Documenting processes regarding the management of methadone or buprenorphine for admitted patients (on therapy as maintenance pharmacotherapy for opioid dependence) reduces the risk of inadvertent withdrawal or toxicity.

Effective communication between the community pharmacy, hospital pharmacy, community prescriber and hospital treating medical practitioner regarding patients who are on treatment with either methadone or buprenorphine as maintenance pharmacotherapy for opioid dependence.

When a patient who is receiving methadone or buprenorphine treatment (as maintenance pharmacotherapy for opioid dependence) is admitted to, or discharged from hospital, there is a risk of confusion about when the last dose was administered. This creates the possibility of dual dosing on the same day, with resultant methadone/buprenorphine toxicity.

Refer to Appendix for the following flowcharts that summarise admission and discharge processes for handling and coordination of methadone oral liquid for opioid use disorder:

Flowchart 1.1 Process for patients newly admitted to hospital

Flowchart 1.2 Handling of methadone liquid takeaway doses on/during admission

Flowchart 1.3 Organising supply of methadone liquid for inpatients during BHS Pharmacy operating hours

Flowchart 1.4 Organising supply of methadone for inpatients outside BHS Pharmacy operating hours

Flowchart 2.1 Handling of methadone prescription and communication to community pharmacy on discharge

Flowchart 2.2 Handling of methadone takeaway doses on discharge

On admission

The practice of using a patient's own supply of take-away doses while admitted to hospital is not recommended due to the uncertainty of adminstering a dose that has not been prepared by the hospital

If the patient is on a methadone or buprenorphine program for maintenance pharmacotherapy for opioid dependence, the hospitals treating medical practitioner must (where possible) contact the dispensing pharmacy to confirm the dose and when it was last administered. The dispensing pharmacy will also be able to outline whether or not the patient has been issued with takeaway doses. When on duty, the clinical pharmacist may be able to assist with gathering this information. The pharmacist will complete eMR092.4 Methadone/Buprenorphine Record, printing and placing a copy with the patients medication chart.

Take-away doses brought to hospital by a patient should be discarded to reduce the risk of a double dose being consumed during the patient's stay in hospital and after discharge. Discarding of the take away doses should be completed as per CPP0496 Medication Security (treated as a "whole" dose). The patient's regular pharmacy should be informed about the circumstances of any takeaway doses brought to hospital by the patient, including whether any takeaway doses brought to hospital were discarded.  On the occasions that the takeaway doses are not available in hospital, this needs to be communicated clearly to the patients dispensing pharmacy so they know the patient still has takeaway doses in their possession at home when the patient is discharged from the hospital. The patient's community prescriber may also be able to provide details of the patient's therapy (e.g. copy of the patients prescription). This may be completed by medical officer or clinical pharmacist.
Prescribers may order methadone or buprenorphine for the purpose of continuing treatment of a stable patient. For initation or unstable patients contact Drug & Alcohol Clinical Advisory Service (DACAS) on 1800 812 804 for guidance.

Contact the clinical pharmacist or hospital pharmacy to provide details of the treatment and provide the medication order written on a hospital drug chart. Ensure the order gives clear and unequivocal directions.

If a patient's methadone treatment has been interrupted by 72 hours or more (or 5 days or more in the case of buprenorphine), then the treating medical practitioner is required to reassess the patient and contact the Drug & Alcohol Clinical Advisory Service (DACAS) on 1800 812 804 for guidance.

Safescript should be checked on admission by the admitting medical officer and the clinical pharmacist who completes the BPMH on admission.

Note: buprenorphine is available in combination with naloxone (Suboxone) as a film, this is the prefered option for patients admitted to BHS. When taken sublingually, the naloxone in the combination product is not extensively absorbed and has no clinically significant effect. When injected by a neuroadapted opioid dependent user, buprenorphine/naloxone will either precipitate unpleasant withdrawal symptoms or have less opioid effect than buprenorphine alone.

Dosing Instructions

All doses are to be administered on the ward or department only.
The prescriber should be notified if there are concerns that the patient may be attempting to divert this medication.

Given the risk of overdose or drug interaction, a dose should not be administered if a patient appears to be intoxicated or has other clinical signs of CNS depression (e.g. slurred speech, unsteady gait, drowsiness, pupil constriction, shallow breathing). Contact the prescriber immediately for instructions before dosing.

Methadone solution
The dose prepared by pharmacy will already be measured and diluted in water (to an approximate volume only) and labelled accordingly.
After recording dose details in the relevant Drug of Addiction recording system and completing administration checking steps (as per Medication Administration Policy CPP0287), the following procedures are to be observed.

• Pour solution into a disposable cup and give entire contents as a single dose.

• Ensure that the solution has been swallowed (e.g. talk to patients after they take the dose as means of ensuring the solution has been swallowed). Rinse bottle with water and give the water to the patient to drink also.

Buprenorphine sublingual film
After recording dose details in the relevant Drug of Addiction recording system and completing administration checking steps (as per Medication Administration Policy CPP0287), the following procedures are to be observed.

1. Count and check the buprenorphine films.

2. Carefully cut the top of each individual packaging along the "cut" line, then count and check the buprenorphine film/s into a transparent, dry dosing cup (retain the film/s in their packaging).

3. Ensure that the patient's mouth is empty by inspecting the mouth cavity. Gum, lollies etc., must be removed.

3. Provide the following instructions to the patient:

• Once the film/s are given to you, they are your responsibility and will not be replaced.

