The Future of COVID Take Home Doses

This may be a controversial blog post. I’ve been mulling over the ideas I’m presenting in this blog for many weeks and have changed my mind several times. So don’t get too upset with what you read, because I may have changed my mind again by the time you read it.

The events of this past year have given us experiences and information, and it seems prudent to learn what we can from them.

In the spring of last year, state and federal authorities moved quickly to allow patients enrolled in opioid treatment programs to receive more take homes doses than usual. They did this to reduce the risk of patients’ exposure to the COVID virus. Most opioid treatment programs were able to give many more take home doses of buprenorphine or methadone than ever before. This cut down the number of patients physically present at OTPs at any one time, thus creating more social distancing than ever before.

Now patients – and providers – are wondering what will happen after our country no longer has a high risk of COVID transmission in crowds. Will the previous regulations snap back into place? Will patients receiving extended take home doses now be asked to come more frequently and give up the convenience of extra take home doses?

In my state of North Carolina, as I understand it, once the state is no longer under a “state of emergency” declaration, the permission to give extra take homes to patients will no longer exist.

I’m not sure what state and federal authorities will advise, but I have some thoughts.

As I see it, we have two sets of questions. The first is what to do about patients presently receiving extra take homes. The second is deciding if information from events of the past year should cause us to change regulations about methadone take home doses.

At my opioid treatment program, we have about half our patients dosing of buprenorphine and half on methadone. Because of its better safety profile, buprenorphine patients already get take homes more quickly than methadone patients. So, my next paragraphs will be about patients being prescribed methadone at opioid treatment programs.

Let’s take the first question: what shall we do about patients who are getting extra take homes now? This has been an unusual time in history – I hope – and we have a cohort of patients who were suddenly given many more take homes than they were accustomed to getting.

Some patients had problems with those extra take homes. They came back to the opioid treatment program early, saying they didn’t know what had happened to the extra doses, or that the nurse hadn’t given them extra doses, or that some other person stole their medication. These problems almost always came to light within the first few months. Those patients were not ready – at that time – for extended take homes, though they may be able to do so in the future.

However, most patients with extra methadone take home doses did well. We’ve done bottle recalls (like pill counts done at pain management clinics) and most patients brought their bottles back in with the correct number of bottles untouched, with the appropriate amount of medication contained in them. This reassures us that these patients can take only one dose per day and are able to store it safely where it won’t be stolen or tampered with. Most of these patients have been reachable by their counselors for weekly in-person or telehealth meetings, showing further evidence of stability.

For patients who have proven their ability to manage their take home doses, it seems counterproductive to reduce the number of take- home doses again after the COVID emergency passes. Why would we want to do this? So long as patients have been making appropriate contact with their counselors at their programs and are doing well, I will advocate for them to stay at their advanced take homes. I might have to submit an exception to get permission for this from state and federal authorities, but that’s easy to do, and would seem a reasonable request.

Then comes the question of what to do with these patients if they have drug screens positive for illicit drugs. Should these patients move back to daily dosing? What if the only illicit drug they use is THC? Before the extra COVID take homes, our state said patients who remained positive for THC couldn’t advance past a level 1, which means they had to come every day but Sundays. In the past, I agreed with this policy. I reasoned that people using THC weren’t as stable as those not using it.

Now I have changed my mind.

Don’t misunderstand. I am no fan of marijuana. I think it can hold patients back in some insidious ways. It’s not harmless, as some people think, but neither is it a toxic substance, like alcohol is. Some day we may have beneficial medications derived from the marijuana plant, but at present, lighting the plant on fire to inhale the smoke isn’t a medically safe way to ingest those chemicals. We know marijuana use affects adolescent brains adversely, but even in adults, it can shave off IQ points, and may interfere with motivation to make life changes.

However, regular marijuana doesn’t cause the chaos that other illicit drugs cause.

 Since COVID, I’ve seen many patients, long-term smokers of marijuana, managing their additional take-home doses quite well. They appear as stable as non-smokers of THC. I don’t see that it would help anyone to revoke those take-home doses, and it may benefit some of these patients to be able to give even more take homes. At present I am more open to such ideas than I ever have been in the past.

