) non-users reduced or stopped injecting by 1993 (P < 0.001). Exchange users shared needles less than non-users (P < 0.05 in 1993). HIV infection was unrelated to these reductions in injection. CONCLUSIONS: Methadone-treated IDU with access to a needle exchange reduced injecting and needle-sharing. This pattern of harm reduction, which began at least 4 years before the needle exchange opened, occurred in both those who did and did not utilize the needle exchange. Needle exchange, as a strategy to reduce injection-related harm, should not be viewed as discordant with methadone treatment
— id: 43582, year: 1996, vol: 10, page: 1729, stat: Journal Article,

Directly observed therapy: the medicine works
Gourevitch MN
1995 Fall;1(4):ix-ix, Journal of public health management & practice
— id: 43586, year: 1995, vol: 1, page: ix, stat: Journal Article,

Neurosyphilis in patients with human immunodeficiency virus infection
Gourevitch MN; Klein RS; Schoenbaum EE
1995 Apr 27;332(17):1170-1170, New England journal of medicine
— id: 43588, year: 1995, vol: 332, page: 1170, stat: Journal Article,

Effects of HIV infection on the serologic manifestations and response to treatment of syphilis in intravenous drug users
Gourevitch MN; Selwyn PA; Davenny K; Buono D; Schoenbaum EE; Klein RS; Friedland GH
1993 Mar 1;118(5):350-355, Annals of internal medicine
OBJECTIVE: To describe the effects of human immunodeficiency virus (HIV) infection on the serologic manifestations and response to treatment of syphilis in intravenous drug users. DESIGN: Cohort study of intravenous drug users. SETTING: Medical clinic in a hospital-based methadone maintenance treatment program in New York City. PATIENTS: Fifty patients with syphilis, of whom 31 were HIV seropositive and 19 HIV seronegative. MEASUREMENTS: Serologic tests for syphilis and clinical manifestations. RESULTS: Stage of syphilis at presentation was not associated with HIV serologic status. No unusual or fulminant manifestations of early syphilis or neurosyphilis were noted among HIV-seropositive cases. Maximum nontreponemal titers were higher among HIV-seropositive (median, 1:128) than among HIV-seronegative (median, 1:32) patients with syphilis (P = 0.05); this difference was present only among patients with first-episode syphilis. All 26 evaluable, HIV-seropositive patients treated for syphilis responded appropriately, including 13 patients given standard or less-than-standard doses of penicillin. Seven of 43 patients (16%) showed reversion to negative treponemal antibody assay results after treatment for syphilis; this finding was not associated with HIV infection, CD4 count, or stage of syphilis. Low nontreponemal titer was weakly associated with treponemal test reversion. CONCLUSIONS: Infection with HIV did not alter the stage at presentation, clinical course, serologic manifestations, or response to treatment of syphilis in this cohort of intravenous drug users
— id: 43589, year: 1993, vol: 118, page: 350, stat: Journal Article,

ACCESS TO HEALTH-CARE
Gourevitch, M; Lipkin, M; Bryan, JA
1990 Sep 15;113(6):478-478, Annals of internal medicine
— id: 31924, year: 1990, vol: 113, page: 478, stat: Journal Article,