Opioid Replacement Treatment – Justice Health … · Web viewFail to attend dosing resulting in termination from the program or Cease treatment against clinical advice Each of these

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Canberra Hospital and Health ServicesClinical Procedure Opioid Replacement Treatment – Justice Health ServiceContents

Contents....................................................................................................................................1

Purpose.....................................................................................................................................2

Scope........................................................................................................................................ 2

Section 1 Assessment and Commencement of Opioid Replacement Treatment......................2

Phase 1 – Drug and Alcohol (D&A) Nursing Triage Assessment............................................2

Phase 2 – D&A Nursing Assessment......................................................................................4

Phase 3 – Medical Officer Assessment..................................................................................4

Referral for D&A Counselling................................................................................................7

Monitoring During Induction................................................................................................8

Section 2 – Diversion/Ceasing Treatment.................................................................................9

Management of Arriving Late or Ceasing ORT......................................................................9

Management of Diversion of ORT.......................................................................................11

Section 3 – Dosing...................................................................................................................13

Dosing Procedures..............................................................................................................13

Dosing Adjustments............................................................................................................29

Transferring to a Different Form of ORT.............................................................................30

Management of Take-away Medications from the Community brought into a Secure Setting................................................................................................................................. 32

Section 4 – Discharge Planning...............................................................................................32

Implementation...................................................................................................................... 33

Related Policies, Procedures, Guidelines and Legislation.......................................................33

References.............................................................................................................................. 34

Definition of Terms................................................................................................................. 34

Search Terms.......................................................................................................................... 35

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Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

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Purpose

The purpose of this procedure is to provide clinicians with information on safe opioid replacement treatment (ORT) dosing principles for adult clients of Justice Health Services (JHS).

Back to Table of Contents

Scope

This document applies to: Medical Officers Nurses and Midwives who are working within their scope of practice (Refer to Scope of

Practice for Nurses and Midwives Policy)


Section 1 Assessment and Commencement of Opioid Replacement Treatment

As per the National Guidelines for Medication Assisted Treatment of Opioid Dependence (Gowling et al., 2014) the goal of induction is to safely achieve an adequate dose of medication, stabilise illicit or unsanctioned opioid use and address co-occurring conditions.

In a secure setting methadone is the preferred agent for induction to ORT, due to issues of client compliance and risk of diversion with suboxone. Suboxone may be used as an induction agent in rare case-by case exceptions. These exceptions must be supported by clinical evidence (e.g. allergy to methadone). Suboxone is not routinely prescribed in a secure setting as a maintenance agent.

The assessment process has a three phase approach to determine a client’s suitability for the Opioid Replacement Treatment Program (ORTP). Induction is indicated for clients who: Are opioid dependent and at the time of entering a secure setting are not on ORTP; Continue using opioids (licit or illicit) in a secure setting in a manner which constitutes a

significant risk of harm; Are at significant risk of using opioids in a secure setting or on discharge.

Phase 1 – Drug and Alcohol (D&A) Nursing Triage AssessmentEquipment D&A Nursing Triage Assessment form



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Procedure The initial triaging of a client for their suitability for the ORT program is conducted by a nurse. 1. All clients entering a secure setting (custodial or mental health) on an ORT program must

still be assessed for continuation of ORT whilst in a secure setting. Clients will be maintained on ORT unless clinically indicated otherwise.

In a secure setting, methadone is the preferred treatment for managing opioid dependence except where it is contraindicated i.e. allergy.

2. In order to be triaged for suitability for ORT, clients in custodial setting must self refer to JHS using a Health Request form (Barcode #10225). Clients at Dhulwa Mental Health Unit (DMHU) will self refer to their “primary nurse”.

All clients will have a D&A Nursing Triage Assessment form completed by a registered nurse in order to triage the request according to a range of clinical risk factors.

All clients requesting to commence on ORT will be managed symptomatically in the first instance (unless they meet the clinical criteria as a “priority access” client). Nurses will assess the severity of withdrawal and discuss with the medical officer to determine if medication is required to assist with the management of the symptoms.

Priority access clients are those who fall into the following groups: Pregnant women; Clients who identify as Aboriginal and/or Torres Strait Islander origin; Clients with human immune-deficiency virus (HIV); Clients who are hepatitis B carriers; Clients commencing or currently receiving hepatitis C treatment; Clients with significant co morbid conditions (mental or general health); Clients who have been in the Regional Watch House and have missed 2-3 doses.

Priority access clients will be assessed by a medical officer (MO) as soon as practicable to ensure positive client outcomes.

Clients who do not meet the criteria for priority access are referred to as routine applications.

3. Clients should be referred to the Population Health nurses for support regarding any high risk behaviour such as needle sharing etc.

4. Triage forms are provided to the D&A nurse to review if assessment is to be conducted in order to confirm suitability for ORTP.

In the event of a client being given priority access to treatment a medical officer assessment should be carried out within 24 hours of the initial triage assessment.



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For routine applications for commencement on ORTP, a D&A nursing assessment should be conducted at the next available D&A nursing appointment.

Phase 2 – D&A Nursing AssessmentEquipment D&A Nursing Triage Assessment form – completed; D&A Nursing Assessment form; Electro Cardio Gram (ECG) Machine; Venepuncture equipment as per Venepuncture Blood Specimen Collection Procedure. Urine specimen jar

Procedure Clients that have identified as Aboriginal or Torres Strait Islander should be asked if they would like to nominate a person to be present during their assessment.

1. D&A nursing assessment will be completed on all clients requesting to be commenced on the ORT program. The assessment will include:a. Completion of D&A nursing assessment;b. Offering of Blood Borne Virus (BBV) screening, and collection if client consents, in

accordance with Venepuncture Blood Specimen Collection Procedure (CHHS16/207).c. A urine drug screen may be indicated if there are concerns about the accuracy of the

drug history that has been provided.2. Explain to the client all of the risks and benefits of ORT.3. Upon assessment completion where the client is deemed suitable for ORT:

a. The client is booked in with a medical officer at the next available appointment (within 3 days);

b. A baseline ECG is completed.4. In the event where the client is assessed as not found suitable for ORT at this time,

clients will be provided with harm minimisation education. 5. Clients will be informed of the outcome but their request will be brought to the ORT

clinical meeting for further discussion. 6. All outcomes are recorded in the client’s clinical record.

Phase 3 – Medical Officer AssessmentEquipment ORT Medical Assessment form (available on the forms register); D&A Nursing Assessment – completed; D&A section of current Induction Health Assessment form - completed on entry into

custodial setting; D&A Clinical follow up post reception form, if completed; D&A Substance Withdrawal monitoring form, if completed; Medication charts; Relevant clinical notes / health reports (D&A / primary health / population health /

mental health or from external agencies); Application for approval to prescribe controlled medicines;



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ORT Prescription and treatment sheet - obtained from ACT Corrective Services (ACTCS) health officer;

JHS Health Notification form (available on the forms register; Clinical Information System – for checking current pathology results; Clinical record.

Procedure To minimise concerns about clients commencing ORT without a history of opioid dependence, the medical officer will consider all assessment information compiled by the JHS team before completing the medical assessment. The National Guidelines for Medication Assisted Treatment of Opioid Dependence (Gowling et al., 2014) recommends the following assessment principles: Use collateral history to confirm previous episodes of opioid dependence. Potential risks and benefits of commencing methadone treatment should be identified

and documented. If there is doubt regarding the suitability of a client for ORT, consultation with the

Clinical Director may be indicated.

The long term use of opiates is associated with an increased risk of misuse. These risks will increase with time of use and with dose (Medicinewise, 2015).

Clients that have identified as Aboriginal or Torres Strait Islander should be asked if they would like to nominate a person to sit in with the assessment with them.

1. All clients will attend an appointment with a medical officer where a D&A Medical Assessment will be completed.

2. The medical officer will review the baseline ECG for prolonged QTc interval:

Prolongation of the QTc interval is potential issue with clients treated with methadone and less commonly buprenorphine. Clients require careful assessment weighing up relative risk/benefits of methadone and other contributing factors such as antipsychotic medicationa. Prolonged QTc for Men >450 msb. Prolonged QTc for women >470 ms

Clients should be informed of the cardiac side effects of methadone and provided with the Methadone Treatment and ECG Screening consumer handout.

