12 December 2003

Australian national opioid treatment guideline publications August 2003.

Commonwealth Department of Health and Aging. Australian national treatment guidelines (full citations and internet address below) published Aug 03

Dear Colleagues,

Below are the web contacts for the Australian National treatment guidelines which were distributed in December 2003 by the Department of Health and Aged Care in Canberra. There are four volumes, a full and abbreviated version for both methadone and naltrexone. The authors are to be congratulated on a 'generic' set of instructions for the basic approaches to maintenance treatments, regardless of where this may be given.

http://www.healthyactive.gov.au/internet/main/publishing.nsf/Content/phd-illicit-methadone-treatment (old 1997 version)

http://www.health.gov.au/internet/main/publishing.nsf/Content/phd-illicit-methadone-cguide-s (abbreviated version 2003)

http://www.health.gov.au/internet/drugstrategy/publishing.nsf/Content/pharmacotherapy
(link to other guidelines available for buprenorphine, naltrexone, methadone, etc)

Australia’s eight different jurisdictions have eight different sets of treatment rules, from quite liberal (South Australia) to almost barbaric (Northern Territory). However, doctors do not normally have the liberty of giving sub-standard treatment because of the jurisdiction they practice in. According to the British Medical Journal, where there is clear research evidence, doctors are normally required to follow it. Hence, as these Guidelines point out, all Australian opioid dependent residents should have access to appropriate dose levels of the right drug in the right setting. Also, in all community treatment settings there should be some level of take-away dosing available for stable patients as this improves compliance and retention rates, according to these Guidelines. In the absence of regular take-away doses one of the most important ‘incentives’ of supervised methadone treatment is lost and patients may feel condemned to almost daily attendance indefinitely (as apparently sometimes happens in Victoria as well as the NSW public sector clinics). If local rules should impinge on appropriate dosing, they should be addressed and overcome in the interests of making treatment safe, effective and humane (for example the ACT rules on daily methadone doses of over 100mg; the Victorian DOH will allow waivers for take-home doses under certain circumstances if doctors apply appropriately).

An area of major difficulty in these and other guidelines remains induction protocol for methadone. Mortality from overdose in the first week has caused a knee-jerk reduction in starting doses from 40mg to 20mg in some settings. However, there has been no evaluation of this rather dramatic change and it may well have caused an increase in treatment drop-outs. Despite the stated wide variations in methadone metabolism in these guidelines, no clinical protocol is given for determining who is a fast metaboliser and thus may need higher doses. In one paper it is stated that due to variable absorption and metabolism of methadone, “the rate of clearance from the body has been reported to vary by a factor of almost 100” [Ward J, Bell J, Mattick RP, Hall W. Methadone Maintenance Therapy for Opioid Dependence. A guide to appropriate use. (1996) CNS Drugs. 6;6:440-449]. Thus increasing doses by only 10mg per week may take many months to reach optimal levels in some folk who may need 200mg or even more to achieve ‘normal’ or therapeutic blood levels.

There is no substitute for careful clinical assessment and gradual dose adjustments for this drug, as with insulin, digoxin or Dilantin in unstable folk at the commencement of treatment. Perhaps somebody should describe a ‘sliding scale’ for methadone inductions. The American Health Department “TIP” protocols allow up to 60mg on the first day in three divided doses under very close clinical supervision. Few clinics can support the clinical supervision necessary for this, hence 40mg is the usual starting dose in many cases in the USA. Most Australian drug services now apparently use a standard 30mg starting dose in the great majority of cases.

I hope this is of assistance for colleagues involved in methadone and buprenorphine treatments. Naltrexone should only be prescribed for opioid dependency in specialist settings, whereas for alcoholism all primary care physicians should be familiar with it.

Andrew Byrne ..

Clinical guidelines and procedures for the use of methadone in the maintenance treatment of opioid dependence - Abbreviated version (pdf file 176Kb) Date Published: 2003 ISBN: 0 642 82263 8
Author: National Drug Strategy Australian Government Department of Health and Ageing.