Guest Dosing at Opioid Treatment Programs

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Patients of opioid treatment programs have to dose daily on their medication, unless they meet criteria for take home doses. For buprenorphine (formerly known as Suboxone or Subutex) regulations have loosened in many states, so that take home doses are granted much earlier. (The federal regulations have completely dropped the time in treatment requirement for take home doses of buprenorphine.) But for methadone, patients have to dose at the facility each day for at least the first ninety days, and after that, if doing well, they can get up to three take homes per week for the next ninety days, then up to four per week after a half of a year, and so on.

What happens if the patient needs to go out of town?

There are three options: leave treatment, the worst option, because of the increased risk of death for patients who leave treatment; special take home doses, often risky if the patient isn’t able to take them as prescribed; and guest dosing.

Guest dosing means a patient of one treatment program can be dosed at another program if that patient travels to another area. All opioid treatment programs send their patients for guest dosing and allow guest dosing for patients of other facilities. It should be a smooth and simple process, under ideal circumstances.

But sometimes circumstances get complicated.

Most difficult are the last-minute guest dosing requests. These tend to come at particularly stressful times for the patient, because often a patient’s family member is sick, or just passed away. The patient needs to be with his family.

Setting up guest dosing at the last minute is more difficult for the referring clinic, the accepting clinic, and the patient. Most clinics ask for 24-48 hours advance notice for guest dosing, but some situation don’t allow that much time. We do the best we can, try to explain circumstances to the receiving clinic, and usually are able to work out something.

Guest dosing requires good communication between clinics. Usually the home clinic needs to fax a form with the patient’s picture, their dose, and any take home doses to be dispensed. Most receiving clinics like to see at least the last three drug screen results. Some receiving clinics ask for a doctor’s signature to assure the physician is aware of the guest dosing request. Then when the guest dosing patient arrives at the receiving program, the nurse calls to verbally confirm all of the info on the guest dosing request.

Some opioid treatment programs charge steep guest dosing fees, affecting the patients’ ability to pay for guest dosing. Some clinics charge a one-time fee to set up guest dosing, and after that pays the same as any other patient dosing at that clinic. Some programs charge elevated fees every day the patient guest-doses.

As the medical director, I am consulted any time one of our patients wants to guest dose at another clinic, and any time a patient from another clinic wants to guest dose. We have general guidelines for guest dosing, but often have to consider other factors.

For example, at both of the treatment centers where I work, we prefer not to guest dose patients during induction. Induction is the riskiest time of treatment, and usually lasts at least thirty days. But each request must be considered and the risk/benefit analyzed. What about if a patient admitted three weeks ago finds out a close relative is dying, and wants to be with them? I might agree with guest dosing such a patient, if she is doing well, isn’t actively using benzodiazepines or alcohol, and won’t be gone for many days.

Some clinics won’t allow guest dosing for any patient with positive drug screens. Generally I would agree with that, but for me it depends on what the drug is, and why the patient needs to go out of town, and for how long. For example, if a patient is stable on his dose, but is still smoking marijuana with every drug screen positive for THC, I’d still support guest dosing if this patient needs to work out of town. I’m not OK with continued illicit marijuana use, but the problems caused by missing a work opportunity may be greater than problems caused by marijuana use. If that same patient were using benzodiazepines or alcohol, I probably wouldn’t agree with guest dosing, due to the much higher risk of methadone when combined with these drugs. If the marijuana-smoking patient wanted to guest dose out of town in order to attend a friend’s bachelor party…I’d be hesitant, as I’ve heard rumors that these events tend to involve heavy drinking of alcohol. I’d have to talk to the patient.

Guest dosing in patients on buprenorphine is usually out of the question, since so few programs are using buprenorphine. One of the programs where I work is owned by CRC Health, and they are the only large opioid treatment program operator (that I know of) offering buprenorphine at all of their clinics. If a buprenorphine patient is lucky enough to be traveling near one of CRC’s clinics, guest dosing can be arranged easily.

But since buprenorphine is such a safer medication than methadone, usually we can get permission for take home doses, if the patient doesn’t already qualify for them. Even though federal regulations dropped the time-in-treatment requirements for take homes in buprenorphine patients, my state still requires time in treatment, unless we ask for an exception, which is usually granted.

The whole goal of treatment is to help drug addicts regain their ability to live a normal life. Opioid treatment programs should make every effort to remove obstacles to travel during treatment, while still following state and federal regulations. And of course, the freedom to travel and guest dose must be balanced with patient safety. Ideally, the decisions regarding guest dosing should be made by the physician, who is informed by the input of the treatment team, so that the best possible decisions can be made.

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15 responses to this post.