3. The decision to commence a client on ORT is the responsibility of the medical officer; however, all collateral information should be considered prior to the commencement of treatment. If a urine drug screen has been collected and the medical officer assesses the client as requiring immediate commencement on the ORT program, it is not necessary to await the results of the urine drug screen before commencement on the program.

The medical officer must clearly demonstrate the potential benefits to the client’s health and well being and confirm that the benefits outweigh the potential risks of the client commencing ORT.Doc Number Version Issued Review Date Area Responsible PageCHHS17/158 1 20/07/2017 01/05/2019 MHJHADS - JHS 5 of 35


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4. If after being reviewed by the medical officer, commencing the client on ORT is clinically indicated, then the following documents must be completed:a. ORT Treatment Agreement form (available on the forms register)

This is a consent form for treatment and informed consent must be obtained prior to commencement. The client must be provided with a copy of “The Methadone Handbook” or “The Buprenorphine Handbook” and the contents of the handbook discussed with the client so that they are clear about what commencing on treatment will entail. It is the responsibility of the medical officer to ensure that this is completed prior to commencing dosing.

The medical officer must ensure that they have explained to the client that ACTCS operations managers will be notified that they have commenced on the ORT program.

Clients must read and sign the ORT Treatment Agreement thus agreeing to abide by the rules of the ORT program. The form must be adequately explained to the client. Clients must be advised refusal to sign the agreement warrants the person not being commenced on the ORT program. The signed ORT treatment Agreement form should be kept with the client’s prescription and treatment sheet.

b. Client Rights and Responsibilities form (available on the forms register)This form tells the client what behaviour is expected of them when they are being dosed. It also outlines JHS dosing procedures and advice for discharge planning.

Clients must read and sign the Client Rights and Responsibility form thus agreeing to abide by the rules of the ORT program. The form must be adequately explained to the client. Clients must be advised refusal to sign the agreement warrants the person not being commenced on the ORT program. The signed Rights and Responsibilities form should be filed in the client’s clinical record.

c. Application for Authority to Prescribe a controlled medicineThis form is completed by the prescribing medical officer. It is the responsibility of the nurse to ensure that the form is faxed to the ACT Health Services (HSU).

The HSU will approve the application to commence the client on treatment. Once approval has been obtained the HSU will fax back the Authority to Prescribe form with the HSU authority number and expiry date. The authority expiry date and authority number is to be transcribed onto the clients ORT Prescription and Treatment sheet.

Clients can be dosed for a total of 72 hours while awaiting approval from the PSU.

d. ORT Prescription and Treatment SheetThis form is completed by the medical officer. All prescriptions for ORT must satisfy all legal and regulatory requirements.



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The treatment sheet should have the pink “new to treatment” sticker. The stickers are to be placed on the ORT Prescription and Treatment sheet whenever a client is new to treatment. This may be the first occasion the client has been on treatment or it may be some time since they were last on treatment. The sticker only needs to be placed on the first treatment sheet and thereafter it is no longer required. This will have the added advantage of also highlighting to staff the client may require greater support or review because they are new to the program.

e. JHS Health Notification formThis form notifies ACT Corrective Services the client has been commenced on the ORT program.

Please document “Client commenced on opioid replacement treatment. Client will be reviewed as clinically indicated”.

A copy of this form is to be provided to the ACTCS Area Manager (Corrective Officer 3) and the original is placed in the client’s clinical record.

f. Clinical Progress NotesA summary of the intervention is to be documented into the client’s clinical record by any health professional when they review / assess the client.

5. Starting dose and dose regimens are outlined in Section 3.

6. The client should be reviewed by a nurse, within three days of the initial dose, weekly for two weeks and then monthly or as required thereafter while the client’s dose is being titrated to a stable level. All new clients to ORT will be reviewed by a medical officer within 7 days following commencement of ORT.

The client has access to nurses daily for questions regarding the ORT program and will be clinically reviewed every three months by a nurse and a medical officer (D&A medical review form).

7. Clients found to be unsuitable for induction to ORT, the rationale and all relevant information should be clearly documented in the client’s clinical record at each stage of the assessment process. For example, the assessor should clearly document the reason for unsuitability and discuss at the next D&A ORT clinical meeting.

Referral for D&A CounsellingEquipment D&A Nursing Triage Assessment form

ProcedureAll clients will be referred to the D&A Nurse or CNC using the D&A Nursing Triage Assessment form. Doc Number Version Issued Review Date Area Responsible PageCHHS17/158 1 20/07/2017 01/05/2019 MHJHADS - JHS 7 of 35


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The D&A nurse or CNC will provide D&A short term interventional education to clients. If the client is assessed as requiring more interventions the D&A nurse /CNC will refer the client to the ADS Counselling and Treatment Service.

Monitoring During InductionEquipment ORT Monitoring form (available on the forms register); Observation equipment.

ProcedureDuring induction to ORT, clients will be administered their first dose in the health centre prior to 2pm. All subsequent doses will be administered in a therapeutic environment that provides JHS nurses the ability to assess the client for intoxication. This is assessed on a case by case basis.

The greatest risk of methadone toxicity occurs during the peak time of methadone effects (three – four hours after each dose) during the initial days of treatment. During the first five days of treatment nurses will review the client three to four hours after dosing to monitor for signs of methadone intoxication (e.g. sedation, constricted pupils) or withdrawal symptoms, side effects, and other substance use.

The ORT Monitoring form should be used to monitor: Behavioural parameters of intoxication, with assessment of the client speech, gait and

level of consciousness. Physiological parameters of intoxication, including pupil size, blood pressure and pulse.

1. Clients new to ORT will be assessed for intoxication (using the ORT Monitoring form) immediately pre-dose from day 1 to day 10, as well as 3-4 hours post dose from day 1 to day 5.

The following observations, made using the ORT Monitoring form, may be features of intoxication: Pupils < 2mm; Pulse rate > 100; Respiratory rate < 12; Blood pressure systolic <90mmHg or diastolic <60mmHg; Slurred or pressure speech; Impaired gait or impaired consciousness (drowsy).

2. It is the responsibility of both dosing nurses to assess if the client is intoxicated.

3. If the client exhibits any features of intoxication or methadone toxicity, nurse will Withhold methadone and other medication; Contact the medical officer for instructions; Communicated process to the client.



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Section 2 – Diversion/Ceasing Treatment

Management of Arriving Late or Ceasing ORTClients who come off the ORT program will either:a. Cease treatment as part of a successful completion of the programb. Fail to attend dosing resulting in termination from the program orc. Cease treatment against clinical advice

Each of these scenarios is managed slightly differently. Before commencing a reduction in medication, the clients should be assessed to determine their motivation, psychosocial stability, current drug use, expectations, source of support, concerns and release plans.

a. Cease treatment as part of a successful completion of the programThese clients will have been on a treatment plan with the aim of reducing their ORT medication dose slowly and then finally ceasing treatment altogether once they are down to a minimal dose.

Successful completion of withdrawal from methadone maintenance program is more likely undertaken over a longer period of time. The likelihood of premature withdrawal from ORT is reduced by ensuring clients are well informed about the maintenance program.

The client should be followed up clinically within 7 days of ceasing treatment. It is important that the client is then reviewed by the D&A nurse to discuss risks of overdose and to consider what other supports can be offered to the client once they come off treatment. This discussion is to be documented in the client’s clinical record.

Clients are to be referred to ACT Health ADS Counselling and treatment to be provided with further support including: information, harm minimisation intervention, counselling and psychologically based treatment for drug dependency.

b. Failure to attend dosingClients who miss one dose of methadone / suboxone can be provided with their normal dose the following day. Where a client misses two consecutive doses the medical officer must be contacted so the client can be clinically reviewed before treatment can resume. It is important to interview the client to ask whether they have used any other substance since their last doe of ORT medication.

