Revoking Methadone Take Home Doses

 

 

 

(The information presented has been changed to protect patient identity.)

Last week, staff at our opioid treatment program had a lively discussion about take home doses for a patient on methadone. She’s been in treatment for several years and was on take home level five, meaning she dosed on premises once per week and was given six take home doses. We needed to talk about revoking her take home levels because she was recently arrested for sale of a Schedule II narcotic.

The news of her arrest surprised us. She passed several bottle recalls, which is when we call a patient and give them twenty-four hours to return to the opioid treatment program with their take homes, so we can inspect them to make sure they haven’t been taken early or tampered with in any way. We do this because the state and federal regulations demand it and because it’s good practice. It’s like pill and film counts done by pain clinic providers and office-based buprenorphine providers. She hadn’t failed any of our bottle recalls.

As a treatment team, we discussed her situation at case staffing. (Twice a week, the nurses, counselors, and doctor meet to talk about the needs of newly admitted patients and the progress of other patients, among other things. We also discuss patient who are ready to advance in their treatment and get more take home doses, and those who aren’t managing their home doses as well as we’d like.)

Unfortunately, the patient in question had her picture published in the local paper along with an article describing her alleged criminal misdeeds. Both state and federal regulations say patients enrolled in opioid treatment programs aren’t allowed to receive take home doses if there is “recent criminal activity.” I suppose the officials think that if the patient is involved in criminal activity, there’s a risk the patient could sell take home medication on the street.

I understand this reasoning. And if the patient is accused of selling drugs, I don’t want to provide the patient with a drug they can sell.

But this regulation raises all sorts of questions. What constitutes criminal activity? Does driving to the treatment program without a license count as criminal activity? And what’s “recent”? Last week or last month would count to me, but what about a charge from two years ago that’s just come to trial?

And are we talking about criminal convictions only? Or is being arrested enough proof the person has been committing crimes? Sometimes criminal charges are dropped after more investigation.

What is the standard of proof that we need to use? Is an arrest alone enough to say the patient is engaging in criminal activity? Most patients, when confronted, insist that they have been set up by another person and that they don’t usually sell drugs, but were pressured to do so by a police informant who is trying to reduce their own legal woes.

I know this happens. Local police do use the people they’ve caught selling drugs to try to set up other people to do drug buys in order to charge them too. But if they allow themselves to participate in sales, that means they broke the law.

In my patient’s case, I was worried she had sold her methadone take homes. Eventually, she brought in a copy of paperwork she had been given by the police, and it appeared she’d been arrested for the sale of a handful of oxycodone pills.

But as her counselor said during case staffing, being charged isn’t the same as being convicted, and isn’t a person considered innocent until proven guilty? Another staff member said that applied to the criminal justice system, when a person may be denied their freedom, but in an opioid treatment program that standard of proof wouldn’t apply.

It’s a thorny issue. Patients must wait months to get take home doses, and after they’ve earned them, are extremely disappointed to have them revoked. I understand this; people need to plan their time, and dosing at the opioid treatment program claims time they could spend doing something else.

Some people will ask what’s the big deal? What’s a little more methadone on the street compared to the deadly fentanyl that’s covering the nation? It is a big deal to me, because methadone has (as Dr. Wartenburg says), “No sense of humor.” It’s easy to overdose and die with methadone because of its very long half-life. People take a little methadone, don’t feel much, take more, and by the time they feel a euphoria, they’ve taken a fatal dose.

It’s a dangerous drug to have on the street.

What if the patient were on buprenorphine instead of methadone? Since it is a considerably safer drug, would I still revoke take homes? In this situation, yes.

Opioid treatment programs want to keep our patients alive and to help them lead their best lives. And we also have an obligation to our communities to be good citizens. We don’t want to promote the black market use of any drug, and diverted buprenorphine, though safer than methadone, can still kill an opioid-naïve person or a child

When this patient was told that we were revoking levels, she blew up with rage. She felt she was being treated very unfairly, since no one had proven she’d done anything wrong. We tried to tell her this is a state regulation, but that didn’t help much. She said some choice words about our program, and they weren’t positive in nature.

