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The Car Dosing Cart

Nurse Sylvia behind the Car Dose Cart















At our opioid treatment program, we’ve been dosing some patients in their cars, either because the patients have fragile health and we’re trying to keep them away from crowds, or because they have COVID infections, possible COVID infections, or have been exposed to someone with COVID infection.

In order to give more protection to our nurses while they deliver a dose to a patient in a car, one of our excellent employees, Jerry, created the Car Dosing Cart (Patent is pending.) as pictured above

As you can see, it’s made from a wheeled cart. Plexiglass sheets were attached to the front and sides of the cart, with a cut-out for a window just large enough to push a dose of methadone or buprenorphine toward the patient seated in the car. Just below the top level, there’s a second shelf where the patient can push their lock box onto the cart so that it can be filled with take home doses. The rest of the car is enclosed in plastic which is taped on three sides to the cart.

It’s genius.

The nurses feel protected while using it, and there’s enough surface area for everything they need. It’s wheeled, so it can be pushed easily out of the pharmacy, out our front door and to the curb outside. It’s the next best thing to a take-out window.

Per protocol, nurses never go by themselves to the parking lot to administer a dose. For security, another staff member accompanies him or her, both to discourage theft, and to provide a second set of eyes to vouch that the dose was given to the patient for whom it was intended. All of this is documented in the patient’s chart.

The idea for the Car Dosing Cart was born after a case staffing, when the staff asked me to allow car dosing for all our patients who work at a local poultry plant, after they had a large outbreak of COVID 19 infections.

I balked at this idea, feeling there were too many patients involved. I also worried the nurses would be more exposed to patients when dosing them in their cars. But as the number of cases at the poultry plant soared, I had second thoughts. I asked other doctors working at opioid treatment programs for advice. They recommended car dosing all poultry plant employees, who could unintentionally spread COVID infection. I backtracked my initial decision and we started to car dose many more patients.

That’s when Jerry invented the Car Dosing Cart.

Thus far, the cart is working very well. It’s stocked with everything the nurses might need, like cups, tissues, gloves, etc.

We will car dose patients for as long as the state allows, for as long as we have consistently elevated number of new cases of COVID 19 in our county and state.

I’m so grateful for the courage, compassion, and creativity of all our staff at our opioid treatment program.


Cartoon style illustration of a sign or symbol that says ban, stop coronoavirus or COVID-19 being stamp out and prohibited on isolated white background.




I’ve had a rough week.

I’ve been so careful. I’ve worn an N95 mask every day at work, removing it only briefly when I need to eat or drink. I’ve wiped my office multiple times per day with cleaning wipes, not forgetting my cell phone, computer keyboard or door handles.

I haven’t gone anywhere, except once to the pharmacy for my blood pressure pills, and even then I used their drive- through. And I made several short trips for groceries, wearing my mask while inside.

That’s why I was so surprised when, shortly after going to bed one night early last week, I got a shaking chill more suitable to being on an icy Tibetan mountaintop rather than my snug bed.

It grew worse. I ached in every part of my body. I was too cold to get out of bed for more covers but eventually had to do so. While I was up, I went to the bathroom and ratted around trying to find a thermometer.

When I found one, my temp was 98.8. I laughed at myself. I am such a silly goose, imagining I’m ill when I’m not. But my symptoms continued with my chills and when I checked again a half hour later, the thermometer read 101.2.

My beloved fiancé was asleep in the bed next to me. I had to get some distance between us and moved to the upstairs guest room. I didn’t want to make him sick. I took some Tylenol and tried to get some sleep. But then the dry cough started, and later, some diarrhea.

As I lie in bed, feeling like I was wearing a jumpsuit of muscle aches, I thought, “This is it. I’ve got The COVID.” (That’s the way we say it here, “The COVID,” not COVID 19 or Coronavirus.)

I didn’t sleep any that night, and the next morning told my fiancé to stay away, I was sick. I sent emails to work supervisors telling them of my condition and that I could not come to work. My fiancé arranged COVID testing for the next day.

My fever jumped between 100.4 and 101.9 even with generous amounts of Tylenol and Advil.

But then the diarrhea got worse. My sweetie said, “Maybe you just have one of those 24 hour stomach flus.” I pooh-poohed him. I felt too bad for this to be a mere GI virus. Besides, the fever was lasting much too long for that and I had no nausea.

Then, about 48 hours after it started, I felt better. My fever started to come down, though the diarrhea grew ferocious. The cough never developed into anything. I took my COVID test and two days later, got the results: NEGATIVE

All I suffered from was  probably viral enteritis and a vivid imagination.

It’s easy to get carried away with any illness in the middle of the COVID 19 pandemic, especially if it’s accompanied by fever. At one point, I wrote my last will and testament. I laugh about it now, but I felt so bad, and my pessimism seemed to rise with my fever.

At least I got a chance to see what wonderful people are in my life.  At work, I was told not to worry about anything, and arrangements were made for another physician to do admissions for our OTP. I still handled the minor things by phone. My co-workers sent me encouraging emails and prayed for my wellness. My fiancé took great care of me – at a distance of course – and friends and family brought food and sent funny emails.

