How To Start A Methadone Clinic

vi.1. INTRODUCTION

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

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

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

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

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

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

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

Case study: The Hong Kong Methadone Maintenance Program

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

-: Low cost of treatment – HK$ane (about 12 U.s. cents) per clinic attendance
-: Open vii days per calendar week and are open from early in the morning to late at night
-: Operate on a "low threshold" model – this means that there are few weather condition that patients must come across to begin handling
-: Non-judgemental approach that includes providing harm reduction data and condoms

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

Rationale for MMT in closed settings

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

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

Reducing risks associated with injecting drug utilize

MMT in closed settings reduces drug injecting by prisoners. In Commonwealth of australia, a trial of MMT in prison house plant that despite being in prison, over fourscore% of inmates starting methadone treatment had used heroin in the previous month; however, later on four months of handling, only 25% of prisoners were withal using heroin.¹⁶ Past reducing drug injecting, MMT reduces opportunities for HIV to be transmitted between prisoners.

Reducing chance of re-incarceration

Many drug users feel multiple episodes of detention in airtight settings. All the same, patients who remain in MMT after leaving airtight settings are less likely to return to closed settings than not-treated heroin users.¹⁷

Reducing the risk of relapse following release

People who leave airtight settings oftentimes relapse to regular drug utilise within a few days or weeks of being released. Being in MMT in the closed setting so continuing handling in the customs reduces the hazard of relapse.

Instance study: Methadone maintenance treatment in prison in Indonesia

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

Some of the patients in the methadone programme are standing treatment begun in the customs, while others have started methadone handling in prison house. Patients who are HIV-positive receive free antiretroviral treatment in addition to methadone.

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

Required resources

Essential staff

Physicians

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

Nurses

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

Taking part in handling reviews and providing reports to clinic doctors
Providing vaccinations (e.g. hepatitis A and B) and referring patients for communicable diseases testing (e.g. HIV, hepatitis, sexually transmitted infections, tuberculosis)
Attending to general health needs of patients, for example, dressing wounds and ulcers; profitable with general hygiene and infection command

Counsellors

Counsellors back up medical staff of the treatment program past:

Providing general counselling on bug of business organization to patients
Undertaking motivational interviewing with patients to increase motivation to reduce illicit drug utilise
Providing pre- and post-exam counselling for patients seeking testing for HIV or other infectious diseases

Other professionals

Although not essential, the post-obit staff can also assist patients in methadone maintenance treatment:

Psychologists

Psychologists can help patients suffering from co-morbid mental illnesses and psychiatric problems such equally low, anxiety or post-traumatic stress disorder.

Social or welfare workers

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

Community liaison officers

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

Facilities

Medical dispensary

Methadone should be dispensed via a medical dispensary inside the closed setting. The dispensary must be staffed and open to patients 7 days per calendar week. The clinic should exist equipped with a dispensing pump or measuring cylinder for ensuring authentic methadone dosing, and should as well maintain adequate supplies of basic start aid and resuscitation equipment.

Secure storage area

Methadone must be stored in a secure area within the medical dispensary, for instance, locked in a room or safe. It should non be obvious to patients that this is where methadone is stored.

Post-dosing supervision room

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

Furnishings of methadone

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

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

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

Near people first MMT experience few side effects. However, there are some side furnishings of methadone, including:

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

Interactions between methadone and other medications

Interactions betwixt methadone and other drugs can atomic number 82 to overdose or death. Drugs that depress the respiratory system (e.g. benzodiazepines) increase the effects of methadone. Drugs that touch on metabolism can induce methadone withdrawal symptoms. Clinically of import drug interactions are listed in Table 12 (p.83). In item it is of import to note interactions betwixt methadone and medications used to handling HIV and tuberculosis:

Table 12

Methadone-medication interactions.

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

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

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

Run across also AIDSinfo, http://www.hivatis.org/, for upwards-to-engagement listings of antiretroviral medications and interactions with other drugs.

6.2. Inbound Treatment

Indications

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

Patients must as well exist able to give informed consent for methadone maintenance treatment.