• Place the film/s under your tongue and allow the film/s to dissolve.

• Do not chew the film/s.

• Do not swallow the film/s [buprenorphine has poor bioavailability (i.e. not well absorbed by your gastrointestinal tract) when taken orally compared to sublingually].

• Do not consume food or drink until the film/s is/are completely dissolved or for 30 minutes after dose.

• Do not swallow saliva until the film/s have dissolved.

4. Give the film/s to the patient and observe the patient opening the packaging of the films. Ask the patient to place the contents under the tongue. Discourage patients from handling film/s with their hands. If more than one sublingual film is necessary to achieve the prescribed dose, advise the patient to place it sublingually on the other side of the tongue.

5. Observe the patient until you are satisfied the film/s is/are not able to be diverted (usually takes > 2 minutes).

Vomited dose of pharmacotherapy

Patients may vomit after ingesting their pharmacotherapy doses, creating uncertainty about whether they have absorbed it. Consider the interval between ingestion and vomiting.

Methadone is fully absorbed within 20-30 minutes of ingestion. Vomiting early after ingestion may prevent absorption of the dose, although the patient may not vomit all the stomach contents. If vomiting occurs more than 20 minutes after ingestion, the dose is likely to have been absorbed. If vomiting occurs within 20 minutes of ingestion of the dose, review the patient. If the patient is reviewed within four to six hours after consumption of the dose, plasma levels will be at their peak. If there is good evidence of opioid withdrawal at this time, consider a supplementary dose of half the usual dose ( up to a maximum of 40mg). If there are doubts about the amount of pharmacotherapy absorbed despite vomiting, it is better to be cautious and not administer an additional dose. Review the patient the next day.

Take extra care with pregnant patients because withdrawal symptoms can cause foetal distress.

As buprenorphine is absorbed sublingually within minutes, vomiting after a dose will not reduce the clinical effect.

Weekend or Day leave for palliative care patients

Patient's being treated under palliative care who are receiving methadone/buprenorphine for opioid dependence will be allowed to have take aways for their methadone/buprenorphine if they require day/weekend leave. It must be confirmed that we believe there is no risk of diversion, and that the patient usually receives take aways. No more than 2 days of take aways should be supplied. The regular pharmacy and prescriber must be aware of the arrangment. The discussion must be documented in the progress notes. The palliative care registrar/consultant and clinical pharmacist must agree to the weekend/day leave.

On Discharge

As a part of discharge planning:

-  The treating medical practitioner must ensure that the patient has a valid prescription for treatment in the community and a local pharmacy to provide the supervised dosing. If the prescription that the patient was being dosed with has expired, or the dose has changed, ensure that arrangements are made for the patient to be reviewed as soon as possible with their usual prescriber to avoid missing doses. If the patient's prescription is expired or their dose has changed, and the patient is unable to obtain an appointment with their prescriber (or covering GP) that day or the following day a prescription may be provided to the patient for the smallest quantity (e.g. the smallest number of days required) to get them through to the appointment, but for no more than 7 days. A permit is not required, but safe script is required to be checked by the prescriber and clinical pharmacist. In this situation the patient's usual prescriber and pharmacy must be made aware of the circumstances and that the date of review with the usual prescriber is known.

- As described earlier (under On admission) there may be some occasions where a patient was not able to bring in his/her take away doses during the hospital admission. This needs to be communicated clearly to the patients dispensing pharmacy so they know the patient still has takeaway doses in their possession at home when the patient is discharge from the hospital.

- The treating medical practitioner must contact the clinical pharmacist or hospital pharmacy to advise the date/time of discharge and the date/time of last dose administered. The hospital pharmacy will contact the patient's community pharmacy and provide this information. The pharmacist will complete eMR092.4 Methadone/Buprenorphine Record and provide a copy to the patient's community pharmacy.

- Safe script is not required to be checked at discharge, unless a script is supplied as above or other drugs of dependence are supplied. If required safe script must be checked by the prescriber and clinical pharmacist. If the script is dispensed at BHS the dispensing pharmacist is, also, required to check safe script.

- If treatment with methadone/buprenorphine is stopped, complete a 'Notification of termination of methadone or buprenorphine program' form and forward it to the Drugs and Poisons Unit. The form is sent by facsimile to the Drugs & Poisons Unit on 1300 360 830. A copy is forwarded to the clinical pharmacist or Pharmacy Department. The form is also available as a SmartForm that can be submitted online to the Drugs & Poisons Unit. Record in the patient's medical record when the SmartForm has been submitted online. Ensure the GP and local pharmacy is made aware of the cessation.

Please note that doses CANNOT be given to the patient to be taken with them on discharge or leave, with the exception being for palliative care patients on leave (see above). Any doses that have been prepared and issued to the ward are for INPATIENT USE ONLY. After the patient is discharged, any unused doses should be returned to pharmacy for destruction.

Clinical Support
The Drug and Alcohol Clinical Advisory Service (DACAS) provides advice and information on the clinical management of patients with drug and/or alcohol problems, including:
- Advice on recognising and managing withdrawal symptoms
- Information about drug use complications
- Drug information
- Prescribing information
- Assistance with cases of acute intoxication.
They are contactable 24 hours a day on 1800 812 804. Their website is www.dacas.org.au