Right now, I feel very, very grateful. I’m now in my usual state of good health, which is wonderful. I’ll be able to get back to work this week, at a job I enjoy, with people I love. I have fantastic friends and family, and my life partner, the love of my life, didn’t get sick because of me.

And I don’t have The COVID.

Update on COVID 19 at an Opioid Treatment Program




This pandemic hasn’t struck all places in the U.S. at the same time. Back when I was watching the horrors faced by New York City, I felt relief things weren’t like that in my rural community, but also worried we would eventually face something similar.

Now COVID 19 has come to town. For now, it hasn’t been as awful as I saw on the news in the cities, but we’ve had many more people testing positive.

Part of this could be that testing has really ramped up. Early in the pandemic, not much testing was being done, either because there weren’t many test kits or because local health department officials were following the CDC’s relatively restrictive testing guidelines. As I’ve posted before, we had a few patients hospitalized with respiratory failure who weren’t tested for COVID 19. I read their hospital records. They were tested for influenza and when those tests were negative, were told to assume that they had COVID and isolate for two weeks.

After people who work at the meat processing plant in our county tested positive for COVID, suddenly there’s been extensive testing for people who work there.

According to our local paper, the total number of COVID 19 cases remained at four known cases from April 5 until April 21. During the last weeks of April, the number of people testing positive rose slowly, then more quickly. As of today, with businesses re-opening under Phase 1, we have two hundred and sixty-one people in our county testing positive for COVID 19, out of a population of around sixty-eight thousand people.

Our opioid treatment program had to decide how to respond to this new information. Last week, the staff petitioned me dose all our patients who work at this facility in their cars. They wanted potentially infected people to be kept out of our facility. I balked, thinking the risks of car dosing those people outweighed the benefits. Now, after talking to some other doctors about the situation, I’ve changed my mind. We intend to car dose all patients who work in high-risk environments with multiple people testing positive, like the meat packing plant.

It’s not as bad as it sounds. Many of these patients have been stable for months or years and were already on advanced take home levels. Under the blanket exception allowed by federal and state authorities, a significant minority of the only come once per month. Others need to come daily, with most patients coming to the OTP a few times per week.

Our facility got some N95 masks from our parent company. I’ve worn mine for the last three weeks. It still works, though the elastic is getting frayed. We also got a few hundred paper masks that are somewhat helpful. We’ve asked patients to wear masks or other face coverings while at our opioid treatment program. Nearly all patients have supported our request, but a few grumbled about it. We won’t refuse to dose patients who don’t wear masks, but we encourage them to do so. I still bring my Breath Buddy respirator mask to work with me each day, in case I need to see a patient sick with acute COVID 19 symptoms.

Every few hours, there’s an announcement over our intercom to ask for help wiping down our waiting room. Any staff member who isn’t busy with patients comes to pitch in and wipe down chairs, keypads, door handles, bathrooms, etc, with antibacterial liquid meant to murder Coronavirus. It doesn’t take long with many people helping. It’s become part of the daily routine. Patients have voiced repeated appreciation for our actions, which makes me feel good.

I’ve been dealing with patients who appear to have mismanaged their extra take home doses. Around nine patients have had some problem with their take homes. Some patients returned early, when they should still have take home doses, and can’t explain what happened. Some have had bottles missing, lost, spilled, or damaged in some fashion. No one has died from extra take homes, and so far as I know, there have been no close calls with overdoses among our patients from extra take homes.

In most cases, I can’t be sure what happened. The situations came to light either when patients returned early, or when they had drug screens that didn’t contain the medication we are prescribing. In one case, the patient said she was doing fine with weekly take homes, but when she suddenly got 27 take homes under the blanket exception for our COVID 19 situation, she was unable to take them as prescribed. She took extra medication compulsively, even though it didn’t make her feel any different. She ran out of medication a week early. I was happy she told us what happened, and we dropped her back to weekly take homes. Thankfully, she was on buprenorphine and not methadone.

I’m sure these nine cases are the tip of an iceberg. Most patients likely won’t tell us if they’ve mismanaged their extra take home doses.

Patients are at risk both ways: if we decrease the number of take home doses, their risk of contracting COVID 19 increases; however, extra take home doses (especially methadone) can de-stabilize patients accustomed to more accountability with their dosing. We try our best to balance the risks.

We’re still doing intakes for patients, both to methadone and buprenorphine. These patients must dose daily during their induction onto medication, as do patients who aren’t doing well, who have continued alcohol or benzodiazepines drug use.

I feel uneasy about the Phase 1 opening of businesses this week, because we are only now seeing the number of cases increase. I know this could be from accelerated testing recently, and that we must live with some degree of risk.

No matter what happens, our OTP plans to continue to be open for admissions and established patients. We want out patients to know we aren’t closing, that we will be here to provide care for our patients.

We plan to keep doing all we can to keep our patients healthy, both from opioid use disorder and from COVID 19.

