Posts Tagged ‘methadone take home doses’

Revoking Methadone Take Home Doses

 

 

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

Revoking Methadone Take home Doses

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My decisions to revoke take home doses provoke more anger and outrage from my patients than anything else I do. This is a sensitive issue.

To understand their fury at losing take home doses, I need to describe how hard it is to get those take homes in the first place. Patients don’t waltz into treatment and get take home doses right away.

For patients on methadone at opioid treatment programs, (OTPs), eight criteria must be met before the patient can get any take home doses.
1. Time in treatment
2. Urine drug screens negative for illicit drugs and alcohol
3. Ability to store medication safely
4. Stable home environment, stable social relationships
5. No recent criminal activities
6. Regular clinic attendance – doesn’t frequently miss days
7. No behavioral problems at the opioid treatment program
8. Rehabilitative benefits of take homes outweigh the risk of take homes

Of all the requirements, time in treatment limits patients the most. Many patients do very well right from the start, with no drug use, criminal activity or any other complications. Even so, they must come every day the program is open (often 7 days per week) for a minimum of three months. After that, they can be granted two additional take home doses per week, as long as all of the other seven criteria are met. After three more months, they get one more take home per week, and so on. Once they get to the take home level where they come only once per week, they have to be compliant and in good recovery for at least one year before being allowed to get take homes every two weeks.

Patients expend time, money, and effort to get these take home doses.

That’s for methadone. For buprenorphine (Suboxone, Subutex, Zubsolv, etc.) there is no federal requirement saying how long a patient has to be in treatment to get a take home dose. So long as buprenorphine patients meet the other seven criteria, they can get take homes from the start, as far as the federal standard is concerned. However, state requirements may be stricter than federal requirements. For example, my state didn’t drop the time in treatment criteria for patients in opioid treatment programs on buprenorphine, but is willing to grant exceptions on a case-by-case basis, as long as the request is reasonable.

Most patients manage their take home doses perfectly. This fact gets lost in the hoopla over the few patients who don’t take their take home medication as prescribed. The actions of a few rogue patients, when made public, taint the reputations of all our patients. Their actions unfairly perpetuate stigma and bias against medication assisted treatment.

At any given time, you can google “methadone overdose on take home” or something similar and read news stories about patients who sold or gave their dose to someone who died as a result. It makes big splashy headlines and causes people in the community to wring their hands and lambaste opioid treatment programs for allowing people to get take home doses at all. In reality, many more people have died from methadone diverted from pain medicine clinics.

Part of my job as an OTP medical director is to decide, with the help and input of all staff, when a patient is taking the medication I prescribe as I prescribe it, and when it’s being misused.

Now obviously most people won’t tell OTP staff if they plan to misuse their medication, or divert it to someone for whom it was not intended, so OTPs have to have ways to assure patient compliance. One of those ways is called a “bottle recall.”

In a bottle recall, a staff person, usually the patient’s counselor, calls the patient at the given contact number and asks them to return to the facility within 24 hours so we can see that they have all their bottles and that bottles to be taken later in the week are still sealed and full of medication.

Yes, there are ways to falsify bottle recalls. In the past, patients would pull the plastic bottles apart at the seams, remove the methadone, fill the bottle with red Kool-Aid or similar, and glue the bottles back together. Some patients’ efforts were easily detected, and some do a slick job.

Now that we have pressurized seals on the take home bottles, we think it’s more difficult to get into the bottle without being detected, but some clever patient will invent a way to thwart the pressure seals…or already has done so.

If the patient fails a bottle recall, we must eliminate all take homes, at least temporarily. Sometimes patients don’t give us a working phone number, sometimes they say they never got the call, they just dropped their phone in a mud puddle and it wasn’t working, they got the message but forgot to return to the clinic, they just went out of town and only got the message when they got back, are out of town and can’t make it back for a bottle recall…we hear many reasons for a failed recall. Many are legitimate, and it’s nearly impossible to sort reality from lies.

According to patients, take home medication has been lost, stolen, left in hotel rooms, spilled in the sink, run over by cars, eaten by family pets, black bears, and other animals, burnt up house fires, and dumped out by angry spouses and highway patrolmen. In one creative story, the patient said a tree fell on her house during a storm. The great wind that felled the tree also created a sort of vacuum in her house, and a whirlwind sucked her medication bottle up, up into the sky as she watched helplessly.

Another patient said he couldn’t come in for a bottle recall because he buried his bottles in the back yard and forgot where he buried them, because he had Alzheimer’s dementia. Of course, I asked why he buried them, and he said, “So my wife wouldn’t get into them.” No, he didn’t get any more take homes.

Of course weird things can actually happen, and that’s the problem. What should I do if a patient who appears stable and who appears to be doing well, reports loss of medication? It’s a judgment call. With the help of the rest of the staff, we discuss the past stability of the patient and the believability of the report. We can’t look into the hearts of all our patients and tell who has criminal intent and who doesn’t. People can’t be perfectly assessed. I do the best I can, and with the help of the rest of the staff, make judgment calls about take home doses.

As the prescribing physician, I have a responsibility to make sure every patient who gets a take home stores it safely and takes it as directed. If a patient is unable or unwilling to do this, I have to revoke their take homes, at least for some period of time, especially if there’s evidence my patient is selling or giving away their medication.

Diversion of take home doses to someone other than the patient for whom it was prescribed is always a concern at opioid treatment programs. But we don’t want to limit freedoms for patients doing well because of the illegal activities of other patients. As with so many things relating to human behavior, it’s an issue of balance. I admit we don’t always get it right.

Some anti-methadone activists would like to change the law, and force patients on medication-assisted treatment to come daily for their doses, and eliminate take home doses. That would reduce the problem of diversion, but cause a bigger problem. It would disrupt the lives of thousands of MAT patients who take their medication as prescribed as they go about their life.

In the other extreme, some pro-MAT people say patients should be allowed to be prescribed methadone and buprenorphine a month at a time, just like medication for other chronic illnesses like diabetes and high blood pressure. But the medications I prescribe, methadone and buprenorphine, have street value, and can cause euphoria in people unaccustomed to taking opioids. Therefore, because of the properties of these medications, sound medical practice tells us we have to have some safeguards in place to detect medication misused and diversion.