Opiate users are often:
These concerns and the level of anxiety are added to by the fact that:
For these reasons it is important to be clear with drug users about who will become aware of their methadone treatment. If information is to be passed on then the method and content of the disclosure needs to be explained clearly.
Fears about the lack of confidentiality within the NHS and other drug services is one of the areas cited by clients who are not in contact with services as a reason for not making contact. Being explicit with all clients about what confidentiality means to you and your agency will help reduce paranoia and anxiety among both the group who are in contact with your service and those who are not.
Clients going away
If the client is leaving the country they may need an export licence: see Section 5: Methadone and the law.
As with all other aspects of prescribing it is important to weigh any possible risks – particularly those of overdose and illicit sale of methadone – against the therapeutic advantages of work or holiday.
Other possibilities for retaining some degree of control while allowing the travel or work plans to proceed are:
However, in the end, it is important for the prescribing doctor not to feel pressured into making prescribing arrangements that may not be safe, and for the client to realise that sufficient warning must be given and that some negotiation has to take place before prescribing arrangements can be altered.
It should be borne in mind that there are few other areas of health care which require people to enter into contracts. A badly written contract that is simply a list of rules the client must obey can leave the client feeling devalued. Contracts should include the complaint procedures available to the client should they be dissatisfied with the service they receive.
It is important to read the contract to each client and discuss each issue in detail, not least because they may have literacy problems which they are reluctant to disclose.
In drawing up a contract it is important that if cessation of prescribing is mentioned as a response to behaviour, it is in terms that allow a measure of discretion or it is used only in circumstances in which there would be no doubt about the decision to stop prescribing.
This is particularly important with regard to clauses about illicit drug use as you may not want to respond to increases in drug taking and HIV risk behaviour by withdrawing treatment.
Components of a prescribing contract
The agreement should include what each party agrees to do, which in most cases would include the doctor agreeing to:
The drug worker agreeing to:
The client agreeing to:
And all parties agreeing that:
The testing procedure
The pathology lab form can be filled in by anyone but, unless there are special arrangements, must be signed by a doctor. The form would normally state: ‘receiving methadone treatment, full drug screen please’ although some services specify the drugs they want screened for e.g. ‘…please screen for methadone and other opiates, cocaine and amphetamine’.
The urine sample should be:
The tests used
The tests used are:
The benefits of urinalysis
and, once treatment has commenced, to:
The value of urinalysis in these functions is largely unresearched and, in some respects, a flawed procedure. Its use in each of these functions is outlined below.
Urinalysis prior to treatment
However it is only evidence of at least one dose of a drug having been taken in the last 24–72 hours: see the drug clearance times chart below. It gives no indication as to the quantity of drugs being used nor evidence as to how long the client has been using those drugs. And as it is widely known among drug users that a urine screen for drugs will be part of the assessment procedure they will generally ensure that the result is ‘opiate positive’.
The taking of a urine sample as part of the assessment procedure can easily convey to the client a message of distrust. It is therefore important to stress its role as a safeguard for the prescribing programme and as corroboration of the history given at assessment, rather than as a way of catching people out.
Confirming that methadone is being taken
Because methadone is a long-acting drug which is metabolised over a period of days, false negative urine screens are rare in clients who are taking their medication regularly – and should therefore be taken seriously and repeated as a further safeguard.
Confirmation that methadone is being taken requires a sample to be positive for both methadone and methadone metabolites.
Discouraging illicit/additional drug use
Although there are individual cases in which urinalysis can be helpful the extensive literature search carried out by Ward et al91 failed to find any studies that could demonstrate a reliable link between urinalysis (as part of a methadone maintenance programme) and reduced illicit drug use.
Assessing illicit/additional drug use
If the client cannot stop using other drugs, even when they know a urine test is imminent, it is likely that they have not got much control over their drug use and this is an issue which needs addressing.
Informing treatment decisions
However it is important that if a drug screen result is to be used in clinical decision making it is not the only indicator that is used.
Providing information to support research into prescribing programmes
Because of this the interpretation of results may well depend on whether the reader is a drug user, drug worker, doctor, service funder, politician or researcher and whether or not they are hostile to or supportive of prescribing services.
Drawbacks of urinalysis
The experience of many workers is that the more heavily methadone prescribing is policed, and the more the feeling of ‘them and us’ grows, the more ingenious the dodges become to avoid getting caught.
The ‘them and us’ syndrome can be countered through careful explanation of the test and the rationale for it. Most clients accept that some people are motivated to get methadone simply to sell it and that it is legitimate for services to use objective measures from time to time to check that they are providing an appropriate service. Clients also accept that many seek treatment to maximise drug consumption and that workers need objective tools to help determine what the real patterns of drug use are.
There are a number of ways clients can avoid getting a urinalysis result that is unfavourable, such as:
The only reliable way of avoiding these is to supervise the production of the sample. This is a demeaning procedure for both client and staff member. However if the benefits are clear it may be worth while.
Typical drug clearance times
Always remember that drug clearance times vary according to the:
Hair analysis is commercially available in the UK. For most services it will complement rather than compete with urinalysis as it is rather expensive for routine use.
It is particularly valuable in:
Drug clearance times chart
Pros and cons of urine and hair analysis
Everyone who wants something will try different stratagems in order to get it – and the more they want it the more inventive they are inclined to be in the devices they employ. Furthermore if a strategy (however socially unacceptable) has worked once it is likely to be repeated.
