Details on How to Use Methadone Vehicles: Two OTPs’ Experience

Two treatment providers with many years’ experience using mobile methadone outlined their lessons learned and more in an August 11 webinar hosted by the American Association for the Treatment of Opioid Dependence (AATOD).

The Drug Enforcement Administration (DEA) okayed methadone dispensing from vans – which are actually more like RVs – provided that the vehicles are operated by brick-and-mortar opioid treatment programs (OTPs), effective July 28 (see https://atforum.com/2021/07/dea-methadone-vans-otps/).

Also featured at the webinar: speakers from the DEA and the Substance Abuse and Mental Health Services Administration (SAMHSA). Both agencies regulate OTPs.

The vans cost about $200,000 each. SAMHSA says that the Substance Abuse Prevention and Treatment (SAPT) block grant can be used to purchase the vans. According to Mr. Parrino, the Office of National Drug Control Policy (ONDCP) was instrumental in getting the approval, as well. Mr. Parrino also thanked the National Association of State Alcohol and Drug Abuse Directors (NASADAD), which has authority over the SAPT block grant, as well as the SOR and STR grants.

Any controlled substance, including buprenorphine, can also be dispensed from these vans. Before approval, methadone could be dispensed for opioid use disorder (OUD) only by OTPs. The approval means that methadone and associated services, including counseling, can go to the patient, and that patients don’t need to always travel long distances.

John Brooks and jail reentry

The John Brooks Recovery Center in Atlantic City, New Jersey CEO Michael Santillo said the van, which is about the size of a school bus, is “more like an RV” than a van. Admissions and counseling are done in the van, which has two doors – one in front, for the driver, and one in the back, for patients.

The van is fully equipped with an alarm (the same that the OTP uses), Wi-Fi, and links to the electronic health record (EHR). There are spaces for physical examinations, dosing (pump is linked to EHR), water supply, safe, and bathroom with toilet and sink.

Originally begun in 2008, John Brooks’ bus was parked in a spot in the community where methadone and buprenorphine inductions could be done on demand. At the time, counseling and other ancillary services were provided by the John Brooks’ brick-and-mortar OTP.

John Brooks also has a program for people who are going to be released from the local jail. Called Project Kickstart, this program relies on the van.

Some details about the jail program:

  • The bus is driven from the overnight site to the brick-and-mortar OTP to pick up the methadone.
  • The driver and registered nurse (who does the dosing) then take the methadone to the jail for dispensing.
  • The bus then goes back to the OTP to transfer the methadone to the safe there.
  • The inmates are given take-homes for Saturday and Sunday; these doses are dispensed by the jail’s medical contractor.

Lessons learned at Evergreen

At Evergreen Treatment Services in Seattle, Washington, mobile methadone started in 1999, explained Sean Soth, director of integration and innovation. At the time, funding came from SAMHSA”s Center for Substance Abuse Treatment, allowing Evergreen to partner with public health clinics in the area. All inductions were done at the brick-and-mortar location, but other services (maintenance dosing, counseling, and more) were done remotely.

This lasted until 2004, when the SAMHSA gran ran out. Funding was an issue for Evergreen’s partners, who needed the space the van was taking in the parking lot. “This created a change in our approach,” said Mr. Soth.

The problem was the community relationships, which were lacking without the funding support. “We moved locations quite a few times between 2004 and 2011, to different areas of the city,” he said. By 2011, Evergreen recognized that all the services that were needed could not be provided through the mobile system. A shortage of nurses and counselors meant the mobile services were pulled back, with the van parked at the Seatlle OTP, and used only as an additional dosing window to expand access.

This continued until 2018 – the van parked outside of the OTP.

Then, more grant dollars came through in 2018, and Evergreen was able to purchase a new van. In fact, it purchased two: one for methadone and buprenorphine dispensing, and one for counseling and medical services.

This was structured so that both vans would roll out together.

Evergreen had already learned a very important lesson: that the ancillary services “were a necessity and we needed them in the community with us,” said Mr. Soth. “Separating the services was not effective, and did not meet the needs of the patients and the community around us.”

In this new iteration, Evergreen focused on specific areas: low barrier direct access to street-based services, with same day access to all MOUD services.

There are two public safety staffers on the van – one is the driver, and one is street-based, who “keeps an eye on the community” as treatment is being provided.

There is a safe and a security panel, with a panic button for the nurse to use, in the dispensing van.

Because of COVID, the van had to be shut down.

Under the new rule, OTPs are permitted to dispense Schedule 2 through 5 medications at places remote from but in the same state as the brick-and-mortar treatment facility.

And key to the regulation: OTPs with a brick and mortar registration do not need a separate one for the van. Mobile dispensing is intended to be a coincident activity with the brick-and-mortar OTP, according to the DEA. In addition, OTPs may operate more than one van.

Before starting up mobile units, the OTP needs to receive approval from the local DEA office. Finally, o medications can be shared between OTPs or vans.

According to the DEA, the vans must:

  • not be used to transport patients,
  • not be used to transfer controlled substances to another OTP,
  • not have medications that are accessible from outside the vehicle,
  • have medications accessible to a minimum number of employees,
  • have observation of any visitor going through the vehicle,
  • store narcotic drugs in the safe (the same requirements for the safe as brick-and-mortar OTPs),
  • maintain control over narcotic drugs at all times,
  • have patients wait in an area that is physically separate from the safe and storage area and
  • be stored at the OTP in a fenced-in area, unless it’s in another fenced-in area (in which case the DEA must approve of this first).

The DEA has discretion when looking at the number of patients treated in the van. Keep all records at the OTP.

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