Copy
Email not displaying correctly? View it in your browser.
Methadone News masthead

December 2012


IN THIS ISSUE
Your chance to contribute
Circle of Care
New Prescribing Policy
Physician-Pharmacist Collaboration
Caring for MMT Patients 
Prescriber's Conference Follow-up


MMT Practitioner Recruitment
Your chance to contribute
In the September issue of Methadone News, we published an article regarding challenges in the recruitment of MMT physicians. Institutional, professional and public stigma makes it difficult to meet the growing need for MMT physicians. It was pointed out that Australia and Canada share many of these difficulties. Both countries have significant populations of injection drug users. Each has several large urban centres separated by vast, sparsely populated rural landscapes.

Dr. Christopher Smith, Department of Sociology, Deakin University (Melbourne, Australia) has launched a project aimed at the development of practice guidelines to make this area more attractive to physicians. By conducting qualitative interviews with public health authorities and practising methadone prescribers in both Canada and Australia, Dr. Smith’s project aims to generate a series of guidelines, best practices and/or lessons learned concerning methadone service provider recruitment that can in turn be applied in various areas facing similar problems throughout the world. To that end, he invites interested physicians to participate in a brief interview. Respondents are still very much welcome.

If you are willing to take part in this project by participating in a short 30-45 minute interview, please contact Dr. Christopher Smith by phone at 0420 844 619 (m) / 924 43974 (o), or by email at christopher.smith@deakin.edu.au.

Circle of care
Physicians have asked about the extent to which they are able to share patient health care information with methadone prescribers, other physicians and other regulated health professionals (e.g. pharmacists providing care for MMT patients).

There is a legitimate concern that some health care providers will discriminate against MMT patients when the use of methadone is disclosed. However, it is important to note that a failure to share important medical information about a patient can introduce a significant risk of patient harm or death.

Ontario’s health information privacy legislation, the Personal Health Information Protection Act, 2004 (PHIPA), specifies the requirements for patient consent to the collection, use, and disclosure of personal health information.

The term “circle of care” is commonly used to describe the ability of certain health information custodians to assume an individual’s implied consent to share appropriate health information with members of the patient’s health care team, including information about MMT. Assumed consent can only be considered when some very specific conditions are met.

In general, under the circle of care, information can be shared only with health care practitioners who are part of the patient’s health care team; the information must be shared for health care purposes (providing or assisting in the patient’s care); and, the patient must not have indicated that they withhold permission for information sharing. For example, providing all conditions are met, members of the health care team can share and use the patient’s health care information to confer about test results, discuss symptoms, and brainstorm different options for treatment without having to ask the patient or the substitute decision maker for consent at each step.

It is very important for physicians to review the specific wording of the conditions to confirm that the circle of care concept applies. The Information and Privacy Commissioner’s brochure, Circle of Care: Sharing Personal Health Information for Health-Care Purposes is a great starting place. In addition to spelling out the conditions that must apply, it includes case examples to illustrate common situations and the implications for sharing information. Physicians can access this brochure at: http://www.ipc.on.ca/images/Resources/circle-care.pdf.

Please note that this information regarding the circle of care relates only to consent obligations respecting personal health information. Separate obligations apply in order to obtain consent for treatment. See the Health Care Consent Act, 1996 for further information.

Prescribing and dispensing policy
College Council approved the revised Prescribing Drugs policy at their meeting on December 3. This new policy is a consolidation of seven policies covering a variety of issues related to drugs and prescribing, including faxing prescriptions and prescription drug abuse. Become familiar with this new document by viewing it on our website: available here.

Interprofessional Collaboration
On November 9th, following the MMT prescribers day, the College held an invitation-only workshop on issues of interprofessional collaboration between pharmacists and physicians on MMT prescribing and dispensing. This event was a first attempt to help improve the care provided to patients by the two key health professionals involved in MMT. 

Caring for MMT patients

Trends to avoid in 2013
A review of assessments by the Methadone Committee carried out since the 2011 guidelines were published indicates that the majority of assessments have been positive with no need for reassessment. There are some trends that appear to have developed that are cause for concern in that they are inconsistent with the standards established in the current version of the Methadone Program Standards and Clinical Guidelines.

The following is a list of these trends. Please take a look and refer back to the Guidelines for more information. Section references and some page references are included. Please note that the page references refer to the ONLINE version available on the College website [see link above].

1. Dose increases above 80mg are sometimes noted to be greater than 10mg. All dose increases above 80mg should be 5-10mg. Standard 6.13 - see Section 6.7 for more information regarding this.

2. Patients on carries receiving benzodiazepines or narcotics under the care of the family doctor where there is no attempt to communicate with the family doctor.

3. Starting doses started ABOVE 20mg in high-risk patients who are on sedating agents such as benzodiazepines, Gravol, or sedatives. See Table 03 - page 32 - Standard 6.6.

