For Clinicians | Why Patients Run Out of Medication: The Ordinary Disruptions, Not the Disaster

By Dr. Jamie Wilkey, PharmD, Director of Clinical Education
Medically reviewed and edited by Kristen Carpenter, PA-C

As a pharmacist, I’ve helped patients keep access to their medications through real disasters (especially wildfires out here in Utah). Much much more commonly, I spent my time behind the counter helping patients get access to their medications during ‘normal life.‘ No epic natural or structural disaster caused the disruption, but it was still a giant pain for my patients to deal with.

Some of what got in their way, patients could do something about: whether they had a ride that week, or whether they could pay for their medications when they got to the counter.

The rest was totally out of their hands. 

• A manufacturer stops making a product and the shortage runs for months (and we covered how long those actually last here). 
• The pharmacy that filled their prescriptions for twenty years just closed.
• Their prescriber leaves the practice and the refill request sits in a queue nobody is watching. 
• The insurance plan changes its coverage rules on January 1 and nobody clearly loops in the patient on that
• The local chain pharmacy keeps temporarily closing due to staff shortages

Today we’re walking through both: what patients can stay ahead of, and what is out of their control. Most of the practical tips sit in that second group, because that’s where patients have the least wiggle room. It’s not quite as exciting as a full-scale disaster, but it’s a part of daily life I believe you should be prepared for because I dealt with it in some form daily with my patients for over a decade.

What patients can get ahead of

Cost is a big factor. 

• About 8% of US adults taking a prescription didn’t take it as prescribed in order to save money¹. Patients are getting better about raising the issue of medication cost with you in the appointment. GoodRx is the best tool we have here, especially for anyone with a high copay or anyone choosing not to run it through insurance. It’s a good, simple way to eyeball the cash cost of an Rx ahead of time. 

Travel is the one that arrives as an emergency. 

• Someone flies out Thursday and realizes Wednesday afternoon they don’t have enough medications for the trip. Their home pharmacy already has the prescriptions on file and can usually put together a vacation supply, but that takes lead time and sometimes a call to the plan. A pharmacy at their destination has none of their history and far less to work with. Tell patients to start working on their medications weeks before the departure date, not the night before (especially for overseas travel!). The more warning we in the pharmacy get, the more we can do, and their emergency doesn’t have to become ours.

For patients who depend on someone else for a ride, the best fix is usually removing the trip entirely. 

• I worked for a big chain for years, and it was clear that delivery there is a low priority and gets missed very often. A locally owned pharmacy that delivers is a different experience: you get to work with the same humans every time, and they have a stake in it going right. Mail order can work as well, depending on how easy the company is to work with. Some are atrocious and others are the easiest thing in the world. 

And finally, theft. 

• Theft as a loss for medications is more infrequent, and almost always a controlled substance and almost always someone living in the house with the patient. There isn’t much a pharmacy can do with it. The patient needs a police report, and for a Schedule II they need a new prescription from the prescriber, because those can’t be refilled at all.

What’s out of their hands:

• The drug is on shortage: ASHP was tracking 227 active drug shortages as of mid-2026, the third straight quarterly increase². Even so, the pharmacy has more room here than patients expect. We can usually work with whatever we have of it in stock, and at a chain we can see which nearby stores are holding it and send the prescription over so it’s in process within minutes. Patients can call around themselves, and once they find a pharmacy that has it, that pharmacy can pull it across. When it’s really gone gone everywhere, that’s when we need a new prescription from you. 
• Their pharmacy closed for good: Nearly one in three US retail pharmacies closed between 2010 and 2021, and roughly a third of counties ended that period with fewer pharmacies than they started with³. When a pharmacy closes, whoever bought the files now has the prescriptions, so nothing vanishes. Patients will feel friction on the first few fills, because pulling another location’s information into our system takes longer than it looks. They should have gotten a letter, but profile addresses are almost always outdated, so there’s no guarantee the patient heard anything ahead of time. Tell them to expect a few extra days and start the refill process early with a new pharmacy.
• Their pharmacy is closed today: We’ve had a pharmacist shortage across Utah for a while, so stores that should be open Saturday aren’t, and some close mid-day when nobody can cover a shift. It’s not just Utah, but all across the US. Patients find out by driving there and seeing a handwritten sign: ‘closed due to pharmacist/staff shortage, will reopen on X date/time.’ Chains are more exposed to staffing shortages, and also easier to recover from, because any store in the chain can see the profile and patch around the closed one.
• The refill request never reached you: This is usually a routing problem. Pharmacy systems grab the first address on file for a prescriber rather than the clinic the prescription came from, which breaks constantly for urgent care and for anyone practicing at several sites. If you’ve wondered where those requests go, that’s where.
• It’s January: Formularies change, and the bigger shock is the deductible resetting. The patient who paid nothing in December pays full price until they clear it, up to $615 on Part D this year⁴. The year has a shape now: expensive at the start, copays through the middle, then nothing once they hit the $2,100 cap⁴. Insurance doesn’t explain any of that. We do, at the counter, and we hate it too. We don’t set the prices. We just charge what insurance tells us to charge. 
• You don’t know whether the plan will cover it: Plan policies vary wildly, so don’t guess. Pharmacy billing is live, so as soon as we get the Rx we can tell you on the spot whether the plan will cover a vacation supply, an early refill, or a replacement. It isn’t a medical claim and it doesn’t take days. 

Two things from the pharmacy side prevent most of what’s in this article.

Write for 90 days at a time wherever the clinical picture allows it. I know most of you are doing that already. Keep it up! More insurers are covering 90 days supplies and it really does help a lot. 

This feels obvious, but make sure the right office phone number is on the prescription when you eRx it over. I’ve lost a lot of time calling the number on file and finding out the prescriber is somewhere else that day.

Last Thought

We’re a medical preparation company, and most of what we publish is about disasters. This is the other half of the same work. Appropriate medical preparation fits in daily life as well, not just big behemoth disasters. The same habits carry a patient through a wildfire, and they’ll use them far more often on an ordinary Tuesday. None of it replaces primary care. It’s the layer underneath, that keeps everything humming along.

Patients who are prepared are easier to take care of. They call before they’re out, they know what they take and who prescribes it, and the care goes better on both sides of the counter.

