Question one. 1. You increase her to 90mg 2. You increase her to 95mg 3. You hold her dose where it is (80mg)

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1 What it all means

2 Question one. Ms. Presley was on methadone under your care years ago. She had been off the program for a few years and restarted back on methadone after a lengthy IV heroin and Oxycontin addiction. She has no features that put her at higher risk of overdose. She was previously on 150mg of methadone. She has now been on 80mg for the past 3 days. She complains of classic opiate withdrawal symptoms 12 hours later. She has ongoing IV use of heroin in the evening time when most of her withdrawals and cravings for opiates start. As 3 days have passed, what do you do?

3 Question one. 1. You increase her to 90mg 2. You increase her to 95mg 3. You hold her dose where it is (80mg)

4 Question one ANSWER Answer 3 Key message After a dose of 80mg has been obtained, you should wait 5-7 days to pass before another increase in methadone. dose increases above 80mg should be 5-10 mg only even if no high risk features

5 Question two. Ms. Presley has reached 120mg and is still complaining of withdrawal 15 hours later. She denies any sedation or side effects from methadone. She denies using he.roin but recently started smoking crack cocaine once to twice a week She wants an increase as she was previously on 150mg and feels uncomfortable with withdrawal late night. What do you do? 1. You increase her cautiously to 130mg after consulting with another specialist 2. You decide to leave her at 120mg as you are not comfortable with high range dosing and offer counselling around her cocaine use 3. You insist on an EKG prior to increasing the dose above 120mg

6 Question two ANSWER Answer either 2 or 3 Key message Cocaine use is a risk factor for QT prolongation. An EKG is required for dosing above 120mg for high risk patients

7 Table 07: Risk Factors for QTc Prolongation in Patients on Methadone Older Age Heart disease cardiomyopathy Myocardial infarction, congestive heart failure, valvular disease, HIV infection Low potassium level On drugs that lower potassium eg. Diuretics Low prothrombin level On medications that inhibit Cytochrome p450 3A4 HIV antivirals e.g. indinavir Antifungals e.g., Fluconazole, ketoconazol Calcium channel blockers e.g., Diltiazem, verapamil Antimicrobials e.g., Norfloxacin Antidepressants e.g., Fluvoxamine Contraceptives e.g., Mifepristone Foods: e.g., grapefruit juice Alcohol use Cocaine use Family or past history of long QT syndrome History of syncope or sudden cardiac death in the family On medications that prolong QTc Cardiac medications amiodarone, sotalol Antipsychotics (chlorpromazine, haloperidol) pimozide, thioridazine Antibiotics e.g., clarithromycin, erythromycin c Anti-nausea drugs e.g., domperidone

8 Question three. Mrs. Jones is on chronic benzodiazepines (Valium 20mg bid recently discontinued by her GP) and is injecting 1 gram of heroin per day. She will be starting methadone today. Her initial urine shows positive opiates and benzodiazepines. She is in obvious opiate withdrawal and has visible track marks. She states she hasn`t had any Valium for the past week, and is worried about having a seizure. She insists that 20 mg will not be enough, as she was previously on methadone last year at a dose of 120mg, and she tells you she has an extra high tolerance as she has been injecting heroin for over 15 years. What dose would you start this patient at?

9 Question three 1. Start on 20 mg with reassurance 2. Start at 25 mg as it is under 30mg, and she has a known high tolerance 3. Start at 30mg given ongoing IVDU heroin use and risks of this. 4. Either 2 or 3

10 Question three ANSWER Answer 1 only Key point. Patients who are on chronic benzodiazepines, or alcohol are high risk for overdose and should be started at 20mg or less regardless of opioid use history

11 Table 03: Patient Factors that Increase Risk of Methadone Toxicity High Risk Patients Recent benzodiazepine use Use of other sedating drugs Alcohol-dependent patients Over 60 years old Respiratory Illnesses Taking drugs that inhibit methadone metabolism Lower opioid tolerance Decompensated hepatic disease Recent discharge from inpatient rehabilitation facility Recent incarceration

12 Question four. Mr. Lee is doing well on 4 carries...the pharmacy has notified you that he was getting a prescription for 80 Percocets a week from his GP. All of his UDS are negative. What do you do?