4. Carries given every 3 weeks instead of 4 weeks with probable misreading of calendar information. Patients need to be at the current carry level for four weeks before increasing carries. See Guideline 8.3.

5. Accelerated carries being given without proper documentation and special carries being given without proper documentation. Standard 8.5 and as well. See Section 8 (Take Home Doses).

6. Lack of documentation about discussion of CARRY SAFETY AND STORAGE prior to starting carries. Carry Agreements are a great way to handle this. It can be reviewed with the patient when they are starting carries (and not when they start the program) and then signed and documented that this was reviewed and discussed. See Standard 8.1.

7. Lack of documentation in discussing strategies to reduce risk of overdose in the first 2 weeks of stabilization. See Standard 6.2 and discussion about this in Section 6.3 Strategies to Reduce Risk of Overdose.

8. Infrequent physician assessments during the carry acquisition phase and lack of reassessment of the carries by the physician the following week in the event of a positive drug test. Drug screens between physician appointments can be very useful but they do need to be monitored and actions taken for positive urine screens.

9. Infrequent physician assessments during the stabilization phase. Patients should be seen at least every week during Stabilization Phase until dose is stable and patient is doing well. Standard 6.17.

10. Lack of EKG above 120 mg in high-risk patients such as patients with ongoing cocaine use. See Guideline 6.5 Table 07, page 43.

11. Lack of documentation to justify a deviation from guidelines or standards. Documentation is a problem that we see across many assessments. Please refer to the CPSO guidelines about documentation.

12. Lack of initial urine BHCG prior to starting methadone. See Guideline 5.9.


Questions from the Methadone Prescriber's Conference

Response from the MOHLTC
The following questions were asked of the MOHLTC at the CPSO Methadone Prescriber’s Conference held on November 9, 2012.

Q. Why don’t the flags come up with MDs the way they do with pharmacists when a concern is identified?
The Narcotics Monitoring System (NMS) is intended to enable reviews of dispensing activities for monitored drugs.

The NMS was built on the pharmacy claims processing system platform (the Health Network System) and is designed to interface with pharmacy IT systems rather than physician electronic medical records (EMRs). As such, the system tracks dispensing activity for monitored drugs and issues real-time alerts to the pharmacy in certain circumstances where inappropriate use may be identified.

Prescribers, dispensers/pharmacies, and other health care providers are not able to view patient profile information (e.g. patient prescription history) on the NMS.

Point-of-care access to patient information is part of the larger Medication Management System (MMS) initiative currently under development through eHealth Ontario. The NMS was designed to be an interim step to quickly address a public health crisis until the MMS goes live.

Q. Why is Suboxone so hard to access for short-term users and methadone so easy?
As of October 30, 2012, Suboxone (buprenorphine) is now listed as a Limited Use product on the Ontario Drug Benefit formulary. This means that, in order to access Subuxone and have it covered through the ODB program, a patient’s physician must confirm that the patient meets the Limited Use criteria for Suboxone – which are that the patient cannot tolerate methadone (allergy, adverse reaction, or other contraindication) or a methadone maintenance program is not available or accessible to the patient.

Q. How do you justify the violation of personal privacy when flags are raised with pharmacists?
We would emphasize that pharmacists do not have access to patients’ medical history through the Narcotics Monitoring System. If, during dispensing, the system detects a potential problem, it will issue an alert to the pharmacist with the type of potential problem (refill too soon, poly-pharmacy, double-doctoring, etc.) and provide contact information for the pharmacist to follow up. Pharmacists are then able to work with the patient as well as the patient’s other health care providers to determine the most appropriate response.

Under the Personal Health Information Protection Act, 2004, the consent for collection, use, and disclosure of personal health information for direct health care purposes in Ontario operates on an “implied consent” model. For more detail on this see the article Circle of Care in this edition of Methadone News.

Q. Does the NAS require the permission of the patient to have the pharmacist call the physician(s)?
No, the Narcotics Safety and Awareness Act does not require the permission of the patient to have the pharmacist call the physician, or to have the pharmacist call other pharmacies the patient may have visited.

As above, prescribers and dispensers are encouraged to work collaboratively and to use their professional judgment to ensure there is effective communication and appropriate information shared to achieve optimal care for the patient and to help to prevent misuse and abuse of monitored drugs.


Season’s Greetings from the Methadone Program

Our offices will be closed from December 24, 2012 at 3 pm until January 2, 2013 at 8:30 am.

Word from the Chair












On December 4th the new slate of Council committees was approved for 2013. I would like to re-introduce our returning members of the Methadone Committee. These include Drs. Michael Franklyn, Trevor Gillmore, Kumar Gupta, Karen Jones, Meldon Kahan, and public member Diane Doherty. I will continue as your Chair and look forward to another year of good work with this very experienced committee.

