Hi Guys

I am new to this forum and currently doing my part 2. I am working in 2 different clinics that I have inherited from previous drs. The drug workers in both clinics are very used to doing things a certain way. I am concerned that the usual practice in the clinics seems to deviate from the guidelines.

I suppose my question is this:
When starting methadone, how often do you as the prescribing actually see the patient and how often should the drug worker see them. I have tried searching online and on this forum already for this.

It has been suggested that i only need to see them 1 month later and if i tried to see them sooner they would probably not attend. I am also unclear exactly what monitoring the drug workers are putting in place during this time. It all seems a bit vague. I know the guidelines seem quite intensive (eg do not chg dose without seeing etc.), does everyone see their patients very regularly to start with. The context for me is that the 2 clinics are in different locations and occur weekly. I do not have the opportunity to see them myself in general practice but see them in a clinic with the drug worker.

Hope this makes sense and grateful for any feedback.

andy

The guidelines need to be the starting point for discussion in your practice I feel. Following them should be customary with occasional exceptions.

Seeing someone regularly and frequently during induction is important to that an effective dose can be established safely and without uneccessary delay. If you are waiting a month without reviewing dosage i can only assume induction must be either very slow, or unsafe.

Keyworkers with clients undergoing induction should contact them twice a week or more to check concordance, pharmacy relationship and behaviour etc, monitor the effect the prescription is having, and support the client in making the transition from 100% street drugs to (usually) a mix of the two.

I prescribe for 1 week initially, with perhaps a small increase after 3 days built in, then review face to face. Supervised consumptiom too. Not expecting them attend is a counsel of failure from the start and suggests very low view of clients.

Part 2 Cert standards are not being met if I understand your post correctly, but it may be possible to use the Cert as a lever to influence change. One of the expectations is that Part 2 holders exert a strategic leadership role in their area. I hope you can do this.

hi andy,
i agree with jim. Start with the guidelines, but beyond that, look at the particular needs of the particular patient. In these target driven times we are again and again led towards putting systems and processes before individual patient's needs.

As we are all aware, methadone induction is a very dangerous part of a person's drug taking journey. You are signing the scripts. so the buck stops with you.

Having said that, I recognise the picture you describe. This is one of the many reasons why drug users should generally be treated in primary care, where appointments are so much more flexible, and where the prescriber has control, rather than the clinic system and can se the person daily for the first week if they feel it is needed for safe prescribing.

I too work in two different clinics (as well as my surgery) In one, the appt systems have over the years become rather inflexible,because most appointments are booked up well in advance, with long term review slots, but we have always had a pre-blocked slot a week after the induction appt, in which to review a new starter.At this clinic, we used to have a system which expected the third appointment to be not until 6 weeks later, but this was seen to be too long for a new-to-treatment person, so it has been changed so that we now have blocked review appts which follow each new patient slot, after one week, three weeks and nine weeks. (if the person does not turn up to the induction appointment, these pre-blocked slots can then be released) Then they generally go into a 12 week review cycle..seeing drug workers in between...

Like Jim, I will usually write a first induction script with an automatic increase after 3 or 4 days, then review at day 7. The supervising pharmacists are aware that they have a duty to monitor the person's well-being before dispensing each day.The aim is to get up to a maintenance dose (over 60mgs )within 2 weeks.

I think you need to find the time to sit down with the managers of your two clinics, and look at their appointment systems and explain your clinical concerns. I would be very very unhappy to start a brand new script without being able to see the person again myself, before i signed another script for the second week. In the short term you might need to add extra slots at the end of you fully booked clinics, to review the previous week's new starters, as presumably the clinics are already full with long term reviews. This solution will not be popular with either the clinic workers or your partner at home, so hopefully the managers will quickly see that changes to their systems are needed imediately.

The needs of the patients should of course drive the system, not the other way around. In these target driven "business" models the NHS has moved towards, the people involved (patients/prescribers/drug workers)frequently get lost.Terrifying. Good luck

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

many thanks Jim and Judith.
v helpful.

I am going to speak to the drug workers and management. Will need to tread carefully as I think there are different approaches to this between clinicians within the service.

Andy

Hi Folks, it would be nice for me as a pharmacist providing substitute medication, if key -workers DID phone us up to ask how their patient is going on - are they attending regularly, are they intoxicated etc.etc.. Induction is a very tricky stage on the road to stablisation. Also it would help to know who is on an initial induction Rx.
I always try to phone prescribers with any concerns I have with their patients - please can we have a two way dialogue?
Regards
BobD

Hi Bob

thanks for the input.
I must admit I had presumed this did occur with these paients. I know our drug workers ring the commun pharm when we have decided to start to check it is OK etc. However, I am beginning to wonder if here is less dialogue going on after that than I thought.

andy

That's interesting Bob. Maybe we should stamp a new person's script with :
"Pharmacist: Please note this is a new induction first prescription" or
"please note this is a re-start induction prescription"

I can see a whole new set of stamps could be designed.

I;m amazed that its assumed patients won't turn up sooner than one month. I write the induction script for 3 days then another script with increase to be given by the keyworker and its rare they fail to turn up. We felt it was too big an ask to rely on pharmacists to reassess how they were getting on, plus it helps build the all important therapeutic relationship with keyworker early on.
I agree with Jim and Judith: you are in a risky situation right now, most patients who die in treatment do so in the first two weeks of induction. I don't think you have much option here, its got to change. What are the barriers?

susi

I suppose I have read the guidelines and tried to interpret them in the context of the service I am working in. I do not increase by more than 5-10mg per day or more than 30mg in 1week as per the guidelines. However, when I started 2 months ago I was new to substance misuse and working alongside a medic in a parallel clinic who had been doing it for a long time and built up a way of working with the drug workers which they felt as a group was how things were done.

Additionally, the geographical location is a bit isolated and it is difficult to get secondary care input for more complex patients.

I was informed that there was no point giving them an appointment to see me sooner than 1 month as they would not attend and they would not be used to that arrangement as it isn't how they are normally treated. This I have really struggled with as I feel I have not been in control of how I want to treat my patients and minimise risks.

In GP land my response would be "tough" and they either come and choose to see me and receive treatment or choose to forego that Rx. It seems a bit more complicated working within the harm minimisation environment. Our service provides continuation scripts from a central office to pharmacies and it is only after their second missed appointment with me that anything would then change with their scripts. Interestingly, from the second clinic, all the scripts are printed out from clinic when they attend.

I agree following the useful feedback I have had here I need act on this which I will start doing this week. I think it will be confusing for the punters if two Medics work in different ways but I will just need to work on that.

many thanks

andy

well it might be worth mentioning to your colleague that he's in a risky situation too! It will be a bit tricky trying to manage a change like this I imagine, you could do with an ally (is that how you spell it?) I'd suggest you point it out to the manager or whoever supervises you pretty soon that the custom and practice are dangerously outside 2007 DH clinical guidelines and you think its a significant clinical governance issue as patient's lives are at risk, then be constructive and make sure they know you want to work with them on it, not just report them or walk away. Find out what the barriers are to change, and see if you can come up with some alternative ways of working that will make things safer without undue impact on the service.