Office-based Treatment of Opioid Addiction

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When DATA 2000 was passed, the office-based treatment it created was envisioned
as another option for opioid-addicted people. There was, and still is, a large gap between the numbers of people in the U.S. who need medication-assisted treatment for opioid addiction, and the number of treatment slots available at traditional opioid treatment programs. DATA 2000, it was hoped, would create treatment slots to shrink that gap.

DATA 2000 succeeded in making medication-assisted treatment more available, but there are still too many opioid addicts dying from their addiction.

Just like with other chronic diseases, opioid addiction exists on a continuum. Some opioid addicts get to treatment only after they’ve lost everything, have serious co-occurring mental health issues, and have few emotional supports. Others are able to reach for help earlier in the course of addiction, have no co-occurring mental health issues, and a supportive network of friends and family. One opioid-addicted patient will need more intensive treatment than another, just like some patients with diabetes are so ill that they need hospitalization. Other diabetics manage fine with outpatient doctor visits every three months. One form of treatment doesn’t fit all patients.

The American Society of Addiction Medicine (ASAM) created the Patient Placement Criteria over twenty years ago. This textbook, just revised again late last year, is widely used to determine the appropriate level of care for a patient with addiction. The Patient Placement Criteria describes the levels of care needed for addiction treatment. ASAM says there are six dimensions doctors should look at before deciding what intensity of care the patient needs:
Dimension 1 – Acute Intoxication and/or withdrawal potential
Dimension 2 – Biomedical conditions and complications
Dimension 3 – Emotional/behavioral/cognitive conditions and complications
Dimension 4 – Readiness to change
Dimension 5 – Relapse/continued use/continued problem use
Dimension 6 – Recovery environment

Depending on the severity in these six dimensions, the appropriate level of treatment can be recommended. This can be anything from an early intervention service to intensive outpatient treatment to inpatient hospital care. The length of treatment at each level of care is based on the patient’s severity of illness, with frequent re-evaluations of the patient’s status as it changes. This is a more objective and scientific way to treat addiction, as opposed to treating all patients with addiction with inpatient treatment for twenty-eight days.

Prescribers of medication-assisted treatments for opioid addiction should use the ASAM criteria when deciding which level of care is most appropriate. Ideally, MAT could be provided at any level of care, though in real life, many abstinence-based programs won’t admit patients on methadone or buprenorphine. In real life, at least in my neck of the woods, MAT is provided at opioid treatment programs, which follow more stringent federal, state, and local regulations, and at office-based programs, with few regulations.

I think it makes good sense to save office-based treatment for the most stable patients on MAT. Opioid-addicted patients with a higher severity of illness should be treated at an opioid treatment program, at least initially, due to the added accountability built into the system at an OTP. The patient can be re-evaluated periodically, and if the patient is doing well on buprenorphine, could be encouraged to transition to an office-based program.

That’s what we do at one of the opioid treatment programs where I’m medical director. I have patients in three types of treatment: in the OTP on both methadone and buprenorphine, and then office-based patients on buprenorphine. Having an office-based option for buprenorphine patients encourages then to meet treatment goals of stability in order to transition to a less restrictive treatment setting. Sadly, there is no office-based option for patients on methadone, due to the increased risk of the medication.

Patients can move seamlessly from one treatment to another as needed. If an office-based patient suffers a bad and continuing relapse, I can move him back to the opioid treatment program arm, where he can be seen and dosed every day until stability is regained. With this model, the intensity of treatment is determined by patients need.

In an ideal world, providers at both opioid treatment programs and office-based programs would work together in a cooperative rather than adversarial manner. This would benefit the patients and the treatment programs.

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6 responses to this post.

