Levels of care

Ambulatory Withdrawal Management (Level 2-D)

IOP (Level 2.1)

Continuing Care (Level 1)

Six sites in urban and suburban Washington, D.C. and Baltimore

In operation for 44 years

Funding: commercial insurance and co-pays

Demographics: working and middle class, ages 19 and older

1985 – 2002: Exclusively naltrexone Withdrawal management with alpha-2 agonists and non-opioid medications

Observed self-administration of naltrexone

Results

Poor rates of IOP program completion

Rare entry into continuing care

Highest rate of overdose deaths

2003 – 2017: Predominantly buprenorphine Results

Significant improvement in IOP program completion Increased ability to do the psychological work of recovery

Routine entry into continuing care

Reduction in overdose deaths

33% of total patient population have an opioid use disorder

Compare with 19% in 2000

Number of patients on buprenorphine

Cumulative: 5,030

Admitted in 2016: 501

Current: 287

Longer than 1 year: 39%

Longer than 2 years: 24%

Variation by office:

Baltimore area: 76%

Washington area: 24%

Treatment staff Negative methadone experiences

Patient Concern about getting off

“Not really in recovery”

Patient family Negative publicity

“Exchanging one drug for another”

Addiction treatment community

Narcotics Anonymous “Unable to work the steps”

When

Task based rather than time based

How

Protocols

Relationship to long term recovery

Stabilization doses

Vary by individual

Co-morbid pain management

Chronic

Elective surgical procedures

Specialized group vs. integrating with other substance users

Medication preauthorization

Increased patient limit and allowing NPs and PAs to prescribe

Integrating with outside community

Shifting patient to primary care physician

Bridging with bup given in ED

Withdrawal management protocol to expedite naltrexone induction

Preventing stress triggered relapses using alpha-2 agonists