COVID19 and Medication-assisted Treatment of Opioid Use Disorder

Pretty But Dangerous




As the COVID19 debacle drags on, treatment for patients with opioid use disorder continues to evolve in some ways.

Last week, I saw my office-based patients via telemedicine rather than in my private office. It went well, for the most part, but out of the fifteen people I saw, two had such bad connections that I could barely communicate. The picture blurred, the voice distorted, and I felt frustrated.

I think patients with poor connectivity may not have the bandwidth to do telemedicine. I don’t know if this is a problem that’s easily fixable. I may have to resort to phone calls only in these cases. In fact, phone calls would have been much better than the telemedicine on these two patients.

However, I also gained some insights into my patients’ lives. I got a small peek into their everyday lives, in some cases. I saw how they dress while at home and saw a few details about their home in the background of the picture. Several seems much more relaxed than when I see them in my office. Others were more tense, struggling with the technology.

Overall, patients appreciated the convenience of telemedicine and appreciated not having to expose themselves to the outside world, with possible Coronavirus floating around. I know I did.

At the opioid treatment program where I work, I came to the facility on my usual days, but things have been slow. I didn’t have any patients wanting to do intake this week and saw only a handful of patients each day for other reasons, mostly dose adjustments.

Patients have not had to wait to dose at all, except for Monday. That day we had many people with extra take homes coming back to dose with us and to get more take homes. Our nurse manager is fine-tuning the schedule, to even out the number of people dosing on site as much as possible. I told him he has a very hard job, trying to juggle nearly 600 patients so that everyone has the least amount of wait time. Other than Monday, we had negligible wait times.

We renewed our blanket exception requests for extra take homes with the state, and I think this is something we will renew every two weeks until the COVID19 mess is over with.

Our rural county, population of a little over 68,000 people, has two confirmed COVID cases. However, few tests have been done. According to an article in our local paper, our Health Department has done 28 tests, with 24 negatives and four pending. This number didn’t count any testing done at the local hospital, though, where the two positive tests were done.

I’ve read the hospital records of a few of our OTP patients who went to the hospital over the last two weeks with acute respiratory failure, cough and fever. It appears they were given COVID precautions but were not tested. They were told to quarantine, though. We’ve dosed those patients in their cars and given take homes to keep them away from the OTP. Initially we decided we would do this only for confirmed cases, but that idea appears unworkable, both because not many patients are being tested, and because of the delay in results of a week or more. We must act as if those patients have COVID 19.

I find the reluctance to test patients with symptoms to be odd.

I’ve heard that local testing policies are based on CDC recommendations: people with symptoms who have traveled to areas with active COVID infections are being tested, and people who have been in close contact with known COVID patients are being tested. Perhaps reluctance to test any patient with symptoms is based on a lack of test kits. I don’t know, but I’m repeatedly struck by this reluctance to test. Even nurses with symptoms have not been tested for COVID.

We continue to wear what masks we have – paper disposable ones that we re-use day after day, or hand-sewn cloth masks that can be laundered frequently. We have sanitizing wipes and take turns wiping down doorknobs, chairs, reception counters, etc. We practice social distancing among staff and patients. We use our homemade hand sanitizers and wash our hands with soap and water too.

Patients can have either in-person sessions, sitting at least six feet from their counselors, or have phone sessions. Counselors are trying to call patients with extended take home doses weekly. That can be a problem, given than many of our patients have the disposable phones and they change numbers frequently. If they can’t be reached, counselors document that they tried to call, and we try to get a working phone number the next time the patient comes to dose on site.

We are doing all we know to do to keep our patients and ourselves safe.

We have weekly teleconferences for program directors and medical directors of OTPs. There’s been much debate around telemedicine capabilities. Under federal regulations, physicians (or other providers) can’t admit methadone patients to an OTP unless they have an onsite admission process. However, OTPs can admit patients to buprenorphine via telemedicine. I think regulators feel buprenorphine is much safer, and office-based providers even do home inductions, so an on-site interaction isn’t needed. But with methadone, which is more dangerous to start, particularly in the first two weeks, the provider needs to see the patient in person, face-to-face. That’s the way the federal regulation reads at present.

There’s a petition floating around OTP circles, asking SAMHSA to re-consider their block on methadone admissions via telemedicine. If this petition succeeds in changing federal regulations, prescribers still must obey their state laws on this topic.

I am not in favor of telemedicine admissions to methadone. I’m aware this isn’t a popular opinion at present, and I understand the benefit of making admission to OTPs as easy as possible and eliminating barriers.

However, I’ve been working at OTPs for nineteen years, and I’ve had methadone patients die during induction under the best of circumstances. Methadone is a different breed of cat than buprenorphine, and even though induction overdose deaths are still rare, they are devastating when they do happen. I think I could miss subtle signs of sedative intoxication via telehealth, which could make a big difference in my decision to start treatment. It may be difficult to discern subtle withdrawal signs. If there’s another medical professional on site to do the exam, that could fill in some information gaps, but will this professional be an RN? It would be (in my state) outside the scope of practice for an LPN, and certainly could not be done by a counselor.

