1

setting standardsfor prescribing

Dr Keron Fletcher

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standards of what?

• clinical effectiveness

• clinical safety

• clinical risk

• cost-effectiveness

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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)

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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 60-120 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?

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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

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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 it’s much easier to say “no” to the offer of something else.

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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 can’t do anything to you

• CLUE: if the patient says that buying heroin is now a waste of money – you’ve got the dose right!

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methadone – feeling comfortable

• does not cause sedation

– If so, reduce dose.

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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

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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”

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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

– ???

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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.”

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standard 3: risk

% patients on prescribed benzodiazepines

=

< 10%

???

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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

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shropshire/powys outcome data% Time (months) Х2

P =

t-test

P = meth bup meth bup

retained

3 months90 55 <0.001

***

retained

12 months58 26 <0.001

***

clear urine 85 64 4.7 2.7 <0.001

***

0.004

**

stop injecting 92 72 3.8 2.0 <0.0012

**

0.02

*

take home 54 34 9.9 6.3 <0.001

***

0.015

*

stay true 80 18 <0.001

***

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shropshire/powys outcome data% Time (months) Х2

P =

t-test

P = meth bup meth bup

retained

3 months90 55 <0.001

***

retained

12 months58 26 <0.001

***

clear urine 85 64 4.7 2.7 <0.001

***

0.004

**

stop injecting 92 72 3.8 2.0 <0.0012

**

0.02

*

take home 54 34 9.9 6.3 <0.001

***

0.015

*

stay true 80 18 <0.001

***

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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

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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???

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monitoring tools

• the “front sheet”

• the “summary sheet”

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SUBSTITUTE PRESCRIBING – St AustinsName:____________________________________________________________________________________PHARMACIST: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ TEL NO: ________________________________FAX NO:___________________________________PICK UP DAYS ___________________________________________________________________________

Date Doee1mg/ml

Form NextScrpDue

NextAppt

URINE RESULTS InjFreq

Pickup

Hep B Jab

Me Op Am Bzp(I)

Bzp(P)

Coc

04/02/10 30,40,50

Meth 11/02/10 11/02/10 + + - + - + 3x

Daily

7s 1

11/02/10 60,70,80

Meth 04/03/10 04/03/10 + + - + - - 1x Daily

7s 2

02/03/10 90 Meth 24/06/10 24/06/10 + - - - - - 0 7s 3

Form: Meth = Methadone SBX = Subutex Pick-up: 7s = daily supervised 7 = daily 3 = 3 x weekly 2 = 2 x weekly 1 = weeklyBenzos: I = illicit P = prescribed

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summary sheets

• shared care monitoring group 2005:

Cl Mean dose Pick-ups per week%S = supervised

Testedforhep

viruses

Immunsagainst

hepviruses

Opiates in urine Other drugs in urine

iv use at start

Stilliv use

Mth Sb 7S 7 3 2 1 3neg 3pos 3neg 3pos

LW 89 11 42 0 32 10 16 95% 79% 58% 11% 68% 0% 68% 16%

xx 52 - 0 0 0 0 100 100% 100% 0% 100% 0% 100% 40% 40%

yy 71 10 0 0 0 50 50 100% 100% 30% 50% 70% 10% 60% 40%

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summary sheets

• shared care monitoring group 2008:

Cl Mean dose Pick-ups per week %S = supervised

Opiates in urine

Other drugs in urine

iv use at

start

Stilliv use

Mth Sb 7S 7 3 2 1 3neg 3pos 3neg 3pos

LW 89 11 42 0 32 10 16 58% 11% 68% 0% 68% 16%

xx 95 2 29 14 14 0 43 43% 43% 43% 57% 86% 29%

yy 75 0 27 19 0 27 27 55% 0% 55% 0% 18% 9%

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four suggested local standardsprescribing

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