  1. Posted by Nancy on August 9, 2013 at 3:32 pm

    I am very thankful for treatment programs. However it seems a bit archaic to still be using methadone as a main treatment option. What other disease requires an individual to go in daily for medication, as well as being denied “take homes” until after 30, 60, or 90 days of treatment-or even having to go through hoops in order to “guest dose” if an emergency comes up. Perhaps methadone treatment still has its place in the grand scheme of things, but with all the new medications and options I would think methadone would be a last choice for sure. I know my life would be quite disrupted if I had to go to a clinic each morning for my necessary medications. Who wouldn’t?

    Reply

  2. Posted by Benjamin K. Phelps on August 9, 2013 at 11:08 pm

    Dr Burson, both of the most recent clinics I have been in want 2 whole weeks of notice to arrange a guest dose. While I understand that notice is necessary to facilitate all that has to be faxed & signed, etc, 2 weeks seems to me to be quite excessive. Yes, if I’m planning a trip to Disney World, I probably will know this months ahead of time. That would be acceptable & reasonable if I waited til the last minute to deny the request. However, say a work situation comes up & I have 1 week’s notice – which isn’t uncommon in the working world, as many places don’t schedule more than 1 week out – how the heck am I supposed to be able to ask 2 weeks in advance? And let me tell you – just TRY asking my clinic to make an exception to ANYTHING!! Ain’t happenin’. No way, no day. I don’t get that type of oversight on the program… where their motto is “We’re not going to do ANYTHING to help make your life any easier, NO MATTER the problem, the cause, or the necessity of the assistance you need. Their reasoning when you ask them? “We have xxx number of patients. If we give you guest dosing or an extra takehome when you didn’t give 2 whole weeks notice, then we have to do it for everybody else.” And that’s it. But that’s crap, b/c no you DON’T have to do it for everybody else. You discern whom you give takehomes to, based on a # of factors – you don’t give them to everybody just b/c you give them to 1 person. You don’t set up guest dosing if we have positive drug screens in the last 2 months (at my clinic) – but you WILL set it up for those who don’t have + drug screens. You charge 2 different amounts, based on income (at my clinic – not that there’s much difference…), which means the people paying more aren’t getting the same deal that the others are. And finally, you don’t grant more than 5 takehomes to anybody w/o a job, while people w/jobs can get up to 2 weeks. So what gives w/saying you have to do for everybody what you do for 1 person? I guess my point here is that we (the patients) get SO tired & SO burned out on hearing lies & excuses, which are SO common at 2 of the 4 clinics I’ve been in in my lifetime (& 1 of the other 2 I can’t say for sure b/c I wasn’t there long enough to know). Every single time you ask ANYTHING they don’t want to do, they give you 1 of a few excuses: 1) It’s against the regulations (even when we KNOW it’s not); 2) We can’t do it for you if we don’t do it for everybody (see above); or 3) We can’t be sure it’s safe b/c we can’t REALLY be sure you aren’t using/selling/sharing/diverting/hoarding your medication (even when you’ve had PERFECT compliance for many years). These excuses & lies insult our intelligence & basically imply that we’re too stupid, often times, to know the difference. Like the policy of my clinic to withhold doses for reasons other than you coming in drunk or high. They SAY it’s b/c they need to KNOW you haven’t taken any drugs that morning that might interact w/your dose & kill you…. but they don’t do instant tests other than at intake, so how are they going to know if I have taken something dangerous & DID give a urine sample? I could theoretically take 100 Xanax tomorrow morning & go in to dose before it kicks in – & if they test me, I can STILL give them a urine sample, & they won’t have any idea until it comes back a couple of days later from the lab! So it’s like PLEASE, go ahead & just tell me – it’s b/c you are pissed off that I won’t just give you the sample you’re demanding right this second… it has NOTHING to do w/you being concerned about my health or safety. And I’ll finish by saying that YES, I understand & am fully aware that the state & federal law does require urine samples regularly. However, they also DO NOT state that you should or must withhold doses if I can’t provide 1 on demand 1 day. Many clinics simply count it as a + & then dose you anyway – & they have a limit on how many times that can happen w/in a year’s time or something of that nature (like my last clinic). B/c if I am unable to urinate on demand, & you threaten to make it an automatic +, then if I STILL can’t give a sample, it pretty much means it’s for real – not that I’m trying not to be caught for using, doesn’t it? I mean, if I’m going to be counted + anyway, then why hide it??? So this is 1 of the BIGGEST reasons patients, in my experience of over a decade, get SO sick of being under the dictatorship of a clinic!! We get done ANY kind of way, then told ANY old thing as a reason – when we KNOW for a fact it’s bull. If they would respect us enough to just be honest, I think that would go a L-O-N-G way in building some trust & respect between the patients & staff. Although my clinic doesn’t really care about either of those things between patients & staff – they really couldn’t care any lesser about that. They KNOW full well that none of us trust them, nor do they trust a single 1 of us. And as for respect, we get disrespected DAILY – by the front desk lady, who talks to all of us like dogs for absolutely NO reason… by some of the counselors, 1 of whom humiliated me in group last time b/c I was participating in group TOO much for her tastes… & by the director, who’s never ruled in favor of a patient in the entire time she’s been there that I’ve EVER known or heard of when anything comes up. I could really get going on the examples there, but I’ll spare you all.
    So what I want to know is: Do you (Dr. Burson & other readers) think that a STRICT 2 week requirement for guest doses &/or takehome requests (or even to move your current takehomes so that you could go out of town) is fair in EVERY situation?? In other news, I’m in the process of transferring to a private clinic once again in the next few days or weeks (they are currently not doing intakes, but I’m on the waiting list). So hopefully, I will be away from these problems VERY soon…

