San Francisco has about 15,000-17,000 heroin users, but the Department of Public Health can treat less than 3,000 of them with methadone.

Alice Gleghorn, PhD, a leader in the San Francisco Demand Treatment! initiative, described the city's alternative solution for opiate addiction -- an office-based opioid treatment (OBOT) program -- at the American Public Health Association meeting last week.

The guiding principles of the OBOT program have been to expand access to effective treatment, increase patient choice, integrate care, reduce stigma and assure regulatory consistency for existing narcotic treatment programs. The department of public health started planning the program in 1998, and the first patient was enrolled in July, 2003. Enrollment and monitoring continue today.

A Well-Organized Community Effort

The program features are central administration, multiple patient access points, a treatment team approach, individual treatment plans, and certified staff with access to continued training. There are two community primary care health centers involved, one private psychiatric practitioner's office, a narcotic treatment program's satellite clinic, a buprenorphine induction clinic (which was the first in the US), two community pharmacies, and an affiliated NTP at San Francisco General Hospital.

The effort involves the directors and staff of existing narcotic treatment programs, primary care physicians, substance use disorder counselors, pharmacists, consumers, DPH staff, staff from SAMHSA's Center for Substance Abuse Treatment (CSAT), the State Department of Alcohol and Drug Programs, and the Drug Enforcement Agency. Regular meetings have kept the program moving forward.

The central administration has been crucial to the program's success, especially due to the complex regulatory requirements. The evaluation found that counselors and pharmacists play a larger role in the program than originally anticipated.

Quality improvement efforts involve a core OBOT team made up of medical directors and counselors. Each site has a QA leader on staff responsible for assuring compliance with regulations and reporting requirements. Along with regular staff training, there are electronic and paper chart reviews, quarterly state audits, case conferences and warm line support.

An electronic database keeps all related records. This centralized information system is a secured internet site and is used by all on the team. It is used for communication, records methadone medical order information acceptable to the DEA and OBOT physicians, and provides up to date real-time patient information.

The program uses a central induction clinic so that patients have their dose of medication stabilized before referral to community physicians and dispensing of medications that can be taken home. Referring physicians and counselors work with the patient to determine eligibility to participate in the program, choose the appropriate medication, determine whether the patient needs stabilization or can go straight to a community OBOT site, and handle the transfer to the appropriate community site and pharmacy.

This program has been treated like a clinical trial in that patient consent is required. The data and inclusion and exclusion criteria are kept with the patient information, along with extensive assessment of patient clinical status and program progress.

Early Results

Preliminary evaluation of the pilot program reported that over 150 patients have been evaluated for program admission. Eighty have been admitted OBOT stabilization or community treatment; 58 are in treatment, 35 are using methadone, and 22 are taking buprenorphine. All of the buprenorphine patients used the induction center prior to moving to community providers. There has been high compliance, few missed doses, and high program retention. In addition, pharmacists have indicated enthusiasm for participation in the program.

Patients using buprenorphine told program evaluators that they are very pleased with this treatment, and say that the most important outcome has been that they feel "normal."

The program was originally funded through a CSAT grant. Currently care is paid for through the Department of Public Health. The city decided to establish a successful treatment program first and then worry about costs of care. Buprenorphine is not yet on the California formulary, but the state health plan has paid for it in some circumstances.

DPH anticipates that OBOT will save the city money. Heroin users in San Francisco use black tar heroin and are subject to serious abscesses that require medical attention. If treatment can reduce money spent on the physician and nurse time that abscess care requires, and on other health care demands that chronic heroin use places on the public health care system, then the OBOT program will produce significant savings to the city.