Download Methadone Maintenance Treatment Program Standards and Clinical

What it all means…
Question one…….
Ms. Presley was on methadone under your care years
ago. She had been off the program for a few years and
restarted back on methadone after a lengthy IV heroin
and Oxycontin addiction. She has no features that put
her at higher risk of overdose. She was previously on
150mg of methadone.
She has now been on 80mg for the past 3 days. She
complains of classic opiate withdrawal symptoms 12
hours later. She has ongoing IV use of heroin in the
evening time when most of her withdrawals and cravings
for opiates start. As 3 days have passed, what do you do?
Question one….
You increase her to 90mg
2. You increase her to 95mg
3. You hold her dose where it is (80mg)
1.
Question one ANSWER
Answer 3
Key message…
 After a dose of 80mg has been obtained, you should
wait 5-7 days to pass before another increase in
methadone.
 dose increases above 80mg should be 5-10 mg only
even if no high risk features
Question two….
Ms. Presley has reached 120mg and is still complaining of
withdrawal 15 hours later.
She denies any sedation or side effects from methadone.
She denies using he.roin but recently started smoking crack
cocaine once to twice a week
She wants an increase as she was previously on 150mg and feels
uncomfortable with withdrawal late night. What do you do?
1. You increase her cautiously to 130mg after consulting with
another specialist
2. You decide to leave her at 120mg as you are not comfortable
with high range dosing and offer counselling around her
cocaine use
3. You insist on an EKG prior to increasing the dose above 120mg
Question two ANSWER
Answer either 2 or 3
Key message…
 Cocaine use is a risk factor for QT prolongation.
 An EKG is required for dosing above 120mg for
high risk patients
Table 07: Risk Factors for QTc Prolongation in Patients on Methadone
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Older Age
Heart disease
Myocardial infarction, congestive heart failure, valvular disease,
cardiomyopathy
HIV infection
Low potassium level
On drugs that lower potassium eg. Diuretics
Low prothrombin level
On medications that inhibit Cytochrome p450 3A4
HIV antivirals e.g. indinavir
Antifungals e.g., Fluconazole, ketoconazol
Calcium channel blockers e.g., Diltiazem,
verapamil
Antimicrobials e.g., Norfloxacin
Antidepressants e.g., Fluvoxamine
Contraceptives e.g., Mifepristone
Foods: e.g., grapefruit juice
Alcohol use
Cocaine use
Family or past history of long QT syndrome
History of syncope or sudden cardiac death in the family
On medications that prolong QTc Cardiac medications
amiodarone, sotalol
Antipsychotics (chlorpromazine,
haloperidol)
pimozide, thioridazine
Antibiotics e.g., clarithromycin,
c
erythromycin
Anti-nausea drugs e.g., domperidone
Question three….
Mrs. Jones is on chronic benzodiazepines (Valium 20mg bid
recently discontinued by her GP) and is injecting 1 gram of
heroin per day. She will be starting methadone today. Her
initial urine shows positive opiates and benzodiazepines. She
is in obvious opiate withdrawal and has visible track marks.
She states she hasn`t had any Valium for the past week, and is
worried about having a seizure.
She insists that 20 mg will not be enough, as she was
previously on methadone last year at a dose of 120mg, and she
tells you she has an extra high tolerance as she has been
injecting heroin for over 15 years.
What dose would you start this patient at?
Question three…
Start on 20 mg with reassurance
2. Start at 25 mg as it is under 30mg, and she has a
known high tolerance
3. Start at 30mg given ongoing IVDU heroin use and
risks of this.
4. Either 2 or 3
1.
Question three ANSWER
Answer 1 only
Key point….
Patients who are on chronic benzodiazepines , or alcohol
are high risk for overdose and should be started at 20mg
or less regardless of opioid use history
Table 03: Patient Factors that Increase Risk of
Methadone Toxicity
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High Risk Patients
Recent benzodiazepine use
Use of other sedating drugs
Alcohol-dependent patients
Over 60 years old
Respiratory Illnesses
Taking drugs that inhibit methadone metabolism
Lower opioid tolerance
Decompensated hepatic disease
Recent discharge from inpatient rehabilitation facility
Recent incarceration
Question four….
Mr. Lee is doing well on 4 carries...the pharmacy has
notified you that he was getting a prescription for 80
Percocets a week from his GP. All of his UDS are
negative.
What do you do?
Question four…
Counsel the patient on dangers of double doctoring
and inform doctor to discontinue the Percocets for
safety reasons. Leave carries at 4 as he was drug free.
