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Clinical Guidelines for Withdrawal Management and Treatment of Drug Dependence in Closed Settings. Geneva: World Health Organization; 2009.

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Clinical Guidelines for Withdrawal Management and Treatment of Drug Dependence in Closed Settings.

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6Methadone maintenance treatment

6.1. INTRODUCTION

Methadone is an opioid, like heroin or opium. Methadone maintenance treatment has been used to treat opioid dependence since the 1950s.14 The opioid dependent patient takes a daily dose of methadone as a liquid or pill. This reduces their withdrawal symptoms and cravings for opioids.

Methadone is addictive, like other opioids. However, being on methadone is not the same as being dependent on illegal opioids such as heroin:

  • It is safer for the patient to take methadone under medical supervision than it is to take heroin of unknown purity.
  • Methadone is taken orally. Heroin is often injected, which can lead to HIV transmission if needles and syringes are shared.
  • People are heroin dependent often spend most of their time trying to obtain and use heroin. This can involve criminal activity such as stealing. Patients in methadone do not need to do this. Instead, they can undertake productive activities such as education, employment and parenting.

Methadone has been included on the World Health Organization's List of Essential Medicines. This highlights its importance as a treatment for heroin dependence.

There has been a great deal of research on MMT. This research has found that

  • MMT significantly reduces drug injecting;
  • because it reduces drug injecting, MMT reduces HIV transmission;
  • MMT significantly reduces the death rate associated with opioid dependence;
  • MMT reduces criminal activity by opioid users; and
  • Methadone doses of greater than 60mg are most effective.15

In closed settings, MMT should be available to patients who have been receiving MMT in the community and wish to continue this treatment in the closed setting, and patients with a history of opioid dependence who wish to commence MMT. Patients should receive MMT for the entire duration of their detention in the closed setting. This ensures the maximum benefits of the treatment are obtained.

Case study: The Hong Kong Methadone Maintenance Program

Hong Kong has had a methadone maintenance treatment program since 1972. The program was started in response to rising levels of drug use. More recently, the program has been crucial to controlling the HIV epidemic. Hong Kong methadone clinics have several important characteristics that make them easy for drug users to access:

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Low cost of treatment – HK$1 (about 12 US cents) per clinic attendance

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Open seven days per week and are open from early in the morning to late at night

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Operate on a “low threshold” model – this means that there are few conditions that patients must meet to begin treatment

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Non-judgemental approach that includes providing harm reduction information and condoms

Research conducted with patients of the Hong Kong methadone program has shown that patients who attend the clinic regularly show reduced levels of drug injecting and HIV risk behaviours. It has also been shown that patients receiving methadone doses of greater than 60mg per day were less likely to use or inject drugs than patients receiving doses of less than 60mg per day.

Rationale for MMT in closed settings

In countries where MMT is available in the community, it should also be available in prisons. This is in line with the public health approach to HIV prevention and the principle of equivalence of care.

MMT is provided to inmates in prisons in at least thirty countries, including Australia, Canada, Indonesia, Iran, and Spain. There are several compelling reasons for providing MMT to opioid dependent patients in closed settings:

Reducing risks associated with injecting drug use

MMT in closed settings reduces drug injecting by prisoners. In Australia, a trial of MMT in prison found that despite being in prison, over 80% of inmates starting methadone treatment had used heroin in the previous month; however, after four months of treatment, only 25% of prisoners were still using heroin.16 By reducing drug injecting, MMT reduces opportunities for HIV to be transmitted between prisoners.

Reducing risk of re-incarceration

Many drug users experience multiple episodes of detention in closed settings. However, patients who remain in MMT after leaving closed settings are less likely to return to closed settings than non-treated heroin users.17

Reducing the risk of relapse following release

People who leave closed settings often relapse to regular drug use within a few days or weeks of being released. Being in MMT in the closed setting and then continuing treatment in the community reduces the risk of relapse.

Case study: Methadone maintenance treatment in prison in Indonesia

Indonesia established a pilot methadone maintenance program in prison in 2005. The program was started as part of Indonesia's comprehensive HIV prevention strategy for prisons. Other components of the strategy include distributing condoms and bleach (for cleaning used needles and syringes) in prison and providing free antiretroviral treatment for HIV-positive prisoners.

