clinicRx created in Wix 2016

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Pharmacist reference page

My core message to all pharmacists I work with is this: I will always back any decision you make regarding a client when I am away. This includes the provision of appropriately-dated prescriptions. As those of you who phone me know, my clinical decision is always based on your assessment and I take the lead from you about how to handle the situation.

I am a solo doctor which makes covering my clients trickier when I am on leave. However, most GP's in group practices suffer the same problems - their colleagues refuse to assess clients on methadone and suboxone and pharmacists and clients often find themselves caught in the middle. This is why I a have provided so much detail. 

I have sent consent to the Ministry of Health Pharmaceutical Services so that in NSW Riverlands OTP clinic doctors can act on my behalf when I am on leave. Their involvement is so that clients can have safe, sensible continued dosing until I am back. You may like to contact them to request a copy of their protocols for acting as GP clinical back ups in urgent situations.

 

My Suggestions for when I am on Leave

  • The bottom line is: opioid withdrawal is horrible.

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  • Dosing continuity underpins the biological and psychological success of the opioid substitution program. My strong clinical intent is that all clients receive continuous dosing of their medication wherever possible. This policy may be taken as standing orders to which I will adhere.

  • NB - these are my preferences only: I always respect and adhere to individual pharmacy decisions and I instruct my clients to do the same.

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  • If any prescription inadvertently expires while I am away, this is an oversight. Please continue to dose the clients and I will always provide an appropriately dated prescription upon my return

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  • If a client has not dosed for five days or less they can be half dosed and restarted with NO TA

  • If a client has not dosed for more than five days they should be re-inducted at 40mg and increased at 10mg after each third dose with not TA until I can review them.

  • This is an excellent compromise between safety and common sense.

  • In a proven family emergency I would always approve up to seven consecutive TA for any patient and I will provide an appropriately dated prescription for this. Decades experience in prescribing has led me to the certainty that this is the safest thing to do.

  • I will always back up any decision made to provide additional TA by a pharmacist.

  • If TA are lost or stolen I only replace those with a police report ONCE per patient. However if I am not contactable the matter is trickier. In the event of an unequivocal and proven emergency like a bush fire house destruction, if there is a police report made I would support daily dosing in-pharmacy for the destroyed TA period.

  • For floods or chemist closures due to emergency, kindly send a copy of your dosing records to Riverlands before closing so they can continue dosing.

  • Riverlands have a doctor on-call 365 days per year. You and the clients can also try to ask for help there if they need urgent out of town travel for bereavement or family illness. 

  • Further information if you are interested...

  • When a client is declined dosing they virtually always seek other opioids. Or alcohol or methamphetamine

  • Opioid withdrawal is excruciating and unbearable. Even the anticipation of not being dosed creates intense fear in our clients and can provoke poor decision-making and behaviour. When a client is declined dosing they virtually always seek other opioids. Or alcohol or methamphetamine

  • These options are expensive and come at a risk. People engage in crime, fraud, sex work to get the money. They go without food, the rent doesn't get paid, their children go without basics. They risk overdose, violence, sexual assault, a criminal charge, infection and death. A simple dose at a pharmacy vs the above options – they are hardly equivalent choices.

  • Continuous dosing is the safest thing we can do for our clients. Withholding doses always results in poor choices and compromises the safety of our patients. When a person is not dosed, they almost always seek opioids elsewhere. This includes black-market methadone and suboxone, heroin of uncertain origin, other prescription opioids which they inject including fentanyl and fentanyl analogues from the dark web

  • Controversial fact - In 25 years of OTP prescribing I have come to a strong clinical belief: It is safer to accidentally double-dose a patient than to withhold a dose. I have been asked to review patients who have been accidentally double-dosed many times. The standout protective factor of methadone is that it induces such a high tolerance to opioids that clients are protected from overdose – I have even assessed clients who have had 3 x 200mg doses in one day and they have not come close to requiring opioid reversal. On the other hand I have reviewed many, many clients who have been denied a dose and have made a poor decision in order to access that days opioid requirements. Prescribed TA doses are usually swallowed – black-market TA methadone is virtually always injected.

  • Family Emergencies: I have been providing up to seven day TA for family emergencies for many years. In that time I genuinely cannot recall an incident where I have regretted that. But the feedback from clients is unanimously very grateful. This avoids the horror of having to deal with the grief of a parent whilst also having to access black-market opioids in a city where you have no contacts. I have witnessed several stand-out episodes where the worst outcomes have occurred because a person has been declined TA to travel.

  • Riverlands refused to dose any GP patients in the floods three years ago because they claimed they did not have dosing records from community pharmacies who were underwater.  They would not work from my prescriptions. This created an entirely un-needed clinical disaster on top of the flood itself. Please send copies of you dosing histories to Riverlands if you need to close for any unforeseen reason. Please ask Riverlands for a copy of their regional emergency plan.

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  • If a patient misses three to five days of methadone or suboxone I would always approve a half dose then return to normal TA on the following day. I will always provide an appropriately dated prescription for this. Not dosing a patient who has had a minor wobble will ensure that it becomes a major relapse with all the morbidity and mortality that entails. Retention in treatment indicators of any opioid substitution program. Allowing a person to re-enter the program easily after a short wobble is essential. Remember, the tolerance induced by methadone ensures the safety of the person involved.

  • If a patient misses more than seven days of methadone or suboxone then I would approve daily half doses and they should see me on the day of my return. (I am limiting my leave to two weeks, so this should only be a few days)

  • Riverlands have a doctor on-call 365 days per year. Patients can also try to ask for help there if they need urgent out of town travel for bereavement or family illness.  Failure to receive assistance can be taken further upon my return.

  • Public opioid treatment clinics are well-funded and have secure dosing and doctors on 365 day call. I contend that they should take clinical responsibility in this area. This is also the expectation of the Ministry of Health Pharmaceutical Services.