Sources

1. Mykyta L, Cohen RA. Characteristics of Adults Aged 18–64 Who Did Not Take Medication as Prescribed to Reduce Costs: United States, 2021. NCHS Data Brief No. 470. National Center for Health Statistics, June 2023. Cost-saving measures included skipping doses, taking less medication than prescribed, or delaying filling a prescription. https://www.cdc.gov/nchs/data/databriefs/db470.pdf
2. American Journal of Managed Care. Active US Drug Shortages Rise for Third Straight Quarter. 227 active shortages as of Q2 2026, reporting ASHP tracking data. https://www.ajmc.com/view/active-us-drug-shortages-rise-for-third-straight-quarter
3. Health Affairs, December 3, 2024. DOI 10.1377/hlthaff.2024.00192. Nearly one in three US retail pharmacies closed between 2010 and 2021; roughly one-third of counties saw a net decline in pharmacies. Summary: https://schaeffer.usc.edu/research/pharmacy-closures-united-states-health-affairs/
4. Centers for Medicare & Medicaid Services. Final CY 2026 Part D Redesign Program Instructions. Annual deductible $615; annual out-of-pocket threshold $2,100. https://www.cms.gov/newsroom/fact-sheets/final-cy-2026-part-d-redesign-program-instructions

For Clinicians | Drug Interactions in a Disaster: The Combinations a Bad Week Creates

By Dr. Jamie Wilkey, PharmD, Director of Clinical Education
Medically reviewed and edited by Kristen Carpenter, PA-C

When we think about prescription medicine in a disaster, we most often think about supply. Does the patient have enough of what they’re already taking? Can we get them something for the wound or the infection that happened because of the disaster?

I’m a pharmacist, so I also think about another way that disasters mess with our medications and that is drug interactions. Drug interactions are what happens when one thing changes what another thing does inside the body. Two prescriptions can do it. So can a prescription and something off a shelf, an ibuprofen, an antihistamine, a supplement nobody thinks to mention. And so can a prescription and the shape the patient is in, which is the version a disaster is good at making. Most of the year a computer catches these. In a disaster people take more medication and newer medication with less prescriber and pharmacist oversight, because we aren’t as easily reached.

Adverse drug events send about 4 of every 1,000 Americans to an emergency department each year, and the top two classes are anticoagulants and antibiotics.¹ A disaster does three things at once. It puts new drugs in people’s hands. It also can lead to dehydration. And lastly, it takes away convenient lab work. Today I’ll walk through the three dangerous drug interaction combinations that can result from a disaster, a few smaller traps, and how to keep an eye out for your patients ahead of time. 

Few New Medications

It’s easy to picture a disaster putting everybody on a pile of new medication. That isn’t what happens. Most people are taking what they were taking a week ago. A smaller group picks up something new, and it lands in three classes: an antibiotic, an NSAID, and an antihistamine.

As far as medications go those drug classes are generally basic and largely benign. What I want to talk with you about is that these are three drug classes you’d hand someone without a second thought because two of them produce all three of the cases below. Ordinary is what makes them dangerous, because nobody stops to check an ordinary drug.

The antihistamine is the odd duck here, because it doesn’t need a collision with another drug or new health condition to cause a problem. Diphenhydramine sits on the Beers list as highly anticholinergic, and clearance falls with age, so confusion, dry mouth and constipation all get more likely in an older patient, and cumulative anticholinergic exposure carries its own risk of falls and delirium.² Beers still says it may be appropriate for acute treatment of a severe allergic reaction, which is the disaster presentation, so here is a tricky medication that should be used in an emergency, but also watched very carefully for anyone over 65 years old.

 The Kidney Triple Whammy from Dehydration

A patient on a diuretic and an ACE inhibitor or ARB has been fine on that combination for years. Then comes three days of hauling debris in the heat, less water than they should be drinking, maybe some diarrhea. Their back hurts, so they take an ibuprofen.

Those three together have a name, the triple whammy, and the kidney is what gets walloped. A kidney filters by holding pressure across the filter, and when blood volume drops it protects that pressure two ways: it widens the vessel coming in and tightens the one going out. The NSAID blocks the widening. The ACE inhibitor or ARB blocks the tightening. Both of the kidney’s own defenses are gone at the same moment the diuretic and the dehydration are sending it less blood to work with. A 2025 meta-analysis of four studies and 42,367 patients put the odds of acute kidney injury at about double, OR 2.01 (95% CI 1.30 to 3.10).³ One study inside that review found the three-drug combination carried 1.64 times the risk of the two-drug version,³ so the ibuprofen really is what tips the scales here.

Nothing about their prescription changed. The dehydration and the extra NSAID broke a smooth-running system. 

Warfarin Plus an Antibiotic, With No Lab Draw

The second case here is the same story, but mixing it up with a different organ. This interaction will surprise nobody because it is warfarin–the medication that is ultra sensitive and seems to interact with everything. Warfarin plus a handful of common antibiotics pushes the INR up, partly because the antibiotic slows the enzyme that clears warfarin, partly because it kills off the gut bacteria that make vitamin K. The high-risk list is pretty short: TMP-SMX, ciprofloxacin, levofloxacin, metronidazole, fluconazole, azithromycin and clarithromycin.⁴

Disasters make blood draws a lot harder to get and they aren’t particularly top of mind in an event like that. In a cohort of 22,272 warfarin patients, TMP-SMX carried a hazard ratio of 2.09 for serious bleeding and ciprofloxacin 1.87, and 9.7% of the patients given fluconazole ended up with an INR above 6.⁴ Then the part that matters for a storm: patients who got an INR within 3 to 14 days of starting the antibiotic had a lower risk of serious bleeding, HR 0.61 (95% CI 0.42 to 0.88).⁴

The interaction was always there. The lab is what disappeared in a disaster.

Bactrim +  Spironolactone

This third and final big interaction is kind of the opposite because nobody expects it. Bactrim for a UTI, in a patient on spironolactone for heart failure, and both drugs are holding onto potassium like it is going out of style. Trimethoprim blocks the same channel in the kidney that amiloride does, so it behaves like a potassium-sparing diuretic stacked on top of the one the patient is already taking.

In a population study of Ontario patients 66 and older who were taking spironolactone, sudden death within 14 days of an antibiotic prescription was more than twice as likely with TMP-SMX as with amoxicillin, adjusted OR 2.46 (95% CI 1.55 to 3.90).⁵ Ciprofloxacin came in elevated too, at 1.55.

