Methadone Management and Administration

1. Methadone Management and Administration New Corporate Policy March 20, 2013

2. Methadone Management and Administration Why a Methadone Management and Administration Policy? • LHSC did not previously have a corporate wide methadone policy and as a result of a critical event involving methadone a methadone policy has been developed. • The goal of this policy is to assist all members of the health care team to safely manage the ordering, dispensing and administration of methadone

3. Methadone Management and Administration Ordering Methadone • MRP or Consulting Physicians may order methadone. This order can be given to a Resident or Clinical Fellow via telephone or verbal order but it must be signed within 24 hours. • MRP or Consulting PhysiciansMUST have or obtain an exemption (i.e. authorization) to prescribe methadone. • The exemptions are obtained specifically by indications: • methadone maintenance treatment (MMT) – addiction • pain syndromes (Pain I, Pain II, Pain III) – chronic pain

4. Methadone Management and Administration Ordering Methadone – Temporary Exemption • For Medical Staff that do not hold a prescribing exemption, a Temporary Exemption must be obtained as soon as possible after the patient is admitted. • The exemption is for a specific patient only and expires upon discharge or after 60 days. If a patient is admitted for longer than 60 days, a new exemption is required. • Any time a methadone order is issued, the prescribing physician MUST have an exemption (i.e. if the Medical Staff changes on a clinical team AND the patient requires a change in does – so a new order is written – a Methadone exemption is required for the new prescriber. • Responsibility to obtain a temporary exemption lies with the MRP, however Pharmacy is able to assist in obtaining this in a timely manner. Patients cannot receive methadone at LHSC unless it is prescribed by Medical Staff with an exemption

5. Methadone Management and Administration While in hospital • Most patients continue on the same dose of methadone during hospitalization • Dose adjustments may be required because of: • Drowsiness or intoxication (e.g., because of other drugs) • QTc prolongation • MMT patients that have missed 3 or more doses • Drug interactions • Often it is most appropriate to consider dose adjustments in consultation with a patient’s community methadone prescriber

6. Methadone Management and Administration Dispensing • Previously patients brought their own methadone into the hospital. It was secured and used throughout their stay • This will NO longer be the practice at LHSC. All inpatients receiving methadone treatment will have their methadone dispensed from the inpatient pharmacy. • Any methadone that is brought into hospital will be sent home or secured until discharge as per the policy.

7. Methadone Management and Administration Verifying the Dose • Before methadone can be dispensed at LHSC, the patient’s community pharmacy must be contacted and all relevant information about the patient’s methadone must be verified and documented in the chart • On most units, Pharmacy staff will complete this documentation.

8. Methadone Management and Administration Dispensing • Methadone in the community is dispensed as tablets or bulk liquid for chronic pain management, or as a single-dose (daily) format for MMT patients • LHSC will dispense all methadone in appropriately labeled unit dose format on a daily basis. • This will be delivered to the units and signed into the narcotic disposition record and administered as per the Narcotic and Controlled Substances Policy. • Methadone for PAIN will be dispensed as tablets or undiluted liquid • Methadone for MMT will be dispensed as a liquid diluted in an orange liquid (usually in 100 mL)

9. Methadone Management and Administration Leave of Absence • The patient’s usual methadone dispensing pharmacy MUST be notified by LHSC pharmacy staff that the patient is on LOA to ensure patient doesn’t double dose. • Pain I & Pain II (For Chronic Pain and Palliative Care Patients): • Methadone will be prescribed according to the Narcotic policy and at the discretion of the physician with exemption status. • Dispense according to LHSC Pharmacy procedure for LOAs. • For Methadone Maintenance Therapy (MMT) & Pain III: • Patients who are granted a Leave of Absence form LHSC should return to the inpatient unit to receive their daily doses of methadone. Follow specific procedure as per Methadone Management and Administration

10. Methadone Management and Administration Discharge • Discharge planning is very important for MMT patients. • Weekend discharges should be avoided whenever possible • Community physicians and pharmacies providing outpatient care for methadone patients to be discharged MUST be contacted well in advance of discharge to ensure that transfer of care of methadone prescribing and dispensing is not interrupted. • Patients should receive their methadone dose at LHSC on the day of discharge. • A temporary exemption does not allow prescribing of methadone on discharge. • Discharge prescriptions should be marked “not required” for methadone Follow specific procedure for discharge as per Methadone Management and Administration

11. Methadone Management and Administration Questions? • Contacts • Nursing Professional Practice OR • Pharmacy