By Holly Broce, MHA, LCADC, President, Opioid Treatment Program (OTP) Division, Pinnacle Treatment Centers
New Rules Simplify the Process
When the Food and Drug Administration (FDA) approved methadone as the first medication for opioid use disorder (MOUD) in 1972, a new era of treatment for opioid use disorder (OUD) began. Although no one knew it at the time, medication-assisted treatment (MAT) for OUD would – close to three decades later – become what physicians, addiction therapists, and substance use counselors and clinicians refer to as the gold-standard treatment for opioid addiction.
People with OUD in MAT programs can verify that label. MAT changes lives. MAT programs help participants escape destructive cycles of addictive behavior, reduce overall opioid use, reduce likelihood of relapse, and improve their ability to meet responsibilities and obligations related to family, work, and academic pursuits.
However, when methadone received approval, federal officials from the FDA, the Drug Enforcement Agency (DEA), and the Department of Health and Human Services (HHS) created a set of strict rules and regulations that restricted the how and by whom methadone could be prescribed, how and by whom methadone could be dispensed, and the amount of methadone a person in a methadone program could take home, known as take-home doses.
When buprenorphine received FDA approval thirty years later, the nature of the medication meant that it required fewer restrictions, particularly with regards to take-home doses. Whereas rules made it difficult for a person in a methadone program to take home more than one, two, or three days of medication, rules allowed physicians to write prescriptions for a thirty-day take-home supply of buprenorphine.
Let’s be clear: the FDA and DEA regulated methadone with good intentions. Their goals, among others, were to eliminate the possibility of diversion, reduce the chance of accidental overdose, and ensure the health and safety of not only those in methadone programs, but their family members and the people in the communities where they live.
The restrictions, however, created challenges for people on methadone. One challenge was travel: the rules made it seem impossible for anyone on MAT to take a vacation.
Travel While on MAT for OUD is Possible
While we know there are more pressing issues in the country right now than vacationing – overdose rates, mass shootings, inflation, you name it – we know vacations are important, too. And we’re not talking about jet-setting off to a resort in Tulum, Mexico or booking a high-end spa weekend in Palm Springs. We’re talking about regular people taking regular trips – with friends, a spouse, or kids and the family dog – to go camping at a state park, spend a weekend at the lake, or get away for a few days to the beach.
We’re talking about whether a person on MAT who receives their medication in Hamilton, New Jersey can take a trip to down to Cape May and not worry about missing their dosage. We’re talking about whether a person who lives in Pittsburgh, Pennsylvania can take a trip to the Poconos, or whether a person living in Culpepper, Virginia can travel to the beautiful beaches of Back Bay National Wildlife Refuge.
The answer: yes.
A person on MAT can travel and take vacations. It takes planning, but it is absolutely, one hundred percent possible.
We already said it: with proper planning – well in advance.
How to Plan Your Medication When You Go Out of Town
We’ll start with people who participate in MAT programs that use buprenorphine – commercial names Suboxone or Subutex – because those rules are the least restrictive and easiest to understand. Here’s how buprenorphine regulations affect vacations for people on MAT.
Buprenorphine and Travel
For vacations of less than thirty days, federal regulations for MAT with buprenorphine have no effect. Current laws allow a physician to prescribe a 30-day supply of medication with a total of five refills. In March of 2020, the DEA expanded the maximum supply to 90 days, an expansion that should remain in place as long as COVID-19 is classified at a public health crisis.
That’s it for buprenorphine: current federal laws should not impact any typical vacation plans. We will add that it’s important to plan to be home when it’s time to refill the prescription, and when traveling, to take every effort – exercise an abundance of caution – when storing or transporting your medication. If you’re flying, put it in your carry-on, not your checked bag. If the airlines lose your bag, your meds will be gone, and it will not be easy to replace them, especially if you’ve travelled far from home.