Some of the patients in the methadone program are continuing treatment begun in the community, while others have started methadone treatment in prison. Patients who are HIV-positive receive free antiretroviral treatment in addition to methadone.

There are plans to expand the methadone maintenance program to other prisons in Indonesia. The success of this pilot program has demonstrated that it is feasible to introduce methadone maintenance treatment in resource-poor settings.

Required resources

Essential staff

Physicians

Only a medical doctor may prescribe methadone. A medical doctor should conduct the assessment on which the decision to prescribe methadone is based. Doctors also take part in treatment planning and treatment reviews.

Nurses

Nurses are required to conduct methadone dispensing and supervision of its consumption. Other roles for nurses in methadone maintenance treatment include:

  • Taking part in treatment reviews and providing reports to clinic doctors
  • Providing vaccinations (e.g. hepatitis A and B) and referring patients for infectious disease testing (e.g. HIV, hepatitis, sexually transmitted infections, tuberculosis)
  • Attending to general health needs of patients, for example, dressing wounds and ulcers; assisting with general hygiene and infection control
Counsellors

Counsellors support medical staff of the treatment program by:

  • Providing general counselling on issues of concern to patients
  • Undertaking motivational interviewing with patients to increase motivation to reduce illicit drug use
  • Providing pre- and post-test counselling for patients seeking testing for HIV or other infectious diseases

Other professionals

Although not essential, the following staff can also assist patients in methadone maintenance treatment:

Psychologists

Psychologists can assist patients suffering from co-morbid mental illnesses and psychiatric problems such as depression, anxiety or post-traumatic stress disorder.

Social or welfare workers

Social workers and welfare workers can provide general counselling and assist patients with practical concerns such as contacting their family or finding housing for when they leave the closed setting.

Community liaison officers

A community liaison officer is employed specifically to assist patients to transfer to community-based MMT programs on their release from the closed setting. This person may have skills or training in social or welfare work.

Facilities

Medical clinic

Methadone should be dispensed via a medical clinic within the closed setting. The clinic must be staffed and open to patients seven days per week. The clinic should be equipped with a dispensing pump or measuring cylinder for ensuring accurate methadone dosing, and should also maintain adequate supplies of basic first aid and resuscitation equipment.

Secure storage area

Methadone must be stored in a secure area within the medical clinic, for example, locked in a room or safe. It should not be obvious to patients that this is where methadone is stored.

Post-dosing supervision room

Following dosing, patients must move into a supervision room located next to or close to the medical clinic. This is to help prevent diversion of methadone to others. Patients in the supervision room must be monitored for around 15-20 minutes after dosing.

Effects of methadone

Methadone is a synthetic opioid agonist. This means it produces effects in the body in the same way as heroin, morphine and other opioids. It is taken orally as a tablet or syrup.

When an opioid dependent person takes methadone, it relieves withdrawal symptoms and opioid cravings; at a maintenance dose, it does not induce euphoria.

Onset of effects occurs 30 minutes after swallowing and peak effects are felt approximately three hours after swallowing. At first, the half-life (the length of time for which effects are felt) of methadone is approximately 15 hours; however, with repeated dosing, the half-life extends to approximately 24 hours. It can take between 3 and 10 days for the amount of methadone in the patient's system to stabilise.

Most people beginning MMT experience few side effects. However, there are some side effects of methadone, including:

  • Disturbed sleep
  • Nausea and vomiting
  • Constipation
  • Dry mouth
  • Increased perspiration
  • Sexual dysfunction
  • Menstrual irregularities in women
  • Weight gain

Interactions between methadone and other medications

Interactions between methadone and other drugs can lead to overdose or death. Drugs that depress the respiratory system (e.g. benzodiazepines) increase the effects of methadone. Drugs that affect metabolism can induce methadone withdrawal symptoms. Clinically important drug interactions are listed in Table 12 (p.83). In particular it is important to note interactions between methadone and medications used to treatment HIV and tuberculosis:

Table 12. Methadone-medication interactions.

Table 12

Methadone-medication interactions.

  • The HIV medications nevirapine and efavirenz increase metabolism of methadone, causing opioid withdrawal. Some protease inhibitors (PIs) may have the same effect, especially when associated to a small boosting dose of ritonavir.
  • The tuberculosis medication rifampicin increases metabolism of methadone and reduces the half-life of methadone.

