Patient Impairment

Ukrainian art from ETSY: Alex Gru

Patients on MOUD (medications for opioid use disorder) need to dose daily for stability unless they are on depot-release forms of such medications such as Sublocade. We encourage patients to dose daily around the same time whether it’s from a take home dose or at our facility. Patients taking consistent and sufficient doses have reduced rates of overdose death, improved mental and physical health, and better employment.

However, sometimes it’s not safe to dose a patient. This can be due to a medical crisis that must be resolved, or due to impairment from sedative medication. It’s relatively rare for patients to arrive at their opioid treatment program with impairment, but it does happen, and physicians and providers need to be prepared for how to handle these events.

Sedatives like benzodiazepine (Xanax, Valium, Klonopin, and the like), alcohol, and other sedatives do not mix well with opioids. Both opioids and sedatives affect the part of the brain that tells us to breathe when we are asleep. People can die from single large doses of opioids, and they can also die if they mix sedatives and opioids. They go to sleep, stop breathing, and die from lack of oxygen to the brain, heart, and other important organs. This can happen quickly, as with a potent dose of fentanyl, or it can take much longer, perhaps hours, with longer-acting sedatives and opioids.

Before the patient gets to the unconscious stage, there’s often a period of impairment, when the patient doesn’t act or sound like their usual alert selves.

Impairment is defined, for these purposes, as a decline in mental function over baseline. Instead of being alert, the patient may be drowsy or inattentive. Instead of having clear speech with appropriate content, the patient may have slurred words, rambling or incoherent speech. There may be loss of control of motor function, leading to unsteady gait, stumbling, or even falling.

Impairment happens on a continuum; at one end a patient can be so impaired that he’s unconscious and needs to be revived with Narcan and CPR. At the other extreme, impairment might be so light that clinicians can’t detect it.

Part of our job at an OTP is to evaluate risks and benefits. If a patient is impaired, the risk of dosing her that day might outweigh the usual benefit of that dose.

Impairment must be evaluated by medical personnel. While receptionists, security guards or counselors can alert medical staff about a potential problem, the medical evaluation must be done by medical personnel.

This evaluation is done by the physicians or physician extenders unless there are none on site. In that case, an RN can gather data and evaluate for impairment. He or she can decide about the safety of dosing or may call the program physician for help with the decision. In our state of North Carolina, the Board of Nursing has said while RNs can work independently, LPNs cannot. LPNs can collect data but then must consult an RN, physician extender or physician to decide about the safety of dosing.

At our opioid treatment program, we take the patient to a private area. We don’t want to embarrass any patient in front of other people. I walk with my patient to my office, observing gait and balance. I try to be friendly and compassionate, realizing that the patient may be feeling fragile.

Once in my office I ask them how they are feeling, and about recent drug use or new medications. I listen to the content of what they tell me and to the delivery of their information. I listen for slurred speech or softening of consonants, speech content, and flow of conversation.

It’s helpful to get vital signs: temperature, blood pressure, heart rate, and respiratory rate. I add a pulse oximetry reading too. If these readings are abnormal, it can indicate a physical health problem as a cause of impairment. This can be serious and requires immediate medical investigation, usually at the local emergency department.

After talking to the patient, I turn to my computer and take my time typing data. While I do this, I watch the patient too. If she nods or falls asleep during conversational lulls, it’s probably not safe to dose her.

We have several tests we can ask the patient to do to test for motor impairment from sedatives. There’s the tandem gait test, which is what policemen do when they ask motorists to walk in a straight line. There’s the finger to nose test where the patient extends both arms, closes their eyes and brings the index finger to touch their nose.

My favorite is to ask my patient to stand on one foot for thirty seconds. It’s easy to do and I do it with them, so they won’t feel so put on the spot. Most people wobble a little but can keep their balance without touching down with the free foot or reaching for furniture.

We can also look for nystagmus of the eyes. This simple test, often misinterpreted by non-medical people, involves asking the patient to look to their extreme left or right. Then the examiner watches for slight bouncing of the eyes back and forth as the subject tries to keep their eyes in the extreme lateral position. Normal people can have one or two beats of nystagmus, but patients who have taken sedatives such as alcohol or benzodiazepines will have continued movement of their eyes.

Medical providers must remember that some medical crises can look like impairment from sedatives. A few months ago, a patient checked for impairment had a blood pressure of around 70/40 with an irregular heart rate into the 150’s, obviously in atrial fibrillation. We called the ambulance to take him to the hospital and he ultimately recovered.