Patients using alcohol and other sedatives are not getting extra take homes at the opioid treatment program where I work, due to the dangers of mixing methadone with sedatives. I have not changed my mind about that.

What about stimulant use? We’ve seen an uptick in methamphetamine use over the past several years, and some of those patients are getting extra take homes now. Some are not, depending on an assessment of each patient’s overall stability. I have not been consistent with decisions about take home doses for such patients, because stimulant-using patients can differ widely.

For example, one patient has tested positive for methamphetamines for about a year, but she has a job, a stable relationship, and no apparent clinical decline, at least thus far. But another patient tested positive for methamphetamines for two months. Since then, his family committed him once to a mental institution for a few days, for auditory hallucinations related to drug use. He’s lost twenty pounds in two months and is twitchy and easily distracted when I try to talk to him.

I was generous with take homes for the first patient and denied take homes to the second one. Of course, the second patient feels like this is unfair towards him. After the COVID take-home exceptions end, should both patients be moved back to daily dosing?

Let’s move on to the idea of changing existing take home regulations. There are eight criteria that patients ordinarily need to meet to get take home doses of medication. In an abbreviated form, these are:

  1. No ongoing drug or alcohol use
  2. Regular attendance
  3. No serious behavioral problems at the OTP
  4. No recent criminal activity
  5. Stable home environment
  6. Ability to store medication safely
  7. Benefits of take homes outweigh risks of diversion
  8. Time in treatment

I agree with all these requirements, except perhaps the last one, which I feel is the most restrictive. Federal and state authorities have firm regulations about how soon a patient, doing very well otherwise, can be granted take home doses, based only on how long that patient has been in treatment. New patients can receive up to one take home dose per week for the first three month, then if all is going well, can get three take home doses per week for the next three months, then four doses per week for three months, etc. At the one-year mark, even an extremely stable patient will need to come once per week for a year.

That’s a long time, and perhaps unduly restrictive for many patients.

Before readers criticize me for risking lives due to putting methadone at risk for diversion, let me explain that I do know how much harm methadone take homes can cause in the wrong hands. I can tell you horror stories about diverted methadone, but I won’t do that now.

But on the other side, more patients thrive with extra take- home doses, able to feel less stress about getting to their OTP in time to get dosed and get to work on time. They can spend more time with their families in the morning hours. That’s worth quite a lot.

If we decide to revisit our present methadone take home schedule regulations and ultimately relax them a bit, it will fall to treatment center staff and ultimately the medical director to decide if a given patient is stable enough for take homes. That means the medical director will need to know her patients well. This requires time at the opioid treatment program and involvement with the patients. That should already be happening, but I know that’s not always the case.

Here are a few of the warning signs we’ve seen that can indicate problems forming: coming in a day or two early to dose, even when the patient should already have take-home doses; being unable or unwilling to give urine drug screens; giving falsified urine drug screens; counselors being unable to reach the patient for telehealth counseling sessions; poor attendance or repeatedly coming at the last minute to dose; new mental health issues or new physical health issues, and unexplained change in appearance or affect.

Since the medical director is ultimately responsible for the consequences of methadone take-home doses, the medical director needs to be made aware of any warning signs seen in patients, aside from positive urine drug screens. The medical director needs to know the patients well, and have input from counselors, nursing, and even front office staff when making these important decisions. Therefore, time for case staffing, sometimes also called treatment team meetings, is so important.

At the OTP where I work, we usually have case staffing twice per week, and it includes medical and counseling staff. We make decisions about take home doses at these meetings. Sometimes we disagree, and that’s good. It means differing opinions are being voiced. Sometimes emotions run high, a reflection of the importance of our decisions to patients. It’s often a difficult process.

But because of the importance to patients, perhaps take-home regulations should be re-evaluated at national and state levels, in the light shed by our recent experiences with the extra COVID 19 take home doses.

16 responses to this post.

