Continuum of Care for Opioid Use Disorder

 

 

 

 

 

 

“Continuum of care is a concept involving an integrated system of care that guides and tracks patient over time through a comprehensive array of health services spanning all levels of intensity of care.” (Evashwick, 1989)

Continuum of care isn’t a new concept. It’s a pattern of care that we use to treat patients with all sorts of chronic medical illnesses. For mild forms of a chronic illness, primary care providers manage patients’ illnesses. For more severe forms of the same illness, patients are referred to specialists, with more experience and training in that area of medicine. Ideally these shared patients flow back and forth between specialists and primary care providers as needed based on the severity of illness as it may fluctuate over time.

We ought to apply this same concept for the management of opioid use disorder. It’s a chronic illness which can have exacerbations and remissions over time, just like diabetes and asthma.

I try to follow this concept at the opioid treatment program where I work. Patients new to treatment often are ill, not only from the drug use, but also from neglected physical and mental health issues. They need more intense care. An opioid treatment program offers more structure and supervision than an office-based practice, so it’s a level of care that’s appropriate for such patients.

At the opioid treatment program, we can do daily observed dosing, to make sure patients take the dose I prescribe. We assess the adequacy of the dose by asking about withdrawal symptoms and observing withdrawal physical signs. We can monitor for side effects. We can do frequent drug screens, to provide information about the proper level of counseling needed. Counseling, both group and individual, are built into the system at opioid treatment programs.

At the other end of the spectrum, stable patients with years of recovery in medication-assisted treatment need less care. We still need to monitor for relapses, but they usually don’t need as much counseling, and no longer require observed dosing. They need the freedom that office-based practices provide.

Stable patients on methadone get more take home doses, but opioid treatment programs are their only option for treatment setting. Stable patients on methadone can’t get their treatment in primary care settings. It’s illegal for office-based physicians to prescribe methadone for the purpose of treating opioid use disorder. Primary care doctors can prescribe methadone to treat pain, but not if the patient also has opioid use disorder.

It’s different for patients on buprenorphine (Suboxone, Subutex, Zubsolv, Bunavail). Since 2000, it’s been legal to prescribe this medication from office-based settings for patients with opioid use disorder.

But that doesn’t mean this is the right setting for all patients with opioid use disorder.

I have an advantage, since I see patients in both settings, both opioid treatment program and an office-based practice. I have the luxury of being able to treat new patients in the opioid treatment program, and after they stabilize, talk to them about transitioning to the office-based practice. If a patient encounters a rough patch, I can ask them to return to the opioid treatment program for more intense treatment until they again stabilize.

I can use the same concept as used with other chronic medical illnesses.

Sometimes a new patient can safely be treated in an office-based program. This all depends on individual patient circumstances. One patient may have a fantastic support system at home, while another may have to put up with active drug use in his home. Obviously, the latter patient needs more support from treatment staff.

Sometimes patients on buprenorphine aren’t appropriate for office-based treatment, even after months of treatment.

Unfortunately, most patients with opioid use disorder aren’t placed in a treatment setting based on their needs. Most patients end up in whatever facility they enter for the duration of their treatment, which may not be the best thing for the patients.

It’s rare for an office-based practice to refer their patients who are struggling to opioid treatment programs. Many office-based providers, enthusiastic about treating patients with opioid use disorder, still regard opioid treatment programs with great suspicion. It’s partly due to lack of knowledge about OTPs. It’s also partly due to that old bugaboo that blocks so much of appropriate treatment for people with substance abuse disorders: stigma. Some providers believe all sorts of outlandish things about what takes place at opioid treatment programs.

It’s painful to admit, but some providers’ opinions are formed based on the actions of poorly run opioid treatment programs. Some opioid treatment programs provide little more than daily dosing of medication. In our business, those programs are referred to derisively as “juice bars,” meaning patients get a daily dose of methadone, which looks like red juice, and little more.

These programs taint the reputation of good opioid treatment programs which offer an array of services all meant to help the patient. This is a real shame.

So, what about me? Do I refer stable buprenorphine patients at our opioid treatment program to other office-based buprenorphine practices? Well…not so often.