Patients who are deemed to be impaired by medical providers often say they didn’t get any sleep the night before. This may be true, but lack of sleep shouldn’t cause slurred speech or problems with balance, unless they’ve been without sleep for days, in which case they probably need to go home and sleep before they get their next dose anyway.

It’s difficult for me to tell a patient they can’t be dosed that day. I know it will upset them and make them angry. I just keep trying to tell them that I’m refusing to dose them due to safety concerns, and that I’d rather they be angry with me but still alive.

Medical providers should expect a great deal of anger and should not take it personally.

We also try to get a urine sample for drug testing, thought that test won’t tell us if the patient is impaired. A urine drug screen only tells us if a given drug has been used in the recent past. Patients can be impaired with a negative drug and can be alert and fine to dose with a drug screen positive for multiple things.

Alcohol breath testing is the only drug where levels correlate with blood levels. Depending on the alcohol breath test, we can determine if the patient is under the influence of alcohol or not. The legal limit is .08, but patients on MOUD may be impaired at a much lower alcohol level, due to alcohol/drug interaction. We don’t dose patients if alcohol is detected.

After determining a patient to be too impaired to dose, I ask for help from the patient’s counselor. We must find a way to get them home without allowing the patient to drive. In big cities, public transportation takes care of this, but in our rural community, everyone drives everywhere because there is no public transportation. This can be difficult.

Also, we want to get permission to call a friend or family member to stay with our patient to watch them. We want to educate this person to call 911 if the patient becomes unresponsive and can’t be wakened, and make sure they know how to use Narcan, while waiting for EMS.

Anytime a patient can’t be dosed due to impairment, the physician must meet with the patient the next day, or as soon as possible. Impairment might be a warning that the patient has so little control over drug use that an inpatient treatment setting is indicated, at least temporarily.

Above all, it’s important to encourage the patient and let them know we care about what happens to them. We remind them part of our job is to make treatment as safe as possible. More than that needs to wait until the patient is clear and not impaired.

As I said in the beginning of this blog, impairment events are rare. Most of our patients never have such an episode. But when we do have a patient with impairment, we must be ready to intervene with compassion and good judgment about what is in the patient’s best interest.

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28 responses to this post.

  1. Posted by Kevin Rogers on July 30, 2022 at 4:58 pm

    Thank you so much for your blog. I help run an OTP in Middle Georgia, and your blog is always full of helpful information.

    Reply

  2. Posted by Patrick on July 30, 2022 at 5:11 pm

    Unfortunately here in Texas we are not Blessed to have a dr at the clinic during the day and most clinics do not have RN’s on staff. Many times a well trained counselor can spot the above symptoms to the medical staff who then calls the dr and gets orders. The dr most of us have Barley show up to admit the client. We may have the dr a hour a week. I know the state regulations require more but us hard to enforce due to the lack of qualified physicians who are willing to come in( unfortunately we still have huge stigma here).

    Reply

  3. Posted by M. C. McClure, D.O. on July 30, 2022 at 5:43 pm

    Patrick, check the reimbursement. At the nearest OTP the rate for a physician is less than half what I get paid by our hospital system . I had checked 18 months ago when contemplating a change.

    Reply

  4. My father had been on methadone for 22 years when he dosed at his TN clinic for the last time in Jan ‘22. He had been admitted to the hospital and when I arrived he had been in the hospital for 9 days (and not medicated for that entire time, never did get his methadone before he passed away but that’s a whole different issue). We learned the morning of his admission he had driven to his clinic & made it all the way there & back (2.5 hrs round trip) before ultimately totaling his car as he tried to park in his driveway. He fell after exiting the car & a girl on her way to her bus stop saw him and called 911. He had liver failure, COPD and b-cell lymphoma. His legs/feet were so swollen they looked like tree stumps. He was incoherent & seemed like he’d slipped into dementia in just a few days. He had monthly take homes. His sister had been trying to set up medical transportation for his appts knowing he was in no shape to drive (my sister & I didn’t know until the hospital) but she was unaware of how the clinic worked or that if his driver did not arrive, (which is what happened) he would absolutely try to get himself to the clinic come hell or high water. I can’t believe the clinic dosed him in the condition he was in, barely able to walk and definitely unable to have a coherent conversation for the time it takes to stand at the counter and get 27 bottles made up. I can’t believe he made it to his driveway before wrecking, but am thankful he didn’t hurt anyone else. I can’t believe the hospital staff dropped the ball and the massive miscommunication caused him to likely die in hardcore withdrawal (all they gave him was oxygen and ativan, and morphine IN the oxygen which they said would help him breathe) even though we called as soon as he was admitted and many times til we arrived to notify them of his status on MMT, and spoke to the doctor who assured us he was getting his methadone, then the next day denied the conversation and said he was unable to medicate him because of the compromised liver and he didn’t “want to be accused of euthanasia” because the liver would hold onto his dose for “4-5 days” and “could overdose him” (he hadn’t dosed in 9 days at this point). He also said he didn’t know patients could take methadone and then drive 🤦‍♀️. If they’re not in a medical crisis, obviously we know MMT patients are perfectly capable of driving. But this doctor of medicine, in the middle of both the opiate and covid pandemic, was so ignorant of all things methadone that I’ve lost faith in the system completely, as it completely failed my father during his last two weeks of life. I wish all clinic employees were as compassionate and understanding as you, and I hope those that need to recognize the signs of a medical emergency (as well as other reasons to withhold a dose) read over your information and maybe save some lives in the future.

