Right now, Hurricane Sandy is hitting the NE. I’m in Ohio, near Cleveland, the heartland; the closest body of water is Lake Erie. For the last week we’ve gotten a barrage of news stories estimating the potential damage and dangers of her to the east coast, and warnings about how best to prepare for what would surely cause power outages at minimum. It never once occurred to me to be concerned about a potential disaster here in Ohio. Storms, sure. Winds, rain- but hurricanes in Ohio?
Then this morning I started hearing warnings that there might be dangerous winds and flooding through out Ohio. As the day drew on, the potential warnings started to seem a bit more like certain ones, and as of this moment, they are a surety. Streets have been closed, trees and power lines downed; a friend said the city sent a recorded messages warning residents not to leave the house. The forecast says it will be worse over night and into Tuesday morning.
While everyone else is stockpiling batteries and water and bags of ice, I’ve been thinking about something else: the methadone clinic.
All of this obviously begs the question of what would happen if the clinic was closed. And while I’m sitting here with my fingers crossed for Ohio- a scenario that seemed heavily improbable- it’s also apparent to me that those who are living further on the east coast are facing much longer potential closures.
So what exactly happens when your clinic is forced to close for a disaster situation? The answer is pretty frightening.
The vast majority of content on the web correlating to disaster contingency plans refers not to actual plans, in place, but rather, the need for them, the requirements of some, and reviews of past examples where existing policies failed.
Not one actually discussed or outlined a specific clinic’s plan, or even a a summarial one for all MMT clinics, sanctioned by federal regulations. There are no official statistics on the issue, but a survey of clients using the Addiction Treatment Forums (Vol. IV, #1, Winter, 1995) asked clients if their clinics had a contingency plan. Of the respondents, 59% said “yes”; 41% answered “no.”
The ATF believed those numbers to be inflated, and durther complicated by misconceptions of what a disaster contingency plan entailed. Those who did believe they had one described it as being able to go to the local ER and get their doses there; others said they would visit clinics further out from them for guest dosing- none, however, had any sort of documentation, established protocol, or reasonable demonstration of proof to cover them in such instances. For the most part, those solutions would be ineffective and at best, extremely short lived. The Harrison’s Narcotic Act of 1914 stipulated that no general practitioner may prescribe methadone or other opiates to treat opiate addiction; those who may are held under strict regulation and licensing requirements, and must be affiliated with a federally apporved clinic or unit specializing in addiction services. Hospitals may prescribe a maximum of three doses, when all other reasonable means of obtaining proper dispensation are exhausted, and in the event the patient is displaying marked withdrawal that is potentially detrimental to their health. Three days, that’s all. Let’s recall hurricane Katrina- and the millions who were displaced and awaiting rescue for more than two weeks, only to be shuttled to mass-refuge facilities with barely enough water, let alone medications. Three days.
The Katrina and more recent disasters have at least brought the issue to light- which I’ll discuss more in a moment- but the crux of the problem lies firmly in the hands of inaction. Currently, the federal regulation of MMT clinics requires MMT clinics to have some sort of contingency plan in place- but the guidelines are minimal, and the execution is almost non-existent. When I asked one of the Intake Coordinators at a Cleveland MMT Clinic if they had one, his response was “oh yes, of course. We have to”. No further comment on the topic ensued, nor was any education or explanation ever given- prior to or at that moment- to the actual clients. A plan is all well and good, but it’s rather ineffective if the persons who need to utilize it are not aware of it.
The same goes for the federal guidelines- plans are required, presented, and periodically reviewed, but that is little more than a general theory on paper, with no application to real life circumstances.
At one time, there was a program in place for this kind of scenario: D-ATM (Digital Access to Medication) was a pilot program by the Center for Substance Abuse Treatment, which ran for ten years under the wing of SAMHSA. The program’s purpose was to ensure that in an emergent situation, opiate treatment clients had access to medication at other clinics, courtesy of guest dosing.
Guest dosing is a common practice; it allows clients who don’t qualify for take homes to still get dosed if they have an unavoidable reason for being out of their clinic’s vicinity. The difference being that in those cases, clients had time to request the service through their own clinic, who could then forward any needed medical records to the courtesy clinic, ensuring the client would get their proper dose. In an emergency situation, there may not be time for the home clinic to reach a courtesy clinic, particularly when they are dealing with mass numbers of clients needing services. Without that information, courtesy clinics, hospitals, etc. have no way of knowing what a client’s dose is, or if they’re really an MMT client at all.