Clients that have missed dosing for three days will be removed from the ORT program and will be offered a follow up with the D&A nurse.



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The client should be followed up clinically within 7 days of ceasing treatment. It is important that the client is then reviewed by the D&A nurse to discuss risks of overdose and to consider what other supports can be offered to the client once they come off treatment. This discussion is to be documented in the client’s clinical record.

Clients are to be referred to ACT Health ADS Counselling and treatment for further support including information, and counselling.

c. Cease treatment against clinical adviceCeasing treatment reasons should be explored with the client in an appropriate and sensitive manner. This process should occur outside of the dosing round and the reasons for their request to come off ORT must be documented in the client’s health record.

Side effects of treatment may be a reason that the client wishes to cease treatment. Many side effects e.g. constipation, can be managed effectively. If these concerns are addressed with the client effectively, they in fact may decide to remain on treatment.

In the event of a client requesting to cease ORT ensure to ask the following: Reasoning behind request – are they experiencing side effects e.g. constipation,

weight gain; What’s different now? What skills have been acquired to stay drug free? Sentence/bail option for a residential rehabilitation program? Is he/she receiving D&A counselling? Examine other treatment options.

Despite being informed of the risks relating to ceasing ORT, clients may still choose to cease treatment. This discussion should be documented in the client’s progress notes.

The client should be followed up clinically by the D&A nurse within 7 days of ceasing treatment. It is important that the client is then reviewed by the D&A nurse to discuss risks of overdose and to consider what other supports can be offered to the client once they come off treatment. This discussion is to be documents in the client’s clinical record.

Where clients have chosen to abruptly stop participating in the ORT program against clinical advice and there are no underlying mental health concerns, the client needs to be made aware that if they wish to return to treatment, that is unlikely that they will get back on for some time due to capacity issues of the program.

Management of Diversion of ORTEquipment ORT Treatment Agreement; ORT Prescription and Treatment sheet; ORT Diversion Incident form; Riskman; Clients clinical record.Doc Number Version Issued Review Date Area Responsible PageCHHS17/158 1 20/07/2017 01/05/2019 MHJHADS - JHS 10 of 35


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Procedure The reasons behind diversion may not be known. Diversion is the act of supplying a controlled or regulated medication to someone other than whom it was prescribed to, and supplying to illicit drug markets. This includes the selling, trading, sharing or giving away of prescription medications to a third party and the storing or saving of doses of any drugs for any purpose. Diversion may be voluntary or involuntary.

The nurse should be certain that when they are reporting incidents of diversion or suspected diversion, that it was the client’s intention to divert, and not for example as can occur with suboxone, a few particle of the medication floating around the mouth. In addition, the client may not be compliant with the dosing procedure e.g. throwing part or all of the ORT medication on the ground, which does not constitute diversion / attempted diversion.

JHS consider reduction or withdrawal from ORT as a clinical decision made for the safety of the client and not a punitive decision.

1. All incidents of diversion of ORT medication either suspected or substantiated must be logged on Riskman as an adverse event and documented in the client’s clinical record with reference to the Riskman number and description of the incident.

2.3. The JHS Clinical Nurse Consultant (CNC) or Assistant Director of Nursing (ADON) is to

discuss the JHS ORT Treatment Agreement with the client to ensure that the client is clear about what behaviour is expected during dosing and is acceptable when on the ORT program.

Where a staff member suspects or has confirmation of a client diverting or attempting to divert their dose of methadone / suboxone, the dosing nurse should refer the matter to the D&A nurse/CNC/ADON who will interview the client in a private setting as part of a formal case review. Reasons for the client diverting should be explored with the client as it may be that the client is being “stood over” by another client and may feel they have no other option, but to divert their dose. Documentation should be made in the client’s clinical record.

In situations where the client states that they are being “stood over”, the ADON is responsible for investigating the incident with the D&A nurse. ACTCS may need to be consulted as part of the process of developing a new treatment plan for the client. Ideally, where this is the case with suboxone, transfer to methadone treatment should be considered as a strategy. Other strategies include reviewing the way dosing is arranged – e.g. calling clients in a different order, holding some clients back for further observations etc.

However this should be discussed with the client and the management plan should be put in place. The client must be informed of the consequences of diverting particularly by



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where it may result in involuntary withdrawal for treatment, regardless of the reason provided by the client.

Where diversion is suspected for a second time, the client must be triaged as a priority with a medical officer for further treatment discussion.

4. Consultation with the Clinical Director, regarding the ongoing management of the client, must occur where: There is conflict between staff on the ongoing management of a client suspected of

diverting / non-compliance; More abrupt or rapid termination of treatment is being considered to prevent or

manage violence; Extended time frames for involuntary withdrawal regimens are being considered by

the prescribing medical officer; A client is placed on an involuntary withdrawal and continues to divert their dose or

threaten staff whilst on the withdrawal regimen; The client is due for release from the secure setting within the next four weeks.

5. Clients who are placed on involuntary withdrawal are to be informed that their opioid tolerance may be reduced, and are to be reminded of the risks of overdose associated with resuming opioid drug use. This discussion must be documented in the client’s clinical record. Symptom management for withdrawal should be provided to clients where clinically indicated. Clients being withdrawn from buprenorphine / suboxone should be offered methadone maintenance.

An involuntary withdrawal from ORT does not prohibit a client from accessing treatment again in the future.

At the beginning of treatment clients sign the ORT Treatment Agreement which specifies the conditions under which they may be involuntarily discharged or have the provision of their treatment reviewed. Situations that may warrant this action include: Diversion of doses; Violence or threat of violence against health centre staff or other patients during

dosing; Methadone / suboxone theft or attempted theft from health centre premises; Property damage to health centre or dosing location; Poor compliance with treatment.

6. Dosing regimens for involuntary withdrawal from methadone:The reduction regimen for methadone will be completed within four weeks. Consultation with the Clinical Director regarding the ongoing management of the client, must occur where extended timeframes for involuntary withdrawal regimens are being considered by the medical officer.



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A referral to ACT Health ADS counselling and Treatment should be initiated by the JHS team to ensure additional support is offered to the client at this point in time. The clinical record should reflect that this referral has occurred.

Dosing regimens for involuntary withdrawal from suboxone:All clients taken off suboxone must be offered the option of transferring to methadone in the first instance. If the client does not wish to go onto this treatment modality this must be recorded in their current health record.

The reduction regimen for suboxone should be complete within two weeks. The rate of reduction as recommended by the National Guidelines for Medication-Assisted Treatment of Opioid Dependence (Gowling et al., 2014) should be 4-8mg reductions every three to four days. Clients that pose a considerable risk to the safety of other clients and staff may result in their treatment being terminated without gradual reduction.

If the client is found to divert their medication while on the reduction regimen, treatment should cease immediately. Consultation with the Clinical Director regarding the ongoing management of the client, must occur where extended timeframes for involuntary withdrawal regimens are being considered by the JHS medical officer, or where there is any conflict within the team about the revised treatment plan.

A referral to ACT Health ADS Counselling and Treatment should be initiated by the JHS team to ensure additional support is provided to the client. This process must be documented in client’s clinical records.


Section 3 – Dosing

Dosing ProceduresORT Dosing RegimensAll ORT prescriptions must meet the ACT Health standards by including: Name and Date of Birth; Methadone/suboxone dose in milligrams written in both numbers and words; Signature and legibly printed name of prescribing medical officer; Prescription expiry date; Name of prescriber; Increase and decrease dose instructions.

Dosing is in accordance with National Guidelines for Medication Assisted Treatment of Opioid Dependence (Gowing et al., 2014). Clients new to treatment should be reviewed within three days of the initial dose, weekly for two weeks and then monthly or as required thereafter.

METHADONE



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Methadone is the front line treatment option for the majority of opioid drug dependent clients needing opioid replacement treatment in JHS.