It is not so long since the only way any doctor could be persuaded to write an opiate prescription for an ‘addict’ was if s/he was made to believe that the person genuinely wanted to give up drug use forever, and that the only thing that would help was a detoxification to help with the initial withdrawals. Clearly in these circumstances anyone who wanted a prescription, regardless of their true intentions, knew that their only hope was to spin the old ‘I want to get off’ yarn. The failure of these ‘detoxes’ has been a formative experience for many doctors.
With the advent of more flexible prescribing this problem has been reduced. Most drug services have found that any increase in flexibility and understanding is met with a corresponding reduction in ‘manipulative’ strategies to obtain the desired treatment.
The limit to flexibility is that the prescribing must not increase drug-related harm. Drug users may still employ techniques to persuade the providers of treatment to do things that will not be helpful to them.
However opportunities for manipulation with its resulting friction and dissatisfaction will be minimised if we:
It is often easier to identify these clients after they have been started on a prescribing programme rather than before and the review procedures should take this into account.
Treatment may be terminated if:
Termination of treatment is a serious step, especially if there may be a return to high-risk behaviours as a result. Prescribing staff must be certain that it is a necessary intervention.
It is important that the criteria for removal from methadone prescribing are understood by all concerned and that they are applied fairly and without discrimination. Where possible clients should receive verbal and written warnings prior to removal from treatment. Other options that fall short of permanent removal, such as suspension of prescribing, may be considered.
Where possible entry criteria for returning to methadone treatment, including the earliest date a referral will be considered, should be made clear to the client.
Benzodiazepines are sometimes used by opiate users to help them sleep, although often in doses far in excess of the normal therapeutic range. They are also used during the day when the user has no intention of sleeping to achieve the following effects:
The relationship between benzodiazepines and methadone is twofold:
The main problems are that:
As they are not controlled drugs it may not be possible for services to arrange dispensing of any less than a week’s supply at a time - and there is often a high risk of them all being consumed in the first 24 hour period. It is therefore difficult to prescribe benzodiazepines using the rationale of harm reduction.
Methadone prescribing services that operate a non-benzodiazepine prescribing policy may:
but they will not meet the needs of people with genuine benzodiazepine dependency or be able to take advantage of the short-term therapeutic benefits when their use is clinically indicated.
Many clients are willing to ‘trade’ their benzodiazepine request for extra methadone. A regime of 5mg methadone for 10mg temazepam/5mg diazepam to a maximum of 25% above the assessed methadone need, based on opiate use alone, is used by some services. This is not always appropriate and is thought by some to be flawed in terms of logic, especially as methadone will have little or no effect on benzodiazepine withdrawals. Some services offer a diazepam detox running alongside methadone treatment for the first few weeks to give people a realistic chance of coming off.
If a client remains adamant that they need prescribed benzodiazepines it is reasonable to start the methadone prescribing and to require them to remain in treatment for a period of extended assessment prior to a decision being made on prescribing benzodiazepines.
Recreational drug use
The test which needs to be applied is not that of abstinence but rather of the treatment aims. If the additional drug use is not compromising the treatment aims then it should not jeopardise the continuation of prescribing. If it is threatening the treatment aims then the care plan may need to be adjusted in order to achieve those aims before termination of treatment is considered. Problematic additional opiate use is discussed in the next section: Prescribing for groups with special needs: People who ‘use on top’.
It is important that prescribing services are clear among themselves and with clients on what the treatment aims are and what the response will be to recreational drug use.
Problem alcohol use
Some clients alternate between opiates and alcohol and for these people methadone is often helpful because while on methadone alcohol consumption falls or stops. It is those who have a dual dependency that present the biggest problems to prescribing services.
Additional services that may be offered to reduce risk and increase appropriateness of treatment include:
Worker supervision and support
In order to offer an equitable, consistent and sustainable service clinicians must have access to supervision which allows them to discuss both the clinical and personal issues that are raised for them in their work.
Clinicians involved in working with opiate users also benefit from the support and opportunities to develop practice through:
Transfer from injectable to oral methadone
The transfer from injectable to oral methadone can be a very difficult and slow process which is one of the reasons many services choose not to prescribe injectables and instead try and stabilise clients on oral methadone from the start.
The process is one of a negotiated reduction in the injectable portion of the prescription and a simultaneous increase in the oral portion. Sometimes this process can be made easier by increasing the oral portion of the prescription by a little more than the reduction in the injectable methadone. For instance a client on 1x10mg ampoule per day may be given an extra 15–20mg oral methadone to replace it.
During this process it is important to check injecting sites regularly and encourage the client to use counselling and psychological support services.
Sometimes, as with detox, the best approach is to agree with the client prior to any changes that the process is an experiment, with the option to return to the original dose/route remaining open. This removes the pressure on both worker and client to see the process in terms of sucess or failure and for clients to resist change for fear they might be giving something up forever.
The transfer is more likely to be successful (in terms of avoiding a relapse to injecting illicit drugs) if it takes place in gradual steps. For people with a long history of injecting, full transfer to oral medication can take up to two years. Towards the end of the process, when nearly all the ampoules have been ‘converted’ into oral methadone, the client may continue to have one injecting day per script cycle, and this final phase can be the longest. Relapses need to be expected and dealt with as learning experiences.