March 2012

Welcome to our first Online Issue

In this Issue

Thank you!
MMT Treatment Forms 
Verbal Confirmations 
Opioid Dependence Treatment Certificate Program  
Methadone Q&As

Thank You!
We wish to thank all prescribers and their staff for completing our Clinic Update Form. This form permits us to update our clinic lists showing who is currently accepting new patients and the services that are offered by prescribers and clinics, and helps us improve our customer service to patients who contact the CPSO Methadone phone line.

MMT Treatment Forms
One of the features of the MMT Treatment Form is the ability for physicians to transfer their patients from one physician to another within the same clinic setting. Recently, we received a number of incomplete/incorrect transfer forms and we would like to remind you to please follow the instructions for completing this section outlined in the MMT Program Standards and Guidelines (Appendix E, page 105). For ease, Section C states the following:

This section can only be filled out if the patient is being transferred to another physician within the same treatment site. A patient cannot be transferred to another clinic location using the transfer section – the cessation section of the form must be completed. Both physician signatures must be provided otherwise the form can not be processed.

Verbal Confirmations

There has been an increase in the number of telephone calls requesting a verbal confirmation to initiate MMT. While there may be times when it is appropriate to obtain a verbal confirmation, it should not be the norm. We currently have a 24 hour turnaround time to process the treatment forms and provide a confirmation response back to the clinics. However, we do remind you that regardless of our ability to respond quickly the decision to place a patient on methadone is a clinical judgment. As such, it is ultimately your decision.

Opioid Dependence Treatment Certificate Program

As of January 1, 2009, physicians who obtained their methadone exemption are required to complete the full Opioid Dependence Certificate Program within three years of receiving their exemption from Health Canada.

For your information, CAMH offers the Advanced and Safe Prescribing Courses only once a year. All other courses identified in the certificate program are offered two to three times per year.

For additional information regarding dates for upcoming courses, and/or to inquire on the status of your certificate, please contact: Ms. Robyn Steidman at CAMH at 416-535-8501 ext. 6640. 

Methadone Q&As
Q: I have a patient who is not a candidate for regular take-home doses due to continued problematic cocaine use once to twice a week. He is otherwise stable, working and living with his brother. His father lives in New Jersey and is in palliative care there. The patient would like to visit him and is asking for seven take-home doses for this trip. The patient would be travelling with his brother who has been a great support for him over the years. He has shown me e-mails from his father outlining the details of the diagnosis and updates from his mother about his father’s condition. The patient will bring in the flight itinerary once he books the flight. I do believe him and would not want him to miss seeing his father before his passing. Can I give take home-doses?

A: Special take-home doses for patients who may not be stable enough to warrant weekly take-home doses can occur for exceptional circumstances where not giving the take-home dose would likely compromise the patient significantly (e.g., illness, family crisis, unusual employment circumstance, etc.). Good clinical judgment along with good documentation is needed. Special take-home doses can be given for exceptional circumstances if the patient has been on the program for at least one month and requires seven or less take-home doses. Special take-home doses for compassionate purposes should be a rare occurrence and this should be made clear to the patient.

Before prescribing take-home doses for exceptional circumstances, the MMT physician should attempt to verify the patient’s personal or family crisis (with corroborating information from a third party) and travel plans. All arrangements for the patient to dose at a pharmacy should be attempted before take-home doses are given to patients not already receiving take-home doses. For example, for travel in Ontario, another pharmacy should be contacted and every attempt made to dose the patient at a pharmacy located near the destination. In other provinces in Canada you may consider speaking with a pharmacist in the community to see whether they would accept a prescription from an Ontario provider for methadone. Many provinces will accept a methadone prescription from Ontario thus allowing a patient to dose at a pharmacy in another province. The previous take-home dose level should be resumed after the period of special take-home doses.
 
If a patient is receiving 1-2 take-home doses already, additional take-home doses may be given for sound personal reasons (vacation/holidays) for up to seven take-home doses.
 
If a patient is receiving 3-6 take-home doses and is otherwise stable, additional take-home doses up to 2-4 weeks may be given for travel purposes. If more than four weeks of take-home doses are required, a second opinion with another MMT provider should be sought.

Q: As an integral part of the patient's recovery plan, I collect regular, routine urine drug screens on a fixed schedule between office visits. Sometimes the urine is collected when I am not in the office. When am I expected to interpret the urines collected outside of office visits?

A: Urine drug screens are used to manage the care of each individual patient. Urines that are collected in between office visits, or when the physician may be away, should be interpreted in a reasonable time period for the purpose of monitoring or managing the patient. For example, in the guideline checklist, a reasonable time frame for interpretation of the urine by the physician is considered to be within 7 to 10 days. If the physician plans to be away longer than a two-week period, then arrangements should be made for the patient's care to be supervised by a colleague. If urine drug screens collected outside of the office visit are positive for illicit drug use and the next scheduled office visit is more than one week away, arrangements should be made by the physician to assess these patients sooner than the next scheduled office visit so that take-home doses can be reassessed and intervention occurs. The results of all tests should be used in the overall care and management of the patient. Infrequent office visits (e.g., once a month office visits with weekly urines in between) can potentially lead to ineffective contingency management if the results of the urines are not interpreted in a timely fashion leading to appropriate intervention.

An example of appropriate urine interpretation in the management of a patient who is seen infrequently is as follows:

Week 1 office visit: drug free sample >> Continue current take-home dose level (the next scheduled office visit is week 5).

Week 2 urine only: drug free sample >> Urine interpreted in a reasonable time frame and continue current take-home dose level

Week 3 urine only: cocaine positive >> Urine interpreted in a reasonable time frame. Plan is to continue current take-home dose level and reassess the patient the following week to discuss the slip for intervention, or see the patient that week to reassess the take-home dose level.

Week 4 >> earlier office visit arranged with discussion about the previous week with a slip and take-home dose reassessment

Week 5 >> the scheduled office visit.

If patients on take-home doses are inconsistently drug free, the frequency of office visits with the physician along with urine collection should be increased for effective contingency management. Regular (weekly to biweekly) encounters with the physician along with urine collection and interpretation can improve effective contingency management of take-home doses along with counselling which may lead to improved rates of abstinence, and decreased rates of relapse.