Induction onto methadone treatment:The National Guidelines for Medication Assisted Treatment of Opioid Dependence (Gowing et al., 2014) suggests low doses (20mg or less per day) are suitable for those with low or uncertain levels of opioid dependence.

Methadone in the ACT is dispensed at 5mg/1ml. Clients will commence on a methadone dose of no higher than 20mg daily. There may be situations where the medical officer deems it clinically indicated to commence the client on a starting dose of 10-15mg daily. For clients with uncertain or low opiate tolerance commencement on a methadone >20mg daily requires consultation with the Clinical Director. This discussion is to be documented in the client’s clinical record.

The methadone dose cannot be increased for the first 7 days of treatment, as the client will experience increasing effects from the methadone each day. Occasionally, there may be a clinical indication e.g. pregnancy, to increase the dose more rapidly, but these clients require close monitoring. This type of increase can only be commenced after consultation with the Clinical Director. This discussion is to be documented in the client’s clinical record.

Methadone Split DosingSplit dosing may be considered for clients who rapidly metabolise methadone (e.g. in the case of acute pain or during pregnancy). Prior to authorising split dosing, the medical officer should consult with the Clinical Director to confirm the need for split dosing.

Methadone for Chronic PainFor chronic pain, the long-term use (greater than 4 weeks) of opiates is associated with reduced benefits because of the development of tolerance to the analgesic properties. For non-cancer chronic pain there is little evidence for benefit of long term use, more than 3-4 months (Medicinewise, 2015).

BUPRENORPHINEAll clients entering a secure setting on buprenorphine will be commenced on a suboxone withdrawal regime or transferred to methadone treatment. The exception to this is pregnant women.

SUBOXONEClients on suboxone in the community, prior to induction to secure setting, will be offered withdrawal management on admission, or maintained on their community dose for a period not exceeding 14 days, if a confirmed court date is within the 14 day period. Thereafter the withdrawal regime, or transfer to methadone will be implemented.



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Only community clients with a documented allergy to methadone will have their suboxone prescription continued whist in the secure setting.

Clients in a secure setting should be placed on a daily dosing regimen as routine practice. Some individuals may request to go on alternate day dosing regimens because they may have been on those prior to entering the secure setting. Due to the huge problems associated with diversion of suboxone within a secure setting, this is not normally an option. This type of regimen can only be commenced after consultation with the Clinical Director.

Induction onto suboxone:The initial dose of suboxone should be administered at least 6 hours after the last heroin use, or at least 24 hours after the last methadone dose (e.g. last dose of methadone – early morning; first dose of suboxone – late next day). This is to decrease the likelihood of the client going into precipitated withdrawal.

The client must be clinically assessed as being in withdrawal prior to administering the first dose of suboxone. Clinical decisions to dose the client in absence of signs of withdrawal will require the prescribing medical officer to discuss the clinical indications with the Clinical Director.

Suboxone withdrawal regimen:Clients that decline commencement of methadone but would like to have medication supported withdrawal may be commenced on a six day suboxone withdrawal regime.

The medical officer will interview the client and prescribe the following suboxone withdrawal regime; 4-6mg, 8mg, 8mg, 6mg, 4mg, 2mg over a six day period.

The initial dose of suboxone should be administered at least 6 hours after the last heroin use, or 24 hours after the last methadone dose (e.g. last dose of methadone – early morning; first dose of suboxone – late next day).

Pre-release suboxone: Due to increased clinical risk and safety when clients decrease their methadone dose to transition from methadone to suboxone, JHS does not commence pre-release suboxone.

Transfer onto suboxone can occur post release/discharge if the client is committed to the ORT program. The client will attend an appointment with a medical officer at Building 7, to be assessed for suitability.

Clients not on ORT will not be commenced on suboxone for the purpose of release.

Educational NotesThe National Guidelines for Medication Assisted Treatment of Opioid Dependence (Gowling et al., 2014) advise daily methadone doses of 60mg or more are associated with better



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treatment outcomes in terms of reducing illicit opioid use, criminal activity and HIV risk taking behaviour and improving retention in treatment.

When methadone treatment is initiated, the dose may be gradually increased until the client is beginning to feel comfortable and the craving for use of opioids has stabilised. The client should be reviewed regularly in the first and second weeks of commencing treatment.

Clients may increase their methadone dose by a maximum of 5-10mg after a minimum of 1 week on a dose. The client must have dosed consecutively for seven days prior to requesting to increase their methadone dose. Education should be provided to the client on the management of side effects caused by this medication which include symptoms such as nausea, constipation, sweating and dry mouth.

Clients wishing to decrease their methadone dose can do so every two weeks. This will allow time to make sure that they are comfortable, sleeping adequately and not using opioids at each reduction in dose. Clients who have decreased their dose and find that they are not feeling stable on the lower dose can be returned to the previous dose following a discussion with the medical officer. Clients with coexisting mental health or pain issues should also be monitored for any deterioration in their condition.

Suboxone is a pharmaceutical combination product, designed to reduce diversion of buprenorphine by the inclusion of naloxone. Clinical experience indicates that it reduces but does not eliminate problems of diversion and self injection associated with buprenorphine.

Care should be taken not to administer a dose to clients intoxicated on opioids. If this occurs the client will likely experience withdrawal as the suboxone will displace the heroin and other opioids from the opioid receptors. This Suboxone precipitated withdrawal usually begins 1-4 hours after the first suboxone dose and is generally mild to moderate severity and lasts up to 12 hours. If this happens the client may require symptomatic withdrawal medication, and should be reviewed by the medical officer. Subsequent does of suboxone (taken the following day) should result in minimal withdrawal if the client has not been using heroin in the intervening period.

Clients New to ORTEquipment ORT prescription and treatment sheet – obtained from ACTCS health officer; Clients Current medication chart; Application for approval to prescribe controlled medicines form – completed; ORT Treatment Agreement form – completed; Clients Rights and Responsibilities form – completed; JHS ORT Monitoring form (available on the forms register); “New to treatment” stickers.

Procedure 1. Clients may be dosed for a period of no longer than three business days while awaiting

authority approval from Health Services Unit (HSU).Doc Number Version Issued Review Date Area Responsible PageCHHS17/158 1 20/07/2017 01/05/2019 MHJHADS - JHS 16 of 35


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Please refer to the Clients on ORT who are transferred to JHS section for further information on ORT prior to entering a secure setting.

2. Clients must have read and signed the ORT Treatment Agreement and Rights and Responsibility form thus agreeing to abide by the rules of the ORTP. The forms must be adequately explained to the client. Clients must be advised refusal to sign the agreement warrants the person not being commenced on the ORTP. The signed ORT treatment Agreement form should be kept with the client’s prescription and treatment sheet.

The prescription and treatment sheet should have the pink “new to treatment” sticker. The stickers are to be placed on the ORT prescription and treatment sheet whenever a client is new to ORT. This may be the first occasion the client has been on ORT or it may be some time since they were last on ORT. The sticker only needs to be placed on the first prescription and treatment sheet and thereafter it is no longer required. This will have the added advantage of also highlighting to staff the client may require greater support or review because they are new to the program.

An entry in the client’s current medical record should occur to reflect the interaction with the client. Any issues raised by the client in relation to their ORT medication should be referred by the nurse administering the dose to the D&A nurse.

3. Clients new to ORT will be assessed for intoxication (using the ORT Monitoring form) prior to dose administration by the dosing nurses for the first 10 days of treatment. Clients will also be assessed 3-4 hours post dose for the first 5 days of induction.

It is the responsibility of both dosing nurses to assess if the client is intoxicated.

If the client is assessed as having any signs of intoxication the dosing nurses are to withhold the clients dose and further discuss with the medical officer. This is to be communicated to the client.

Clients on ORT who are Transferred to JHSEquipment Consent to Share and / or Release Information form – completed; Last dose request form; ORT prescription and treatment sheet – obtained from ACTCS health officer; Clients Current medication chart; Application for approval to prescribe controlled medicines form – completed; ORT Treatment Agreement form – completed; Clients Rights and Responsibilities form – completed.

