Dose Logistics

This section describes MOUD dosing logistics in a correctional setting. It provides information on medication formulations and options for onsite dosing protocols in jails for methadone and buprenorphine. When dosing occurs offsite, the community provider will be responsible.

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Key Points

HOW

  • There are many different modalities for dosing MOUD in a jail setting.
  • MOUD can be dosed all at once, in a small group, or individually
  • MOUD can be dosed in a separate pill call or together in the general pill call
  • Medical and security staff must work together to get dosing done sufficiently and properly to prevent diversion. Each medication type requires special steps to prevent diversion.
  • Dosing can be administered in the medical unit, general housing, or designated MOUD area
  • There are some supplies jails should buy to assist with dosing MOUD and adhering to DEA regulations, including a safe, pill crusher, and MOUD dose record logbook.

WHY

  • Comprehensive dose administration protocols help ensure pregnant patients receive their MOUD promptly, jails comply with DEA regulations and minimize diversion.
  • Dosing protocols should account for the role of the medical staff, security staff, and patients receiving MOUD.

KEEP IN MIND

  • Devise a daily dosing protocol that fits your jail’s needs and capacities.
  • While dosing protocols should include strategies and vigilance to minimize diversion, it is important to maintain a respectful and trustful demeanor with patients. Take extra care not to stigmatize patients for being on MOUD.
  • Dose timing should be consistent for each day so patients acclimate to a schedule. If possible, consider split dosing (i.e. dosing twice per day) to ensure medications do not wear off before the next dose. This may be needed for pregnant patients.
  • Jails should consider patients regarding the time of day for MOUD dosing. Early morning dosing may be ideal logistically but may cause unintended effects on patients like the dose wearing off before the day is over.
  • If a patient has court or another offsite obligation, ensure they get their MOUD dose before they leave the facility.
  • If someone is caught diverting, they should be referred to medical to discuss their dosing needs and treatment goals. However, they should not automatically be discontinued from MOUD. See MOMCARE Preventing Diversion for more details.

🤰 PREGNANCY-SPECIFIC CONSIDERATIONS

  • Pregnant patients can be dosed in the same group as non-pregnant patients
  • Nausea and vomiting during pregnancy may be an issue for people taking methadone since they need to swallow it (it’s not an issue with buprenorphine since it is not swallowed). Consider giving crackers and an anti-nausea medication (e.g. promethazine or, if 2nd or 3rd trimester, ondansetron) before dosing methadone.
  • Pregnant patients may need frequent dose increases. While they should also have regular dose assessments with a clinician, they may tell the pill-call nurse about cravings or withdrawal symptoms. The nurse should convey this to the MOUD clinician in a timely fashion so that dose changes can be made.

Deeper Dive

HOW

How can MOUD be dosed in a jail setting?

  • All MOUD patients at once, in groups of 5 or less, OR individually
  • If only MOUD patients, some jails have security officers remind patients of protocol with a standardized script (i.e. expectations of being on MOUD at the facility)
  • A security officer checks hands and mouth before the nurse doses
  • Have the patient take a sip of water to make sure the mouth is moist enough for absorption (important for buprenorphine)
  • Some strategies to reduce diversion:
    • Barber cape, place it around the patient and have them sit in a chair.
    • Shirts with no pockets
    • Barber cape
  • Clinical providers should log all dosing in a standardized log book.

The table below provides some nuances for each MOUD type and formula.

Methadone
Buprenorphine tablets (e.g. Subutex, Zubsolv):
Buprenorphine film (e.g. Suboxone)
  • Dosed as a liquid
  • Have the patient swallow
  • There is no need to wait for it to absorb
  • Dosed as a tablet that must be dissolved under the tongue, NOT swallowed
  • While generally not recommended to crush, because not all of the dose may be delivered, this is a reasonable step to prevent diversion.
  • Crush tablets, then place them under the patient’s tongue.
  • Do not talk, chew, or swallow anything until the dose is dissolved. This takes 5-10 minutes in most cases.
  • Dosed as a film that must be dissolved under the tongue.
  • Do not talk, chew, or swallow anything until the dose is dissolved. This takes 5-10 minutes in most cases.
  • Have the patient drink water after to get rid of any residual. Some jails also give crackers after this just in case there is residual.

When should MOUD be dosed in a jail setting?

There are two options for dosing MOUD in jail:

  1. Separate MOUD-only pill call
    • Requires a dedicated MOUD dosing team (nurse and security officer)
    • PROS: Consistency in who administers the dose, does mouth checks, and messaging/instructions can mean less diversion; staff can focus on appropriate handling and logging of MOUD per DEA requirements
    • CONS: Can tie up security staff for a while depending on the number of patients
    • Some jails find staffing for this easier on the night shift, in the early morning. This is very early for patients, however.
    • Some jails find staffing for this easier on the day shift.
  1. MOUD pill call that is integrated into regular pill call
    • PROS: Medical and security staff already doing pill call with mouth checks, does not require staff to leave usual assignments; more efficient if there are only a few patients on MOUD
    • CONS: Potentially less consistency, more opportunities to deviate from DEA-required protocols, may be more difficult to observe after dose

Who should dose MOUD in a jail setting?

A nurse or other licensed health professional who can administer medications at your jail AND a security officer who works with patients to prevent diversion

Where should MOUD be dosed in a jail setting?

There are a few options for where MOUD dosing usually takes place in a jail facility:

  1. Clinical unit
  2. General housing units where patients reside
  3. Designated MOUD housing unit
  4. Another area with adequate space for observing patients after the dose

What supplies are needed to dose MOUD in jail?

Supplies you might need for dose administration, in addition to methadone and buprenorphine itself, include:

  • Gloves
  • Water & cups for before and after dose
  • Pill crusher if using tablets
  • Safe, (DEA-approved) for storing methadone
  • Logbook to record dosing
  • Barber’s cape (so that you can easily see that hands are not maneuvering to divert dose)
  • Crackers

For clinical details on dosing initiation and titration protocols, please see this quick guide to buprenorphine initiation in pregnancy. For methadone information, see The ASAM National Practice Guideline for the Treatment of OUD (p. 51-52 for pregnancy dosing information)

WHY 

MOUD helps people who use opioids get to a state of feeling normal so they can function without pain and cravings. Having thorough, comprehensive dose administration protocols will ensure that pregnant patients receive MOUD dosing promptly, that jails comply with DEA regulations, and that diversion is minimized.

Many jail staff are understandably concerned about diversion—that a patient taking buprenorphine or methadone by mouth will not actually absorb the dose, but will hide it and then take it back to their cell with them—where they may save it to take at a different time or to give/sell to another individual.  Having a dosing protocol where medical staff, security staff, and the patient are partners together will build trust and ensure smooth, safe dosing.

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