  1. Posted by Benjamin Keith Phelps on November 3, 2014 at 4:10 am

    And in an ideal world, methadone patients could be moved, once stable, to office-based settings, rather than being forced to REMAIN in draconian clinic settings that place FAR too many restrictions on them, day in, day out, for the rest of their natural lives or time in treatment! It’s unfortunate & unthinkable to me that they have not allowed MMT to move out of the clinic environment in ANY capacity by now. There have been investigational studies into this for YEARS & YEARS now, with great success stories! Yet they still have not moved beyond investigational studies. But why should I be surprised at that when methadone itself was still considered investigational up until 2001? We’re still, as patients, subjected to embarrassing observed urine screens 100% of the time at many, if not most, clinics. We’re still subjected to having our dose withheld for being unable to go on demand with someone staring at our genitals, even if we have paruresis. We’re still subjected to inadequate dosing at many, if not most, clinics. We’re still being subjected to the notion that preferring tablets to liquid means we’re probably diverting our methadone & selling it by our docs, our nurses, our counselors, & others. We’re still subjected to groups after years in treatment & even when they are no longer of any help to us. Suboxone patients can simply find another doc when they don’t like the requirements of the current one. We can’t do that quite so easily. So what I’m saying is that the restrictions placed on MMT are draconian, they’re overdone, & they’re restrictive to the point of making MMT impossible for many many people. That’s not a good thing. Sure, I understand the need for accountability, & for some restrictions & guidelines. I understand that methadone is dangerous when not used properly & that in the wrong hands, it will kill very easily. But I’ve watched FAR too many people fish Suboxone out of their pockets (who weren’t being prescribed it) to believe for ONE SECOND that Suboxone isn’t being sold by a HUGE portion of the patients getting it. Literally, every pill-popper I’ve run into over the last 6-7 years has had Suboxone in his or her pocket. And not a one of them were being prescribed it legitimately – they ALL bought it off someone who was. And the sad thing is that they’ve removed all time-in-treatment restrictions on it, so the addict still in his addiction can walk into a doc’s office & by the end of a couple of days, have a month’s script for it. Nobody THAT new to treatment is ready for a month’s worth of meds to take home. They just aren’t. And yes, the same applies to MMT patients. But while theirs is too short, ours is FAR too long. State restrictions make most people wait YEARS before they can get more than a week of medication, & a few states won’t even let ANYBODY have more than a week’s worth… EVER! And then, clinics impose their own restrictions on takehomes on top of that – SouthLight wouldn’t let you get to 5 takehomes until a year in treatment, & then you couldn’t get #6 until a year & a half. Then you had to sit at 6 takehomes for another ENTIRE YEAR & A HALF before moving up to 2 weeks. And then they wouldn’t let you get anymore – no 27 takehomes there – because they know better than the federal government or other treatment centers. According to federal regulations, a patient on methadone could earn 1 month’s worth of meds by the 2 year mark. I know of not a single clinic that allows even close to that. The disparity between the 2 treatments is FAR too great, & without a good enough reason. Withdrawal is every bit as bad for most people coming off Suboxone as it is with other opioids, at least according to them. And as for drug safety – well, I know it’s somewhat safer in terms of OD’s, but I don’t think it’s THAT safe as to allow indiscriminate prescribing by the month for patients who’ve just entered treatment & are likely still using, still buying & selling illicit drugs, & haven’t shown any propensity to stay clean for any real length of time yet. I’m sure it sounds like I have a chip on my shoulder about Suboxone, & truth be told, I do to some extent. I’m just worn out on seeing its praises touted everywhere, while methadone continues to take a beating everywhere it’s mentioned. I don’t mean that Dr Burson does that, but just in general. The clinic is THE SINGLE most aggravating, hassling, troublesome thing in my life & has been for the last 11 years. When I can’t take a trip, that’s why. When I can’t take a job, that’s why. When my transportation gets stolen, they take my takehomes for half a year, making me have to get there DAILY when I LEAST have a way there. When a false positive pops up, they wait to tell me about it until it’s too late for a challenge via GC/MS, therefore sticking me with the hassle of having to fight it out with the director to get my privileges back that should’ve never been taken to begin with. When they do a call-back, I have to drop everything & run to the clinic within 24 hours or lose everything I’ve worked so hard for. How many call-backs have been done on Suboxone, I wonder? How many empty Suboxone bottles have been required to be returned? I’m gonna guess zero. We had to return our empty pill bottles at the clinic I was in that used tablets 4 years ago! What is the point there? I can understand it may prevent some level of diversion with liquid, but tablets? Anyway, you have a good idea of why I’m frustrated with this all. And I don’t get to throw my hands up & walk away from it… So at some times, it all becomes too much to bear, & I have to vent it all out like this. I get that there’s increased risk with methadone. But what I don’t get is why patients who have shown themselves to be stable in treatment for long periods of time STILL aren’t offered any type of office-based methadone treatment, & here we sit in 2014 (almost 2015!) We should be beyond this by now. This clinic system was set up in the 1970’s & was so restricted b/c it was still experimental in nature back then. We’ve come a LONG ways since then, & our treatment methods should reflect it, but they don’t. All we’ve really done besides allowing monthly takehomes is to add Suboxone to the long list of 1 medication available for MAT. We actually HAD 2 medications at that time – methadone & LAAM, but LAAM is not available anymore since 2004, so…. That’s just another example of their nastiness – they never did, in over 10 years, allow a single takehome of LAAM. Restrictions like that don’t open up treatment to many people… It just succeeds in limiting severely the number of people who have access to it. VERY few people can or will drive more than an hour to receive treatment either every day of their life or every other day. It just gets to be too much very quickly. I’ve driven an hour & a half each way, 7 days a week for treatment for 3 months, & it literally almost killed me.

