Safe Storage of Medication

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Please please PLEASE, patients on opioid treatment programs, store your medication safely.

Of course, the vast majority of patients in opioid treatment programs, dosing with methadone or buprenorphine, store their medication safely and never have any medication storage issues.
The public never hears about these people, who calmly go about their daily lives as productive members of society.

But one incident of a pediatric overdose on medication prescribed for a patient in an opioid treatment program threatens the reputations of treatment programs and their patients. Each time a pediatric overdose occurs due to improper storage of medication, people who oppose opioid treatment programs get new ammunition to say patients should never be allowed any take home doses.

By the way, this information about safe storage of medication applies to opioids prescribed for pain and other controlled substances. Anyone prescribed any medication should store it safely.

So let’s review what should be done to keep medication safe and out of the hands of people for whom it isn’t prescribed, including children.
1. Store your medication in a lock box that is locked. It does no good to have a lock box if you leave the key in the lock. The key must be stored in another place. Otherwise, it’s just a box.
2. Unless you’ve been directed to split your dose, take your medication all at one time. The seal on the bottle is there for a reason. Once the seal is broken, all of the medication is meant to be taken at once. This gives less chance for part of your dose to be ingested by accident or on purpose by another person.
I know patients like to take a little bit of their dose at a time, multiple times during the day. That’s a pattern leftover from active addiction with short-acting opioids. Each time an addict takes something, it gives a feeling of benefit.
But the unique pharmacology of both methadone and buprenorphine means patients can take the entire dose once daily and feel the same as if they take multiple doses. In fact, with buprenorphine, some people in the early studies did OK with every other day dosing.
Some patients are fast metabolizers of methadone and have to have split dosing. We can determine who needs split dosing with careful dose titration and peak and trough blood levels when needed. Then the dose can be split precisely, in individual bottles.
3. Plan for the unexpected. People who don’t have children living in the home often get complacent about medication storage. But what about when friends or family visit? You may not remember to remove your medication bottles or unlocked box from plain site. It’s best to stay in the habit of storing your medication, in a locked box, out of sight and reach.
4. Children are driven by curiosity. If medication is stored where kids can get into it, overdose is more likely. Don’t underestimate a child’s capacity to get into things.
5. Be careful with your empty bottles. Patients are instructed to drink their methadone dose, and then put a little water in it to rinse any residual and drink that too. It’s possible a small amount of medication could still be in the bottle. That’s one reason we ask you to store empties in the lock box, too.
6. Don’t let your child be any part of your daily medication administration. Kids naturally like to imitate their parents. Take doses of all medications in private, out of their view. Of course, don’t let your kids play with or handle your empty bottles.
7. Your take home bottles should spend all their time in the lock box. That’s their home. That’s where they live. The only time they leave the lock box is for the few moments it takes to consume your day’s dose, and afterward the bottle goes right back in to the lockbox. It makes me nuts to see patients transporting empty bottles in their coat pockets and purses.
8. Don’t tell other people what medications you are on. Addicts in active addiction can do desperate things like break into your house and steal medication.
9. If your medication does get stolen, call the police right away. That way, if someone overdoses and dies from the medication dispensed to you, you have a record of doing all you can to report that it’s fallen into the wrong hands.
10. If the worse thing happens and a child or other person takes your medication, call 911 right away. You will lose take home medications, but it’s still the right thing to do. Remember that methadone and buprenorphine cause a peak effect anywhere from two to five hours later. Just because you don’t see any problems in the child for the first hour does NOT mean the child is safe. Don’t take any chances.
11. If you or a member of your household takes opioids either by prescription or illicitly, get a naloxone kit. Keep it in your house so that if an overdose happens, it can be reversed quickly. You can read more about naloxone kits on my blog post on April 27, 2013. You still need to call 911, because naloxone’s effects wear off much faster than methadone or buprenorphine.