  1. Posted by Lisa Wheeler, MS Ed, PA-C on February 22, 2021 at 1:00 am

    AMEN!

    Reply

    • Posted by Patty on April 2, 2021 at 7:23 pm

      Is there any regulation that says that if the patient is on take home and uses benzodiazepines, do they have to be prescribed by a psychiatrist?

      Reply

      • Posted by npcz83 on April 2, 2021 at 10:36 pm

        There aren’t any regulations that specifically speak on it, so it’s really at the discretion of the clinic physicians. Some clinics may require the benzo to be prescribed by a psychiatrist but it can be from a primary care physician as well, as some patients have a very good rapport and long history with their PCP.

  2. Posted by Lori Regenstreif on February 22, 2021 at 1:25 am

    Hi,
    In Ontario, Canada, we developed a set of COVID carries guidelines last March and there has been some interim evaluation of outcomes. I would be happy to share what we created.

    Reply

  3. Posted by Robert Schafer on February 22, 2021 at 1:41 am

    As a licensened social worker (LMSW) in Arkansas and a former addict that got clean on methadone then detoxed myself twice successfully, in the ’80s and ’90s, I find your views on methadone dosing, take outs and regulations refreshing. As someone that had years of experience on methadone, on getting off methadone and now, as a social worker, plenty of experience as a social worker with addicts, I agree with most everything you say on this blog. I’ve seen and have gotten dosed at some very poor examples of methadone clinics and some very good clinics mostly in Little Rock, Longview, TX and Ft. Worth, TX, but also in 4 or 5 other states as a temporary client for only days or weeks when traveling. I have found that the respect and opportunity to participate in my treatment decisions affected my outcomes greatly. From what you write, you are a shining example of the right way to run a clinic! I wish your practice rationale was followed by more medical directors in methadone/buprenorphine clinics. Having experienced discrimination and poor treatment with some clinics, i’ve also been fortunate to have found one or two in the ’80s and ’90s that were more progressive like you are. I am greatful to no longer have the methadone ball and chain attached to me although I usually had weekly or bi-weekly takeouts back when that was possible. I’ve been to clinics that only allowed a max. dose of 40 mg. and ones that allowed 200 mg or much higher if you were a rapid metabolizer. Other clinics that would punatively cut your dose any time you had a dirty UA and others that increased your dose until you quit having dirty UAs.! There used to be such vast differences in the way clinics were run and doses determined, most without any regard to evidence-based practice. I don’t know how badly those clinics are run these days, but I hope with the push toward evidence-based practice that the bad old days for some of these clinics are gone. I know that respect and dignity of the client is still a mixed bag, with too many clinics not practicing those aspects. To me, that was a very critical component, along with some degree of input in my treatment options. Just wanted to thank you for modeling good practice among methadone clinics. I hope more practice as you seem to, but I lnow even at the best there are outliers that fail to practice both respect for the client and evidence-based practice. I do hope, as do you, for more liberalized take home doses as although I usually had weekly dosing I’ve also seen the negative impact of daily dosing that effectively prevented clients from holding a job due to daily dosing and long travel distances to their clinic. Ilook fofward to reading your blog for the insight into cjrrent practices in your field. It helps keep me abreast with current treatment and helps when looking for solutions with my clients! Thank you for your efforts towards improving your field of practice.
    Sincerely,
    Robert Schafer

    Reply

  4. Thanks for sharing this thoughtful piece. In Myanmar, my NGO (AHRN) facilitate about 4000 clients on MMT, the health authorities allowed fairly early on in the C19 pandemic increased – up to 14 days – MMT THD. This has been assessed as very successful, of the over 80% of our cohort on THD all of them experienced improved working conditions, increases social cohesion, and regarded this as a stabilizing factor. Only a view diversion incidents, although with the current political situation it is hard to tell if and to what extend MMT THD will continue post C19, but initial discussions showed willingness to continue.