    Reply

    • Well said, Benjamin… I largely agree. The point I wanted to make in a comment (then I saw your comment immediately after reading the piece) was that it’s unfortunate that the office-based opioid treatment (OBOT) option for methadone has been allowed under the most recent, and current, federal regulations since the early 2000’s but to date there are only a couple in NYC, one in Baltimore and one in Boston (that is closing, sending the stable patients back to an OTP with a two week max of takehomes). The unfortunate reality is that for the long-term, stable patients who are living productive lives in recovery who happen to be taking methadone vs. buprenorphine we just don’t have the option for OBOT despite it being allowed and legal. To be fair, methadone doesn’t have special legislation like DATA 2000 that makes OBOT so very easy and practically regulation-free, but OBOT with methadone is allowed under the current regulations and it’s unfortunate it hasn’t expanded. Then again OTPs don’t want to lose their “easy” patients like me, like you, who attend once a month, always pay our clinic fees, remain in “compliance,” and just take up 20-30mins of the clinic’s time once a month. We pay the same fees as those patients who require many more services and attend daily (the patients who cost more), so we’re the patients that give the OTPs the biggest “return” on their money. While I am one of the first individuals to defend against the attacks leveled at for-profit OTPs and DATA 2000 practices, they are businesses and sometimes business decisions drive policy. The only real reason I can see for OBOT with methadone not expanding more, despite even AATOD making a policy statement in favor of its expansion, is that OTPs just simply don’t want to “lose” or refer out patients like us who are easy and provide the largest “return” on our fees. OBOT with methadone, unfortunately, requires a partnership of sorts with an OTP to dispense the methadone (unlike DATA 2000 for buprenorphine where the provider can just write a prescription and the patient can fill it at the local pharmacy)… This gives the OTPs an ability to determine whether or not OBOT with methadone will expand: they have to agree to this “partnership” to order and dispense the medication (though there are rural exceptions that family physicians and retail pharmacies in rural areas can get for OBOT with methadone, but these are even more rare these days). My hope was that the combination of the Patient Protection and Affordable Care Act (ACA) and the Mental Health Parity & Addiction Equity Act would create an environment where OBOT with methadone can and will expand, but that remains to be seen.

      Overall I think Dr. Burson makes some excellent points in this blog entry, but it’s unfortunate that the office-based option is currently only available (mostly) for patients of one medication… One that has many more lobbyists and big money behind it while methadone only has evidence and science.

