
This may be a controversial blog post. I’ve been mulling over the ideas I’m presenting in this blog for many weeks and have changed my mind several times. So don’t get too upset with what you read, because I may have changed my mind again by the time you read it.
The events of this past year have given us experiences and information, and it seems prudent to learn what we can from them.
In the spring of last year, state and federal authorities moved quickly to allow patients enrolled in opioid treatment programs to receive more take homes doses than usual. They did this to reduce the risk of patients’ exposure to the COVID virus. Most opioid treatment programs were able to give many more take home doses of buprenorphine or methadone than ever before. This cut down the number of patients physically present at OTPs at any one time, thus creating more social distancing than ever before.
Now patients – and providers – are wondering what will happen after our country no longer has a high risk of COVID transmission in crowds. Will the previous regulations snap back into place? Will patients receiving extended take home doses now be asked to come more frequently and give up the convenience of extra take home doses?
In my state of North Carolina, as I understand it, once the state is no longer under a “state of emergency” declaration, the permission to give extra take homes to patients will no longer exist.
I’m not sure what state and federal authorities will advise, but I have some thoughts.
As I see it, we have two sets of questions. The first is what to do about patients presently receiving extra take homes. The second is deciding if information from events of the past year should cause us to change regulations about methadone take home doses.
At my opioid treatment program, we have about half our patients dosing of buprenorphine and half on methadone. Because of its better safety profile, buprenorphine patients already get take homes more quickly than methadone patients. So, my next paragraphs will be about patients being prescribed methadone at opioid treatment programs.
Let’s take the first question: what shall we do about patients who are getting extra take homes now? This has been an unusual time in history – I hope – and we have a cohort of patients who were suddenly given many more take homes than they were accustomed to getting.
Some patients had problems with those extra take homes. They came back to the opioid treatment program early, saying they didn’t know what had happened to the extra doses, or that the nurse hadn’t given them extra doses, or that some other person stole their medication. These problems almost always came to light within the first few months. Those patients were not ready – at that time – for extended take homes, though they may be able to do so in the future.
However, most patients with extra methadone take home doses did well. We’ve done bottle recalls (like pill counts done at pain management clinics) and most patients brought their bottles back in with the correct number of bottles untouched, with the appropriate amount of medication contained in them. This reassures us that these patients can take only one dose per day and are able to store it safely where it won’t be stolen or tampered with. Most of these patients have been reachable by their counselors for weekly in-person or telehealth meetings, showing further evidence of stability.
For patients who have proven their ability to manage their take home doses, it seems counterproductive to reduce the number of take- home doses again after the COVID emergency passes. Why would we want to do this? So long as patients have been making appropriate contact with their counselors at their programs and are doing well, I will advocate for them to stay at their advanced take homes. I might have to submit an exception to get permission for this from state and federal authorities, but that’s easy to do, and would seem a reasonable request.
Then comes the question of what to do with these patients if they have drug screens positive for illicit drugs. Should these patients move back to daily dosing? What if the only illicit drug they use is THC? Before the extra COVID take homes, our state said patients who remained positive for THC couldn’t advance past a level 1, which means they had to come every day but Sundays. In the past, I agreed with this policy. I reasoned that people using THC weren’t as stable as those not using it.
Now I have changed my mind.
Don’t misunderstand. I am no fan of marijuana. I think it can hold patients back in some insidious ways. It’s not harmless, as some people think, but neither is it a toxic substance, like alcohol is. Some day we may have beneficial medications derived from the marijuana plant, but at present, lighting the plant on fire to inhale the smoke isn’t a medically safe way to ingest those chemicals. We know marijuana use affects adolescent brains adversely, but even in adults, it can shave off IQ points, and may interfere with motivation to make life changes.
However, regular marijuana doesn’t cause the chaos that other illicit drugs cause.
Since COVID, I’ve seen many patients, long-term smokers of marijuana, managing their additional take-home doses quite well. They appear as stable as non-smokers of THC. I don’t see that it would help anyone to revoke those take-home doses, and it may benefit some of these patients to be able to give even more take homes. At present I am more open to such ideas than I ever have been in the past.