Here’s why it belongs in a disaster article. This is the combination you’d normally check a potassium on, and in a really bad week nobody is checking anything. The good news is that the fix is so easy: just picking a different antibiotic. Amoxicillin is the drug everything else in that study was measured against.

A Few Smaller Traps

These don’t each need their own section, but they come up every time.

• Know the acetaminophen ceiling. FDA’s over-the-counter limit is 4,000 mg in 24 hours for adults,⁶ Tylenol’s own Extra Strength label lowered it to 3,000, and the label warns separately about 3 or more alcoholic drinks a day.⁷ Prescription combination products have been capped at 325 mg per unit since 2014, but over-the-counter cold, flu and sleep products never were, which is how somebody stacks two products and blows past the ceiling without exceeding a single label.⁶
• Know which way to swap between ibuprofen and acetaminophen. For the patient who is dehydrated, on a diuretic with an ACE inhibitor or ARB, or on warfarin, acetaminophen is the safer analgesic. Use ibuprofen when the liver is the bigger worry: heavy alcohol use, liver disease, or a patient already getting acetaminophen from a combination product.
• Don’t let thirst be the cue. CDC lists diuretics, ACE inhibitors and ARBs as reducing thirst sensation, so the patients who most need to drink are the least likely to feel like it.⁸ Tell them to drink on a clock whether they feel thirsty or not.
• Watch what may bind with the antibiotic. Antacids, calcium and iron cut absorption of both doxycycline and the fluoroquinolones,⁹ and bismuth subsalicylate, the Pepto in the cabinet, is on doxycycline’s list too.¹⁰
• Address the sun! Doxycycline causes an exaggerated sunburn reaction and the and the fluoroquinolones carry their own photosensitivity warning.⁹ The doxycycline label says to stop the doxycycline at the first sign of skin redness,¹⁰ which is a hard instruction in a week with nothing else on the shelf, so make sure they know to cover up and stay out of direct sun for the whole course.

Where This Fits

We want everyone looking at the whole picture of a patient’s medications in a disaster. We’re a team of pharmacists, physicians and PAs, and we catch these same interactions in ordinary clinic weeks: the ibuprofen on top of the ACE inhibitor, the Bactrim in the spironolactone patient. The chemistry doesn’t change in a disaster. What changes is that the catching stops. The screen, the lab and the pharmacist who would have caught it all get harder to reach in an emergency.

So, Jase does the clinical work early. A licensed provider reviews the request and writes the prescription ahead of time, for a short list of predictable problems, for emergency use only and after the patient has tried to reach a qualified provider. That’s what we mean by appropriate medical preparation. We also mean helping patients know, before a disaster, which items on their own medication list are most likely to cause trouble.

The drugs a disaster adds are boring. What makes them dangerous is the patient’s existing medication list. 

Sources

1. Shehab N, Lovegrove MC, Geller AI, Rose KO, Weidle NJ, Budnitz DS. US emergency department visits for outpatient adverse drug events, 2013-2014. JAMA. 2016;316(20):2115-2125. https://pmc.ncbi.nlm.nih.gov/articles/PMC6490178/
2. 2023 American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2023;71(7):2052-2081. https://doi.org/10.1111/jgs.18372
3. Calvo DM, Saiz LC, Leache L, Celaya MC, Gutiérrez-Valencia M. Acute kidney injury and morbi-mortality associated with “triple whammy” combination: systematic review and meta-analysis. Br J Clin Pharmacol. 2025;91(11):3031-3041. https://pmc.ncbi.nlm.nih.gov/articles/PMC12569550/
4. Lane MA, Zeringue A, McDonald JR. Serious bleeding events due to warfarin and antibiotic co-prescription in a cohort of veterans. Am J Med. 2014;127(7):657-663.e2. https://pmc.ncbi.nlm.nih.gov/articles/PMC4116816/
5. Antoniou T, Hollands S, Macdonald EM, Gomes T, Mamdani MM, Juurlink DN. Trimethoprim-sulfamethoxazole and risk of sudden death among patients taking spironolactone. CMAJ. 2015;187(4):E138-E143. https://pmc.ncbi.nlm.nih.gov/articles/PMC4347789/
6. US Food and Drug Administration. Acetaminophen. Safe Use of Over-the-Counter Pain Relievers and Fever Reducers. https://www.fda.gov/drugs/safe-use-over-counter-pain-relievers-and-fever-reducers/acetaminophen
7. Tylenol Extra Strength (acetaminophen) Drug Facts label. DailyMed, US National Library of Medicine. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=59773893-09a8-47a2-943a-e9ea9da4458a
8. Centers for Disease Control and Prevention. Heat and Medications: Guidance for Clinicians. https://www.cdc.gov/heat-health/hcp/clinical-guidance/heat-and-medications-guidance-for-clinicians.html
9. CIPRO (ciprofloxacin hydrochloride) tablets, prescribing information. US Food and Drug Administration, 2024. https://www.accessdata.fda.gov/drugsatfda_docs/label/2024/019537s095,020780s050lbl.pdf
10. Doxycycline hyclate tablets and capsules, prescribing information. DailyMed, US National Library of Medicine. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=fad03768-f1d2-459f-965e-0ec29f189f1f

For Clinicians | Animal Sting Reactions: Large Local Reaction vs Cellulitis, and When It’s Anaphylaxis

By Dr. Jamie Wilkey, PharmD, Director of Clinical Education
Medically reviewed and edited by Kristen Carpenter, PA-C

This is part two of our Animals + Disaster series. Part one was all about which bites actually need antibiotics. Today we are talking about stings. And stings get a sharper answer (gotta love that pun, right!): almost none of them. The drug that matters in stings isn’t an antibiotic at all. Today we’re sorting all of this out, plus what fire ant pustules are doing and the two stings that need something other than an antibiotic.

What a sting does to the body

A sting is venom, injected on purpose, by an animal defending itself. A bite is a wound with mouth bacteria in it. A sting inoculates almost nothing, so infection isn’t really that likely.