13 Question four 1. Counsel the patient on dangers of double doctoring and inform doctor to discontinue the Percocets for safety reasons. Leave carries at 4 as he was drug free. 2. Inform doctor to discontinue Percocets for safety reasons, and cancel all carries due to double doctoring. 3. Cancel all carries but you are not obliged to speak with the GP about this prescription. 4. Counsel the patient about risks of diversion of Percocets and continue your care as it was.

14 Question four ANSWER Answer 2 Key message If this patient was taking 80 Percocets weekly along with methadone you would expect a positive UDS for oxycodone. With a negative UDS, he is either diverting his prescription or bringing in someone else s urine for testing. Carries should be held until stability is ensured.

15 Question five Mrs. Jones has been a stable level 6 patient for many, many years. Recently her father died suddenly of a massive MI, her husband left her with 3 children for another woman, and her son was diagnosed with diabetes. When she sees you she is quite upset and not coping. She admits to recent cocaine use over the last week in order to stay awake to be able to help her mother and cope with her 3 children on her own. What do you do?

16 Question five 1. Hold all carries until you are assured that she is stable without any drug use at all. 2. Her use of cocaine has been short lived. You decide to change her to 5 carries, set her up with counselling and see her in 1 week. 3. Continue her at 6 carries, set her up with counselling and see her in 1 week. 4. Either 2 or 3

17 Question five ANSWER Answer 4 Key message It is important to know your patient and set up appropriate supports for this patient. Carries can be decreased if you have concerns or held at 6 carries and follow closely.

18 Question six. You see Mrs. Jones weekly after her slip with cocaine and she was able to stop using cocaine for one week. At the next visit she admits to ongoing daily use of cocaine. She is still receiving 6 carries. She states that her use has increased to daily now for the last week. She is smoking crack cocaine now multiple times daily and has not been able to stop. She begs you not to change her carries. She admits that there is a problem and is willing to get counselling, however removing or changing her carries would result in more stress and she feels that this will result in further drug use. What do you do?

19 Question six.. 1. You are working with this patient closely and feel that with counselling from the therapist and you, she would do better with 6 carries. You continue her with 6 carries and see her weekly. 2. She has now had sustained drug use for more than 4 weeks. You hold all carries. 3. Given sustained drug use, you decrease carries to CPSO level 5 and discuss importance of counselling and dealing with current issues. You advise that you will continue to decrease carries if ongoing use.

20 Question six ANSWER Answer 2 Key message. With ongoing substance use a patient is deemed unstable and all carries should be held. Counselling and ongoing close monitoring of this patient is important.

21 Question seven.. You see Mrs. Jones weekly. It is 8 weeks later. Mrs. Jones is not receiving any carries now. She has been seeing the addiction counsellor weekly and is doing well and managing with her children and the situation with her ex-husband. She has not had any drug use for the last 2 weeks (her urine drug screens for the last week are negative). She is asking for her carries back as she is having a really difficult time getting to the pharmacy daily. What do you do?

22 Question seven. 1. Return all carries. She was a longstanding stable patient and needs her carries back. 2. Return 3 carries for now and consider increasing more carries if ongoing stability. 3. You advise that you can restart one carry for now and increase weekly so long as she remains stable. 4. You advise that you can restart one carry for now and increase every 4 weeks so long as she remains stable.

23 Question seven ANSWER Answer 3 Key message... When carries are removed (with a relapse for example), they can be reinstated weekly so long as the patient continues to be stable.

24 Question eight Ms. Presley has been abstinent on 80 mg of methadone. The pharmacy informed you that she is getting a regular script of Rivotril from her family physician after she has been drug free She admits to being on Rivotril for the past 10 years for anxiety disorder and gives you consent to speak to her GP. She is getting monthly prescription of Rivotril of 2mg TID What do you do?

25 Question eight. 1. You call the family physician and let him know to discontinue all benzodiazepines as she has misled you 2. You inform the family physician of the potential dangers of benzodiazepines with methadone and ask for daily dispense of the Rivotril and suggest a taper to Rivotril 2mg BID at a rate of 0.5 mg to 1 mg per week. You ask of history of previous diagnosis, and prior SSRI treatment. 3. You ask to take over the prescription so you can be in a better position to taper.