We talked about the prohibition of telehealth admissions for methadone on our OTP phone call today, and most providers voiced the opinion that it would be perfectly safe to do this, so I’m clearly in the minority with my opinion. Fortunately for now, I’m able to work on site at my OTP, so it’s not an issue.

On our phone call, there were some interesting ideas about what OTPs are doing around the country. One state apparently asked agencies to agree to share staff. That is, if one OTP has all their nurses out sick and unable to work, a nurse or two could be brought in from another OTP that has all of its staff able to work. That would be great, and such a policy would be in the best interest for all patients… but would require a great deal of cooperation between organizations that are accustomed to competition.

We talked about financial hardship policies; in other words, what to do about patients who, suddenly out of work, can’t pay for treatment. Some programs said they would work with such patients and try to help them make a budget or agree to a financial contract. Some programs agreed to allow patients to charge part of their daily fee, to be paid back later. Our OTP is allowing patients to charge for take home doses, hoping they will be able to pay again at some point. It sounds as if other programs are doing similar.

Unfortunately, state funding for patients unable to pay, under the SORs grant, was set to run out of money in early May, at the worst possible time for our patients who’ve just been laid off from work due to COVID 19 shutdowns. It now appears that some extra money may be found, but there’s much uncertainty now. I pray it works out, because we have many patients who are doing well in treatment, at risk for relapse if their grant for treatment runs out.


Twined leather rug

My most recent rug

Coping in the Days of COVID19

My homemade masks

When I rolled into our opioid treatment program parking lot at 7 this morning, there was only one vehicle in the patient parking lot. When I got inside, the waiting room was empty.

It’s quiet at the opioid treatment program these days. We’ve already implemented accelerated take homes for most patients, which drastically reduced traffic through our lobby. Patients new to treatment on methadone are still coming daily, as are unstable patients, but many patients got anywhere from six to twenty-seven take homes, under the blanket exceptions we submitted to our state officials.

Our nurses wear protective gear and dose potentially infected patients in their cars, if they aren’t stable enough for take home doses. Our patients with severe immunosuppression or other conditions that place them at higher risk of death if they contract COVID19 are also dosed in their cars.

We have another group of patients, mostly older people with COPD, whom we dose in an expedited fashion, moving them to the front of the line to shorten their time of exposure to other people. That created resentment when we had wait times, but now that there’s practically no wait time (except for the last fifteen minutes of the day, because that’s always the busiest time), everyone gets dosed in an expedited way.

We are open for business as usual. I haven’t seen as many people seeking admission as usual, but there have been a handful this week. In accordance with SAMHSA (Substance Abuse and Mental Health Services Administration) and state guidelines for treatment in the age of COVID19, I’ve been trying to get new patients to agree to start on buprenorphine so that they can get take homes sooner. However, not all patients do well on buprenorphine, and some can’t tolerate it. A few patients, miserable on buprenorphine, wanted to switch to methadone this last week, and we did this. As good as buprenorphine products are when they work, they don’t work for everyone.

I’ve seen a handful of patients each day for various reasons but mainly for dose adjustments. I’ve helped the staff by wiping down doorknobs, computers, dosing counters and the like, taking turns with other staff.  I’ve had extra time to look at patients on our state’s prescription monitoring program. So far, no unpleasant surprises.

We made a bunch of decisions about take home doses very quickly, to try to prevent COVID19 spread in our community. I pray I’ve had the right decisions, and patients will be able to take their extra doses as prescribed.

Counselors are doing phone sessions to provide support for patients but are available to do in- person sessions as well, at six feet apart. We cancelled group sessions until the age of the COVID passes. I hate that, but we want everyone to be safe.

So, for now, at the opioid treatment program, I’m going to work each day. The time may come when I will need to telecommute, and that will be fine, too. I’m ready.

I see patients in my private office on Fridays, and most are people for whom I prescribe buprenorphine products. Tomorrow, instead of driving to my office, an hour away from my home, we are using telemedicine. Regular readers will remember I’m a bit of a dunce with technology, but my fiancé is a whiz. He has a computer program set up and showed me how to use it. I think I will like it. The sound and picture look great, and I’m hopeful it will work very well.

We’ve called all my patients to explain what they need to do to see me from the comfort of their home, via the computer. Most are younger than me and computer savvy.

We have one older gentleman, well over seventy, who doesn’t have the capability of getting on a computer. I completely understand. I plan to talk to him on the phone, see how he’s doing, and then send in his electronic prescription. Given his situation and that he’s been stable in his recovery for twelve years, I feel it’s reasonable to do phone sessions until COVID19 goes away.

The advantage to me is that I could go to work in my pajamas. I won’t, of course. But I could.

My home life hasn’t changed much. When I’m not working, there’s no place I’d rather be than home, so I’m an expert at “sheltering in place.” Since my fiancé, my dogs, and the cat are there with me, I’m happy. I have my hobbies: writing, weaving rugs, reading, and carving our backyard quartz into interesting shapes. We have several weeks of food at home, so we are more fortunate than most.