Note: the rules and regulations for buprenorphine are less strict than those for methadone because of its classification by the Federal Drug Administration (FDA) and the Drug Enforcement Agency (DEA). Buprenorphine is a Schedule III analgesic narcotic. Drugs in this class are defined as those with “moderate to low potential” for adverse physical and behavioral effects.
Methadone and Travel
There are no silver linings to the COVID-19 pandemic. However, when the federal government eased the rules around methadone dispensing to reduce barriers to treatment in March 2020 and extended those new rules in 2021, one result was that traveling for people in licensed methadone Opioid Treatment Programs (OTPs) became much easier.
Before COVID-19, take-home doses of methadone had the following restrictions:
- No take-home doses during the initiation phase
- One dose per week after initiation, during the first 90 days of treatment
- Two doses per week after 90 days
- Three doses per week after 180 days
- Six doses per week after a year
- Thirty-day supply after two years
That situation made any travel for people in the early stages of methadone treatment very difficult. However, there was a procedure in place to manage those difficulties, known as guest dosing. Before we talk about guest dosing, we’ll review the current, COVID-era rules around take-home doses for methadone from OTPs.
Here are the new rules:
- No take home doses during initiation
- For patients considered stable: 28 days of take-home doses permitted
- For patients considered less stable: 14 days of take-home doses permitted
That means that for people on methadone programs in OTPs in states that have implemented the allowed expansions, taking short vacations is now far less stressful. It’s actually easy. Plan to be home when it’s time to get a new supply of take-home doses, and that should be all the planning you need to do. Our same advice applies to traveling with medication, though. We strongly encourage anyone traveling with methadone to be very careful with their meds and use an abundance of caution while storing or transporting their medication. If you’re flying, it goes in your carry-on bags, not your checked luggage. Again, if the airlines lose your bags, your meds are gone – and it might be difficult to replace your medication before the symptoms of withdrawal appear.
Note: the rules and regulations for methadone are more restrictive than those for buprenorphine because of its classification by the Federal Drug Administration (FDA) and the Drug Enforcement Agency (DEA). Methadone is a Schedule II narcotic. Schedule II drugs are those which are defined as having “high potential” for adverse physical and behavioral effects.
Now we’ll talk about something we mentioned a moment ago: guest dosing.
What is Guest Dosing?
Before we answer that question, we’ll address something that may be nagging at you.
How long will the less-restrictive guidelines implemented during COVID-19 last?
Our answer is based on three documents published by the federal government:
- This DEA document extends the new buprenorphine rules – which is good news, but not really relevant to this topic.
- This SAMHSA document explains that new methadone rules will remain in place for one full year from the end of the COVID-19 Public Health Emergency.
- This White House Notice announces an extension of the COVID-19 Public Health Emergency beyond March 1st, 2022, with no end-date indicated.
Based on our understanding, what that means is that the new rules are still in effect, and will be, at minimum, until mid-2023. That’s good news, in general. However, we advise anyone in an MAT program to double-check anything related to their medication with their treatment provider. If you’re unsure, then ask.
Now we can talk about guest dosing. In a nutshell, guest dosing is when a person in a methadone program at one OTP has their methadone prescription and distribution plan temporarily transferred to a different OTP or healthcare provider, such as a hospital. Guest dosing occupies a curious place in the federally regulated MAT landscape. Technically speaking, any OTP in the country can accept guest patients and send patients to other OTPs – temporarily – if needed, and if all parties meet the paperwork requirements.
We use the phrase curious place because of this paragraph in the SAMHSA publication “Federal Guidelines for OTP Programs”:
“Patients who need to travel but do not meet criteria for take-home medications should be considered for guest dosing. Guest dosing is not specifically provided for in the regulations but is consistent with SAMHSA’s approach to both medication safety and supporting recovery. A sample policy for guest dosing was developed by the American Association for the Treatment of Opioid Dependence.”
See what we mean?
