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regulation.1 By regulation, patients must those medications have been approved for
earn take-home medication privileges by this indication and if the physician has “the
demonstrating, via urinalysis or other drug capacity to refer the patients for appropriate
testing, that they are free of illicit drugs, and counseling and other appropriate ancillary
by demonstrating cooperation with other services.”
treatment requirements. Research has Several different models of OBOT have
shown that the best outcomes are found been tested in the US and in other
when medication (methadone) is combined countries. In a US model of OBOT usually
with psychosocial treatments. Over time, called Medical Maintenance, there is a
many patients graduate to less structured close affiliation between the office practice
services, with medications dispensed in and the OTP that refers stable patients and
weekly to (at most) monthly take-home continues to offer ancillary psychosocial
quantities. The frequency and intensity of treatment services as needed. In this
psychosocial services should vary model, exemptions must be requested by
according the phase of care, determined by OTPs, and OBOT physicians must be
patient progress and needs. affiliated with a sponsoring OTP.
2. Office-Based Opioid Agonist Treatment European and Canadian models of
(OBOT): agonist care are significantly less restrictive
OBOT refers to models of opioid agonist because they are not OTP clinic-based.
treatment that seek to integrate the Patients may be admitted and entirely
treatment of opioid addiction into the managed in the physician’s office with
general medical and psychiatric care of the periodic visits, drug testing, and medication
patient. The foundation of OBOT is the management. In the Canadian model, for
conceptualization of opioid addiction as a example, agonist medications are
chronic medical condition with similarity to dispensed as frequently as daily from a
many other chronic conditions. An collaborating pharmacy, and, in addition to
important feature of OBOT is that it allows physician visits, patients participate in
primary care physicians to provide addiction community-based psychosocial care. In
treatment services in their usual clinical such models physicians work relatively
settings, thus expanding the availability of independently of OTPs.
care.
OBOT can refer to treatment with
3. Treatment Components, Structure
methadone (a Schedule II medication) or
and Intensity:
with buprenorphine (a Schedule III
medication). At present, only two Examples of treatment components
medications (both formulations of include counseling (individual and group),
sublingual buprenorphine) meet the general medical care, psychiatric services,
requirements of the authorizing law, the programs for family members,
Drug Abuse Treatment Act of 2000 (DATA educational/vocational counseling, financial
2000). DATA 2000 provides for a model of counseling, and legal services.
OBOT by authorizing Schedule III-V Treatment structure refers to elements
medications to be used by qualified such as the requirements a patient must
physicians in their offices for the treatment meet in order to continue in treatment.
of opioid dependence or opioid addiction if Examples of such requirements are
attendance compliance, no use of illicit
1
In 2003, the manufacturer of ORLAAM©, Roxane drugs, and participation in psychosocial
Pharmaceuticals, announced that it was ceasing production and
distribution of the product and expected supplies to be depleted
services.
by February 2004. The remainder of this Public Policy
Statement, therefore, refers only to methadone and
buprenorphine.
ASAM Public Policy Statement on Office-based Opioid Agonist Treatment (OBOT) 3
Treatment intensity refers to the number opioid agonist medication to be used. The
of treatment components the patient utilizes selection of an opioid agonist treatment
(each of which can range from less to more program, like the selection of any modality
rigorous) and the frequency with which the of treatment, should be based upon a
patient participates. For example, the multidimensional assessment of the
frequency of counseling sessions can vary patient’s severity of illness, matching
from one per day to one per month; the intensity and structure of treatment (level of
length of counseling session can range care), using objective criteria such as those
from ten minutes to one hour; the type of found in ASAM’s Patient Placement
counseling can range from classroom Criteria, Second Edition Revised (ASAM
sessions to those where the patient PPC-2R).
engages in an active role with the Some opioid-addicted patients can be
counselor. treated effectively with buprenorphine;
Current US models of opioid agonist others will require methadone. Some,
treatment rely on providing access to particularly those new to treatment, may
psychosocial services such as group require highly structured treatment
therapy, patient education classes, relapse programs involving on-site, observed
prevention services, mental health care, administration and dispensing of medication
access to medical diagnostics and care, such as is utilized in OTPs, combined with
and randomized urine drug testing. intensive psychosocial and adjunctive
Generally speaking, unstable patients in therapies. Other patients do well in less
early treatment require both more structured settings and with a lower level of
structured treatment and greater intensity of psychosocial services. The needs of
such services than patients who are stable patients change as their time in treatment
and have embraced a recovery-oriented lengthens and as they accomplish
lifestyle. treatment goals and life changes
associated with recovery. One size does
However, in areas where such services not fit all, and ASAM strongly supports the
are not available, such as areas where need for a full continuum of service, linked
there are no OTPs, pharmacological to psychosocial stability, results of urine
treatment alone with support of the treating drug tests, and other patient-progress
clinician may still represent an important criteria.
option for some patients.
ASAM believes that the level of
structure and intensity of services in
Rationale for Expansion of Office-Based treatment programs in which patient are
Opioid Treatment Programs: initiated on opioid agonist treatment with
Two formulations of buprenorphine are methadone should be higher than in
authorized by the Drug Abuse Treatment programs treating stable patients. ASAM
Act of 2000 (DATA 2000) for OBOT in the believes that appropriate levels of structure
US. Methadone is approved for OBOT in and intensity of services can be maintained
Canada and several European countries, by OBOT programs as well as by OTPs.
but not in the US. This situation means that For example, OBOT programs can have
whether a patient can be routinely treated in observed administration of medication, and
an office setting in the US is determined by psychosocial recovery resources, and
the Schedule of the medication to be used trained and qualified OBOT physicians,
and the approved indication, not by the knowledgeable about treating opioid
clinical circumstances of the patient. addiction.
The decision to provide OBOT should ASAM’s policy recommendations seek
not have to be made on the choice of the to simplify current procedures for providing
ASAM Public Policy Statement on Office-based Opioid Agonist Treatment (OBOT) 4
American Society of
Addiction Medicine
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