    Reply

    • I’ve always thought 2 weeks’ notice for guest dosing was ridiculous, with the possible exception of a vacation site where the clinic gets hundreds of people guest dosing. Then, maybe the staff at the OTP needs the extra time.

      Health care should be individualized to the degree it can be. Each patient’s situation is different, and unless safety factors or state/fed regulations dictate otherwise, the doctor and staff should take the time to decide what’s best for the person being considered. Often the patient doesn’t agree with what we decided, but at least we take the time to think about it. And no, the program doesn’t have to do the same thing for every patient.

      But one problem with deciding each case based on overall patient stability is that another patient will complain that patient X got this and you denied me, it’s not fair, and I’m gonna complain to the state. I’m OK with that, so long as I’ve taken time to make the decision and can explain & document why I make different decisions for different patients. But too often, the regs don’t give us much room to individualize care anyway. And the staff (including me) do have to be very careful we don’t play favorites when we individualize care. Because that would mean patients are right when they say decisions aren’t fair. Things like dose exceptions, etc. shouldn’t be decided based on if I like that person. That’s why such things are best decided in discussion with the the entire staff.

      Opioids, especially methadone, can cause urinary hesitancy, meaning it’s hard to initiate flow of urine. This happens more often in men. But part of the deal with opioid treatment programs is that we are treating addiction, and standard of care is to get random urine drug screens. If the patient is unable to comply, we have a big problem. The regulations say we have to have a certain number of drug screens, and that at least half must be observed. So how can we keep patients in treatment who have a really hard time giving us a sample, possibly due to a side effect of the medication we’re giving, but still adhere to regulations? I don’t think denying the patient his dose is right, unless the patient is impaired. But it’s not good care to allow patients to refuse a drug screen and just “admit a positive” because that limits our ability to know what’s happening with this patient, and the program will be out of compliance with the state.

      Mouth swabs help a little. They have their limitations, but can help. I don’t want to go by all oral swabs because they are good at detecting some drugs but not others.

      I don’t know of a great solution to this problem.

      Reply

      • Posted by Benjamin K. Phelps on August 11, 2013 at 3:15 am

        Dr Burson, 1st of all, thanks for your complete response! I appreciate your views. 2ndly, I wanted to say that the problem at my clinic is that they DON’T just do half of the screens observed… They do 100% of the screens observed – & for the men, it’s w/a female. We now have to pull our pants all the way down, b/c somebody a couple of months ago tried to sneak some pee in again, so now ALL of us MUST be punished, rather than them making an example of that person & kicking him or her out of the program. I don’t necessarily advocate kicking someone out of opioid treatment for a 1st time offense of something not violent or the likes, but you can take action on THAT patient, if the rules are sufficient for the rest of us & we’re complying. Pulling my pants all the way down in front of a female to urinate when I already have a TERRIBLE time from paruresis AND I’m taking methadone, which as you say, creates difficulty starting a urine stream – at least in me & many others, makes matters EXTREMELY embarrassing for me, for the female nurse who monitors me, & puts EVEN MORE pressure on me, which raises up the paruresis – b/c as we all know, that’s totally caused by mental anxiety, so raising anxiety even higher is the WORST thing you can do for that problem! For them to monitor 100% of the tests simply b/c they are DETERMINED & HELLBENT on catching someone who has used & not letting them “get over”, is just stupid, considering it’s not seen as needed by the law, the medical professionals who define best practices, nor many of the other clinics out there. Sure, some would get over in an unmonitored situation from time to time, but they’ll get caught eventually anyway if they’re using regularly. And the fact of the matter is, if they’re REALLY wanting to get over, they’ll just get their takehomes, & not use w/in 2-3 days of going to pick up. That’s just the way it is. All the monitoring & pressure & punitive measures in the WORLD aren’t going to change that people will STILL occasionally use & get by w/it. It’s the nature of drug treatment, unfortunately. But back to the policies, I believe we should have the RIGHT to dignity in our treatment – & having a woman watch me w/my pants around my ankles while I hold my genitalia is NOT in ANY way dignified, nor does it create trust in ANY way whatsoever. All they ever are worried about is that somebody MIGHT get over on them. God forbid.

