Objectives: The objective of the study was to analyse the practice of giving take-home dosages of opioid medications to patients
with reference to the reasons for and the quantity of the medications given as additional or extra take-home dosages. Methods: All
the patients were checked regarding the kind of medication, urine samples, reasons for extra take-home dosages and their quantity.
Results: Of the 150 patients selected for the group in the programme, 27 needed one or more extra take-home dosages in 2007. 10
(11*) of those patients had negative urine samples for all illicit drugs and never used alcohol at any stage of the year of the study. 7
patients used marijuana, benzodiazepines or alcohol only once or just occasionally in that year. 10 patients used other illicit drugs or
used alcohol and benzodiazepines more often. Among the reasons for extra take-home dosages, hard physical work was listed 7 times,
vomiting because of the bad taste of the medication 3 times, difficulties in intiating medical therapy after entering the programme 3
times, vomiting as a part of illness twice and lowering the dosage too quickly twice. Other reasons were listed once each. Altogether,
the percentage of the overall quantity of medications received by patients during the year as extra take-home dosages was: 0.47% for
methadone, 0.75% for buprenorphine and 0.10% for SR morphine. Conclusions: Reviewing the fairly good results of treatment at the
centre, therapeutic decisions to give additional take-home dosages to the patients have proved to be reasonable and usually correct.
Throughout this study a continual therapeutic wish to achieve a better understanding of opioid addiction as just one among other
chronic diseases has been made evident.
Take-home dosages of opioid medications are a matter of
delicate balance in the therapist – client relationship. There
are various important reasons for the therapist to worry about
the destiny of the medication that has been handed over to
the patient. Some medications (methadone, SR morphine)
can ‘kill’ the person who has not adapted to the medication
or the dosage.
Treatment education for patients, medical training for
prescribers and the right choice of pharmaceutical forms
appear to be means that need to be developed simultaneously
to optimize treatment .
Opioid medications are also present on the Slovenian
black market. In 2005, 6 of 45 drug-related death cases
involved methadone, usually combined with other drugs
and alcohol .
The decision whether to hand the medication over to an
opioid-dependent patient is a difficult one, as it involves a
risk of misuse. In 2004 there were 2,944 arrests/reports for
drug offences (use and/or possession) in Slovenia; 42 of
these involved methadone. There was a total of 545 cases
of drug-related dealing/trafficking and 20 of those referred
to methadone; the numbers recorded for drug-related use
and trafficking was 94 in all and 2 of those referred to
methadone  .
In 2005, out of a total of 45 cases of victims of a drugrelated
death in Slovenia, methadone was involved in 6; in a
majority of these cases, methadone overdose was diagnosed
as accidental, not as suicide . According to the Slovenian
Therapeutic Agreement, in centres for the prevention and
treatment of drug addiction (CPTDA) only “trustworthy”
patients can get the medication into their own hands. Take-
home dosages are generally a bonus that patients can get by
showing good and stable behaviour . In the international
inquiry into the quality of work in Slovenian CPTDAs in
the year 2007, it was stressed that “leakage is difficult to
control, and it is hard to prevent someone from selling his/
her medication” . Patients can get their first take-home
dosages after 3 to 6 months of negativization of urine samples
for illicit drugs – with the debatable exception of marijuana.
After 6 to 12 months of negative samples, they can get takehome
dosages for the whole week or, in case of holidays, for
10 days. However, the “actual rules” for giving take-home
dosages differ from one centre to another, as the inquiry
showed . The numbers and the motivation of staff play
a role in these decisions .
In Slovenia the percentage of the medications used in CPTDAs
in 2007 was 81% for methadone, 13% for buprenorphine
and 6% for SR morphine . Compared with medications for
other chronic diseases, opioid-dependent patients sometimes
need additional (extra) dosages of medications even when
they are clinically perceived as being stable. According to
the National Therapeutic Agreement, they have no right to
get extra dosages. This decision was made by the Coordination
Committee of CPTDA therapists to prevent misuse of
the medication. On the other hand, clinical work showed the
need for a better understanding of patients’ problems, and,
therefore, the appropriateness of giving extra take-home
dosages for a variety of therapeutically sound reasons.