Procedure 1. All clients stating that they are on methadone or suboxone treatment when they are

received into a secure setting must still be assessed for continuation of ORT whist in the secure setting. The clients current details must be confirmed with the appropriate



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external health service before the first dose of treatment in a secure setting can be administered.

All clients (except pregnant women) entering a secure setting on buprenorphine will be transferred to Suboxone. This does not require a new PSU authorisation.

Clients on suboxone in the community, prior to induction into the secure setting, will be offered withdrawal management on admission, or maintained on their community dose for a period not exceeding 14 days, if a confirmed court date is before the 14 day period.

If there is no confirmed court date or the confirmed court date is greater than 14 days, the suboxone withdrawal regimen, or transfer to methadone will be implemented.

Clients prescribed suboxone in the community will only have their prescription continued in the secure setting if they have a documented allergy to methadone and this has been approved by the medical officer.

2. For clients already on an ORT program at the Wruwallin clinic (ADS, Building 7, CH&HS), the admitting nurse must contact Wruwallin and request to be provided with a copy of the clients ORT dosing history and current script. This will assist with the clients treatment whilst in a secure setting:

For clients already on an ORT program at a community chemist, the admitting nurse will complete the following forms in order for the clients treatment to continue whilst in the secure setting: Consent to Share / Release Information form (available on the forms register)

Include the name and contact details of the external health service from which you are requesting the medical information. Contact the relevant service provider by telephone during office / health centre hours and by fax at other time and provide them with a copy of the completed consent form. Written confirmation of current treatment details from the service provider must be received and reviewed by a registered nurse before the first dose of ORT medication can be administered to the client in a secure setting.

Last dose details request form (available on the forms register)Complete the form and fax along with the Consent to share and/or release information form to the relevant community chemist

3. If a medical officer is not available to prescribe the ORT in person, a RN and a deemed suitable second nurse may take a phone order for ORT, as per the ACT Health Medication Handling Policy. A medical officer must sign the order within 24 hours of receiving. ORT can be administered from this order for a maximum of one week. The phone order is to be documented on the ORT prescription and treatment sheet, and entry must be made in the client’s clinical record to reflect the phone order that has been received.



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4. Clients must read and sign the ORT Treatment Agreement and the Client Rights and responsibilities form thus agreeing to abide by the rules of the ORT program. The forms must be adequately explained to the client. Clients must be advised refusal to sign the agreement warrants the person not being commenced on the ORTP. The prescriber should be consulted. The signed ORT treatment Agreement form should be kept with the client’s prescription and treatment sheet.

5. An entry in the client’s current medical record should occur to reflect the interaction with the client.

6. Clients entering a secure setting who have not been dosed for three consecutive days must be reviewed by a medical officer.

ORT Dosing ProceduresEquipment ACTCS ORT Prescription and Treatment Sheet – completed; JHS ORT Treatment Agreement form; Application for approval to prescribe controlled medicines form – completed; Prisoner ID card; Water; Methadone; Dosing cups.

Procedure Where possible JHS will aim to provide consistency in the dosing times or ORT.

1. As a general policy it is important that the number of distractions to medication administration is reduced as much as possible. This includes not answering phones, or other staff holding conversations in the dosing room etc. Where there is a level of distraction during dosing, staff may not be fully concentrating on the task of medication administration and this may result in a medication error. Supervised medications may be administered during ORT administration.

It is important that all staff realise that if a medical emergency occurs whilst medication round is occurring; the priority is to manage the medical emergency. All medication administration is to cease, and S8 medications are to be secured appropriately, as per the ACT Health Medication Handling Procedure. Once the client is stabilised, medication administration may recommence.

2. Two ACTCS officers must be present to supervise clients when dosing to monitor for diversion of ORT.

3. As per General Managers Instruction 89 AMC 092014; Dispensing Biodone; 28 August 2014, ACTCS officers will take the following actions when observing the administration of methadone: Detainee frisk search; Detainee drinks the water provided by health staff;



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Detainees remains in the designated area until the staff person is satisfied that the detainee has taken the Biodone. The staff member will:o Complete a check of the inside of the detainees mouth;o Speak with the detainee so that detainee will communicate in a manner that

satisfies the officer there is nothing in the mouth.

If, in the opinion of health staff, ACT Corrective Services officers are not carrying out their designated duties as per GM INSTRUCTIONS RE: DISPENSING BIODONE, this must be raised immediately with the JHS CNC or ADON for resolution. The GM INSTRUCTION should be available for all staff in the clinic area. Every effort should be made to solve the problem at a local level. If a problem persists, the CNC or ADON should seek assistance from the ACTCS DGM.

In the absence of the JHS CNC or ADON (afterhours) the incident must be raised with the delegated nurse in charge to discuss resolution with ACTCS senior management.

4. There must only be one client at the dispensary window at a time. The client must be easily visible and face the nursing staff during the entire dosing procedure. A correctional officer can assist with this by being near the client during dosing.

5. ORT medications are to be administered by a nurse and the administration of the dose is to be witnessed by a second staff member. This person may be another registered nurse or anyone who is deemed “responsible” as per the Medication Handling Policy.

6. All clients presenting for dosing are to have their identification checked and confirmed before dosing. The administering staff must sight this card and an assessment of a true likeliness is to be made before the dose is administered. The dosing nurses will check that the ID card actually belongs to the client presenting at the window.

The dosing staff must be able to clearly see the client’s face and eyes. The client is to be asked to remove any headwear, sunglasses or anything else that might prevent the dosing staff from seeing them clearly.

Clients that present for ORT administration without their card are to have the administration of their ORT delayed until the client has a temporary ID card issued to them. Clients may present with their “muster card”, this is also an acceptable form of identification, for the purposes of medication administration.

Clients that are housed in the Management Unit and Crisis Support Unit are not issued with ID cards. For clients in these accommodation units, staffs are to utilise the ACTCS “muster cards” to identify the client. Staff will take the muster book to the dispensary window to identify the client to assist with identification of the client.

Clients that are attending courts and are housed in the Management Unit or Crisis Support Unit will not have an ID card to present to nurses in the admissions area prior to



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dosing. In this situation, ACTCS officers will print an ID slip verifying the client name, DOB and PID number. The officer will sign this slip. The slip will be filed in the client’s medical record and the dosing nurses will document identification process in the client clinical record.

7. Clients are to be assessed for any signs of intoxication prior to receiving their dose. It is important to engage the client in conversation to determine coherence in speech and to review pupil size. If the client is wearing sunglasses ask them to remove them. Where there are any signs of intoxication the client is not to be dosed. If dispensing staff have any doubts as to whether the client is intoxicated, always err on the side of caution and do not dose.

8. Explain to the client the reason why they will not be dosed at this time, document in the client’s medical file and defer dosing until assessed by the on-call Medical Officer;

9. Clients must not consume food or drink during dosing. If the client has a drink or food with them, ask that it be placed to one side throughout the dosing process.

10. For clients that have just been commenced on ORT, dispensing nurses are to assess clients, using the ORT monitoring form for the first 10 days of treatment.

11. Current Methadone / Suboxone dose for the identified client is be ascertained from the ORT prescription and treatment sheet. Administering staff must verbalise clearly and loudly the following: The client’s name; The dose in millilitres (ml); and The dose in milligrams (mg); and The date on the bottle; if applicable Prescription expiry date.

12. This information is confirmed by the second authorised staff member against the prescription, including checking the prescription parameters, previous days dose and currency of the authority.

13. It is the responsibility of both dosing nurses to ensure that the dose administered has been swallowed (in the case of methadone) or absorbed fully sublingually (in the case of Suboxone).

If the supervising staff are not satisfied that the dose has been taken correctly, tell the client at the time and inform the on-call Medical Officer and JHS CNC or ADON and document in the client’s medical file. In every instance of suspected diversion, a Riskman report must be completed by the nursing staff member within 24 hours.

14. Both dosing staff have equal responsibility to ensure that these procedures are adhered to at all times.

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Clients prescribed methadone must receive their dose prior to 2pm in the afternoon each day. This is to ensure there is health professionals onsite when the methadone is at its peak efficiency (3-4 hours post dose).