    Reply

  5. Posted by SlimJim on July 31, 2022 at 2:29 am

    My comment may be controversial, so you can decide whether to publish it. In Australia we are dosed in a pharmacy by pharmacists. They are responsible for checking for impairment but can’t do drug/alcohol tests as far as I know – it’s down to personal opinion.

    My whole heroin career was spent working in a job I would’ve lost if I were to break the law (even outide of work) so getting caught would’ve been catastrophic. Nobody ever suspected a thing for 7 years.

    Once I started suboxone I still went to dosing every day (in the beginning) as high as a kite. Never once was I challenged. In fact they loved me there.

    I found a way to take suboxone without taking it (won’t go into here) so they thought I was fully compliant but I didn’t dose for months. I only stayed for the times I ran out of H or wanted an overseas holiday.

    I feel like you’d need to be completely BLASTED for anyone to notice unless you had a crazy benzo addiction as well. Maybe not with all the tests ar your disposal, but I’ve learned that by looking at someone it’s hard to tell. Even moreso when they wear a suit and tie every day.

    So I guess, watch out for your patients that seem compliant too. Make sure they really are. My state doesn’t require urine tests and I don’t remember the last time I did one.

    Reply

    • Thanks for the info from down under.

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      • Posted by SlimJim on August 1, 2022 at 12:38 am

        Thank you for publishing my comment. I’d like to clarify one statement in it as on reflection it could be taken the wrong way.

        The comment is: “Once I started suboxone I still went to dosing every day (in the beginning) as high as a kite.”

        What I meant by this is that at the start of my treatment I kept using ‘H’ daily whilst also attending dosing appointments. Because of the ‘trick’ I learned I didn’t ever actually dose, but they thought I did.

        I am not proud of this – just pointing out that loopholes exist. I actually think that if they caught and “punished” me I may have left and either never gone back (or waited years to go back out of shame).

        Instead, about 6 months into this ridiculousness, a light bulb went off. I realised I was wasting my opportunity at sobriety. So, over the next month or so, with a few slip ups, I stabilised; I have been stable for many years now (apart from when I underwent surgery, the only opioid that has entered my body is suboxone).

        To be clear: The anaesthetist and surgeon were fully aware of my past and present and were very accommodating. They managed my pain medically using an individually tailored approach and were super cool about it. Not once did I feel stigmatised; I felt like a patient with a complexity that had to be considered (not unlike a diabetic etc.). They kept my Suboxone Doctor informed the whole time too.

        Anyhow, the main reason for my initial post was to say that IN MY EXPERIENCE visual patient inspections for impairment don’t tell you much unless the patient is completely out of it.

        This second post is me clarifying that I am not some loophole seeking drug monster. I was someone in a really difficult spot trying to figure out how to (at that time) keep using but ‘under control’. Once I realised that my plan was unrealistic AND that I had an opportunity to truly stop using, I did. I am ever so glad that I never got caught being a ‘cheat’ and that I found my sobriety all those years ago.

        Thanks for all your hard work, Dr Burson. It must be difficult being an author, managing a MAT Centre(?), running this blog, and having a life outside of it all as well. Just know you’re helping people worldwide.

        Cheers!

