13 April 2006

Take-aways in opioid replacement treatment - Case Studies & Discussion

Tuesday March 28, 2006



Presenters:
Professor James Bell, Director, The Langton Centre, Surry Hills.

Professor Bob Batey, Hunter New England Area Health Service.



Chaired by Dr Richard Hallinan, Redfern Dependency Practice.

Case Studies


Click here for summary of main presentation
Professor James Bell had indicated in his presentation that the therapeutic relationship in opioid replacement treatment was not based on trust, but rather on clarity and transparency of boundaries and decisions. Asked if there was any place for trust at all, he gave the thought-provoking answer "None". In response it was suggested that a case given of the folly of trust actually showed want of discretion. Another view was that a therapeutic relationship where trust had been lost ought to be ended. However the point was made that clear guidlelines can protect staff against manipulation and pressure from patients, and also provide a level of reassurance and protection to patients against arbitrary decisions, or the the appearance of them.

Asked whether Takeaway Guidelines were in fact rules, Professor Bell replied, perhaps tongue in cheek, that they were "Commandments". However in the case studies which followed, opinion differed on how to implement even Commandments.

Setting the scene, there was a tale from the prisons: a 35 year old male, intermittently on MMT over 15 years, currently getting 180mg daily with 4 takeaway doses/week. After 10 days in custody on daily supervised doses, prison staff became concerned at his level of sedation.

No-one in the room needed the obvious pointed out: the possibility that this man had not been consuming his takeaways as directed. The doctor who submitted this case suggested the corollary that some patients actually cope quite well on second daily methadone dosing, while others considered that this was unusual. It was also possible that this man had been consuming part but not all of each takeaway dose.

It was suggested that period of daily supervised dosing may help establish compliance with daily dosing, provided the patient is examined 3-4 hours post dose during this time.

Next came a simple case illustrating basic issues: a 31 year old woman on MMT for 3 years, daily dose 140mg and 4 weekly takeaways, returned a series of urine drug screens positive for benzodiazepines but denied taking these drugs.

A major concern was that she had felt the need to deny benzodiazepine use. On the basis that ongoing use of benzodiazepines was a clear contraindication to giving any takeaway doses, one expert opinion was that takeaways should be stopped until she could submit a clear urine drug screen, which she would probably do with this incentive. Others suggested examining the patient 3-4 hours post dose, and restricting but not stopping takeaways. All were agreed on the need to go into the reasons for her benzodiazepine use.

It was asked whether there was any evidence that self-report of substance use was inproved where no punitive consequences were expected. While no-one was aware of such evidence, there is good evidence that the possibility of urine toxicology being required improves self-report.

The third case involved methadone injecting: a 41 year old man working part time, on MMT for 10 years, currently 75mg/day dispensed from a pharmacy, with 5 takeaways/week. After the patient admitted buying and injecting extra black market methadone, he was offered and agreed to an increased methadone dose and a period of suspended takeaways. On the dose of 110mg/day his 24 hour trough methadone concentration was 0.37 ng/ml.

As he reported having ceased injecting, and had taken up full-time work, takeaways were gradually returned . However a year later, after being in hospital with severe cellulitis of the leg, he admitted having resumed injecting methadone months before.

Although he agreed again to daily supervised dosing and more frequent consultations, he dropped out of treatment, blaming the onorous attendance requirements and complaining about his increased dose which made it harder to jump off. The doctor received information that he was surviving on black market methadone.

Discussion centred on the need to balance supervised dosing with retention in treatment and the benefits of a person working. It was agreed that this man might have been offered injectable methadone in some jurisdictions. The benefits of providing methadone takeaway doses in an additive-free formulation to reduce injecting harms, or diluting them with orange juice to prevent injection were discussed: it was noted that diluted methadone is not an approved formulation in NSW but is mandatory in Victoria. The importance of examining veins was pointed out, as well as the difficulties of examining femoral veins � in this case the injection site was old and hollowed out, making evidence of current injecting difficult to find.

Although increasing methadone dose is one suggested response to methadone injecting (Eap et al 2003), it was not helpful in this case.

In a fourth case, a "concerned relative" had written to the Health Department claiming the children of a couple on MMT "may be at risk from exposure to methadone and/or illicit drugs" as the parents were "polydrug users and misusing take-aways" and there was "current Department of Community Services involvement with the family."

The prescriber received an official letter reminding of the guidelines about children under the age of 4: with current DOCS involvement there should be no takeaway methadone.

The team involved requested the original letter and noted it included a request that "methadone contain some sort of contraceptive." They established there was no current DOCS involvement, and previous involvement had been only brief, over the matter of the electricity being cut off. Subsequent review by the team concluded as before that the parents were suitable for takeaway doses.

Opinions varied as to whether the advice from the Health Department had been high handed, and whether credence should ever be given to complaints of this kind. It was argued out that the staff had acted properly and the result had been a good one, that they should not have felt threatened by the official letter; and nor should parents feels threatened by DOCS officers who had a serious responsibility and generally avoided draconian actions. It was suggested that having the electricity cut off was not a trivial matter, and indicated a serious level of disorganisation.

The final case was of a 34 yo man: on disability support pension, and 10 yrs MMT with a current dose 80mg/day, and 4 takeaways per week. He had been prescribed dexamphetamine years ago for ADHD. After urine toxicology showed amphetamines, he admitted injecting about twice a month. He said he needed takeaways for part time work and was often called at short notice.

With reduced takeaways and future takeaways contingent on amphetamine-free urine tests, he produced a series of clear urine drug screens. However he was unable to bring payslip evidence of his work as he was working for cash and said his employers would sack him if he they found out about his methadone. The dispensing pharmacist confirmed that he appeared regularly dressed in work clothes, and never intoxicated

On one occasion he admitted that a urine test that day would show amphetamines, and on this occasion was allowed to continue 4 takeaways for his honesty, and given an opportunity to "redeem himself" in 2 weeks.

Issues raised included: the difficulties for some people in the 'fringe' economy demonstrating their need for takeaways;, the importance of liaison with staff at the dosing point; the implications for a person's frankness in future if they were 'punished' for admitting illicit drug. This case showed a "carrot and stick" approach. An ambiguity was pointed to in the current NSW takeaway guidelines which refer to stability defined in terms of amphetamine use in times per month - this might refer to single 'shots' or episodes (which might include several 'shots' or 'smokes' ).

A useful draft document reminds us that NSW takeaway guidelines emphasize "process and documentation", including assessment , monitoring and review, and that "the essence of a therapeutic relationship is the capacity to set limits, to withstand manipulative behaviour and to decline to prescribe inappropriately, without becoming angry or judgmental. This is the critical skill at the heart of methadone prescribing."

At the same time we might remember to keep an eye out for manipulative behaviour in our mass media, politicians, pharmaceutical companies and perhaps even .... ourselves.

Summary by Richard Hallinan



Ref: Eap CB, Felder C, Golay KP, Uehlinger C. Increase of oral methadone dose in methadone injecting patients: a pilot study. J Addict Dis. 2003;22(3):7-17.