Patients receiving these medications, or other medications listed in Table 12, in combination with methadone should be monitored for signs of withdrawal or intoxication, and their methadone dose adjusted accordingly. See also AIDSinfo, http://www.hivatis.org/, for up-to-date listings of antiretroviral medications and interactions with other drugs.

Patients in methadone maintenance treatment can become tolerant to the pain-relieving effects of opioids. In the event that an MMT patient requires pain relief, non-opioid analgesics such as paracetamol can be given. If methadone patients are provided with opioid analgesics, they may require higher than normal doses to experience pain relief.

See also AIDSinfo, http://www.hivatis.org/, for up-to-date listings of antiretroviral medications and interactions with other drugs.

6.2. ENTERING TREATMENT

Indications

Methadone maintenance treatment is indicated for patients who are dependent on opioids or have a history of opioid dependence. In closed settings, it is important to remember that patients not currently physically dependent on opioids can benefit from the relapse prevention effects of methadone maintenance treatment.

Patients must also be able to give informed consent for methadone maintenance treatment.

Contraindications

Patients with severe liver disease should not be prescribed methadone maintenance treatment as methadone may precipitate hepatic encephalopathy.

Patients who are intolerant of methadone or ingredients in methadone formulations should not be prescribed methadone.

Priority patients

Patients who meet any of the following criteria should commence MMT without delay:

  • HIV positive
  • Receiving treatment for HIV or hepatitis C
  • Patients who have been on community methadone maintenance treatment programs. In these cases, the patient should continue MMT in the closed setting at the dose that they were receiving in the community. It is very important that the patient's treatment is not interrupted unnecessarily; hence, the closed setting should have a procedure in place for people who are detained while on methadone.
  • History of drug overdose in closed settings
  • History of self-harm/suicidal behaviour in relation to opioid dependence
  • Pregnant, opioid dependent women should commence methadone maintenance treatment as soon as possible. Pregnant women should be assessed and dosed in the same manner as other patients. Should a patient fall pregnant while in MMT, she can be maintained on her usual daily dose. In the last trimester of pregnancy, it may be necessary to increase the daily dose in order to adequately control withdrawal symptoms. Babies born to mothers on methadone maintenance treatment may experience a withdrawal syndrome, which should be managed by a postnatal care specialist.

Risks and precautions

There are few risks associated with the long-term use of methadone. Methadone does not damage any of the major organs or systems of the body. There are few side effects of methadone and those that do occur are less harmful than the risks associated with illicit opioid use.

Overdose

The major risk associated with methadone is overdose. Overdose is a particular concern in the initial stages of MMT and when methadone is used in combination with other depressant drugs. Methadone overdose may not be obvious for three to four hours after ingestion. Patients should be closely monitored during the first week of treatment for signs of overdose, including:

  • Pinpoint pupils
  • Nausea and vomiting
  • Dizziness
  • Excess sedation
  • Slurred speech
  • Snoring
  • Slow pulse and shallow breathing
  • Frothing at the mouth
  • Unconscious and unable to be roused

Overdose is more likely to occur if the patient is using other drugs that depress the central nervous system e.g. alcohol, benzodiazepines or opioids. Patients should be informed of the risks of using these drugs in combination with methadone.

In case of overdose, naloxone should be administered. This reverses the effects of methadone. Because methadone has a long half-life, it is necessary to provide a prolonged infusion or multiple doses of naloxone over several hours. Patients who have overdosed should be transferred to a hospital and monitored for at least four hours.

Ongoing poly-drug use

Methadone should be prescribed with caution to patients who are using other drugs, particularly those that depress the central nervous system (e.g. alcohol, benzodiazepines). Patients should be advised of the increased risk of overdose associated with using methadone in combination with other drugs.

