Bad Weather Take Home Doses for Opioid Treatment Program Patients

We’ve had some snowy days in my area, and this means administrators at our opioid treatment program must decide if we should provide extra take home doses to patients for the days when travel will be treacherous.

Because take home doses are closely regulated at opioid treatment programs, both for methadone and buprenorphine, we must get special permission from state and federal regulatory agencies to give extra take home doses. We do this by submitting what’s called an “exception request.” This is an online form where we describe why we are requesting an extra take home, and for whom it will apply. Part of our job is assuring the authorities we won’t give extra take homes to patients who can’t manage them safely.

Ultimately, it’s up to me, the medical director, to decide the risk level of each patient. Which is more dangerous, driving on snowy roads to get to the opioid treatment program to dose, or having an extra take home bottle of medication? I need input from the staff to make the best decisions, so this can be time consuming.

Admittedly, my program failed our patients this last week.

The trouble is, we must decide when to submit a request for extra take homes about 48 hours in advance. It may take a day to submit online and get the medical director’s signature, the state opioid treatment authority signature, and the federal agency signature. Then we must give out the extra take home one day before the harsh weather is predicted.

Sometimes it’s hard to forecast bad weather. Early this month, we got an extra take home exception for a day when ice was predicted. In our area, a few degrees can make the difference between ice and rain. As it turned out, no ice fell and it was a perfectly normal day for driving.

I think that over-reaction was in our minds when we were monitoring the weather last week. At first, weather was expected for late Tuesday night. We were expected to get 1-2inches. We discussed if we should submit an exception, and finally did so late Monday night. I signed it, and it was approved by state and federal authorities, but we chose not to enact the exception Tuesday morning, based on updated forecasts.

It was not the right decision.

Tuesday night, it began to snow during the wee hours. By early morning, we had 3-4 inches and it kept snowing until afternoon. Somehow the forecasted 1-2 inches turned into 8 inches, at least on my side of the Brushy Mountains.

I live in the Brushy Mountains, and have a very steep driveway. Really, really steep. Imagine the steepest paved road you’ve ever driven on, and crank that up a few more degrees and you have my driveway. Plus, it has two curves in it. The only way I can get my small Toyota down the driveway would be to ride it like a luge sled, so it stays in the garage during bad weather.

My fiancé has a four-wheel drive vehicle, so he takes me to work, or I call a co-worker to come get me and I walk down my driveway to the road.

A group of physicians who work at opioid treatment programs were discussing this issue of severe weather take home exceptions on our monthly conference call last week. We pondered the factors that help us decide:

  1. Since buprenorphine has a greater margin of safety than methadone, I’m willing to grant bad weather take home doses for buprenorphine patients, unless there are other concerns to be considered.
  2. Patients in the induction phase of treatment, the riskiest time in treatment for methadone patients, shouldn’t get extra take homes.
  3. Patients who already receive take home doses for Sundays and holidays are likely OK for bad weather days, too.
  4. Patients using alcohol or benzodiazepines are at higher risk, and may not be appropriate for extra take home doses.
  5. Patients who live in a home with other people with active substance use disorders may not be able safely to store their medication, and may not be appropriate for the extra take home.
  6. Patients who have had recent episodes of suspected diversion won’t get extra take homes.
  7. Patients who live around the corner, are healthy, and can easily walk to the opioid treatment program don’t need extra take homes.
  8. Patients who live in more treacherous terrain or longer driving distance may need take homes. Our opioid treatment program is in the foothills of the mountains, but some patients live in a spur off the Appalachian Mountains called the Brushy Mountains. We have some steep and winding roads.

That’s a rough idea of most of the factors that go into deciding who should get take homes and who shouldn’t.

Then there are transportation issues. I mistakenly thought Medicaid-funded patients, who ride a transportation service that contracts with Medicaid to provide transportation to medical appointments, could get their usual ride to the opioid treatment program. Later I found out they have only a few four-wheeled vehicles. On one of our worst snow days, they only transported dialysis patients and others with “life-threatening illnesses.” My patients weren’t transported.

So, now I know that I cannot count on this agency to get patients to treatment on bad weather days.

As a group, OTP physicians are re-evaluating criteria for extra take homes in these bad weather situations, along with some help from our SOTA (State Opioid Treatment Authority). I feel fortunate to live and work in a state with an active SOTA. These remarkable people are tireless in their quest to continually improve the quality of care for patients at opioid treatment programs. They are valuable allies for physicians.

Because that’s the bottom line: we all want the best and safest care possible for our patients.

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16 responses to this post.

  1. I have been going to a clinic of some kind for over 8 years.except for federal holidays we have never had a bad weather take home dose and I drive over 110 miles 6 days a week for over half that time cause I was stupid and kept using pot and pain pills.when I learned my lesson I got monthly. But in the Midwest we have snow n cold n ice. Its flat dangerous. I’ve left home 8 hours ahead of opening or stayed in a motel up to 6 days to keep from wrecking.which happened 3 times in 3 n a half years due to bad weather.. You are very kind, very smart, and very empathetic to your patients needs..where I go we aren’t patients, we are junky trash(I have heard Dr.s , therapists, nurses and other employees say this at all 5 locations repeatedly) and we are treated as such. The Drs, nurses, counseler’s , and front desk help all can miss during bad weather but not us or its a write up and there are consequences..thanks for being caring n kind .that is super human of you.