2. Inform doctor to discontinue Percocets for safety
reasons, and cancel all carries due to double
doctoring.
3. Cancel all carries but you are not obliged to speak
with the GP about this prescription.
4. Counsel the patient about risks of diversion of
Percocets and continue your care as it was.
1.
Question four ANSWER
Answer 2
Key message…
If this patient was taking 80 Percocets weekly along with
methadone you would expect a positive UDS for
oxycodone. With a negative UDS, he is either diverting
his prescription or bringing in someone else’s urine for
testing. Carries should be held until stability is ensured.
Question five…
Mrs. Jones has been a stable level 6 patient for many,
many years. Recently her father died suddenly of a
massive MI, her husband left her with 3 children for
another woman, and her son was diagnosed with
diabetes. When she sees you she is quite upset and not
coping. She admits to recent cocaine use over the last
week in order to stay awake to be able to help her mother
and cope with her 3 children on her own.
What do you do?
Question five…
Hold all carries until you are assured that she is
stable without any drug use at all.
2. Her use of cocaine has been short lived. You decide
to change her to 5 carries, set her up with counselling
and see her in 1 week.
3. Continue her at 6 carries, set her up with counselling
and see her in 1 week.
4. Either 2 or 3
1.
Question five ANSWER
Answer 4
Key message
 It is important to know your patient and set up
appropriate supports for this patient.
 Carries can be decreased if you have concerns or held
at 6 carries and follow closely.
Question six….
You see Mrs. Jones weekly after her slip with cocaine and she
was able to stop using cocaine for one week. At the next visit
she admits to ongoing daily use of cocaine. She is still
receiving 6 carries. She states that her use has increased to
daily now for the last week. She is smoking crack cocaine now
multiple times daily and has not been able to stop. She begs
you not to change her carries. She admits that there is a
problem and is willing to get counselling, however removing
or changing her carries would result in more stress and she
feels that this will result in further drug use.
What do you do?
Question six…..
You are working with this patient closely and feel
that with counselling from the therapist and you, she
would do better with 6 carries. You continue her with
6 carries and see her weekly.
2. She has now had sustained drug use for more than 4
weeks. You hold all carries.
3. Given sustained drug use, you decrease carries to
CPSO level 5 and discuss importance of counselling
and dealing with current issues. You advise that you
will continue to decrease carries if ongoing use.
1.
Question six ANSWER
Answer 2
Key message….
 With ongoing substance use a patient is deemed
unstable and all carries should be held.
 Counselling and ongoing close monitoring of this
patient is important.
Question seven…..
You see Mrs. Jones weekly. It is 8 weeks later. Mrs. Jones
is not receiving any carries now. She has been seeing the
addiction counsellor weekly and is doing well and
managing with her children and the situation with her
ex-husband. She has not had any drug use for the last 2
weeks (her urine drug screens for the last week are
negative). She is asking for her carries back as she is
having a really difficult time getting to the pharmacy
daily.
What do you do?
Question seven….
1.
Return all carries. She was a longstanding stable patient
and needs her carries back.
2.
Return 3 carries for now and consider increasing more
carries if ongoing stability.
3.
You advise that you can restart one carry for now and
increase weekly so long as she remains stable.
4. You advise that you can restart one carry for now and
increase every 4 weeks so long as she remains stable.
Question seven ANSWER
Answer 3
Key message...
 When carries are removed (with a relapse for
example), they can be reinstated weekly so long as the
patient continues to be stable.
Question eight…
Ms. Presley has been abstinent on 80 mg of methadone.
The pharmacy informed you that she is getting a regular
script of Rivotril from her family physician after she has
been drug free
She admits to being on Rivotril for the past 10 years for
anxiety disorder and gives you consent to speak to her
GP. She is getting monthly prescription of Rivotril of
2mg TID
What do you do?
Question eight….
You call the family physician and let him know to
discontinue all benzodiazepines as she has misled
you
2. You inform the family physician of the potential
dangers of benzodiazepines with methadone and ask
for daily dispense of the Rivotril and suggest a taper
to Rivotril 2mg BID at a rate of 0.5 mg to 1 mg per
week. You ask of history of previous diagnosis, and
prior SSRI treatment.
3. You ask to take over the prescription so you can be in
a better position to taper .
1.
Question eight ANSWER
Answer 2 or 3
Key message…
 Communication between family physicians and
methadone prescribers are important for safety of the
patient
 A taper of High dose benzodiazepines is
recommended
 The benefit of taper should be stressed to the patient
 Ms. Presley has been getting chronic benzodiazepine from yourself at a dose of
Rivotril 1mg TID . She wants carries. How do you manage this patient? She has
had failed attempts of multiple SSRIs’. She has a diagnosis of chronic anxiety
disorder. She is unwilling to taper further at this point,.
