Qualities of Good Opioid Treatment Programs

Not all opioid treatment programs are created equal, meaning some are better than others. Over the years, studies have shown which clinic factors are associated with better patient outcomes. Over the next week or so, my blog postings will elaborate on each of the following factors:

  • Good communication between medical, counseling, and administration portions of the clinic
  • Experienced staff with adequate training and low turn-over
  • Low patient to counselor ratios
  • Program follows evidence-based guidelines for dosing
  • Opioid treatment program provide more care than just methadone treatment (also provide primary care, vocational rehabilitation, etc)

Today I’ll blog about communication between staff members. Communication is a good quality in any business, allowing it to run more smoothly. But it’s even more important in healthcare, where patients’ lives and well-being are affected.

In opioid treatment programs, communication happens in many ways, but case staffing is the most formal and efficient. Case staffing is when multiple members of the treatment team gather in one place, usually at a set time, to discuss what’s going on with patients. The treatment team usually includes all of the counselors, the nurses, the doctor, and the program manager. Besides communicating information about patients, case staffing also helps generate creative solutions to problems, and checks for negative emotions among staff. This can also be a forum where concerns about clinic protocols can be raised by staff.

At the program where I work, once or twice per week, after we finish seeing the day’s patients, the nurses, the counselors, nurses, program director and program manager sit in our lobby and discuss patients. First we talk about the new admissions. I tell the staff of any medical concerns I found on my intake assessment. For example, if a patient was found to have an enlarged liver on my exam, I ask the counselor to follow up with the patient later in the week to make sure the patient makes an appointment with his primary care doctor. The counselors raise concerns about new patients. Perhaps one of the counselors noticed symptoms of depression and we decide I should check that patient again the next week, when opioid withdrawal isn’t as severe.

Then we discuss established patients, and try to problem-solve. For example, maybe a patient needs to travel out of town for work, and there’s no opioid treatment program nearby where he can guest dose. We talk about the patient’s progress and whether it’s appropriate to ask the state methadone authority for extra take-home doses. We have some leeway to decide about Sunday and holiday take home doses, and discuss who is ready for these take homes.

Counselors may ask about how to approach ongoing drug use. The approach is different for different types of drugs. If a patient has had repeated relapses to opioids, maybe the methadone dose needs to be increased. If benzos are a problem, we must discuss if it’s safe to continue to dose that patient with methadone. For marijuana and cocaine, more intense counseling is indicated, and we discuss the best approaches.

Case staffing also helps us watch each other for negative attitudes. Patients with addiction sometimes behave badly. In active addiction, some addicts have had to lie and deceive to survive, and these tendencies don’t disappear overnight. The whole staff of an opioid treatment program needs to watch each other for negative or pessimistic attitudes developing toward patients.

For example, recently I was in a case staffing where we were talking about the repeated relapses of a patient. I made a comment which was more negative than the situation warranted, and this patient’s counselor appropriately challenged my comment. I’m no different than any other human and can take a skeptical view of a patient when it’s not reasonable. This counselor made me re-consider my opinion, and she was right to do so.

We talk about clinic policies that may need to be changed. For example, when patients can’t pay for treatment, how long do I have to taper their methadone dose? I’ve worked in clinics where if you didn’t have money for that day’s dose, you didn’t get a dose. They had no policy in place to allow a taper. I’ve worked in clinics where the dose was tapered over 4 days. At my present clinic, the dose is tapered over ten days. That’s still too short, and I’d prefer to keep everybody in treatment for free, but that’s not possible. The program would fold. I’ve had the unpleasant experience of working for a methadone program that closed because it ran out of money to operate. So it’s important to include the clinic administrators in some aspects of case staffing.

The best part of case staffing is talking about patient successes. Counselors talk about patients who are participating in counseling, who’ve had negative drug screens, and qualify for take home levels. Unless any staff member has concerns, I sign a form to make it official. We talk about patients who have recently gone through difficult situations without using drugs. We even have an unofficial “patient of the week,” a term for the patient who has worked hard on recovery and had a recent success. Sometimes it’s a patient who got a job promotion. Sometimes it’s a patient who has started going to 12-step meetings. Sometimes it’s a patient who has a negative drug screen for marijuana because he’s stopped smoking pot for the first time in his entire adult life.

Talking about this good stuff is so important for staff. We get to feel like we are at least some small part of the positive changes happening in the lives of our patients. Fortunately, there’s much to celebrate at every case staffing. As I’ve said before, I never saw the kind of positive changes when I worked in primary care that I see working in addiction medicine.

