Hi - we have a client who is 21 wks pregnant, still vomiting on and off despite hospital investigation and various anti sickness pills, and can't tolerate methadone mixt, concentrate, or subutex. She finds it oK to use street DF118 or smoke heroin. We have started low dose meth tablets ( supervised 5 days a week ) Her partner asked if meth suppositories were available - i can't see this in BNF - wondered if anyone had tried suppositories or had any other ideas ? thanks
Gill

my only knowledge of suppositories in this field comes from trainspotting and that was not a good advert! I have never heard of methadone ones and I think I would have. The clinical guidelines ask you to consider slow release oral morphine in these situations. They do state, however, that these should only be prescribed by clinicians with 'appropriate specialist competancies'.

would local palliative care team be able to advise? different indication for the opiate but they often deal with people who have intractable vomiting, though perhaps not terribly often with people who are pregnant..........

If she is tolerating the methadone tablets, then i am sure you should carry on with those. If she is still using heroin, does she need a higher dose?

If you have supervised for a while to check compliance, could she come off supervision experimentally, so that she can try splitting the dose, or taking it at unusual times of the day or night? How does she get on with her takeaway doses at the weekends?

Hopefully the nausea will ease soon. I've never heard of methadone suppositaries, though its probably a good idea. Maybe we should get the drug companies on to it?

We had a similar patient, unable to tolerate methadone mixture during pregnancy, but could cope with methadone tablets. The house was very rural, hence supervision wasn't an option. The stories about the availability of methadone tablets only surfaced after she delivered.
I would be inclined to go for slow release morphine in future unless well supervised.
Rob

Thanks for all this - am reviewing client on thurs. Looking at BNF there is no meth suppos but there is morphine suppos. so maybe we could try this if tabs fail, rather than slow release morphine tabs ( which may cause nausea or be misused ). Can't imagine misuse of suppositories ........ well, there may be stories out there - the client's boyfriend was the person who asked about them .... go on, surprise me ! Also - are there any simple conversion charts from morphine to methadone and vice versa ?
Many thanks

Hi Gill,
Wouldn't it be simpler to continue the Methadone tablets if they are working? Everything else does seem a lot more complicated.
I wonder are Methadone tablets allowed on Blue scripts though?
It would seem that you have good justification for prescribing the tablets.

I would be careful before going out on a limb with this Gill. I haven't heard of anyone using morphine suppositories in this field and if anything were to go wrong it might be difficult to back yourself up. I think if you really want to go down this route a second opinion would be a good idea in order to cover yourself.
I don't know enough about the formulation of the suppositories to be able to evaluate their diversion potential- one things for sure supervised consumption is going to be tricky!

Yes, I would only prescribe suppositories if tablets dont work - my feeling is I will get same response from client that i had to the trial of subutex and meth concentrate, and am just thinking ahead.
Also the potential to misuse suppositories is less than with tablets, i would have thought .... but of course as with any situation on going outside of guidelins it would be weighed up , backed up and justified.
Just an interesting clinical situation, and perhaps they should think of making meth suppos .......

PS yes meth tabs can be written on blue script.

I've just picked up on this discussion and wondered how the client got on.

Methadone suppositaries have reared their head (that conjures up rather unpleasant thoughts)in my local area.

A word of warning from the "methadone briefing"- Methadone suppositories
Methadone can be prepared as a suppository under the special licensing system. They are rarely used in the treatment of dependency. Although they would be expected to have a rapid onset of action the possible therapeutic benefits of this would probably be outweighed by the ease with which they dissolve in water and could thus be injected.

This message has been edited. Last edited by: Daniel Chapelle,

quote:

Methadone can be prepared as a suppository under the special licensing system.

And will take the pharmacy a couple of working days to obtain.

Jeff

quote:

Originally posted by Jeff Green:

quote:

Methadone can be prepared as a suppository under the special licensing system.

And will take the pharmacy a couple of working days to obtain.

Jeff

Being mindful of tax payers money I'd imagine these would be very expensive.

I would also be concerned about consistent rates of absorption, potential ulceration, consistent supply and the licensing and PPA's contractual framework.

All interesting points - I have always thought of suppositories as rather greasy objects which would not be easy to dissolve .... but am obviously wrong. As an update - the client did seem to stabilise on meth tablets, but then went through a phase of not attending, so we obviously have some concerns about compliance and perhaps it underlines the unease I had in the first instance when she stated that smoking heroin or taking DF118's was the best way to treat her sickness - most Service Users state that smoking or taking opiates actually makes them feel sick. She is on 6 days per week supervised consumption and the script is held at the CDT, not posted, so that we can arrange to see her in person. Gill