      • Now I know why in Memphis- patients were not allowed to discuss what mess they were taking or being prescribed ad if were caught talking about it, you would get kicked out of clinic.

        It must have been bc people say that drs have favorites, now I get it. I admire you for taking the time to examine and document!!

        That’s so very important!

        My last appt with swamy- I told her I was passing out, throwing up, and lost 32 lbs.

        All she documented was pt is doing ALOT better, but says she is nauseous.

        She later told me that passing out was psychological. But only thing documented is what I stated above. That’s not fair to me not honest on her part.

        So I am glad to see that you document and try to help every individual person! From your blog, I know you are a great dr! And that makes all the difference!

  3. Totally agree Dr Burson! Say a prayer that I find a subutex dr Monday! The one who is willing to take me has 100 PTs but said he could get rid of one if had to bc he didn’t want to see anyone going thru what I am! Say a prayer that I get in with him. The past 3 months have been hell mentally to say the least! I didn’t know how much I depended on my dr until I was abandoned by him! Thanks for your blog, I am so glad I found it during this time. Thanks! Nacole

    Reply

  4. Thanks for bringing attention to the difficulties many patients often face when facing situations that require guest dosing at programs away from their home clinic. It can be a difficult and stressful experience for many patients, as you’ve indicated. It doesn’t have to be, though, and most of the time it is one of the clinics involved has CREATED the difficulties.

    Another large chain (though not as large as CRC Health Group) that is now offering buprenorphine at all of their OTPs is Behavioral Health Group (BHG) that owns 9 of 12 OTPs in the State of Tennessee. It is also my understanding that Colonial Management Group LC (CMG), the 2nd largest chain after CRC, is currently in the process of implementing buprenorphine therapies at all of their locations as well. I think buprenorphine’s much lower retention rate compared to methadone will be increased by more patients accessing this medication in the OTP setting in the early phases of treatment, as opposed to walking into a DATA 2000 office and being handed 1, 2 or even 4 weeks of medication on their first day. We shall see; that’s an area of much debate.

    Thanks again for all your work. This is an important issue for patients that rarely gets the discussions/attention it needs.

    Because treatment works,
    Zac Talbott
    NAMA-R TN

    PS- I must say that I am impressed with the corporate team at CRC Health Group overall recently. I’ve developed an amazing relationship with Jerry Rhodes, Chief Operating Officer, and his concern for improving the lives of patients is unparalleled. He’s been committed to an ongoing dialogue with NAMA from which I believe MUCH good can come!

    Reply

  5. I’m sure there are a lot of government regulations governing how these clinics are operated but, why make it so hard for the people in treatment. Is it because active addicts try to game the system to get methadone to supplement their other sources of opium based drugs?
    I thought methadone did not get people “high”.

    Reply

  6. I am traveling to Dundalk Maryland the w/end of July 4th to visit family, I’ve called over 60 places today and all clinics only offer methadone!!! I am on sunoxone and I need to find a clinic that will prescribe me my Suboxone!!! ALL I need is Saturday and Sunday’s prescription I’m getting Thursday and Friday here Myrtle Beach so I need to find a clinic for Saturday and Sunday!!! So please please please please PLEASE respond to this email soon as possible thank you!!!!

    Reply

  7. Nice blog,great read 🙂

    Reply

  8. Posted by Alicia Moss on June 17, 2015 at 7:08 pm

    Thank you very helpful!

    Reply

  9. Posted by Maureen gorman on May 16, 2017 at 10:48 pm

    I’m been at a methadone program here in the Bronx NY for around 4 years I’m coming to the Bahamas to be with my siblings that I haven’t seen in many years my siblings do not drink there are involved in alenon I’m coming from June 16 th and leaving on June 19 th but in them 3 days I’m going to need to be meditcated I’m on 100 mg of methadone and would be in bad shape with out being meditcated please if you could give me a call I can set everything up with my countsler and my program here in the Bronx for all the information you would need

    Reply

    • Sorry, but you have to go through your program. Please discuss with your counselor. This is just a blog with information about opioid use disorder and its treatment.

      Reply

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