There’s no real policy, but it’s allowed. It’s consistent with the SAMHSA approach to MAT. And there’s a sample policy developed by the American Association for the Treatment of Opioid Dependence.
Here’s what that policy says:
Responsibilities of the Home Clinic, or the patient’s initial OTP location:
- Rules for the patient. The patient should:
- Be in good standing with the Sending Clinic
- Not guest dose during the induction phase of treatment
- Be on a stable dose and not scheduled for a dose increase or decrease during guest dosing
- Be medically and psychiatrically stable
- The Home Clinic should provide the following information:
- A valid release of information signed by the patient
- Current medications
- Date and amount of last dose administered or dispensed (provide nurse to nurse verification if required by the Receiving Clinic)
- Physician order for guest dosing, including first and last dates of guest dosing
- Description of clinical stability including recent alcohol or illicit drug abuse
- Any other pertinent information
- The Home Clinic should provide the patient with:
- Contact person, address, directions, and phone number of the guest clinic
- Information about any fees required
- Medication schedule
- Reminders to bring: driver’s license, passport, or other official identification
Responsibilities of the Guest Clinic, or the patient’s destination OTP or provider. The guest clinic should:
- Respond to the Home Clinic quickly and verify receipt of information and acceptance of the patient for guest medication
- Provide the same dosage the patient currently receives
- Only change dosage in consultation with the Home Clinic
- Set reasonable fees, and notify the patient of any additional fees related to guest dosing
- Provide location and updated dispensing hours.
- Determine appropriateness before dispensing any take-home doses. The Guest Clinic can deny dosage for reasons such as inebriation, red-flag behavior, loitering, harassing other patients, or inappropriate interactions with other patients or clinic staff
- Communicate any problems to the Home Clinic, including termination of guest-dosing
- Communicate last dose date and amount to the Home Clinic
Responsibilities of the Patient. The guest-dosing patient should:
- Bring the information sheet from Home Clinic to Guest Clinic
- Bring proper ID to Guest Clinic
- Pay any fees required by Guest Clinic
- Know the name, position, and contact information for the person who acted as the point of contact between the Home Clinic and the Guest Clinic
- Speak and behave in “the best possible manner.” Patients should understand that they may be refused medication at the discretion of the Guest Clinic.
In addition to all this important information – these guidelines really will make traveling while on MAT as smooth as possible – we’ll add some extra pointers. Here’s what we advise, in case the regulations revert back to their pre-COVID-19 state:
- If you plan to travel, start the paperwork as far in advance as possible
- Double-check everything with your home clinic, every step of the way
- Check everything again
- Double-check everything with your guest clinic, every step of the way
- Check everything again
- Make copies and backups of every piece of paperwork involved
- Make a record of phone calls, emails, or any communication regarding guest dosing
- Check everything again, the day before you leave
Finally, we should make it clear that SAMHSA has updated the extension of their COVID-19-related rules changes with regards to take-home methadone for MAT. States may apply for extensions under specific guidelines. For details on those extensions and their guidelines, including a list of FAQs, please refer to the publication Methadone Take-Home Flexibilities Extension Guidance, which we also link to above.
Traveling While on MAT: Vacation is Self-Care
We encourage people on MAT for OUD to return to full participation in all activities as soon as that participation feels safe and stable. Recovery from opioids is challenging, and in some cases, people in recovery get the idea that they’ll never be able to do all the normal stuff again. We want to correct that notion. The normal stuff – like little vacations – helps people in recovery rebuild their lives and understand they can lead a full and fulfilling life while in recovery. In the best case scenario, a person on MAT would talk to their therapists or counselors about taking a trip, run it by recovery peers at a community support meeting, come up with a relapse prevention plan to cover their time on vacation, and then…get outta town!
In all seriousness, people in recovery and people on MAT need getaways just like everyone else. With the information in this article, we hope to help people on MAT for OUD take that much needed break they deserve, and, in all likelihood, earned through their hard work and commitment to recovery.