The Lancaster office based opiate treatment program: A case study and prototype for community physicians and pharmacists providing methadone maintenance treatment in the United States

BACKGROUND: As part of a National Institute on Drug Abuse multisite study of office based opiate treatment (OBOT) we report on 2 years experience with primary care physician prescribing and community pharmacy dispensing of methadone to a group of stable methadone patients in an Methadone Maintenance Treatment Program (MMTP) clinic 40 miles from Lancaster. METHODS: Eligible patients were stably in treatment (median 3 y) and without evidence of current illicit drug use. They met monthly with the prescribing physician (a general internist) in his office for clinical review, urine toxicology, and individual counseling. Methadone dispensing with an observed dose at each visit occurred at a family-owned community pharmacy in Lancaster. The pharmacists and technicians had undergone training for OBOT and did all the weekly filling, labeling, and record keeping required by state and federal regulations governing methadone maintenance. All clinical and administrative records were routinely copied to the MMTP, where patients remained registered throughout this study. Patients were followed for 24 months: the principal clinical outcomes were treatment retention and drug use. In addition, all details of the program's community approval and legal authorization were documented, and extensive qualitative data on patient and provider satisfaction were collected. RESULTS: The dispensing process, including an observed dose in a closed room, took approximately 5 minutes. Medical charges were $70/mo and pharmacy charges $140 (total $210/mo) saving OBOT patients $90/mo as compared with the clinic fees of $300/mo, plus saving them 2 hours travel time. Dosages and pickup schedules were very similar to these patients' MMTP data for the previous 6 months: The median OBOT dose was 90 mg (range 30 to 200 mg) and pickup was weekly or bi-weekly for all patients. Retention in the program was 10/12 (86%) at 12 months; 2 patients left the area or returned to the clinic for insurance or administrative reasons. No patients left voluntarily. Three (3) patients had one or more positive urines for drugs other than methadone (for sedatives and opiates) as compared with 1 in the previous 6 months in the MMTP. All but one of these positive results (for heroin) was associated with prescribed medications (confirmed). The sole patient with heroin positive notified the doctor in advance that he had had a slip, and no other positive was seen in his 22 months of treatment. The pharmacists and medical staff reported great satisfaction with the OBOT model and found dealing with these patients was uniformly positive: "professionally gratifying." Several remarked on "appreciating these patients and feeling very comfortable with them." Patient satisfaction was very high-all preferred OBOT to MMTP care, liked having a skilled and experienced private practice physician overseeing their care, and "were very pleased" with the pharmacy and its system of providing their medication (the pharmacists "treated me like a human being, like a regular person"); and felt inconspicuous in the pharmacy, "the average person who walks in here would have no idea we were methadone patients." CONCLUSIONS: This model of OBOT (1 doctor, 1 pharmacy, and a small group of patients) allows stable MMTP patients to be in methadone treatment in a community setting that complies with all state and federal regulations and produced clinical results equal or superior to the MMTP, at lower cost and with greater patient satisfaction. After 2 years (despite these positive outcomes) the program was terminated precipitously by the state methadone authorities for alleged failures of compliance by the sponsoring MMTP. Nonetheless this pilot clearly demonstrates that the Lancaster OBOT model is feasible and efficacious and should be a model in localities where no MMTP clinic is available and patients must travel long distances for their care.