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
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
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DOI：
10.1097/adt.0b013e31802b4ea1
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发表时间：
2007-09-01
影响因子：
1.1
通讯作者：
Tuchman, Ellen
中科院分区：
文献类型：
--
作者：
Drucker, Ernest;Rice, Sam;Tuchman, Ellen
背景：作为国家药物滥用研究所办公室鸦片治疗 (OBOT) 多中心研究的一部分，我们报告了 2 年初级保健医生向距离兰卡斯特 40 英里的美沙酮维持治疗计划 (MMTP) 诊所的一组稳定的美沙酮患者开处方和社区药房配发美沙酮的经验。方法：符合条件的患者稳定接受治疗（中位 3 年），并且没有当前非法药物使用的证据。他们每月与处方医生（一名普通内科医生）在他的办公室会面，进行临床审查、尿液毒理学和个人咨询。每次就诊时，在兰开斯特的一家家庭拥有的社区药房都会按观察剂量配发美沙酮。药剂师和技术人员接受了 OBOT 培训，并完成了州和联邦美沙酮维持法规要求的所有每周灌装、贴标签和记录保存工作。所有临床和管理记录均定期复制到 MMTP，在整个研究过程中患者均在 MMTP 中进行登记。对患者进行了 24 个月的随访：主要临床结果是治疗保留和药物使用。此外，该计划的社区批准和法律授权的所有细节都被记录下来，并收集了有关患者和提供者满意度的大量定性数据。结果：配药过程（包括在封闭房间中观察剂量）大约需要 5 分钟。医疗费用为 70 美元/月，药房费用为 140 美元（总计 210 美元/月），与 300 美元/月的诊所费用相比，OBOT 患者每月节省 90 美元，此外还节省了 2 小时的出行时间。剂量和取药时间表与这些患者过去 6 个月的 MMTP 数据非常相似：中位 OBOT 剂量为 90 mg（范围 30 至 200 mg），所有患者每周或每两周取药一次。 12 个月时，该计划的保留率为 10/12 (86%)； 2 名患者因保险或行政原因离开该地区或返回诊所。没有患者自愿离开。三 (3) 名患者在 MMTP 中出现一次或多次除美沙酮以外的药物（镇静剂和阿片类药物）尿液呈阳性，而前 6 个月只有 1 名患者尿液呈阳性。除一项阳性结果（海洛因）外，所有这些阳性结果均与处方药物相关（已确认）。唯一一名海洛因呈阳性的患者提前告知医生，自己出现了滑倒，在他的22个月的治疗过程中没有发现其他阳性结果。药剂师和医务人员对 OBOT 模式表示非常满意，并发现与这些患者的治疗一致是积极的：“专业上令人满意。”一些人评论说“欣赏这些患者，并与他们一起感到非常舒服。”患者满意度非常高——所有人都更喜欢 OBOT 而不是 MMTP 护理，喜欢有一位熟练且经验丰富的私人执业医生监督他们的护理，并且对药房及其提供药物的系统“非常满意”（药剂师“像对待一个人一样对待我，像一个普通人一样”）；并在药房感到不起眼，“走进这里的普通人不会知道我们是美沙酮患者。”结论：这种 OBOT 模式（1 名医生、1 家药房和一小群患者）允许稳定的 MMTP 患者在符合所有州和联邦法规的社区环境中接受美沙酮治疗，并产生与 MMTP 相同或优于 MMTP 的临床结果，成本更低，患者满意度更高。2 年后（尽管尽管这些积极成果）该计划因主办 MMTP 未能遵守规定而被州美沙酮当局突然终止，尽管如此，该试点项目清楚地表明兰卡斯特 OBOT 模式是可行且有效的，并且应该成为没有 MMTP 诊所且患者必须长途跋涉接受治疗的地区的模式。
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.