The patient has met the following criteria for length of time in treatment starting from the date of admission:
Three months in treatment before being allowed to take home doses for 2 days.
Three years in treatment before being allowed to take home doses for 6 days.
The patient provides assurance that take-home medication will be safely stored in a locked metal box within the home.
The rehabilitative benefit to the patient in decreasing the frequency of service attendance outweighs the potential risks of diversion.
Time in treatment criteria.
The time in treatment criteria under par. (d) 6.
shall be the minimum time before take-home medications will be considered unless there are exceptional circumstances and the service applies for and receives approval from the FDA and the state methadone authority for a particular patient for a longer period of time.
Individual consideration of request.
A request for take-home privileges shall be considered on an individual basis. No request for take-home privileges may be granted automatically to any patient.
Additional criteria for 6-day take-homes.
When a patient is considered for 6-day take-homes, the patient shall meet the following additional criteria:
The patient is employed, attends school, is a homemaker or is disabled.
The patient is not known to have used or abused substances, including alcohol, in the previous year.
The patient is not known to have engaged in criminal activity in the previous year.
A patient receiving a daily dose of a narcotic medication above 100 milligrams is required to be under observation while ingesting the drug at least 6 days per week, irrespective of the length of time in treatment, unless the service has received prior approval from the designated federal agency, with concurrence by the state methadone authority, to waive this requirement.
Denial or rescinding of approval.
A service shall deny or rescind approval for take-home privileges for any of the following reasons:
The absence of laboratory evidence of FDA-approved narcotic treatment in test samples, including serum levels.
The service physician shall review the status of every patient provided with take-home medication at least every 90 days and more frequently if clinically indicated.
The service treatment team shall review the merits and detriments of continuing a patient's take-home privilege and shall make appropriate recommendations to the service physician as part of the service physician's 90-day review.
Service staff shall use biochemical monitoring to ensure that a patient with take-home privileges is not using illicit substances and is consuming the FDA-approved narcotic provided.
Service staff may not recommend denial or rescinding of a patient's take-home privilege to punish the patient for an action not related to meeting requirements for take-home privileges.
Reduction of take-home privileges or requirement of more frequent visits to the service. DHS 75.15(11)(k)1.1.
A service may reduce a patient's take-home privileges or may require more frequent visits to the service if the patient inexcusably misses a scheduled appointment with the service, including an appointment for dosing, counseling, a medical review or a psychosocial review or for an annual physical or an evaluation.
A service may reduce a patient's take-home privileges or may require more frequent visits to the service if the patient shows positive results in drug test analysis for morphine-like substances or substances of abuse or if the patient tests negative for the narcotic drug administered or dispensed by the service.
A service shall not reinstate take-home privileges that have been revoked until the patient has had at least 3 consecutive months of tests or analyses that are neither positive for morphine-like substances or substances of abuse or negative for the narcotic drug administered or dispensed by the service, and the service physician determines that the patient is responsible in handling narcotic drugs.
A patient receiving a 6-day supply of take-home medication who has a test or analysis that is confirmed to be positive for a substance of abuse or negative for the narcotic drug dispensed by the service shall be placed on clinical probation for 3 months.
A patient on 3-month clinical probation who has a test or analysis that is confirmed to be positive for a substance of abuse or negative for the narcotic drug administered or dispensed by the service shall be required to attend the service at least twice weekly for observation of the ingestion of medication, and may receive no more than a 3-day take-home supply of medication.
Employment-related exception to 6-day supply.
A patient who is employed and working on Saturdays may apply for an exception to the dosing requirements if dosing schedules of the service conflict with working hours of the patient. A service may give the patient an additional take-home dose after verification of work hours through pay slips or other reliable means, and following approval for the exception from the state methadone authority.
A service may grant an exception to certain take-home requirements for a particular patient if, in the reasonable clinical judgment of the program physician, any of the following conditions is met:
The patient has a physical disability that interferes with his or her ability to conform to the applicable mandatory schedule. The patient may be permitted a temporarily or permanently reduced schedule provided that she or he is found under par. (c)
to be responsible in handling narcotic drugs.
The patient, because of an exceptional circumstance such as illness, personal or family crisis, travel or other hardship, is unable to conform to the applicable mandatory schedule. The patient may be permitted a temporarily reduced schedule, provided that she or he is found under par. (c)
to be responsible in handling narcotic drugs.
