Key Researchers
 

 

Key Results: Treating Opioid Addiction in an Office-Based Practice

Citations Listed in Key Results

  • Stabilized, long-term methadone maintenance patients can be treated safely in medical office-based practices (methadone medical maintenance programs) without adverse effects and with high rates of treatment retention and improved satisfaction.
    Most methadone-based treatment services are offered through specialized and federally certified Opioid Treatment Programs (OTPs). But treatment through these centers can be difficult to access, carries significant stigma, and in some states is simply not available (Merrill, 2002). In an effort to broaden treatment options for opiate addiction, methadone medical maintenance programs were initiated in experimental settings to allow OTP patients who are considered stable to get treatment from physicians in a general practice setting. Typically, methadone medical maintenance patients see their physicians once a month where they receive a one-month supply of medication, rather than going to a clinic more frequently (Salsitz et al., 2000). In 2001, the first methadone medical maintenance program was approved outside the experimental setting and within the existing regulatory structure (Merrill et al., 2005).

    Several studies looking at the experience of stable methadone maintenance patients in office-based treatment programs have concluded that methadone medical maintenance can be an effective way to treat opioid dependence. A study examining 15 years of treatment in a New York City methadone medical maintenance found that of 158 patients who entered the program, 132 (83.5 percent) adhered to the program rules and proved to be treatable in an office-based setting (Salsitz et al., 2000). Researchers also have found that the simplified approach makes it easier for the patients receiving office-based treatment to deal with work and business situations and finish school than patients in traditional clinics (King, et al., 2002).

    While treatment in an office-based setting is known to be effective, establishing a medical maintenance program can be a complex undertaking. For example, it can take a year or more to obtain the necessary regulatory exemptions required to offer methadone outside of a traditional clinic and training is needed for participating physicians and pharmacists (Merrill et al., 2005).
  • While stabilized patients appear to do well after switching to office-based treatment, international research shows that new patients also can successfully initiate treatment in such settings. However, research investigating the effectiveness of office-based treatment for new patients has been restricted in the United States.
    Having established that office-based programs are effective for stabilized patients, a key issue for researchers and policy makers is whether they would be suitable entry points for new patients seeking methadone for addiction treatment.

    There is evidence from abroad that if given proper support, primary care physicians can successfully participate in methadone treatment programs on a large scale and safely initiate methadone treatment (Weinrich and Stuart, 2000). Research also shows that expanding methadone treatment options to include a large number of private physicians doesn’t simply prompt patients to choose office-based services over traditional clinics. Rather, the change allows more of those in need to receive treatment by offering services to those who were unable to get help through existing programs (Brands et al., 2002).

    But while U.S. researchers explore the risks and benefits of office-based methadone treatment, existing regulations make it difficult for them to extend the evidence to include patients new to methadone treatment. Thus, methadone medical maintenance remains available only to the minority of patients who have proven to be successful in treatment—not to new patients (Merrill, 2002).
  • US-based methadone medical maintenance programs may fall short when it comes to enhancing access to addiction treatment because under the current regulatory structure, only a small proportion of methadone maintenance patients qualify for office-based services.
    It’s important to consider that in the US, patients treated in one of the relatively small number of office-based methadone programs may not be representative of all those with opioid dependence. Thus, lessons learned for their experience in office-based treatment may have limits.

    The patients now allowed to enter methadone medical maintenance programs are those who are considered “stable,” meaning they have been successfully receiving treatment at a methadone clinic for over a year (Merrill et al., 2005). And while the patients selected to participate in office-based programs may be happier receiving methadone through a physician’s office, they probably would have continued to function well in a traditional clinic setting (King et al., 2002).

    There is also the question of whether existing opiate treatment programs will be eager to create methadone medical maintenance programs or refer stable patients to office-based services. With current regulations restricting office-based services only to stable patients, clinics may view losing patients who require relatively little attention as having financial implications because they essentially help subsidize the cost of treating more difficult cases (Merrill, 2002).

