Editor: Deborah K. Stephenson, MD, MPH
for the CSAM Committee on Treatment of Opioid Dependence

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INTRODUCTION
The physician in an opioid treatment program (OTP) practices in a uniquely challenging medical environment, responding to a diverse array of medical, psychiatric, and social problems in a largely indigent population with limited access to health care. In addition, the past experiences of opioid dependent patients in medical settings often result in mistrust, and even hostility, toward mainstream medical providers, which discourages them from seeking even the limited care available.

Characteristically, addicted patients receive high-cost crisis care in Emergency Departments and hospitals. After discharge there is little to no follow-up. The physician in the OTP is often the first medical provider with whom these patients establish a long‑term therapeutic relationship. The OTP physician can be an important, even lifesaving, resource for patients enrolled in treatment, identifying the multiple medical problems that characterize heroin and opioid addiction and providing treatment or referrals to address these problems. The OTP physician is also in a position to positively impact the public health of the community by screening for and treating communicable disease and offering other preventive health services.

OBJECTIVE
This document is intended to assist OTP physicians in understanding their role and responsibilities in treatment, including those areas governed by state or federal regulation. It describes the role of the physician in an Opioid Treatment Program and the clinical judgment involved in the development of an appropriate treatment plan for the delivery of patient care. It describes responsibilities that should be carried out by the physician or the physician's designee. It does not describe a standard of care. It does not prescribe specific treatment choices. Judgment regarding specific clinical situations must be made on the basis of the clinical information available and on the treatment options available.

CSAM Committee on Treatment of Opioid Dependence:

• Judith Martin, MD , Committee Chair; Medical Director, 14 th Street Clinic and East Bay Recovery ‘Project, Oakland
• Peter Banys, MD ; Director, Substance Abuse Programs, VA Medical Center, San Francisco
• Gail Jara ; Consultant to CSAM; Staff to the Committee on Treatment of Opioid Dependence and the Task Force on Pain and Addiction
• Lori Karan, MD ; Drug Dependence Research Center, UCSF
• Walter Ling, MD ; Chief of Substance Abuse Programs, UCLA
• John J. McCarthy, MD; Executive and Medical Director, Bi-Valley Medical Clinic, Sacramento
• Karen Miotto , MD ; Medical Director, Substance Abuse Program, Los Angeles VA Ambulatory Care Center
• David Smith, MD ; Founder and Medical Director, Haight Ashbury Free Clinics; Medical Director, California Department of Alcohol and Drug Programs
• Laurene Spencer, MD ; Medical Director, Geary Street Clinic, Bay Area Addiction Research and Treatment, San Francisco
• Deborah Stephenson, MD, MPH ; Perinatal Substance Abuse Program, San Jose
• Matthew Torrington, MD ; Integrated Substance Abuse Programs, UCLA
• Ernest Vasti, MD ; Medical Director, Methadone Maintenance, San Joaquin County
• Donald Wesson, MD ; Consultant, CNS Medication Development