In France, because of positive outcomes maintenance
treatments were not officially questioned . A national
evaluation of maintenance treatment in France showed
that the decrease of 80% in fatal overdoses and of 67% in
arrests for heroin use (1994–1999) were directly related to
treatment accessibility . Once the authorities decided to
implement control measures over patients, the innovations
approved might make access to treatment more difficult. The
effectiveness of substitution treatment could be affected as
a result .
One general objective of this study was to provide an
important practical tool for improving the quality of the
work carried out by the CPTDA in Logatec. The therapists
give extra take-home dosages to implement a motivational
approach as a powerful resource in enhancing staff-client
interactions, quality of services and programme functioning
as a whole .
The specific aims of this study were:
a) to check the topic of so-called »therapeutic reasons« for
giving extra take-home dosages;
b) to check the therapeutic status of patients at the moment
when they receive extra take-home dosage;
c) to find out the amount of extra take-home dosages for
each medication with reference to the quantity taken over
one whole year and the percentage of total medication
distributed in this way.
At the centre the data were collected from the protocols
on giving medications to patients. The research involved
included the collection of the following data:
a) dosages given to patients at the centre to be used under
close observation by the nurse
b) dosages given to patients as their take-home dosages
c) dosages given to patients as their extra take-home dosages
The number and proportion of all dosages for each of these
three types of medication were calculated from the written
dispensary protocols (i.e. the nurse’s book and the computer
programme setting out the regime for giving medications).
The reasons for extra take-home dosages were taken
from the therapist’s protocol for each patient. For all extra
take-home dosages there were two descriptions, of the
psychosocial and somatic status of the patient and the »reasons
« for prescribing extra take-home dosages. The first was
selected by the therapist herself in writing the protocol, and
the second was chosen by the patient at home and added to
that protocol, together with the patient’s application for extra
take-home dosage or dosages.
As one of the measures for discovering the therapeutic
stability of the patients, their urine samples were used. The
results were taken from the documentation on each patient.
In descriptions of the frequency of drug use, the word »occasionally
« meant the use of a substance more than once but
less than four times during the year.
2.2 Description of the patients
On the question of extra take-home dosages, the population
of all 150 opioid-substituted patients attending the centre (29
females and 121 males) in 2007 was checked. 101 patients
(19 females and 82 males) were receiving methadone; 32 (7
females and 25 males) were being treated with buprenorphine,
and 17 patients (3 females and 14 males) with SR morphine.
At the centre, mean daily dosages were 101.9 mg for
methadone, 14.2 mg for buprenorphine and 672.3 mg for
Mean age of patients who got extra take-home dosages
was 28.6 years (min. 20 years, max. 39 years) for methadone
(3 F and 18 M); the ages of the buprenorphine patients (all
men) who got extra take-home dosages were 25, 27 and 31.
The one patient (a man) who was given extra take-home
dosages of SR morphine was 25.
Mean duration of the opioid treatment of the patients with
extra take-home dosages was 5.43 years (min. duration was
1 year and max. was 11 years).
Most of the patients that needed extra take-home dosages
were working (17/25): 12 of them had a regular job with a
working contract, 3 were working regularly but without a
contract, 2 were working without a contract and at the same
time going to school, and 4 patients were working occasion
ally to earn some money. Only 4 patients out of 25 (16%)
had no organized work or school.
At the time when they needed extra take-home dosages
the patients were coming to the centre at varying frequencies,
depending on the therapeutic agreement, the duration
of treatment and their therapeutic stability: 2 came once
every 2 weeks, 14 once a week, 2 twice a week and 2 three
times per week. Two thirds (2/3) of them were travelling to
the centre, 20 to 40 km one way. Others were living nearer.
In 2007 at least one or sometimes more extra take-home
dosages of the medication were given to 27 patients out of
150 (15.3%) . Extra methadone was given to 20.7% of the
methadone patients, to 12% of buprenorphine patients and
to 5.08% of SR morphine-substituted patients.
Regarding urine samples in the year of the research, 10 of
the patients (10/27) who got extra take-home dosages (10/27)
were negative for all illicit drugs and with complete abstinence
from alcohol throughout the year. For 1 patient who needed
extra take-home SR morphine, abstinence was very likely
but impossible to confirm – because of the cross-reactivity
of the tests. 4 patients had once or only occasionally positive
THC in urine, 1 had THC and BZO in urine occasionally. 1
had THC occasionally in the urine samples and was drinking
alcohol occasionally. Altogether, 17 patients used no other
illicit substances or used marijuana, benzodiazepines or
alcohol once or only occasionally (table 1).
