Although advances in pharmacotherapy have enabled people living with HIV/AIDS to live longer, fuller lives, some leave medical care, resulting in sub-optimal treatment and increased health risk to themselves and others. Forty-one patients who dropped out of an urban, publically funded primary care HIV clinic were contacted and encouraged by outreach staff to return. Participants were interviewed within two weeks of returning, and themes associated with dropping out and returning were elicited and content analyzed. Dropping out was associated with drug/alcohol use, unstable housing/homelessness, psychiatric disorders, incarceration, problems with HIV medications, inability to accept the diagnosis, relocation, stigma, problems with the clinic, and forgetfulness. Returning was associated with health concerns, substance abuse treatment/recovery, stable housing, incarceration/release, positive feelings about the clinic, spirituality, and assistance from family/relocation. Because a large number of patients reported substance abuse, depression, and past suicide attempts. Clinic staff should assess substance use, depression, and suicidal ideation at each primary care visit and encourage patients to obtain substance abuse treatment and mental health care. Future interventions could include providing SBIRT and/or onsite mental health and substance abuse treatment, all of which may boost retention.

This paper briefly reviews the evolution of opioid addiction treatment from humanitarian to scientific and evidence-based, the evidence bases supporting major medication-assisted treatments and adjunctive psychosocial techniques, as well as challenges faced by clinicians and treatment providers seeking to provide those treatments. Attitudes, politics, policy, and financial issues are discussed.

Opioid misuse, abuse, and dependence are global problems whose patterns vary across cultures. In the USA, the non-medical use of prescription opioids has become particularly serious because of its association with addiction and overdose death. Agonist and antagonist medications have been shown to be effective for opioid-dependent adults, and there is a growing body of data that they are also effective for youth. Here, we summarize evidence that detoxification alone results in high rates of treatment dropout and relapse but that the limited but growing data on the extended use of medication-assisted treatment for opioid-dependent youth have been positive. The implementation of medication-assisted treatment as a standard practice is feasible, easily integrated with counseling or psychotherapy, and has potential to greatly improve outcomes. Although concerns about safety and efficacy with youth require more research, and we do not advocate indefinite maintenance, we suggest that opioid-dependent youth should be considered as candidates for medication-assisted treatment delivered in a comprehensive, developmentally appropriate context, beginning at the first episode of care, with the strength of the recommendation to use medication increasing with each care episode.