    Reply

  2. Posted by Larry Lovelace on January 22, 2018 at 2:44 am

    Jana. Thank you so much for all the advice. I look forward to each installment. I have been thrust in to the job of medical director at 2 OTPs. I’m soaking up everything you write.

    2 Kings 2: 23-24 ἐπὶ δηλώσει δὲ καὶ ἀδικίῃ εἴρξειν love; Lace

    >

    Reply

  3. Posted by Andrew Angelos on January 22, 2018 at 2:57 am

    As far as suboxone everyone should get a chance for take home doses for weather or other things. Say a feuneral for example. There’s no reason to worry about a few doses getting out on the streets. It’s worth people feeling like humans. The way most of these places are I feel like I’m looked at like a commodity.

    Reply

  4. Posted by Andrew Angelos on January 22, 2018 at 2:58 am

    Just to add I have found a very good doctor in this field. He follows your blog I was amazed to learn.

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  5. I admire you you for bringing much needed attention to this issue , well as methadone treatment programs.. I would like to speak with you what we are trying to do for hardships patients see if you would be interested in backing a product that could help treat SUD my number is3046461167 looking forward to hopefully speaking with you soon.. Thanks

    Reply

  6. Posted by Larry Lovelace on January 22, 2018 at 3:37 pm

    Doc; I love your blog. I recently (and unexpectedly) became the medical director at 2 OTPs and had a steep learning curve. Your blog and the references contained within have been the most valuable resource I have found. I look forward to your next article. I have read all of the federal guidelines, all of my state guidelines, TIP 43 , all of your previous blogs, and all of the Toxicology Times Newsletters. I have researched all of the potential drug interactions and all of the drugs that cause increased QTc. What else should I consume? Keep up the good work.

    Reply

    • Wow, that’s great!
      Thankfully we have a lot of online resources now. I’m biased but I think there’s no substitute for attending an American Society of Addiction Medicine conference. If you can’t get away, you can go to their website and buy access to recorded sessions of the entire conference and get CME credits. That’s really where the latest data is found. I’ve also been to a conference of AAAP (American Academy of Addiction Psychiatrists) and had a wonderful time – good stuff there too. Plus there’s the PCCS-MAT website to support education form providers. You can access webinars and training modules: https://pcssmat.org/
      Then there’s the AATOD site – American Association for the Treatment of Opioid Dependence: http://www.aatod.org/ They have conferences that are great too – maybe not as geared to physicians as the ASAM conference, but still good information and networking. Their next conference is this March in NYC.
      If you are in NC, please let me know and I can connect you with our group of OTP physicians doing monthly teleconferences. It’s a great place to talk about difficult situations with other OTP docs. It can be a lonely job since not many doctors in the community know much about what we do.
      If you plan to prescribe buprenorphine products from an office-based setting, you can join UNC ECHO project – a weekly 2-hour meeting with case presentations, more experienced docs, and novices. Usually there’s a short didactic session too, and you get CME hours and it’s FREE!

      Reply

    • I’m so pleased to hear that someone actually cares about the needs of recovering addicts. It is so hard when you are looked at and treated like you are always going to be at the bottom of the barrel and your needs aren’t important. Not everybody want to stay stagnant or pay dearly for a slip up or a missed appt.

      Reply

  7. Posted by Brooke Stanley on January 22, 2018 at 5:59 pm

    I greatly respect and appreciate your admission

    Reply

  8. Posted by Joseph on January 22, 2018 at 11:46 pm

    I so appreciate your honesty and humility. Your willingness to admit that you don’t always get every decision right all the time is refreshing. I recently switched from a clinic in Virginia to a clinic in North Carolina because of the advances North Carolina seems to be making in medication assisted treatment. I appreciate your blog.

    Reply

  9. Posted by matt mcclure on January 23, 2018 at 2:23 pm

    I was wondering what they did in Houston when the hurricane hit. Did they give a weeks
    worth of take-aways with the expectation the clinic would be back up on running that soon. Would they have had contingency plans for longer delays. Years ago I participated in relief for Katrina (just general psych) and that was a debacle in Mississippi. I wasn’t involved in MAT at the time so don’t know what happened but I suspect they were left hanging.

    Reply

    • Posted by Craig on January 24, 2018 at 4:51 am

      Why sure they were left hanging due buracratic idiots that don’t care if people get their meds or not,what is sad is 13yrs after Katrina we have come no further,people are still having to go without their meds in Times of bad weather or natural disaster,no one cares until it happens to them

      Reply

  10. Posted by Andy on May 27, 2018 at 12:49 am

    I’m going to a clinic in Connecticut I’m able to have 13 take home bottles since I’m on split dose in need 26 take homes they are not letting me do it.Seems unfair I travel 1hr each way to work and have to be there by 7am.
    Are they allowed to do this it’s been on going for months with them and DOMHAAS.
    Can help?

    Reply

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