A OTP/OBOT collaborative care model currently in use at Johns Hopkins Medicine

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(Stoller, K.B., 2015. A collaborative opioid prescribing (CoOP) model linking opioid treatment programs with office-based buprenorphine providers. Addict Sci Clin Pract 10, A63.)

GOAL: To support the availability and efficacy of office-based buprenorphine maintenance through enhancement with concurrent psychosocial treatment, collaborative stepped care, and expert consultation.

OVERVIEW: Physician practice provides office-based opioid treatment (OBOT) via buprenorphine prescriptions, typically in the context of ongoing somatic or psychiatric treatment. Opioid Treatment Program (OTP) partner concurrently provides non-pharmacologic addiction treatment, and when needed, assumes medication dispensing. Step-wise collaborative process matches treatment intensity, pharmacotherapy, delivery method/setting, and supportive treatments to indicators of patient stability. OBOT and OTP closely coordinate substance abuse and somatic/psychiatric care throughout duration of treatment.

STRUCTURE:

  • Concurrent treatment at a specialized addiction treatment program with an OTP component available, and community DATA 2000 waivered physician practice.
  • Comprehensive addiction evaluation and individualized treatment plan instituted at the OTP.
  • Buprenorphine induction and initial stabilization either at the OTP or physician practice, based on provider and/or patient preference.
  • If induction is done at the OTP, buprenorphine provision transferred to physician practice when initial clinical stabilization is achieved.
  • OTP and physician practice maintain frequent communication regarding treatment process, adherence and response.
  • Stepped care system uses indicators of treatment response (adherence and toxicology results) to adjust (bi-directionally):
    1) intensity of scheduled OTP counseling sessions, and
    2) source and schedule of buprenorphine dosing – ranging from monthly physician practice prescriptions to daily on-site OTP dispensing.
  • Patients not responding to the highest level of care are offered methadone maintenance at the OTP (temporary or indefinite duration depending on patient preference, response).

OTP SERVICES OFFERED:

  • Comprehensive substance use disorder evaluation
  • Buprenorphine induction
  • Buprenorphine or methadone maintenance
  • Group and individual counseling ranging from once per month to 10 hours weekly
  • Case management services
  • Collaboration with community-based medical and psychiatric providers
  • Expert telephone/email consultation with OTP Medical Director available to collaborating OBOT clinicians
  • Wrap-around services (e.g., recovery housing, peer recovery advocates, integrated psychiatric evaluation/treatment, co-management of chronic medical disorders, on-site occupational therapy)

stepped care system

Please click HERE for better view of chart.

Step 1 – “Stable OBOT”: (Patient stable in treatment)

  • Physician practice: Long prescription fill duration as indicated
  • OTP: Low-level counseling services

Step 2: “Intensive OBOT”: (Patient begins to destabilize in Step 1)

  • Physician practice: Decrease prescription fill duration (e.g., to once weekly)
  • OTP: Intensify treatment (increase counseling frequency; may add other elements such as involve drug-free support person, support productive activity, consider disulfiram, etc.)

Step 3: OTP buprenorphine: (Did not stabilize in Step 2)

  • Physician practice: Stop OBOT prescriptions.
  • OTP: Start opioid maintenance treatment. Dispense buprenorphine daily through the dispensary until stabilization occurs. Continue intensive counseling schedule.

Step 4: OTP methadone: (Did not stabilize in Step 3)

  • Physician practice: Still no OBOT prescriptions
  • OTP: Offer methadone maintenance. (Alternatives: AMA buprenorphine taper or more intensive treatment level such as residential/inpatient or partial hospitalization.)