Patients using alcohol and other sedatives are not getting extra take homes at the opioid treatment program where I work, due to the dangers of mixing methadone with sedatives. I have not changed my mind about that.
What about stimulant use? We’ve seen an uptick in methamphetamine use over the past several years, and some of those patients are getting extra take homes now. Some are not, depending on an assessment of each patient’s overall stability. I have not been consistent with decisions about take home doses for such patients, because stimulant-using patients can differ widely.
For example, one patient has tested positive for methamphetamines for about a year, but she has a job, a stable relationship, and no apparent clinical decline, at least thus far. But another patient tested positive for methamphetamines for two months. Since then, his family committed him once to a mental institution for a few days, for auditory hallucinations related to drug use. He’s lost twenty pounds in two months and is twitchy and easily distracted when I try to talk to him.
I was generous with take homes for the first patient and denied take homes to the second one. Of course, the second patient feels like this is unfair towards him. After the COVID take-home exceptions end, should both patients be moved back to daily dosing?
Let’s move on to the idea of changing existing take home regulations. There are eight criteria that patients ordinarily need to meet to get take home doses of medication. In an abbreviated form, these are:
- No ongoing drug or alcohol use
- Regular attendance
- No serious behavioral problems at the OTP
- No recent criminal activity
- Stable home environment
- Ability to store medication safely
- Benefits of take homes outweigh risks of diversion
- Time in treatment
I agree with all these requirements, except perhaps the last one, which I feel is the most restrictive. Federal and state authorities have firm regulations about how soon a patient, doing very well otherwise, can be granted take home doses, based only on how long that patient has been in treatment. New patients can receive up to one take home dose per week for the first three month, then if all is going well, can get three take home doses per week for the next three months, then four doses per week for three months, etc. At the one-year mark, even an extremely stable patient will need to come once per week for a year.
That’s a long time, and perhaps unduly restrictive for many patients.
Before readers criticize me for risking lives due to putting methadone at risk for diversion, let me explain that I do know how much harm methadone take homes can cause in the wrong hands. I can tell you horror stories about diverted methadone, but I won’t do that now.
But on the other side, more patients thrive with extra take- home doses, able to feel less stress about getting to their OTP in time to get dosed and get to work on time. They can spend more time with their families in the morning hours. That’s worth quite a lot.
If we decide to revisit our present methadone take home schedule regulations and ultimately relax them a bit, it will fall to treatment center staff and ultimately the medical director to decide if a given patient is stable enough for take homes. That means the medical director will need to know her patients well. This requires time at the opioid treatment program and involvement with the patients. That should already be happening, but I know that’s not always the case.
Here are a few of the warning signs we’ve seen that can indicate problems forming: coming in a day or two early to dose, even when the patient should already have take-home doses; being unable or unwilling to give urine drug screens; giving falsified urine drug screens; counselors being unable to reach the patient for telehealth counseling sessions; poor attendance or repeatedly coming at the last minute to dose; new mental health issues or new physical health issues, and unexplained change in appearance or affect.
Since the medical director is ultimately responsible for the consequences of methadone take-home doses, the medical director needs to be made aware of any warning signs seen in patients, aside from positive urine drug screens. The medical director needs to know the patients well, and have input from counselors, nursing, and even front office staff when making these important decisions. Therefore, time for case staffing, sometimes also called treatment team meetings, is so important.
At the OTP where I work, we usually have case staffing twice per week, and it includes medical and counseling staff. We make decisions about take home doses at these meetings. Sometimes we disagree, and that’s good. It means differing opinions are being voiced. Sometimes emotions run high, a reflection of the importance of our decisions to patients. It’s often a difficult process.
But because of the importance to patients, perhaps take-home regulations should be re-evaluated at national and state levels, in the light shed by our recent experiences with the extra COVID 19 take home doses.