After a few days, she’d cooled down some. She wasn’t happy, but she has dosed with us daily because she had no other choices.

Now she’s been at take home level one for over a month, dosing with us on site every day except Sunday. She wants her take home level back and I’m not willing to approve any more take home doses yet.

Some of the staff thought that was too harsh, and that she ought to be given a second chance. Other staff members agreed with me that it was too early for more take homes. What had changed, after all? She still didn’t see anything wrong with her behavior and blamed other people for her criminal charges.

I do listen to staff’s thoughts and opinions, but in the end the decision is mine. I need a good understanding of regulations, mixed in with common sense and compassion – for both the patient and our community. These are difficult decisions.

 

29 responses to this post.

  1. Posted by Who cares on January 26, 2020 at 5:03 pm

    Bottom line is she could be innocent and you have decided to take action against her anyway Instead of waiting to see if she is found guilty because you think addiction is a moral issue not a disease that needs replacement medication. You always say how you defend patients but your no different than all the other people who think their shit don’t stink , fact is that you think all addicts can never be trusted , no one should be messed with and treated the way clinics treat methadone patients, I get there are federal laws but you people take it a lot further by holding medication hostage and threatening to kick them out or hold the medication until you act right , I know someone who lost their take homes because the dosing nurse didn’t like a question that was asked and the tone of the person because the power was out and they said no take homes today and this person said at the last clinic she was at they hand wrote on the labels and this nurse never said anything and next week no take homes again for 30 days , sorry you will lose your job because you have to wait in our long lines that are long because 5 windows are never open at same time because who cares if a addict complains , I could go on with stories but you know most of them , addicts are treated less than human . Do you really think just because one person might sell a drug that everyone should suffer and be forced to stand in line and beg for a life saving medication? It’s a life sentence with no parole and if you get take homes you still live in fear that any time someone like you thinks they shouldn’t have them even though they did nothing wrong technically and that you know best . You are 100% wrong . You do know that innocent people die in prison and are sitting there now ? Some Cops are morons and hold grudges and lie , I know this for a fact . It’s time to close all clinics , get government out of treatment and let doctors treat each patient individually and if some people sell it oh well the government let it happen with opiates for 20 years on a scale that could never be reached with methadone, just so you know addicts do not seek out methadone to get high . 99%of people on methadone need to take it and do .

    Reply

    • I just told my fiancé last night that every time I write a blog post about take home doses, someone writes in, wanting to make me responsible for all the failings of the whole system. Today I got this comment….

      Reply

    • Posted by Brooke on January 27, 2020 at 4:41 pm

      How extremely ridiculous for you to attack Dr. Burson. She is on our side (“our” being individuals such as myself who are on MAT). I am not a patient at Dr. Burson’s clinic, but I have little doubt that she is doing what she feels is best for this patient. I also feel fairly certain that my current doctor would do the exact same thing. I thank God for the many professionals that looked out for my best interest when I wasn’t able to. Part of treatment is accountability. Furthermore your ranting to Dr. Burson about how evil clinics are is seriously misdirected. Her clinic is operating under the same federal guidelines as the others. She has many more rules to follow than us (the patients). The fact that you think closing all the clinics is the answer speaks to how clueless you are about the lives being saved as a result of said clinics. No one is denying that “bad” clinics exist, but there are “bad” private practices too….should we shut them all down? And do you really think the medical directors, such as Dr. Burson, control the lines?? Come on now….that’s an administrative issue….but hey, let’s lash out at this one doctor for every bad thing that has ever happened at a clinic….ridiculous. I think its worth noting that I have been a patient at 4 different clinics over the course of the past 12 years. I quickly was able to learn when each clinic was the busiest and when was a good time to go. I also always have tried to allow ample time, especially for counseling and drug screens. Most everyone that I have ever heard complaining about being late for work could have solved their own problem by getting to the clinic earlier. I’s sorry that you are so angry, I’m sorry that your “friend” was treated unfairly by a nurse, I’m sorry that you feel failed by law enforcement, and I’m really sorry that you are unable to see the value in OTP’s, but many of us do. Lastly, it’s worth noting that I have had the pleasure of hearing Dr. Burson speak multiple times. I don’t recall ever meeting a medical professional that was more on our side or that spends more hours advocating for us (the patients). So THANK YOU, Dr. Burson, for fighting the good fight and for your transparency about the difficult decisions you have to make every day. I wish we had more like you and Dr. Wartenburg.