Contraindications

Patients with astringent liver affliction should not exist prescribed methadone maintenance treatment as methadone may precipitate hepatic encephalopathy.

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

Priority patients

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

HIV positive
Receiving treatment for HIV or hepatitis C
Patients who have been on community methadone maintenance handling programs. In these cases, the patient should continue MMT in the closed setting at the dose that they were receiving in the customs. It is very important that the patient's treatment is non interrupted unnecessarily; hence, the closed setting should have a procedure in place for people who are detained while on methadone.
History of drug overdose in closed settings
History of self-harm/suicidal behaviour in relation to opioid dependence
Pregnant, opioid dependent women should embark methadone maintenance treatment equally soon as possible. Significant women should be assessed and dosed in the same manner equally other patients. Should a patient fall pregnant while in MMT, she can be maintained on her usual daily dose. In the terminal trimester of pregnancy, it may be necessary to increase the daily dose in order to adequately control withdrawal symptoms. Babies born to mothers on methadone maintenance treatment may experience a withdrawal syndrome, which should be managed by a postnatal intendance specialist.

Risks and precautions

There are few risks associated with the long-term apply of methadone. Methadone does non damage any of the major organs or systems of the body. There are few side effects of methadone and those that do occur are less harmful than the risks associated with illicit opioid employ.

Overdose

The major risk associated with methadone is overdose. Overdose is a particular concern in the initial stages of MMT and when methadone is used in combination with other depressant drugs. Methadone overdose may not be obvious for 3 to iv hours after ingestion. Patients should be closely monitored during the first week of treatment for signs of overdose, including:

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

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

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

Ongoing poly-drug employ

Methadone should exist prescribed with caution to patients who are using other drugs, particularly those that depress the primal nervous system (eastward.g. booze, benzodiazepines). Patients should be advised of the increased take a chance of overdose associated with using methadone in combination with other drugs.

Concurrent medical problems

Methadone should be prescribed with caution in patients with:

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

Informed consent and treatment planning

Earlier beginning MMT, the patient must be given plenty information for him or her to brand an informed decision about commencing handling. The patient should be told:

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

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

Patients eat their complete dose in front of dosing staff and do non give or sell any part of their dose to others.
No violence or threats of violence against staff or other patients
The patient is to attend consultations with their physician every bit required
Consequences for breaching these rules

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

Afterwards obtaining informed consent from the patient, develop a treatment plan that outlines the patient's starting dose and the schedule by which doses volition increase. Encounter page 28 for more data about handling plans.

The get-go dose

The outset dose of methadone given to a patient is low. The size of the dose is gradually increased until the maintenance dose is reached. The maintenance dose is the amount of methadone the patient requires to preclude opioid withdrawal symptoms, but does non induce euphoria.

The beginning dose of methadone should be between 10-30mg. Patients who have recently used opioids can be given a offset dose at the higher terminate of this range. The first dose given to a patient who has not recently used opioids should exist no greater than 10-20mg. When determining the size of the first dose, keep in mind that deaths from methadone overdose in the first 2 weeks of treatment have occurred at doses every bit low as xl-60mg per day.

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

Provide the same dose daily for 3 days. The patient will experience increasing effects from the aforementioned dose over this time. After the first iii days, assess the patient's withdrawal symptoms. If the patient is experiencing withdrawal, increase the dose by 5-10mg every three days. Dose increases should not exist greater than 20mg per week.

Monitor the patient for signs of withdrawal and intoxication and adjust the methadone dose accordingly to find the patient'southward maintenance dose. This process may have several weeks. The maintenance dose volition usually be between 60-120mg, only may exist higher or lower, depending on the patient'southward history of opioid utilize. Meet also Figure 3.

Figure 3

Methadone maintenance treatment dosing flowchart.

Induction Catamenia

Patients who have been treated with buprenorphine

If a patient is detained who has been on buprenorphine maintenance treatment in the community, you should endeavour to assist the patient to continue this treatment. However, if buprenorphine is non available, the patient should be transferred to methadone maintenance handling (Figure 4).