However, routine decisions can have big consequences. Over the weekend, I needed some little thing for cooking, and my fiancé was going to Lowes, so I asked him to stop by Walmart, which is nearby. While he was gone, I thought, “What have I done? There will be crowds at Walmart, and he could get infected and get sick.” I felt so guilty and worried. He laughed it off when he got home, but little decisions like that matter now.

To combat the feelings of unease, last weekend I did one of the most hopeful things I could think of: I planted a garden. I realize I might be pushing the season, and that we may get another frost, but I felt like I wanted to do something optimistic. I planted tomato seeds in little compartments, to grow into seedlings that I’ll plant later. Then I planted green and yellow squash, cucumbers, carrots, lettuce, and spinach into the ground. I do this every year, but usually not until mid-April.

Last weekend, I made cloth surgical masks for our nursing staff. I took tightly woven cotton cloth, cut it up and constructed the masks, then ran them through the high-temperature cycle with Clorox. Of course, being 100% cotton, they came out wrinkly as hell. I ironed them flat with a steam iron, perhaps further killing the little viral/bacterial bugs. I reasoned that most masks aren’t sterile, outside the operating room, so these may be of some help.  I’m not very fast at it, though. It took me three hours to make seven masks. Staff were very appreciative.

Twelve-step recovery continues to flourish. Though some groups have ceased to hold meetings for now, online meetings have opened. On a recent Narcotics Anonymous meeting held on Zoom, over forty recovering people shared their experience, strength and hope in the traditional manner. Participants shared one at a time, sharing their fears and challenges, and how they were coping with difficulties without using drugs to mask their fears. There was a real sense of comradery, every bit as real as in face-to-face meetings.

People who want to attend these meetings should contact Narcotics Anonymous or Alcoholics Anonymous in their area, to get times and meeting codes. These meetings can be excellent support during these difficult times.

Even though the evening news is a horror show, I plan to carry on with life as best I can, like everyone else. I’ll do the best I can to protect me and the people I love from COVID19. In my free time, I’ll continue making the arts & crafts that relax me. I’m going to try my best to have as normal a life as possible, and enjoy every moment.

Update: Coronavirus at Opioid Treatment Programs



It’s only Wednesday but it feels like the week should be over already.

Our opioid treatment program is making sure that our patients know that as a healthcare facility, we will be open, and that we have enough medication to treat everyone as usual. Federal officials have stated that no shortages of methadone or buprenorphine products are expected. I hoped we have relieved patients’ worries with these reassurances. They will not be abandoned.

But treatment may look a little different.

On Monday, our OTP instituted social distancing by placing chairs in our lobby at least six feet apart. Someone in administration (not me) decided to let only ten people into our building at a time, while the rest stood in a line outside, standing at least six feet apart from each other. It wasn’t terribly cold that day, but some patients were uncomfortable and not prepared to wait in cold weather. Thankfully our forecast is for warmer temperatures this week. There was a little grumbling from a few patients about waiting outside in the cold. But more patients thanked us for taking precautions to reduce their risk.

Over the weekend, I decided, with input from our nurse manager, that I would no longer ask patients dosing with buprenorphine to wait in our lobby until dissolved. Since I recently found out that most other North Carolina OTPs already allow patients to place their buprenorphine dose beneath their tongue and leave before the dissolving process is complete, I thought it was reasonable to suspend observed dissolving of buprenorphine for now, until the risk of Coronavirus in gone.

Ten days ago, I sent in a bunch of exceptions for medically fragile patients whom I felt were stable enough for advancement of levels, so at least that issue was already resolved. Some medically fragile patients aren’t safe for extra take home doses, so we decided that when they come to the opioid treatment program, they get expedited dosing. This means they go to a separate area to wait, away from other patients, to reduce risk of virus transmission.

I worked a normal day on Monday, and did only one admission, which was a little slow. But I was able to do a few yearly physicals on established patients, and saw more patients for follow ups, dose adjustments, and the like. Between each patient I washed my hands with soap and water (we were nearly out of hand sanitizer) and wiped down the patient’s seat, my desktop, and door handles with Sani-wipes. In my few spare moments I paced the lobby and wiped down every doorknob I could find. I chatted with patients and all of them seemed to be calm, handling the situation well.

We had case staffing as usual, after closing at our usual time. We sat at least six feet from each other and talked again about plans to do some blanket exceptions for take homes for patients meeting certain stability criteria.

Over the weekend, SAMHSA issued statements to guide decisions about advancing take home doses, particularly for patients who are diagnosed with COVID, to help us make sure they get their usual medication despite being put into isolation either at the hospital or at home. They made it clear that previous barriers would be suspended to allow for continued care.

Then yesterday, our state SOTA also helped, both by issuing statements and holding a conference call. It was a very well-attended conference call; I think nearly all our state’s OTPs had representatives on that call. Requests for exceptions for extra take homes were discussed, as was the option of doing counseling sessions on the phone or some sort of teleconferencing. Our OTP’s previous decision to suspend group counseling to reduce risk of viral transmission was supported by our state officials, which made me feel better.