Almost everything that stings you is female because stingers are modified ovipositors. The 3 bugs that are most likely to sting you in the US are honeybees and bumblebees, the vespids (yellowjackets, hornets and paper wasps), and imported fire ants. Honeybees leave the stinger behind still pumping venom, so get it out fast. Speed is what matters and technique doesn’t. ¹ Vespids keep theirs and can sting over and over, which is how one disturbed nest becomes a multiple-sting patient. Fire ants bite to hold on, then pivot and sting in an arc, and that’s where the ring of pustules comes from. ²

Bee and vespid venom is mostly protein, and protein is what IgE recognizes, so those are the stings that turn allergic. Fire ant venom doesn’t have much protein and is mostly piperidine alkaloids which are directly cytotoxic. That’s the pustule, and it’s why no Rx you prescribe changes it. ²

So what you’re looking at comes down to which insect, how many stings, and whether that patient has already made IgE. Scorpions and spiders aren’t going to be covered today (hang tight for that article coming up soon!), and scorpion envenomation is neurotoxic rather than allergic anyway. 

Is a hot, swollen sting site cellulitis?

Usually not. The clock tells you more than the exam does. A large local reaction is a late-phase IgE response, not an infection. A typical sting will progress normally as swelling over 10 cm that’s still there past 24 hours,³ peaking somewhere in that 24 to 48 hour window, then taking 3 to 10 days to fully settle.⁴ Patients will tell you their whole arm is swollen, and they’re often right. Cellulitis runs on a different clock. It shows up later, and instead of peaking and receding it keeps spreading past the sting site. So check out which direction the site has been moving, not how angry it looks on the day you see it. A site still spreading after 48 hours is the one to treat.

You’re probably wondering how an anaphylactic reaction plays in here, and whether it relates to these exaggerated sting sites. They might relate a little. The guideline puts the risk of a systemic reaction under 10%, and anaphylaxis under 5%. It also says these patients usually just get another big local reaction.⁴ So the swollen arm by itself isn’t what makes you refer or write for epinephrine. A systemic reaction is.

Fire ant pustules are supposed to look like that

Leave them alone. That’s the whole intervention. Easy, huh!?

Fire ants create their own community raft on floodwater, with thousands locked together, and they sting on contact when somebody wades into one.⁵ So stings climb after heavy rain and flooding across the Southeast and Gulf. Dozens of stings on the feet and ankles, in rings, is fire ants and nothing else.⁶ 

24 to 48 hours post-sting the sting sites become sterile pustules. ² They really are sterile! They look exactly like infection and nothing reverses them, because the alkaloid already killed the cells. ² The skin over a pustule is protecting the tissue underneath. Lancing one creates a wound that may need an antibiotic.  Therefore, just good ‘ol soap and water plus an antibiotic cream if a pustule opens on its own. ² Fire ant anaphylaxis does happen, but is pretty uncommon. Serious systemic reactions run around 2% of fire ant stings in people who seek care. ² 

When is a sting an emergency, and how long do you watch?

There’s really only one sting emergency, and it’s anaphylaxis. You recognize it one of two ways: either two+ organ systems are involved, or the blood pressure drops (a systolic < 90 in an adult or a fall of more than 30% from their own baseline). Hives plus vomiting counts, and so does hives plus wheezing. A drop in blood pressure after a sting is enough on its own, without a second system getting involved at all. ⁷

When you see these symptoms give epinephrine. Must be epinephrine! An antihistamine and a steroid aren’t a substitute here and they don’t keep the reaction from coming back a few hours later, which is the thing we all hope they’ll do. ⁷ 

How long do you watch? We all learned 4 to 6 hours for everybody. Well, the 2023 practice parameter cut that down. If the reaction wasn’t severe, one hour with no symptoms after it resolves is enough, because nearly every biphasic reaction has declared itself by then. ⁷ Only a severe reaction, or one that took more than one dose, needs longer.

And just keep in mind a second epinephrine dose may be needed. In a 2021 systematic review, 17% of venom-triggered reactions needed one when a health care professional was there to give it.⁸ That’s more than most of us would guess, so don’t discount it.

When it’s the venom, not the allergy

A patient with 50 or more stings is a different problem entirely. There’s enough venom on board at that point to do direct damage, so what you’re watching for is rhabdomyolysis, acute kidney injury and hemolysis rather than an allergic reaction.⁹ Tolerance runs about 22 stings per kilo, which means roughly 500 can kill a child.¹⁰ Management of being a human sting pin cushion is aggressive fluids with an eye on urine output, and plenty of people add bicarbonate, though it has never been shown to beat saline alone.¹²  Either way it needs a hospital and not an autoinjector. All of it comes from case reports, though. There’s no guideline here.

The referral almost nobody makes

Anyone who has had a systemic reaction to a sting should be referred for venom immunotherapy. Untreated, about 40% of those patients have another systemic reaction the next time they’re stung. On immunotherapy it’s under 3%. ¹¹ Patients know this as allergy shots for bee stings, and that’s the phrase to use at the counter, because “venom immunotherapy” means nothing to them. After a disaster sting the referral almost never gets made, and it’s the only thing on this list that changes what the next sting does to them.

Where this fits

Nearly everything in this article is a decision rather than a prescription. Is the arm swelling or spreading? Is the pustule intact or opened? Those calls are all or none right now. Either a patient reaches a clinician who reads the clock, or they’re home staring at a hot red arm with a search bar and a leftover antibiotic.

Jase works the layer in between, and for stings that mostly isn’t a drug. It’s the thinking done in advance: which reaction is expected, which one is spreading, and which one means the epinephrine comes out. Where a prescription is part of it, a licensed provider reviews the request and writes it, for emergency use only and after first trying to reach a qualified provider. That’s what we mean by appropriate medical preparation, and it’s in no way a replacement for primary care. It’s for the days primary care isn’t reachable.

Part one of this series was about bites, and how few of them actually need an antibiotic. And as you’ll see in part two, stings need one even less often. We’ll keep publishing how we make these calls for appropriate medical preparation.

The bottom line

Antibiotics really don’t help with stings. The hot swollen arm that looks infected almost never is, and the sting that actually needs a drug needs epinephrine.

So read the clock instead of the redness. Leave the pustules alone from those fire ants. When two systems are involved or the pressure drops, give epinephrine and watch the hour. And when a patient has already had a systemic reaction, make the referral, because it’s the only thing you’ll do that changes what the next sting does.

