Boston Medical Center – STATE OBOT-B

What is it?

The State Technical Assistance Treatment Expansion Office-Based Opioid Treatment Program with Buprenorphine (STATE OBOT-B) is an innovative, multidisciplinary opioid treatment network that employs addiction-trained nurse care managers who, working alongside waivered physicians, play a central role in the evaluation and monitoring of patients. This collaborative care model was created by Boston Medical Center (BMC), which has led its expansion to community health centers across the state and enabled widespread access to treatment in community health centers under STATE OBOT-B. The model can be used in most treatment settings; however, in community health centers, which often care for underserved populations, it brings insurance-based treatment for addiction to patients. In medical settings that employ nurses, it facilitates multidisciplinary care for a complex disease using nurse care managers.

Who is it for?

Patients with a substance use disorder in need of medical management.

Why do they do it?

More than 129 people a day across the United States die from accidental overdose related to opioids. It is the number one public health crisis. Addiction is a treatable disease that can be managed in a health care practice with the right resources and expertise. Treating one’s addiction will allow a patient to engage in preventative care, decreasing emergency department visits and hospital encounters, and promoting wellness. In 2002, the Drug Addiction Treatment Act was passed, enabling physicians who received a waiver from special registration requirements in the Controlled Substances Act to treat addiction with medications that were FDA approved for this purpose in outpatient treatment practices, a desirable alternative to methadone clinics for those seeking privacy with their medical provider. It also brought treatment for addiction into medical care where it belongs, so that medical providers could treat this chronic disease with other medical issues.

Despite its demand and the numerous studies demonstrating its effectiveness, buprenorphine remained underutilized, and there were lengthy waiting lists for individuals seeking treatment. Less than 5 percent of eligible U.S. physicians were waivered to provide it. Among the barriers to uptake identified by physicians surveyed in Massachusetts by the Department of Public Health were lack of clinical nursing support, increased monitoring needs, lack of institutional support and insufficient staff and/or self-knowledge in addiction. Another challenge has been cost. Although Massachusetts has almost universal insurance access, many providers don’t take public insurance and may charge cash regardless of insurance. Integration of treatment into community health centers allowed patients with limited means the ability to access treatment utilizing their insurance.

In 2007, the Massachusetts Department of Public Health’s Bureau of Substance Abuse Services (BSAS) issued two funding opportunities to increase access to treatment in response to the unmet need for medication-assisted treatment in the state. BMC had already developed a collaborative care model of OBOT utilizing nurse care managers at the hospital’s outpatient general medicine practice, which had proved successful in both expanding access to and decreasing costs of opioid addiction. As such, BMC was awarded the grant to partner with BSAS and lead the expansion of its model to 14 community health centers across the state, and to provide the requisite training and technical assistance to get the newly funded sites up and running.

Impact

Across Massachusetts, the STATE OBOT-B program has: (1) increased access to treatment with buprenorphine; (2) improved outcomes for those struggling with opioid use disorders; (3) reduced the costs associated with substance use; and (4) demonstrated sustainability and replicability. The number of prescribing physicians rose from 24 to 164, a 530 percent increase from 2007 to 2014 in community health centers, where the model was replicated. The number of patients accessing OBOT increased from 327 to 3,000, a nearly 800 percent increase from 2007 to 2014. Since 2007, more than 8,000 patients have accessed buprenorphine treatment through STATE OBOT-B at BMC and at funded community health centers. Further, these sites have been particularly successful in engaging and retaining traditionally underserved black and Hispanic/Latino patients (35 percent) compared with methadone maintenance treatment programs (19 percent).

In the OBOT program at BMC, among 382 patients treated in the first five years, 51 percent remained successfully engaged in treatment one year after starting, and 91 percent of those treated with buprenorphine were abstinent from opioids and cocaine. What is especially striking is that in the 11 years of OBOT at BMC, where 450 patients are being treated at any given time, there have been no overdose deaths while patients have been in treatment. Further, within the first year of implementation, the BMC model of OBOT was adapted successfully for homeless patients at Boston Healthcare for the Homeless Program (BHCHP). Despite greater social instability and co-morbidities, BHCHP patients achieved similarly high rates of treatment success at 12 months, with 55 percent retained in care with buprenorphine and 36 percent successfully housed.

Note: The program began as OBOT but has since moved into OBAT (office-based addiction treatment) to be all inclusive since they now have injectable naltrexone, which can be used for both opioid dependence and alcohol use disorders.

Contact: Colleen LaBelle, MSN, RN-BC, CARN
Program Director
Telephone: 617-414-7453
Email: colleen.labelle@bmc.org