This document summarizes the levels of care and treatment approaches at an addiction treatment facility over the past 44 years. It offers ambulatory withdrawal management, intensive outpatient treatment, and continuing care across six sites. From 1985 to 2002, treatment predominantly used naltrexone which resulted in poor program completion rates and higher overdose deaths. From 2003 to 2017, treatment has predominantly used buprenorphine which has significantly improved program completion rates and reduced overdose deaths. The number of patients using buprenorphine long-term has increased over time.

2.  Levels of care
 AmbulatoryWithdrawal Management (Level 2-D)
 IOP (Level 2.1)
 ContinuingCare (Level 1)
 Six sites in urban and suburbanWashington, D.C. and Baltimore
 In operation for 44 years
 Funding: commercial insurance and co-pays
 Demographics: working and middle class, ages 19 and older

3.  1985 – 2002: Exclusively naltrexone
 Withdrawal management with alpha-2 agonists and non-opioid medications
 Observed self-administration of naltrexone
 Results
 Poor rates of IOP program completion
 Rare entry into continuing care
 Highest rate of overdose deaths
 2003 – 2017: Predominantly buprenorphine
 Results
 Significant improvement in IOP program completion
 Increased ability to do the psychological work of recovery
 Routine entry into continuing care
 Reduction in overdose deaths

4.  33% of total patient population have an opioid use disorder
 Compare with 19% in 2000
 Number of patients on buprenorphine
 Cumulative: 5,030
 Admitted in 2016: 501
 Current: 287
 Longer than 1 year: 39%
 Longer than 2 years: 24%
 Variation by office:
 Baltimore area: 76%
 Washington area: 24%

5.  Treatment staff
 Negative methadone experiences
 Patient
 Concern about getting off
 “Not really in recovery”
 Patient family
 Negative publicity
 “Exchanging one drug for another”
 Addiction treatment community
 NarcoticsAnonymous
 “Unable to work the steps”

6.  When
 Task based rather than time based
 How
 Protocols
 Relationship to long term recovery

7.  Stabilization doses
 Vary by individual
 Co-morbid pain management
 Chronic
 Elective surgical procedures
 Specialized group vs. integrating with other substance users
 Medication preauthorization

8.  Increased patient limit and allowing NPs and PAs to prescribe
 Integrating with outside community
 Shifting patient to primary care physician
 Bridging with bup given in ED
 Withdrawal management protocol to expedite naltrexone
induction
 Preventing stress triggered relapses using alpha-2 agonists