Sources

1. Visscher PK, Vetter RS, Camazine S. Removing bee stings. Lancet. 1996. PMID 8709689.
   https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(96)01367-0/abstract
2. Kruse B, Anderson J, Simon LV. Fire Ant Bites. StatPearls. Treasure Island (FL): StatPearls Publishing. Updated August 7, 2023. Venom is 95% water-insoluble alkaloid with a 5% aqueous protein fraction. Vesicles form within 4 hours and become sterile pustules by 24 hours. Serious systemic reactions occur in about 2% of fire ant stings among patients who seek care.
   https://www.ncbi.nlm.nih.gov/books/NBK470576/
3. Tripolt P, Arzt-Gradwohl L, Čerpes U, Laipold K, Binder B, Sturm GJ. Large local reactions and systemic reactions to insect stings: similarities and differences. PLoS One. 2020;15(4):e0231747. Large local reaction defined as swelling exceeding 10 cm lasting more than 24 hours. Median duration 7 days, range 1 to 21 days, in 310 patients.
   https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0231747
4. Golden DBK, Demain J, Freeman T, et al. Stinging insect hypersensitivity: a practice parameter update 2016. Ann Allergy Asthma Immunol. 2017;118(1):28-54. Large local reactions increase in size for 24 to 48 hours, exceed 10 cm contiguous to the sting site, and take 3 to 10 days to resolve. Patients with large local reactions have less than 10% chance of a systemic reaction and less than 5% chance of anaphylaxis, and usually have large local reactions again on subsequent stings.
   https://www.aaaai.org/Aaaai/media/Media-Library-PDFs/Allergist%20Resources/Statements%20and%20Practice%20Parameters/Stinging-insect-hypersensitivity-2016.pdf
5. NIOSH. Hurricane and Flood Key Messages for Employers, Workers, and Volunteers, Third Edition. Atlanta, GA: US Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. 2025-106; 2025. Fire ants “can cling together and float along in floodwaters,” sting aggressively when disturbed, and red bumps “within a day or two become white fluid-filled pustules.”
   https://www.cdc.gov/niosh/docs/2025-106/pdfs/2025-106.pdf
6. Diaz JH. The impact of hurricanes and flooding disasters on hymenopterid-inflicted injuries. Am J Disaster Med. 2007;2(5):257-269. PMID 18491841.
   https://doi.org/10.5055/ajdm.2007.0034
7. Golden DBK, Wang J, Waserman S, et al. Anaphylaxis: a 2023 practice parameter update. Ann Allergy Asthma Immunol. 2024;132(2):124-176. PMID 38108678. Reduced blood pressure defined as systolic below 90 mm Hg in adults or a decrease greater than 30% from that person’s baseline. Biphasic anaphylaxis is unlikely when the reaction is not severe and the patient remains symptom-free for one hour after resolution, a 95% negative predictive value (95% CI 90.9%-97.3%), and is likelier with increasing severity and in patients given more than one epinephrine dose.
   https://www.aaaai.org/Aaaai/media/Media-Library-PDFs/Allergist%20Resources/Statements%20and%20Practice%20Parameters/Anaphylaxis-Practice-Paramaters-2023.pdf
8. Patel N, Chong KW, Yip AYG, et al. Use of multiple epinephrine doses in anaphylaxis: a systematic review and meta-analysis. J Allergy Clin Immunol. 2021. PMID 33862009. Across 86 studies and 36,557 events, 7.7% of anaphylaxis events from any cause required more than one dose. Among venom-induced reactions in which a health care professional administered the subsequent dose, 17.1% (95% CI 11.3-25.0).
   https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8588837/
9. Osman UMA, Turfan S, Mohamud MFY. Multi-organ dysfunction due to envenoming syndrome following a massive bee attack: a fatal case study and comprehensive literature review. Int Med Case Rep J. 2024;17:353-357. PMID 38646457. More than 50 stings is categorized as massive envenomation, with rhabdomyolysis, acute kidney injury, hemolysis, DIC and myocardial injury described. Case report with literature review.
   https://doi.org/10.2147/IMCRJ.S456777
10. Insect Stings. Merck Manual Professional Version. The average unsensitized person tolerates 22 stings/kg body weight, so an adult can withstand more than 1,000 stings whereas 500 stings can kill a child.
    https://www.merckmanuals.com/professional/injuries-poisoning/bites-and-stings/insect-stings
11. Boyle RJ, Elremeli M, Hockenhull J, et al. Venom immunotherapy for preventing allergic reactions to insect stings. Cochrane Database Syst Rev. 2012;CD008838. PMID 23076950. Subsequent systemic sting reaction in 3 of 113 treated patients (2.7%) versus 37 of 93 untreated (39.8%). Risk ratio 0.10, 95% CI 0.03-0.28.
    https://doi.org/10.1002/14651858.CD008838.pub2

For Clinicians | Carbon Monoxide Poisoning Recognition: The Question That Beats the Symptom List

By Dr. Jamie Wilkey, PharmD, Director of Clinical Education 
Medically reviewed and edited by Kristen Carpenter, PA-C

September is National Preparedness Month, so we’re spending it on the disasters that actually turn up in your patients’ lives. One of them arrives with no smell, no color, and no symptom you can trust: carbon monoxide (CO). A family can be getting hurt for days without knowing, because symptoms alone can’t separate it from whatever is going around. Headache, nausea and fatigue are so common that we as clinicians typically match them to whatever is going around then (the flu in late January, heat exhaustion in July, etc). Today you’re going to get a refresher on how CO poisoning works, who is most at risk, where it happens most commonly, and how to help patients who may be experiencing this silent, un-smelly, and deadly gas exposure.

How often does CO exposure actually kill someone?

Rarely, compared to how often it happens. CO sends roughly 50,000 people to US emergency departments every year.¹ In 2021 it killed about 500 people unintentionally, and about 500 more by suicide.²

(Everything that follows uses the unintentional numbers. Intentional poisoning is coded and reported separately, so it isn’t mixed into any figure in this article.)

That difference between 50,000 affected and 500 dead is thanks to physiology and it’s good news. CO binds hemoglobin with about 250 times the affinity of oxygen, and what it forms, carboxyhemoglobin, is reversible.3 Get the patient into fresh air and it clears on its own, with a half-life of about five hours on room air and about an hour on high-flow oxygen.4 Symptoms start around 10% COHb, and killing a healthy adult usually takes levels above 50%.3 Most exposures never come close, because the source was weak, the room wasn’t sealed, or somebody opened a door.