Concurrent medical problems

Methadone should be prescribed with caution in patients with:

  • Asthma and other respiratory conditions
  • Hypothyroidism
  • Adrenocortical insufficiency
  • Hypopituitarism
  • Prostatic hypertrophy
  • Urethral stricture
  • Diabetes mellitus

Informed consent and treatment planning

Before beginning MMT, the patient must be given enough information for him or her to make an informed decision about commencing treatment. The patient should be told:

  • The rationale for methadone maintenance treatment
  • The reasons it has been recommended to treat their opioid dependence
  • Side effects and risks of treatment
  • Expected length of treatment
  • Other treatment options

As part of informed consent, tell the patient about the rules that must be followed to receive methadone treatment. For example:

  • Patients consume their complete dose in front of dosing staff and do not give or sell any part of their dose to others.
  • No violence or threats of violence against staff or other patients
  • The patient is to attend consultations with their doctor as required
  • Consequences for breaching these rules

The patient should be given a patient information statement containing all of the above information and asked to read it. If the patient cannot read, the patient information statement should be read aloud. A sample patient information statement is shown on page 89. If the patient is happy to begin treatment after this process, he or she should sign a consent form to this effect. A sample consent form is provided on page 90.

After obtaining informed consent from the patient, develop a treatment plan that outlines the patient's starting dose and the schedule by which doses will increase. See page 28 for more information about treatment plans.

The first dose

The first dose of methadone given to a patient is low. The size of the dose is gradually increased until the maintenance dose is reached. The maintenance dose is the amount of methadone the patient requires to prevent opioid withdrawal symptoms, but does not induce euphoria.

The first dose of methadone should be between 10-30mg. Patients who have recently used opioids can be given a first dose at the higher end of this range. The first dose given to a patient who has not recently used opioids should be no greater than 10-20mg. When determining the size of the first dose, keep in mind that deaths from methadone overdose in the first two weeks of treatment have occurred at doses as low as 40-60mg per day.

Observe the patient 3-4 hours after the first dose has been taken. If the patient is showing signs of overdose, continue to monitor the patient at fifteen minute intervals. If the patient enters a coma, administer naloxone as a prolonged infusion.

Provide the same dose daily for three days. The patient will experience increasing effects from the same dose over this time. After the first three days, assess the patient's withdrawal symptoms. If the patient is experiencing withdrawal, increase the dose by 5-10mg every three days. Dose increases should not be greater than 20mg per week.

Monitor the patient for signs of withdrawal and intoxication and adjust the methadone dose accordingly to find the patient's maintenance dose. This process may take several weeks. The maintenance dose will usually be between 60-120mg, but may be higher or lower, depending on the patient's history of opioid use. See also Figure 3.

Figure 3. Methadone maintenance treatment dosing flowchart.

Figure 3

Methadone maintenance treatment dosing flowchart.

INDUCTION PERIOD

Patients who have been treated with buprenorphine

If a patient is detained who has been on buprenorphine maintenance treatment in the community, you should endeavour to assist the patient to continue this treatment. However, if buprenorphine is not available, the patient should be transferred to methadone maintenance treatment (Figure 4).

Figure 4. Methadone maintenance treatment flowchart: Patients transferring from buprenorphine maintenance treatment Patient information sheet.

Figure 4

Methadone maintenance treatment flowchart: Patients transferring from buprenorphine maintenance treatment Patient information sheet.

Methadone is a medicine used to treat heroin dependence. It is taken daily to relieve heroin withdrawal symptoms and reduce cravings for heroin. The aim of methadone maintenance treatment is to help you reduce your illicit drug use. Before you begin methadone maintenance treatment, you should be aware of the following:

  • Methadone is an opioid, like heroin. While in this treatment, you will still be dependent on opioids. But, taking methadone will be much safer than taking heroin. Taking methadone can give you a break from the drug-using lifestyle and give you a chance to work on any social, financial or family problems you are having as a result of your drug use.
  • Methadone maintenance treatment is a long-term treatment. Some people receive methadone for many months or even years. While in methadone maintenance treatment, you will need to attend the clinic once a day to receive your dose of medicine.
  • Tell your doctor if you are taking any other medications or herbal remedies as these may interact with methadone, causing health problems.
  • Some people experience side effects from taking methadone. These include constipation, nausea, feeling tired, perspiring more than usual, a dry mouth and feeling dizzy.
  • If you begin methadone maintenance treatment, you must avoid taking other opioids such as heroin, codeine, morphine or opium. Taking these drugs in combination with methadone can lead to overdose, which can be fatal. If you drink alcohol, be sure to do so in moderation, as alcohol and methadone in combination can also lead to overdose.
  • There are other drug treatment options available besides methadone maintenance treatment. Ask your doctor if you would like to know about these.

