Coroner calls for restriction of methadone takeaway doses

The coroner in Victoria has commented on the intrinsic risk of methadone takeaway (unsupervised) doses in her finding in the inquest into the death of a girl who took a methadone dose which was dispensed to her cousin. The statement from the coroner indicates a concern about who should take responsibility for methadone doses and a view that "[leaving] the decision-making and storage arrangements solely in the hands of the addicted person seems to be an approach which is fraught with risk, given the unreliability often associated with persons suffering with substance addiction".

Whilst the coroner has made a valid point in relation to the risks involved in the provision of methadone doses, the resources involved in inspecting medication storage arrangements of each and every patient receiving methadone takeaway doses would be prohibitive and impossible to enforce.

The requirement for checks on stability of patients prior to providing takeaway doses is designed to try an minimise the risk such that only patients who are stable enough in treatment so that their "unreliability" is lessened are eligible for takeaway doses - i.e. only patients who are able to take responsibility for storing takeaway doses appropriately have access to them. If a patient who is stable and has had the importance of appropriate storage of their takeaways explained to them then choses not to store their takeaway doses correctly, they need to be held responsible for that lack of care.

Perhaps instead of a call for greater direct supervision (which would be resource intensive in a sector that already suffers from a shortage of resources) there should be a greater onus on ensuring that the checks for stability are more closely adhered to. This would prevent "unreliable" patients form having takeaway doses.

Patients need to be seen regularly, need to have their dosing at the pharmacy checked up on, need to have random urine screening, need to be checked for injecting sites... It is part of the clinical risk assessment that is vital to the safe provision of service (and in Victoria the stability criteria are clearly documented in the state prescribing policy). Arguably if a prescriber is unable to check on adequate stability for takeaway doses, then that prescriber should not be prescribing takeaway doses.

Treatment works!

Yesterday I had a win!

A patient I have been seeing for several years had reduced off opiate substitution pharmacotherapy. I'm not normally so happy to hear of someone stopping treatment, as addiction is of course a chronic, relapsing condition. In this case, however, I'm chalking it up as a success.

I first started seeing this patient (lets call her Ms X for sheer originality, and to keep all identities well hidden) at a time of crisis for her. She had been on/off pharmacotherapy for some time but had been struggling trying to stay in treatment and dosing. This was in large due to her partner who was a drug dealer, and supplied her with various drugs in order to keep her dependent on him. He had just been arrested for dealing and was looking at a substantial period of incarceration, and she was left sick, in withdrawal, and homeless.

Ms X was from a country town, where her parents still live. She had a young son from a previous relationship whose care she had given over to her parents. At the time I met her, she had not seen her son for close to a year, although she had maintained enough of a connection with her parents to keep in phone contact.

Ms X restarted opiate substitution pharmacotherapy, and we linked her in with a case manager as well as some psychological therapies. After a short period of time in crisis accommodation, she found some more stable (although still transitional) housing through one of the housing services. With support, she gets free of illicit drugs.

After a few months, she moved back to the country town to live close to her parents and her son. This period of time close to the support of her family and away from her old drug using haunts was pivotal in getting her well. She started a new relationship with a non drug using person, and now has her son back in her care.

A few months ago, her new partner was transferred by his work place to Melbourne. She is living with him in the suburbs. She has not used illicit drugs for 2 years. Her son goes to the local school. Opiate pharmacotherapy becomes an inconvenience and an embarrassment for her in her local community. We therefore work out a gradual dose reduction schedule to get her off treatment - she completed this reduction 4 weeks ago.

I saw her yesterday 1 month off treatment and still drug free. The withdrawals from stopping treatment have now resolved, and she reports no cravings or thoughts of drug use. She sees a counsellor for ongoing relapse prevention regularly. She has plans to return to study part time next year.

I have a real sense of optimism for her future success.

It's a win, and I'll take those where I can.