      Reply

    • Posted by Daniel Brian on April 20, 2020 at 9:02 am

      The problem is addicts by nature have little control when it comes to their addiction, and are likely to lie if it would maintain the status quo. I speak from experience, because I’m likely to be punished in some way, or adjusted?, I have little motivation to be honest. It’s a fight between your addiction and your logic, and I’m sorry to say logic does win as often as you’d hope.

      Reply

      • Posted by Mark Wulff on April 21, 2020 at 1:42 am

        There is good reason for that Daniel.

        Addiction doesn’t happen in the prefrontal cortex, which is the area responsible for discerning the difference between right and wrong.

        Research has proven that addiction actually bypasses the prefrontal cortex’s right/wrong decision-making abilities, and the midbrain, which is the primitive brain that is responsible for keeping us alive (survival) is where addiction resides primarily.

        Unfortunately, after a person has been using opioids for a few months or longer, whether prescribed under the care of a doctor or not, a person’s brain can not only become dependent upon opioids, but it can also link “survival itself” to the opioid drugs.

        When a person’s midbrain links survival to the drug and their prefrontal cortex’s ability to think about consequences and care about consequences is not a part of the process, a drug addict’s behaviors are more easily understood.

      • Posted by Mark Wulff on April 22, 2020 at 2:29 pm

        This will validate my comment:

        Dr. Russell Surasky, FAAN, ABAM, ABPM, is a triple board certified neurologist.

        He is the only physician in the U.S. with this combination of credentials.

        He serves as the chief physician and consultant to multiple addiction centers on Long Island.
        His private practice, Recovery Revolution, is located in Great Neck, New York. Additionally Dr. Surasky is a national speaker on the topic of opiate and alcohol addiction.

  2. Posted by Obsteve on January 26, 2020 at 6:32 pm

    A thorny problem indeed. In my state, we don’t have to suspend TH’s for arrests. We suspend them for pos UDS for unprescribed substances confirmed on LC|MS/MS because it’s so ubiquitous that I’ve let “that ship sail”. It gives us the opportunity to intervene w more structure & hopefully improve the situation while enforcing some degree of accountability. I realize that may or may not be of much value, however. I also suspend TH’s for urine substitution. Even though we do observed UDS, we still occas see specimens w MTD & no metabolite which ups the ante for possible diversion. As you say, methadone has no sense of humor and the possibility that I am being party to diversion is very troublesome to me. It’s a tough problem. On one hand I don’t want to created hardships but on the other, I want to treat pts and not just be a methadone dispensing center. It’s difficult to walk the fine line between Harm Reduction and mandated or valid (in my mind) rules. I’m occas blasted on social media for my stance but most of the ‘blastees’ have never been in the position of an OTP Med Director with responsibility for several hundred lives

    Reply

  3. Posted by Charles Erickson on January 26, 2020 at 7:09 pm

    It is two issues to me: the arrest as well as the behavior. She cussed you out, she didn’t accept responsibility for her actions. She only came back because she had no choice. I would say no more take-homes until there are some changes in her attitude. And if her attitude never changes, guess what?