Later yesterday, I was on a conference call with the medical director of our company, and he crafted some blanket exceptions which were submitted to our state’s SOTA today and were approved. Starting tomorrow, we have permission to implement plans to give reasonably stable patients extra take home doses. These will have to be phased in over the next week, and the number of extra doses varies, depending on how long the patient has been in treatment and overall stability.

We are giving a lot of extra doses to patients. Even though I think it’s the right thing to do in order to reduce our patients’ risk of contracting COVID19, it makes me nervous. I don’t want to lose a patient from a methadone overdose from inappropriate consumption these take home doses, either.

So far, there are no positive COVID tests in our county. This isn’t because we have all healthy citizens, but rather because patients aren’t being tested unless they have traveled to a high-risk area or have known exposure to someone with a confirmed COVID diagnosis. People with only cough or intermittent fever aren’t being tested. They are being told they don’t meet criteria for testing. You can read more about this nationwide dilemma here:

Medical professionals in this area don’t have enough test kits yet. We won’t know how many infections we have until symptomatic people can get tested. And what do we tell people with symptoms but no test? Should they isolate themselves? For how long? Word has it that our county is expecting to get test kits soon, so this situation will (hopefully) resolve soon.

We ran out of hand sanitizer yesterday. But this was no problem. This being Wilkes County, famous for home brew and moonshine, my Program Director decided to make her own. As it turns out, there are simple recipes on the internet to make hand sanitizer. All you need is some aloe vera gel and rubbing alcohol, or ethanol, and mix them together in a certain ratio to form hand sanitizer. She poured her concoction into empty sanitizer containers and they worked well. The alcohol content is adequate (more than adequate by the smell) to do the job. One problem solved, at least.

She’s inspired me. I like to do crafts, so I think I will make some fabric face masks over the weekend.

We will get through this. For however long this contagion lasts, we will take all the precautions we can, and strive to be examples of courage and calm in the face of difficult uncertainties.

Above all else, we must reassure patients that they won’t be abandoned.

Coronavirus and Opioid Treatment Programs





I intended to blog this week about the new mobile opioid treatment program proposed rules, but I’m saving that for later. This week I’m writing about dealing with the Coronavirus at the OTP, and dealing with the fear of the Coronavirus.

Let me preface this blog post by saying I’m not an infectious disease expert, and that I don’t have specific knowledge about the coronavirus outbreak. But I’ve been thinking about ways to protect patients and staff at our opioid treatment program, talking to other Addiction Medicine specialists in our state, and reading advisories for OTPs issued by state and federal agencies.

Those agencies have given us some guidelines and ideas of how to continue to treat our patients as safely and seamlessly as possible, even if some patients and staff contract Coronavirus. That’s the main goal of this blog post: to reassure patients that their OTPs are reading recommendations from SAMHSA (Substance Abuse and Mental Health Services Administration) and SOTAs (State Opioid Treatment Authority). We want to do the best job possible, and we won’t abandon our patients.

Let’s not panic. All of us are scared, unsure what the next days and weeks will bring. But panic often brings more problems than the actual situation. Just look at the unfortunate effect from private citizens who hoarded medical face masks. Now medical personnel are having trouble obtaining face masks that are essential for their jobs. Let’s also take a deep breath and think about how much toilet paper we really need for the foreseeable future, before panic-buying the shelves bare. The plunging stock market is worrisome, but maybe it’s also an opportunity. If I had extra money lying around, I’d invest it now. Again, I have no financial expertise except “buy low, sell high.” And this is as low as the stock market has been for some time.

Our OTP will remain open. We do not plan to close our facility. Personnel who become ill will be asked to stay at home, and we may be short-staffed on some days, but we will be open. Patients do not need to panic about getting their medication. Authorities say they do not expect any shortages of either methadone or buprenorphine products over the coming months, which should be a relief to all patients.

Here are some of the highlights from CSAT (Center for Substance Abuse Treatment), a division of SAMHSA:

-Extra take home doses can be given, after seeking exceptions through the extranet exception website, for patients with confirmed COVID19 infections who are quarantined. This can also be available for people in quarantine because they’ve been exposed to people with COVID infection. These diagnoses and exposures need to be verified by the patient’s healthcare provider, of course.  OTP providers can ask for up to 14 days of take homes, where appropriate.

-Teleconferencing or even just telephones can be used for counseling if face-to-face meetings aren’t feasible, if the technology used meets patient confidentiality standards.

-If a patient is ordered to quarantine at home, authorities are allowing OTPs to deliver medications, or allow a designee to pick up medication and take it to the patient, if chain of custody documentation is done properly. Of course, proof of quarantine will be required.

-CSAT recommends good infection control practices: handwashing, wipe surfaces frequently, ask patients with cough or fever to use masks if available, and use social distancing Though there’s no safe distance to prevent COVID transmission, six feet is recommended. That may be difficult in small counseling offices, but we can get creative.

