Guideline for Physicians Working in California Opioid Treatment Programs

Guideline for Physicians Working in California Opioid Treatment Programs

This monograph was developed by the Committee on Treatment of Opioid Dependence of the California Society of Addiction Medicine to provide an overview and discussion of the matters of clinical care that fall under the responsibility of the opioid treatment program (OTP) medical director and program physicians. It was prepared and distributed first in 1998 and updated once in 2004. This 2008 edition incorporates current information. (for more information click here) (142 pages $20.00)

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Editor: Deborah K. Stephenson, MD, MPH
for the CSAM Committee on Treatment of Opioid Dependence


The physician in an opioid treatment program (OTP) practices in a uniquely challenging medical environment, responding to a diverse array of medical, psychiatric, and social problems in a largely indigent population with limited access to health care. The past experiences of opioid dependent patients in medical settings often result in mistrust, and even hostility, toward mainstream medical providers, which discourages them from seeking even the limited care

Characteristically, addicted patients receive high-cost crisis care in Emergency Departments and hospitals. After discharge, there is little to no follow-up.

The physician in the OTP is often the first medical provider with whom these patients establish a long‑term therapeutic relationship. The OTP physician can be an important, even lifesaving, resource for patients enrolled in treatment, identifying the multiple medical problems that characterize heroin and opioid addiction and providing treatment or referrals to address these problems. The OTP physician is also in a position to positively impact the public health of the
community by screening for and treating communicable disease and offering other preventive health services.

As of September 2008, there are two medications available and approved for use in opioid maintenance treatment: methadone and sublingual formulations of buprenorphine. This document focuses primarily on treatment with methadone and includes a brief review of treatment with buprenorphine in Appendix B.

Methadone maintenance treatment (MMT) in the United States is regulated, comprehensive treatment which requires observed dosing, random urine drug testing and participation in counseling. It offers major pharmacologic benefits, such as the alleviation of the symptoms of physical withdrawal, the reduction or elimination of opioid craving and partial or complete blockade of the euphoric effects of outside opioids. All of these benefits help to support patients' efforts to achieve and maintain abstinence. However the benefits of MMT extend beyond pharmacologic ones. Medical and counseling interventions help patients to reduce needle sharing and unprotected/risky sexual behaviors associated with drug use. Retention in treatment allows medical and psychosocial issues to be addressed. MMT allows patients to receive consistent and ongoing counseling to support the lifestyle changes necessary to progress in recovery. It is helpful for OTP personnel to have a basic understanding of 12 Step programs and of all elements of recovery to assist patients toward long-term goals. Ultimately, long term goals include improved family stability, decreased hospital admissions, regular medical and dental care, decreased criminal activity and incarceration, and vocational rehabilitation. Achieving these goals benefits society as well as the individual patient.

CSAM Committee on Treatment of Opioid Dependence:

  • Karen Miotto, MD, Committee Chair, Medical Director, Substance Abuse Program, Los Angeles VA Ambulatory Care Center
  • Peter Banys, MD, Director, Substance Abuse Programs, VA Medical Center, San Francisco
  • Gail Jara, Consultant to CSAM, Staff to the Committee on Treatment of Opioid Dependence
  • David Kan, MD, Head of the Opioid Replacement Team, VA Medical Center, San Francisco
  • Lori Karan, MD, Drug Dependence Research Center, UCSF
  • Walter Ling, MD, Chief of Substance Abuse Programs, UCLA
  • Judith Martin, MD, Medical Director, Turk Street Clinic, Bay Area Addiction Research and Treatment, San Francisco
  • John J. McCarthy, MD, Executive and Medical Director, Bi-Valley Medical Clinic, Sacramento
  • Carolyn Shuman, MD, Medical Director, 14th Street Clinic, Bay Area Addiction Research and Treatment, Oakland and Medical Director, San Mateo Medical Center Methadone Treatment Program
  • Stephen Ruh, MD, Medical Director, CRC Health Group, Inc., Wilmington, CA
  • David Smith, MD, Medical Director, Centerpoint, San Rafael
  • Laurene Spencer, MD, Medical Director, Geary Street Clinic, Bay Area Addiction Research and Treatment, San Francisco
  • Deborah Stephenson, MD, MPH, Perinatal Substance Abuse Program/Central Valley Clinic, Santa Clara Valley Health and Hospital System, San Jose
  • Charles W. Stewart-Carballo, MD, Private Practice, HIV Medicine, Oakland
  • Matthew Torrington, MD, Integrated Substance Abuse Programs, UCLA
  • Donald R. Wesson, MD, Consultant regarding CNS Medication Development