Should you begin methadone maintenance treatment at this clinic, you will be required to follow these rules:

  • You must attend for dosing each day.
  • You must attend treatment review sessions with your doctor regularly.
  • You must not sell or give your methadone dose to anyone else. Your dose has been determined based on your level of opioid dependence. Other people may overdose if you sell or give them your dose. If you are being bullied or forced to give your dose to someone, tell a staff member of the clinic.
  • You must not engage in any threatening or violent behaviour towards staff or other patients, or you will be removed from the treatment program.

Patient consent form

I, _____________________, have read (or have been read) the patient information sheet about methadone maintenance treatment. I have been offered the chance to ask questions about this treatment and am satisfi ed that I have the knowledge to make an informed decision about this treatment option.

I have been informed of the rules I must follow to continue receiving this treatment, and am aware of the penalties for breaking those rules.

I am aware that I can choose to cease this treatment at any time.

Signed:

Name:

Date:

Witness signature:

Name:

Date:

6.3. MANAGEMENT OF DOSING

Patients in methadone maintenance treatment must be dosed once every day. Methadone dosing must be strictly managed in order to minimise diversion. Diversion refers to patients giving or selling their methadone to others for other's use:

  • A patient may deliberately not swallow, or swallow and then vomit, their dose in order to sell it or give it to another resident
  • A patient may be forced by another resident to give their dose away

A well-managed program can minimise the risk of diversion by having clear dosing procedures, such as provided below, that are strictly followed.

Dosing procedure18

Dosing should be conducted by nurses or other health professionals under the supervision of nurses.

  1. The patient (or a group of patients) is escorted to the medical clinic by a security officer. The security officer must ensure the patient:
    1. Has their sleeves rolled up
    2. Is not holding anything (other than an identification card, if required)
    3. Does not have any containers hidden in their clothing
    4. Has no absorbent material such as a sponge in their mouth
  2. The nurse or other staff member conducting dosing must identify the patient. This can be done using a photograph attached to the patient's file, or an identification card held by the patient. It is crucial that the patient is correctly identified each time they are dosed.
  3. Assess the patient for signs of intoxication:
    1. Watch for unsteady gait (e.g. stumbling while walking).
    2. Engage the patient in conversation to assess coherence of speech.
    3. Check for constricted pupils.
    4. If the patient is intoxicated, do not dose. Patients who present for dosing while intoxicated should be reviewed as soon as possible by the prescribing doctor and dosing nurses. Continued drug use despite being in treatment may be a sign that patient's methadone dose is inadequate for controlling their withdrawal symptoms. Therefore, the dose may need to be increased.
  4. Check the patient's file for the size of their dose. Dispense the appropriate amount of methadone into a dosing cup. If desired, add water to the cup to dilute the methadone. Provide the cup to the patient and watch the patient consume the dose.
  5. Ensure the patient places the dosing cup in a designated waste bin inside the clinic.
  6. Ensure the patient has swallowed the dose. Ask the patient to drink a glass of water or speak.
  7. Record the dose provided in the patient's file.
  8. Isolate patients receiving methadone in a post-dosing supervision room for 15-20 minutes. While in this room, patients should be supervised by security or healthcare workers. Staff should observe patients carefully to minimise the possibility of diversion.

Requests for dose increases

Patients who request a dose increase should be provided with their prescribed dose and referred to the prescribing doctor for review.

Dosing errors

Accidentally dispensing too much methadone to a patient can result in a life-threatening situation. It may be three to four hours after dosing before the patient shows signs of overdose. In case of overdose:

  • Advise the patient of the mistake and the possible consequences (e.g. increased drowsiness, increased risk of respiratory depression).
  • Observe the patient every fifteen minutes for fours hours and every thirty minutes for the next four hours. Each time, check the patient's breathing, circulation and level of sedation.
  • Inform the clinic doctor of the mistake.
  • If the patient loses consciousness, administer naloxone as a prolonged infusion and transfer the patient to hospital for further observation.

Missed doses

Patients are required to attend the clinic daily for dosing unless other special arrangements are made. However, patients may sometimes miss doses. They may choose not to attend for dosing, or may miss dosing through no fault of their own.

A suggested schedule for dosing patients who have missed doses is provided in Table 13. In all cases, staff should consult with patient as to why they did not present for dosing, as you may be able to assist the patient in resolving problems that have prevented them from attending the clinic.