Though I’m the only physician or medical provider at our OTP, I can work from home if I’m diagnosed with Coronavirus, or exposed to it. These days, secure video conferencing technology is advanced enough that I should be able to carry on with patient care. And thankfully, even though I’m clumsy with technology, I live with my fiancé who is fluent with computers and their programs.

The most medically fragile OTP patients may be able to get more take homes than usual, as decided by the medical director of each OTP. The benefits and risks must be weighed carefully, and the medical director can go through SAMHSA’s exception website to ask permission to give these patients more take homes than usually allowed.

At case staffing a few days ago, we talked about the importance of good hand washing, use of hand sanitizers, and wiping down surfaces frequently that are touched by many people. This would include doors, handles, counters, and the like. To set a good example (and because it was really slow, and I had no patients waiting to see me) I wiped down lobby chairs with sanitizing wipes. I gave them a good scrub and asked our employees to remember to wipe down offices and doorknobs frequently. Am I going to prevent Coronavirus from darkening our doorway? Maybe not, but I felt better as I pictured the Sani-wipes murdering Coronavirus on our patient chairs.

Our OTP has discussed how to change dosing procedures for patients with COVID infections, patients exposed to COVID infections, and for suspected cases of COVID. We want to keep those patients away from the rest of the patients and limit their contact with staff, while still providing needed care. These procedures may cause delays and I hope patients will be patient.

We’ll keep an ear to the news in our area, to stay informed about confirmed cases. I think we will see a spike in the number of COVID19 cases once test kits are available. That will be alarming, but it’s expected, since we haven’t been able to diagnose suspected cases over the last few weeks, due to lack of testing equipment at our local hospital and Health Department.

My biggest message is this: we will not abandon our patients. We will keep working to provide the best care possible under difficult circumstances.

As this pandemic unfolds, we will constantly evaluate the risks and benefits of how we are providing care at our OTP. We’ll look to see what’s working and what’s not working. We may change our minds about procedures as time goes on and we get more information. I think the coming week will give us more data about the extent and locations of COVID infections.

We’ll stay flexible, and we will hope our patients will be patient as we all get through this thing together.

News Briefs





I just got my copy of the most recent issue of the Journal of Addiction Medicine, my favorite medical journal. It was filled with interesting articles. Here are highlights from a few articles.

One study found that vitamin D supplementation improved cognitive functions and mental health status of patients in methadone maintenance treatment in Iran.

The incidence of opioid use disorder is rising in Iran, with opium as the most common drug, followed by opium ashes, illicit methadone, heroin and morphine. This article, by Ghaderi, et al., said about 1.2 million Iranians have opioid use disorder, giving a prevalence about three times what is found worldwide. About half a million people in Iran are now in treatment with methadone and buprenorphine.

The author of the study wanted to see if vitamin D supplementation improved cognitive function in patients in methadone maintenance treatment. Several past studies showed higher incidence of cognitive deficits in patients undergoing treatment for opioid use disorder, and other studies have shown lower Vitamin D levels in patients on methadone maintenance programs compared to controls not on methadone treatment.  Also, previous studies have shown that low vitamin D levels are associated with impaired mental function and mental health disorders.

The authors of this present study have done past studies that demonstrated vitamin D administration helped patients with major depression, improving depressive symptoms.

However, the authors acknowledge that a meta-analysis study by Gowda et al., 2015, plus two other meta-analyses, showed no significant reduction in depression scoring after vitamin D administration.

This study was done to add to the literature around vitamin D supplementation in people susceptible to having lower vitamin D levels, who were also diagnosed with opioid use disorder and in treatment with methadone maintenance.

This was a randomized, double-blinded, placebo-controlled study, so the design was good. However, not many patients participated in this trial. Out of the screening of 425 prospective trial subjects, only 90 were interested in participating in the study. Those ninety subjects were reduced to 70 after twenty didn’t meet inclusion criteria.

These 70 people were randomized to either placebo or vitamin D treatment. Oral supplements were the only form of vitamin D that was counted; for obvious reasons, it would be quite difficult to quantify the amount of vitamin D that each subject got from sun exposure. The test subjects were compliant with taking their dose of either vitamin D or placebo, and the group of subjects on vitamin D had significantly higher vitamin D levels after twenty-four weeks of supplementation compared to subjects in the placebo group.

The vitamin D group had improved mental function. Specifically, this group performed better on a test known as the Iowa Gambling Test, which is a test designed to simulate real-life decision- making abilities. They also had better verbal fluency, logic and memory scoring. Results of the study showed improved depression scoring but no effect on anxiety test scoring.

How intriguing this is! I advise my patients with poor nutritional habits to take a one a day multivitamin, which should have all the vitamin D most people require. Vitamin D is one of the stored vitamins (along with vitamins A, E and K) so it is possible to get too much of a good thing, but routine supplemental doses are helpful for many people.

The study was interesting, but hardly conclusive. The study was relatively small, and most patients opted out of participation, for some reason. A larger study would give results more statistical power.

For now, I’ll keep recommending daily multivitamins in patients with unhealthy dietary habits, which includes vitamin D.