    Reply

  4. Posted by william taylor on January 26, 2020 at 10:52 pm

    If she sold oxycodone for cash, as alleged, she has no business receiving methadone takehomes. You could sweeten things by offering to reinstate her take homes if charges are dropped or she is found not guilty. I know a lot of people are pretty casual about sharing pills, with or without money exchange, but we expect better from long term OTP patients receiving methadone take homes.

    Reply

  5. I see your dilemma and your decision is no doubt based on your intuition which has developed over many years.
    Your hands are also tied because you have laws to obey no matter your personal feelings about a patient.
    I say this without knowing this young lady personally, and I also understand that doctors have been ‘burned’ by their patients in the past which can make it difficult to trust in future, but every now and again showing a bit of faith in someone can give them the self esteem and self dignity they so badly need to recover and create a new life.
    I had been dosing on Suboxone for 18 months when the head pharmacist asked me to come work for him transporting and handling every ‘juicy’ drug going, methadone, suboxone, all the drugs needed for palliative care.
    He took a risk and it was absolutely instrumental in my recovery.
    The fact he showed such great faith and trust in me made me feel like a worthwhile human being and there was absolutely no way on earth I would have violated that trust and I certainly had no shortage of opportunities.
    But yes, such a risk can backfire.

    Reply

  6. Posted by John on January 27, 2020 at 11:19 am

    One is innocent until proven guilty, ‘even’ an addict!
    When you deny an addict, or whoever, this very basic right then you are discriminating, and I’m sure you would have a problem when taken to court. Even with the best intentions it’s wrong to take people’s basic rights.
    Cause how far can you go with that? Where does it stop?
    The law is pretty clear in this, so there’s no room for error.

    Reply

    • Did you even read my blog post?
      I don’t think methadone take home doses are a “basic right.”

      Reply

      • Posted by John on January 28, 2020 at 6:34 pm

        Of course I meant the right to be held innocent until proven guilty, is that so hard to see?
        In the United States (and in most countries), a person is considered innocent until proven guilty. The 14th amendment to the US Constitution guarantees to every person, aliens included, “equal protection under the law.”

        This “equal protection” ‘even’ includes addicts 😉

  7. Posted by John on January 28, 2020 at 6:55 pm

    It’s also one of the basic human rights. Article 11.
    And we don’t want to be messing with people’s human rights either, do we?
    Junkies or not.

    Reply

    • Posted by John on January 28, 2020 at 7:44 pm

      I just found out that institutions are allowed to have their own set of rules when it comes to sanctions, and that in some cases a mere allegation of a crime can be enough to evoke them.
      Sorry for my ignorance.

      Reply

  8. Posted by John Hanley on February 5, 2020 at 8:43 pm

    Just because she sells drugs doesn’t mean she isn’t in full compliance with methadone treatment in every other way.
    I think maybe this situation has been taken to the extreme for no real reason.

    Reply

  9. Posted by Shawn Hudson, LCMHC, LCASA on February 11, 2020 at 12:03 pm

    I am a counselor at an OTP and have a client who didn’t call in to our automated system one day and therefore missed a scheduled call-back. The regulations ask for OTPs to “maintain a diversion control program” but are woefully non-specific on what that means. Our company policy is to revoke take-home privileges if a client misses a callback. On the other hand, this client has been stable and participatory for five years. We recently dropped her to daily dosing, which I know for a fact puts an incredible burden on someone who is already poor and has a car that smokes when she comes in.

    As a client advocate, I want a better way to deal w/ issues such as this one. This client hasn’t committed a crime; they’re not testing non-therapeutically – they are however being punished the same as if they were.

    My second issue is that my clinic puts the burden of enforcing these policies on the counselors. 42 CFR 8.12 specifically reads “medical and admin staff of the OTP” are responsible “for carrying out the Diversion Control Plan.” This buries my rapport w/ the client. It creates a power dynamic in which clients begin to come to me asking, “When can I get my take-homes back?” This kind of power-dynamic isn’t conducive to counseling – it creates a mistrust, a client who will tell me what I want to hear for fear that things will be used against them.

