clinicRx created in Wix 2016

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OTP in a ( random bullet point) nutshell

I can also say things now that I'm freed from the public service and I'm a somewhat older, somewhat grumpier (but much wiser) man

  • OTP = opioid treatment program
  • OST = opioid substitution program - these terms are interchangeable
  • Aren't you just swapping one opioid for another...... YES!
  • We do indeed and we don't shy away from that, it is the key to the lifesaving success of treatment. We swap an illegal, dangerous, expensive, potentially impure opioid that is associated with crime, being ripped off and danger for one that is clean, cheap, pharmaceutically pure, safer and legal.
  • This is the same way a cardiac transplant surgeon replaces a diseased, damaged heart that is associated with illness and death with one that is healthier and will hopefully increase quality of life and survival. No one criticises cardiac transplant programs for "just replacing one heart with another"
  • But just like a heart transplant is associated with a whole raft of other supportive interventions to ensure it's success, a quality OTP program uses other interventions to maximise the benefits of the primary treatment of opioid "transplant"
  • You deserve to be treated with respect, courtesy and politeness. Shame has no place in a treatment program. If you feel like you are being treated like a 'filthy junkie' then something is very wrong.
  • The two drugs we use are methadone and buperenorphine. The phrase "same same but different" was invented to describe these two drugs. Your prescriber should educate you about the differences.
  • The key to success is matching the right drug to the right person.
  • Some people do not stabilise on buperenorphine (they don't feel comfortable and never lose the desire to top up with other opioids) and should be offered an alternative ie methadone.
  • Suboxone provides us (you) with treatment choice. In a quality client-centered treatment program it is not, and never will be, a replacement for methadone. Not even the pharma company who produce suboxone  promote that approach. Suboxone-only clinics should question the validity of their approach.
  • I get asked a lot - how many people on methadone or suboxone get "cured"...... In a diabetes clinic success is measured by how many people have good vision, good circulation, a healthy cardiovascular system, well-functioning kidney's and feet that have a good blood and nerve supply. The term "cure" is rarely used.
  • We measure success in how many people stay out of jail, get their Hepatitis C treated, have stable mental health, have safe housing, are united with their families and children, avoid violence and being ripped off, have good self respect, how many are engaged in study or work, how many are out of debt. How many do not overdose, get heart infections, skin abscesses or bone infections etc
  • Measurement of successful treatment in a chronic health condition is about reduction in the numbers of bad or pathological outcomes of that condition. Some diabetics lose 100kg and no longer need insulin, some people on the methadone program go to rehab and no longer use drugs - these are terrific outcomes, but we hesitate to use the word cure.  Being healthy and in treatment is a great success in its own right.
  • You can see a pattern emerge - the OTP program is just like any other chronic medical condition treatment: we have evidence-proven treatments and we use medications to achieve positive outcomes.
  • The quality of the relationship between your prescriber, dispensing pharmacist and you is of vital importance.  People with a good therapeutic alliance with their doctor and chemist have higher survival rates! Doctors have proof now that if they treat their clients well, they stay in treatment longer and hence they survive betterer. Yes, sadly, it did take research to point that out.
  • There exists good quality recent research in the British Medical Journal that shows that people on methadone with anxiety who are co-prescribed Valium (diazepam = benzodiazepines = BZD) when they are on the program  have higher survival rates and less morbidity (harm). In our current benzo-phobic society it is unlikely that this will change prescribing patterns. We are meant to be guided by harm reduction and evidence based medicine...... Prescribers only have to talk to (and then listen to) their stable patients who are co-prescribed these medications to discover the way that being taken seriously regarding their anxiety and how diazepam does help them even with long term use means that they decide to stay in treatment (retention in treatment = saves lives.....period!) , How being trusted with diazepam so they didn't have to access black market benzodiazepines and its associate risks meant they were much less likely to use Xanax (alprazolam) in a binge pattern. How they were protected from BZD overdose by their induced-tolerance to daily diazepam in the same way methadone gives them a protective tolerance to opioid overdose etc etc. It is all deductible from first principles and careful history taking... but it is reassuring to have the research to back up acquired clinical experience and judgement.
  • A note to prescribers - A key indicator for OTP program success is "retention in treatment" - ie how many people stay on the program.  When people 'jump off" they aren't sitting at home watching daytime TV, they are out there in some version of personal hell. They don't show up as problem statistics, they disappear. Staying in touch with our patients who involuntarily or precipitously leave treatment is both educating and heartbreaking.  Facilitating low-threshold return to treatment (making it bloody easy for people to get back on) is, I believe, one of our core clinical roles. Don't be precious, do some work, stay 15 minutes late and help another human being back into life saving treatment. It's not about winning, its not an us vs them situation - these people are some of the most vulnerable in society, we can be the grown ups and move on. If this point doesn't make sense to you then you probably have never worked in a public OTP clinic.  
  • I believe a public clinic is at capacity when every member of the team is realistically and actually working at their genuinely maximum safe capacity. Not a just at a capacity where they can enjoy leisurely breaks, watch iView catch up, duck off early.  Getting people in treatment is our core clinical responsibility. Keeping people in treatment is the close second.  Unwieldy, protracted and gargantuan intake meetings, titanic case management meetings, Leviathan-like pre-doctor, pre-treatment assessments extend the time from first point of service contact to first dose. People die in this time. They lose interest, they miss an appointment and have to start again, they get sick of waiting and think its easier to just get drugs from the local dealer or continue to doctor shop. I took a 50% pay cut to walk away from a public system that was so willfully inefficient that it became an ethical dilemma for me to continue to support and witness.
  • OK, I'm passionate about opioid treatment medicine and maybe not everyone shares that, but we are paid health professionals -  it is vital life saving treatment and it's exceptionally important to keep it acceptable, accessible and efficient. Our patients are among the most stigmatised and vulnerable in society. Don't lose sight of their (or your) humanity.