The article chosen for the critique is “Home Buprenorphine/Naloxone Induction in Primary Care” by Lee, Grossman, DiRocco and Gourevitch. The article was published in the Journal of General Internal Medicine in 2009. The article examines the use of buprenorphine induction offered in the home setting. The study examined the safety and efficacy of this treatment methodology for adults with opioid dependency.
Introduction
The article’s introduction offered a solid background on the problem and why it needed further study. The introduction included a basic literature review of the problem. This included a discussion on the safety profile of buprenorphine since its instruction in 2002. The background was sufficient if an individual was not familiar with this specific medication. The authors also examined why this medication has not been readily adopted by physicians. There is a mandatory training and certification required for physicians to prescribe this medication. However, the medication offers significant benefits. The authors explained that several of these benefits include the ability to receive treatment for opioid dependence away from other stigmatized routes. These include in-patient treatment facilities and methadone clinics.

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The authors could have explored more about the problems associated with methadone clinics and other treatment programs. This is a well-known issue with regards to treatment programs. Many communities have refused to allow methadone clinics; this is based upon the incorrect assumption that these sites attract crime (Walker, 2012). As a result, there are often an inadequate number of these in operation. A significant problem with regards to opioid dependency is that many communities do not want treatment programs nearby. Home induction of a treatment offers a solution to this problem.

Methods
The authors offered a thorough description of who was and was not eligible for the program. Ineligibility criteria included a methadone dose of >40 mg daily, pregnant women who were eligible for methadone treatment, disabling psychiatric and medical conditions, and co-occurring substance use. The authors also utilized a large number of referral sources. As well as clinics and hospitals, New York City jails and those referred by word-of-mouth were also eligible. All individuals were seen for eligibility regardless of the ability to pay for the treatment. Government sources did provide some of the funds for the program. The authors needed to provide more information regarding the eligibility of individuals without insurance. They mentioned that they did not have the funds to cover the medications for new patients. However, this part of the methodology appears lacking. The authors needed to provide more information regarding what was done for individuals without insurance since this is often a significant problem. This is a barrier to treatment, particularly for intravenous abusers (Appel, Ellison, Janksy, & Oldak, 2004, p. 129). Uninsured patients were accepted, but it is not known how this was funded in detail.

The authors explained in detail the initial visit and the follow-up visits. They also explained how the workload was divided between the staff. This was interesting because this part is often lacking in many articles. The authors also included the training and certifications of the various providers. The follow-up visits appeared to offer the clients an appropriate level of oversight. This included urine toxicologies. The authors mentioned that follow-up visits occurred at various intervals, based upon the determination of the physician. The authors needed to include more information regarding what criteria the physicians utilized to determine the length of the intervals. It is not known if there is some internal criteria the physicians used or if it was based upon professional judgment. The authors also discussed in detail the data collection and analysis. This was an excellent part for its detail.

Results
The authors did an excellent job of presenting and explaining the results. Overall, this was well-written and presented in an excellent format. This included the use of charts, as well as the discussion. The authors did mention that there was a significant retention problem. This could have been another angle for them to explore in more detail. While it is often difficult to determine why individuals leave a program, a greater effort should have been made. This would allow future programs to minimize the loss possible. It would also provide additional questions for further research.

Discussion
In this part of the article, the authors did discuss some of the questions left with the reader after the results. This included some possible reasons for attrition. An interesting one was Medicaid use. Some clients had difficulty filling their prescriptions. This needed to be examined further. The authors believe this program is best suited to urban heroin users with Medicaid. It is interesting then to note that some Medicaid clients had difficulty. This required further research regarding why some Medicaid programs accepted the treatment and some did not. This is obviously a barrier to treatment. The authors also discussed the difference in results between this setting and a similar North Carolina program. This was also a self-pay program. It is interesting to note that this program had a much lower attrition rate. This may be due to a moral hazard associated with the program and offers another possible issue for study (Pauly, 2004). The authors acknowledged that overall the results are consistent with national results.

Overall, the article was well-written and interesting. It offered a new paradigm for opioid treatment that needs to be explored and utilized by the medical community. It also raised several interesting questions that may provide for additional studies. It is also apparent from this article that opioid addiction is a significant public health issue and one of the most difficult to treat in the United States.

    References
  • Appel, P. W., Ellison, A. A., Jansky, H. K., & Oldak, R. (2004). Barriers to enrollment in drug abuse treatment and suggestions for reducing them: opinions of drug injecting street outreach clients and other system stakeholders. The American journal of drug and alcohol abuse, 30(1), 129-153.
  • Lee, J. D., Grossman, E., DiRocco, D., & Gourevitch, M. N. (2009). Home buprenorphine/naloxone induction in primary care. Journal of general internal medicine, 24(2), 226-232.
  • Pauly, M. V. (2004). Medicare drug coverage and moral hazard. Health Affairs, 23(1), 113-122.
  • Walker, AK. (2012, April 30). Methadone clinics don’t attract crime, study finds. The Baltimore Sun. Retrieved March 20, 2014, from: http://articles.baltimoresun.com/2012-04- 30/health/bs-hs-methadone-clinic-crime-20120412_1_methadone-clinics-methadone- users-crime-data