Buprenorphine Prescribed in Two Settings

 

It’s very confusing. Even medical professionals get confused, so imagine how it is for patients.

I’m referring to the different setting where buprenorphine can be prescribed for the treatment of opioid use disorder.

Opioid treatment programs deliver care for patients with opioid use disorder in a much more structured setting. OTPs are regulated by sets of federal, state, and sometimes even local agencies. This limits flexibility when responding to changing patient needs, but provides a much more structured – some would say rigid – treatment setting.

OTPs must do observed, on-site dosing, with established protocols. Take home doses can be given, but patients must first meet a set of eight criteria. Some states, along with the federal agency, dropped the time-in-treatment requirement for buprenorphine, since it’s a safer medication than methadone.

Substance use disorder counseling is built in this system with stricter monitoring. OTPs must do a minimum set number of observed drug screens on patients. Opioid treatment centers offer a more intense, controlled, and hopefully more supportive setting for patients new to buprenorphine treatment, or who are struggling in treatment.

Office-based settings for treatment with buprenorphine aren’t nearly as regulated. Providers in office-based settings have more freedom to customize the treatment to the needs of the patient. The prescriber can decide how often the patient needs to be seen for follow up appointments and for substance use disorder counseling. Drug screen frequency and counseling intensity are left up to the prescriber. Some practices do observed urine drug screening, and some practices do not.

Opioid treatment programs are inspected by a number of state and federal agencies. Office based practices are not inspected at all, in most states. Other states, like Tennessee and Virginia, have more regulation around office-based practices, but overall, office-based practices vary more widely in quality and intensity than opioid treatment programs do.

So which setting is best? It depends on the needs of the patient.

As I said above, opioid treatment programs may be best for new patients, or those patients who use other substances besides opioids. Office-based programs may be better for stable patients because their treatment can be customized, allowing more freedom.

Ideally, office-based programs and opioid treatment programs should work together, collaboratively, to provide the best care to meet the needs of the patients. This idea of continuity of care happens with other chronic illnesses; patients with asthma may see a pulmonologist during a bad flare of illness, then resume care with a primary care provider after the expert has done everything an expert can do.

But with opioid use disorder, we aren’t there yet. I still sense a spirit of competition rather than cooperation between OTPs and OBOTs (office-based opioid treatment). It’s as if providers think to themselves, “There are only so many patients to go around, and if my patient transfers to that other practice, I will lose money.”

Believe me…there are plenty of patients to go around, unfortunately.

Providers who work at OTPs sometimes make unkind statements, saying OBOT providers are careless, poorly educated about opioid use disorder, and make bad decisions that lead to diversion of buprenorphine products into the black market. Then OBOT providers talk badly about OTPs, saying they are nothing but for-profit juice bars.

I’m as guilty as any – in my blog from last December, I made fun of an OBOT provider who used the cut and paste option of producing notes for office visits, leading to a statement about the patient being 8 months pregnant at each monthly visit for more than a year. (but that was a funny example, no?)

Somehow, we’ve got to start cooperating.

In my next blog, I’ll describe a type of treatment program that was set up to be a bridge between acute care in the hospital or emergency department, and treatment at both settings, OBOT and OTP. It’s inspiring me to be more collaborative and cooperative.

 

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10 responses to this post.

  1. Posted by Kelly Pfeifer on August 23, 2018 at 9:17 pm

    Hello
    In California, we are implementing the hub and spoke model, with the expectation that our opioid treatment programs expand in scope: integrating other MAT options, providing consultation help to primary care sites, managing people with poly-drug use (e.g. integrating contingency management for methamphetamine use disorder), etc. It is not an easy shift, due to numerous barriers: regulatory and finance issues, workflow and workforce issues, clinical expertise, etc.

    It sounds like you have solved many of these in your practice.

    Would you be willing to join a conversation with experts in CA about what it would take to move to a more comprehensive treatment model?

    All my best
    Kelly

    Kelly Pfeifer, MD
    Director, High-Value Care
    California Health Care Foundation
    kpfeifer@chcf.org
    (510) 587-3133

    Reply

    • Posted by Kayce Victoria on August 24, 2018 at 1:45 am

      My counselor is trying to implement the hub in our small community in North Texas.

      What is your opinion on how long to stay on methadone? Is it short term or would you recommend staying on methadone?

      Reply

  2. Posted by Kayce Victoria on August 23, 2018 at 9:35 pm

    Please, I have to know your opinion.

