Methadone Q&A
 Q. I have a patient who spends up to 2 to 3 hours per week trying to leave a supervised urine sample during an office visit. He finds it very challenging to produce a sample under supervision. His supervised samples have been clean to date and he is a reliable patient on full carries. He needs weekly samples because he occasionally slips but, for the most part, tests as drug free. These office visits are very disruptive to his day and he gets in trouble at work because he is late. Can I try unsupervised samples as he has no difficulty when on his own?
A. Some patients have a great deal of difficulty providing urine on demand in a supervised setting. The result can be a lengthy office visit that is disruptive and unsettling for both the patient and staff members. An unsupervised sample can be used for these patients to facilitate a smoother day. However, other measures of testing for reliability of the sample should be used (i.e. temperature monitoring, specific gravity and concentration). And, an occasional broad spectrum can be used for these patients to detect other drugs that they may be taking and to ensure that this is their specimen.
Q. I referred my patient to the ER for an unintentional overdose. How do I manage the methadone treatment following discharge from hospital?
A. It is not uncommon that patients are unintentionally overdosed. In some cases, the ER will administer Narcan. This will change patient management. Additionally, the amount of the overdose also needs to be considered.
If Narcan was administered, this patient should now be considered an opiate naive patient with loss of tolerance to opiates and restarted on methadone as if they had missed doses for 4 or more days. This patient should be considered high risk and started at 20mg or less with up to 10mg increases every 3-5 days until 80mg is reached with weekly increases thereafter. Alternatively, they can be reintroduced to a dose where they are stable for 24 hours.
The answer is more difficult when the patient has been monitored but not treated with Narcan. This patient must be assessed by a physician before any doses of methadone are given. The concern is that methadone, given in addition to the overdose amount, can become additive. For example, if someone is given a double dose and appears to be doing reasonably well and is then given their usual dose the following day – an overdose could result.
Generally speaking, in the absence of specific details it is best to hold the next day’s dose. Reassess the patient the following day. If there are any signs or symptoms of sedation then hold for another day and have the patient assessed yet again. It is not recommended to administer the usual dose unless signs and symptoms of withdrawal are apparent.
The regular dose needs to be re-evaluated as a return to a full dose may create harm to the patient. It may be advisable to give only 50% of dose and increase as per the MMT standards & guidelines thereafter.
Withholding or lowering the dose will result in less risk than adding to the overdose. Be cautious. No one ever dies from opiate withdrawal and if these patients are seen daily the physician can deal with any symptoms.
Q. I have a patient who has been clean and stable on methadone for about one year. He recently lost his weekly carry and needed to restart at 30mg. I am withholding carries for this demonstrated lack of stability. How, if at all, can he earn them back?
A. Determine precisely how the patient lost the doses. For example, were they left on a bus or stolen? Was the patient at fault? Is the patient’s explanation credible? Did the patient report the loss to you and the police as soon as the loss was discovered? Did the patient relapse as a result? Was someone else harmed as a result?
If you believe that the patient was not at fault and took appropriate steps to mitigate any risk to the community by calling you and the police, and, the doses were kept in a lockbox then, once they are stable with no relapse, you may start to return the carries. Depending on whether this is an isolated event and a believable scenario the rate of carries should be based on case-specific clinical judgement. For patients that you believe acted irresponsibly, return their carries as you would in the case of a short relapse (i.e. return one carry every 1-2 weeks depending on the need for carries, patient stability, etc). For patients who had an isolated event (such as accidentally leaving their lockbox on a bus) and who notified you and can provide a copy of a police report, a full return of carries can be issued . If there are repeated episodes of lost or stolen carries they should be reduced or discontinued for a prolonged period of time. It is also appropriate to talk with the patient about the impact of this behaviour on their potential recovery.
If you feel that the patient was negligent in caring for the carries, you can hold them back for now. Then, slowly return them after 1-3 months at the rate of one carry every 2-4 weeks with careful monitoring.
Q. I have a new patient who was transferred to me with 6 carries. This patient also has prescriptions for clonazepam (2mg QID) and lorazepam (2mg, 3-4 a day) to treat anxiety. Other than methadone, there are no other medications. I am not sure if this patient qualifies for 6 carries, however this is what the last physician was providing.
A. The levels of benzodiazepines prescribed by this patient's physician are considered to be high doses.
Before assessing whether this patient meets the criteria for receiving more than one carry with a prescription for benzodiazepines, a few questions need to be answered.
- What is the actual diagnosis? If the medication was prescribed for an anxiety disorder, then, have other medications been tried? If it was prescribed for a sleep disorder or any other circumstance that would not usually require benzodiazepines, this patient would not qualify for more than one carry.
- What other medication is prescribed for this patient’s diagnosis? If no other medications are being prescribed, then why? Daily, ongoing prescriptions for benzodiazepines are not the first line of treatment for generalized anxiety disorder or even anxiety disorder with panic attacks.
- Are the benzodiazepines being prescribed weekly? The guidelines regarding more than one carry require controlled dispensing (i.e. weekly dispensing) of benzodiazepines in low to moderate doses.
The combination of a high prescribed dosage of clonazepam along with lorazepam is not considered low to moderate dosage and is not compatible with more than one carry unless there is clear support for the high dosage. An example of a situation where more than one carry is acceptable would be that of a patient who has an uncontrolled high dosage of benzodiazepines to treat severe anxiety disorder but who is also under the care of a psychiatrist knowledgeable in concurrent disorders.
For high dose benzodiazepines, support should be given to the patient to follow a tapering contract that you can send to the prescribing physician. The contract should initially discontinue the lorazepam (or change the prescription to PRN use if this is needed for panic attacks) and taper the clonazepam by 5-10% of the dose every 1-2 weeks to a lower dose.
The benefit of a taper to either discontinue benzodiazepines or move to an agreed upon lower dose should be explained to the patient. Poor memory, disruption of REM sleep, depressed labile mood, and low energy are common features of excess benzodiazepine dosage. Some patients have tapered their benzodiazepines to a low dose and then experienced anxiety or a resurgence of panic attacks. A benzodiazepine taper for some patients who have been on benzodiazepines for many years may destabilize their mood and a complete taper may not be possible for all patients. The importance of patients receiving clinical support during this change to their medication profile cannot be overemphasized.
Additionally if this patient is not prescribed any other medications to treat the presumed anxiety disorder, this too should be considered.
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Health Canada has changed the prescription-only status of Naloxone, making it more widely available for use in opioid overdose prevention.
The Annual Methadone Prescribers Conference is scheduled for Friday, November 25, 2016 at the Allstream Centre in Toronto and will once again be co-hosted by the CPSO and CAMH. The conference planning committee is putting the final touches on the agenda and confirming speakers based upon your feedback from last year, changes in the opioid prescribing landscape and issues identified through assessment. More information will follow in the next newsletter.