Revoking Methadone Take home Doses

aaaaaaaaaaaamethadone

 

My decisions to revoke take home doses provoke more anger and outrage from my patients than anything else I do. This is a sensitive issue, and it feels like I’ve had to make more of these difficult decisions recently. I get it – revoking take home doses is a terrible inconvenience for patients, and expensive as well, what with the extra drive time to the opioid treatment program. And yet, there’s no denying that patients can develop problems and start misusing their take homes, or even start diverting them for sale.

To understand patients’ fury at losing take home doses, I need to describe how hard it is to get those take homes in the first place. Patients don’t waltz into treatment and get take home doses right away.

For patients on methadone at opioid treatment programs, (OTPs), eight criteria must be met before the patient can get any take home doses.

  1. Time in treatment
  2. Urine drug screens negative for illicit drugs and alcohol
  3. Ability to store medication safely
  4. Stable home environment, stable social relationships
  5. No recent criminal activities
  6. Regular clinic attendance – doesn’t frequently miss days
  7. No behavioral problems at the opioid treatment program
  8. Rehabilitative benefits of take homes outweigh the risk of take homes

Of all the requirements, time in treatment limits patients the most. Many patients do very well right from the start, with no drug use, criminal activity or any other complications. Even so, they must come every day the program is open (often 7 days per week) for a minimum of three months. After that, they can be granted two additional take home doses per week, as long as all of the other seven criteria are met. After three more months, they get one more take home per week, and so on. Once they get to the take home level where they come only once per week, they have to be compliant and in good recovery for at least one year before being allowed to get take homes every two weeks.

Patients expend time, money, and effort to get these take home doses.

That’s for methadone. For buprenorphine (Suboxone, Subutex, Zubsolv, etc.) there is no federal requirement saying how long a patient has to be in treatment to get a take home dose. So long as buprenorphine patients meet the other seven criteria, they can get take homes from the start, as far as the federal standard is concerned. However, state requirements may be stricter than federal requirements. For example, my state didn’t drop the time in treatment criteria for patients in opioid treatment programs on buprenorphine, but is willing to grant exceptions on a case-by-case basis, as long as the request is reasonable.

Most patients manage their take home doses perfectly. This fact gets lost in the hoopla over the few patients who don’t take their take home medication as prescribed. The actions of a few rogue patients, when made public, taint the reputations of all our patients. Their actions unfairly perpetuate stigma and bias against medication assisted treatment.

At any given time, you can google “methadone overdose on take home” or something similar and read news stories about patients who sold or gave their dose to someone who died as a result. It makes big splashy headlines and causes people in the community to wring their hands and lambaste opioid treatment programs for allowing people to get take home doses at all. In reality, many more people have died from methadone diverted from pain medicine clinics.

Part of my job as an OTP medical director is to decide, with the help and input of all staff, when a patient is taking the medication I prescribe as I prescribe it, and when it’s being misused.

Now obviously most people won’t tell OTP staff if they plan to misuse their medication, or divert it to someone for whom it was not intended, so OTPs have to have ways to assure patient compliance. One of those ways is called a “bottle recall.”

In a bottle recall, a staff person, usually the patient’s counselor, calls the patient at the given contact number and asks them to return to the facility within 24 hours so we can see that they have all their bottles and that bottles to be taken later in the week are still sealed and full of medication.

Yes, there are ways to falsify bottle recalls. In the past, patients would pull the plastic bottles apart at the seams, remove the methadone, fill the bottle with red Kool-Aid or similar, and glue the bottles back together. Some patients’ efforts were easily detected, and some do a slick job.

Now that we have pressurized seals on the take home bottles, we think it’s more difficult to get into the bottle without being detected, but some clever patient will invent a way to thwart the pressure seals…or already has done so.

If the patient fails a bottle recall, we must eliminate all take homes, at least temporarily. Sometimes patients don’t give us a working phone number, sometimes they say they never got the call, they just dropped their phone in a mud puddle and it wasn’t working, they got the message but forgot to return to the clinic, they just went out of town and only got the message when they got back, are out of town and can’t make it back for a bottle recall…we hear many reasons for a failed recall. Many are legitimate, and it’s nearly impossible to sort reality from lies.

According to patients, take home medication has been lost, stolen, left in hotel rooms, spilled in the sink, run over by cars, eaten by family pets, black bears, and other animals, burnt up house fires, and dumped out by angry spouses and highway patrolmen. In one creative story, the patient said a tree fell on her house during a storm. The great wind that felled the tree also created a sort of vacuum in her house, and a whirlwind sucked her medication bottle up, up into the sky as she watched helplessly.

