MANITOBA METHADONE BUPRENORPHINE MAINTENANCE
OMMENDEDPRACTICE
[Revised July 2014][Revised May 2020}
CONTENTSContents . iPREFACE . viiTerminology and drug names . viii1. PHYSICIAN LICENSING AND EDUCATION . 1For Methadone . 1For Buprenorphine . 12. PHYSICIAN AUDIT AND REVIEW . 23. REGISTRATION OF SERVICES . 2Registration of Patients in a Methadone/Buprenorphine Program. 24. CRITERIA FOR ADMISSION TO MT PROGRAM . 24.1General Considerations . 24.2Special Situations . 35. ALTERNATE TREATMENT OPTIONS TO METHADONE/ BUPRENORPHINE (Abstinence-basedTreatment) . 35.1Withdrawal Management . 45.2Residential Programs . 55.3Treatment for Other Addictions . 55.4Outpatient and Day Treatment Programs . 55.5Support Groups . 55.6Family Counseling . 56. ASSESSMENT . 66.1Assessment for Admission to MT . 6General . 6Full Assessment . 66.2Assessment at Regular Clinic Visits . 7i
7. PATIENT INFORMED CONSENT/TREATMENT PLAN . 7Methadone/Buprenorphine Treatment Agreement and Consent . 88. A PATIENT’S GUIDE – AVOIDING OVERDOSE IN THE FIRST TWO WEEKS OF METHADONETREATMENT . 129. METHADONE DOSING ISSUES . 139.1The Early Stabilization Phase (0-2 Weeks). 149.1.1Patients at High Risk for Methadone Toxicity . 149.1.2Reducing Risk during the Early Stabilization Phase . 159.1.3Summary of Recommendations for Management of the Early Stabilization Phase . 169.1.4Doses for Patients at Higher Risk for Methadone Toxicity . 179.2The Late Stabilization Phase (2-6 Weeks) . 179.3The Maintenance Phase (6 Weeks ) . 17Stable Daily Dose . 179.4Summary of Recommendations for Dosage Adjustment during the Late Stabilization andMaintenance Phases . 189.5Management of Low Maintenance Doses . 189.6Management of High-maintenance Doses of Methadone . 18Tapering from Higher Doses . 19Risks of Prolonged Q-T Interval . 19Consideration of Dose Tapering in Older Patients . 20Summary of Recommendations for Management of Patients on Doses Higher than 120 mg. . 209.7Split Doses of Methadone . 20How to Assess for Rapid Metabolism of Methadone . 219.8Missed Doses and Loss of Tolerance to Methadone . 219.9Vomited Doses and Guidelines for Replacement Doses of Methadone . 22Guidelines for replacement doses. 229.10Intoxicated Patients/Withholding Doses . 229.11Methadone Tapering . 229.12Management of Wrong Dose/Overdose . 23ii
10. PRESCRIPTIONS & PHARMACY ISSUES. 2311. URINE DRUG SCREENING . 24Urine Toxicology . 2512. CARRY POLICY . 2612.1Safety Considerations . 26Clinical Stability. 26The Length of Time in Methadone/Buprenorphine Treatment . 27Ability to Safely Store Methadone/Buprenorphine in a Locked Box . 2712.2Carry Schedule . 2712.3Reassessment and/or Reduction of Carry Privileges . 2812.4Managing Relapse . 2812.5Proposed schedule for carries during a sustained relapse . 2912.6Complete Forfeit of Carries . 2912.7Measures to Reduce Risk of Diversion . 2912.8Exceptions to the Carry Schedule . 2912.9Carries and Benzodiazepines and Other Mood-altering Prescription Medications . 3012.10 Carries and Medical Disability . 3012.11 Compassionate Basis . 3112.12 Job or Vacation . 3113. EXTENDED METHADONE/BUPRENORPHINE MAINTENANCE (FOR LONG-TERM STABLE CLIENTS) 3114. COUNSELING . 3215. METHADONE/BUPRENORPHINE AND PAIN . 3315.1General considerations . 3315.2Methadone/Buprenorphine and Acute Pain . 34Management of Methadone/Buprenorphine Patients with Acute Pain . 3415.3Chronic Pain . 34iii
16. USE OF BENZODIAZEPINES AND OTHER PRESCRIBED MEDICATION. 35General . 35Opioids . 35Benzodiazepines . 35Other Medications . 3617. SPECIAL HEALTH PROBLEMS . 3617.1Pregnant Patients with Opioid Use Disorder . 36Methadone/Buprenorphine Maintenance in Pregnancy . 36Opioid Withdrawal/Taper of Methadone/Buprenorphine in Pregnancy. 36Analgesia . 37Breastfeeding . 37Confidentiality . 37Neonatal Withdrawal . 37Suboxone in Pregnancy. 3717.2Patients with Hepatitis C. 37Management . 38Treatment . 38Clinical Management of Chronic Hepatitis C . 3917.3Patients with HIV . 39Management . 3917.4Co-occurring Mental Health Issues . 4018. INCARCERATION ISSUES – MMT IN CORRECTIONAL FACILITIES . 4018.1Introduction . 4018.2Dosing on Admission. 4118.3Observed Administration . 4218.4Accidental overdose of methadone/buprenorphine . 4218.5Initiating Inmates while in a Correctional Facility . 4318.6Treatment Planning for Release . 43iv