I know plenty of excellent office-based buprenorphine providers across the state who are diligent and painstaking about the care they deliver. And I know some providers in my area who don’t meet that standard. I’m hesitant to refer to them.

For example, one nearby provider charts extensive patient visits. These notes include everything from history of present illness, complete review of systems, and complete physical exam for each visit. Yet I was troubled about how similar each visit was, and suspected there was a whole lot of “cut and paste” going on, and that the charted care wasn’t actually being delivered.

Recently a patient transferred from this practice back to me, at the opioid treatment program, for purely financial reasons. We requested a copy of her charts, as we do for all patients who have been seeing other practitioners. This is good medical practice, even if it hasn’t been all that helpful with this particular provider in the past.

I was reading the records, and was confused. I read in the exam section of her last visit, “Abdomen consistent with eight month pregnancy.”

How had I missed this, I thought. I’m no obstetrician, but even I should pick up an advanced pregnancy on exam.

I slid my eyes back to the patient, sitting on a chair near the corner of my desk. Her abdomen looked flat.

“Um, so…are you pregnant?”

“No! Why?”

“Well you don’t look pregnant,” I added, not wishing to offend her. “It’s just that this last note says you’re eight months pregnant.”

She sighed and rolled her eyes. “The baby is seventeen months old. I guess they just never changed it in my chart.”

I looked back at each note. Sure enough, the exams for each date all read, “Abdomen consistent with eight month pregnancy.” For many months. Clearly, this was cut and paste charting. It’s not quality care, and may be illegal if the provider charged for services not delivered.

This confirmed my worst suspicions about the level of care provided at that practice, so I don’t think I will be referring patients to them.

In this country, we do have obstacles to providing a continuum of care for patients with opioid use disorders. We have some office-based practices that aren’t well-run and have little oversight. We have substandard opioid treatment programs providing little more than medication dosing, and we have undeserved stigma against opioid treatment programs that have been providing quality care for many years.

In fact, opioid use disorder may have the least organized continuum of care of all chronic diseases.

What’s the answer? Better communication and better education among medical providers.

I’m doing my part.

I go to many conferences, to learn the latest data and standards in my field. I also meet other providers at these conferences, even though by nature I’m a bit of a recluse. I’ve given talks, both to community groups and at medical meetings, to do my part to pass on what I know. I don’t enjoy public speaking, but find that once I get involved in my topic, I lose my fears.

All providers of care for people with opioid use disorders need to do this – we must meet each other, talk to each other, and learn from each other.

Here are a few wonderful opportunities to interact and learn:

ASAM conferences: the American Society of Addiction Medicine holds several conferences per year at the national level, and these are excellent for learning and meeting the leaders in the field. You can read more at their web site: www.asam.org

 

In my state of North Carolina, you can get some valuable information from the Governor’s Institute, at https://governorsinstitute.org/ and also their blog: http://www.sa4docs.org/

You can attend webinars, get clinical tools, and obtain mentoring from the Providers’ Clinical Support System MAT, at https://pcssmat.org/

If you are a provider in North Carolina and want CME hours while you teleconference with peers and mentors, you can participate in the UNC ECHO project. You can read more about that here: https://uncnews.unc.edu/2017/02/15/unc-chapel-hill-initiative-will-combat-opioid-use-disorders-overdose-deaths/

Write to me if you want to participate and I can forward you to the people that can make that happen.

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8 responses to this post.

  1. Posted by Alan Wartenberg MD on December 11, 2017 at 4:19 am

    I have seen MANY MANY charts where the practitioner simply cuts and pastes all the prior entries. I have occasionally cut and pasted old notes, while CLEARLY LABELING them as such, just because they have all the prior hospitalizations, meds etc. I then write an update note on what has changed. Doctors who do the kinds of stuff that Jana talks about here open themselves up to major malpractice issues if those charts ever end up in a lawyer’s hands.

    The cookie cutter aspects of the Federal/State requirements for methadone treatment are also often irrational, in that there are patients who need intensive counseling, while others need far less, and some only need occasional physician advice. The requirement that EVERY patient get the same minimum amount of counseling doesn’t allow programs the flexibility of using their assets in ways that meet patients’ needs.