The program physician or program personnel supervised by the program physician shall record the rationale for an exception to an applicable mandatory schedule in the patient's case record. If program personnel record the rationale, the physician shall review, countersign and date the rationale in the patient's record. A patient may not be given more than a 14-day supply of narcotic drugs at one time.
The service physician's judgment that a patient is responsible in handling narcotic drugs shall be supported by information in the patient's case file that the patient meets all of the following criteria:
Absence of recent abuse of narcotic or non-narcotic drugs including alcohol.
Stability of the patient's home environment and social relationships.
Assurance that take-home medication can be safely stored within the patient's home.
The rehabilitative benefit to the patient derived from decreasing the frequency of attendance outweighs the potential risks of diversion.
Any exception to the take-home requirements exceeding 2 times the amount in that phase is subject to approval of the designated federal agency and the state methadone authority. The following is the amount of additional take-home doses needing approval: Phase 1 = 2 additional (excluding Sunday); phase 2 = 4 additional; phase 3 = 6 additional; phase 4 = 12 take-home doses required for approval.
Service staff on receipt of notices of approval or denial of a request for an extension from the state methadone authority and the designated federal agency shall place the notices in the patient's case record.
Service staff shall review an exception when the conditions of the request change or at the time of review of the treatment plan, whichever occurs first.
An exception shall remain in effect only as long as the conditions establishing the exception remain in effect.
A service shall use drug tests and analyses to determine the presence in a patient of opiates, methadone, amphetamines, cocaine or barbiturates. If any other drug has been determined by a service or the state methadone authority to be abused in that service's locality, a specimen shall also be analyzed for that drug. Any laboratory that performs the testing shall comply with 42 CFR Part 493
A service shall use the results of a drug test or analysis on a patient as a guide to review and modify treatment approaches and not as the sole criterion to discharge the patient from treatment.
A service's policies and procedures shall integrate testing and analysis into treatment planning and clinical practice.
Drawing blood for testing.
A service shall determine a patient's drug levels in plasma or serum at the time the person is admitted to the service to determine a baseline. The determinations shall also be made at 3 months, 6 months and annually subsequently. If a patient requests and receives doses above 100 milligrams, serum levels shall be drawn to evaluate peak and trough determinations after the patient's dose is stabilized.
Obtaining urine specimens.
A service shall obtain urine specimens for testing from a patient in a clinical atmosphere that respects the patient's confidentiality, as follows:
A urine specimen shall be collected upon each patient's service visit and specimens shall be tested on a random basis.
The patient shall be informed about how test specimens are collected and the responsibility of the patient to provide a specimen when asked.
The bathroom used for collection shall be clean and always supplied with soap and toilet articles.
Specimens shall be collected in a manner that minimizes the possibility of falsification.
When service staff must directly observe the collection of a urine sample, this task shall be done with respect for patient privacy.
Service staff shall discuss positive test results with the patient within one week after receipt of results and shall document them in the patient's case record with the patient's response noted.
The service shall provide counseling, casework, medical review and other interventions when continued use of substances is identified. Punishment is not appropriate.
When there is a positive test result, service staff shall allow sufficient time before retesting to prevent a second positive test result from the same substance use.
Service staff confronted with a patient's denial of substance use shall consider the possibility of a false positive test.
Service staff shall review a patient's dosage and shall counsel the patient when test reports are positive for morphine-like substances and negative for the FDA-approved narcotic treatment.
Monitoring of test reports.
A service shall monitor test reports to do all of the following:
Discover trends in substance use that may require a redirection of clinical resources.
Ensure that staff appropriately address with the patient a positive test report within one week after the report is received and that the report and the patient's response is documented in the patient's case record.
The frequency that a service shall require drug screening shall be clinically appropriate for each patient and allow for a rapid response to the possibility of relapse.
A service shall arrange for drug screens with sufficient frequency so that they can be used to assist in making informed decisions about take-home privileges.
Patient retention shall be a major objective of treatment. The service shall do all of the following to retain patients for the planned course of treatment:
Render treatment in a way that is least disruptive to the patient's travel, work, educational activities, ability to use supportive services and family life.
Ensure that a patient has ready access to staff, particularly to the patient's primary counselor.
Ensure that staff are adequately trained and are sensitive to gender-specific and culture-specific issues.
Provide services that incorporate good practice standards for substance abuse treatment.
Ensure that patients receive adequate doses of narcotic medication based on their individual needs.
Ensure that the attitude of staff is accepting of narcotic addiction treatment.