    LSS, we need better regulations. This is a very punitive model, and that doesn’t really jive w/ what we know about treating addictions. Punishment can be called “accountability” all you want, but it is punishment when take-homes are stripped from a 5-years in recovery mother w/ a clunker of a car that barely gets where she needs to get.

    Reply

    • You Have raised such good issues!!
      On the one hand, we don’t want to make life harder for patients who are doing well in recovery but struggling with financial realities. On the other hand, we – arguably – need a way to assess patient compliance and prevent diversion.
      The bottle recalls are only partly for patient safety. Safety is the issue we think about as workers at OTPs, but there is a larger issue; we need to be good citizens of our communities. Part of that is to have some method of making sure our patients don’t give or sell part of their medication to other people. As you know, methadone is a powerful and potentially deadly medication when taken illicitly. OTPs fight against stigma already, and programs with no or little diversion control can get bad reputations in their communities if one person diverts methadone and someone in the community dies.
      the vast majority of patients take their medication as prescribed, but due to the actions of a few, have to endure the inconvenience of bottle recalls, by federal and (usually) state mandate.
      Then if someone fails a bottle recall, we need to enforce reduction of take home levels, or else why do bottle recalls at all?
      Even though we have to reduce take homes, we can use our judgment about how soon such a patient gets back their levels. First, we do our diligence and make sure the patient really is OK and can take medication as prescribed. Next, we need to figure out what went wrong with the bottle recall. Losing take homes is so traumatic that the patient and staff need to figure out how to avoid the situation in the future when take homes are returned.
      Then I feel decisions need to be decided at case staffing, with input from nurses and counselors, about the rate at which take homes are returned. That takes some of the pressure of you – you can advocate for your patient but the final decision is up to the medical director, hopefully with input from staff.
      I also acknowledge that some of my opinions are colored by experience with patients who did misuse their take homes, with disastrous consequences. And then the patient blames the OTP for being foolish enough to give take homes.

      Reply

      • Posted by Shawn Hudson, LCMHC, LCASA on February 11, 2020 at 5:21 pm

        It’s a really tough issue that I wish had more federal or state leadership for a layered approach – until then, we’ll all do the best we can, and I’ll continue to be the advocate role. A lesson from grad school often echoes in my head: “We’re not investigators.” Part of counseling is to be able to believe in the clients, even when they don’t believe in themselves or when they’re being dishonest and then later reviewing with them how that dishonesty may have hurt their long-term goals. In that regard, I see the need to consequence. On the other, it’s really hard to be an advocate and also the heavy hand.

  10. Posted by Alisha on April 14, 2020 at 6:44 pm

    I am a level 4 on methadone I go two days a week and get 5 take homes. I’ve never failed a drug test or nothing but for some reason I resent lay failed one supposedly for meth. How long will I loose my privileges and will I have to start from the bottom again. I’m so upset I haven’t used meth and don’t understand how I failed a test.

    Reply

    • Talk to your doctor about this. Sometimes there are false positive tests for amphetamines from over-the-counter medications. You might be able to ask your clinic to do a secondary testing to determine if it is a false positive.

