Dear members

Patients receiving opiate replacement therapy need to attend medical reviews for obvious reasons. In some clinical settings, when patients don’t attend to the second medical review (they have not been seen for several months), the pharmacist is notified and the medication is put on hold until the client is able to see the doctor. There is some controversy about this issue because some argue that putting the medication's patients on hold would make them more vulnerable. Others agree that patients must be supervised by the doctor in order to verify the current dose and patient general health.
What are your views on this issue? I would be grateful if you could possibly link some literature.

Omar

We're clear that a prescriber carries responsibility for his/her safe prescribing and a patient who is persistently missing reviews can't be safely prescribed for, so prescribing has to go on hold. Since face to face review may be difficult, we allow for telephone consultation after which the pharmacy is informed that the client can resume collecting. But in the end you can't expect prescribers to work blind. They wouldn't do it in other areas of medicine.

Thank you Graham for your valuable response, I entirely agree with your view, but I am looking for some literature to support this.

Omar

quote:

the pharmacist is notified and the medication is put on hold until the client is able to see the doctor

Make that "the pharmacist is informed that the medication WILL be put on hold until the client is able to see the doctor" and you give the pharmacist the opportunity to intervene and warn the patient in advance of the medication being stopped.

Jeff

We work on the basis of the Orange Book's sections 5.5.3.2 to 5.5.5.

"5.5.3.2 Patient misses appointments
In instances where a patient is collecting their medication but failing to attend appointments, as arranged with the clinician in line with the agreed care or treatment plan, the clinician will be unable to monitor progress against identified needs. If this situation persists and the patient does not respond to requests to contact the clinician, the patient may be offered incentives to attend or evening appointments. An urgent review needs to take place to enable prescribers to review patients and satisfy themselves that the medication is optimised and safe."
"5.5.4.4 Application of safe prescribing boundaries
Prescribers have a responsibility to make individuals aware of the criteria they apply as healthcare professionals, when deciding whether or not it is safe to continue to prescribe..."

Ho Omar,
You could let the Patient know they'll get the next prescription when they see you. That might make them more likely to come. We always issue prescriptions at appointments so patients mainly do come and see us.

Yes but our problem is that this is all open to interpretation - fortunately for us, John Dunn, Clinical team psychiatrist at the NTA has written some rather helpful guidance on this which examines it from the patient's view as much as the doctor's http://www.nta.nhs.uk/publicat.../completions0909.pdf see pages 29-31

quote:

Originally posted by susi:
[url=http://www.nta.nhs.uk/publications/documents/completions0909.pdf]

It is helpful as a totality. I just wish that this document hadn't put "referred on" as a "planned discharge" (Table 17 and appendix 10). This implies something postive, rather than something that is actually neutral. I would have thought that it skews the figures when almost half of the "planned discharges" are comprised of this and this could make some readers rather cynical of these statistics. I was brave enough to ask this recently at a conference, and took some pleasure in what I thought was a bit of wriggling taking place!

Any thoughts on poor attendees who ostensibly are doing well on long term maintenance where as a prescriber there are lingering doubts as to whether the full dose is being taken.
Might it be permissible in such circumstances to introduce random supervision of say 5 days? Particularly now that we are being admonished for only doing half a job by the NTA, we are invited to think creatively and be more ambitious for patience.

Thanks Susi, i hadn't seen john Dunn's paper. I find it very reassuring mainly because it seems to confirm all my instinctive beliefs, and back many of them with useful references!

Jim, i think it has to be correct that "referred on " amounts to a planned discharge from a service.. eg when a person's treatment moves from a community drug team to a GP surgery team? It is not suggested that they are in any way cured, (or "recovered" as it seems to be now called) but being "referred on" to another provider in a planned way has got to be better than an unplanned discharge?

Dr O.. As you may be aware from other postings, i feel strongly that the prescriber should be themselves in a position to review the person from a physical health and prescription point of view at least every 3 months (as the guidelines say)and as you say, if this appt is missed it can sometimes mean the person is not eventually tracked down and encouraged in for a review until some weeks later, but I think stopping the script should be very very far down the list of actions.. see john dunn's table 5, (actions to be taken when appointments are missed). It may well be helpful at some point to ask the pharmacist to "hold" the script just on the day of the appointment, or the pharmacist may well be able to talk to the patient and find out what is behind their non-attendance, or even sometimes to ring the clinic or surgery when the patient is in the shop, to allow a conversation with the patient.

I will read John Dunn's paper more carefully when less tired!

Glad the paper was helpful to people. I thought he did a great job, and managed to get it published in record time!

Perseverance, I can see the sense behind what you are saying, but bear in mind you might inadvertently overdose someone if they are not taking the full dose and you force them to do so. This sort of thing needs to be addressed collaboratively with the patient. Usually I have a conversation about it if the person is still using illicit drugs. We have a full motivational chat about their long term goals and end with a conclusion (nearly always) that what they really want is to stop taking illicit drugs altogether. A lot will say they don't take the meth on the days they have decided to use, so it doesn't mean their habit has gone up. Then they usually agree that if not drug free by a goal date (set by them) they will let me put them back on supervision to stabilise them. A few will achieve the goal, the others go back on supervised, and after a week or two often want to go for a higher dose. If someone is not using on top they usually start to ask for reductions in dose all by themselves, with which we are only too happy to oblige!

GMC guidance on repeat prescribing is clear - Any prescriber must know the up to date situation with their client - especially use of prescribed, non prescribed and illicit drug use, and any other factors affecting safety of script and client
There's a GMC website link ( prescribing and ethical guidance ) which I will post later
Gill

This message has been edited. Last edited by: gill redshaw,

here's a link on the ethics of prescribing / repeat prescribing

http://www.gmc-uk.org/guidance...escriptions_faqs.asp