26 Question eight ANSWER Answer 2 or 3 Key message Communication between family physicians and methadone prescribers are important for safety of the patient A taper of High dose benzodiazepines is recommended The benefit of taper should be stressed to the patient

27 Ms. Presley has been getting chronic benzodiazepine from yourself at a dose of Rivotril 1mg TID. She wants carries. How do you manage this patient? She has had failed attempts of multiple SSRIs. She has a diagnosis of chronic anxiety disorder. She is unwilling to taper further at this point,. 1. You can give only one carry and not more 2. You should consult with a psychiatrist before giving any carry. 3. You can give one additional carry per month as long as the following criteria are met A.Controlled dispensing of the rivotril,.,ie daily B. A documented diagnosis with documented failed attempts of non benzodiazepine alternatives such as SSRI C. An attempt to taper further D,.You may consult with an addiction specialist instead of a psychiatrist.

28 Question nine Bill is a long term patient receiving 6 carries for the last number of years. He comes to see you once monthly but leaves a urine drug screen every 2 weeks, which are all negative. Your staff are suspicious of tampering (cold sample which is negative for methadone) and ask for another urine sample. Bill becomes angry and upset at the staff but eventually leaves another sample that is warm and positive for EDDP and cocaine. What do you do with respect to his carries?

29 Question nine. 1. Discuss the relapse with the patient and if he is remorseful and understands what he did wrong, you can continue 6 carries but watch more carefully. 2. Decrease to 5 carries and arrange for twice weekly urine drug screens to follow more carefully given the relapse 3. Hold all carries given tampering of the sample. Increase frequency of urine samples to follow more carefully and return all carries once you feel patient is stable. 4. Hold all carries given tampering of the sample. Increase frequency of urine samples to follow more carefully and return all carries one at a time back to 6 carries with ongoing stability.

30 Question nine ANSWER Answer 4 Key message... The MMT physician shall cancel all take-home doses abruptly in the circumstances listed below. The daily observed dose should be reduced if the MMT physician suspects the patient may not have been taking the full take-home dose. There is reasonably strong evidence that the patient has diverted their methadone dose, or has tampered with their UDS. The patient has missed 3 or more days of methadone (except in unavoidable circumstances such as hospitalization). The patient has become homeless or in unstable housing, and can no longer safely store their methadone. The patient is actively suicidal, cognitively impaired, psychotic, or is otherwise at high risk for misuse of their methadone dose. The patient has recently been released from jail when incarcerated for prolonged periods of greater than 3 months. Once carries are removed, they should be increased 1 every week or more back to 6 carries.

31 Question ten Sheila has been a patient for more than 1 year. She has been stable since starting methadone and is now receiving 6 carries. She was had charges pending from illegal activity prior to starting methadone. She goes to court and ends up in jail for 3 weeks. Her methadone is continued while she is incarcerated. She comes to see you after she is released. She has not missed any doses and has not relapsed. She is married, has stable housing and a job that she is returning to on Monday. What do you do with her carries?

32 Question ten. 1. Hold all carries given that she was incarcerated and therefore unstable. Return one every week back to 6 carries. 2. Given charges were from prior to becoming stable on methadone and short incarceration, and given ongoing stability without relapse, reinstate all carries now and continue to monitor as you were prior to incarceration. 3. Decrease to 5 carries and monitor more carefully to ensure stability.

33 ANSWER Answer 2 Key point The MMT physician may reinstate take-home doses immediately for patients who remain clinically stable without problematic drug use, and: 1) had take-home doses cancelled due only to missed doses 2) have been incarcerated for less than 3 months

34 Question eleven Sandra is a new patient who started on the program 2 weeks ago. She has stabilized on her dose and it is now lasting 24 hours without any withdrawals or need for opioid use. She is not using any other substances. She has been missing every Sunday as her pharmacy is closed. You discuss this with her and she states that she is now only using opioids on the day she misses the pharmacy. She is upset about having to use pills still and she asks for a Sunday take-home carry. What do you do?

