Posts Tagged ‘take home doses from opioid treatment programs’

Bad Weather Take Home Doses for Opioid Treatment Program Patients

We’ve had some snowy days in my area, and this means administrators at our opioid treatment program must decide if we should provide extra take home doses to patients for the days when travel will be treacherous.

Because take home doses are closely regulated at opioid treatment programs, both for methadone and buprenorphine, we must get special permission from state and federal regulatory agencies to give extra take home doses. We do this by submitting what’s called an “exception request.” This is an online form where we describe why we are requesting an extra take home, and for whom it will apply. Part of our job is assuring the authorities we won’t give extra take homes to patients who can’t manage them safely.

Ultimately, it’s up to me, the medical director, to decide the risk level of each patient. Which is more dangerous, driving on snowy roads to get to the opioid treatment program to dose, or having an extra take home bottle of medication? I need input from the staff to make the best decisions, so this can be time consuming.

Admittedly, my program failed our patients this last week.

The trouble is, we must decide when to submit a request for extra take homes about 48 hours in advance. It may take a day to submit online and get the medical director’s signature, the state opioid treatment authority signature, and the federal agency signature. Then we must give out the extra take home one day before the harsh weather is predicted.

Sometimes it’s hard to forecast bad weather. Early this month, we got an extra take home exception for a day when ice was predicted. In our area, a few degrees can make the difference between ice and rain. As it turned out, no ice fell and it was a perfectly normal day for driving.

I think that over-reaction was in our minds when we were monitoring the weather last week. At first, weather was expected for late Tuesday night. We were expected to get 1-2inches. We discussed if we should submit an exception, and finally did so late Monday night. I signed it, and it was approved by state and federal authorities, but we chose not to enact the exception Tuesday morning, based on updated forecasts.

It was not the right decision.

Tuesday night, it began to snow during the wee hours. By early morning, we had 3-4 inches and it kept snowing until afternoon. Somehow the forecasted 1-2 inches turned into 8 inches, at least on my side of the Brushy Mountains.

I live in the Brushy Mountains, and have a very steep driveway. Really, really steep. Imagine the steepest paved road you’ve ever driven on, and crank that up a few more degrees and you have my driveway. Plus, it has two curves in it. The only way I can get my small Toyota down the driveway would be to ride it like a luge sled, so it stays in the garage during bad weather.

My fiancé has a four-wheel drive vehicle, so he takes me to work, or I call a co-worker to come get me and I walk down my driveway to the road.

A group of physicians who work at opioid treatment programs were discussing this issue of severe weather take home exceptions on our monthly conference call last week. We pondered the factors that help us decide:

  1. Since buprenorphine has a greater margin of safety than methadone, I’m willing to grant bad weather take home doses for buprenorphine patients, unless there are other concerns to be considered.
  2. Patients in the induction phase of treatment, the riskiest time in treatment for methadone patients, shouldn’t get extra take homes.
  3. Patients who already receive take home doses for Sundays and holidays are likely OK for bad weather days, too.
  4. Patients using alcohol or benzodiazepines are at higher risk, and may not be appropriate for extra take home doses.
  5. Patients who live in a home with other people with active substance use disorders may not be able safely to store their medication, and may not be appropriate for the extra take home.
  6. Patients who have had recent episodes of suspected diversion won’t get extra take homes.
  7. Patients who live around the corner, are healthy, and can easily walk to the opioid treatment program don’t need extra take homes.
  8. Patients who live in more treacherous terrain or longer driving distance may need take homes. Our opioid treatment program is in the foothills of the mountains, but some patients live in a spur off the Appalachian Mountains called the Brushy Mountains. We have some steep and winding roads.

That’s a rough idea of most of the factors that go into deciding who should get take homes and who shouldn’t.

Then there are transportation issues. I mistakenly thought Medicaid-funded patients, who ride a transportation service that contracts with Medicaid to provide transportation to medical appointments, could get their usual ride to the opioid treatment program. Later I found out they have only a few four-wheeled vehicles. On one of our worst snow days, they only transported dialysis patients and others with “life-threatening illnesses.” My patients weren’t transported.

So, now I know that I cannot count on this agency to get patients to treatment on bad weather days.

As a group, OTP physicians are re-evaluating criteria for extra take homes in these bad weather situations, along with some help from our SOTA (State Opioid Treatment Authority). I feel fortunate to live and work in a state with an active SOTA. These remarkable people are tireless in their quest to continually improve the quality of care for patients at opioid treatment programs. They are valuable allies for physicians.

Because that’s the bottom line: we all want the best and safest care possible for our patients.