TOXICOLOGY ASSOCIATES

STAFFING OF A METHADONE PROGRAM

PROGRAM NURSE:

Dispensing hours are arranged to facilitate the employment schedule of the patient. Tardiness in opening the clinic will not be tolerated.

No patient or other party should be admitted into the clinic until at least two staff persons are present.

The nurse is directly responsible to the program physician. The nurse is responsible for assuring that the dose of Methadone administered to each patient is in compliance with orders given by the program physician. Orders for Methadone may be given in writing, by telephone, voice or standing orders in accordance with a written protocol (See Appendix). Any change in dose must be justified in writing (see Request for Dose Change) in the medical records and countersigned by the program physician within

72 hours. The nurse shall be knowledgeable concerning medications other than Methadone being taken by the patient and any changes in current medications.

A locked container must be presented by the patient to receive take-out medication.

The dispensing nurse is the staff person with the most frequent contact with the patient and should not hesitate to require further assessment when concerned about changes in patient behavior. Any unusual changes in behavior requires that the patient be seen by the counselor prior to medication. If, in the opinion of the counselor, changes in medication should be considered, that information must be provided to the nurse. If standing orders do not accommodate a change, then the program physician should be consulted (see Standing Orders).

The nurse will facilitate admission evaluation by recording vital signs prior to the physician examination, noting signs and symptoms manifest by the patient. For new admissions, the nurse will perform the TB skin test and record the results in the patient’s records. Depending upon the clinic, the nurse may be required to draw blood.

During the initial days in treatment while the appropriate maintenance dose is being determined, the patient should not be medicated until first interviewed by the counselor who will assist the nurse by recording the patient’s symptoms in the titration records and provide this information to the nurse.

After the initial stabilization dose is determined, some modification of the dose of Methadone by the dispensing nurse is permitted. In accordance with standing orders, the nurse may reduce the current dose of Methadone by one-half or decline to medication if the patient presents impaired by intoxication as manifest by slurred speech, ataxia or drowsiness. The patient must also be referred to his counselor for investigation of circumstances and possible urine collection. No take-out medication will be provided, so that the patient may be observed the following day.

The nurse is responsible for custody and security of the Methadone. Whenever the safe is open, no other person is allowed to be in the secured dispensing area.

A daily dispensing report and Methadone balance report must be prepared at the close of dispensing. An incident report must be prepared for any discrepancies in the Methadone inventory. The nurse received new lots of Methadone for the clinic and records appropriate changes in Methadone inventory. The nurse is the only person with knowledge of the combination of the safe. The safe should never be opened at a time when any persons (including State and Federal agents) are in position to observe the combination. Whenever the nurse leaves the dispensing area, all Methadone must be secured in the safe and the safe locked.

Re-medication is occasionally requested. If the dose is spilled in full view of the nurse, re-dosing is permitted and an incident report prepared. If vomiting occurs before the patient leaves the clinic, re-medication at one-half of the usual dose is permitted. There is extensive literature demonstrating that vomiting occurring with a few minutes of ingestion of a liquid drug formulation recovers less than half of the administered dose of drug. Once the patient leaves the clinic, no re-dosing is permitted regardless of the circumstances.

If take-out medication is lost or stolen, the nurse does not have the authority to replace the missing methadone. Such an event will call to question the patient’s competence to receive take-out medication. Lost, stolen or diverted take-out medication places the public as well as the program at risk and cannot be tolerated. Should such an event occur, the patient should not be denied medication but administration of methadone should be

provided on a daily basis with no replacement of take-out medication. Administrative evaluation of circumstances should determine the subsequent course of action concerning take-out privileges.

The nurse does not have authority to change the regularly scheduled frequency of clinic visits without specific orders from the program physician except as detailed above.

Previously stable patients requiring a change in dose should be referred to their counselor to submit a Change of Dose Request (see Appendix).

Medication of pregnant patients with morning sickness presents a unique problem. Eating some food prior to medication often is helpful. Medication later during medication hours may also assist retention. The patient is encouraged to consult their obstetrician concerning anti-emetic medication.

All pregnant patients will be encouraged to obtain prenatal care. Counseling staff will assist in appropriate referral. The patient must advise the obstetrician that she is on methadone maintenance treatment.

Withdrawal symptoms during the second and third trimester of pregnancy may occur as a result of changes or protein binding of Methadone, thereby requiring additional Methadone to prevent withdrawal. Usually, the dose may be reduced after delivery to prevent symptoms of opiate excess.

If a patient misses one or two days of medication, the usual dose of Methadone may be administered after seeing the counselor who will record in the chart the circumstances for the absence.

If a patient misses more than two days but less than 14 days, medication at half the usual dose is administered but no take-home medication will be provided. If, upon returning the following day, there are no signs or symptoms of sedation, the usual dose may be resumed but no take-out medication will be provided. On the next daily visit, the usual take-out schedule may be resumed if the counselor determines that the patient may be expected to be responsible with the medication. After missing more than 3 days, an increase in the frequency of clinic visits is indicated.

If a patient misses more than 14 days, dose adjustment by titration should be utilized as with a new patient, after a new treatment plan has been prepared by the counselor. Dose adjustment as permitted on the order of the physician should occur, with increases or decreases of 10 mg. Since the impact of change is a function of percent change in dose, smaller changes are not justified. Patient on 40 mg or more per day should be moved to even 10’s both for convenience and accuracy of measurement. Changes of medication under 40 mg per day will occur in 5 mg steps.

Because drug interactions can prolong the half-life of Methadone by decreasing metabolism or decreasing urinary excretion, it is possible for patients to experience opiate excess and sedation without a change in their dose. Any change in the patient’s appearance consisting of sedation, impaired gait, slurred speech or daytime sleepiness should be investigated concerning the addition of prescription drugs or use of anti-anxiety drugs, most commonly Valium and Xanax. The daily dose of Methadone should be reduced to half, and no take-out medication should be provided until the problem has been resolved.

Drug interactions can also result in increased metabolism of Methadone, leading to withdrawal symptoms in a previously stabilized patient. Changes in medications should be explored. For example, a patient starting on Dilantin or Rifampin can be expected to increase hepatic metabolism, resulting in withdrawal symptoms. Upward adjustment of the dose of Methadone will be required to maintain stability. Discontinuation of the drug without modifying the dose of Methadone may result in symptoms of opiate excess.

Signs reminding patients to advise the nurse of any changes in medications not prescribed by the program physician should be displayed prominently at the dispensing window. A table of know or suspected drug interactions should be immediately available to the staff.

Because Methadone is metabolized in the liver, major disruption of liver function can cause gradual accumulation of Methadone, resulting in elevated levels in the blood and excess opiate effects. Any patient who manifests signs of liver dysfunction such as jaundice should be questioned closely concerning symptoms of opiate excess. Obtaining tests for Methadone blood levels might be useful in resolving questions of metabolic abnormalities. It should be kept in mind that the ultimate determination of an appropriate dose is the clinical appearance of the patient. The correct dose is the one that prevents withdrawal without sedation, regardless of blood level.

While viral hepatitis may impair metabolism, several recent reports suggest that

Hepatitis C might increase hepatic metabolism. Many patients who are in frank liver failure with jaundice may continue their usual dose of Methadone as determined by blood levels. Paired peak-and-trough blood Methadone analysis allows direct determination of the rate of Methadone metabolism, and is encouraged when questions exist.

Methadone is Poison!!