Another patient said he couldn’t come in for a bottle recall because he buried his bottles in the back yard and forgot where he buried them, because he had Alzheimer’s dementia. Of course, I asked why he buried them, and he said, “So my wife wouldn’t get into them.” No, he didn’t get any more take homes.

Of course weird things can actually happen, and that’s the problem. What should I do if a patient who appears stable and who appears to be doing well, reports loss of medication? It’s a judgment call. With the help of the rest of the staff, we discuss the past stability of the patient and the believability of the report. We can’t look into the hearts of all our patients and tell who has criminal intent and who doesn’t. People can’t be perfectly assessed. I do the best I can, and with the help of the rest of the staff, make judgment calls about take home doses.

As the prescribing physician, I have a responsibility to make sure every patient who gets a take home stores it safely and takes it as directed. If a patient is unable or unwilling to do this, I have to revoke their take homes, at least for some period of time, especially if there’s evidence my patient is selling or giving away their medication.

Diversion of take home doses to someone other than the patient for whom it was prescribed is always a concern at opioid treatment programs. But we don’t want to limit freedoms for patients doing well because of the illegal activities of other patients. As with so many things relating to human behavior, it’s an issue of balance. I admit we don’t always get it right.

Some anti-methadone activists would like to change the law, and force patients on medication-assisted treatment to come daily for their doses, and eliminate take home doses. That would reduce the problem of diversion, but cause a bigger problem. It would disrupt the lives of thousands of MAT patients who take their medication as prescribed as they go about their life.

In the other extreme, some pro-MAT people say patients should be allowed to be prescribed methadone and buprenorphine a month at a time, just like medication for other chronic illnesses like diabetes and high blood pressure. But the medications I prescribe, methadone and buprenorphine, have street value, and can cause euphoria in people unaccustomed to taking opioids. Therefore, because of the properties of these medications, sound medical practice tells us we have to have some safeguards in place to detect medication misused and diversion.

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21 responses to this post.

  1. Here’s a paper by the Open Society Foundation on low threshold MMT. Notice how much more successful the programs are when the multiple barriers we face at the the OTP models in the US.https://www.opensocietyfoundations.org/sites/default/files/lowering-the-threshold-20100311.pdf

    Reply

  2. Posted by Alan Wartenberg MD on February 21, 2016 at 6:20 pm

    One nice thing about buprenorphine within an OTP is that it is perfectly reasonable to double the daily dose and give it on Monday and Wednesday, and give 21/2 to three times the daily dose on Friday, and you have off-the-bat 3 day status without major potential for diversion (as long as people are checked so they are not ‘lipping’ or ‘cheeking’ the dose prior to leaving). Have done that in several programs with close to 100% acceptance, and very high tolerability – a few patients had to transition to those doses over a couple weeks.

    Reply

    • I had poor results when I tried that at my OTP. Nearly all the patients didn’t do well, and most still used opioids. Our retention in treatment was awful, too. I don’t know why we saw such poor results. As you say, three times per week dosing has been done in studies. Maybe I picked the wrong patients…did you have any special criteria for 3 times per week dosing?

      Reply

  3. Posted by Icecutter on February 21, 2016 at 6:46 pm

    This gave me quite a laugh today. You guys must have heard them all. I once got in trouble at my clinic because I asked to have my dose reduced and my counselor refused repeatedly. She was probably tired of having clients go down on their dose, just to want to go back up again. So I just took the lesser amount I needed and set aside the rest at home. Well, that resulted in my getting confused about the day I was supposed to come back and next thing I know I got a call from my counselor 6 days past my due date screaming about where was I? Well, I told the truth to the clinic, they didn’t believe me, of course and I got my take homes taken away for awhile. I ended up getting a different counselor later after mine got fired.

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  4. Posted by Chuck Hilger on February 21, 2016 at 11:19 pm

    Just a few points of clarification:

    CFR 8.12 (i)2 says “Treatment program decisions on dispensing opioid treatment medications to patients for unsupervised use beyond that set forth in (i)(1) of this section, shall be determined by the medical director. In determining which patients may be permitted unsupervised use, the medical director shall consider the following take-home criteria in determining whether a patient is responsible in handling opioid drugs for unsupervised use”.

    You article states that the criteria “must be met” and that is simply a misreading of regulations. The rule clearly states “the medical director shall consider the following take-home criteria….” If a person on Methadone at an OTP is consistently positive for THC on drug screens a medical director can, and often does, still allow for take home doses. There is no “must meet criteria” but there is a requirement that the MD “shall consider”. This makes a big difference in how treatment gets individualized. I also recognize that some states have rules that are more restrictive then the federal regs.