    • I betcha I know exactly how you accomplished taking not taking meds. I’ve actually stood in line before and witnessed some incredibly clever ways of diverting, pocketing or pretending to be complaint. One married couple told me that if one of them couldn’t afford the money order to dose, then whichever one went inside didn’t actually swallow the methadone. Some remarkable stash of deep inside throat situation. That way they’d open up and say “AHHH!” wave bye. Then go out their car where they passionately kiss their significant other while transferring about half of what’s inside their throat.
      Damnit I just knew if I’d been married I’d never have to go without

      Reply

  6. I have worked in the medical field and also have been in MAT for two decades. I read your blog so that I am reminded that there are still good doctors out there….because most of the doctors I encounter lately (at work and as a patient) seem to delight at adding to a addicts pain instead of rage against it. Just wanted you to know I appreciate all the things you do for your patients and your readers.

    Reply

    • Thank you, and I’m sorry for your negative experiences. Have you considered letting the director or your facility know about the physician’s behavior/attitude?

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  7. When I first started treatment I was an avid advocate at my clinic and in my community. I often wrote letters and complaints about stigma and mistreatment encountered by other patients and myself. The majority of the problems were encountered outside the clinic by healthcare staff. I finally stopped trying, i admit. I recently went to an appointment with a doctor I hadn’t seen in a few years. I have been his patient since he delivered my daughter 28years ago. Over the years he has done many surgeries, procedures, medications and countless visits. When he saw me this time he said “hey there! I know you! Give me a minute, I haven’t seen you in a while right? I am trying to remember what we have done together!” I tried not to be hurt, he has a lot of patients and I hadn’t seen him in a while!…….but then he breaks my heart……. He says “Oh yeah! Didn’t you have a problem with pain meds and get arrested a while ago?” …..yes, its been 20 years since that arrest or any other. 20 years! Ain’t it great that he remembered me?

    Reply

    • Ok flashback

      I’d been a dosing, paying methadone maintenance “client” for approximately 13 years when I had to schedule an appointment with the clinics specialist. Sitting across from his desk as he silently flipped through my medical file. He starts to comment on some aspect of my patient care. “Yes so I can see no new prescriptions were written for you Ms. Ms. Ms….”
      Clearly at a total loss for my name. He doesn’t simply ask for a reminder outta my mouth. He spins his chair around looks my birth name up by my unique methadone identification number. I’m waiting patiently since I decided not to interrupt. Why not make him work a bit for all the cash I had paid.
      “Majority Ruhl! Yeah I thought very familiar!”
      Ok maybe that’s cuz like for every single day for the last 13 long years. You’ve passed me waiting outside on the sidewalk as the building opens. Even on Christmas morning you may recall I was also present. Or perhaps it was the hours and hours of noticing me in the facilities waiting area when I’m forced to complete an activity, that I have no real interest in but am required to anyway and my bozo clinician can’t manage to make it to her job in a timely fashion. If no other time has sparked recognition in your brain. Don’t forget doctor. Your office door actually intersects the hallway where I end up in another line waiting to be dosed every twenty four hours, seven days a week. 13 years now. Last week you practically ran me down squeezing on by!”

      Reply

  8. OH! just one last thing! My career is in medical laboratory science. I have done a lot of reading about current drug screening methods etc. You may consider having saliva screening kits available for times when you need to evaluate a possibly impaired patients? For many drugs the saliva level is comparable to blood levels–which would give you a better idea if the patient is currently under the influence. It can be tested even when you aren’t there and results can be confirmed by a lab. Its not perfect–its expensive, its take more time etc. However, if you used it like you do your breathalyzer tests it might really help? Thank you again for all you do!

    Reply

  9. Posted by Sparky on August 11, 2022 at 2:36 pm

    Excellent post,I would venture to guess that impairment happens more in new patients also,

    Reply

  10. S, I’m really sorry. Not just for you. But your poor father. I totally understand being hard wired to access the daily dose or clinic no MATTER what else is occuring. After all, without your essential meds. You won’t be able to accomplish much else. That’s a scary thought in your mind. It was for me at least as I fought my way on foot sometimes during emergency weather alerts. No one in their right mind would go out into the storms I’ve been through. Plus remember. Your father wasn’t going to skip even when I was under the influence I’d feel so panicked I simply had to try. Actually I only showed up after a late night drinking with coworkers. But frankly I wasn’t fit to be dosed. I don’t know how I ever made it home. I was still relatively new. The same exact panic mode occured anytime transportation was threatening to interfere. I’m furious he wasn’t dosed one last time. Heartbreaking