Table 13. Dosing for patients who have missed doses.

Table 13

Dosing for patients who have missed doses.

Vomited doses

Sometimes, patients may vomit their dose before it is absorbed into the body. Table 14 provides advice on re-dosing patients who have vomited. In all cases, consult with the patient to determine if they have been harassed or forced to vomit their dose to give to someone else.

Table 14. Dosing for patients who have vomited.

Table 14

Dosing for patients who have vomited.

Recording dispensed amounts

Medical clinics dispensing methadone should maintain clear records of the amount of methadone dispensed each day, and the amount of methadone stored on the premises. Records should also be kept of accidental spillage of methadone. Discrepancies between the actual amount of methadone on the premises and the amount recorded as being on the premises should be investigated by an independent staff member.

6.4. MONITORING MMT

Treatment review

At regular periods, the patient and prescribing doctor should meet for a treatment review. The following should be discussed at a treatment review:

  • Suitability of the current methadone dose, withdrawal symptoms and side effects, requests for dose increases
  • Other medications the patient is taking
  • Physical and psychological health
  • Current drug use, including signs of injecting drug use
  • Review of treatment goals

At the commencement of MMT, treatment review should occur weekly. After two months in treatment, the frequency of treatment reviews can be reduced to once every four to six weeks.

Patients who are using illicit drugs, are suspected of diverting their methadone dose, or have recently had their dose increased or decreased should attend treatment review meetings weekly.

Urine drug screening

Analysis of a patient's urine for evidence of illicit drug use is expensive and will not stop patents from using other drugs. Furthermore, results can be unreliable. There is no evidence that punishing patients for returning positive urine samples results in decreased illicit drug use. Urine drug screening should only be used for therapeutic purposes, for example, when a patient is suspected of using drugs and confirmation of this is required. This provides information that the doctor can use to identify if the patient's treatment needs are being met. For example, if a patient's urine sample shows continued heroin use despite being in MMT, it may be a sign that the patient needs a higher methadone dose.

Treatment duration

There is no set rule for how long someone should stay in methadone maintenance treatment. However, it is well known that the longer a patient remains in treatment, the better the outcome. Generally, patients should be encouraged to remain in methadone maintenance treatment for the length of their detention, and then provided with assistance to continue with treatment after release from detention.

Additional treatments

All patients should be encouraged to access additional treatments such as psychosocial interventions. However, they should not be mandatory. Counselling and similar treatments are more effective if they are entered into voluntarily.

Release planning for methadone patients

It is recommended that all patients receiving MMT in closed settings be assisted to transfer to a community-based MMT program to continue treatment. Remaining in MMT in the community will help the patient to avoid illicit drug use and HIV risk behaviours such as sharing syringes. It will also reduce the likelihood of drug overdose. Arrangements for transferring the patient's prescription should be made by the prescribing doctor several weeks before the patient is due for release, in order to allow time for the transfer request to be processed. It can be useful to employ a community liaison officer who can assist in arranging transfers between the closed setting and doctors in the local community.

Factors to consider when planning a patient's release include:

  • Will the patient be living in an area with easy access to a methadone clinic?
  • Will the patient be able to afford methadone treatment? Are government-subsidised treatment places available (e.g. for patients living with HIV)?
  • What other support services can the patient access once released?

Case study: Release planning for prisoners in MMT in New South Wales, Australia

Prisoners in New South Wales, Australia, can access methadone and buprenorphine maintenance treatment. Continuity of maintenance treatment between prison and community settings is critical to reducing the risk of relapse to drug use and criminal re-offending. To help patients access community methadone maintenance programs after their release from prison, Justice Health (the organisation providing MMT in prisons) collaborated with community Area Health Services to implement an “in-reach project”.

The in-reach project employs community health workers to visit prisoners receiving maintenance treatment who are soon to be released. The health worker assists the patient to arrange to continue methadone treatment in the community. The health worker also identifies other needs of the prisoner, such as accommodation, education or health needs and refers the prisoner to appropriate services. The objectives of the in-reach project are to:

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Minimise drug-related morbidity and mortality in released prisoners

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Minimise the barriers to entering methadone or buprenorphine programs

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Establish links between health agencies to ensure continuity of treatment between prison and the community

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Link patients with other services required to address their individual needs

An external evaluation of this project found that over 90% of patients referred to community-based treatment presented to the arranged clinic within 48 hours of release from prison.

