I was speaking to someone yesterday who has in 4months of engagement and t/ment 'had' 6 pharmacy changes.
Has this chap who is on 50ml daily been suffering from any ill effects from the continuous changes in the 'brand' of m/done(as he hasn't been offered Fhyseptone yet)?
Chap presents with stomach cramps and V+D.
Aching and painful joints.
Sneezing fits in mornings.
Pain lefthand side of abdomen.
Where previously sleeping til 11am(retiring at 10 or 11pm) now he is waking at 6am and finds this distressing as this seems to 'seal the deal' to the point where he feels he is 'clucking'. W/drawing.
He also adds that he now 'has' to take his dose earlier(much 9am).
These sound very much like w/drawals but i do not want to even put it into this guys head that he needs a top up but for the very same reason i do not want to see him suffering.
Can or could it just be the changes in his meds and not the dose.
History is that he was 'satble', in his opinion, for the first 4months of his recovery but the last 2/3weeks have been very difficult. Obviously he has only been in t/ment a few months and to be frank i am a little shocked at all these changes.
His 'shared care' seems, to me, to be a inpenetrable maze of different agencies who could not all communicate with each other if their own lives were at stake. This, i feel, has contributed to his, now, difficult journey.
Please someone feedback with anything relevant that could help as it would be a shame for him to up his dose if he just needs some continuity.
Best
Tony B

Tony,
I've heard this many times and the methadone in each product has to be the same. We are told we must prescribe generically to save cash. Prescribing generically i'm told means we can have moer people in treatment and also cost savings over the whole practice budget means again I can have more people in treatment. The practice I work for does not get any dispensation for the extra costs of subutex/methadone. Subutex as i'm sure you know is quite costly.
Back to the issue you raised, some people when switching to sugar free as I believe it is slightly thinner see thinner as weaker. I guess also different brands are different colours and the mind is a very powerful thing. If we associate one product as good and that is what we are used to then switching to something different can be unsettling.
An example of this is some years ago when I worked at a hospital one of the nursing assistants who did not want to be seen stealing hospital cornflakes fetched in an empty Kelloggs box and filled it with the cheapo hospital ones. The other staff thought they had one over on her by taking her 'Kellogg's' brand and they thoroughly enjoyed them. It was only me and her who knew they were eating the hospital cheap stuff.
I also remember the hospital going to generics and switching from the anti-psychotic Largactil to the generic chlorpromazine. Some of the old staff believed it was not nearly as good and i'd hazard a guess that maybe some people tipped a bit more in 'Just to make sure'. I have no evidence that this did occur.
So with a wealth of information to say that generics have exactly the same ingredients, why them are we told not to change some of the epileptic drugs or lithium to generics ?
I really don't know the answers but there are many reasons that people rate one brand more than another even if it's to do with the quality of the box or bottle, colour or texture.

oh and pain left hand side of abdomen could be constipation, better ask him about that. Sometimes people get really bunged up and think they have diarhoea as the only stuff that comes out is the really loose stuff, leaving the solid stuff inside. It's termed overflow. I try and always ask people about the bowels as it is common when people take opiates and often patients are a bit embarrassed to mention it.

If I had a patient who felt his was clucking on 50mls I would think he was probably right, as that is a low dose for maintenance methadone. Research shows (see various references in the library section, or I could find a link or two)that doses need to be between 60mls (some say 80mls) and 120mls daily, to provide safest and most effective treatment for the majority of people.(perhaps surprisingly, higher doses lead to less drug related deaths)

It has been found to be most effective to get people onto whatever dose they feel makes them feel comfortable (it seems that nobody wants to take more methadone than they need on a regular basis) then to provide all possible help towards sortng out the psychosocial aspects of life (ie to "get a life") after which it is just as easy or hard to come off 80mls or 100mls daily as it is to come off 50mls daily .

2. I would agree with Simon, he may well be constipated.
3. Though I almost always prescribe generic methadone, as like Simon, I have been taught to save all our taxes by aiming to make the NHS as cost effective as possible, I am told that branded methadone (ie "physeptone") is in fact a few pence cheaper per dose than the generic price. This may well be true..it was when I last compared the prices, so that might be an option.

4. I still think sounds like he needs a higher dose (and probably some lactulose or similar laxative)

Thanks on that.
Yes I know Physeptone is indeed cheaper by a few pence as we in Goshire have just rolled it out countywide, after a citywide trail first.
This chap is in another area, fairly close geograph speaking and personally a lot more and is not in anyway a client but someone close in 'need'.
I, personally, do not like the sound of the lack of continuity around his care generally and all these pharmacy changes have created a total dis-trust in these professionals, tho from what i can make out he seems to trust his Care Coordinator still.
I was also concerned to hear that his current GP was almost 'thrusting' Benzos at him and 'so far' he has resisted the temptation and declined the doctor's kind offer.
I know there is quite a lot there but you cannot help caring.
Best
Tony B

Hi Tony.. agree with what's said but thought also about HCV screening, because I had a client who was very stable then complained of feeling as though he was withdrawing but couldn't work out why as not using on top etc..but he was having antiviral treatment. Then i read a study which suggested clients having treatment for HCV may need slight increases in meth due to effects on liver of the /treatment/virus. I did as suggested and he felt ok again with no symptoms of withdrawal..... thought it was an outside chance worth consideration... take care.