Guest Dosing at Opioid Treatment Programs

 

 

 

 

“Guest dose unto others as you would have others guest dose unto you.”

I think all opioid treatment program physicians should follow this twist on the Golden Rule.

That is to say, when OTP physicians are contemplating the appropriateness of approving one of our patients to be guest dosed at another OTP, we need to consider whether we would want to be on the receiving end of a similar patient.

First, let me explain what guest dosing is for my readers who may be unfamiliar with it.

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 before they are eligible for these take homes?

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 used to be difficult, since so many OTPs weren’t using buprenorphine. Now, most OTPs do offer both buprenorphine and methadone to their patients in treatment, so they can accept guest dosing for both.

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.

So who should not be approved for guest dosing? As above, patient in induction shouldn’t be guest dosed unless there are extreme extenuating circumstances – death in the family, personal medical crisis, or other extraordinary circumstance.

Sometimes I get frustrated not with patient of other treatment programs, but with the people who work at other treatment programs.

For example, last weekend we had a patient show up on a Saturday for guest dosing with no advance notice. Ordinarily, we ask for 48 hours’ notice to make sure guest dosing goes smoothly. Since it was a Saturday, our nurse had to stop dosing our own patients, call me for permission to guest dose her, and then call her home clinic for needed information.

We had already guest dosed this patient a few times within the past few months, so we kind of knew her. Otherwise, I’d have been tempted to say no, because it’s an inconvenience to our waiting patients and a hassle for our nurse. But it seemed harsh to deny her due to her clinic’s ineptitude.

If we had sent a patient to another OTP with no advance notice, I can almost guarantee they would say no, too bad, your counselor should have set this up days ago.

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.

Oh, and please, OTP counselors everywhere… it is “guest” dosing, not “guess dosing.” I cringe every time I see that written in any records from any program. We do not guess a dose. We do guest dose patients.

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13 responses to this post.

  1. Posted by Scott on March 26, 2018 at 1:45 am

    Out of curiosity, what is the problem with a patient using marijuana (or other illicits) while on MAT? I see this topic pop up a lot.

    Patients enrol themselves in MAT because they want to quit Opioids, not necessarily become teetotal.

    I can understand concerns about heavy alcohol or sedative usage, but not marijuana and other drugs.

    I know that being totally clean is ideal, but I would’ve thought cutting people off of MAT for ongoing non-opiod, non-alcohol, non-benzo drug usage would do more harm than good.

    For clarity, I am on MAT and don’t use any other illicit drugs, but that’s because I’ve no interest in them, not for any other reason.

    Reply

    • Great points. The harm from not guest dosing could far outweigh the harm from whatever substance the patient has used.

      Reply

    • Posted by Steve Straubing on March 26, 2018 at 2:08 pm

      I think your question is very pertinent and cuts to the very core of the concept of addiction as a brain disease. Many if not most of us that treat substance use disorder key in on the principal that addiction is not so much about the particular drug but about the biopsychosocial causes of the disease.
      Currently opioids are in the news every day but the reality is that many more people die from alcohol and nicotine related disorders than opioids.
      So using the reasoning that we are treating a disease that cuts across the lines of specific drugs of choice, quitting the drug that you want to quit, despite that being an important goal, doesn’t really address the core issues.
      So using an illicit or licit drug which may, in fact, ultimately be lethal is not the goal that one should shoot for when treating addiction. Addressing the core issues like environmental, developmental, psychiatric, medical problems which lead up to use of drugs of abuse, should be the goal. Use of other drugs isn’t compatible with that concept.
      Now having said that, in my OTP, I very strongly adhere to the concept of harm reduction. My prime directive question is: Will discharging the patient have a worse prognosis than keeping the patient in treatment? In most cases the answer is yes and therefore I try very hard to keep a patient in treatment.
      But at some point, if I see a patient using dangerous drugs like cocaine or methamphetamine, not just as an occasional lapse, but as I regular part of their routine, I will refer that patient to higher level of care which essentially intensifies the psychosocial treatment while allowing the patient to continue to dose in OTP.

      Reply

      • Well said!
        It’s a very hard call to make. When does the risk of treatment with MAT outweigh the benefit? As you say, usually keeping someone in treatment is safer. But patients coming to the OTP impaired, or having overdoses & close calls from using benzos or alcohol with MAT are a different story.
        THe best solution is to be able to transfer those patients – temporarily – to an inpatient unit that will treat the co-occuring substance use disorder while maintaining MAT.
        Those places are very hard to find in my area. Right now, there’s only one place in the whole state that is capable of doing this.

