Methadone Take-Home Decision Note (OTP)

Date of Decision: [date]

Effective Date: [date new schedule begins]

Author: [name, credentials]

Decision Type: [New / Increase / Decrease / Hold / Denial / Reinstatement]

Prior Take-Home Schedule: [previous arrangement and date of last decision] (If unavailable, state reason and whether decision is deferred or proceeding with mitigation.)

Decision Context

[Reason for today's decision] [Days in treatment or treatment start date] [Current methadone dose and dosing schedule] [Current take-home status]. (Write 2–4 concise sentences. Include only details directly relevant to the take-home decision. Note any interval changes since last decision that affect risk or safety. Omit detailed OUD history unless directly relevant.)

Information Reviewed

(Provide a brief paragraph or short list. If expected information is missing or pending, explicitly state what is missing, why, and whether decision is deferred or proceeding with mitigation.)

• [Toxicology results: date range, findings, pending tests]
• [PDMP check: date reviewed, pertinent findings]
• [Attendance and adherence: on-time dosing, missed or late doses]
• [Diversion-control activities: call-backs, bottle counts, dates and outcomes]
• [Counselor or nursing observations: sedation, intoxication, withdrawal, stability]
• [Relevant medical or psychiatric records affecting overdose risk]
• [Missing or unavailable information and reason; state whether decision is deferred or proceeding with mitigation]

Eligibility Criteria & Risk Assessment

(Indicate for each criterion whether it is met, not met, or partially met, with brief explanatory comment anchored to documented evidence. Do not infer low risk solely from time in treatment or attendance.)

Regulatory Criteria (per 42 CFR § 8.12):

• Absence of active substance use or conditions posing overdose/safety risk: [Met / Not met / Partially met] — [brief comment]
• Regular attendance for supervised dosing: [Met / Not met / Partially met] — [brief comment]
• Absence of serious behavioral problems: [Met / Not met / Partially met] — [brief comment]
• No evidence of recent diversion activity: [Met / Not met / Partially met] — [brief comment]
• Ability to safely transport and store medication: [Met / Not met / Partially met] — [brief comment]

Overdose Risk Factors:

• [Sedation or intoxication at dosing: present or absent; details]
• [Concurrent CNS depressants: prescribed vs. non-prescribed; names and doses if known]
• [Recent overdose or high-risk exposures: dates and context]
• [Relevant medical comorbidities and implications]
• [Naloxone access and training status]

Diversion Risk Factors:

• [History of lost or stolen dose reports; frequency and most recent date]
• [Household composition and risks: children, unstable housing, shared spaces]
• Specific Storage Plan: [lockbox location, how secured, who has access, transport method from clinic]

Re-earning Criteria: [What is required to earn or re-earn take-homes and timeframe for reassessment] (Include only if take-homes are denied or reduced.)

Shared Decision-Making

[Patient's request or preferences] [Clinician's explanation of risks, benefits, and regulatory requirements] [Agreed plan including any tradeoffs or conditions]. (Optionally include a direct patient quote demonstrating understanding of storage plan and responsibilities.)

Take-Home Decision

Decision: [Approved / Denied / Deferred / Conditional]

Take-Home Doses Authorized: [number] (If Conditional, specify required conditions prior to dispensing.)

Pickup Schedule: [specific days and dates; next observed dosing date]

Dose and Formulation: [daily dose; liquid or tablet; split dosing if applicable]

Rationale: [2–4 sentence explanation tying criteria and risk assessment to the chosen quantity. Explain why benefits outweigh risks or why they do not. Justify why this number of take-homes rather than more or fewer, referencing documented evidence. Do not base justification solely on time in treatment or attendance.]

Patient Education Completed

• Safe transport from clinic to home: [completed / not completed]
• Secure storage in locked container with child safety measures: [completed / not completed]
• Prohibition on sharing or selling medication: [completed / not completed]
• Overdose prevention (avoiding CNS depressants, recognizing overdose, using naloxone, calling 911): [completed / not completed]
• What to do if doses are lost or stolen: [completed / not completed]
• Teach-back understanding demonstrated: [Yes / No / Partial] — [brief summary of patient explanation or gaps noted]
• (If education declined or understanding insufficient, document modifications to take-home plan or deferral with follow-up education plan.)

Monitoring Plan

• [Next clinician review date or timeframe]
• [Toxicology testing plan: frequency; random vs. scheduled]
• [PDMP recheck schedule]
• [Diversion-control measures: call-backs, bottle counts, lockbox verification; timing]
• [Triggers for immediate reassessment: intoxication at dosing, positive for undisclosed substances, missed appointments, evidence of diversion, unsafe storage, new high-risk medications]

(Ensure all conclusions are anchored to documented evidence. Do not copy forward prior rationales without documenting interval changes since last decision.)