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CDHB

Opioid Substitution Programmes

Buprenorphine with naloxone (Suboxone) sublingual tablets are now subsidized for the treatment of opioid dependence, and patients on this medication are managed by the Christchurch Methadone Programme.

Methadone and buprenorphine/ naloxone prescribing and supply

• The Christchurch Methadone Programme (CMP) is available for consultation in the management of these patients.
• It is an offence for a medical practitioner to prescribe controlled drugs for the treatment of dependence unless a practitioner is approved or authorized under the Misuse of Drugs Act 1975.
• The prescribing and administration of methadone or buprenorphine/ naloxone to patients on an opioid substitution programme is governed by strict guidelines.
• SMOs, RMOs, nursing staff, and pharmacists working in CDHB hospitals need to be aware of the relevant regulations contained in the Ministry of Health publications, Practice Guidelines for Opioid Substitution Treatment in New Zealand, 2008 and New Zealand Clinical Guidelines for the Use of Buprenorphine (with or without Naloxone) in the Treatment of Opioid Dependence 2010. These are available on the Ministry of Health website. The following aspects of these guidelines are drawn to your attention.

  Exception: The 2008 restrictions do not apply to those using methadone for chronic pain, such as those in palliative care, and who are not enrolled in an opioid substitution programme.

• Patients who are enrolled with an opioid substitution programme are not to receive methadone or buprenorphine/ naloxone in any CDHB hospital until their daily dose (in milligrams) has been confirmed with the patient's CMP case manager:
  • Weekdays between 0830 and 1700 hours, Christchurch Methadone Programme, 335 4350
  • After-hours, phone the Kennedy Detox Centre, 339 1139
• Some patients on buprenorphine/ naloxone may only be prescribed a dose every 2-3 days due to its long half-life.
• No methadone or buprenorphine/ naloxone is to be prescribed or dispensed until confirmation is obtained of the last consumed dose. This is to protect against accidental overdose. CMP/Kennedy will check with the dispensing pharmacy to determine whether the patient has had their dose on the day of admission and if takeaways were provided, and will suspend third party scripts. This is so that extra supplies of methadone or buprenorphine/ naloxone cannot be collected by a third party while the patient is admitted.
• If the patient presents in the afternoon or evening they have probably already attended their pharmacy. If the time of the last consumed dose is unable to be confirmed, do not prescribe methadone or buprenorphine/ naloxone until the following day.
• If the patient brings takeaway doses into hospital, these doses should only be used for the patient to consume after they are discharged from hospital.

  Note: Takeaway doses of methadone are diluted.

• Prescribers to patients receiving methadone or buprenorphine/ naloxone need to ensure that:
  • The potential for overdose is minimized,
  • The patient is not unsafely intoxicated with other drugs, and
  • The potential for diversion is limited.
• Written authorization must be obtained from the CMP before hospital doctors can prescribe methadone or buprenorphine/ naloxone to in-patients. The CMP has provided a form that can be faxed to obtain appropriate authorization. Each authority to prescribe lasts one week. The CMP can extend or cancel authorities on request.
• Once CMP has confirmed the dose, methadone can be sent from a CDHB pharmacy to be used while the patient is admitted. After discharge, the methadone will be removed from the ward. The only wards to hold a methadone supply in their controlled drug safes are those who require it for chronic pain management.
• For out-of-town patients receiving methadone or buprenorphine/ naloxone:
  • Contact the originating programme to confirm dosage, find out when it was last dispensed, and determine if the patient is in possession of any takeaway doses not yet consumed. This is the responsibility of the admitting team. The patient will know some of these contacts but any details they provide must be checked.
  • Arrange an authority form to allow scripting while in hospital.
  • Ensure that the dispensing pharmacy in Christchurch is notified of admission and halts the script (this is to prevent patients attempting to obtain further doses in the community resulting in overdose as has occurred in the past).
• Patients receiving opioid substitution therapy should be prescribed analgesia for pain as for other patients. It is recommended that you consult with the methadone programme doctors. Due to the partial agonist activity of buprenorphine, the management of acute pain can be clinically challenging and advice should be sought from the Acute Pain Team.
• At discharge, the CMP case manager or (if after hours) the Kennedy Detox Centre must be called to arrange reinstatement of opioid supply in the community.
• Do not discharge any patient with a methadone or buprenorphine/ naloxone supply or prescription.

Driving Considerations

• For all patients prescribed methadone or buprenorphine/ naloxone, it is important to consider the implications of their driving, as per Section 18 of the Land Transport Act. Patients who are on a stable dose of methadone and are not prescribed or using other drugs which could affect their reaction time, motor coordination, or sleepiness, are deemed safe to drive. However if the patient is prescribed benzodiazepines, opiates, or other drugs which could affect the above, the patient should be advised not to drive.

Topic Code: 3871