35 Question eleven 1. Allow for the Sunday carry as she tells you her pharmacy is closed. She has been on the program for 2 weeks and the missed dose is creating problems for her. 2. Advise that she is not allowed carries within the first 2 months and there is nothing you can do. 3. Advise her that she can start to have a Sunday take-home dose in 2 weeks as this is allowed after 4 weeks so long as she is stable and able to safely store the carry. 4. Look into alternate arrangements (other pharmacies in her community or hospital dispensing) until she has been on the program for 2 months and can then start regular carries

36 Question eleven ANSWER ANSWER: 3 and 4 Key Message. Sunday take home doses are allowable after 4 weeks only if the patient: 1. Is able to safely store the medication 2. Dose not have an active addiction or mental illness that increases the risk of methadone misuse or diversion 3. Lives in a community that does not have a pharmacy that is open on Sunday 4. Has no hospital available for Sunday dispensing 5. Does not have transportation to a different community

37 Question eleven Two months have passed and Sandra is doing quite well. She is stable at 85mg of methadone. She is receiving 1 take-home dose and continues to leave supervised urine drug screens that are all negative for any illicit substances. Sandra follows up in your office for her regularly scheduled visit and is visibly upset. She asks you to reduce her methadone dose and get her off of this as soon as possible. On further questioning, she tells you that she needs to work. She found a job however will be working 1 hour out of town. She will be picked up by a co-worker at 0700 and may not get home until after 7:00pm. The community pharmacy is only open from 8:00am 6:00pm and there are no other pharmacies in the community that open earlier or later. She tells you that she needs to take this job and cannot be on methadone. Can you expedite her carries?

38 Question eleven 1. Not yet. She must continue to come to the pharmacy 6 days a week and can only increase carries as per the regular schedule. 2. She could be eligible for expedited carries. These carries would be increased every week until she is receiving 6 carries. 3. She could be eligible for expedited carries however these carries would be increased every 2-4 weeks up to 5 carries (M-F). 4. She could be eligible for expedited carries and given that she is already receiving a carry, she can be given 5 carries to accommodate her work situation.

39 Question eleven ANSWER ANSWER: 2 or 3 Key Message.. The MMT physician shall prescribe an accelerated take-home schedule only if: 1. prolonged daily pick up is likely to cause the patient to drop out of treatment because of a lack of transportation or work or family commitments 2. the patient is able to safely store the medication 3. the patient does not have a active addiction or mental illness that increases the risk of methadone misuse or diversion 4. The first accelerated take-home dose may be given after one month, with one additional weekly dose every 2-4 weeks.

40 Question twelve Stephen is a new patient and doing well on methadone. He has stable housing, is in a relationship now, and looking for a new job. He has been on the program for more than 2 months now and has a stable dose without any illicit substance use. On September 10 you start 1 carry. You document on the program for more than 2 months and ongoing stability now. You see him on September 17 and he continues to do well. On September 24 he complains that his dose is not quite enough. He is continuing to notice sweats, chills, restlessness, irritability, anxiousness and runny nose for 3-4 hours before his dose is due. You document all of this in your notes and increase his dose 5mg. On October 1 you see him and he is doing well and you start 2 carries (the forth week). You are being assessed and the CPSO methadone assessor has some concerns about this chart. What could they be?

41 Question twelve 1. You did not document discussion about carries, safety of carries, risks of carries to children and diversion. 2. You increased the carries too quickly 3. You continued carries despite the patient needing minor dose adjustment 4. Both 1 and 2 are correct 5. 1,2 and 3 are correct

42 Question twelve ANSWER ANSWER: 4 Key Message. Even if you have information about carries and safety in your treatment agreement, safety and safe storage of carries must be discussed and documented. You can use a carry agreement and document that this was reviewed prior to starting carries. Small dose adjustments do not mean that a patient is not stable Carries should be increase every 4 weeks (having 1 carry for 4 weeks Sept 10, 17, 24 and Oct 1 and then increase to 2 carries on October 8). Many physicians have difficulty with this. Ensure they have had their carry level for 4 weeks and then increase carries.

43 Question thirteen Ms. Presley had been stable at 80mg receiving 6 carries. She missed 4 days of methadone She used valium once 3 days ago and used daily IV heroin She is in obvious withdrawal when you see her. What do you do with her dose? 1. You start her at 30mg and increase by 10mg per day back up to 50mg and then reassess her at 50mg 2. You restart her at either 20mg or 30mg and reassess her in 3 days to assess clinical stability and counsel patient on dangers of benzodiazepines. 3. You drop the dose to 60mg and hold her on this dose for one week.

44 Question thirteen ANSWER ANSWER: 2 You should restart at 20mg or 30mg. and reassess the patient in 3-7 days after 4 missed days After 3 missed days, the dose may be decreased to 50 percent of the previous dose. 10mg daily increases should only be done after 3 missed days. The patient should be reassessed after 3 days if you are increasing the dose daily by 10mg daily

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