Advocating for Patient Care with Opioid Treatment Program Administrators

The Addiction Medicine Conference was excellent. I stayed glued to my computer screen for all of Friday and Saturday, and it was worth it. There wasn’t one weak presentation; all were great. The national speakers were as good as expected, but our statewide speakers were excellent as well. We are fortunate to have talented Addiction Medicine providers in our state.

One of my little parts of the conference was on the topic of how to advocate for patient safety with OTP administrators. I thought it went OK, but it was a little depressing. I’m not the only provider who struggles with advocating for change without getting fired.

One doctor described how administrators, upset with a judgment call he had made on a patient, confronted him about his decision. This never feels good, and naturally produces feelings of anger in the physician. We are very likely to think, “Who are you to question my medical decisions? Have you gone to medical school? To residency? To repeated trainings? Have you passed a board exam in Addiction Medicine?” And yet, medical providers are often questioned by administrators, who in some cases may have only a high school education.

I do much better in my relationships with corporate personnel when I remember their job is not my job. We share some common goals, and don’t share others. It does no good to vilify them as bean counters or money crunchers because those counters and crunchers keep the business afloat and sign my paychecks. They make it possible for a facility to be open to serve our patients. Even so, healthcare providers must be able to provide quality medical care.

I wrote down some of my thoughts before the session and worked most of them into the conversation.

Here are a few of my points, in expanded forms:

Don’t take conflict personally.

OPTs are in the business of making money. Some are owned by venture capitalists, so their focus will be on profit. If the physician is perceived as impeding this goal, conflict will naturally occur. We can argue about whether this is right or wrong, but in the U.S., healthcare is a business.  Healthcare is not considered to be a right, but a privilege. If you don’t like it…vote.

It’s not only OTPs who are profit -focused. Hospitals, for-profit and non-profit alike, want to make money. The physician practices they own are scrutinized by administrators. My point is that these days, few medical practices are owned only by doctors or other medical providers, so the push-and-pull between administrators and care providers happens in all types of settings, not only OTPs.

When advocating for change, back it up with data. We have many published guidelines and best practice documents. We have SAMHSA’s TIP 63, and the ASAM practice guidelines. When administrators are shown how practices at their particular OTP are outside accepted standards, it should sway the decisions of these professionals. If an aspect of treatment is addressed in written guidelines, it’s harder to dismiss than one doctor’s opinion.

Also, since OTP administrator often aren’t science people, follow up your discussion of standards with real-life narratives. Give an example of a patient who had difficulties because of present policies, and how that could be improved. Some administrators respond much more to concrete examples that have real consequences.

Be cheerful and friendly with OTP administrators. It costs nothing and can smooth a lot of friction. It’s a bonus when you really like the administrator, but even if you don’t, keep it to yourself. You catch more flies with honey…and other things.

Do not use sarcasm, no matter how loudly a situation screams for it. Your humor will not be appreciated, and you will make people angry.

I’ll give you a real-life example that I regret:

At one of the first opioid treatment programs I worked for, the president of the company wanted doctors to order liquid valium to be added to methadone in patients who struggled with co-occurring benzodiazepine use disorder. He thought we could gradually lower the Valium dose and achieve benzo taper, allowing patients to remain at their usual dose of methadone.

What I should have said was: “There are no studies to show safety or efficacy of this idea, and dosing both at the same time might increase the risk of overdose death, since blood levels of both would be peaking at the same time. Plus there’s no assurance these patients wouldn’t continue to use the same illicit benzodiazepines that they’re already taking. Also, we couldn’t let those patients drive themselves home, as their driving would be impaired from Valium.”

What I actually said was: “Sure, boss. And let’s mix that in some Jack Daniels and give them a fat one to burn on the way home.”

My humor was not appreciated.

Be cheerful and friendly with patients and other staff, too. If you don’t feel that way – fake it. Our patients have enough to deal with and don’t need to contend with a provider in a foul mood. If you need help with a personal problem, get it. Don’t bring it to work with you.

This should go without saying, but because I’m guilty of it, I’m mentioning it: don’t grumble.

Don’t talk about administrators disparagingly. They may be terrible people, focused only on how large their bonus will be this quarter, giving little thought to the welfare of patients or staff. Even so, don’t grumble about it, because this is how workplaces get poisoned. Grumbling contributes to a general milieu of discontent and that doesn’t help anyone. Don’t be part of it. If you get so miserable that you can’t bear it, dust off your curriculum vitae and go somewhere else.

Know where your work boundaries are. If your care of patients is impeded by the decisions of non-medical administrators, you may need to look for another job. Now, with so many new employment options for Addiction Medicine providers, this is much easier than it was twenty years ago.

I opened my first solo addiction medicine practice over eleven years ago, and I’m glad I did. It provided some financial security while I navigated the sometimes-choppy waters of OTP employment.

Right now, I work in my own office only one morning per week because I work at the OTP the other days. I sublet my office to help pay for rent, and that works well. I feel less financial insecurity because I know if I had more time (read if I get fired), I could easily ramp up my buprenorphine practice.

Ten years ago, when I interviewed for the job of medical director at the place I work now, I told the administrator doing the interview that I had just quit an OTP where my medical judgment was undercut. I told him, forcefully, that I had no desire to return to a similar predicament and if that was going to be an issue, let’s not go any further with the interview. He indicated that the program would not interfere in any way with my decisions, and he kept that promise.

That program has changed hands several times and he no longer works there, but so far, I still feel I can deliver quality care. It’s not perfect, but there haven’t been any deal-breakers in the past ten years. This is a record for me.

Part of the reason I’ve stayed employed at one facility is personal growth. Over the years, I’ve gotten better at asking myself, “How important is it?” If it won’t adversely affect patient care, I want to remain amiable to change, even if I perceive the change to be silly or ineffective.

In summary, I approach patient advocacy with program administrators with the spirit of the Serenity Prayer. I try to accept the things at the opioid treatment program that don’t matter in the long run, and try to change things that could adversely affect patients. And I constantly pray for the wisdom to know the difference.

2 responses to this post.

  1. This is a two-way street. There are many amazing OTP Administrators, and most of us have WELL more than a high school education. Many state OTP regulations mandate graduate level clinicians to serve in the role, and the majority mandate at least some OTP experience (1-2 years, typically). Unfortunately, the decisions that have led to patient deaths (30, 40, 50, 60, 70, dead case where I was recently an expert witness) are driven by poor physician decisions, as there are no formal required trainings for OTP physicians nationally. No requirement for Board Certification. Medical decision making should be granted to the greatest extent possible, and I certainly do not believe in practicing medicine by policy or without a license. That said, it is often the Administrators across the United States who are having to point the physicians to ASAM National Practice Guidelines and TIP 63, not the other way around. Our field has much growing to do, and mutual respect is certainly the key.


    • Zac, if every OTP administrator could have your education and experience, the world would be wonderful indeed. I should have said that some of the finest people I’ve ever met were OTP administrators. Unfortunately, some of the biggest scoundrels I’ve met have also held these jobs. You know the kind – those that dictate “no money no dose,” with no taper. Or those that insist people be admitted to MOUD who don’t even have opioid use disorder. My blog post was advice for providers who work with these second type of administrators.


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