Another article was a study of job satisfaction of medical providers at methadone maintenance programs in China. Knowing next to nothing about methadone maintenance in China, I didn’t realize China has had methadone maintenance treatment available for the past twenty years. To be sure, that’s not long, compared to many other nations, but I was pleased to read of their programs.

The article, by Chen et al., said there were nearly eight hundred treatment programs in China as of the end of 2015, treating over 167,000 patients.

At Chinese methadone maintenance programs, doctors see these patients and do physical exams, some counseling, and prescribe methadone. Those patients (called clients in this article) take their prescriptions to pharmacists, and nurses then administer the medication and observe their dosing.

Some of the Chinese opioid treatment programs offer other services, like testing for sexually transmitted diseases, social support counseling, or employment skills training.

This present study was done in order to explore factors relating to job satisfaction among these medical professionals. Previous studies found challenges to medical personnel working at opioid treatment programs including worry about their safety, low pay, large workload, and negative attitudes toward methadone maintenance treatment in general in China.

Ten methadone maintenance programs were included in this study, and they were all located in urban areas. The average number of patients treated at the programs was 114, so these were relatively small programs compared to what we usually see in the U.S. There were only seven to fifteen employees total at these programs, and the study was only open to medical staff members, meaning doctors, nurses, or pharmacists. Only seventy-six subjects were included in this study.

The subjects were asked questions about their demographics and work history, about their job satisfaction, about perceived institutional support, and about perceived stigma due to working with drug users.

The results showed that low job satisfaction was associated with working at a program that was associated with the Centers for Disease Control, high perceived stigma due to working with drug users, prior experience outside of infectious disease areas, and perceived low institutional support.

Several of the findings make sense, but why was program association with the CDC negatively correlated with job satisfaction? As it turns out, physicians and nurses who work at these programs are largely contract employees. These workers tend to have lower pay and benefits and are asked to work more on weekends and holidays. They also may perceive less job security.

As for the other findings, the article says that in China there’s a belief that heroin users congregate at methadone maintenance programs, making them dangerous places. Some workers felt their personal security was at risk and that they may be exposed to infectious diseases by working with this patient population.

I think some medical workers in U.S. programs feel the same way. I don’t know of any statistics showing that this is the case; exposure to infectious diseases can happen in any medical field. I don’t feel my personal security is at risk where I work, but I can understand if some workers feel this way.

An Evening of Enlightenment





I had the great pleasure of going to a training held by Dr. Alan Wartenberg last week, at the Revida Recovery facility in in Johnson City, Tennessee.

His topic was opioid use disorder and its treatment with medication, but the talk was so much more than that. He covered all of that competently and easily, but his talk was funny, poignant, and encouraging. He reminded me of why I love my job.

I loved every minute of his talk, and I felt uplifted and enthusiastic afterward. I went with my long-term fiancé and chatted excitedly for about half of the long drive home. My fiancé, who is an addiction counseling professional specially trained as a Motivational Interviewing Network of Trainers also found the experience to be of great value.

The whole meeting was about four hours, with the first part being educational, then ended with a long question and answer session.

Dr Wartenberg has been around while. He lived through the ridiculous phase of twenty years ago when physicians practically threw opioids at patients for any type of pain. He used intravenous buprenorphine for patients in detox units as far back as 1992, which is kind of amazing.

I particularly absorbed his message about the importance of keeping all patients in treatment, barring specific dangerous situations.

It’s been a very long time, thankfully, since I’ve tapered patients out of treatment because they couldn’t or wouldn’t stop using marijuana. It hasn’t been all that long since I stopped tapering patients out of treatment for continued stimulant use disorder (methamphetamine, cocaine). This year, I’ve become more reticent to taper patients off methadone and buprenorphine because they continue to use benzodiazepine and/or alcohol.

After listening to Dr. Wartenberg, I’m convinced I must go farther in this direction.

In this third wave of the opioid epidemic, fentanyl use changes the decisional balance. Relapse back to heroin/fentanyl use presents such an increased risk of death that it dwarfs the risks of benzodiazepine, alcohol, and other sedative use in methadone patients…in many cases.

There will still be some cases where the risk of remaining on methadone will be too high; for example, if the patient comes to the opioid treatment facility impaired, or if the patient has accidents and continues to drive while on methadone and sedatives. We have a duty to our communities and to other patients to keep the OTP from becoming a negative influence.

But for patients with regular benzodiazepine use without factors that indicate imminent danger, I now feel like I need to work harder at increasing their counseling and contact with treatment staff, without asking them to leave treatment. And I need to push harder for the state ADATC to admit struggling patients to detox and rehab, while continuing their buprenorphine and methadone.

So I had a great evening. Besides what I gained from Dr. Wartenberg, I got to spend a few hours with the love of my life driving through beautiful mountains, I saw some old friends, and I met new friends, other providers working hard to help our patients.

I appreciate Dr. Wartenberg’s experience, passion, and for his ability to re-ignite my enthusiasm for working with our patients. He reminded me of the importance of doing my best for the patient sitting in front of me. And that’s really what’s most important.