Posts Tagged ‘buprenorphine at OTP’

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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