  • Buprenorphine delivered in office based settings is effective for the treatment of opioid dependence and is likely comparable in effectiveness to traditional methadone maintenance treatment.
    Buprenorphine provides another treatment option for opiate addiction. Like methadone, it can block illicit opiates and control withdrawal but, unlike methadone, there are fewer limits to its dispensation by physicians. That’s because the different chemical properties of Buprenorphine and its use in a combined tablet with another medication, Naloxone, that blunts the effect of opiates are seen as making it safer and less prone to abuse.

    While Buprenorphine treatment is new in the US, other countries have substantially expanded capacity for opiate addiction treatment through the use of Buprenorphine in office-based practices. In France, for example, expansion of access in a minimally regulated environment has led to a reduction in opioid overdose deaths (Auriacombe et al., 2001), but also to abuse of Buprenorphine. However, in France Buprenorphine has been used primarily without the Naloxone that is intended to reduce such abuse (Obadia et al, 2001).

    There is evidence that Buprenorphine delivered through primary care physicians is as effective as traditional methadone treatment programs in dealing with opiate addiction (O'Connor et al., 1998). Its efficacy appears to remain constant whether administered to those already in treatment or those just initiating treatment (Harris et al., 2005). But more research is needed to guide doctors in identifying patients more likely to be successful with Buprenorphine as opposed to methadone, and to help improve adherence to Buprenorphine treatment (Fiellin et al., 2006). There is some evidence that patients who are employed and receive counseling are more likely to stick with the treatment program (Stein et al., 2005).
  • Compared to patients receiving methadone maintenance treatment, patients receiving office-based Buprenorphine treatment in the United States are more likely to be younger, Caucasian, relatively affluent and dependent on prescription opioids.
    One issue with Buprenorphine is that, by allowing more physicians to offer treatment for opiate addiction, it alters the demographic of those seeking help. One study found that patients getting Buprenorphine in a primary care setting are more likely to be younger, male and holding full time jobs and less likely to be injecting drugs than patients in a traditional methadone clinic (Sullivan et al., 2005). Also, there is evidence that compared to those seeking help with heroin addiction, those seeking treatment for prescription-opiate addiction are more likely to be Caucasian and earn a higher income and may be more likely to complete treatment (Moore et al., 2007). It may be that Buprenorphine, by being more available within the medical system, allows access to addiction treatment for patients who would not consider enrolling in methadone maintenance treatment.
  • Office-based opioid treatment with methadone and Buprenorphine has been implemented slowly due to a combination of policy restrictions and the slow development of a physician workforce.
    Despite the fact that Buprenorphine is now available to physicians and restrictions on methadone have been relaxed somewhat, there remain a variety of impediments to having either drug prescribed in an office-based setting. For example:

    -For methadone, there remain concerns about its potential abuse and unease with treating one drug dependency with another. And despite recent moves to ease restrictions, current policies continue to ensure that the vast majority of patients with addiction—those who have never received treatment or have relapsed—will have to look outside of mainstream medical care for methadone (Merrill, 2002).

    -There are fewer restrictions on prescribing Buprenorphine, but health care providers still face barriers to prescribing it for their patients. Physicians must adhere to ;Buprenorphine-specific licensing and training requirements imposed by the Drug Addiction Treatment Act of 2000, and states have the ability to impose limitations on treatment provided through public funding. The actual availability of methadone and Buprenorphine through private and public treatment systems in different states is an important research question. These restrictions can be difficult and costly to overcome for many physicians, even those who treat HIV patients and who, given the links between opiate abuse and HIV, want to integrate Buprenorphine into their offerings (Schackman et al., 2006).

    -Inexperienced primary care physicians may see patients with opioid addiction as demanding, disruptive and manipulative and worry that their practices lack proper access to the mental health services, social services and other support required to effectively provide treatment with either methadone or Buprenorphine (McMurphy et al., 2006). But if offered the opportunity to treat opiate addiction, physicians may be more willing to prescribe Buprenorphine than methadone (Turner et al., 2005).
 
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