The 12th annual Methadone Prescriber’s Conference held on November 9th at the Metro Toronto Convention Centre was well attended with over 250 participants. Plenary sessions focused on RADARS and the trends in drug use, First Nation’s and addiction treatment, provincial government initiatives and Safe Injection sites. Workshops focussed on the MMT Guidelines and Standards, Children’s Aid Society and the MMT client, Alternatives to MMT, Naloxone and Overdose and Pain. Materials for these sessions are on the CPSO website. View here

Thank you to those attendees who completed both the individual workshop and overall conference evaluations.  These evaluation forms assist the planning committee and program staff in ensuring that objectives for the day are being met and also assist in the planning for the next annual event.

Respondents rated this year’s program: 21% excellent, 64% good, 7% fair and 3% poor. 79% of respondents indicated they would be encouraged to make changes in their practice based on conference sessions and workshops and 93% indicated they would recommend the conference to their colleagues.

This year’s venue was very well received by the majority of attendees and some topics suggested for future presentations were:
> more suboxone now that it is on ODB, > future mandate for funding for buprenorphine,
> discussion of medical complications of drug use/recognition and treatment,
> more sessions/workshops on chronic pain management within a methadone setting, and
> effective counseling techniques.

All feedback and suggestions will be provided to the Planning Committee for consideration.


Methadone Q&As

The management of methadone naive patients and patients who are already on methadone who missed days is different.

The standard states that after 4 or more missed days of methadone, the dose should be dropped to 30 mg or less.

Complete tolerance to methadone is typically lost within approximately 2 weeks. Therefore, with missed doses of 2 weeks or more in a patient who is at higher risk for overdose, the dose should be dropped to 20mg.

It is recommended that a patient who was binging on sedatives that he was not tolerant to be restarted at 20mg after 4 or more missed days, given the patient's high risk of overdose. On the other hand, if the patient was on chronic benzodiazepines that he was tolerant to, and missed less than 2 weeks of methadone, then the methadone dose may be dropped to 30mg if there is no evidence of extra benzodiazepine abuse or other concerns that put the patient at higher risk of overdose.

The physician should use his or her judgment with regards to lowering a dose after 4 missed days. If there are concerns about overdose, the physician can restart a patient at 20mg or less even if it has not been 2 weeks of missed doses.

Q. My patient, who is on 70mg methadone for the past year and on chronic Rivotril therapy, missed 5 days of methadone. Am I required to drop his dose to 20mg as this was his starting dose? His UDS was positive for methadone and Oxycodone. He was still taking his Rivotril during this period on his usual dose. What if he missed 3 weeks?

A. The methadone dose can be decreased to 30mg or less as he only missed 5 days and he is already on a stable dose Rivotril to which he developed tolerance. If he missed 3 weeks or more, then it is probably safer to drop his dose to the original starting dose of 20mg as complete tolerance to methadone would be lost after 2 weeks, and, the likelihood of extra benzodiazepine abuse is higher.

Q. I have a patient who was on 120mg and missed 4 days of methadone. He admits to binging on valium and alcohol along with IV heroin use during the days that he missed his methadone dose. Can I restart him at 30mg?

A. It is probably safer to drop the methadone dose to 20mg, as a binge on valium and alcohol is a potential risk factor for methadone toxicity during re-stabilization even after 4 missed doses.

Q. I have a patient who missed 2 weeks of 40mg methadone during maintenance. He has no risk factors for overdose. His UDS was only positive for Oxycodone, verifying his self report of Oxycontin use during the missed days. Do I need to restart him at 20mg (his initial starting dose)?

A. The dose may be dropped to 30mg or less as there are no high risk factors.

Q. After missing doses and restarting a patient, am I required to see this patient twice a week to re-stabilize?

A. Physicians should use their own judgment in determining whether to see a patient once or twice a week when restarting on methadone. Once a week visits to promote retention on the program during restabilization may occur if you feel the patient is at a high risk of missing more days. Often patients miss days to try to detox themselves off the program in view of the hardships of the frequent visits to the clinic combined with the demands of work or family life.

Some patients may request twice a week visits to re-stabilize more rapidly. If the patient demonstrated high risk behaviors such benzodiazepine or alcohol binges during the missed days, then twice a week visits may be also safer for the patient.




Patient Forum
Patient Forum is a supplement to Methadone News and highlights issues of particular interest to methadone patients. View Archives


Please send your comments and feedback to:
qmdnewsletters@cpso.on.ca


Visit our website at:
www.cpso.on.ca


You are receiving this email because you are on the subscriber's list for Methadone News from the College of Physicians of Ontario, or because you opted in online.

Unsubscribe <<Email Address>> from this list.

Our mailing address is:
College of Physicians and Surgeons of Ontario 80 College Street Toronto, Ontario M5G 2E2 Canada

Our telephone:
416 967 2600

Copyright (C) 2007 College of Physicians and Surgeons of Ontario All rights reserved.

Forward this email to a friend