1 setting standards for prescribing Dr Keron Fletcher

2 standards of what? clinical effectiveness clinical safety clinical risk cost-effectiveness

3 standards Average DOSE of methadone per clinic (as a proxy for clinical effectiveness) PICK-UP regimes, especially % supervised (as a proxy for clinical safety) BENZODIAZEPINE prescribing – or lack of (as a proxy for clinical risk) METHADONE vs SUBUTEX (as a proxy for cost-effectiveness)

4 standard 1 - effectiveness: dose of methadone P 49: –Following the first week, doses can continue to be increased incrementally up to a total of between mg a day, and occasionally more – a level at which the patient reports feeling comfortable and is no longer using illicit heroin –Q: How do you assess feeling comfortable?

5 methadone – feeling comfortable no withdrawal symptoms for 24 hours –How do you feel one hour before you take your methadone? –Do you feel as comfortable one hour before you take your methadone as you do one hour afterwards? CLUE: patient goes to chemist the moment it opens CLUE: the patient sleeps poorly CLUE: the patient uses heroin soon after waking

6 methadone – feeling comfortable patient feels satisfied –Do you find yourself thinking about heroin? –Do you feel any craving? EXPLANATION: if you are hungry and have a sandwich it will stop you feeling hungry but you might still want more. If you are hungry and have a good meal its much easier to say no to the offer of something else.

7 methadone – feeling comfortable blocks effects of heroin –Q: If you use heroin do you get any benefit from it? –Q: Does heroin stop you feeling rough? –Q: Does heroin give you a buzz?? EXPLANATION: the proper dose of methadone fills up all of your receptors to that heroin cant do anything to you CLUE: if the patient says that buying heroin is now a waste of money – youve got the dose right!

8 methadone – feeling comfortable does not cause sedation –If so, reduce dose.

9 standard 1 - effectiveness mean dose of methadone in a clinic: > 60mls ??? av. dose in UK has risen over the last 10 years from 45 – 55mg/day

10 standard 2 – safety: pick-up regime P 51: –Take home doses should not normally be prescribed where: Dose not yet stable Use of illicit drugs or benzodiazepines, heavy alcohol use Psychiatric illness or risk of self-harm Risk of inappropriate use or diversion of medication Concerns about safe storage at home and risks to children

11 standard 2 – safety % patients on supervision = % patients not producing 3 consecutive clear urines + up to an additional 20% + 20% to allow for other factors –Psychiatric problems/self harm –Child care problems –Alcohol/benzodiazepines –Concerns about diversion –???

12 standard 3 - risk: benzodiazepines P 60 –…there is increasing evidence that long-term prescribing (especially of more than 30 mg diazepam per day) may cause harm. in the treatment of bzp dependence: –To prevent symptoms of withdrawal, the clinician should continue the prescription but the dose should gradually be reduced to zero. Only very rarely should doses of more than 30 mg diazepam per day be prescribed.

13 standard 3: risk % patients on prescribed benzodiazepines = < 10% ???

14 standard 4 – cost effectiveness: methadone vs subutex P 48 NICE recommendation (TA 114, 2007): If both drugs are equally suitable, methadone should be prescribed as the first choice. Reason – primarily cost, although some evidence that methadone is better at retaining people in treatment

15 shropshire/powys outcome data % Time (months) Х 2 P = t-test P = methbupmethbup retained 3 months 9055 <0.001 *** retained 12 months 5826 <0.001 *** clear urine <0.001 *** ** stop injecting < ** 0.02 * take home <0.001 *** * stay true 8018 <0.001 ***

16 shropshire/powys outcome data % Time (months) Х 2 P = t-test P = methbupmethbup retained 3 months 9055 <0.001 *** retained 12 months 5826 <0.001 *** clear urine <0.001 *** ** stop injecting < ** 0.02 * take home <0.001 *** * stay true 8018 <0.001 ***

17 summary of audit Methadone was significantly better than Subutex at: –Retention in treatment at 3 & 12 months –Producing a clear urine sample –Stopping injecting –Achieving take-home doses –Satisfying patients Subutex produced poorer but quicker results: –Clear urine –Stop injecting –Achieving take-home BUT: –Subutex patients are more likely to be non-injectors. When compared to a non-injecting methadone group the time to achieve the above 3 criteria is not significantly different

18 standard 4 – methadone:Subutex no more than 20% of prescription should be for Subutex???? everyone who is prescribed Subutex must have the clinical reasons for not prescribing methadone written in the notes???

19 monitoring tools the front sheet the summary sheet

20 SUBSTITUTE PRESCRIBING – St Austins Name:____________________________________________________________________________________ PHARMACIST: ___________________________________________________________________________ ___________________________________________________________________________ TEL NO: ________________________________FAX NO:___________________________________ PICK UP DAYS ___________________________________________________________________________ DateDoee 1mg/ ml Form Next Scrp Due Next Appt URINE RESULTS Inj Freq Pick up Hep B Jab MeOpAmBzp (I) Bzp (P) Coc 04/02/1030,40, 50 Meth11/02/ x Daily 7s1 11/02/1060,70, 80 Meth04/03/ x Daily 7s2 02/03/1090Meth24/06/ s3 Form:Meth = MethadoneSBX = Subutex Pick-up: 7s = daily supervised 7 = daily 3 = 3 x weekly 2 = 2 x weekly 1 = weekly Benzos:I = illicitP = prescribed

21 summary sheets shared care monitoring group 2005: ClMean dosePick-ups per week% S = supervised Tested for hep viruses Immuns against hep viruses Opiates in urineOther drugs in urine iv use at start Still iv use MthSb7S73213neg3pos3neg3pos LW %79%58%11%68%0%68%16% xx % 0%100%0%100%40% yy % 30%50%70%10%60%40%

22 summary sheets shared care monitoring group 2008: ClMean dosePick-ups per week % S = supervised Opiates in urine Other drugs in urine iv use at start Still iv use MthSb7S73213neg3pos3neg3pos LW %11%68%0%68%16% xx % 57%86%29% yy %0%55%0%18%9%

23 four suggested local standards prescribing 1.effectiveness: average dose of methadone 1mg/ml in a clinic should be greater than 60mls 2. safety: % patients on daily supervised consumptions should equal the % patients still using illicit drugs PLUS 20% to allow for other safety factors 3. risk: % patients receiving prescribed benzodiazepines should be less than 10% 4. cost effectiveness: % patients prescribed Subutex should be less than 20% and/or everyone who is prescribed Subutex must have the clinical reasons for not prescribing methadone written in the notes