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U.S. Department of Health and Human Services
Opioid Stewardship in the Indian Health Service

Office Based Opioid Treatment (OBOT)

Treatment Program Overview

Treatment of substance use disorders can occur in specialized opioid treatment programs or through general health care practice in an office based opioid treatment program model. Opioid treatment programs have historically been the primary treatment environment for opioid use disorders, but according to the Surgeon General’s “Facing Addiction” Report there has been a shift to providing more services through primary care and general health care practice (DSM Reference: American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013.)

Office Based Opioid Treatment

An Office Based Opioid Treatment (OBOT) allows primary care or general health care prescribers with a DATA waiver to dispense or prescribe any Controlled Substances Act (CSA) scheduled III, IV, V medication approved by the Food and Drug Administration (FDA) for the treatment of opioid use disorders under 21 CFR §1306.07 Exit Disclaimer: You Are Leaving www.ihs.gov .

The medications (Buprenorphine, Buprenorphine/Naloxone and/or Naltrexone) are available for treatment of opioid use disorders allowed to be prescribed in an OBOT setting. Naltrexone is not a controlled substance and is not subject to DATA 2000 regulations.

Buprenorphine and buprenorphine/naloxone can be prescribed as take home prescriptions or administered on-site while naltrexone is administered once a month in the clinic setting. An oral formulation of naltrexone is commercially available but is not recommended for OBOT due to poor rates of retention in treatment.

Offering treatment through primary care or general practice removes barriers for patients seeking treatment. Unlike outpatient treatment programs (OTPs), integrated psychosocial and behavioral health services are not a legal requirement for OBOT; however, these resources should be accessible via referral. It is highly recommended that OBOT prescribers establish linkages within their communities with relevant resources and/or medical sub-specialties (e.g. behavioral health, infectious disease, job retraining, etc.)

Treatment Agreements

Treatment agreements serve as an informed consent and can guide the relationship between a provider and patient by describe the roles and responsibilities of each party.

Clinical Guidelines/Best Practices

Example Documents

Patient Assessment

Assessment and Diagnosis Tools

Diagnosis of Opioid Use Disorder must be determined prior to starting medication-assisted treatment. According to DSM-5 Criteria, Opioid Use Disorder Exit Disclaimer: You Are Leaving www.ihs.gov is a problematic pattern of opioid use leading to clinically significant impairment or distress.*

Clinical withdrawal scales:

  1. Objective Opioid Withdrawal Scale (OOWS) Exit Disclaimer: You Are Leaving www.ihs.gov  [PDF - 121 KB]
  2. Subjective Opioid Withdrawal Scale (SOWS) Exit Disclaimer: You Are Leaving www.ihs.gov  [PDF - 93 KB]
  3. Clinical Opioid Withdrawal Scale (COWS) Exit Disclaimer: You Are Leaving www.ihs.gov  [PDF - 606 KB]

Laboratory testing may include: urine drug screen (inclusive of buprenorphine and methadone, complete blood count, liver function test, Hepatitis C, HIV, pregnancy, other sexually transmitted infections, tuberculosis);

42 CFR Part 2 – Disclosure of Substance Use Disorder Patient Records

Title 42 of the Code of Federal Regulations (CFR) Part 2 Exit Disclaimer: You Are Leaving www.ihs.gov : Confidentiality of Substance Use Disorder Patient Records (Part 2)

  • Federal confidentiality law and regulations to protect the privacy of substance use disorder (SUD) patient records by prohibiting unauthorized disclosures of patient records except in limited circumstances and/or with patient’s written consent.
  • Intended to protect the confidentiality of patient’s receiving treatment for substance use disorders (SUD) by restricting the disclosure of their SUD related records.
  • Programs are prohibited from disclosing any information that would identify a person as having or having had a SUD unless the person provides written consent.

Training

Substance Use Treatment Record Confidentiality 42 CFR Part 2 recorded session on RPMS Training Repository Exit Disclaimer: You Are Leaving www.ihs.gov  - RPMS General, Substance Use and Confidentiality CFR42.2

Resource

In partnership with the American Society of Addiction Medicine (ASAM), a patient informational booklet on Opioid Addiction is available for ordering. The patient booklet is intended to provide patient and caregiver information about Opioid Addiction, including treatment, recovery and overdose prevention. Additionally, a provider quick reference with evidence-based tools to assist providers with medication assisted treatment prescribing, monitoring and follow-up considerations for Opioid Use Disorder is also available to order.

ECHO Support Model

The Indian Health Service (IHS) Telebehavioral Health Center of Excellence (TBHCE) provides technical assistance, implementation, training, and evaluation support for remote health care, and serves isolated American Indian/Alaska Native (AI/AN) communities and areas with limited or no access to behavioral health services. TBHCE may present opportunities to offer consultation to waivered providers or primary care in a peer to peer consultation model.

The Indian Health Service Alcohol and substance Abuse Program provides additional information surrounding substance abuse.

Find treatment through the Indian Health Service Treatment Locator

Opioid Treatment Program

An Opioid Treatment Program (OTP) is an outpatient program, which provides comprehensive treatment services including pharmacological treatment for opioid use disorders. Opioid Treatment Programs are required to provide counseling, treatment, as well as planning and diversion control. SAMHSA provides guidance Exit Disclaimer: You Are Leaving www.ihs.gov  on satisfying the federal requirements for opioid treatment standards 42 Code of Federal Regulation (CFR) Exit Disclaimer: You Are Leaving www.ihs.gov .

  • The medications (Methadone, Buprenorphine, Buprenorphine/naloxone and/or Naltrexone) provided through an OTP are dispensed or administered on site. An OTP is the only way Methadone is provided in an outpatient setting for opioid use disorders.
  • Prescribers must meet appropriate DEA licensing requirements for the medications being prescribed. Prescribing Buprenorphine in an OTP does not mandate a max number of patients as would an OBOT. However this stipulation may vary from state to state.
  • Prescriptions are not written for Methadone and home doses are a privilege that can be earned after several weeks of compliant program attendance, drug screens and overall treatment plan. Buprenorphine can include onsite administration, take-home doses and occasionally a prescription.
  • Medications dispensed through OTPs are not reported to State Prescription Drug Monitoring Programs (PDMPs).