(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.
- 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)
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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.)