When someone dies it is usually due to concentration, not duration. The power goes out, a generator comes on, and it’s running somewhere it shouldn’t be. For example, a gasoline engine in an enclosed space drives the concentration up fast, and rapid high-level exposure incapacitates a person before they can get themselves out.3

That’s the difference between the household that shows up at your office feeling flu-ish for three days and the person found unconscious on the garage floor. Same gas, but different exposures.

Who is most at risk for unintentional CO poisoning deaths?

When I think of CO poisoning, I picture a young family with babies and toddlers, poisoned in their own house while they sleep. The death data says otherwise. Adults 45 and older are roughly two thirds of it, and children under 15 are 3%.3 Children don’t tolerate CO better. It’s just that risk is around machines, and the person nearest to (or operating) the machine is an adult. Kids still get exposed, but they show up in ED visits instead of death certificates. Children aged 0 to 9 have the highest rates of poison center calls and CO-related ED visits of any age group.5

Proximity to the CO-emitting device is the whole ballgame here. In one review of disaster-related poisonings, two thirds of the fatal generator cases involved a generator placed indoors, and another third involved one placed outside but too close to the house. Most of the nonfatal cases traced to an attached garage, or a spot right outside a window.6 

That’s also why men are about four out of five of these deaths.3 Those same incidents average two people poisoned each, so the man who dies usually isn’t the only one exposed…he’s the one who was closest to the exhaust.6

So where does it actually happen, and when? 

At home, about three quarters of the time.3 Thirteen percent happen in temporary shelters (cabins, campers and trailers people are sleeping in), mostly from a heater or a generator. Eight percent happen inside vehicles, where somebody ran a generator or an LP heater in there, or burned charcoal in the car.3 Another 34 deaths in 2022 were in detached structures like the shed and the detached garage.

And it isn’t always a generator. Most CO deaths happen in the cold months, 55% of them from November through February, and the winter version of this runs on heating equipment: furnaces, room and space heaters, and the vent that quit working. Heating appliances were the second-largest category in CPSC’s 2022 count at 76 deaths, and charcoal accounted for 18 of the 20 solid-fuel deaths.3 

Geography decides what happens after. The most rural addresses carry about three times the share of CO deaths you’d expect from their population,3 and those are the same patients sitting furthest from an ED in a real emergency.

What actually raises suspicion for CO poisoning?

Ask,  “Who else in the house feels the same way?”

It is simple, short and helps flag CO poisoning separately from other ailments with similar symptoms. 

That question has been tested. In the study that validated it, 65 winter patients presented with headache or dizziness and no known exposure. Symptomatic cohabitants alone identified occult CO poisoning with 75% sensitivity and 90% specificity, and the authors called it the most dependable marker they had.7 

The second question is, “Does it get better away from the house?”

You can guess why this is helpful: if you get away from the source and feel better then that’s your answer. COHb falls by half in about five hours on room air,4 so the patient who spends a workday out of the building feels better by afternoon and gets re-dosed the moment they walk back in. Headaches that lift in the car and return overnight are the pattern. Ask about the dog, too. The dog doesn’t leave for long the way you and your kids do for work and school.

The exposure window is days, not hours. In a New York study of pediatric CO poisoning, four hours without power raised the odds of an ED visit by at least 50%, and by 150% or more when the outage was large-scale, with the risk tracked across the days that followed.8

Why a normal pulse ox proves nothing

The bedside tool, aka a pulse ox, most of us reach for first fails hard on CO poisoning. You see, in a case of poisoning:

• Standard pulse oximetry still reads falsely normal. A two-wavelength oximeter can’t tell carboxyhemoglobin from oxyhemoglobin, so it counts the poisoned blood as saturated.4,5 That 99% on the monitor is measuring the wrong molecule.
• Pulse CO-oximetry, the seven-wavelength kind that reports an SpCO, is better and still can’t clear the patient. Performance is good, not perfect, and it isn’t adequate to exclude CO poisoning when you already suspect it.4 A normal SpCO with a suspicious history means you still draw the blood.
• The COHb level doesn’t tell you how sick someone is. There’s no validated relationship between the number and the symptoms.4 Treat the patient and the history, not the number.
• Cherry-red skin is a postmortem finding. It’s in every review and it is not a bedside sign because your patient is still alive.5

Two extra notes: a COHb level runs on venous blood, so nobody needs an ABG for this.4 And a smoker’s baseline can sit as high as 10%, which is enough to blur real exposure at the low end.5

The test that helps the most and is free is so simple. It is as we just learned above: asking who else in the house feels this way.

What to do when you suspect it

Get everyone out of the building first, into outdoor air, and call 911 if anyone has symptoms. Fresh air starts the clock by itself, and high-flow oxygen speeds it up: about five hours to clear half the COHb on room air, about one hour on 100% oxygen.4 Oxygen is the treatment.

Then evaluate everyone who was inside, including the ones who say they feel fine. Those incidents average two people poisoned each.6 Before anyone goes home, tell the family what to watch for. New neurologic or cognitive symptoms can show up 2 to 40 days after the exposure, and delayed sequelae appear in something like a quarter to a half of hospitalized patients.1,5 The risk runs higher with loss of consciousness, a longer exposure, a COHb at or above 25%, or abnormal imaging.¹ Neuropsychological testing belongs a month or two out…not at discharge.5

If you confirm CO poisoning in an adult who was alone, with nobody else affected and no obvious source, you really need to consider intent here. Roughly half of American CO deaths are suicides,² and that patient does not look different when they appear in your office from the one who parked the generator too close. 

What to tell them before the next outage

Almost everyone already knows not to run a generator indoors. In a study of 32 generator owners in North Carolina, people ran them in attached garages, screened porches, covered patios, basements and sheds, and many of them did not count an attached garage or a covered porch as being “in the house.”9 Only half of them had a CO alarm.9

So the counseling point for you to remember with your patients isn’t a warning, it’s a distance and a direction. Outside only, at least 20 feet from the house, exhaust pointed away from doors, windows and vents. Never a garage, a basement, a crawlspace, a shed or a porch, and opening the door doesn’t fix it. Never leave a car running in an attached garage.10

Then, get the alarm! A CO alarm that is battery-operated or with battery backup, one on every level outside the sleeping areas, tested monthly.10 Most states require them in homes now.² 

We publish regularly about what supplies to have on hand to be prepared in a disaster. There’s nothing to stock for carbon monoxide other than a working alarm on every floor and making sure there is a minimum of 20 feet between the generator and the house. What prepares us is asking who else in the house feels the same way.