 1. You can give only one carry and not more
 2. You should consult with a psychiatrist before giving any carry.
 3. You can give one additional carry per month as long as the following criteria
are met
 A.Controlled dispensing of the rivotril,.,ie daily
 B. A documented diagnosis with documented failed attempts of non
benzodiazepine alternatives such as SSRI
 C. An attempt to taper further
 D,.You may consult with an addiction specialist instead of a psychiatrist.
Question nine…
Bill is a long term patient receiving 6 carries for the last
number of years. He comes to see you once monthly but
leaves a urine drug screen every 2 weeks, which are all
negative. Your staff are suspicious of tampering (cold
sample which is negative for methadone) and ask for
another urine sample. Bill becomes angry and upset at
the staff but eventually leaves another sample that is
warm and positive for EDDP and cocaine.
What do you do with respect to his carries?
Question nine….
Discuss the relapse with the patient and if he is
remorseful and understands what he did wrong, you can
continue 6 carries but watch more carefully.
2. Decrease to 5 carries and arrange for twice weekly urine
drug screens to follow more carefully given the relapse
3. Hold all carries given tampering of the sample. Increase
frequency of urine samples to follow more carefully and
return all carries once you feel patient is stable.
4. Hold all carries given tampering of the sample. Increase
frequency of urine samples to follow more carefully and
return all carries one at a time back to 6 carries with
ongoing stability.
1.
Question nine ANSWER
Answer 4
Key message. ..
 The MMT physician shall cancel all take-home doses abruptly in the circumstances listed
below. The daily observed dose should be reduced if the MMT physician suspects the
patient may not have been taking the full take-home dose.
 There is reasonably strong evidence that the patient has diverted their methadone
dose, or has tampered with their UDS.
 The patient has missed 3 or more days of methadone (except in unavoidable
circumstances such as hospitalization).
 The patient has become homeless or in unstable housing, and can no longer safely
store their methadone.
 The patient is actively suicidal, cognitively impaired, psychotic, or is otherwise at high
risk for misuse of their methadone dose.
 The patient has recently been released from jail when incarcerated for prolonged
periods of greater than 3 months.
 Once carries are removed, they should be increased 1 every week or more back to 6 carries.
Question ten…
Sheila has been a patient for more than 1 year. She has
been stable since starting methadone and is now
receiving 6 carries. She was had charges pending from
illegal activity prior to starting methadone. She goes to
court and ends up in jail for 3 weeks. Her methadone is
continued while she is incarcerated. She comes to see
you after she is released. She has not missed any doses
and has not relapsed. She is married, has stable housing
and a job that she is returning to on Monday.
What do you do with her carries?
Question ten….
Hold all carries given that she was incarcerated and
therefore unstable. Return one every week back to 6
carries.
2. Given charges were from prior to becoming stable on
methadone and short incarceration, and given ongoing
stability without relapse, reinstate all carries now and
continue to monitor as you were prior to incarceration.
3. Decrease to 5 carries and monitor more carefully to
ensure stability.
1.
ANSWER
Answer 2
Key point…
 The MMT physician may reinstate take-home doses
immediately for patients who remain clinically stable
without problematic drug use, and:
1) had take-home doses cancelled due only to missed
doses
2) have been incarcerated for less than 3 months
Question eleven…
Sandra is a new patient who started on the program 2
weeks ago. She has stabilized on her dose and it is now
lasting 24 hours without any withdrawals or need for
opioid use. She is not using any other substances. She
has been missing every Sunday as her pharmacy is
closed. You discuss this with her and she states that she
is now only using opioids on the day she misses the
pharmacy. She is upset about having to use pills still and
she asks for a Sunday take-home carry.
What do you do?
Question eleven …
Allow for the Sunday carry as she tells you her pharmacy
is closed. She has been on the program for 2 weeks and
the missed dose is creating problems for her.
2. Advise that she is not allowed carries within the first 2
months and there is nothing you can do.
3. Advise her that she can start to have a Sunday take-home
dose in 2 weeks as this is allowed after 4 weeks so long as
she is stable and able to safely store the carry.
4. Look into alternate arrangements (other pharmacies in
her community or hospital dispensing) until she has been
on the program for 2 months and can then start regular
carries
1.
Question eleven ANSWER
ANSWER: 3 and 4
Key Message….