    Second, you state that a person must come daily for the first 90 days with the exception of clinic closed days. Federal regs for take-home doses in the first 90 days allows for 1 additional take-home beyond any clinic closed days, so a person may come as few as 5 times per week and receive a maximum of 2 take-home doses for the first 90 days. Again, as long as there are not more restrictive state rules in place.

    Reply

    • Thank you.
      As you say, we also must follow state regulations.
      I can tell you from personal experience that if all 8 criteria are not met, inspectors from the state organizations would be most unhappy. I’ve worked at programs that got “deficiencies” for giving take homes when the patient didn’t meet criteria.
      There are circumstances where I think patients need more take homes than ordinarily permitted by the 8 criteria, and SAMHSA’s exception website allows me to request these in special circumstances.

      Reply

  5. Jana, can you give me some typical benefits of methadone over buprenorphine? Having worked in a methadone program, early in my own recovery, I just didn’t see much interest in addressing the related issues to their addictive disorders. They were there to get the methadone, it did its job and that appeared to be the end of the change process. Conversely, we have many opiate dependent patients enter our outpatient program, engage in day treatment (PHP), 12 step mtgs. that are very MAT friendly, engage family in the tx. process and appear to experience greatly enhanced lives. Some of our patients, come from methadone programs and our biggest problem is getting the methadone program to help us transfer (per the patient’s wishes) from methadone to buprenorphine. In many cases, they have increased the methadone dose to 120mgs. making induction difficult, as we try to get them down to 30mgs. since the methadone is so much stickier on the Mu receptor sites. Most of these methadone programs are private and non-supportive of shifting to a partial agonist. They, also, face losing a nice profit margin from the amt. the patient pays to the cost of the methadone. We have had better success with buprenorphien, as an anaelgesic than the full agonists that the pain patient has become dependent on. Any insight would be helpful.

    Reply

    • I think it all depends on the patient. I’ve switched many patients from methadone to buprenorphine, and I’d say 85% do very well. The other 15% just never seem to feel OK. I’m also relatively cautious about making the switch – patients taper by 5 mg per week to 40mf or less, miss 2 days of dosing so that there is at least 72hrs between last methadone dose and first buprenorphine dose.
      Some patients say methadone helps their chronic pain issues better, but I believe there was a study of patients with both chronic pain and addiction. Half were put on methadone and half on bupe, and after stabilization the groups reported similar amounts of pain remaining.

      The biggest benefit of methadone over buprenorphine is that it is cheaper, and that it’s stronger, for patients with high opioid tolerance. We also see a higher retention in treatment with methadone compared to buprenorphine.

      I know you’re right about some OTPs pushing methadone over buprenorphine, especially if that particular OTP doesn’t offer buprenorphine. Four years ago I worked for a methadone-only OTP who’s CEO asked staff not to mention buprenorphine as an option to patients there for MAT. I quit that program.

      Reply

  6. Posted by Alan Wartenberg MD on February 22, 2016 at 5:07 pm

    my 2 cents – methadone is NOT stickier at mu sites – the only drugs with higher association coefficients than buprenorphine are naloxone and fentanyl congeners. The problem is that there is SO MUCH OF IT around because of its half-life, lipid solubility and sticking around in tissue and bound to blood proteins. If there is a lot of methadone stuck on receptors turning them on 100%, and you give the MUCH stickier drug buprenorphine, you literally tear off the methadone from receptors, replacing it with a drug that activates them 20-30% instead of 100%, resulting in an 80% drop in activity aka withdrawal. If someone is on 120 mg, you can still transition to buprenorphine by waiting a long, long time – weeks. During that time, if the person is cold-turkey, they will develop severe withdrawal and have a tendency to relapse. Some doctors will transition the person to short acting opioid for that week or ten days, then just stop that for 24 hours and buprenorphine induction can occur. This however requires a physician with skill and experience in the field, something not always found in your average buprenorphine doc.

    Reply

  7. Posted by mike on February 22, 2016 at 8:21 pm

    Hey! Your blog is amazing! I have been working in the same OTP in Baltimore, MD for almost 18 years and have been really disappointed in the lack of, well…ANYTHING resembling THIS on the internet! THANK YOU, THANK YOU, THANK YOU!!! Can’t wait to do more perusing and use this as a resource for clients and staff. Have a great day!

    Reply

  8. Posted by mcd on February 23, 2016 at 1:39 pm

    Every time I read about MMT in other countries, I thank God I was born in the UK where we’re a little bit more civilized about these things and prescribing doctors have a lot more flexibility.