      Zac Talbott
      NAMA Recovery of Tennessee
      National Alliance for Medication Assisted (NAMA) Recovery

      Reply

      • Posted by david monosson on December 2, 2014 at 8:36 pm

        I am one of the very few and very very lucky methadone patients who was reached out to by CAM lifein Baltimore and offered treatment on their methadone OBOT program which is limited to approx. 120 patients. I am eternally grateful and thankfull for this as it has returned to me a life worth my living as well as a life which is now again able to be lived with a full measure of peace and tranquillity……something almost impossible to experience while a patient on 90% of the MMT’s in this country (at least on the east coast)…..I have been on countless MMT’s in Massachusetts (pretty much terrible), Conn. (not bad), New York (terrific for the most part and I was on 3 there and my ex-wife on 2), Florida (decent but imminently variable one from the other and so leaving one with having to accept a life of “walking on tip-toes” if one happens to need to ever move anywhere and do a transfer). I can actually take a full breath whenever I want!
        Most med. dir’s in MMT I don’t think realize or ever stop to consider just what it takes out of someone to have to submit to the way of life incidentally imposed on one when he enters into the aggreement(s) required for acceptance at an MMT. It is because of these kind of obstacles that the more high functioning addicts in need choose NOT to be willing to submit to and so hardly ever do they become patients on methadone treatment. I have seen some among the best of my generation, the cream of the crop who adamantly refused to go onto methadone (the word has been out about clinics for years)…..and so predominantly the clinics never get to see much other than the “bottom of the barrel” when it comes to the full range of the opiate-afficionados true population. It is ultimately the countries loss along with all the friends of mine who refused methadone (not the drug itself of course, but all that usually comes with it), and who either died from alcoholism, or live a life far beneath their potential because sooner or later the law reared its ugly head and so dissapeared away most of the job/business oportunities which otherwize would have been there.
        If a way were there where someone could see clear to a normal and reasonable form of treatment……where he/she came in 1/month, paid a $100+ fee, did not stand in a line, did not have to demonstrate swallowing ones med., sat down in an office with a clinician, was not subjected to being “hit on” by other patients for all and sundry manner of things, gave a unobserved urine sample and was free to leave without a huge bagfull of bottles I would otherwize (and used to) have had to worry about……then I believe I would still have these friends in my life and/or have them living closer to their true potential instead of what is. For U penn and then Wharton Sch Bus., masters in international finance, speaks 4 languages fluently, ran the Pepsi operation in the Japans (marketing, bottling, advertising etc.,…..prior to this ran the Baby Oil Division for Johnson and Johnson, worldwide (product manager)……..who would not even consider gov’t run MMT…..because of the gov’t part (not the medication which she had had access to for years and liked)…..is now and has been working at a Panera sandwhich place cleaning tables/floors, the restrooms etc….and this is just one of the consequences of there not being more places like the OBOT-like program I am on in Baltimore Md. run by a Dr. Hayes who recognized the need for patients who could prove themselves honorable, trustworthy, able to fully comply with having clean urine screens (with room for a very occasional positive false or actual just so long as they are far and wide between), who show up on time for their appointment (yes appt,..just like a regular dr’s appt), and who are available for a call back whenever and/or an observed urine maybe once every few yrs………If this kind of treatment were made available and known about…it is my opinion that there would be far more takers from the middle and upoper classes from our society coming out of the woodwork…if only there was available an adjunct to the existing MMT system that then would attract the segment I am speaking for…and make for an overall better outcome for methadone therapy and its reputation….there might even be a few “poster children” to who might allow their stories to be used to promote expansion of this level of treatment as well as develop some much needed good will re the current public impression of methadone pt. as “loser personified”
        I am about to try convincing a particular clinic MMT in D.C. to consider creating something here (in DC) that will replicate what I have in Baltimore, so that it will be a trial ballon for this area and model to work from if it does as well as the 120 patients have done through the CAM program in Md…..as well as allowing me to transfer back to where I live and have a break from having to drive once a month (can you imagine thats the only gripe I have….but I have worked for it for many many yrs of feeling angry at clinics, angry at myself for being trapped into the whole scenario, but proud at having hung in there for the duration so I feel I deserve what I have and that it needs to be available as a reward system to attact certain others…who in my opinion would otherwize be “lost”……..david monosson, d.c.

  2. Posted by lesly on November 3, 2014 at 10:12 am

    Thank you very much for all your articles. I am a keen follower thereof.
    Here’s a question to you.
    Repeated administration of mu-opiod receptor agonists cause profound functional and structural neurobiological changes in the brain (which affect control of behaviour and result in a chronic relapsing disorder. )
    How does medication address these structural neurobiological changes in the brain?
    Awaiting your response.
    Kind regards.
    Lesly
    Cape Town

    Reply

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