D-ATM attempted to circumvent that problem preemptively by providing courtesy clinics with client information, before the actual disaster strikes. In order to do this, participating clinics would have to link their digital client management system up with the courtesy clinic’s, and allow for periodic updates on client changes. Once the clinic agreed to participate, each client was given the option to do so as well, by signing a release form (renewed every 90 days), and having a fingerprint scan, which was then assigned a numerical pin number. The pin number was what went into the system, as opposed to the client’s name, as a protective measure of privacy. In the event of a disaster that precluded the client from getting to their own clinic for dosing, they would then proceed to the courtesy clinic. If the clinic was a participant, they would then scan the fingerprint of the guest doser to verify the pin number; if they did not participate, they could still use the ID# to access the client’s information in the D-ATM system- and if the clinic did not have digital systems, they still would be able to access the information by calling the D-ATM and giving them your number.
The program was introduced in the wake of the World Trade Center bombing and Hurricane Katrina disasters, both of which left thousands of clients without access to treatment. Initial concerns were raised, discussed, and ultimately a consensus was reached that something needed to be done, but out of sight, out of mind. With no natural disaster looming in sight, the efforts were more or less forgotten, and there are few people outside actual clients who will likely place any importance on them. For most of the population, ex-junkies are the last on the list to worry about, especially when so many others are struggling with their own loses from the same events.
To further cement the lack of interest, consider this: despite the program’s best efforts to encourage other clinic throughout the country to engage with the system, only 62 clinics agreed to participate in the program voluntarily. Of those that did, a significant number were located in California and New York. This factored into denial of funding, since the number of participants was too low to make a substantial difference in disaster preparedness, and on August 31st, 2012, the program ended.
That this program was not continued is absolutely mind blowing to me, as is the clinics’ lack of participation- while SAMHSA and the D-ATM program are not to blame, and if anything, should be commended, the lack of interest on the part of clinics demonstrates at best negligence for their patients, and at worst, represents an indication that even those serving MMT clients don’t consider our treatment important, or our needs serious. With so much of the world campaigning against MMT programs, and the never-ending tide of NIMBY-ers, what chance do we have to be taken serious, as real people, with a real disease, requiring treatment, when those who are treating us don’t stand up for it?
The issue isn’t going away overnight, either- the impact is far more reaching. Even a year after the Katrina disaster, surrounding state were scrambling to accommodate the displaced MMT clients. During times of stress, recovering addicts are even more at risk for relapse, while long-lasting disaster effects on availability of treatment are further compounded by the fact that many new addicts and alcoholics are often borne out of the tragedy at hand, requiring a greater need than ever for treatment.
So what should we do, as clients? How many of you know if your clinic has a plan? If they do, are you well versed enough with it to not need to be reminded how it works, in the event the clinic is unreachable?
I remember some years back, during the time when we were getting placed on high orange alerts from Homeland Security’s terrorism scale, asking one of the nurses what would happen if the clinic had to close for an emergency- at the time, the idea of another terrorist attack seemed highly likely. She looked at me like I had asked the most ridiculous question she’d ever heard, and then simply said “that won’t happen”. Not exactly the most reassuring words. What’s worse, I knew it wasn’t re-assuring, yet failed to ask more questions or investigate at the time, not wanting to make waves or seem like the consummate pesky client.
To their credit, I’ve been incredibly lucky as a client there; in the last decade, there has only ever been one instance of disaster. Rolling blackouts in 2003, which affected much of the NE, left our clinic without power. When we arrived at the clinic, they were still closed, but we were assured there were people inside preparing, and within an hour or so, we were all let in, and the nurses dosed each client manually, by using the client’s case file. We even made a juice run for them since the normal machines were down. But that doesn’t really cut it, particularly now, in the face of not only power outages, but flooding and undrivable road conditions. Access to our records digitally or on paper would be impossible, and I am confident that none of the other clients there now would have a clue as to what to do.
The following is the state of Ohio’s checklist for disaster preparedness, as it applies to people with special needs, in correlation with medication needs:
• Extra supply of medicines you’ll need to take (if possible, a two-week supply). Check expiration dates every few months
•Extra copies of prescriptions (ask your doctors and let them know the prescriptions are for your emergency supply kit)
•Ice chest, if your medication needs to be cold (keep your ice trays filled in your freezer, in case you need ice)
Lovely thoughts, but what do people who cannot get those extra stockpiles do? The obvious answer is that we need a system like the D-ATM in place, or we need some alternate means of obtaining our medication, including take homes if the disaster is likely to complicate the clinic for more than a single day. Emergency take homes given to clients at the onset of treatment, to be used only in such situations, would seem the most obvious solution, but is unlikely to ever be put into effect.