That’s appropriate medical preparation too. We’re in no way a replacement for primary care. We’re the clinicians who would rather you catch this before it even happens.

The bottom line

CO doesn’t announce itself, and the symptom list won’t separate it from other sicknesses. The household will. One sick person is usually a virus. A whole household that feels better away from the house is a building problem. The pulse ox won’t tell you which one is in front of you.

So when the power has been out a couple of days and a family turns up feeling wrung out, ask who else feels it and whether it lifts when they leave. If the answer points at the house, get everyone outside and call 911 for anyone symptomatic.

Sources

1. American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Carbon Monoxide Poisoning; Shih RD, Tomaszewski CA, Kaji A, Diercks DB. A Critical Issue in the Management of Adult Patients Presenting to the Emergency Department With Acute Carbon Monoxide Poisoning: Approved by the ACEP Board of Directors January 22, 2025. Annals of Emergency Medicine. 2025;85(4):e45-e59. https://pubmed.ncbi.nlm.nih.gov/40118649/
2. Hampson NB. Carbon monoxide poisoning mortality in the United States from 2015-2021. Clinical Toxicology. 2023;61(7):483-491. https://doi.org/10.1080/15563650.2023.2237667
3. U.S. Consumer Product Safety Commission. Non-Fire Carbon Monoxide Deaths Associated with the Use of Consumer Products: 2022 Annual Estimates. May 2026. https://www.cpsc.gov/s3fs-public/Non-Fire-Carbon-Monoxide-Deaths-Associated-with-the-Use-of-Consumer-Products-2022-Annual-Estimates.pdf
4. Internet Book of Critical Care (EMCrit). Carbon monoxide poisoning. https://emcrit.org/ibcc/co/
5. McMahon K, Launico MV. Carbon Monoxide Toxicity. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Updated April 19, 2025. https://www.ncbi.nlm.nih.gov/books/NBK430740/
6. Iqbal S, Clower JH, Hernandez SA, Damon SA, Yip FY. A review of disaster-related carbon monoxide poisoning: surveillance, epidemiology, and opportunities for prevention. American Journal of Public Health. 2012;102(10):1957-1963. https://pmc.ncbi.nlm.nih.gov/articles/PMC3490658/
7. Heckerling PS, Leikin JB, Maturen A. Occult carbon monoxide poisoning: validation of a prediction model. American Journal of Medicine. 1988;84(2):251-256. https://pubmed.ncbi.nlm.nih.gov/3407653/
8. Northrop AJ, Do V, Flores NM, Wilner LB, Sheffield PE, Casey JA. Power Outages and Carbon Monoxide Poisoning in Children. Pediatrics. 2025;155:e2024068213. https://pubmed.ncbi.nlm.nih.gov/40320254/
9. Damon SA, Poehlman JA, Rupert DJ, Williams PN. Storm-Related Carbon Monoxide Poisoning: An Investigation of Target Audience Knowledge and Risk Behaviors. Social Marketing Quarterly. 2013;19(3). https://pmc.ncbi.nlm.nih.gov/articles/PMC4559492/
10. U.S. Consumer Product Safety Commission. What to Know About Generators and Carbon Monoxide (CO). CPSC publication 468. https://www.cpsc.gov/s3fs-public/468-WhattoKnowGenerators_2022.pdf

For Clinicians | Controlled Substance Emergency Refill Rules: A Pharmacist’s Q&A

By Dr. Jamie Wilkey, PharmD — Director of Clinical Strategy, Jase
Medically reviewed and edited by Kristen Carpenter, PA-C

Hi again, it’s Jamie, your pharmacist. 

Here at Jase, we really like to help people be prepared for disasters, whether they be natural or supply chain or just being far from medical care. Most of the time we’re talking about regular medications, blood pressure and diabetes, etc.  But those aren’t the only medications that are really important to patients.

Today we’re talking about controlled substances, because they are much more complicated in a disaster. The same rules don’t apply for them as they do for the regular, or legend, medications. So here’s how these controlled substances generally work, what the different categories mean, and the problems I see go wrong most often when someone can’t get one filled.

One caveat: each state has different rules, so this is an overview and in no way comprehensive. Your local pharmacist knows your state’s rules very well and can help you the most.

Before we start, three things. 

1. We are not telling anyone to get extra opioids or extra stimulants. We never will, and federal law mostly doesn’t allow for it anyway. 
2. Jase does not sell controlled substances at all, not one, in any kit or any add-on. 
3. This class gets complicated faster than anything else in the medicine cabinet, which is exactly why we’re covering it instead of skipping it like most preparedness writing does.

“What schedule is it?”

This is the first question I ask, and most patients have no idea their prescription has a number, or schedule as we call it, attached to it. Here’s how those drug classes work:

• Schedule II is the stimulants, oxycodone, hydrocodone, morphine, methadone. No refills, ever. That’s federal law, not a pharmacy policy. But a prescriber can write two or three prescriptions at the same visit, up to a 90-day total supply, each with a “do not fill until” date on it.¹ That’s federal too, where state law allows it.
• Schedule III through V is buprenorphine, most benzodiazepines, tramadol, pregabalin. Those can carry refills. They can be transferred between pharmacies if both are open and willing to transfer. In a lot of states a pharmacist can step in during an emergency here.
• There is a Schedule I, but I’m not writing about it here because these meds are not allowed to be dispensed in a pharmacy in any state ever. Think heroin or LSD, etc. 

Two bottles can sit in the same drawer in the same house for the same patient and be in completely different situations. The Rx label won’t tell you which class of medication the drug is, either.

“Which ones are actually dangerous to stop?”

Benzodiazepines are the medical emergency. Stopping abruptly in a physically dependent patient can cause seizures and delirium, and that includes patients on a therapeutic dose who have never had a seizure in their life. ASAM and nine other societies published a tapering guideline in June 2025 that says outright not to discontinue abruptly in anyone likely to be dependent.²

Opioids are the opposite problem. The withdrawal is miserable and rarely lethal on its own, though it isn’t benign in pregnancy. The danger is the restart. Tolerance drops within days, and the dose that was routine two weeks ago can be the one that stops their breathing. So the plan has to cover going back on, not just running out.