    In addition, SUD treatment in general, and opioid use disorder treatment in particular, is a matter of “no right door.” The business concept of “no wrong door” was started by Ritz Hotels, where they wanted to make sure that whoever was asked a question or to do some kind of task by a hotel customer would either know the right answer, or could direct that customer immediately to someone who did. In opioid treatment, we have few “honest brokers” who will do an assessment and tell you which form of treatment might be best for you. If you walk into a 28 day program, you get a 28 day program (no matter how many times you walk into it). If you walk into a methadone program, you get methadone. If you see a buprenorphine provider, you get buprenorphine.

    It would be nice if our field required that there be a neutral party doing triage, who could figure out what the best choices were for each patient, without having a financial or ideological stake in the outcome. I don’t expect this in my lifetime.

    Reply

    • Posted by Obsteve on December 12, 2017 at 12:41 am

      There is no neutral party; there is a neutral entity which if used correctly, will almost always suggest the level of care best suited to the individual patient. It’s called the ASAM Placement Criteria. All of us in ADM know of it but few of us utilize it to its fullest. A few reasons: 1. If a facility only offers Residential or PHP, guess where the pt is told his/her best chance for success lie? 2. Even though third party payers are now supposed to abide by ASAM PPC, few do, in reality 3. Third party payers know that many providers only offer the highest levels of care so frequently disallow even very valid documentation of needs.
      The answer I think lies in real outcome data which seems to be almost impossible to generate in an industry (I hate using that term), that in part relies on successful marketing.
      So you may be right; not in your lifetime, nor mine.

      Reply

    • Thanks! You are right – with addiction treatment, the common practice seems to be, “If all you have is a hammer, everything looks like a nail.”

      Reply

  2. Posted by Brooke Stanley on December 11, 2017 at 7:41 pm

    As someone that is very stable on methadone, I would give anything to be able to receive treatment in a primary care setting. While I am receiving the max amount of take homes that are allowed by the state, I, at times, feel discouraged that I have to abide by many of the same policies as patients that have not earned levels or that have only been in treatment a few months. It’s not that I want special treatment, but more that I feel that I have hit a plateau. I have already achieved the “highest” level, so then what is next for me? What am I working towards now? Of course there are always personal goals that I am working towards. I just wish there was more for me to strive for in regards to my treatment. I wish there was a way for me to “graduate” out of the clinic, other than detoxing off methadone (which is not something I desire to do anytime soon, if ever). Or, at the very least, I wish that I could move up to only having to dose in clinic once a month. I feel guilty for complaining and really do try to keep a grateful attitude, as I have so much to be thankful for. I am in treatment at an amazing facility, so I frequently remind myself that it could certainly be much worse! I have recently found myself having mild anxiety on the evenings before my day to be in clinic. Not sure what that is stemming from. I often fear the “worst case scenarios” such as my lockbox being stolen, my bottles leaking, and bad weather that would prevent me from getting to the clinic on my pick-up day. I wonder if I would I be so fearful if I was in a primary care setting….maybe, maybe not…doesn’t seem that I will ever have the chance to find that out. I appreciate you recognizing that the rules and requirements can be irrational at times, especially for people in my position. Maybe one day there will be more flexibility that allows the medical directors to dictate what each patient needs and doesn’t need. As always, thanks for being the advocate that you are!

    Reply

    • Thank you.
      I remember a study done in New York City with stable methadone patients. They were allowed to see an addictionologist in an office-based setting. Most did very well. That was right before the opioid overdose deaths skyrocketed…made office-based methadone an unpopular idea, which is a shame.

      Reply

      • Posted by Craig on December 12, 2017 at 2:38 pm

        Sad to say but with the idiot addicts trying to shoot up suboxone and subutex I’m afraid buprenorphine is headed for something like methadone having to go to a clinic to get the buprenorphine,if that ever happens it will be the day I relapse

  3. Posted by Sean McKinnon on December 17, 2017 at 7:34 am

    You can always ask your clinics medical director to file an sm-168 waiver request with your SOTA to increase the amount of take home doses beyond what is allowed (you know individualized treatment and all)

    Also there are two paths to OBOT with methadone. They are not easy and there are a lot of obstacles but it is possible. While it is illegal to prescribe methadone outside an OTP there are ways to dispense methadone either in partnership with an OTP or by setting up facilities in the office.

    Reply

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