Methadone is to be dispensed into transparent dosing cups provided. A full cup of water is to be added to the dose. Used cups are to be placed into a designated waste bin.

Observe the client drinking the methadone. Ensure the client is facing forward and do not allow them to turn sideways or move out of sight. Talk to the client immediately after they ingest their methadone.

Methadone must be mixed with water to minimise the diversion of methadone concentrate. A full dispensing cup full of water must be taken after a dose is given to ensure that Methadone has been swallowed. The drinking of water after a dose of methadone also prevents tooth decay and minimises constipation. It is the responsibility of the dosing nurse to watch the client as they drink the methadone.

The cup is disposed of in a waste bin; the empty methadone bottle is discarded at the Hume Health Centre (HHC) in yellow bins (contaminated waste).

16. For Suboxone FilmClients on suboxone will be dosed at the HHC after 2pm to ensure there is operational capacity for nurses to administer the medication. This decision may be changed at the discretion of JHS senior management.

Suboxone film is a formulation of buprenorphine and naloxone that is a licensed for the treatment of opioid dependence, with the same active ingredients and does as the sublingual tablets (buprenorphine and naloxone in 2/0.5mg and 8/2mg preparations). The films have a lime flavour and are orange in colour with the strength printed in white (N2 or N8). Each film is individually packaged in child resistant sachets.



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16.1 Administration of Film:Collect and check the total dose of unopened sachets against the prescription. Suboxone film should not be cut by the dosing nurse. (E.g. half a 2.0/0.5mg film in order to achieve a 1mg dose). Dosing staff should clarify such prescriptions with the prescriber.

Fold the sachet along the dotted line and tear down the slit as indicated on the packaging.

Client is to be provided with a full cup of water and advised that they must drink the entire cup.

Present two films at a time to the client in a transparent plastic medication cup rather that one by one, as this increase the risk of dosing errors and interferes with supervision. The nurse must avoiding handling the film with bare fingers and uses tweezers to remove the film from the packaging, or have the client remove the film from the sachet. If it is necessary for the nurse to touch the film with their fingers, then a disposable glove should be used.

If the film is accidently dropped, or becomes wet before being given to the client it is to be destroyed and a new dose dispensed. Follow the requirements under the ACT Health Medication Handling Policy.

Instruct the client to make sure their hands are clean and completely dry before handling the film.

The client should hold the film between two fingers by the outside edge of the film and should place each film individually sublingually close to the base of the tongue on either side. Films should not overlap.

Clients that are prescribed doses that require more than 2 films must only be provided with a maximum of 2 at a time.

Some clients may report accidently placing the film against their teeth or tongue. Experience to date indicates this has little impact upon the clinical effects of the film.

Adherence of the film occurs within seconds, and then the film is difficult to dislodge or remove after 30-60 seconds, but not impossible. Adherence to the mucosa can be delayed if films are overlapping, and longer supervision time may be required. The film takes approximately 2 to 5 minutes to dissolve and be absorbed.

Once film has been applied, the client should avoid chewing, swallowing, talking or moving film until the film has dissolved. The dose does not need to be replaced



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if the client vomits after this time. Refer to Section 6 – Complaints of nausea or vomiting.

Nurses will look inside the clients mouth every 30 seconds to check for absorption and decrease the likelihood of diversion of the dose.

The client should remain under supervision until the film has dissolved and is to be instructed to drink a cup of water after the film has fully dissolved.

Under normal circumstances no significant active drug will remain on the inside of the packaging, and empty sachets should be disposed of discreetly in normal rubbish containers.

Suspicion of Intoxication in clients on maintenance ORTPProcedure 1. All clients are to be assessed for any signs of intoxication, prior to receiving every dose of

Methadone / Buprenorphine / Suboxone. It is important to engage the client in conversation to determine coherence in speech and to review their pupil size. If the client is wearing sunglasses, ask them to remove them.

If dispensing staff have any doubt as to whether a client is intoxicated, do not dose and seek further advice from the medical officer. REMEMBER – withholding a dose will not have fatal consequences - methadone / suboxone in combination with other drugs may.

Clients who are thought to be intoxicated need to be carefully assessed. The following factors need to be considered as they can impact on the presentation of the client: Mild to moderate drug/alcohol related brain injury; Organic illness e.g. head injury; Intellectual impairment; Speech impediment; Non-communicative clients. Continuity of dispensing staff is therefore desirable –

change in affect and demeanour is more obvious if a client is known to nursing staff.

In some instances clients may present with increasing levels of sedation and deny any other drug use... Consideration should be given that they client suffering from inter-current medical conditions (e.g. liver disease or is post partum), which may affect the metabolism of the opioid prescribed.

2. If in doubt, request that the client returns to the holding area until dosing of all clients is completed so that a full assessment can be made. Do not create a potentially aggressive situation by announcing to the client that they are intoxicated. Advise them that you will need to speak with them/assess them before they are dosed. Contact the medical officer for advice as required.

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4. The client is to be clinically reviewed by the drug and alcohol nurse within 7 days of the suspected intoxication incident.

Complaints of Nausea/VomitingProcedure 1. If a client informs JHS staff that they have vomited immediately, (immediately = within

20 minutes), after receiving their methadone dose but it has not been witnessed by JHS or ACTCS staff, then no additional dose can be authorised.

If a patient has vomited immediately, (immediately = within 20 minutes), after being dose methadone and it has been witnessed by JHS or ACTCS staff, then a supplementary dose may be authorised by the medical officer. Note the time, amount and colour of the vomit. The incident must be documented in the client’s medical record. Anti-emetics may need to be prescribed for the client (to be taken 30-60 minutes prior dosing), after review of their circumstances.

If a client vomits later than 20 minutes after consumption of their methadone dose, no action beyond reassuring the client that their dose will have been adequately absorbed, is required. Investigation and management of gastrointestinal problems for the client should occur as indicated.

Buprenorphine / Suboxone is absorbed sublingually within 2-7 minutes. Vomiting after this time makes no difference to the absorbed dose.

For pregnant clients on methadone who experience nausea and vomiting after receiving their daily dose, every effort should be made to ensure that they are reviewed and discussed either in person or via phone consult with the medical officer to ensure that no signs of withdrawal are occurring. Consideration should be given to supplementation of the dose because withdrawal symptoms can produce foetal distress. The incident must be documented in the client’s medical record. Consideration should be given to splitting the clients dose and / or providing and anti-emetic (prior to dosing) in future, if regular vomiting occurs.

Education NotesNausea and vomiting are not uncommon occurrence for clients when they commence on methadone treatment. This usually subsides after a couple of weeks. In some instances clients may find the nausea is less severe if they line their stomach with something to eat or drink before attending for dosing.

Where a client has recurrent nausea associated with methadone dosing, the client should be medically reviewed to determine the appropriate action and to consider any underlying medical causes. Clients with recurrent vomiting should be dosed in the health centre and held for thirty minutes after dosing, until the problem has been resolved.

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The presentation of nausea and vomiting in women of child bearing age, who are on methadone, is often the first symptom of pregnancy. This should be ruled out in this target group as a potential cause.

It is recommended that split dosing of ORT medication be available as a clinical option for all pregnant women who experience withdrawal symptoms as pregnancy advances. Vomiting is a serious concern in pregnancy women on methadone treatment. Vomiting of a methadone dose may lead to withdrawal in both mother and foetus. Withdrawal symptoms may cause foetal distress, and in severe cases may case premature labour, or earlier in pregnancy, miscarriage. Where vomiting persists, consultation with the medical officer should occur as a priority.

The following points are recommended for managing problems with vomiting during pregnancy: Women should be discouraged from ingesting ORT medication on an empty stomach; Women should be encouraged to sip their methadone dose slowly; If the dose of methadone appears to consistently cause vomiting, consider splitting the

doe or giving anti-emetics 30-60 minutes prior to dosing; If a woman vomits constantly and not necessarily in relation to her ORT medication, she

should be assessed and treated accordingly to obstetric protocols for hyperemesis gravidarum;

Look for other causes of vomiting (e.g. urinary tract infection).

