Misuse of COVID 19 Extra Take Home Doses?




Opioid overdose deaths in North Carolina have risen recently, coinciding with the COVID 19 pandemic. Some state officials wonder if this increase is related to the increase in the number of take-home doses given by the state’s opioid treatment programs to our patients.

My own experience convinces me this increase is NOT related to opioid treatment programs take homes. When the toxicology results are known, I believe we’ll see the overdoses were due to fentanyl and its analogues, found in the heroin that’s currently being sold. I also think benzodiazepines will be a major contributing factor, possibly due to use fueled by anxiety brought by the changes the COVID 19 pandemic has brought to us.

We’re now three months into our COVID 19 response, so our OTP has given extra take home doses during this time. I’ve been pleasantly surprised at how few problems we’ve had. Thankfully, we’ve had no overdoses due to extra take home doses, and no deaths. Around half of our patients are on buprenorphine, and we were a little more liberal with extra take homes for those patients, given its better safety profile compared to methadone.

But we also gave many extra take homes to methadone patients, with no fatal outcomes, and so far, no overdoses.

Out of our present patient population of around five hundred and seventy-five people, only about a dozen have had problems with their take home doses. Of course, that’s probably the tip of the iceberg, since I’ll never know about most cases of medication diversion or misuse. But still, that’s much better than I expected. Other OTP providers report similar experiences.

In those dozen patients, most of came to my attention when they returned early to dose on site with us. Most returned a day or two early, saying they had no idea what happened to the doses for those days.

Why did I expect more medication misuse than we had? I worried because one of the hallmarks of addiction is loss of control. I worried that especially for patients relatively new to treatment, we could be setting them up to fail, by giving them more doses than they were used to managing. However, we had to weigh that risk against the risk of spreading COVID 19 to patients if we had a lobby full of patients dosing daily.

I underestimated my patients. Recovery is about regaining control and learning to manage impulses to misuse medications. Most patients rose to the challenge and took the extra doses just like prescribed. These extra take homes helped keep patients from crowding at the opioid treatment program and gave them more freedom to dose at home and stay safe.

Repeatedly, patients have voiced appreciation to our staff for the extra take homes and the other safety precautions enacted at our opioid treatment program. I’ve had ten or twelve people tell me they appreciated that our opioid treatment program was able to act to quickly to issue extra take home doses. I tell all of them it wouldn’t be possible without cooperation from our governmental agencies. Our state opioid treatment authority (SOTA) held frequent teleconferences early on and throughout the last three months to answer questions and give advice for how best to help patients dosing at opioid treatment programs. Our state’s Department of Health and Human Services has been very supportive of actions necessary to allow patients more freedom to dose at home, where they are safer.

Curiously, some patients told me they expected our opioid treatment program might close during COVID and they would be” out of luck” regarding dosing on their medication. That hurt my feelings a little bit. I told them we are a medical facility and of course we would remain open. We have remained open for business as usual with no change in our hours through the past three months.

Of course, catastrophe can hit anywhere, but each OTP is required to have an emergency plan for continued care of patients to limit disruption of care. If, for example, our OTP disappears into a giant sinkhole, (This is a thing in North Wilkesboro. One Taco Bell was eaten by a sinkhole but that’s an oddity for another time.) we have plans to get our patients dosed at a nearby facility until we are open again.

Our county had an outbreak of COVID 19 at the local poultry plant. According to the newspapers, around one-fourth of the two or three thousand workers tested positive for COVID 19. Fortunately, many didn’t have symptoms, but others got plenty sick. Thankfully, by now most have recovered and are back at work. If we had not given extra take homes, we could have had a catastrophic COVID outbreak at our opioid treatment program.

We’re not out of the woods yet. In fact, in North Carolina, we are still in the first wave on infection. The total number of people with COVID infection has risen, of course, with the increased number of tests done. However, more critically, the number of patients hospitalized with COVID has risen to an all-time sustained high. Every day last week, we broke records for the number of hospitalized COVID patients. This is an important indication of the burden of serious COVID illness in the state.

We are all sick of COVID. I am sick of hearing about it, talking about it, thinking about it. I’m sick of wearing a stupid mask and I’m tired of wiping my keyboard, cell phone, and stethoscope over & over. My hands are chapped from washing and using hand sanitizer.

But now is not the time to stop taking precautions.  We can’t let up know, at least not in my area, with increasing cases. We need to continue all the common sense precautions like social distancing, mask wearing, hand washing, etc. And we must continue to give take home doses to patients so they can stay safer at home. As far as I know, there are no plans to revoke the exception that allowed the emergency take home doses.

At our opioid treatment program, we will continue to monitor patients as best we can. We will continue to balance the safer-at-home strategies behind the extra take home doses with safety concerns about medication misuse. We will keep a watchful eye, but I do not think these doses are behind the uptick in opioid overdose deaths. As I said above, once the toxicology reports are back, we’ll have more information.


5 responses to this post.

  1. Yes! I love this so much! We’ve had such a similar experience at our clinic as well. Thank you for this encouragement and hope. (From a sister OTP in NC.)


  2. Posted by Stephen Beck on June 25, 2020 at 7:57 pm

    I love reading your blog. I was wondering about the buprenorphine take homes. I give my patients monthly prescriptions and I rarely have any problems (that I know of). Most of my patients are responsible but if they relapse they sort of disappear.They don’t come back for more. I thought it’s very unlikely to od from subs even with benzos- I see psychiatrists giving patients benzos all the time with suboxone. Is your policy on suboxone take homes your policy, state policy, or federal policy? I am in private practice and I know the rules are different for you. I am in ny and am not a licensed methadone provider. Thanks,

    Stephen beck md


    • Thanks for reading.
      It’s my policy.
      It’s still possible to die from an overdose from combining buprenorphine and benzos. It’s much less likely to happen than with methadone, but still possible. But more importantly, prescribing guidelines clearly say benzodiazepines are discouraged in patients on buprenorphine. The prescribing guidelines for benzodiazepines say they shouldn’t be used for more than three months, with the exception of end-of-life care. Benzodiazepines have been proven to make PTSD worse, and complicate ordinary grief reactions.
      Just like opioids appear to make people more sensitive to pain when used long term, benzos make people more anxious when used long term, due to the body’s adaptations.


  3. Posted by Agustain Sullivan on April 5, 2021 at 1:44 pm

    What happens to a patient who misused a weeks worth what do you do to them?


    • Usually I like to talk to the patient, to get an idea what happened. We go back to daily dosing at the opioid treatment program until we can figure out the basis or trigger of the medication misuse.
      When the patient re-stabilizes, we like to gradually go back up on take homes and monitor the patient a little closer.


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