    • Please don’t misunderstand – I don’t cut people off MAT for using marijuana. However, the state regulations say patients with THC in their drug screens don’t qualify for take home doses, unless it is for a special reason. That’s why we must get exceptions from state/federal authorities before giving take homes in these situations.

      Reply

  2. I truly enjoy reading your articles. I’m an heroin addict, I’ve been clean for heroin for about 4 yrs now. I take Suboxone on a daily basis. I’d like to know your thoughts on another addiction that comes with heroin addiction. I’m talking about IV use. I wasn’t only addicted to heroin! I was also addicted to using a syringe to inject the drug. I was also addicted to the daily routine of an heroin addict. Having to wake up in the morning, find my tenth of dope and then if I didn’t have money I had to talk my way into the “guy” giving it to me and I’d owe him for it. One things for sure, I never robbed anyone for there money or possessions. But, I did hustle a lot. Making something out of nothing. It was the one thing I learned and I still have this ability to make something out of nothing. I started out working at subway restaurant. I did very well. Then I started taking classes online for criminal justice. Today I am a private investigator working for a law firm. The goal is to start my own PI agency. I’ll get there one day. Please, keep up the great work. I truly love reading your articles.

    Ryler Grey

    Reply

    • Thanks for reading.
      I have had many patients tell me they become addicted to the act of injecting; that is, the process of drawing something into a needle, seeing the blood flash, etc. I’ve had patients struggle to stop injecting saline. There’s a physiologic reason – the brain gets used to pairing the sight and action of injecting with a huge release of dopamine, the “pleasure” chemical. Eventually, the brain can release dopamine just with the act of injecting.
      From what I’ve been told, this gets better with time, and better when there are other good things in life with which to distract from cravings. I think MAT helps with this, too, at least somewhat.

      Reply

  3. Guess dosing?! 😂😂
    This is a great piece. Although I disagree it’s ok to deny guest dosing over positive urines alone (unless Benzos)… The whole purpose of guest dosing is for patients we can’t qualify for normal take-homes or justify an exception. Should someone who slipped up and took a hydrocodone after a bad fall be denied the ability to vacation with their family is there is a clinic in the area that can provide guest dosing services? The liability is on the sending clinic, not the guest dosing clinic…so it’s really annoying when overly punitive clinics want to pick apart a guest dosing request signed by my physician when it’s her license giving the order.

    But great piece. An important topic that doesn’t get enough attention.

    Reply

    • Thank you, Zac.
      You’re right – it is the sending clinics ultimate responsibility. However, you and I both know programs who will send someone to guest dose with their only requirement being: a pulse! I’ve had to refuse several guest dosing requests because the patient started methadone within the last week or two. Another program asked us to guest dose someone who had not dosed at their home OTP for 4 days.

      Reply

  4. Posted by Sean mckinnon on March 26, 2018 at 2:56 pm

    Dr. Burson or Zack,

    What is your opinion of an OTP who refuses to guest dose a patient who is traveling for work because the paperwork said they would be there two days but they showed up on the second day because the sending clinic made an error and that patient was guest dosing at another clinic the day they were “supposed” to be there? Basically a blanket if you don’t show up on day one we don’t take you rule? What if a patients connecting flight was delayed or canceled?

    Reply

    • That’s tricky. I don’t like to dose a patient as a guest unless we can confirm what the last dose was and when it was given. That’s why it’s so important to get the dates right. I know things can happen, and if a flight is cancelled I’d say it was up to the patient to contact the home clinic, who in turn needs to update the receiving clinic with new info.
      A “blanket” policy makes it easier for the receiving clinic, but not so good for the patients, so I would encourage more flexibility.

      Reply

  5. Posted by Bonnie on March 26, 2018 at 3:48 pm

    Not long after starting methadone last year I had to travel from Va to Daytona Beach for a 3 day business trip. After finding a clinic 9 miles from the hotel I would be staying my counselor called to make sure I met criteria for guest dosing there. We faxed over the required paperwork and I was ok n my way. The clinic in Daytona was ready for me & had all my paperwork in front of them the first day of dosing.. North Carolina was a different story.. Very few clinics offered Methadone anywhere near Nagshead & when my counselor & I did find one almost an hour away the maximum dose for guest dosing is 120mg.

    Just starting an OTP, guest dosing made it possible to continue taking business trips & traveling until I could earn my take homes. Hopefully Methadone will once-again be offered at more OTPs

    Reply

    • In the case of going to Nags Head, the problem isn’t that OTPs don’t offer methadone…it is that there are no OTPs near the Outer Banks. We have problems every time one of our patients wnats to go to the Outer Banks for vacation.

      Reply

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