Office-based Opioid Treatment Research Articles

Treating Homeless Opioid Dependent Patients with Buprenorphine in an Office-Based Setting

ContextAlthough office-based opioid treatment with buprenorphine (OBOT-B) has been successfully implemented in primary care settings in the US, its use has not been reported in homeless patients.ObjectiveTo characterize the feasibility of OBOT-B in homeless relative to housed patients.DesignA retrospective record review examining treatment failure, drug use, utilization of substance abuse treatment services, and intensity of clinical support by a nurse care manager (NCM) among homeless and housed patients in an OBOT-B program between August 2003 and October 2004. Treatment failure was defined as elopement before completing medication induction, discharge after medication induction due to ongoing drug use with concurrent nonadherence with intensified treatment, or discharge due to disruptive behavior.ResultsOf 44 homeless and 41 housed patients enrolled over 12 months, homeless patients were more likely to be older, nonwhite, unemployed, infected with HIV and hepatitis C, and report a psychiatric illness. Homeless patients had fewer social supports and more chronic substance abuse histories with a 3- to 6-fold greater number of years of drug use, number of detoxification attempts and percentage with a history of methadone maintenance treatment. The proportion of subjects with treatment failure for the homeless (21%) and housed (22%) did not differ (P = .94). At 12 months, both groups had similar proportions with illicit opioid use [Odds ratio (OR), 0.9 (95% CI, 0.5–1.7) P = .8], utilization of counseling (homeless, 46%; housed, 49%; P = .95), and participation in mutual-help groups (homeless, 25%; housed, 29%; P = .96). At 12 months, 36% of the homeless group was no longer homeless. During the first month of treatment, homeless patients required more clinical support from the NCM than housed patients.ConclusionsDespite homeless opioid dependent patients’ social instability, greater comorbidities, and more chronic drug use, office-based opioid treatment with buprenorphine was effectively implemented in this population comparable to outcomes in housed patients with respect to treatment failure, illicit opioid use, and utilization of substance abuse treatment.

Office-based Opioid Treatment (OBOT)

Objective: This article is the second in a series on office-based methadone treatment in primary care settings in conjunction with community pharmacists and social work. This article describes a multi-site study of office-based treatment of stable methadone maintenance (MM) patients utilizing a team consisting of primary medical care practitioners as prescribers, community pharmacies as methadone dispensing sites, and psychosocial treatment and case management through a social worker. Prior to beginning the clinical trial in New Mexico, we surveyed the clinical team as to knowledge, attitudes, and expectations about MM. Methods: A self-administered 34-item survey of each practitioner's knowledge, attitudes, and expectations about MM was completed prior to a 4-session methadone-training program. Eighteen medical providers, 9 community pharmacists, and 1 social worker who had agreed to participate in the pilot study completed the survey. Results: Sixty-one percent of the medical providers, 66% of the community pharmacists, and the social worker were convinced of methadone's effectiveness, supporting methadone “treatment on demand.” The majority of the providers surveyed (72% of the medical providers, 77% of the pharmacists, and the social worker) strongly support MMT for all heroin users who want methadone. However, specific attitudes about the goals and length of methadone treatment vary substantially among this group. Two thirds of the medical providers, 1 pharmacist, and the social worker thought abstinence from all opioids, including methadone, should be the principal goal of treatment. Conclusions: The findings from this study indicate that the clinical team has a good general understanding of MMT and supports its wider use though OBOT in New Mexico. Some of their attitudes and beliefs underscore the need for further education and ongoing supervision in OBOT.

Pharmacists’ and Technicians’ Perceptions and Attitudes Toward Dispensing Buprenorphine/Naloxone to Patients with Opioid Dependence

To assess the perceptions and attitudes of pharmacists and pharmacy technicians involved in an office-based opioid dependence treatment program using buprenorphine/naloxone. Cross-sectional attitudinal assessment. Community, outpatient hospital, and clinic pharmacies. Pharmacists and technicians participating in a clinical trial of opioid dependence treatment using buprenorphine/naloxone. Written and telephone surveys followed by interviews with open-ended items. Attitudes and perceptions regarding opioid-dependent patients and use of buprenorphine/naloxone for treatment of opioid dependence. Pharmacies in seven states (New York, Virginia, Illinois, Florida, Texas, California, and Washington) participated in the clinical trial. A total of 40 pharmacists and pharmacy technicians responded to the initial written survey, representing 27 of the 32 pharmacies (84%). Follow-up interviews were obtained from one individual at 30 of those pharmacies (93.8%). Most pharmacy personnel (77.5%) involved with this study were not more concerned about theft or break-ins and would be willing to participate in opioid dependence treatment as the medication became available commercially (70%). The majority of respondents (85%) indicated that patients did not cause problems at their pharmacies. Compared with their experiences in administering other narcotic medications, most respondents did not express increased concern regarding prescription forgery (75%) or diversion (80%) of buprenorphine/naloxone. The majority of respondents expressed positive attitudes and perceptions regarding patients treated for opioid dependence with buprenorphine/naloxone.