Lastly, and it’s self-serving for me to say so, but store your take home doses safely for your doctor’s sake. That take home dose with my name on it is a vote of confidence that you will be careful about how you store your medication. It’s always a judgment call, and sometimes I get it wrong. I am affected when bad things happen with diverted or improperly stored take home doses that I’ve prescribed. Plus, I become more cautious when considering patients for take home doses. Medication-assisted patients complain about overly restrictive regulations around take home doses of medication, particularly methadone, but cases of pediatric overdose make those regulations necessary.

However, I try to remember that the vast majority of medication-assisted patients store their medication correctly and never have any incidents of accidental pediatric ingestion or any other misuse of medication. They’re responsible and careful. For every episode of carelessness leading to a pediatric overdose, hundreds of patients never have an episode with improper storage. It’s not fair to paint them with the same brush.

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7 responses to this post.

  1. For years I medicate, rinse my bottle and then pull off the label and throw it away. I don’t understand the reason for putting all those bottles back in a lock box (lock boxes can paint targets on patients’ backs and also could violate a patients confidentiality… I wonder what’s in that lock box someone walking out of a clinic is carrying?) … Many programs also put solid medication all in one bottle, just like any other medication at the pharmacy. For many patients who get 2-4 weeks or who are in medical maintenance all of those bottles are a thing of the past. Part of giving someone take homes is trusting they can store them properly or safely. If that is a question then the OTP shouldn’t award takehomes. That’s one of the 8 point criteria.

    These guidelines might be good for some programs that always use individual bottles, require the return of those bottles (*rolls eyes) and require lock boxes (which are not required by regs), but some things don’t make sense at other programs who do things differently.

    Reply

    • Actually, I think all opioid medications should be stored in either locked boxes or locked areas. It could reduce drug overdoses. This isn’t just for patients on opioid treatment programs.

      I am bound to see things differently, since it’s mostly my responsiblity to judge who is safe for take homes (I get information from other OTP staff, like nurses and counselors).

      We used to give 4 weeks of buprenorphine take homes in one bottle but stopped doing that. Patients had a harder time taking the correct dose. Addiction being what it is, more accountability helps the patient, particularly in earlier recovery. The patient has to make a conscious decision to break a seal on a second bottle to take extra medication. If it’s all in one bottle, I do think it’s easier to rationalize taking a little extra. Later in recovery it probably doesn’t matter much.

      I can NEVER be certain about what patients do with their take homes. Trust isn’t black and white, all or nothing. It’s a judgment call based on the information I have at the time. Patients who have been stable for years have evidence they manage their medication appropriately. With those patients, I actually don’t think bringing back empties is helpful, but other patients complain it’s not fair to pick and chose who has to bring back their bottles (they don’t always understand about individualized care).

      But with new patients, at some point OTPs want to take the risk of giving a patient their first take home dose. To say we have to be sure about a patient’s capability for safe storage…I don’t think it’s possible. I know I’ve had some nasty surprises. As a human assessing other humans, I make judgment errors, as do my patients. But I hope I learn from experience.

      Reply

      • I understand your points, and I think many of them are valid. But it’s just important to note that many programs and clinics do things different ways so the suggestions here might not even be possible for some patients depending on their clinic’s practices. I think it’s important that you made the point this is something you recommend for ALL opioids and/or controlled substances – not just addiction treatment medications or those dispensed through opioid treatment programs. All too often OTPs are the focus and all kinds of “extra stuff” is expected of patients of OTPs while the vast majority of opioids involved in diversion, overdose and death results from prescriptions filled at pharmacies and not from medication dispensed by OTPs. In one state recently, I believe it was Maine, the number of pediatric overdoses/cases of toxicity from buprenorphine were more than 8 times the number of cases from methadone. Perhaps what sometimes appears to be the OVER-regulation we deal with in the clinic system is responsible for some good, as if I were a betting man I’d say those regulatory requirements placed on OTPs, and as such all methadone given for addiction treatment, is why the methadone cases were so much lower than buprenorphine – which can largely be obtained by prescription for weeks to a month’s supply at a time before patients are truly in recovery or have “proven” themselves the way earning takehomes through OTPs requires.