Withdrawal from methadone prior to leaving the closed setting is not recommended. However, under some circumstances, it may be necessary. The patient may not be able to transfer to a community-based program, or the patients may request dose reductions with the aim of ceasing MMT before he or she is released. Patients should be advised that ceasing MMT prior to release might increase their risk of relapse and drug overdose. If a patient insists on ceasing MMT before release, follow the guidelines set out in section 6.5 Ending treatment.

6.5. ENDING TREATMENT

Voluntary cessation of treatment

Patients who wish to stop MMT should see their prescribing doctor to discuss their treatment options. The doctor should establish why the patient wants to stop MMT. Reasons for wanting to stop MMT may include:

  • Belief that methadone is not appropriate in their case
  • Belief that they no longer need treatment
  • To avoid problems associated with MMT e.g. side-effects, harassment from others to divert dose
  • To be “drug-free” prior to release from the closed setting.

Each of these reasons is legitimate, but the doctor should ensure the patient is aware of the benefits of MMT and has made an informed decision to cease treatment. In particular, patients who wish to cease MMT just before release should be informed of the increased risk of relapse and drug overdose in the weeks following release from a closed setting.

If a patient chooses to discontinue treatment, their treatment plan should be revised so that they will start receiving lower doses of methadone over a period of time. The patient should be told that this will happen.

Recommended dose reduction schedule:

  • Reduce by 10mg per week until a dose of 40mg per day is reached.
  • From then, reduce by 5mg per week until a zero dose is reached.
  • Dose reductions should occur once a week or less often.

This schedule is a recommendation only. Rates of dose reduction should be discussed with the patient. If the patient is experiencing withdrawal symptoms, it may be appropriate to maintain the patient on a reduced dose for several weeks before recommencing the reduction schedule. Patients should be provided with additional psychosocial support during the dose reduction period.

A patient may begin to reduce his or her dose and later decide that they would prefer to remain in MMT. There should be procedures in place for these patients, and recently discharged patients, to be re-admitted to MMT on request.

Involuntary cessation of treatment

In some situations, it may be necessary to discharge a patient from MMT for the safety of other patients and/or staff. This may be because of violence or verbal abuse towards other patients or staff, or repeated incidents of methadone diversion. Before deciding to remove a patient from MMT, consider that the patient:

  • May become more difficult to manage if removed from the methadone program
  • May recommence or increase illicit drug use

Patients who commit minor infractions, for example, illicit drug use or refusal to provide a urine sample, can be disciplined, but should not be made to stop MMT. Methadone doses should never be withheld as punishment to patients. Patients should only be involuntarily removed from the program if their behaviour threatens the health and safety of others.

Patients who are made to cease MMT should be placed on the same dose reduction schedule as described for patients voluntarily ceasing treatment. If the patient is considered a serious risk to the safety of staff or other patients, they can be given this reducing schedule of doses in an area away from the clinic, such as their living quarters.

Pregnant patients

Cessation of methadone maintenance treatment during pregnancy is not recommended. Pregnant women should be provided with information about the benefits and risks of methadone during pregnancy. If a woman chooses to stop methadone treatment during pregnancy, it is recommended that dose reductions begin during the second trimester. Dose decreases should be 2.5 to 5mg per week, and the patient should be closely monitored for signs of withdrawal.

Footnotes

14

Buprenorphine is another medicine used as a substitute for heroin in the treatment of opioid dependence. However, these guidelines will focus on methadone as it is the most widely used substitute medicine.

Another medication sometimes used for treating opioid dependence is naltrexone, which blocks the effects of opioiods; however there is very little evidence that this is effective, and it is not recommended for use in closed settings

15

WHO/UNODC/UNAIDS. Substitution maintenance therapy in the management of opioid dependence and HIV/AIDS prevention. Geneva: World Health Organization; 2004. .

16

Dolan K, Shearer J, MacDonald M, Mattick R, Hall W, Wodak A. A randomised controlled trial of methadone maintenance treatment versus wait list control in an Australian prison system. Drug and Alcohol Dependence. 2003;72(1):59–65. [PubMed: 14563543].

17

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