    Reply

    • Posted by kevin0 on February 25, 2016 at 6:05 am

      Yeah sometimes I wish I received methadone maintenence in other countries where doctors didn’t have to ask someone without a medical license if they can increase a patient that desperately needs it

      Reply

  9. Posted by Tiffany Hood on March 11, 2016 at 2:52 pm

    Our clinic is strict, and they are open 365. You also have counceling which is mandatory. You do get to phase up every 90 days if all the criteria is met until you reach 1 year. When you have made it to one year you can not live up again until the 2 year mark, and have done everything right that whole year. And then once you make the 2 year mark you can’t move up again until another year , and have done everything right still. So just to get 6 take homes the minimum amount of time this will take you is 3 years. They move you up so quickly at the beginning and then it just comes to a hault. It doesn’t make any sense me to at all. 6 take homes is the max as well they do not do more than that regardless how long you are in the program. Is someone decides to be in treatment say for 10 years they still will only get 6 take homes.

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  10. Posted by carolyn on March 13, 2016 at 3:44 am

    I have always wondered why they allow suboxone patients to get so many doses at a time? I personally know people on suboxone that sell them, take more, or shoot them up. With methadone patients, to get any amount to take home, a patient must prove their responsibility. Therefore, it seems to me that the methadone patients that do receive take homes are the ones less likely to divert or misuse it. It disheartens me when I hear judgement about how dangerous MMT is for a community, but suboxone is hailed as the greatest treatment for addiction management. The stigma and mis-education perpetuated by the uniformed and by NIMBY groups does so much damage to those that struggle to change their lives. I am currently down to attending once a week, and it is rewarding enough to be its own incentive to continue doing well. Back to my original question though, in your opinion what incentive do suboxone patients have when they are turned loose from the beginning with so much medication that can be sold or injected?

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  11. Posted by jenniferyoung on February 10, 2017 at 4:47 am

    Very upset. I have been clean for many years. I have weekly take homes & recently put in for 2 weeks. My “new” counselor told me today that take homes were a privilege & not a right. Yet, it took me a bit of time to get clean. I am well aware that take homes are a privilege! Soooo, today I was told I had to pour out my take homes, pending further “investigation” because I do not have a job! ( I am SSI pending). I am TOTALLY flummoxed!!!!! I am a competent adult & because of my take homes I have ALWAYS been clean. What’s going ON here???? – please help,

    Reply

  12. Posted by Debra Towne on February 17, 2017 at 10:05 pm

    I too am on a methadone program 21years.i have met criteria to receive take home privileged. I recently was told a swab I turned in showed positive for cocaine idemanded a retest they agreed . They told me that the retest showed positive opiates.i was livid I haven’t done any drugs I swear to god !!!after I protested they said I could do a urine screen so I went in today only to hear that the urine showed pos for amphetamines! Now w t f . I told them I want blood tests there wasn’t any one to sign order for one today so I have to wait for weekend to be over .maybe monday I’ll get some answers I doubt it all I know is haven’t done any drugs what soever I’m baffled what can I do

    Reply

  13. Posted by Joshua Michels on May 3, 2017 at 5:42 pm

    I am from Maryland. I am currently battling to have my take home and level reinstated. I recently moved forcing me to leave my mat program of 8years. I chose to continue my treatment at Maryland. I brought up a couple shady financial issues that they are currently doing to thier clients. One of which was the last straw for them. They are double billing for thier monthly urinalysis. This caused them to changejmi my take home level from 6 to a lvl 1. This has turned my life upside down. I have maintained my level 6 for almost 7 years. No unclean urines or issues at all. I have tapered my dose from 140 mg to my current dose of 54mgs. I am trying to relieve myself from the program completely or to as low a dose as possible. Anyway,trying to hold this clinic liable for what they have done and reinstate my level 6 take home status has been impossible so far. These places are free to do what they want , when and to whomever they choose. I’m so distraught that all the hard work I have put into my treatment has been undone in a stroke of the keys by these horrible, unprofessional people. If anyone knows how to help me please. I could use some help right now, trying to do the right thing.

    Reply

    • You need to enlist the help of your state opioid treatment authority and ask them to investigate the double billing, which of course is illegal. Opioid treatment programs are not free to do what they want – OTPs are inspected by many agencies: you state’s department of health and human services, the DEA, the state authority, and others.
      You could consider filing a grievance, so that your complaint will be forwarded to someone above your counselor. Have you already spoken to the program manager?

      Reply

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