Contingency Management Example 4 of 4: Forming a Buprenorphine-Specific IOP

Disclaimer: nothing in this post should be taken or held as clinical instruction, clinical supervision, or advisory concerning patient care.

A few years later in that same organization I was picked to be on a steering committee that would form and lead a new program. The new program was going to be a buprenorphine-specific Intensive Outpatient Program (IOP) for people with a primary opioid use disorder. (Back then this would have been DSM-IV Opioid Dependence among those with severe and complex clinical presentations).

This idea formed in 2006 and the steering committee got busy in 2007 to build the new program. Our organization was fairly early in implementing this sort of idea, given our organization’s eagerness to innovate. At the time I asked why my help on the steering committee was sought. The answer I received was simple and obvious. I was told that leadership wanted someone on the steering committee who had experience in methadone maintenance, so the committee could have representative knowledge and understanding from outpatient opioid maintenance therapy generally (clinical content, practice guidelines, laws, familiarity with the population and type of service, etc.).

I joined the steering committee and still remember the first meeting. At the first meeting we were told that development of this buprenorphine-specific IOP would be guided by a few important ideas and practices.

One important aim, we were told, was that given buprenorphine was a less problematic medication than methadone, this would be a pilot project that might show us we could eventually transition all our current methadone maintenance therapy (MMT) patients onto buprenorphine instead of methadone.
- But I knew that many of our methadone patients had been stable on various doses of methadone for as many as ten years or more, experiencing full wellbeing and no clinically-relevant problems in their lives. I was concerned about destabilizing some people who were doing very well on the methadone program, only for the hypothetical notion that this medication would be “better” for them (less dependence producing, less side effects, etc.). And all while these individual patients were doing great.
Another principle we were told was that the IOP would be 12 weeks long, and the buprenorphine would be used to achieve initial stabilization then tapered down, with no one taking the buprenorphine longer than 12 weeks. I knew that idea was poor or incorrect in at least a few ways.
- One is that initial induction onto a maintenance medication for outpatient Opioid Maintenance Therapy (OMT) happens in stages and is usually thought of as a project initially taking up to 90 days (as the literature shows). Yes, some initial stabilization is normally achieved much earlier than that, but stabilization is not an event and adaptation in this modality happens in layers. So, to me this plan was rushing the initial stabilization.
- And to have all patients off the medication after 12 weeks because the IOP would be “effective” and the patients “would not need to be on the medication so long” was an arbitrary goal and defied the entire evidence-based literature on OMT. Why discontinue a maintenance medicine while the patient is improving?

To me, the essence of these errors was an error inside the whole plan related to contingency management.

The steering committee was not charged with applying CM to this service.
But, to me, the plan violated the principles of reinforcement: why start a patient in a program on a medication that would stabilize them with the goal of soon ending the medication?
What is being incentivized in that arrangement?

I ended up telling the leadership and other steering committee members that if:

they are admitting patients with complex, chronic, and severe opioid dependence,
who were not so complicated and difficult that the IOP+buprenorphine recipe was necessary and sufficient,
then they would actually still be medicating some of the initial patients a whole year later

I told them my reasoning was based on the nature of the disorder and the value of the clinical service they envisioned, as aimed at helping people. And that it was positioned to help people maintain their improvements. I told them that repair is not sustainability, and the service was actually positioned to achieve both. I told them that as people improve, they tend to become medication non-compliant. I reminded them of the classic example of few people taking every single day of their antibiotic, because as they get better their focus to comply goes down. And I reminded them that this is opioid addiction however, and the patients therefore would be eager to comply.

Regardless, I was assured that no patient would be on the buprenorphine longer than 12 weeks.

Of course, one year later, some of the very first patients that were enrolled in that new IOP were still on buprenorphine maintenance and doing very well.

Lessons learned by our administration from this example of implementing CM included:

The person served decides what is rewarding. The clinician or researcher might think they know what the person will like, but the person served ultimately decides.
The person, their clinical care, recovery support, and CM activities must be understood in context of the person’s life and life situation.

In case you missed it, here is example # 3.