Former Surgeon General C. Everett Koop put it bluntly in 1985 when he said, “Drugs don't work in patients who don't take them.” Today too the “other drug problem” is medication non-adherence where data show that more than 50% of patients do not take their prescribed medicines properly.
In the absence of an implant or injectable form of medication assisted treatment (MAT), a sound strategy to ensure adherence to treatment is directly observed therapy (DOT) much like what is done with public health services for tuberculosis (TB). With DOT, a patient meets with a health care worker every day or several times a week at a time and place that is convenient for the patient to take medicines while the health care worker observes ingestion. DOT is a recognized best practice for community TB control since there is no reliable way to accurately predict whether a patient will adhere to treatment without this assistance. Although supervised dosing is required by federal regulations for methadone in Opioid Treatment Program (OTP) clinics, buprenorphine and naltrexone are not covered by the same federal requirements.
Members of the YRS group see the DOT option with both buprenorphine and naltrexone in oral form as a MAT methodology with distinct advantages. Members with experience and expertise in DOT may be available to assist in establishing and implementing this treatment programming. For providers, there be more revenue, improved medication adherence, less potential drug diversion, and more opportunities for counseling and support during more frequent group clinic visits. For patients, there may be more convenience with no separate visit to a retail pharmacy, several smaller payments for medication instead of a single larger monthly pharmacy bill, the use of a cheaper monotherapy product with supervised dosing, and fewer DOT visits to the clinic with 3x/week or alternate day dosing as opposed to daily dosing with methadone. This type of DOT MAT with buprenorphine or naltrexone may be carried out with a custodial pharmacy, with point of care dispensing by a physician in a medical office, or by the OTP Clinic billing separately for daily dosing in the clinic or via authorized take-homes along with billing additionally for drug reimbursement.
When combined with case management and recovery progress verification (e.g., drug testing, pill counts, prescription drug monitoring program with the Board of Pharmacy, telephone or video support check-ins), this type of DOT may likewise improve outcomes in treatment retention duration, less dropping out of the program and restarting treatment repeatedly, and less use of illicit or recreational drugs while in treatment. Finally, DOT MAT may encourage more private providers to become trained and qualified to offer more buprenorphine and naltrexone services to more patients as this type of service delivery to persons with opioid or alcohol use disorders (OUD/AUD) is both efficient and effective in many ways.
The Amador Health Centerin Las Cruces offers DOT in the clinic and office, by field visit and via video chat with patients receiving oral naltrexone for alcohol use disorders and buprenorphine-naloxone for opioid use disorders. The ALT Recovery Group in Las Cruces provides supervised dosing in the clinic with methadone for opioid use disorders.