The most frequent reason for extra take-home dosages
was a heavier physical or sometimes psychological burden
at the workplace. The following reasons were cited regarding
a) physical status of the patient, b) characteristics of the
medication and c) the patient’s social environment. (Table 2).
The total quantity of all medications given to the patients
attending the centre in 2007 as extra take-home dosages was
calculated. The percentages of the medications given to all
patients as extra take-home dosages were as follows: 0.49%
of the total quantity of methadone taken; 0.75% of the total
quantity of buprenorphine; 0.1 % of the total quantity of SR
morphine. (Table 3)
Most patients responded well to methadone maintenance,
whereas about one in four tends not to respond well to treatment
From the very start of the programme in the CPTDA in
Logatec, in 1995, the therapists at the centre have been trying
to get the most complete picture possible of the centre’s
therapeutic situation. In 2005, when the centre celebrated its
10th anniversary together with its history of using methadone
as the only medication for opioid addiction, an overview of
the treatment in the centre was published in the Journal of
Slovenian Medical Association: “Before starting methadone
treatment the detoxification without medical help was accomplished
by 37% of the patients, 15% were hospitalized
in psychiatric clinics for the purpose of detoxification, 6%
were treated in the therapeutic communities, 3.9% in the
therapeutic community Project “Človek” (man). 11% of the
patients spent a part of their youth in juvenile correctional
facilities. 13% experienced imprisonment. At the time of their
therapy in the centre 79% were working or/and attending
school. 30.8% of them had children and they had a partner
included in methadone treatment in 23%” .
In 2005 a study on one-year abstinence was published:
“In the group of 61 patients treated in CPTDA with methadone
for at least one year, in the last year of treatment in the
centre 67.2% didn’t use heroin, 34.4% didn’t smoke marihuana,
72.1% didn’t use cocaine, 85.2% didn’t use ecstasy
and 65.6% didn’ t use any medications of benzodiazepines
type. Alcohol was not used at all in the last year by 21.3%
of patients. Only 3% of them didn’t smoke tobacco. Chronic
infection with hepatitis C viruses was present in 16.4% of
patients. None was infected by HIV” .
These results give a fairly good overview of the patient
population of the centre and the level of treatment success.
Intractable problems in substitution therapy include the
distance to be travelled in reaching the centres (18 centres
cover an area of 20,256 km2) and their working hours. The
CPTDA in Logatec must meet the needs of a region of 13,000
people. Its premises are shared with the primary health centre,
and it has the same opening hours as other medical departments,
while operating under the same regime; that means
it is open every weekday for half the day: Mon Wed Fri 6.30
a.m.-1.30 p.m. and Tue Thu 1 p.m.-8 p.m. The centre can
count on contributions from 5 family doctors, 1 paediatrician,
1 school doctor, 5 stomatologists, 1 part-time gynecologist
and 1 part-time specialist for occupational medicine. The
centre sometimes uses the help of its GPs for exceptional
distribution of take-home dosages to patients outside the
working hours of the centre (during other weekday hours,
plus Saturdays, Sundays and holidays). For patients who are
obliged to take their medication daily – including Saturdays
and Sundays – and for stabilized patients in situations that
prevent their coming to the centre during opening hours,
their dosages are left in the refrigerator of the emergency
department by the nurse at the centre. She arranges this in
agreement with the doctor at the centre, the patient and the
staff of the emergency department.
All medications that are given under control at the centre
are prepared and delivered by the nurse or by the doctor at
the centre. Take-home dosages of buprenorphine and SR
morphine are prepared by the nurse for each patient separately
at the time of the patient’s visit to the centre. Take-home
dosages of methadone are prepared by the pharmacy on the
basis of a doctor’s prescription for all take-home dosages at
the centre on Thursday afternoons, applying the Soundex
code for each patient. This allows the patient to get his/her
own exact take-home dosages for some days or for the whole
week ahead. The nurse brings all the take-home dosages of
methadone solution mixed with orange juice in 100ml plastic
bottles from the pharmacy to the refrigerator at the centre.
She gives them to each patient in the centre according to his/
her take-home regime as ordered by the doctor.
In the year of the study, a majority of patients who got
extra take-home dosages needed only one or few extra dosages.
There was an exception: a 26-year-old girl in the year
of the study started to encounter difficult family problems
caused by her extremely aggressive father. She lived near
her primary home with her old and sick grandparents and
with her mother, who was seeking this girl patient’s help.
