Friday, April 27, 2012

Office Based Opiate Treatment (OBOT) --Methadone at the Doctor's, Not the Clinic

Methadone has been used to treat heroin addiction for forty years.  In study after study, it’s been shown to be the most effective way to treat opiate addiction.  Yet, in these past four decades, methadone treatment has not escaped the clinic system.  The biggest reason for this, we can assume, is the fear of diversion.  Yet even presumably trustworthy long-term patients must return to the clinic once a month (once a week in some states) and submit to bottle checks and urine tests.  Perhaps this is justified; I don’t know.  It’s worth noting that patients who receive stronger painkillers than methadone in a doctor’s office for pain and disease are subject to no such scrutiny.  Junkies are junkies, I suppose, and the prevailing wisdom is that they can never be trusted.
But contrast the clinic model with the way buprenorphine (Suboxone) treatment is handled in America.  Patients may still be subject to urine tests and medication counts, but they have the dignity of being treated in a doctor’s office.  This way, patients are treated for and receive their medication like they have a disease.  When patients are subject to the clinic regime, with the inherent accusation that they cannot be trusted, addiction is reduced to a moral failing.
So why isn’t methadone dispensed in an office setting, like Suboxone is?  Well, it is, but here’s the catch: you have to be a long term, stable patient, and you have to live in one of the two cities in the entire country that I know of that treat patients with methadone this way.  It’s called office-based opiate treatment, or OBOT for short.  There is a separate exception in federal law for this type of treatment.  As I mentioned, I only know of two cities in the U.S. where this is happening: Baltimore and New York City. 
Why is this so rare?  Well, it may be for several reasons.  First of all, it’s not necessarily easy to obtain permission from the government to do this.  Physicians need to obtain an exception to the usual rules governing methadone treatment.  Doctors have to find themselves a methadone clinic to work with and supply the meds.  They are subject to many regulations.   My main guess at why this isn’t more popular is that there’s no money in it.  There is not a large patient population for doctors to service with this treatment, because only patients who have been stable and on methadone and drug free for two years are allowed on the program.  Now, think about buprenorphine treatment.  A doctor can have up to 100 Suboxone patients under their care now.  Perhaps the biggest incentive is that many insurance companies cover Suboxone (though certainly not all), while most companies don’t cover methadone maintenance.
How simple it would be for methadone patients to escape the clinic system by visiting a doctor for their medication once a month.  What’s most depressing about this is that it’s actually something that could be a reality, but because of red tape and profit motive, it’s virtually nonexistent.

To learn more about OBOT, check out the links on this page:


  • wayovermyhead says:
    May 4, 2012 at 9:43 PM

    Great blog Grey. Keep telling us more about this as you find it out.

  • Zac Talbott says:
    March 2, 2013 at 5:32 PM

    Thanks for posting this, grey! :-) I wasn't aware that there were two cities where OBOT was actually available, despite being aware of the federal regulations that allow it. While I think more treatment options for ANY illness is a good thing in general, my only concern with OBOT is the counseling, groups, etc. that are often provided by & required (at least in the early stages of treatment) by MMT Clinics... While I'm certain there could be a "coordination of care" between the OBOT physician and another private counselor/psychologist independent of them, my concern is for the reality of this actually occurring. The medication is only ONE part of about 3 equally important parts of MMT/MAT... Plus, after a patient is stable & in compliance with clinic, state & federal rules and regulations they are able to get close to a month's takehomes of medication in most states from MMT Clinics... Attending the MMT Clinic once a month & picking up a month's supply of medication really IS a form of OBOT in terms of what is offered & what occurs at each, ya know? :-) But, I also fully understand that many insurance companies who do NOT pay for MMT at a treatment center/clinic would actually pay for the methadone when a prescription is written by a physician & the medicine is filled at a pharmacy (as opposed to being dispensed at a clinic)... Hopefully the expansion of mental health & substance misuse coverage under the Affordable Care Act that goes into effect this next January of 2014 will be expansive enough that it rights the wrong of so many insurance policies discriminating against MMT. :-) Thanks, grey, PLEASE keep up the good work!!

  • jack says:
    April 16, 2013 at 1:59 PM

    . At 60yrs old and 25 yrs at a klinic , standing in a line even 2 times a month , having to see a uncaring state social worker, then have someone watch me piss in a cup finally got to be too much.They worry about diversion ??/ Now that I get my mdone from a pain mgt clinic , I can tell you- - -more is diverted from there and I ever saw at the mdone klinic

  • Gnatrol Macobb says:
    April 29, 2013 at 7:05 AM

    Amen Jack!
    Zac thanx for the link, but I refuse to put up with some state social worker with a nursing license that surely doesn't care if I shat myself right then and there.
    I decided after 2 years playing BS clinic games,and having a PM fall into my lap offering me my meds if I'd come down ten milligrams right now to be quite a deal I couldn't pass up. As the clinics here in Nevada offer only a weeks worth of doses and no groups but once a month a federally mandated one on one that they let you know you are not forced to do anything but sign this paper stating you were here.
    How hard would it be to decide that this PM is a much better deal? This program here in Las Vegas anyhow seriously needs a shot of give a crap!!!

  • lizabaker says:
    June 13, 2013 at 10:04 AM

    How long has it been helping the patients? That's what a drug rehab facility supposed to do right?

  • Zac Talbott says:
    August 30, 2013 at 12:39 PM

    There is also a (very small) OBOT in Boston, MA attached to one of the hospitals.

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