Figure 4

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

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

Methadone is an opioid, like heroin. While in this handling, you will withal be dependent on opioids. Just, taking methadone volition be much safer than taking heroin. Taking methadone can give you a interruption from the drug-using lifestyle and give you lot a take chances to work on whatsoever social, financial or family problems you are having every bit a issue of your drug employ.
Methadone maintenance treatment is a long-term treatment. Some people receive methadone for many months or fifty-fifty years. While in methadone maintenance treatment, you will need to attend the dispensary once a solar day to receive your dose of medicine.
Tell your md if you are taking any other medications or herbal remedies equally these may collaborate with methadone, causing health problems.
Some people experience side furnishings from taking methadone. These include constipation, nausea, feeling tired, perspiring more than usual, a dry oral fissure and feeling dizzy.
If yous brainstorm methadone maintenance treatment, you must avert taking other opioids such as heroin, codeine, morphine or opium. Taking these drugs in combination with methadone can lead to overdose, which can be fatal. If you drink alcohol, be sure to exercise and then in moderation, as alcohol and methadone in combination can also lead to overdose.
There are other drug treatment options available as well methadone maintenance treatment. Ask your doctor if you would like to know about these.

Should y'all begin methadone maintenance treatment at this clinic, yous will be required to follow these rules:

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

Patient consent form

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

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

I am aware that I can choose to stop this handling at whatsoever time.

Signed:

Name:

Date:

Witness signature:

Proper name:

Appointment:

vi.3. Management OF DOSING

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

A patient may deliberately non swallow, or swallow and then vomit, their dose in club to sell information technology or give it to some other resident
A patient may be forced by some other resident to requite their dose away

A well-managed program tin minimise the adventure of diversion by having clear dosing procedures, such as provided beneath, that are strictly followed.

Dosing procedure¹⁸

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

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

Requests for dose increases

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

Dosing errors

Accidentally dispensing likewise much methadone to a patient can result in a life-threatening situation. Information technology may be three to four hours after dosing earlier the patient shows signs of overdose. In instance of overdose:

Advise the patient of the mistake and the possible consequences (e.g. increased drowsiness, increased risk of respiratory depression).
Observe the patient every fifteen minutes for fours hours and every thirty minutes for the side by side four hours. Each time, cheque the patient's breathing, apportionment and level of sedation.
Inform the clinic physician of the mistake.
If the patient loses consciousness, administrate naloxone as a prolonged infusion and transfer the patient to hospital for farther observation.

Missed doses

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

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

Table 13

Dosing for patients who have missed doses.

Vomited doses

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

Table xiv

Dosing for patients who have vomited.

Recording dispensed amounts

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

6.4. MONITORING MMT

Handling review

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

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

At the kickoff of MMT, handling review should occur weekly. After 2 months in treatment, the frequency of treatment reviews can be reduced to once every 4 to half-dozen weeks.

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

Urine drug screening

Analysis of a patient's urine for evidence of illicit drug apply is expensive and will non cease patents from using other drugs. Furthermore, results can be unreliable. There is no evidence that punishing patients for returning positive urine samples results in decreased illicit drug use. Urine drug screening should only exist used for therapeutic purposes, for example, when a patient is suspected of using drugs and confirmation of this is required. This provides information that the md tin can utilise to identify if the patient's treatment needs are existence met. For example, if a patient's urine sample shows continued heroin apply despite being in MMT, information technology may be a sign that the patient needs a higher methadone dose.

Treatment duration

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

Additional treatments

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

Release planning for methadone patients

It is recommended that all patients receiving MMT in airtight settings exist assisted to transfer to a community-based MMT program to proceed treatment. Remaining in MMT in the community will assist the patient to avert illicit drug apply and HIV chance behaviours such as sharing syringes. It volition likewise reduce the likelihood of drug overdose. Arrangements for transferring the patient'south prescription should be made by the prescribing doctor several weeks before the patient is due for release, in guild to allow fourth dimension for the transfer asking to exist processed. It tin exist useful to employ a community liaison officeholder who tin can assist in arranging transfers betwixt the airtight setting and doctors in the local customs.

