As a supplementary prescriber in the field I am involved in tritrating doses of methadone and buprenorphine once the doctor has prescribed the initial dose of the drug to the patient.

The clinical guidelines indicate that if a patient misses 3 or more doses of medication their tolerance to it might have been lost. Re assessment and restarting would be necessary. In my service this would be done by a doctor.

Is there any difference between restarting and induction? To me, if a patient has lost their tolerance to a drug they are basically being 'inducted' once again

I think the clinical guidelines say 'more than 3 days' by the way, meaning 3 days is probabably ok. After this there should be an urgent assessment by the prescriber. I think retitration is the correct term as restart means you would treat them like a new patient (referral, initial assessment etc)

Thanks Jim

Yes it would be a retitration . When you say urgent assessment by the prescriber -if and when it comes to prescribing again- would the initial prescription be signed by an independent medical practitioner? I would say YES myself, but I would like to check that I am in line with majority opinion on this, since I know of other services where there is a different interpretation in relation to the initial prescribed dose.

Hi Louise,
I guess it does depend on how many days have been missed and the dose the patient was on.
Loss of tolerance is thought to take more than 3 days but I can't remember where I saw the reference - maybe some clever person might find it.
I'd almost always give less but if it was just 4 days and I knew the patient well i'd probably give the same, after that i'd start knocking some chunks off. I'd also be seeing the patient more regularly. I wouldn't automatically re-start at 30-40ml if someone had been on a high dose. The more days missed the less i'd give, the figures are in my head though and not an exact science and also depends on how chaotic the patient was.
When it gets as long as 6-7 days i'd really probably not give more than 50ml-60ml even if they'd been on doses more than 100ml.

Hi Louise,
Wouldn't it depend on the experience and expertise of the supplementary prescriber and after that, what was written on the Clinical Management Plan? I can't imagine an experienced supplementary prescriber like Simon G, needs to look for a Doctor for a re-titration, if clear instructions allowing for one are written into the CMP?
Does anybody know when all you SPs are going to be allowed to become IPs for this area? surely the government has finished its swine flu plans by now?

This message has been edited. Last edited by: judith yates,

quote:

Originally posted by judith yates:
Does anybody know when all you SPs are going to be allowed to become IPs for this area? surely the government has finished its swine flu plans by now?

The war in Iran will be the next excuse I fear.