Federal regulations on take home doses are outlined in 42 CFR 8.12- Schedule of Maximal Take-Home Medications per Federal Opioid Treatment Regulation . This is where we come into federal versus state regulations- basically, a state can deviate from the amounts so long as they are still operating within the maximum. So even if by federal standards you qualified for 31, your state may say only 21, and under them, the individual clinic may say even less.
In certain situations of hardship, your clinic may be able to give you more than the federal standard: to do so, they must submit to SAMHSA and the state opiate treatment authority a form, (SMA-168 Exception Request and Record of Justification under 42 CFR 8.12. SMA-168). If approved, the client may be permitted more than the 31 standard.
How does all this apply to disaster stockpiles?
Very few states allow 31 take homes. I know many clients who drive over state lines, just to get into a clinic that allows larger amounts than their own. So there are quite a few clients who could technically be eligible for additional take homes in the event of a predictable, potential disaster. Most clinics require some notice when clients apply for more take homes- my clinic allows qualified clients up to 14 take homes for vacations, twice a year, but the request must be turned in at least 2 weeks ahead of time for approval. I found this baffling for two reasons:
In other words, in the face of a potential storm, my clinic has every right to give me up to 31 take homes, without approval. Since most storms only last a few days at most, and I’m already only getting 6, giving us those extras as a precaution should be a non-issue.
There is some common misconception that this right is altered for clients on doses over 100mg. NOT true. The only limitations on the dose size for emergent take homes would be for those incoming/new clients who are not yet stabilized; in which case:
“a limit of 30mg of methadone for the initial dose, and 40mg for the total daily dose, for new a patient on the first day of treatment. Thus, treatment on the first day with methadone doses greater than these amounts would require approval from SAMHSA and (where applicable) the State Opioid Treatment Authority of an SMA-168 exception request.”. (SAMHSA)
Obviously this privilege is not something the clinic should take lightly, and in the case of vacations or other instances, the clinic physician should oversee these requests, which would require some time. But in a case like this one, where time is of the essence, a broad spectrum approval for clients makes sense.
This still leaves us without a solution for unprecedented situations without any advanced warnings, and once again, is where a two or three day backup supply for every client could make a huge difference.
One of the things my clinic initially tried to do with larger quantities of take homes was institute a requirement that anyone getting them could be called, at random, and required to come into the clinic and present any unused doses they should have. A sort of checking in, if you will, to deter diversion.
For whatever reason, this fell through, but in the instance of a disaster preparation plan, it could be the key to the take home dilemma. Every 90 days, clients could be given 2-3 extra doses as a stockpile for emergencies. If, at the end of the 90 days, there has been no emergency, the client would then keep those three as their next three doses, and be issued another set of three the next time they were in. This would still deter selling or abusing take homes, and also prevent the stockpile methadone from the potential of expiration, since you’re renewing it every three months.
Of course, all of this seems incredibly complicated in the face of a simple system like D-ATM, but when has being an MMT client ever been simple? At the very least, we as clients should all be given a standard letter, a standard emergency prescription, and an emergency contact number to be given to medical personnel so they can verify dose. My clinic offers none of these. I’ve lamented for years the fact that our take home bottles are little more than bottles with poorly types labels, whose credibility I could vastly improve with a simple printer at my own home. In other words, they bear little resemblance to a legitimate prescription. My concern was being pulled over with one, and the likelihood of the police believing it’s authenticity- let alone a skeptic ER doc whose been flooded with several hundred local clients all claiming their clinic is closed and they need their dose.
For now, it would seem, there is no straight answer. While federal regulations are the guiding force, individual states and below them, clinics, are entitled to alter or affect those standards how they see fit, so long as they’re withint the general guidelines. What good does this do us, as clients, though? Particularly if we’re not aware of them?
I’m going to go ride out the storm for now, and I hope all of you are safe, warm, and not facing the same conditions. In the interim, I would really love to hear from everyone about what kind of contingency plans their clinic has, if any, as well as what yours would be in such a situation.
If you don’t know, or you haven’t thought about it, I really encourage you to do so now, even if you’re far away from the mess of Hurricane Sandy.
•If you would like to read more about the D-ATM program, you can find it here: http://datm.samhsa.gov/
And some additional reading you might be interested in:
(DPT.Samhsa.gov) Schedule of Maximal Take-Home Medications per Federal Opioid Treatment Regulation 42 CFR 8.12
The Impact of the World Trade Center Disaster on Treatment and Prevention Services for Alcohol and Other Drug Abuse in New York: Immediate Effects, Lingering Problems, and Lessons Learned
All Hazards Response Planning For State Substance Abuse Service Systems (Guidelines)
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