19. Withdrawing from Maintenance Treatment . 4319.1Voluntary Tapering Process . 4419.1.1 General Considerations . 4419.1.2 Tapering Methadone/Buprenorphine after Treatment Goals have been achieved . 4419.1.3 Assessing Readiness . 4519.1.4 Education and Preparation. 4519.1.5 Dose Adjustment . 4519.2Voluntary Tapering before Treatment Goals are achieved . 4619.3Involuntary Tapering. 4619.3.1 Reasons to Discontinue Maintenance Therapy . 4619.3.2 Process of Tapering . 4619.3.3 Possible Resumption of Maintenance Therapy . 4720. OPIOID DETOXIFICATION/WITHDRAWAL MANAGEMENT . 4720.1Two settings of detoxification . 4720.2Methadone/Buprenorphine in Withdrawal Management – Inpatient Setting . 4820.2.1 Dose of Methadone/Buprenorphine in an Inpatient Setting . 4820.2.2 Useful Considerations in Withdrawal Management . 4820.2.3 Use of Clonidine . 4821. TRANSFER OF CARE . 4922. PRESCRIBING FOR HOSPITAL INPATIENTS . 4922.1Methadone . 4922.2Buprenorphine . 5023. BUPRENORPHINE/NALOXONE (Suboxone ) . 50Appendices . 52Appendix A: Sample Buprenorphine/Naloxone Induction Algorithm (Diagram) . 53Appendix B: Diagnostic Criteria for Opioid Use Disorder (DSM-5 Criteria). 54Appendix C: Intake/Initial Assessment for MT (Sample) . 55Appendix D: Methadone/Buprenorphine Treatment Agreement and Consent (Sample) . 59v
Appendix E: Pharmacy Agreements . 63Satellite Pharmacy Agreement . 63Letter to Pharmacy (Sample) . 65Appendix F: Manitoba Addiction Resources . 66Methadone Clinics . 66Family Practice Clinics . 67Appendix G: Health Sciences Centre Addiction Services . 68Addiction Unit at Health Sciences Centre . 68The Addictions Unit Opioid Assessment Clinic . 68Psychiatric Addiction Services at Health Sciences Centre . 68Residential or Intensive Outpatient Treatment Programs . 68Appendix H: Index of Medications . 70References . 72vi
PREFACEIn 2007, representatives of AFM, Winnipeg Regional Health Authority (WRHA), and University ofManitoba came together to develop consensus guidelines for the provision of methadonemaintenance treatment (MMT) in Manitoba. In 2013, under the jurisdiction of the College ofPhysicians and Surgeons of Manitoba, five experienced clinicians reviewed and revised theprevious recommendations. The results are reported in this publication.The goal of the publication is not to produce a comprehensive review of MMT, but rather topresent a guide for prescribers of methadone/buprenorphine in treating patients diagnosed withopioid use disorder. A framework of usual practices in providing MMT has been developed with aview to establish a structure for the practice of MMT, in this way also giving support to physiciansthat provide MMT. Another goal is to make information available to physicians that provide othermedical care for patients that are on methadone/buprenorphine maintenance. Furthermore, theguide is inspired by the ethic of maintaining high standards of patient care. This can be achieved byincreasing the consistency of and access to safe clinical methadone/buprenorphine maintenancetreatment. The vision is to contribute to the improvement of patient health and social outcomes.No manual can replace sound cl
present a guide for prescribers of methadone/buprenorphine in treating patients diagnosed with opioid use disorder. A framework of usual practices in providing MMT has been developed with a view to establish a structure for the practice of MMT, in this way also giving support to physicians that provide MMT.
buprenorphine followed by methadone in 2012. 13,14 Presently, there are more than 250 opioid agonist treatment centres dispensing buprenorphine and more than 17 methadone maintenance treatment centres supported by various gov-ernment agencies in India. Despite this expansion, there is limited coverage of opioid agonist treatment; only around
Methadone Dispensing - Saskatchewan Prescription Drug Plan 9 Plan Tab Insert the appropriate pseudo DINs for SPDP (and any other plans) on the plans tab. Methadone Prescription Filling When filling a Methadone prescription, the dispensed quantity should reflect the number of milligrams of Methadone HCI that the patient was prescribed. 1.
Nova Scotia Methadone Dispensing This document describes the recommended way to setup and dispense Methadone mixtures. Methadone is commercially available as a solution of 1mg/ml, 10 mg/ml and as powder in 1gm, 25 gms, and 100 gms. The current MAC price for this is 0.005 per mg. The illustrations below show you how to set up Methadone Drug .
inpatient setting clinicians can legally order buprenorphine or methadone if the patient is admitted primarily for another medical reason, regardless of if they have an X license/DATA 2000 waiver. Additionally, prior to starting buprenorphine,
Neonatal Abstinence Syndrome (NAS) and Drug Exposure Research question ? Hypothesis 1 Buprenorphine-exposed neonates will exhibit less NAS than methadone-exposed neonates. Case-Control Study Example Hypothesis 1: Buprenorphine-exposed neonates will exhibit less NAS than methadone-exposed neonates. Bupren Neonates NAS
In Victoria, methadone and buprenorphine are mainly used in OST and in July 2015 , 14,122 people had received OST in Victoria [3]. Despite the benefits of OST, there are some risks with the treatment program, especially with methadone dispensing [1, 3]. Methadone is potentially a toxic drug, that can cross react with other sedating substances [1].
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