Methadone Maintenance Treatment Of Opioid Dependence: Governance Requirements And Lessons Learnt

Assoc. Professor Robert Ali

Discipline of Pharmacology

School of Medical Sciences

University of Adelaide

robert.ali@adelaide.edu.au

Clinical Practice Purpose

•       Right care

•       For right person         

•       At right time

•       In right way

        

Patient Retention Rates for Programs
(beyond minimum “thresholds”)

Principles of Effective Treatment

•      No single treatment is appropriate for all individuals

    

•      Effective treatment attends to the multiple needs of individual not just their drug use

 

 

•      Treatment needs to be readily available

   

Principles of Effective Treatment

•      Remaining in treatment for an adequate period of time is critical to treatment effectiveness

 

•      Medications are an important element but not the only component

 

•      Counselling and other behaviour components are critical

   

Principles of Effective Treatment

•      Treatment progress and continuance of drug use in treatment should be monitored

   

•      Treatment plans need to be assessed and modified continually

 

•      Treatment programmes should provide assessment for HIV, Hepatititis, TB and other infectious diseases and provide help and means to modify risk behaviour

 

•      Treatment of comorbid conditions should be integrated

 

 

   

 

Principles of Effective Treatment

•      Recovery from addiction can be a long term process and frequently requires multiple episodes of treatment

 

•      Detoxification is only the first stage of treatment and by itself does little to change long term drug use

ENABLING LEGISLATION

Provides:

•      authorisation of medical practitioners as prescribers;

•      mechanism for review, amendment, and cancellation of medical practitioners’ authority to prescribe;

•      Procedure to allow patients who have been diagnosed as drug dependent to have access to treatment;

•      licensing authority of clinics;

•      mechanism for investigation of complaints regarding prescribing and the professional behaviour of prescribers;

•      Regulation of the supply, storage, prescription, labelling, packing and handling of products;

•      Requirement of record-keeping of the use of drugs of addiction.

 

The Health Department

•      Authorises supply of methadone

•      Approves the formulation and registration of the products

•      Recalls faulty products.

•      Prepare national policies and guidelines on the use of methadone

•      Tracks the use of narcotics.

 

Provincial Health Department

•      Undertakes service planning and development for the city

•      Promulgates clinical guidelines

•      Formulates policies to assist clinic recruitment

•      Develops accreditation standards for clinics

•      Oversights clinics accreditation

•      Organise training of medical practitioners and accreditation as prescribers.

•      Authorise, review and determine conditions of the authority for prescribers.

 

Provincial Health Department cont.

•      Establish Registration systems for treatment

–  Patient Registration for each treatment episode

–   prevents dual dosing or dual prescribing

–   Provides legal consequences for unregistered possession or diversion of medication

–   standardises treatment programs

–  Prescriber Registration and Authorisation

•       Dispenser Authorisation

 

Pharmaceutical Services Branch

•      Maintains data base of prescribers, clinic sites and patient registrations.

•      Processes applications to allow patients to be treated.

•      Issues licences for clinics.

•      Inspects clinics and pharmacy sites.

•      Liases with the national government to ensure fulfilment of reporting requirements

•      Monitors packing, labelling, storage, prescription and supply of medication

Clinic

•      Establish team structure to meet and discuss cases

•      Establish specialised health committee

–  forum for clinic managers to meet to coordinate policy and service development on a city wide basis

·    Establish an Advice and Complaints Service

Clinic

•      Establish Patient Identity Record system

–   Unique identifier for patients.

•    Requires:

–   Drivers licence (with photo)

–   Birth certificate

–   Identity card

–   Photo ID

 

•      Dispensing Pharmacy

–   Reconciliation of quantities of medication supplied and administered

 

Clinic

•      Monitors program effectiveness against outcomes

–    Retention

–    Drug use

–    Death

–    Crime

–    Employment/Social Reintegration

–    HIV

–    General Health

 

Clinician

•             Medication Stability

–          sleep-wake cycle and relationship to withdrawal or intoxication dose effects

–          consequences of being late for a dose or missing a dose

–          relationship of dose and dosing schedule to craving or use

–          induction of sufficient tolerance

–          the presence and impact of adverse effects

•          including peak post dose effects, day time sedation, driving risk issues

–          storage risk for children

–          stable accommodation

Clinician

•      Drug Use Stability

–   Self reported drug use

–   Clinical examination (inspection of veins, signs of alcohol abuse);

–   Physical indicators of health and well being

–   Presentations intoxicated (confirm with dispensing point);

–   Random urine drug screening

–   Liver function tests can be useful in monitoring alcohol use

–   Breathalyser for alcohol

Clinician

•             Physical Functioning And Psychosocial Stability

–          Self report

–          Attendance, behaviour and presentation at clinic

–          Compliance with treatment

–          Episodes of intoxication/refused dosing

–          Active concerns over mental health issues

–          Presentation at clinical reviews

–          Corroborative information from family/employer/other health care agency

–          accommodation

–          Issues relating to active criminal involvement

Conclusions

•      Reduction in the burden of harm though effective treatment programs relies on evidence-based policies and programmes which are the result of research and its application in an environment of good clinical governance.