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

Will the patient exist living in an expanse with like shooting fish in a barrel admission to a methadone clinic?
Will the patient be able to beget methadone handling? Are government-subsidised treatment places available (due east.grand. for patients living with HIV)?
What other support services can the patient access in one case released?

Case report: Release planning for prisoners in MMT in New S Wales, Commonwealth of australia

Prisoners in New S Wales, Commonwealth of australia, can admission methadone and buprenorphine maintenance treatment. Continuity of maintenance treatment between prison house and community settings is critical to reducing the risk of relapse to drug utilize and criminal re-offending. To help patients access community methadone maintenance programs after their release from prison, Justice Wellness (the organisation providing MMT in prisons) collaborated with customs Area Health Services to implement an "in-attain projection".

The in-reach project employs customs health workers to visit prisoners receiving maintenance handling who are soon to exist released. The health worker assists the patient to suit to continue methadone treatment in the customs. The health worker likewise identifies other needs of the prisoner, such as accommodation, education or wellness needs and refers the prisoner to appropriate services. The objectives of the in-accomplish project are to:

-: Minimise drug-related morbidity and bloodshed in released prisoners
-: Minimise the barriers to inbound methadone or buprenorphine programs
-: Establish links between health agencies to ensure continuity of treatment between prison house and the community
-: Link patients with other services required to accost their individual needs

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

Withdrawal from methadone prior to leaving the closed setting is not recommended. Withal, nether some circumstances, information technology may be necessary. The patient may non be able to transfer to a community-based plan, or the patients may asking dose reductions with the aim of ceasing MMT before he or she is released. Patients should exist advised that ceasing MMT prior to release might increase their risk of relapse and drug overdose. If a patient insists on ceasing MMT before release, follow the guidelines fix out in department 6.5 Catastrophe treatment.

vi.v. Ending TREATMENT

Voluntary cessation of treatment

Patients who wish to cease MMT should see their prescribing doctor to discuss their handling options. The doctor should institute why the patient wants to terminate MMT. Reasons for wanting to end MMT may include:

Belief that methadone is not appropriate in their case
Belief that they no longer demand treatment
To avoid bug associated with MMT east.g. side-effects, harassment from others to divert dose
To be "drug-gratis" prior to release from the airtight setting.

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

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

Recommended dose reduction schedule:

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

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

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

Involuntary cessation of handling

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

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

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

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

Pregnant patients

Cessation of methadone maintenance handling during pregnancy is non recommended. Pregnant women should exist provided with information about the benefits and risks of methadone during pregnancy. If a adult female chooses to cease methadone treatment during pregnancy, it is recommended that dose reductions begin during the second trimester. Dose decreases should be ii.five to 5mg per week, and the patient should be closely monitored for signs of withdrawal.

14: Buprenorphine is another medicine used every bit a substitute for heroin in the treatment of opioid dependence. However, these guidelines will focus on methadone as information technology is the well-nigh widely used substitute medicine.

Another medication sometimes used for treating opioid dependence is naltrexone, which blocks the furnishings of opioiods; however at that place is very little evidence that this is effective, and it is non recommended for use in closed settings
15: WHO/UNODC/UNAIDS. Substitution maintenance therapy in the direction of opioid dependence and HIV/AIDS prevention. Geneva: World Wellness Arrangement; 2004. .
16: Dolan K, Shearer J, MacDonald One thousand, Mattick R, Hall W, Wodak A. A randomised controlled trial of methadone maintenance treatment versus wait listing control in an Australian prison house system. Drug and Alcohol Dependence. 2003;72(1):59–65. [PubMed: 14563543].
17: Dolan K, Shearer J, White B, Zhou J, Kaldor J, Wodak A. Four-twelvemonth follow-up of imprisoned male heroin users and methadone treatment: Mortality, re-incarceration and hepatitis C infection. Addiction. 2005;100:820–828. [PubMed: 15918812].
18: Drug and Alcohol Methadone/Buprenorphine Handling Procedures Index. Sydney: NSW Corrections Health Service; no date..

Source: https://www.ncbi.nlm.nih.gov/books/NBK310658/