    Reply

  5. Posted by Nicole Ross, MA, LCAS on February 22, 2021 at 11:03 am

    Dr. Burson, I love this! This is something that we have been pondering at length too and this COVID time has really been thought-provoking and eye opening for many of us. Thank you for sharing your thoughts here and opening the door for good coversations. I’m sharing this with my staff this morning!

    Reply

  6. Posted by twilit on February 22, 2021 at 3:27 pm

    Such a deeply thought out and considered practice. I agree with your points and most of all deeply respect how deeply you look into the situation and how best to make the most of what we can learn for it for patients benefit.

    I agree with you on marijuana – thought I would add there I’d a way currently used very commonly now with vaping that keeps it from being burnt and smoked. There’s quite a sophisticated array of products and many don’t have the dangers associated with vape cartridges – they simply vaporize the plant. That said I don’t think it’s a benefit to patients to rely on it long term – but as you said it can still allow people to live stable lives while using. In the state I live in, Florida, the clinic doesn’t even test for THC. One of the strange things about methadone regulations is how much they vary by state and how big an effect those variations have on patients lives. It’s not right that a patient in one state can be literally kicked out of treatment for the same behavior that’s not even considered with testing for in another place. We COULD HAVE all the data we need to see what is working by researching and making use of the comparisons of experiences and outcomes for patients in different states under wildly different rules. We should do this and use that information to put the best practices in place to support people in treatment not work against them.

    Reply

  7. Posted by Nathan Czerniak on February 22, 2021 at 3:27 pm

    I have been wanting to collect this very info from clinic directors around my state of Pennsylvania and, if it shows most patients responsibly took their extra COVID take homes, take that to the powers that be and try to convince them that we can safely extend the number of take homes, rather than someone like me, for example, in final phase getting 13 bottles having to go back to 6 bottles.

    Does this sound like something that could be successful? Or do you have any ideas that would be more successful? Because having to be tied to the clinic every week for people with jobs is very counterproductive. Someone with, say, 10 years of compliance should NOT have to go to their clinic every 7 days.

    Reply

  8. This is great. Happy to find another addiction blog on WordPress…im just starting mine. Feel free to follow me 💯💢💯
    https://samantha-waters.com/

    Reply

  9. Posted by Matsaveslives on February 24, 2021 at 6:48 am

    I’m a current patient on methadone. I currently have 4 years in recovery. I personally feel regulations need updated majorly! I hate that buprenorphine seems to be given so freely. Because of this there’s a street value on suboxone but you very rarely see liquid methadone on the streets even when seeking it out you will not find it. I have many friends who on bupe and all of them have a stash of extras they sell here and there when someone needs it. Methadone patients don’t do this because we can’t. I don’t think we need extra, but my point is that suboxone is very obviously diverted, and methadone is still more strictly regulated… You can’t abuse liquid methadone, however many will inject suboxone or snort it. I don’t think suboxone should be more strictly regulated but I believe they should look at how well most patients are doing on methadone and realize we can handle picking up our meds at a pharmacy. I guess its frustrating for me seeing my friends go to a suboxone doctor and get a whole month when they relapsed last week and I’ve been clean 100% for years and I’m still going to a clinic and all that 2 to 4 x a month. Its like we’re punished because suboxone didn’t work for us. I’m just curious tho really why does it seem that professionals always ignore that suboxone is more abused than methadone? Also these regulations perpetuate negative stigma associated with methadone even amongst pts. Ppl believe since suboxone is better or less dangerous because of it. I’ve heard So many times in my clinic how suboxone is safer and methadone is not good for pregnancy and patients will say well they.make u come everyday to make sure ur ok etc. So just something else to think about that the system is somewhat biased towards suboxone…

    Reply

  10. SooNer than later we will see methadone join mainstream medicine and people only going to counseling when needed and ext take homes when ready and community health centers doing along with CVS and walgreens. OTPs will be standard of care or we just watch overdose to kill our friends and family at a more remarkable rate. We need access to this and treatment and needed it yesterday. So all of you who are making profit don’t worry there’s more than a profit for you all to get your money and all if you want power trips remember you can boss around the people that you have in your clinics but just with the list of the rest of us not die.

    Reply

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