Strategies for Outpatient Methadone Treatment: Minimize Liability, Manage Risk, Ensure Patient Safety

1. Minimize Liability, Manage Risk, Ensure Patient Safety:Effective Strategies in Outpatient Methadone TreatmentWebinar August 26, 2009

2. “All medical care involves the management of risk”- Michael Flaherty, Ph.D., 2009 RM Course Director

3. Agenda 1:00-1:15 PM Welcome Todd Mandell, MD , Webinar Facilitator Setting the Stage H . Westley Clark, MD, JD, MPH, CAS, FASAM, Director, Center for Substance Abuse Treatment 1:15-1:30 PM What’s going on out there: An insurance carrier’s perspective Richard Willetts, CPCU 1:30-2:00 PM Managing risk and knowing the rules Lisa Torres, JD 2:00-2:45 PM Managing risk and practice challenges Trusandra Taylor, MD, FASAM, MPH; Todd Mandell, MD; Lisa Torres, JD 2:45-3:30 PM Questions and dialog Todd Mandell, MD (Facilitator)

4. Thank you for supporting this webinar session • Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse Treatment (CSAT) • Opioid Treatment Provider (OTP) Risk management course planning committee • OTP Risk management course faculty • Institute for Research, Education and Training in Addictions (IRETA) • American Association for the Treatment of Opioid Dependence (AATOD), David Szerlip and Associates, and NSM Insurance Group • Those in recovery and the many professionals and families that support their recovery Please note:this presentation is not intended to substitute for actual legal or medical advise

5. Housekeeping • All participants will receive and email following this webinar with the power point presentations and clinical toolbox. • A survey link will be emailed to you after the webinar. • All participant lines will be muted during the presentation so our audio quality remains high for all those participating. • If you have a question please use the chat or Q & A function on your screen. We will address as many questions as possible in the last segment of the session.

6. Lisa Torres, JD Managing risk and knowing the rules

7. Mary T.Segment I Presenting Information Patient Summary: Mary T. is a 28 year old Hispanic female who presented to an opioid treatment program on July 13, 2007. Chief Complaint: “I need to get clean; I’m tired and run down and I don’t want to be a drug addict for the rest of my life because I know it’s going to kill me.” History of Present Illness: Mary admitted using opiates intravenously for the past five years. Her substance of choice is OxyContin, but when she can’t access OxyContin, she uses heroin. She began drug use as a teenager and has used other drugs including alcohol, marijuana, cocaine, benzodiazepines, ecstasy and LSD. She admitted smoking cigarettes, 1PPD times 15 years. Upon intake she denied using any opiates for the past week. She admitted withdrawal symptoms of sweats, chills, restlessness, sleep disturbance, daytime fatigue, and loose stools. However these symptoms had resolved and she denied withdrawal symptoms for the past three days.

8. Mary T.Segment I Presenting Information Past Treatment History: Mary admitted to several admissions for inpatient and outpatient detoxification. Despite participation in 12 Step Meetings, she was unable to sustain abstinence for longer than two or three months. Mary admitted a six month period of sobriety several years ago after she relocated to another state to live with her aunt and uncle. Psych History: She admitted a history of treatment for “depression” and was evaluated by two psychiatrists within the past three years; she admitted previous prescription for Prozac, Celexa and Wellbutrin but they were ineffective and she had discontinued the medications. She admitted to “self medicating” her symptoms by increasing her drug use.

9. Mary T.Segment I Presenting Information Review of Systems (ROS): Except for her previously noted resolved withdrawal symptoms, her ROS was only remarkable otherwise for weight loss of ~ 5lbs within the past 6 months regarding physical complaints. Mental Status Examination: Remarkable for feelings of sadness and depression, described as moments of “darkness”when she “didn’t believe there was a point to her suffering” and while she had considered overdosing, she had not found the “strength” to act upon it. Mary stated she found some comfort in her religion, and the Catholic church.

10. Mary T.Segment I Presenting Information Physical Examination: Mary was examined by the nurse practitioner. Her physical examination revealed vital signs within the normal limits. Her skin was smooth, warm and moist. Her arms and hands revealed scattered scarring consistent with injection marks, but no fresh puncture wounds or abscess formation was visible. Her sclera were mildly injected; pupils slightly dilated; nasal mucosa appeared mildly erythematous; the remainder of her focused physical examination was unremarkable. Laboratory Results: Urine toxicology screen at intake was negative for amphetamines, barbiturates, benzodiazepines, cocaine, opioids, methadone and methadone metabolites.

11. Clinical Opiate Withdrawal Scale Last use (OPIOIDS) :Type, Date, Time Score: 5-12 =mild 13-24 = moderate 25-36 = moderately severe more than 36 = severe withdrawal Source: Wesson, D. R., & Ling, W. (2003). The Clinical Opiate Withdrawal Scale (COWS). Journal of Psychoactive Drugs, 35(2), 253-259.

12. Mary T.Segment I Presenting Information Preliminary Treatment Plan: The physician’s statement for documentation of current physiological dependence upon opioids was completed and signed. The patient was recommended for admission to opioid maintenance treatment because her lack of minimal family and community support which places her at high risk for relapse.

13. Mary T.Segment II: Dose Titration Schedule Mary’s dosing schedule per standing orders: Day 1 Thur Methadone dose 30mg Day 2 Fri Methadone dose 40mg Day 3 Sat Methadone dose 50mg Day 4 Sun (TH) Methadone dose 60mg Day 5 Mon Methadone dose 65mg Day 6 Tue No Show

14. CSAT Guidance“Standing Orders” Dear Colleague Letter – September 9, 2007 Risks associated with initial methadone dosing and the first two-weeks during induction process OTP Inspections Published literature review (Maxwell, 2005) OTP physician responsibility Knowledge of methadone pharmacokinetic and pharmacodynamic properties Individualized initial methadone dosing You are not alone: Physician Clinical Support System www.PCSSmentor.org

15. Mary T.Segment III: Induction Day 1 Mary was started on a dose of 30 mg. methadone with a standing order to increase 5 to 10 mgs daily up to a maximum dose of 80 mg. There were no symptom indications to guide the dose increases. Methadone Dosing Schedule Day 1 Thur Dose 30mg Day 2 Fri Dose 40mg Day 3 Sat Dose 50mg Day 4 Sun (TH)Dose 60mg Day 5 Mon Dose 65mg Day 6 Tue No Show

16. Mary T.Segment III: Induction Day 2 Mary received a dose of 40mg of methadone Methadone Dosing Schedule Day 1 Thur Dose 30mg Day 2 Fri Dose 40mg Day 3 Sat Dose 50mg Day 4 Sun (TH)Dose 60mg Day 5 Mon Dose 65mg Day 6 Tue No Show

17. Methadone Pharmacology Pharmacokinetics Long plasma elimination half-life, drug-drug interactions, individual variation, special populations Pharmacodynamics Tolerance, peak respiratory effect, cardiac conduction effects, CNS depressant and other drug interaction effects, individual variation “Start Low and Go Slow” Practitioner education Patient education

18. A Road-Map to “Steady State” Methadonedose levels Days/Half-Lives – Methadone half-life= 24-36 hoursDose constant at 30 mg daily. Interdose interval = 24 hrs (trough to trough)Peak levels increase daily for 5-6 days with NO increase in dose! Source: Payte;Center for Substance Abuse Treatment,Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs,Treatment Improvement Protocol (TIP) Series 43, DHHS Publication No. (SMA) 06-4214.Rockville, MD: Substance Abuse and Mental Health Services Administration, 2005,reprinted 2006. 18

19. Mary T.Segment IV: Complication - Withdrawal Symptoms Day 3 Mary reported to the dispensing nurse that she was experiencing withdrawal symptoms and asked to see the nurse practitioner. The dispensing nurse advised Mary that her dose was to be increased and administered methadone 50 mg. according to the standing order protocol. She also gave Mary her Sunday take-home methadone 60 mg. dose for Day 4. The clinic was closed on Sundays and as per regulations, the clinic customarily gave all patients Sunday take-home medication. Methadone Dosing Schedule Day 1 Thur Dose 30mg Day 2 Fri Dose 40mg Day 3 Sat Dose 50mg Day 4 Sun (TH) Dose 60mg Day 5 Mon Dose 65mg Day 6 Tue No Show

20. CSAT Guidance“Take-home doses” “Dear Colleague Letter” – January 28, 2008 Medical Director responsibility for all decisions Eight-point criteria in § 291.505(d)(6)(iv)(B) and 42 CFR,8.12(i)(2) Accreditation Guidelines 2007 Clinic closure for business, Sunday, state and federal holidays Alternative arrangement for patients determined by the medical director not to be appropriate candidates

21. Mary T.Segment V: Titration Resumed Day 5 Mary reported that she was no longer experiencing withdrawal symptoms and that she did not want an increase because she did not want to be like those “other patients on high doses”. Mary was noted to be slightly unsteady on her feet at the dispensing window. The dispensing nurse recommended to Mary to adhere to the standing order protocol for a further increase in her dose and Mary was given methadone 65 mg. Methadone Dosing Schedule Day 1 Thur Dose 30mg Day 2 Fri Dose 40mg Day 3 Sat Dose 50mg Day 4 Sun (TH)Dose 60mg Day 5 Mon Dose 65mg Day 6 Tue No Show

22. Mary T.Segment VI: No Show Day 6 Mary’s counselor made an outreach telephone call to her apartment building due to her no-show status for dosing. The counselor was advised during that call that Mary had passed away the day before. When she was found by her landlord that morning, she appeared to have fallen asleep on the couch. She was not breathing and her lips were blue. An ambulance was called and she was pronounced dead at the hospital emergency room. Methadone Dosing Schedule Day 1 Thur Dose 30mg Day 2 Fri Dose 40mg Day 3 Sat Dose 50mg Day 4 Sun (TH)Dose 60mg Day 5 Mon Dose 65mg Day 6 Tue No Show

23. Mary T.Segment VI: No Show Day 6 A subsequent autopsy was performed within 48 hrs of Mary’s death. As the Circumstantial Cause of Death, the autopsy report stated cardiopulmonary arrest due to pulmonary edema secondary to methadone intoxication, history of opioid prescription drug and heroin abuse. The forensic toxicology report indicated high levels of methadone and methadone metabolites. No other drugs were reported. Methadone Dosing Schedule Day 1 Thur Dose 30mg Day 2 Fri Dose 40mg Day 3 Sat Dose 50mg Day 4 Sun (TH)Dose 60mg Day 5 Mon Dose 65mg Day 6 Tue No Show

24. Methadone Dose “Equivalent Effect” Methadone “dose equivalent effect” due to accumulative effect of tissue buildup • Day 1 Thur Methadone dose 30mg 30mg • Day 2 Fri Methadone dose 40mg 55mg • Day 3 Sat Methadone dose 50mg 77.5mg • Day 4 Sun (TH)Methadone dose 60mg 98.75mg • Day 5 Mon Methadone dose 65mg 114.375mg • Day 6 Tue No Show

25. Thank you for your time and your attention • Please tell a friend about our next webinar rebroadcast dates for live Q&A are September 1, 2009 and September 23, 2009 from 1 – 3:30 pm (est.) to register visit www.ireta.org • Starting 3 pm EST, August 27th, 2009 you can watch this same webinar “on-demand” at www.ireta.org free and CEU’s are available through registration

26. Anthony Campbell, RPH, DO, CDR, USPHS – Planning Committee Medical Officer Substance Abuse and Mental Health Services Center for Substance Abuse Treatment Division of Pharmacologic Therapies Eric Ennis, LCSW, CACIII – Planning Committee American Association for the Treatment of Opioid Dependence, Risk Management Committee Chair Senior Instructor of Psychiatry Director of Adult Outpatient Services Addiction Research and Treatment Services (ARTS) University of Colorado Denver Michael T. Flaherty, PhD – Course Director Institute for Research and Education in Addictions – IRETA and the Northeast Addiction Technology Transfer Center (Northeast ATTC) Executive Director/Principle Investigator Carl-Henry J. Fortune, MPH – Planning Committee Project Director Prescription Drug Misuse and Abuse Activities Health and Clinical Services Division DB Consulting Group, Inc. Todd Mandell, MD – Core Faculty/Webinar Facilitator Medical Director, Vermont ADAP David Szerlip – Planning Committee/Core Faculty David Szerlip & Associates, Inc. Trusandra Taylor, MD, FASAM, MPH – Core Faculty Medical Director JEVS Human Services Lisa Torres, JD- Core Faculty Holly Hagle, MA – Planning Committee/Faculty Training and Education Officer Institute for Research, Education and Training in Addictions – IRETA Eric Hulsey, DrPH – Course Evaluator Scientific Director Institute for Research, Education and Training in Addictions – IRETA Tiffany Kilpatrick, CGMP – Planning Committee Regional Program Director Great Lakes Addiction Technology Transfer Center (Great Lakes ATTC) Jane Addams College of Social Work University of Illinois at Chicago Kristine Pond – Planning Committee Logistics Coordinator Institute for Research, Education and Training in Addictions – IRETA Sabato (Anthony) Stile, MD – Planning Committee Assistant Professor of Psychiatry Univ. of Pittsburgh School of Medicine Medical Director SPHS BH Addictions Program, Medical Director UPMC Behavioral Health Associates and EAP Solutions Monica Velazquez – Planning Committee Public Functions Supervisor Great Lakes Addiction Technology Transfer Center (Great Lakes ATTC) Jane Addams College of Social Work University of Illinois at Chicago Alan A. Wartenberg, MD – Planning Committee/Faculty Meadows Edge Recovery Center Rhode Island Richard Weisskopf – Planning Committee State Opiate Treatment Authority Illinois Department of Human Services Division of Alcoholism and Substance Abuse Richard Willetts, CPCU, ARM – Planning Committee/Core Faculty Program Director NSM Insurance Group Faculty and Planning Committee

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