Before these family troubles reached a climax, this girl was
abstinent from all illicit drugs and had drunk no alcohol for
three years in our programme. She was working morning,
afternoon and night shifts and was living more than 20 km
from the centre. Her grandparents and her parents visited the
centre at the very beginning of the treatment, but stopped
doing so afterwards. During that whole period, she refused
to tell them about her taking methadone. She was receiving
take-home dosages of methadone to last one week at a time.
Apart from the distress experienced at home, she also split
with her boyfriend. In those days she started to use cocaine
for the first time in her life. Because she was taking extra
dosages of methadone and due to her stressful personal
situation, her tolerance grew. The therapists slowly raised
the daily dosage to 230 mg. She became stable again and
stopped using cocaine. She has managed to keep her job,
which is very demanding. Her employer is satisfied with
her work. This year she was promoted to a more demanding
position. Unfortunately, she got infected by hepatitis C at the
time when she was using cocaine. A month ago she started
treatment with interferon and ribavirin.
The National Therapeutic Agreement in Slovenia is very
demanding. To ensure successful therapy, some therapists
decide to provide take-away dosages even before some
patients have actually qualified to receive their bonus. Such
a decision is always a question of “sailing between Scylla
and Charybdis”, besides raising the eternal questions of
right and wrong.
Doctors have to help people live, and primum nil nocere
has to be the rule. But there is always the question of how
each doctor applies these solutions in treating individual
patients. Less frequent visits to the centre may create an
opportunity to work better with those who come. In some
ways it also prevents patients from grouping around the
centre. Unduly strict regulations can be harmful in another
way. We can learn this from the German experience, where
the official reaction to the troubles emerging in an organization
providing ongoing opioid treatment was to tighten the
regulations; most of the primary care physicians responded
by giving up their work. “When therapy was predominantly
offered by special maintenance centres, strong concentration
of these specific patients took place.”
Having discussed the results of urine testing compared
with the patient’s real abstinence, we are aware of well-known
difficulties. The frequency of urine testing in the centre varies
from 2 or 3 times per week for some patients to once in
3 or even 6 months for the few of them who are stable and
abstinent in the opinion of the therapist. Besides testing
devices for drugs in urine, saliva test devices are sometimes
used. For the assessment of drinking habits, a saliva test and
quite often the AUDIT and CAGE questionnaires are used.
Each year the therapists at the centre carry out some research.
Patients are asked to fill in a patient satisfaction questionnaire
yearly. The philosophy of the centre aims for an attitude of
“listening, understanding and acceptance” towards patients
or, as the expression goes, of “dancing with clients”.. 
This attitude of therapists provides an explanation for giving
extra take-home dosages, as most patients mostly do not
misuse the therapist’s trust. Each difficult situation is used
as a convenient moment to discuss with a patient his/her
decisions in life, his/her feelings and troubles, worries or
anger. After such discussions the patients usually feel better.
At the beginning of the study, the therapists were afraid
of taking on the task of calculating what had previously been
an unknown (potentially large?) quantity of extra take-home
medications that had been supplied to their patients. But the
top priority of the therapists in carrying out this inquiry was
an honest check on the work they were doing. At the end of
the study therapists have reached a strong conviction that this
has been a positive experience in improving the medical and
social status of their patients, partly through the distribution
of additional take-home dosages; this outcome makes it is
worth discussing the risks involved in not always obeying
the rules set by the National Therapeutic Agreement. Not
giving extra take-home dosages would mean putting the
patient in the position of lacking a required medication. He
or she would have to search for the medication on the black
market or have to buy a certain amount of heroin. A relapse
would be the inevitable result.
The explanations for such therapeutic decisions are easy to
understand in diabetes patients, when dietary mistakes have
been made or when these patients have an acute illness, or
in allergic asthma patients who need more inhaled corticosteroids
when an attack of asthma has been exacerbated by
visiting an old friend who owns a cat or a rabbit.
In reviewing the fairly good results for abstinence and
employment in all the years during which the CPTDA in
Logatec has provided treatment, and its continual objective
of achieving a better understanding of opioid addiction as
just one of many chronic diseases, the therapists at the centre
view their decisions to give extra take-home dosages to their
patients as having been mostly correct.
read more:Rupnik 12(2)2010 2