Administration of incorrect dose of medicationProcedure The first two weeks of methadone treatment is a high risk period of overdose (Cornish, et al, 2010 & Degehet, Randall, 2009). Deaths in the first two weeks have been associated with doses in the range of 25-100mg/day with most occurring at doses of 40-60mg/day (R. Humenik et al., 2000). Typically overdose occurs around the third or fourth day of methadone induction. The National Guidelines for Medication Assisted Treatment of Opioid Dependence (Gowling et al., 2014) provide the following procedures for incorrect dosing or overdose:

1. Methadone overdoseClients in the first two weeks of induction who are accidently given a higher than prescribed dose, requires observation by JHS staff for at least four hours. If signs of intoxication continue, extended observations are required. This may involve sending the client to the Canberra Hospital for ongoing observation.

Intoxication observations should be attended hourly for four hours using the ORT Monitoring form. Any areas of concern should be reported to the medical officer immediately.

The following procedure should be followed in all cases of dosing error: Advise the client of the error and explain possible consequences; Nurses must alert the medical officer of the error immediately;



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The medical officer will advise if the client requires hospitalisation. If so, the reasons for hospitalisation must be explained to the client;

Please follow the “JHS Unplanned Hospital Transfers Procedure”.

In addition to the above the senior nurse on shift must also: Notify the JHS management team of the error:

o ADON – Primary Health or DMHU (depending on location of error);o MHJHADS On-call Director (Afterhours only).

Complete a Riskman. Complete a Health Notification form advising ACTCS officers of symptoms to observe

for, including but not limited to:o Drowsiness;o Difficulty to rouse;o Shallowing breathing;

Place the client on medical observations as advised by the medical officer. Document the error in the clients clinical record.

Caution regarding inducing vomiting: Inducing vomiting may be dangerous and is contraindicated if the client has any signs

of CNS depression; Vomiting after the first ten minutes post dose is not satisfactory for dealing with

overdose as it is impossible to determine how much of the dose has been eliminated; Induction of vomiting by stimulation of the pharynx within 5-10 minutes of dosing

may be appropriate as a first aid measure only. Ipecac syrup is contraindicated as its action may be delayed.

2. Suboxone OverdosePrecipitated withdrawal typically begins one to four hours after the first dose, is generally mild to moderate in severity and last for up to 12 hours.

Suboxone overdose is relatively uncommon, there is a greater risk with other sedative drugs, such as alcohol, benzodiazepines, barbiturates, tricyclic antidepressants and major tranquilisers (Gowling et al., 2014). Risks associated with an incorrect suboxone dose are not as severe as with methadone. If an incorrect dose is administered: Advise the client of the error and explain possible consequences; Nurses must alert the medical officer of the error immediately The client should be warned of likely consequences (increased sedation or

drowsiness may occur for several hours after dosing) and warned against any additional drug use;

If any of the following apply the client should be monitored for at least 6 hours by trained professionals:1. The client is sedated for any reason following the dose;2. The client is in the first two weeks of induction;3. A dose of 64mg or higher was taken.



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The client should be reviewed by a medical officer prior to the next dose of suboxone as a lower dose or no dose may be required.

In addition to the above the senior nurse on shift must also: Notify the JHS management team of the error:

o ADON – Primary Health or DMHU (depending on location of error);o MHJHADS On-call Director (Afterhours only).

Complete a Riskman. Complete a Health Notification form advising ACTCS officers of symptoms to observe

for, including but not limited to:o Drowsiness;o Difficulty to rouse;o Shallowing breathing;

Place the client on medical observations as advised by the medical officer; Document the error in the client’s clinical record;

ORT Arrangements When Clients are in HospitalEquipment Current ORT prescription and treatment sheet Current medication chart

Procedure On some occasions clients may require transfer to hospital. JHS staffs have a responsibility to ensure appropriate transfer of care occurs in these situations.

This means that:1 It is the responsibility of the hospital to provide all medications required for the clients

in their care including methadone and buprenorphine treatment.2 JHS staffs are to provide the hospital facility with all relevant paperwork so that routine

medication administration can occur. The receiving facility will require a copy of the: Current ORT prescription and treatment sheet; Current medication chart.

An entry in to the client current medical record should be made regarding the interaction between JHS and the receiving facility and the arrangements for transfer of care.

3 Clients can only be dosed by JHS staff once the client has been transferred back to the secure setting and confirmation has been received regarding the last dose details, and that is appropriate to do so,. This must be documented in the client’s medical record.

The ORT prescription and treatment sheet should be marked with an arrow from the day the client was dosed in hospital to the day the client is to be dosed in the secure setting. It should be documented next to the arrow “in hospital”.



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Dosing AdjustmentsEquipment ORT Prescription and Treatment sheet.

Procedure Methadone dose should be individualised, although there is evidence indicating that methadone doses of less than 40mg per day are significantly less effective at reducing opioid use and related behaviours that higher doses (and doses of >60mg per day are more effective still).

The dose should be gradually increased in order to achieve cessation in unsanctioned opioid uses, alleviation of cravings, opioid withdrawal features, whilst minimising methadone side effects.

Clients will frequently request dose changes when on an ORT program. The requests will fall into one of the following categories: Dose change requests (No change in treatment plan); Dose change requests (Review of current Treatment plan required); Dose increase requests above 100mg.

1 Dose change requests (No change to treatment plan)A client can requesting to alter their current Methadone / Suboxone dose as long as it is consistent with their current prescription.

Clients can request to increase their methadone dose once a week. Generally clients can increase their dose by 5-10mg/1-2ml. Clients must have dosed for seven days consecutively prior to requesting to increase their dose. Increases in doses cannot occur if this has not happened.

Clients can request to decrease their methadone dose fortnightly. Generally clients can decrease their dose by 2.5-5mg. If a client chooses to decrease their dose by 2.5mg one week, they are unable to decrease their dose again for a further two weeks.

Methadone dose increases may need to be delayed, or reduced or methadone doses withheld completely accordingly to the client’s response to methadone (e.g. side effects) or continued drug use and intoxication. These decisions will be guided by clinical evidence.

2 Dose change requests (Review of current Treatment Plan required)Any client requesting an alteration to their current Methadone / Suboxone dose that is not consistent with the current treatment order and treatment plan must be reviewed by the medical officer. (This means where a client decides that they need to go back up on their dose when previously they were reducing down or vice versa).

3 Dose increase above 100mg (Maximum dose in ACT is 120mg)Any client requesting a dose increase above 100mg of methadone must have a comprehensive file review, ECG and assessment with a medical officer prior to any dose



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increase. All discussions with the client relating to treatment must be recorded in the client’s clinical record.

Educational NotesIn the ACT the maximum dose of methadone is 120mg. Authorisation from the Chief Health Officer is required to prescribe larger amounts. Clients transferring from interstate on methadone doses higher than 120mg will be titrated to down to the maximum ACT dose. This should be done in consultation with the Clinical Director.

It is important to liaise with other relevant treating clinicians (e.g. mental health) to optimise the ability of the client to sustain stability. Clients with co-morbidities e.g. antipsychotic medications need to be closely monitored when adjusting doses.

Opioid withdrawal in pregnant women places the mother and the unborn child at risk. The ORT dose during pregnancy should be titrated to a level that not only blocks withdrawal symptoms, but also suppresses cravings and illicit opioid (heroin) use. During pregnancy, dose increases may be required due to increased metabolism and increased blood volume, particularly in the third trimester.

Pregnant women may request to reduce and case their ORT whilst pregnant. The reasons for this must be explored and discussed with the client to address concerns and dispel myths. Some women may believe that by ceasing treatment is better for their baby and will prevent Neonatal Abstinence Syndrome. Ceasing this treatment should be strongly discouraged, However, where there is agreement by the medical officer to reduce the clients dose, this should only occur slowly during the second trimester.