Sunday take home doses are allowable after 4 weeks only if
the patient:
1. Is able to safely store the medication
2. Dose not have an active addiction or mental illness that
increases the risk of methadone misuse or diversion
3. Lives in a community that does not have a pharmacy that
is open on Sunday
4. Has no hospital available for Sunday dispensing
5. Does not have transportation to a different community
Question eleven…
Two months have passed and Sandra is doing quite well. She is
stable at 85mg of methadone. She is receiving 1 take-home dose
and continues to leave supervised urine drug screens that are all
negative for any illicit substances. Sandra follows up in your office
for her regularly scheduled visit and is visibly upset. She asks you to
reduce her methadone dose and get her off of this as soon as
possible. On further questioning, she tells you that she needs to
work. She found a job however will be working 1 hour out of town.
She will be picked up by a co-worker at 0700 and may not get home
until after 7:00pm. The community pharmacy is only open from
8:00am – 6:00pm and there are no other pharmacies in the
community that open earlier or later. She tells you that she needs to
take this job and cannot be on methadone.
Can you expedite her carries?
Question eleven…
Not yet. She must continue to come to the pharmacy 6
days a week and can only increase carries as per the
regular schedule.
2. She could be eligible for expedited carries. These carries
would be increased every week until she is receiving 6
carries.
3. She could be eligible for expedited carries however these
carries would be increased every 2-4 weeks up to 5 carries
(M-F).
4. She could be eligible for expedited carries and given that
she is already receiving a carry, she can be given 5 carries
to accommodate her work situation.
1.
Question eleven ANSWER
ANSWER: 2 or 3
Key Message…..
The MMT physician shall prescribe an accelerated take-home
schedule only if:
1. prolonged daily pick up is likely to cause the patient to drop
out of treatment because of a lack of transportation or work or
family commitments
2. the patient is able to safely store the medication
3. the patient does not have a active addiction or mental illness
that increases the risk of methadone misuse or diversion
4. The first accelerated take-home dose may be given after one
month, with one additional weekly dose every 2-4 weeks.
Question twelve…
Stephen is a new patient and doing well on methadone. He has stable housing, is in a
relationship now, and looking for a new job. He has been on the program for more
than 2 months now and has a stable dose without any illicit substance use.
On September 10 you start 1 carry. You document on the program for more than 2
months and ongoing stability now.
You see him on September 17 and he continues to do well.
On September 24 he complains that his dose is not quite enough. He is continuing to
notice sweats, chills, restlessness, irritability, anxiousness and runny nose for 3-4 hours
before his dose is due. You document all of this in your notes and increase his dose
5mg.
On October 1 you see him and he is doing well and you start 2 carries (the forth week).
You are being assessed and the CPSO methadone assessor has some concerns about
this chart. What could they be?
Question twelve…
1.
2.
3.
4.
5.
You did not document discussion about carries,
safety of carries, risks of carries to children and
diversion.
You increased the carries too quickly
You continued carries despite the patient needing
minor dose adjustment
Both 1 and 2 are correct
1,2 and 3 are correct
Question twelve ANSWER
ANSWER: 4
Key Message…….
 Even if you have information about carries and safety in your
treatment agreement, safety and safe storage of carries must be
discussed and documented. You can use a carry agreement and
document that this was reviewed prior to starting carries.
 Small dose adjustments do not mean that a patient is not stable
 Carries should be increase every 4 weeks (having 1 carry for 4
weeks Sept 10, 17, 24 and Oct 1 and then increase to 2 carries on
October 8). Many physicians have difficulty with this. Ensure
they have had their carry level for 4 weeks and then increase
carries.
Question thirteen…
Ms. Presley had been stable at 80mg receiving 6 carries. She missed 4
days of methadone
She used valium once 3 days ago and used daily IV heroin
She is in obvious withdrawal when you see her.
What do you do with her dose?
1.
You start her at 30mg and increase by 10mg per day back up to 50mg
and then reassess her at 50mg
2. You restart her at either 20mg or 30mg and reassess her in 3 days to
assess clinical stability and counsel patient on dangers of
benzodiazepines.
3. You drop the dose to 60mg and hold her on this dose for one week.
Question thirteen ANSWER
ANSWER: 2
 You should restart at 20mg or 30mg. and reassess the
patient in 3-7 days after 4 missed days
 After 3 missed days, the dose may be decreased to 50
percent of the previous dose.
 10mg daily increases should only be done after 3
missed days. The patient should be reassessed after 3
days if you are increasing the dose daily by 10mg daily