Hi - a quick question - if a client is not engaging well , but has been on daily pick up ( or less frequent ) how safely can we resume supervised consumption ?
We have a " re- engagement policy " which tries to avoid stopping a script, and is meant to tie script collection with keywork, but for persistent non attenders on the way to that final stage we have the dilemma of continuing script ( maybe issued at the CDT weekly ) and deciding whether to reinstate supervised consumption.
Am aware that some agencies hold the script and just don't give it until the client is seen for a keywork session, or give a 1 day script - somehow that doesn't work where we are - so we are a bit stuck with the above scenario.
If client is not using methadone we wouldn't know, as we ring pharmacy and they confirm client collecting, so we assume some opiate use onging.
Our draft regime would be:

Try to arrange " on the spot " UT as soon as possible ( to confirm opiate use )


Client on < 40 mls methadone daily & weekly / 2 - 3 x weekly pick up

* resume DSC

* alert pharmacy - to advise client not to have meth if looks intoxicated


Client on > 40 mls methadone daily

* resume Methadone 30 mls dsc for 2 days ( 10 - 20 mls take home )

* 40 mls DSC ( 2 days ) remainder TTH

* 50 mls DSC ( 2 days ) remainder TTH

* 60 mls DSC ( 2 days ) remainder TTH

* 70 mls DSC ( 2 days ) remainder TTH

* 80 mls DSC ( 2 days ) remainder TTH etc

* then full dose dsc

Just to cover the fact that the client may have reduced their own dose, be sharing it, or be varying dose due to chaotic drug or alcohol use.
Any thoughts ?
thanks
Gill

Hi Gill,
That is exactly what I would do in the situation you describe..but I have never written it down as a formal policy. I think it will be very useful to do so, so that everyone knows what is in my head, in case of RTA or sudden onset dementia. I will make time to so this.

I have always been very frightened of suddenly re-imposing supervised consumption, for exactly the reasons you describe. Even where there is communication with the person, I find there are very occasional times when it is helpful to ask a person to agree to a short period of supervised consumption, to aid mutual trust (I normally blame the government or some other scape goat but my patients are not daft, and will generally understand my motives) . In this situation it may initially be hard for personal pride reasons for them to admit that they are sharing the dose with a partner or a cousin, and a graduated return to supervised consumption allows us both to save face, and sometimes allows the person at some point to say "actually I may be ready for a bit of a reduction, and would you be able to see my cousin?"

I wonder if we should suggest a new section for the next Orange Guidelines on safe restarting of S.C. ?

Hi Gill, i'd personally just go a bit slower on the 10ml increments, maybe 10 ml every 3 days. as you say, they could have been selling it and you don't want to get into a situation of cumulative toxicity of methadone. if you were though to go 10 ml every 2 days then maybe review them at 60ml before going further? I see this really as a new "induction onto maintenance" in that you wouldn't be reinstating supervision unless there were concerns, so assume the worst, ie. they've sold virtually all of it. apprec I'm cautious but induction is always a tricky time.

Also as in any induction situation I would always repeat about three times that i am anxious about the person's safety and that they are responsible themselves for keeping themselves safe and for letting the pharmacist know if they want to take only part of the prescribed supervised dose for whatever reason. I cannot be with them all the time. Especially, if they feel unwell, or particularly if they develop a chest infection (or swine flu) they need to let me or someone know and probably should not take their full prescribed dose.

In the last 30 years I have had two patients die with pneumonia in the early weeks of induction,

These warnings are all difficult to make adequately if at present the patient is rather disengaged but hopefully it is still possible to check their well being via the pharmacist. I would agree with Nat's 3 day between each increase, particularly at the lower doses.

Hopefully the person will have come in to see you or at least for a key work appt to complain about your new prescribing regime before long..

Something we tried in Bradford and that works very well is to avoid unsupervised consumption in the first place. Does not really help in this scenario you described, but we had a lot of similar cases and we changed the majority of our clients who were unsupervised to this scheme over the last year. It does work very well and is popular with users.
So, instead of unsupervised daily pick up we went to supervised consumption Mon, Wed, Fri. This gives me the certainty that the right dose is taken at least three times a week and avoids two to three trips to the pharmacy for the client.
Even clients that would normally be on unsupervised consumption often prefer this as long as they are not working away from home for a couple of days, in which case they often can work with split scripts (Mon & Wed away, Friday back home).
Changing back from this to daily supervised is an option for high risk users, i.e. groin injectors and binge drinker etc.

From limited experience working in Bradford recently - I'd noticed the prescribing pattern - but had assumed it was done on an individual basis rather than a plan.
Where the local pharmacies informed of the plan (I'm on Bradfords mailing list but could have missed it) or was it something you didn't think worth sharing?

Jeff