Post natal women should be reviewed soon after delivery in relation to their current ORT as their dose may need adjusting.

Transferring to a Different Form of ORTEquipment D&A Brief Nursing Assessment form; Application for approval to prescribe controlled medicines form; ORT Prescription and Treatment sheet.

Procedure 1. Clients will transfer from methadone to suboxone or from suboxone to methadone for a

variety of reasons including: Where a client is experiencing intimidation to divert suboxone they may request

transfer from suboxone to methadone; Involuntary withdrawal from suboxone due to diversion; suboxone is not available as a treatment option upon release in the geographical

area where the client is returning to; Travel distances to dosing points for clients returning to rural/ remote areas.



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Where constant analgesia requirements are needed due to chronic or acute pain; These particular clients pain control may be better managed on a full agonist such as methadone;

Intolerable side effects; Inadequate response with suboxone treatment; Prolonged QTc interval.

2. The client is to be interviewed by the D&A nurse and the D&A Nursing Triage Assessment form is to be completed. The client is to be provided with written information about the new treatment modality. Once this is done the client is to be booked an appointment with the medical officer.

3. If the client is deemed suitable for transfer of treatment modality, the prescribing medical officer must complete a PSU Authority to Prescribe Methadone or Suboxone form and new treatment sheet.Transfers from methadone to suboxone must be discussed with the Clinical Director.

4. Clients should be fully informed about the potential transitional effects, and reminded that any heroin, codeine or other opioid drug use will complicate transition.

5. Clients new to a different medication/formulation should be reviewed the day following commencement of the new treatment, weekly for two weeks and monthly or as required.

Methadone to Suboxone Transfer Transfer from methadone to suboxone is more complicated than transfer from suboxone to methadone due to risk of precipitated withdrawal.

In general, the appropriate methadone dose before transferring from methadone to suboxone is less than 30mgs per day. Clients should have been on this dose for at least one week before commencing on suboxone. Occasionally there may be reasons to proceed with high dose transfer; however the client needs to be fully informed of an increased risk of precipitated withdrawal.

The first dose of suboxone should be given at least 24 hours after the last dose of methadone. The first dose is usually 4mg. Lower doses are generally an inadequate substitute for methadone and higher doses increase the risk of precipitated withdrawal. In situations where access to a client is not a concern, the client can be reviewed 3-4 hours after the first dose. If the client is still reporting withdrawal symptoms, they can be given another 2-4mgs of suboxone. The client should be reviewed again on day 2 and increased depending on clinical assessment.

Suboxone to Methadone TransferMethadone dosing may be commenced 24 hours after the last dose of suboxone with the maximum dose not exceeding 20mg.

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Clients take-away methadone.

Procedure 1. In the community, once a client has been provided with an ORT medication takeaway

dose for a specific day, it is legally assumed that the client has been dosed with that medication for the specified day. The exception to this is where the client has been in custody for a continuous 24 hour period and consequently had no access to their takeaway dose for dosing that day.

When a client has been issued a community take away doses of a schedule 8 medication and ends up in a secure setting on the day that the take away dose was intended to be self administered, then a dose must not be given by JHS staff regardless of whether the client states they have had the dose or not. In situations where someone is medically compromised or pregnant, the medical officer must be contacted for advice. Where this occurs an entry regarding the incident should be made in the client’s clinical record.

2. In the event of a client entering the secure setting with their takeaway doses, these must not be provided to the client as their normal dose by JHs staff. There is a possibility that the dose may have been adulterated. Normal JHS ORT medication stock is to be used for dosing. The takeaway doses received should be separately entered into the returns drugs register. The takeaway doses can be destroyed by the JHs pharmacy. The doses must be checked and accounted for until they are returned to the JHs pharmacy. Takeaway doses are not to be returned to the client on release from the secure setting.

3. Where there is concern about dosing a client who enters custody with takeaway ORT medication, consult with the medical officer.

Education NotesClients who receive regular takeaway doses in the community and who have not been taking them as prescribed may present as intoxicated following regular dosing. The client must be referred to the D&A nurse.


Section 4 – Discharge Planning

All clients on a JHS ORT Program will be discharged from a secure setting with post discharge care arranged in order to ensure a smooth transition back into a community based D&A Service, as a minimum standard.

All clients discharged from a secure setting will be transferred to the Wirullan clinic for continuation of their ORT program. Aboriginal and Torres Strait Indigenes can be transferred to Winnunga.

The D&A nurse and ADS (Wirrulan clinic) or Winnunga should liaise closely in order to manage post-release ORT arrangements for clients on ORT.



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The following areas of activity are the responsibility of JHS staff: A “Client Transfer of Care – Release Summary’ will need to be provided to the accepting

ORT clinic. This letter should provide a summary of all health related concerns and interventions that have occurred during this incarceration period for this particular client as well as a list of medications they will be discharged on;

Clients on ORT should have had a D&A Medical Review form completed; It is the responsibility of the health centre frontline staff to ensure that all the required

post discharge medications have been ordered for the client and are available for the client upon release.


Implementation

This procedure will be implemented through: Education programs via in services; Electronic distribution to all staff; Inclusion in orientation program for all JHS sites; Competency assessment tools.


Related Policies, Procedures, Guidelines and Legislation

Policies Consent and treatment Clinical Record Management Policy Consumer and Carer Participation policy CHHS Patient Identification and Procedure Matching Policy

Procedures Clinical Record Documentation procedure CHHS Patient Identification and Procedure Matching procedure ACT Health Medication Handling Procedure Release or Sharing of Clinical Records or Personal Health Information procedure Venepuncture Blood Specimen Collection procedure (CHHS16/207).

Guidelines National Guidelines for Medication-Assisted Treatment of Opioid Dependence (2014) ACT Opioid Maintenance Treatment Guidelines 2016-2020

Legislation Health Records (Privacy and Access) Act 1997 Human Rights Act 2004 Medical Treatment (Health Directions) Act 2006



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Work Health and Safety Act 2011


References

1. Cornish R, Macleod J, Strang J, Vickerman P, Hickman M (2010). Risk of death during and after opiate substitution treatment in primary care: Prospective observational study in UK General Practice Research Database. BMJ, 341, c5475

2. Gowing L, Ali R, Dunlop A, Farrell M, Lintzeris N. National Guidelines For Medication Assisted Treatment of Opioid Dependence; 2014

3. Degenhardt L, Randall D, Hall W, Law M, Butler T, Burns L (2009) Mortality amounf clients of a state owide opioid pharmacotherapy program over 20 years: risks factors and lives saved. Drug and Alcohol Dependence, 105 (1-2), 9-15

4. Medicinewise News NPS June 2015 Chronic pain. Available at URL: www.nps.org.au/chronicpain


Definition of Terms

ACTCS – ACT Corrective Services ADON – Assistant Director of Nursing ADS – Alcohol and Drug Services BBV – Blood Borne Virus CNC – Clinical Nurse Consultant D&A - Drug and Alcohol ECG – Electro Cardio Gram HHC – Hume Health Centre JHS – Justice Health Services ORT – Opioid Replacement Treatment ORTP – Opioid Replacement Treatment Program HSU – Health Services Unit Primary Nurse – Title given to a nurse whom is primarily responsible for the care

provided to an individual consumer of DMHU Secure setting – A health environment that includes Alexander Maconochie Centre or

Dhulwa Mental Health Unit Stood over – A term used at the AMC when a client is being threatened or intimidated

to divert their medication for the purposes of providing it to another individual.


Search Terms

ORT, methadone, AMC, DMHU, Alexander Maconochie Centre, Dhulwa, Opioid Replacement Treatment, Drug and alcohol, D&A, Hume Health Centre, suboxone



http://www.nps.org.au/chronicpain

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Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Service specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Date Amended Section Amended Approved ByEg: 17 August 2014 Section 1 ED/CHHSPC Chair



Documents

Opioid Replacement Treatment – Justice Health … · Web viewFail to attend dosing resulting in termination from the program or Cease treatment against clinical advice Each of these