Stimulants aren’t physiologically dangerous to stop, and CDC issued a health advisory about it anyway.³ In June 2024 a federal indictment against a large subscription telehealth company put 30,000 to 50,000 adults at risk of losing their ADHD prescriber, in all 50 states, more or less at once. CDC’s worry wasn’t withdrawal. It was that people go looking, and what’s on the street pressed to look like Adderall is frequently fentanyl.

Only the benzodiazepines are likely to hurt someone in the first week. The other two hurt them later, and need to be a part of the patient’s post-disaster care plan.

“Can another pharmacy just fill it?”

Sometimes. It depends on whether it’s already been filled at another pharmacy.

If the prescription is still sitting at a pharmacy unfilled, a rule that took effect in August 2023 lets it move.⁴ Any electronic controlled substance prescription, Schedule II included, can be transferred one time to another retail pharmacy. The patient has to ask, and has to name the pharmacy they want it sent to. The two pharmacists handle it directly. That’s it. One transfer, and the prescription has to still be electronic and unfilled. And both pharmacists have to agree to it. I know in practice still in mid-2026 not all pharmacies are connected online, so from my experience in Utah there’s about a 45%ish success rate between pharmacies in the same state. It’s less successful as you move out of state. I’m sure it’ll improve every month as time marches on, but that’s where we are now. 

If it’s already been filled and you’re looking for the refills, that’s a different rule, and Schedule II is out because there are no refills to transfer. For Schedule III through V, refill information can be transferred once, unless the two pharmacies share a real-time database.⁵ And again, both pharmacists must agree. If a pharmacist doesn’t feel comfortable dispensing it they can refuse the prescription. 

“Can’t the pharmacist just give me a few days’ worth?”

For a lot of medications, yes. Most states let a pharmacist dispense an emergency supply when the prescriber can’t be reached, and many widen that once a governor declares an emergency. How much and under what conditions varies state to state.6

Schedule II is almost always carved out, and the reason is structural. Those laws work by letting a pharmacist extend an existing prescription, and Schedule II has no refills to extend.

There is a federal path for Schedule II. In an emergency a pharmacist can dispense a Schedule II on a prescriber’s spoken authorization, limited to the amount needed to get through the emergency.7 The pharmacist writes it down on the spot, and the prescriber has seven days to send a written prescription marked “Authorization for Emergency Dispensing.” Again, it is still within the pharmacist’s purview to choose to fill it or not if a prescriber calls the emergency Rx in. 

Methadone runs on two different systems depending on what’s being treated. Prescribed for pain, it’s an ordinary Schedule II prescription and everything above applies. Prescribed for opioid use disorder, it can only be dispensed by a federally certified opioid treatment program.⁸ Not a retail pharmacy, not in an emergency, not with a prescriber on the phone. So a displaced patient calling pharmacies is wasting the day. What they need is another certified program willing to dose them temporarily, which programs already do routinely for people who travel.

The bottom line

Every option in this article runs through a prescriber someone can reach. That’s the part that can fail first in a real life emergency. 

For every patient on a controlled substance who’s worried about this and wants to plan ahead with you, decide now what happens if they can’t fill for a week, and talk it through together. Which schedule is it? Does it taper or wait if it can’t be filled? Who authorizes an emergency dose, and at what contact number?

That’s what appropriate medical preparation looks like for a class where preparation can’t mean an extra supply on the shelf. None of this replaces the relationship these patients already have with you, and for this class nothing could. We’ll keep publishing how we work these questions out. For questions in your own state pick up the phone and call your local pharmacist. They are the experts here and happy to help.

Sources

1. 21 CFR 1306.12, Refilling prescriptions; issuance of multiple prescriptions. Schedule II refills prohibited under (a). Paragraph (b) permits multiple prescriptions totaling up to a 90-day supply, each carrying written instructions on the earliest date a pharmacy may fill it. https://www.ecfr.gov/current/title-21/chapter-II/part-1306/subject-group-ECFR8588b52940237ef/section-1306.12
2. American Society of Addiction Medicine et al., Joint Clinical Practice Guideline on Benzodiazepine Tapering: Considerations When Risks Outweigh Benefits. Journal of General Internal Medicine, June 2025. ASAM with nine partnering societies, modified GRADE methodology. Recommends against abrupt discontinuation in patients likely to be physically dependent, with initial reductions of 5 to 10% every 2 to 4 weeks and not exceeding 25% every two weeks. https://link.springer.com/article/10.1007/s11606-025-09499-2
3. CDC Health Advisory CDCHAN-00510, Disrupted Access to Prescription Stimulant Medications Could Increase Risk of Injury and Overdose. June 13, 2024. https://www.cdc.gov/han/2024/han00510.html
4. DEA final rule, Transfer of Electronic Prescriptions for Schedules II-V Controlled Substances Between Pharmacies for Initial Filling. Federal Register, July 27, 2023, effective August 28, 2023. One-time transfer at the patient’s request, prescription must be unfilled and remain electronic, communicated directly between two licensed pharmacists. https://www.federalregister.gov/documents/2023/07/27/2023-15847/transfer-of-electronic-prescriptions-for-schedules-ii-v-controlled-substances-between-pharmacies-for
5. 21 CFR 1306.25, Transfer between pharmacies of prescription information for Schedules III, IV, and V controlled substances for refill purposes. One-time basis only, unless the two pharmacies share a real-time online database. https://www.ecfr.gov/current/title-21/chapter-II/part-1306/subject-group-ECFRe4ae2bfb4eae102/section-1306.25
6. Healthcare Ready, A Review of State Emergency Prescription Protocols. https://healthcareready.org/a-review-of-state-emergency-prescription-protocols/
7. 21 CFR 1306.11(d), Requirement of prescription. Emergency dispensing of a Schedule II on a practitioner’s oral authorization, limited to the quantity needed for the emergency period, with a written prescription marked “Authorization for Emergency Dispensing” delivered within seven days. https://www.ecfr.gov/current/title-21/chapter-II/part-1306/subject-group-ECFR8588b52940237ef/section-1306.11
8. 42 CFR Part 8, Medications for the Treatment of Opioid Use Disorder. No program may dispense methadone for opioid use disorder without SAMHSA certification. https://www.ecfr.gov/current/title-42/chapter-I/subchapter-A/part-8