      Reply

  11. Posted by Christophe Boiny on May 7, 2020 at 8:16 pm

    I’ve been on methadone since 1999 on and off and yes it is a God sent for me it was not till I came to the USA the hole idea was made ALOT more complicated and more of a pain for the person taken it. I never felt methadone was any different than any other drug my GP or family Dr RX not till I came from Spain to NY I sow how unfair, inhumane,and made to feel like a active addict due to the way the US makes one jump through hoops to get away from having to get it every day and sow how Rong they have it in this country. Why should I have to go to groups or go every day not be able to see my sister how lives in an island far from any methadone and my mmtp would not give me a week so we all could be together so I had to buy it on the black market.The fact they make it so hard is the reason that it’s got any street value people don’t wont to be reminded day of there addiction because there still treated as such iv take methadone in Portugal Spain France uk and after about 3week of clean urine you got your take home weekly or monthly in France and uk your own Dr will write RX and u get it at the pharmacy and it’s just so much more fair it’s gets better results and leaves the patient really feel there not active but in the US it’s almost like it’s held over your head for everything because of money it should be our choice if we won’t to go to weekly meetings ECT this is again money they use our plate and make money out of our misfortune of having this disease just like pain is treated with methadone but they don’t have to go jump through hoops to get their methadone and that’s wrong ensure I think the doctor that took away the ladies methadone should have waited to see if she was guilty because there’s always going to be drugs on the street no matter what will never stop trying and that’s just how it is but if you make it like it’s any other medical problem maybe they people will start feeling normal because they would be treated normal

    Reply

  12. I have been working as a contract physician at an OTP for just under a year. The knottiest problem for me has been this issue of bottle recalls, because it can be punitive and remind our patients of the power differential. As Shawn says above, this does not foster a therapeutic relationship. At the same time, the concerns about diversion and misuse are real with life-threatening consequences.

    So, wanting to look at in a way that balances both perspectives, I started thinking of it as any other diagnostic test that can have false positives and false negatives, with a failed bottle recall a “positive” test for diversion or misuse and the passed bottle recall a “negative” test for diversion.

    Some of the people who miss the call, probably really did miss the call. They are the false positives. Those who come in and pass all the bottle recall requirements, but have somehow managed to misuse or divert in reality but were not caught, are the false negatives.

    My sense is that there are probably many more false positives than there are false negatives, so the bottle recalls as currently handled are likely more sensitive than specific. While that may seem like a success, I think we do have to look at the harms done by that loss of specificity. Patients feel as if they have been treated unfairly, their lives are turned upside down, and they feel as if all their work has been overturned in a day. The feedback I have heard is how discouraging it is after much effort and hard work.

    In the TIP 63 there is a reference to call backs as allowing patients to return with their bottles within one or two days. This was the first time I had heard that their might be the leeway of two days instead of just 24 hours. If patients are told that they may come in within 48 hours with a bottle recall, how would that change the specificity and the sensitivity? Would there be fewer missed phone calls because the calls could be done twice? If so, the false positives would go down and specificity would go up.

    However, if this would allow more diverters and misusers to game the system, then the false negatives would go up and the sensitivity would go down.

    Would this change make the patients feel that this system is more fair?

    Those of you who are more experienced than me, please let me know how your thoughts on how this might work, or not.

    Reply

    • Posted by Mark Wulff on May 27, 2020 at 5:45 am

      Hi rays4days,

      I am not an MD but someone who has been through ORT.

      If I am reading your post correctly, I think the best reply is in the words and experience of Dr Faried Banimahd – a practicing Addiction Medicine doctor in Santa Ana, CA.

      If you go to the 15 minute mark of this you tube called ‘Forget everything you know about Opioid Addiction Treatment’ he discusses how he deals with patients who return a dirty urine test.

      I hope you find it helpful and would be interested in what you think.

      Reply

      • I think he is practicing evidence-based medicine; sounds like a good doctor. I agree with how he handles positive drug screens – it means the patient needs more care, does NOT mean it’s time to kick a patient out of treatment.
        The beginning of the video is a little slow, but still good.

    • I think you’ve described the provider’s dilemma beautifully. We are mandated to do bottle recalls, and I agree with that. It’s good medicine. But how do we act on the results, particularly if a patient we think is doing well fails a recall?
      I don’t have the answers. I’ve been accused of being unfair and treating some patients preferentially if I don’t adhere to black & white guidelines…but much of our work is in the shades of gray.
      I don’t know how 48 hours versus 24 hrs would change the sensitivity and specificity of the bottle recall results. the idea of bottle recall results having sensitivity and specificity is interesting.

      Reply

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

%d bloggers like this: