Good evening, everybody, we're going to begin today's webinar. Welcome to AOAAM and ORN's Q&A webinar on changes to methadone treatment at one clinic in central Pennsylvania by Dr. Sarah Kawasaki. My name is Julie Kmic and I'll be your moderator for this session. This is the fourth of a six-hour webinar series on hot topics in addiction medicine in the treatment of opioid use disorder. Dr. Kawasaki is the Director of Addiction Services at Pennsylvania Psychiatric Institute and Assistant Professor of Psychiatry and Internal Medicine at Penn State Hershey. She designed and directs Advancement in Recovery, an opioid treatment program at the Pennsylvania Psychiatric Institute in Harrisburg, PA. She's board certified in internal medicine and addiction medicine and has extensive clinical experience in both primary care and addiction medicine and a career interest in research to improve the delivery of evidence-based treatments to patients with substance use disorders in community-based treatment settings. PPI is the hub and several hub-and-spoke programs in the state of Pennsylvania set up through the Pennsylvania Coordinated Medication Assisted Treatment, PACMAC. So I'd like to turn it over now to Dr. Kawasaki. Thank you. Thank you for having me back, Dr. Cmik, and I understand that there were a few questions that came out of last week's lecture. So I'd like to start with a discussion with you about what general feedback, what questions you'd like answered, and invite everyone who's listening to also write any burning questions you have. Sure. I have some questions just based on my experience. I'm also a medical director at an opioid treatment program and also in Pennsylvania. So I know we're working under the same regulations and changes in our state. And so I just wanted to see how you handle things at your clinic, how we handle things at ours, and some differences in how we practiced and get your insight about things. Sometimes, you know, we're doing all these things are brand new, and you don't know what other people are doing, and it's kind of like this thing, and wondering, am I in the right zone here? Am I, you know, still, because we have so much more freedom than we did in the past in terms of interpreting, you know, what is a stable patient. So one of my first questions, and we'll see what comes in from the audience too, was how did you handle patients that weren't completing their therapy requirements during the pandemic? We had patients at our clinic that had been reduced to once a week supervised dosing, and they weren't doing their either teletherapy or in-person therapy requirement. They all had the option to do telemedicine appointments for therapy, but some chose to stay with coming into the clinic. Would you bring them in for closer supervision to encourage the therapy attendance? Or how did you handle that? Yeah, so great question. I think it really depended on the patient, but largely speaking, if they weren't meeting their counseling requirements, we would put holds on their dose whenever they would come in weekly. If they had less frequent dosing schedules, we would explain to them that they would have their dosing schedules reduced in order to comply with their counseling requirement. And most people got the memo. For folks that were getting a week and they were still unable to make these appointments, we would reduce their take-homes even more. Yeah, that's similar to what we ended up doing. We didn't necessarily bring them back into daily dosing, but we would drop it down, and then hopefully they would become more adherent with their counseling. And if not, then we'd have to make them come in even more regularly. Dr. Kamek, your sound is going in and out. Oh, OK. I'll make sure to sit a little bit closer. That's better. Hopefully that's helpful. Yes. You had mentioned last week that you had moved people out of the clinic if they had tested for less frequently supervised dosing if they tested positive for things like cocaine or marijuana or something. But if it was a benzodiazepine or an opioid, you had them come in more frequently for supervised dosing. What if you had somebody that was out on monthly or twice a month and they tested positive for different substances? How did you handle that? So if somebody were testing positive, they came back and they were testing positive for opioids or benzodiazepines, we would yank all of their take-homes. It was as simple as that. So for folks that were extended, that's what would happen. In some circumstances, we would give them a one-year in grace where they would just say, oh, no, no, no, there's no way that happened. If they were consistently testing negative and then suddenly one year in pops up, we would ask the patient what's going on. Can you help us with this? Sometimes patients had gone into the hospital for some sort of procedure and then we would verify it with the hospital and they didn't lose their take-home privileges. But some folks really did get them taken away for destabilization. I think that's pretty much what we did, too. And sometimes it was, we still had very, we were really concerned about them contracting or having severe consequences from COVID or a severe case of COVID. We might have given a little bit more grace on that as well and maybe brought them down to tries or something. It's a fine line. I mean, you know, it's not a win if somebody is protected from COVID but they die from an overdose. So, you know, we had to sort of figure that out. And with masking and distancing and keeping people out of the waiting room, we kept our clinic pretty safe so that, you know, nobody on our staff was infected by a patient. And that's, you know, and staff didn't infect patients. So we handled those procedures pretty well so far, I guess, because we're not done. Yeah. No, definitely not. And, you know, we're going to be changing. Well, you've already gone back to some pre-COVID dosing, it sounds like, at your clinic. Yes. And I think other clinics are going to be closing or changing by the end of September. I mean, I'm sure they're changing already because it takes time and warning and patient protest and everything else to get it going. Correct. We have a question from the audience. How did you manage medical visits such as pregnancy visits or annual physicals? So, we never stopped in-person visits if they were necessary. Annual visits, I believe, so we did a lot of those through telehealth just because, you know, there's not a whole lot that we would get accomplished in person. But if there were urgent visits needed for health-related conditions, if somebody was pregnant, they needed to be seen for something or another, you know, we would see them in person. All of our new visits, obviously, we would see in person for methadone because that was part of the regulation. Somebody had posed a question about what if their urine was positive for methadone but negative for the methadone metabolite? So, that urine is concerning for being brought in from the outside. And so, we would have that patient leave another urine. We do urines observed. So, and we do point-of-care cups for extended take-homes. And so, that was a way to avoid that from happening. Of course, it happened occasionally. So, for those folks, we would take away their take-homes until we could get a real specimen from them. Yeah, I remember having at least one of those with no methadone present in the urine. Right, then we take a cleanse and that would cleanse everything. Right. So, okay. What about, what was the most frequent observed dosing that you had during the suspension of the regulations during the pandemic? The most frequent was daily except for Sunday when we closed. You know, we had patients in induction. So, we would see them every day. For unstable patients, for patients that had fentanyl and benzos in their system, we would see them every day. So, the idea wasn't to, you know, potentially endanger folks that were unstable. The idea was to keep people as safe as possible in clinic by spacing folks that were stable so they didn't risk infection. You know, once the, like we defined our risk calculus by just saying, you know, once their stability and treatment reached a certain level, the risk of them catching COVID was scarier than the risk of them overdosing. So, when we made those decisions, then those folks got more frequent take homes and vice versa. Okay. We have another question from the audience. What COVID-related regulation changes will you advocate to retain? All of them. You know, I really, I mean, I don't know how you felt, Dr. Kmec, but I really enjoy clinical discretion. Isn't that something else? Just, you know, being able to offer rewards for folks that are doing well and, you know, showing stability and treatment, ability to, you know, to get work, get housing, engage in, you know, being productive members of society and family and anyway, what do you think? I have some mixed feelings because we had a good number of people who we had callbacks on that were not as expected. And that was concerning, especially when they were for the 14 or 28 days. And these people, we didn't just grant 14 or 28 days to who didn't have experience with take homes. So they had to have had basically bi-weeklies for weekly take homes already. And then we extended it during COVID. And so when people very experienced with knowing how callbacks go and how they're supposed to take their medication, come back two weeks early or, and saying that they're out of methadone or we have some bottles that are orange cough syrup, that the lids, you know, the seals have been broken. It makes me wonder what's going on in the people, in some of the people that we didn't do callbacks on. There was a period where we weren't doing regular callbacks right at the beginning of the pandemic. And then started, you know, as we get more comfortable working in that setting, giving callbacks. Yeah. So, I mean, I think that you could develop a system with more robust callbacks to have a sort of safer diversion protocol. But I think the real question underlying this is, you know, what kind of drug treatment culture do we want? Do we want a culture that is, you know, punitive at all costs, you know, to the, to the detriment of folks that are actually doing well, or do we want to reward stability? And I feel like being able to reward stability, particularly in Pennsylvania, when we're like the craziest, strictest state in the country, doesn't feel right. Like, you know, I mean, I think maybe having something more akin to the state regulations in Maryland and New Jersey, and which allow for up to a month if you've been stable in treatment for two years. But doing it in a way that makes sense for diversion risk, etc. You know, I mean, alternatively, I've taken away a Sunday take home for patients like, you know, there, I mean, the most diversion that we had were from the unstable patients getting a Sunday take home. And, you know, we had patients coming back with other people's bottles. And, you know, one person came back, had no idea where his bottle was, and then another patient had brought it in. So, you know, those folks had to get a chain of custody for Sunday. So, you know, we, we took away their Sundays. So, so it is important to make sure that methadone isn't getting into the community and causing overdose deaths. But, but I think there's ways of marrying, you know, clinical discretion, being able to reward stability and being able to keep the community safe and avoid, you know, these risky behaviors. Right. I think I had a good amount of people, too, who did very well with this, you know, that have been on methadone for a long period of time and really enjoyed having these extended take homes and felt that it helped, you know, helped their, them in their lives. They're able to go to work and not have to worry about coming to the clinic every week to get their weekly observed dosing. And so I definitely see both sides of the coin there, too. And I like the fact that of having clinical discretion and being able to make decisions. It reminds me of an article that I read where they quoted Marie Niswander when she was saying that she spent most of her life arguing against regulations, feeling like a Republican and saying, you know, that we shouldn't have all these regulations set on methadone. That's right. Okay. Let me take a look here. It looks like some more people have put some questions in. Somebody had asked, I'm new to the field, so you have patients who are on split dosing. If you do, what is the criteria? So this may be just me not being comfortable with split dosing. What I liked about the pandemic is that that sort of made the point moved. If patients were stable enough to get split dosing, they were capable enough to get take-home bottles, and then I would say, you know, sip it throughout the day. For other folks, if they're unstable, I don't feel comfortable giving them a split dose for the end of the day. The technical criteria is, let's see, are you able to hear me clearly? I'm able to hear you. I think it might be on my end. Okay. Okay. So the technical criteria is when you have a peak to trough ratio that's greater than two when you do your methadone blood work and blood levels. But if somebody is still using, you know, opioids, and they may be still using opioids because the methadone is wearing off early, but, you know, it's not clear, and I would just want to make sure that they're not trying to sell their methadone, et cetera. So I'm actually pretty strict about it and don't offer split dosing for folks that wouldn't otherwise qualify for take-homes. I don't know how you do it. That's how we do it as well at our clinic. Yeah. Then there's a question that says, what about cocaine use? What about it? It's a great question. So our state regulations explicitly say that any illicit substances need to be, you know, accounted for with take-home bottles. I tend to agree with that. So what the COVID relaxation rules did is they said, you know, for people with relative stability, you can define what that is. You know, you can get people out of clinic. And so what we did during this emergency period is allow folks who might still be taking medication that have not been traditionally thought of as, you know, fatally interacting with methadone, fentanyl contamination notwithstanding, but we would see that on a urine and then not allow for take-home bottles of medication. We would give folks with cocaine in their system only, right? You know, no benzos, no fentanyl or methamphetamines would be fine as well. Give them up to two weeks of take-homes. But in an ideal world, you know, let's say we're in non-pandemic times and we're in a state that offers extending take-homes, we would, you know, not include cocaine or methamphetamine use in that criteria. And so somebody using those substances would not be allowed to get take-homes. That's how that would work. Oh, somebody's asking, split dosing is allowed in PA? Ah, I think you can apply for an exception. You know, I think everything needs to be applied for and approved. But like, for example, if somebody's pregnant and they're stable and they're new to treatment or relatively new to treatment, like, you know, between three and six months, you might be able to apply for an exception. Do you have a different answer? We've been doing split dosing for years. I've been at the program now for, since 2008. And so we've had split dosing since, and I don't know if we had to apply for anything to start it. I haven't seen anything in our regulations saying that you can't do it. So that's my, we've been doing split dosing for people who have the, are considered to be rapid metabolizers or some people who've been pregnant. Okay. Please, what is the place of atypical antipsychotics in the treatment for addiction? So that's a complicated question. I am an internist, so I can give my internist perspective on this, but Dr. Kamik, as a psychiatrist, maybe you can chime in mostly. I have a handful of patients that are on atypical antipsychotics and on methadone. We routinely check EKGs, we routinely evaluate for sedation, and that's how we do it. I don't have a hard and fast rule. I worry about street value of medications like quetiapine, but other than that, we have a handful of patients that need them and we just monitor them. Yeah, as far as atypical antipsychotics, I'm not really giving atypicals for any kind of treatment of an addictive disorder. They haven't really been shown to be effective with things like alcohol use disorder or cocaine use disorder, et cetera. But I, like you, am monitoring for people who are prescribed these medications, typically somebody who has a psychotic disorder or bipolar disorder, and I'm using it as a mood stabilizer. So I'm gonna be monitoring for sedation in these individuals, especially if it's an antipsychotic that would be more sedating, like quetiapine or olanzapine. And also I'm going to watch for medications that can increase the QT interval. So I'm going to stay away from things like zeprazodone when I'm treating somebody who needs mood stabilization or an antipsychotic medication. Did that work out better in terms of the microphone, by the way? Yes. Okay. Okay, I'll just stay a lot closer, otherwise I can dial in, but. Okay, I have a couple more questions here too. So you had mentioned that you brought people in daily. How did you handle your patient flow during this time? So we had a policy of no more than five patients in the waiting room at a time, and we had designated seats for them so they wouldn't kind of interact with each other. Everybody needed to wear their masks at all times. Sometimes that led to problems. You know, we're in Central Pennsylvania with varying degrees of adherence to things like masks. I mean, we had a couple of patients that really just spent a lot of time and energy threatening lawsuits about mask wearing in our clinic. That was something else. It was just a very interesting situation. But we were able to get everybody dosed in and out. We assigned folks windows, dosing windows, and generally speaking, they did a great job with that. So, you know, for the few people that couldn't do the windows, you know, we had some grace periods and it just led to no clumping. We were able to reduce our foot traffic by about 40 to 50% on a daily basis so that, you know, we had a lot more spread dosing. We were dosing roughly, I would say probably 20 patients an hour. So pretty, you know, among three nurses. So that was pretty reasonable for everybody to get that through. In terms of appointments, when people came in for appointments, they were whisked back into an exam room really quickly or counseling room really quickly. We had no groups. We started with virtual groups. And, you know, to this day, I don't, I've learned not to touch my face ever. So, you know, just lots of practice with staff on hand-washing and hygiene and making sure that people aren't touching their face and washing their hands frequently and really keeping their masks above their nose. Right, we had to have several meetings, staff meetings about masks and how to handle that. So I think that was common everywhere. In terms of assigned dosing times, did you do any kind of dosing windows and can you explain how that worked for you? Because I know that's something that we talk about at times, but then we also mentioned, well, we'll have the patient who misses the bus and then they come in outside of the dosing hour that they're assigned or like their access is late, et cetera, et cetera. And so how did that work in your clinic? We had a lot of back and forth communication, call us when you're going to be late, let us know when you're going to be late. And so people would do that. They would say, oh, the bus is running late or, you know, I'm running late. For folks that had work, they were given priority on what hour they needed. So whether they were working third shift and needed to come in later or, you know, first shift and really needed to come in right at opening. Those folks were given priority and then everyone else would give their preference. We did rank choice voting. Everybody got a, you know, time slot that they would pick one, two and three, four. And so people got either their first or their second preferred dosing time. That sounds like it worked out really well at your clinic. We did do some assigned dosing times too for people that had trouble with the mask, keeping it above their nose and things like that. And had to work out a system where they would come in like at lower traffic times as well. We had to transfer a couple of people that were having, that were protesting masks. So, I mean, there were people that just wouldn't do it and were sort of flagrantly like, this is all a lie. And anyway, they had other behavioral issues. And so it happened twice, but. Yeah, I think overall our clinic population, you know, accepted it and, you know, we have the staggered line and everything like that. And so it's been working out pretty well in terms of that. How about, how many cases of COVID did you guys have or people who were under investigation for COVID getting tests? And how did you handle that when somebody came in and said they had COVID symptoms or gave you a call beforehand, hopefully? Yeah, so, you know, we encourage folks with any kind of symptoms, fever, stuffy nose, coughs, sore throat, to take their appointment remotely or let us know that they had these symptoms and we would advise them to come and get dosed outside. So for some folks, they could get dosed outside. For some folks, depending on their urines, they could get the full two weeks for quarantine to start. And we just did it on a case-by-case basis, but largely we dosed people outside. We kind of went over that situation and, oh, can we have them get dosed outside? What kind of risk are we putting our nurses in in that case? And so we did do, because of the regulations allowing for alternate pickup or custody of the methadone, having them sign a, they all had to sign releases of information so their emergency contact person would be able to come in and pick up their doses of methadone. And our nurse practitioner kept track of people who were either getting tested for COVID or who tested positive for COVID to talk with them, see how long they needed to be quarantined and when their date to return to the clinic would be and ordering the methadone for extended take-homes if needed for some of these individuals. So we did have a good amount who were either getting tested because of symptoms in the wintertime and tested positive, and it pretty much slowed down up in the spring, around April or May, but we've since had a couple of cases. Starting up again, yeah, for sure. And unfortunately, we've had a couple of patients in the clinic who have died from COVID-related causes in this past year. Wow, we've been lucky. Our patients are younger, so that's, but it's pretty, that's awful. I'm sorry. Okay, we talked about callbacks and my experience with the callbacks. As far as around in the Pittsburgh area, the other clinics and the clinic I'm at, we closed both days of the weekend. So we had five days that we were open. It sounds like you stayed open six days, you closed on Sundays? Yep. How many clinics are in the area where you're located? We have three. And were they similar to you, that they stayed open on Saturdays? They stayed open on Saturdays, and they also gave less generous take-homes. I think, you know, maximum everybody got a week, but they did, you know, for unstable patients, I think they still gave them a week sometimes. So it was always a mixed bag. You know, sometimes we would get people transferring from other clinics because they knew we were giving out more take-homes, but they weren't testing well. So then they got frustrated with us and went back, so. And now you have moved back to pre-COVID regulations at this time. So what does your dosing look like now in terms of how many people are coming in in a day, how many are on six days a week versus weekly? Yeah, so we have now about 40 patients that get a week, about 20 patients that come twice weekly, and an additional 30 that come three times a week. So that's roughly 90 patients, and we have a census right now of about 250 methadone. So that helps somewhat, but not completely. And I wish that were different. You'd mentioned that during COVID, your census increased and your retention increased. Has that been the same now since you've gone back, changed your practices to adapt to these regulations? So I think that what's changed, there's still a lot of interest in starting. I think people have just seen a really awful rise in overdose deaths, and so everybody is seeking treatment at this point. But what's changed is retention in the first 30 days, because when they knew that after 60 days of treatment, they could start getting take-homes, it looks totally different than somebody saying, boy, this is horrible, this is not compatible with how I envision my life. So for those folks, it's less desirable. And are you offering vaccinations at your clinic? No, I wish we had some, but no, we don't have any. Yeah, we've been thinking about being able to offer that we don't have any. Yeah, we've been thinking about being able to do that. When we did poll our patients about their desire to get vaccinated, a lot of them said that they'd already been vaccinated and didn't think that they would take us up on it. But now that the announcement has been made about getting booster injections, some of them have said, oh, well, I would like to come to the clinic for that if you do offer it. So do you have any sense of like the number or the percentage of your patients who are fully vaccinated? I think that it reflects the state, the county. Our county right now is at like 52% total vaccinated. Maybe that translates to 60% of the eligible population. And so in our clinic, it is still, I would say, 60% vaccinated, 40% unvaccinated. And some of that 40% is movable. Like, you know, I can talk to folks and some of them have clearly gotten the vaccine because they're sick of hearing from me, but some of them are really immovable. And so it's interesting. You know, I'll have the following conversations with people simultaneously. You know, I'll ask if they've been vaccinated. They say, no way, I don't trust it. You know, I don't know what's in it and all this other stuff. I just don't believe in vaccines. And I'll, you know, give that standard, oh, but you're a stunning product of science if it weren't for your own childhood vaccinations and the research that brought you methadone versus buprenorphine, you wouldn't be with us today. So isn't it amazing that we have scientific research to cover all those things that allow you to be a functioning adult? And, you know, for some people that moves them and not everyone, and then, you know, simultaneously I'll get somebody else that comes in. Oh, I definitely have my vaccine. I got it right in March when I was eligible. I was like one of the first people in line, blah, blah, blah. So how come you can't come dose daily for methadone? What's keeping you from doing that? Well, I think the methadone is poisoning me. I mean, you know, if it's not one thing, it's another. So just trying to help people realize, hey, listen, you're stable on treatment. It would be a real shame if you had a, you know, had a preventable death in this time without getting the vaccine. So we do our best. We have a pharmacy right around the corner that offers the vaccine. So we've been sending our patients there and, you know, I've got every argument for every situation. I treat folks from all walks of life. So, you know, I treat people that I make different arguments for, whether it's, you know, simply how this vaccine was developed to a complete biochemistry lecture, to a, you know, this is why I need it. And this is why I do this for my family. So I do what I can. I know last fall as well, we offered flu shots in the clinic too, to make sure that people would get vaccinated for the flu. And then perhaps since some of the symptoms overlap, they would be less likely to have worries about COVID or, you know, having the flu. And so we did have some uptake on that in the clinic, people were interested in it, but it wasn't as successful as I thought that it would be as far as as many people coming and doing it. So I don't know that we'll do it again this year. We do have, just like you said, a pharmacy that's right around the corner where they can go and get their vaccinations as well. Now, we do have another question from the audience. Is telehealth still being used and is there a time when it will be stopped? So we are still using telehealth, but not routinely. We'll use it for folks that have COVID symptoms, but largely we are keeping it in person at this point. That's the hospital-wide policy. So what are you guys doing? We're still using telehealth for therapy. The physician visits haven't really been as much in terms of telephone or video visits. We've been pretty much seeing people in the clinic. And then just in other clinics that I work, we're still doing a lot of telemedicine and it is still going to be covered by medical assistance here in Pennsylvania. So that isn't changing. There might be something that you have to do. I would check that on SAS. If you are in Pennsylvania, the Office of Mental Health and Substance Abuse Services, check their bulletin that came out recently to see about telemedicine and coverage through Medicaid. I have to say, I think the reason why we were so generous with telehealth is this isn't just a healthcare situation. It sort of bleeds into all walks of life. So the providers in our clinic, we're also people and parents and kids are not in school. And so are we going to have a bunch of grade school kids parenting themselves? No, we need to be at home. So to accommodate provider schedules so they wouldn't simply walk off, it was really important that we could have schedules such that clinic was staffed every day, but not every provider needed to be in clinic when seeing patients. So that way there was flexibility for providers as well. Okay. It looks like that's some of the questions. I did have something else that I, well, I was wondering for any other of the audience members, if you have any questions, if you're working at an opioid treatment program, any kind of specific challenges that you had over this past year or any kind of issues, how did your clinic operate? You can feel free to send in some comments. And just in terms of methadone, about how it works for some people who might still be or might be new to this and wondering about certain things. So we've talked about split dosing. And then how about with your pregnant women? How are, if somebody is using opioids and wants to get on methadone, how does she start methadone at your clinic? Aggressively. We wanna make sure that they're not in withdrawal. Obviously that can have deleterious effects on the pregnancy, and we are confined by the federal regulations. So, you know, we make sure that they get, you know, depending on how much they use, we make sure that they get the top dose on day one and adjust days after that to make sure that they're at the dose that they need right away so that they can stop using as soon as possible. So you're doing a lot of the induction and stabilization as an outpatient, whereas in the Pittsburgh area, a lot of times they get admitted to the hospital and get started on the methadone there. So they get an aggressive titration as an inpatient and then come out, usually around like 60 some milligrams or maybe more, and then dose is adjusted. And is that obligatory? No, not necessarily. It just seems to be common practice around here. That's fascinating. Yeah, we have a lot of patients that work, and so the inpatient world is like, no, I can't do that, I'm too busy. You know, even if you say like cemeteries are filled with indispensable people, you know, inpatient is really a four-letter word. Right, we, like recently we had somebody and she had been missing for dosing for quite a few days. So her dose was decreased due to the presumed loss of tolerance. And so then she came back and shortly thereafter, we found out that she was pregnant. And so we continued increasing her dose on an outpatient basis and because she didn't want to go to the hospital. Yeah, you know, for people that are coming in, you know, we ask them what they want to do, you know, depending on their urines and, you know, some of them are really not ready for inpatient or they don't want it. So we do in our initial assessment, make sure that they're at the right level of care, obviously, and, you know, can certainly send them. For our pregnant patients, all of them have experienced trauma. Many of them are in intimate partner violence situations. And so when that happens, we absolutely send them inpatient and try to get them inpatient right away. And then what do you see in terms of dosing during pregnancy? You'd mentioned sometimes split dosing. On average, do you see how much do women go up on their methadone dose during the pregnancy? If you have a gas? I know it might be hard to. Yeah, so we had a patient, we've had a couple of patients that have been in like the 180 to 200 range that have needed to go up that high. We just make sure that their QT is stable and, you know, check them every now and then. You know, certainly I've seen similar things with buprenorphine in the second and third trimester needing to go up to a dose of, you know, 24 milligrams and sometimes higher. We don't necessarily do split dosing. So, you know, depending on the stability of the patient. During this time period, we were giving folks take-homes. So sometimes I would say, you know, to the patient unofficially like, hey, leave yourself some at night. You know, you take some in the morning and you can leave yourself some at night. And so it wasn't scientific. It certainly wasn't precise, but just the idea that you didn't have to take the entire dose first thing in the morning was helpful. You know, a lot of women were suffering from morning sickness, constipation. So just a lot to work around. If somebody in here had asked about how you would start a split dose on a pregnant patient. So it sounds like you have more experience with that. So how would you do it? Well, usually we're going to be going about it pretty slowly. We typically aren't going to be, let's just say the person's on 120. We might go back to, so they dose on 120 on Monday and then the next day they would get the 60 and the 60. A lot of times we might do it that way. But other times it would be that if we're going backwards, let's say somebody did have split dosing and then, and this doesn't have to be a pregnant person. This could be somebody with splits and then they're using substances or something happens with the call back. Then we're going to be more gradually phasing it back in and I'll do it. Let's, we had somebody who was on 200. So I just went down by like 10 milligrams a day, adding 10 to the morning dose each day and getting them back into a once a day dose. So we do it that way versus, because if they have the dose at home, they took 100 in the morning and 100 at night, that next day I'm not going to want to give somebody 200 milligrams when they still have the 100 from the nighttime was just recently taken. So you have to be careful when you're doing it more of that reverse way, I feel like. So we had another comment and it sounds like somebody here near the Pittsburgh area saying that there's our women's hospital usually puts people on methadone and then refers them to the closest clinic. And so that seems to be one person's practice around here as well. Now, if somebody started, was pregnant, how often would you go up on the dose if they just started with the program? Would you go up daily or every few days? A short answer to that is yes. The long answer is, so I usually start daily, like I'll do 30, 40 on day two and then 50 on day three. And then I'll go up every other day at five milligrams versus 10 milligrams, depending on cow score. At around 80, I slow down to make sure that I'm not overdoing it. But generally speaking, the cow scores in our region due to the fentanyl influx is tremendous. So I never see folks, like I'm never intoxicating folks in induction and I do the best that I can, but it is outpatient. So it does need to be a little more gradual for your pregnant patients. Now, if you were starting somebody just, who was not pregnant, would you be facing out those dose increases or a little bit more, or are you- I still kind of operate on an every other day schedule. It just may not be as aggressive milligrams. Somebody else has a question here. In addition to urine drug testing for opioids, specifically methadone, are you testing for other substance use disorders such as alcohol, fentanyl, cocaine, methamphetamine, and others? While you are treating for opioid use disorder, how do you handle the need for continuing treatment with methadone while acknowledging the use of these other substances? So that's a great question. We do test for all these other things. If patients are consistently testing positive, first of all, if they have, everybody who's on methadone gets random breathalyzers. And if there's any active alcohol in their system, they can't dose that day. So that's really important. But for folks that are testing positive in their urine, for alcohol, we have a discussion on how much they're drinking and what that looks like for them. For folks that are using benzos illicitly, we offer them inpatient rehab or detox. They have to go to places though that will allow for continuation of methadone treatment. There are too many programs out there that will detox both and it's ridiculous and dangerous. So we do send people places for detox, but it's fewer and far between than I would like in the state of Pennsylvania that allow for continuation of methadone. So with methamphetamines and cocaine use, there's a lot of motivational interviewing around that we try to offer contingency management in our budgets. So if folks are in treatment for a week and they've showed up for dosing every day and they showed up for their counseling and for their medical appointments, they're allowed to pick something from a fishbowl, which can be anything from a good job verbal affirmation to an opportunity to pick from a closet that's filled with like shampoo or soaps or a gift card or something like that. So contingency management's really like the only thing that works for cocaine and methamphetamine use because we can't use Naltrexone and Welbutrin, which is the only pharmacologic evidence-based for this class of drugs. So a lot of counseling, a lot of motivational interviewing, offers for inpatient just to get a short reprieve from their living situation if they need to make a change, but we do talk about all of their substance use. Related to that question, the same participant asked, do you use a written informed consent warning about simultaneous use of methadone and alcohol, et cetera, and risk for death? Yes. I think that's pretty much, we have something similar to that on our consent. I think it's for the regulations, yeah. How often do you see significant problems with constipation and methadone use, and do you give any medications for that? I am a constipation expert. I think that you have to be. If I never wanted you to poop again, I would make sure that you get methadone daily. It is a world-class constipator. I am continually impressed by the patients I have that don't have this problem, but for everyone else, I'm absolutely writing for DocuSafe Sena. For some people, I have to add Miralax. For some people, it's Lactulose. For some people, I have one patient that's on methanol naltrexone, because they've been on methadone for over 30 years, and they started experiencing severe abdominal spasms, which at one point caused a massive relapse to treat that, and so as part of the comprehensive program we developed, in addition to their full workup that ended up negative, we made sure that they were on methanol naltrexone to help. So folks need to be on lots of stuff. I actually have another question, too, just about your practice, and this could be helpful maybe for people new to methadone, too. Do you do any other directly observed therapies at your window? Are you dispensing any disulfiram or any other kind of medicines, maybe HIV medications for patients? So we don't do disulfiram. We don't do HIV medications. I want to. I think that requires a little more permission. The ability to dispense how we're billing for it would need to be worked out, and how to record it in our record. These are all technical challenges, but then also just the cultural challenge of how, what kind of clinic are we? I mean, I definitely think OTPs are perfect for patient-centered medical homes, and I would love the ability to be able to see somebody daily for their other medications. We just haven't figured out how to do it. We're a methadone clinic that's nested within a psychiatric hospital, so whenever I talk about HIV meds to the hospital leadership, they're like, you mean other meds? Anyway, it's a challenge culturally, but it's certainly something that I like to do. We do dose buprenorphine. Oh, you do? You have window dosing of that as well? Yes. Well, we have a few more minutes, and we're getting more questions in, so the next question is, since benzo is a problem, what suggestions do we give to our clients who are on 15 milligrams of methadone, and thinking about, or is encouraged to taper from methadone? Do we encourage them to taper one milligram a week or more? So I'm thinking what's meant in this question is somebody's using benzos. Do we want them to taper off of their methadone so they can stay on their benzo? I'm not 100%. So it really depends on the patient, and it depends on the risk. For folks that are using lots of cocaine, stimulant use, being prescribed benzos in addition to the cocaine use and the methadone is not good, right? It's not wise. You know, fentanyl is in the system sometimes. You know, I don't know what we're treating. It's like seeing somebody on amphetamines and benzodiazepines. It's like, just don't prescribe them either. But it really depends on the patient. For some folks, the benzo prescribing predates the opioid use disorder, and so it's really difficult to get them off of benzos. They've been on it for a really long time, and they're stable on it. There's no signs of aberrant drug-related behavior with the benzos. So I, you know, make exceptions for long-acting benzos. For people that are on gobs of alprazolam, I will make sure, like I will have them sign a release of information. I will talk to that prescriber. We will come up with a plan for either transition to a longer-acting or tapering. So I really, really, I individualize it for folks. You know, it's not a hard rule, no benzos, but I take into account what their needs may be. Somebody had wondered if you, or mentioned that they'd used prescription and Movantic for constipation. It is, I'd have to, generic. I think it sounds like that is methyl naltrexone. No, naloxicol. Yeah, so it sounds like, so I use methyl naltrexone, which is related to naloxicol. So yes, I don't use that particular brand name, but it's a different one, so yes. And somebody had asked, do you ever use a camprosate for alcohol use disorder? I don't, do you? I mean, a camprosate is something that requires a prior authorization each time you use it. It's a three times a day dose medication, and there's not a whole lot of great evidence versus placebo. I will use it for some of my patients that are on methadone or, you know, maybe not even have an opioid use disorder, but just alcohol use disorder. It depends on what they are reporting in terms of symptoms. And, you know, sometimes they want to try something that might be helpful. And I do have some people who say, you know, this is the best drug ever. It really helped me. I felt normal once I started it. Other times people are saying, no, I didn't really do anything for me, or I had one, only one who complained about constipation. Now in our area with the Medicaid population, we're not having many problems with coverage except for one of the managed Medicaid programs, saying that they need a prior auth, but all the other ones it's just covered. And usually I can, you know, we are able to get the authorization because, you know, they're on methadone. And so they can't take naltrexone. And a lot of times they might have some elevated transaminase levels, or, you know, something that would preclude them from taking disulfiram. And so we'll try that. But I do usually, if I have somebody who has an alcohol use disorder, my first line is gonna be a naltrexone formulation if they do not have an opioid use disorder. Because like you said, it's easier. It's only once a day dosing or once a month if they're able to get the injection. And so adherence increases. And so I talk to the patients about it and say that, okay, this is three times a day and you gotta take two pills three times a day. So if you miss the dose in the afternoon, it might be less effective. So it's really important to try to figure out how you're gonna take it three times a day. So I do prescribe that. Sometimes I might use topiramide off-label. I totally, I use topiramide a lot. So, yeah. That would be one of the other things that I'll do for somebody with an alcohol use disorder who's on methadone, or for example, buprenorphine. Real quickly, I just wanna say to the, you know, we don't dismiss from OUD treatment people that are using other drugs. You can't be a clinic that treats addiction only to kick people out for having addiction. So we do our best to try to engage folks in treatment and figure out what their barriers are to stopping those other medications and what, or drugs and what they need for that. I don't do genetic testing for metabolism of meds for effectiveness of methadone. My highest dose is 260 milligrams. What's your highest dose, Dr. Kamek? I'm gonna say 230. Okay. So we have a patient that's, you know, morbidly obese and has been on that dose for a while and is pretty stable on it. So EKGs are meticulously collected and very stable. So there's a question about a supplement that's been prescribed to us and, you know, I don't think that there's any evidence for vitadone. So we don't use it. Yeah, I haven't been prescribing that either. So it seems like, you know, it's six o'clock now. So we've got a lot of questions there in the end, just about practice, which is really interesting to talk about. And so I'd like to take this opportunity to thank you again for doing this webinar last week and then this question and answer period this week. It's really been interesting to hear about your experiences during the pandemic and how your OTT has been operating and the good news that you have from your treatment program. So thank you so much. Thank you for having me. This was a great discussion with everyone. So thank you. And thank you everybody for joining. And next week we have our next webinar, which is on pregnancy and opioid use disorder. And we're also going, our presenters also going to be talking about some differences in mothers of different races and how methadone dosing and treatment in the study that she was able to conduct. Okay. Thank you.

Q&A webinar

methadone treatment

clinic

central Pennsylvania

addiction medicine

opioid use disorder treatment

pandemic

telehealth appointments

dosing windows

patient safety