New standards coming for methadone treatment

Barb Sweet bsweet@thetelegram.com
Published on March 23, 2013
The new guidelines for methadone treatment set out areas for documenting and steps for assessing patients

Extensive new standards for treating opiate addiction with methadone have been drafted by the College of Physicians and Surgeons of Newfoundland and Labrador, The Telegram has learned.

The new methadone maintenance treatment standards and guidelines — which set clear standards for the doctors to follow — are three times as long as the previous guidelines.

“Some sections have been adopted with little or no change, some have been adapted with minor or substantial revision, and others have been substantially rewritten,” states the guidelines, which are effective May 1.

Methadone — which reduces drug cravings and opiate withdrawal while blocking euphoria — is used to treat addiction to opiates like OxyContin. Doctors who administer methadone maintenance therapy must obtain a special exemption.

And there is clear recognition in the guidelines of the perils of methadone if it is taken incorrectly or ends up illegally on the street.

The new guidelines were drafted in consultation with the Department of Health, the province’s pharmacy board and doctors who currently practice methadone treatment. 

The resulting document has been circulated to affected doctors, but not made public yet, though obtained from the college by The Telegram.

The new guidelines set out areas for documenting treatment and also seek physician-pharmacist treatment agreement letters and set out steps for assessing patients, including a requirement to obtain a methadone treatment agreement signed by the patient.

The Opiate Treatment Centre run by Eastern Health has a waitlist of several months. But there are some private practice doctors who administer methadone treatment. Less than 20 doctors in the province have methadone exemptions, including a few who prescribe methadone not for addiction treatment, but for pain management in cancer patients.

Along with introducing new standards, the college is also completing quality assurance reviews of practices administering methadone. The purpose, said the college, is to identify any improvements that could be made to the program, as well as reduce risk of patients diverting methadone to the street. It’s also a chance to get feedback on the new standards.

Generally patients taking methadone for opiate addiction treatment receive their daily dose at pharmacies — drinking the drug in a mixture of Tang or other crystalline juice in front of the pharmacist.

The new 160-page guidelines pay extensive attention to the issue of “carries” — take-home doses that certain stable methadone patients are allowed to have so as to give them a break from daily trips to the pharmacy, based on an allotment of so many days.

Addicts have told The Telegram these carries can be purchased on the street and a 17-year old St. John’s teenager died in 2012 from a methadone overdose, but was not on the methadone program.

“Diversion of take-home doses is a serious public health problem,” the guidelines warn. “The use of methadone for analgesia (pain relief) has increased sharply in the U.S., with a seven-fold rise from 1997 to 2004. This has been accompanied by a 17-fold increase in methadone-related deaths.”

To help control the use of take home doses, the new standards require that when picking up their carries, the patient’s ingestion of that day’s methadone must be witnessed at the pharmacy.

Patients should be in the program three months before being considered for the privilege.

According to the document, controlled trials have demonstrated that patients markedly reduce use of heroin and cocaine when given take-home doses, contingent on drug-free urine testing.

“Surveys and observational studies have found that patients strongly value take-home doses, and treatment retention rates are lower in clinics with restrictive take-home policies,” the guidelines say.

The guidelines also are specific about the storage of the carries — asking patients to store them in lock boxes in their fridge.

Reasons for suspending the carry privilege include if the patient has an unstable or untreated mental illness, continues to use drugs, misses three or more days of methadone, is homelessness or has unstable housing or there’s a suspicion their carries are ending up in other hands.

There are also clear standards set out for dosing during all stages of the methadone maintenance program and for how urine drug screening is carried out. They also delve into areas like counselling the patients and provide a lengthy list of resources.

Doctors should stick to the guidelines, but it also recognizes discretion based on clinical judgement that’s well documented.

The guidelines replace those from 2011 and reflect standards and guidelines issued by the Colleges of Physicians and Surgeons in Ontario and Nova Scotia, as well as changes across the country.

The standards will be in effect for treating any new patients as of May 1 and existing patients will be transitioned, the college said.

bsweet@thetelegram.com