    Reply

    • Thank you so much for the compassionate reply. I realize now I didn’t mention it in the post but I have been on MMT for 22 years as well and I definitely understand why he tried to get to the clinic. I wish I had known any of this was happening with his health and that his sister was managing his medical transportation because I knew she was ignorant of the fact that he could NOT miss his once a month methadone appointment, even if an uber or taxi needed called. After all these years I STILL have nightmares about missing the clinic (and I also obsessively check my voicemail in case I got a call back and my phone was dead or out of signal area) because if I miss that call back I will lose all 27 take homes in one swoop and my own clinic is an hour away and getting their daily would be difficult. I do wish I lived closer to the clinic but in WV we have a moratorium on methadone clinics so there are only a few in the whole state. I hate what happened to my Dad at the TN clinic that should have noticed something was amiss, but I hate more what happened to him in the MS hospital during the final 14 days of his life. I’m absolutely terrified of what happens if I find myself in the same position, in a hospital unable to really communicate being on methadone and my wishes to not be thrown into what equates to a medically induced withdrawal whether or not I’m terminal. I pray the stigma falls off of all of us quicker than it has so far or many more will suffer greatly due to physician ignorance and bias towards addicts both in and not yet in recovery. Love to you! I hope you have transportation now & never have to walk through bad whether to dose again.

      Reply

      • S, this was exactly the type of opportunity I had hoped to have on this blog. Maybe help other people. https://majorityruhl.wordpress.com/2022/06/12/consuming-to-live-living-to-consume-its-almost-time-to-battle/

      • One point that janaburson has made before , that if there’s ANY medical benefit that a patient will receive from being dosed than that’s pretty much reason enough! I had also wondered over the period of years why clinics and physicians in many circumstances seemed to always assume that NOT dosing a Methadone patient was somehow medically helpful (?) I don’t care if a person has violated administrative rules, tested positive for an illicit substance on various and different occasions then suddenly is required to answer for their indiscretions when told by their clinicians(usually) that they’re dose of methadone was going to be decreased or cut in half at some point.
        Unless I’ve stumbled in the clinic and tested positive for several substance over a three or four day period and it’s posing a risk, especially where driving back home is concerned. Pretty sure I’m displaying solid evidence of the behavioral mental health disorder that hopefully is clearly in my medical file that day! Decreasing one’s methadone feels far more like psychological warfare than it does ike legitimate evidence based treatment to me. Playing police is more A power move. How much faith in my sobriety would the doctor have knowing I’m merely complying with regulations not to abuse drugs out of fear instead of properly addressing my substance use problems(?) Methadone isn’t supposed to be used as a weapon or punishment. Plus I’ll personally testify that withdrawal is terrifying. It’s frightening and isolating. I don’t want my doctors unaware that my compliance should always be voluntary and mutual.

      • “ok majority, I’m afraid tomorrow morning if you’ve not been loyal to a fault to that treatment plan we sat down together and agreed you’d not have reason to stray. Well I’m afraid we’re going to withhold the one medication that you’re completely dependent on until you can see the error of your ways! Remember that’s your signature down at the bottom there. Also we’re not going to let you attend your senior prom, raise your allowance or extend the weekend dating curfew. This should teach you how to better manage your disease ok?”

  11. Oddly, as I’m reading your reply. Just for a moment I thought I was confused. I thought I’d written exactly the fears you had described and maybe I wrote it many months earlier or something!! (Early morning)
    I seriously could have provided nearly exactly the same fears. Dosing with methadone for 17 years. Just the implied threat of not having access does affect the patients mentality. And don’t get me started on loosing bottles over administrative bullshit. Once I forgot to update my phone number after I just moved. Lost fourteen. That’s two weeks man. I was only required to attend twice a month and simply cuz I did not have my current information on file..BAM. of course it’s ALWAYS something with take homes. I FINALLY wised up and stopped even requesting regular bottles. Constantly applying myself only to be greatly inconvenienced and distraught at some point. Not worth it. I knew I was more likely to at least predictable make it over the clinic every twenty four hours. I’d much rather be able to plan routine inconveniences than try accommodate for being revoked with no warning later on at..some point

    Reply

  12. And just how free are you to pursue your life when you’re constantly scared you’ll miss
    One phone call
    One voicemail

    Reply

  13. I support Methadone maintenance for the legitimate purposes. What I absolutely don’t understand is the legislation behind it

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  14. Outsiders REALLY can’t understand the intense demand that a person in treatment has upon them. I would sometimes wake up drenched in sweat, scared I had overslept and missed dosing. Even before my eye lids could open. My mind would be in panic mode! I’d jump up throw off covers and race to the kitchen to look at the reliable old fashioned clock(digital can always lead a person astray)

    Reply

  15. Ps I’ll be glad to send your father’s former hospital or his clinic that they failed him

    Reply

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