 

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6 responses to this post.

  1. Dr Burson, thank you SO much for choosing to write about this issue. If you don’t mind, I’m going to print this up (and the following ones) and discuss them with my clinic’s program director – who also happens to be my counselor. We spend a lot of our sessions discussing what could make the clinic better, and I can’t tell you how many times I’ve talked about communication! Communication is vital to trust, and trust between the medical/counseling/admin staff and patients is incredibly important in recovery, in my opinion. I’m just a patient, and I wish I could do more to change how things are done, but sometimes it feels like no one cares…thank you for having the presence of mind to write about this topic, and I can’t wait for more!
    Oh, and if you do mind about me printing this and sharing it with my counselor at my (small) clinic, please let me know. Thank you.

    Reply

  2. Posted by Jason on November 19, 2011 at 10:37 pm

    Dr. Jana,
    Do you treat heroin addiction and pain pill addiction the samee way? And, do you see a difference in pill addicts that started their addiction after going to Doctors vs. the one’s that self medicated?

    Reply

    • Excellent question!
      Yes, we treat all opioid addiction the same, no matter if the main drug was heroin or pain pills. Often we see people who started with pain pills and when they got scare and expensive, switched to heroin.
      I don’t see any differences between addicts who got the pills by prescription as opposed to off the street. Most of the addicts I see have gone to more than one doctor, so they’re already breaking the law just like those that buy off the street. But the disease of addiction makes people do many things they woouldn’t under any other circumstances.
      there are some trials going on now looking at clinical outcomes of heroin addicts versus pill addicts. The trouble is, most heroin addicts have also used pain pills, so there’s a good bit of overlap.

      Reply

  3. Posted by Jason on November 21, 2011 at 10:24 pm

    Dr. Jana,
    I think this latest post opens up a lot of questions..I’m curious to know if you think a PCP should also be one’s Suboxone Doctor. When I first heard that some (maybe all) Doctors could only have a certain number of sub patients, I was upset. Now, I wonder if only primary care physicians are mandated to this. I realized last week my Doctor had confused me with another sub patient and I’ve been seeing him for 2.5 years. If I had the care you described above, I think I would be much further along in treatment. While I know my Doctor absolutely saved my life and is a great Doctor, I think he and his staff are too busy to provide the care you do. I saw the receptionist tell a patient “you’re too early for your appt., you’re going to have to withdrawal.” That scared me and she wasn’t even talking to me. She obviously has never been in withdrawal and has no idea how cruel that is to say to someone who has. Do you agree with that sort of stern mentality with addicts, or would you think that taking more sub is better than relapse? I personally have never relapsed, but if I was made to withdraw, I would relapse in a heart beat..

    Reply

    • I think a primary care doc can absolutely be a good prescriber of Suboxone – as long as she’s educated. Fortunately doctors can’t get a DEA number to prescribe unless they take an 8 hour training course. Is that enough? Maybe, maybe not. Like all other areas of medicine, the more knowledge you have, the better job you can do. Maybe for “easy cases” primary care doctors do great. And maybe patients with more complex history need to see a specialist – just like we do with other diseases.

      All doctors are limited to a maximum of 30 Suboxone patients at a time for the first year they prescribe it. After that, they can petition the government for permission to treat up to 100 Suboxone patients at a time. That applies to addiction medicine docs and primary care docs alike.

      As to the patient who was told they had to go into withdrawal, i’m assuming the patient ran out of medication early? I would hope the doctor would talk with the patient about why this happened, rather than have the receptionist deliver a message like that.

      I’m not sure I’d call it a stern mentality, but docs need to be careful and not prescribe willy-nilly. Some patients are not able to take Suboxone as prescribed, and are best served by finding a different form of treatment. Some patients get an obsession to keep taking more Suboxone. If I have a patient run out early, I want to know why. Did I have them on an inadequate dose to start with? Or did they take them compulsively, like they took pain pills in active addiction? If they take Suboxone compulsively, is there an opioid treatment center nearby that uses buprenorphine? I could refer them to that facility where they’re dosed daily.

      I had one patient who would do great as long as I prescribed one week at a time, but every time I prescribed one month, he ran out early due to compulsive use. So I prescribed one week’s supply, with one refill, saw him every two weeks, and he did great.

      There are options, but it’s impossible to tell what’s best without talking to the patient.

      Reply

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