  2. Posted by Kim Tindl on February 23, 2014 at 9:15 pm

    I have been on Methadone 22 yrs . In the beginning I had a grandbaby to raise and I always kept my medicine box locked and my key has always been pinned to my clothes. Back then things were a whole lot stricter then they are now. I have a built in security box to keep important papers in as well as all ons including my Methadone box. This will save life’s most definitely but there will always be that few who are there for all the wrong reasons.

    Reply

  3. Posted by Getting Better on February 24, 2014 at 2:34 pm

    Hi Jana! I’ve now read almost ALL of your blogs regarding addiction, recovery, and everything in between. First and foremost, I want to say “THANK YOU” again! I’ve read, and commented under many of your blogs, and through reading them, I’ve undoubtedly discovered, what kind of AMAZING person you really are. If only ALL medical pros were as smart, educated, wise, and understanding as you are….. I live in your FAVORITE state!!!!! Drum rolllll…………. you guessed it! TENNESSEE! Needless to say, you don’t even have to TELL me how screwy the subject of addiction recovery really is in this state…. Sometimes I wonder, if I didn’t somehow get launched back into the stone ages when I decided to uproot and move my family here 8 years ago… In Tennessee’s defense though, this state definitely DOES grow some very nice, honest, GOOD people… I dare say, that I’ve never lived anywhere yet, where the citizens were this amazingly kind… the majority of them LIVE to help others and work their butts off regardless of reward… After a good couple years of illegally purchasing and maintaining my own Suboxone maintenance treatment, I’m happy to say, that last week, I finally landed my OWN, legal, treatment. By golly if it didn’t take me almost 2 years to finally do it though! I called and called and searched and searched, and up until now, couldn’t find a single soul, that was willing to take an addiction patient… The addiction specialists are full, and the other doctors don’t seem to want anything to do with addiction and/or it’s treatment… The doctor that I finally got in with last week, said that he, and most other doctors in this state are only allowed 30 patients.He stated (for reasons unknown to me) that he doesn’t particularly want to fill up his 30 patient limit, and in fact, stated that I am only his 4th Suboxone patient. Neverless, I thoroughly appreciate his willingness to take me in, and I can only hope, that other patients out there desperately searching for treatment, might have success as well. I’ve seen you express the importance of acknowledging that Suboxone is NOT in fact a “miracle drug”, but like I said on another post, “the results sure FEEL miraculous!”….. while on Suboxone, I’m a full time employee, happy wife and mother of 3, active member of the PTO and just about any other school related organization/function I can squeeze myself into, and I’m 100% FREE of all cravings and desire to use illicit drugs. When NOT on Suboxone, I’m spending every dollar that comes into this house to support my habit, not paying the bills, not working, not active in my family and home, and quite frankly, barely alive…….. It’s hard to see results like those, as anything less than miraculous….. I love my life now, as opposed to HATING it while in active addiction…. Thank you for all you do…. I’d love the opportunity to talk with you more in depth sometime….. Best wishes 🙂

    Reply

  4. Posted by nspunx4 on February 27, 2014 at 9:43 pm

    According to SAMHSA in the “2013 federal guidelines for opioid treatment” page 67 “medication security” using a lock box to transport take home doses back and forth to the clinic can make someone a potential target for robbery and the lockbox itself can be an identifier that you are in treatment which can lead to HIPPA violations.

    Samha reccomends storing take home medication in a locked box in your home but as far as transport they reccomend carrying them discreetly on your person and go as far as to say that lock boxes offer “little in the way of security” when used to transport medication to and from the program.

    I have been trying to get my clinic to change their lock box policy.

    Reply

    • Interesting. I would guess you live in an area where patients use public transportation to get to and from their OTP. Where I work, in a rural area, patients get to and from the OTP by private vehicles, so the only time the lockbox is seen by others is the short walk from the clinic door to their car. And if the lockbox is seen, it’s because the patient is physically seen leaving the OTP, which is something that can’t be helped.
      I guess the situation may be different for patients taking buses and subways to OTPs. Good reminder that treatment setting differ widely, inner city versus rural.

      Reply

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