    I can’t find an appropriate post for this question that I hope to have answered so here it shall appear. In your opinion, is MAT temporary, or would you recommend staying on methadone forever?

    I’ve been on methadone 5 years now. I always thought it was giving me time to heal to relearn how to cope, etc.

    Reply

    • Kayce Victoria. Hi, My name is Shawn Gross and I have been in abstinence based recovery for 12 years. Previous to my abstinence based recovery I was on both methadone and buprenorphine. I am now a substance abuse counselor with over 6 years of clinical practice and have launched my own recovery program. My point is I have knowledge of treatment and recovery from addiction.
      The answer to your question is how do YOU feel about it? If you are receiving good counseling, moving forward in your life, have broken and replaced the habits and routines that encompassed your life as an active addict and have a strong recovery environment..then how do you feel about titrating (reducing your dose)? In my personal opinion there are some people that will have to stay on for life. Maybe they have already committed 15 years to MAT and the routines of taking the medication seem..well just too hard to overcome. Or their age is a factor. They are 59 been on and off methadone for 20 years and now they are finally stable and have quit the relapse cycle. And there are others that I have helped get off of the medication because they were ready. But their “factors” were carefully considered before any decision was made.
      What are your factors? How long were you in active addiction? How long have you been in MAT? Do you have a strong recovery environment? Have your finished school or bettered yourself in any way? Have your dealt with any trauma? Reconciled and nurturing your finances, past charges, relationships and career? Do you have co-occurring mental health issues that need addressing and if so, are you stable?
      There are so many factors to determine if someone is ready or not. But, clearly if your factors are good minimizing the risk of relapse then no one has to stay on for ever. 3.5 years is the recommended stay…again, considering you and your counselor worked on your risk factors. Journey Well.

      Shawn E. Gross, CSAC, PSS.
      enhanc3urlif3

      Reply

    • I think more and more we see that the patients who are doing the best are the ones who stay on medications the longest. If it’s working, why taper off?

      Reply

      • Hey Dr, Yes,we are seeing increased success relative to time spent in MAT. I was on methadone for 2 years and Buprenorphine for 3ish.. And I agree the longer the better. Speaking from personal experience..the relapse cycle was devastating. As a veteran I was allowed access to long term (1.5 Years) inpatient with strong medical, instrumental and emotional support when tapering off Bupe. So, that is a luxury that many do not have access to.
        The number one reason I see that people are interested in titration is money. Insurance is great but not everyone has it. This is really irritating as some will tell you, their life is now great. For someone making 12 dollars an hour or trying to afford not only their treatment but possibly also their significant others treatment cost burden can reach 900.00 a month.
        The second reason I see people wanting to titrate is age combined with not believing they need extended time on MAT. They are young and they do not feel that they need to be on medication their “whole life.” I just try to help them look at all the factors when they bring up titration. Or in early MAT stages, and I’m asked “how long do I need to be on this?” Relapsing is devastating. I can show clients all the statistics, discuss all the factors, but if they want to come off it or do not see themselves on it for “another year” anything more that advising, teaching and recommending would be unethical in my sensibilities. I do wish 1. everyone had their treatment paid for and 2. Their was a way to create, for example, mandatory terms..(cringe) because I, like you, know the longer the better. But, they also need good consistent counseling. Huge turn over rate in this industry.
        Would you advise someone that has addressed all areas of their life, have lowered the risk factors, finished college, got married and they want to come off the medication, to stay on it because its working? Honestly I would. But if they want to come off of it..
        Personally I would be hard pressed to find a client that really got their lives together in less than 3 years, maybe even 5 years. Its just not as simple as if its working why?
        Stay blessed and I love your blog. I lived in J.C. TN for 20 years, went to that VA and Dr for Bupe there. I’m now in Mooresville and really enjoy the excellent information as well, the culture that is in your narrative. It resonates with me.

      • Thanks for writing.
        I used to practice primary care in Mooresville, by the way. Pretty little town when I was there. It’s grown tremendously, though.

  3. Posted by william taylor MD on August 23, 2018 at 11:39 pm

    Thanks for your always enlightened commentary. One minor quibble: buprenorphine, like methadone, is “dispensed” from OTP’s. The only prescribing in the usual sense is done from office-based providers.

    Reply

  4. Posted by Mark Essex on August 24, 2018 at 10:34 am

    Thank you for the post. It can get very confusing for folks, so thank you for posting this.

    Reply

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