MATOD take away doses - prescribing guidelines

Medication assisted treatment for opioid dependence (MATOD) is based on daily supervised dosing at a pharmacy or clinic.

All doses should be supervised until the patient is stabilised on treatment. Take away doses may be gradually introduced for stable patients in recognition of treatment progress and to improve quality of life.

How take away doses may help stable patients

For stable patients, take away doses may help them to:

• normalise their lives by reducing the need for daily supervised dosing
• participate in the work force
• fulfil family and social responsibilities
• travel for work, family or leisure
• reintegrate into the community
• improve treatment outcomes by increasing retention in treatment

For each patient, the potential benefits should be balanced with the risks of providing take away doses, including:

• diversion for illicit use or trafficking
• injection of dose causing bacterial infection or blood borne virus transmission
• accidental overdose by children or others who gain access to doses that are not stored safely and securely
• using doses in advance to consume an excessive amount

• hoarding doses for deliberate overdose of self or others

Assessing patient stability and the appropriateness of take away doses

Careful clinical assessment is essential before any take away doses are approved.

Before approving takeaway doses, prescribers are encouraged to:

• perform a thorough risk/benefit assessment rather than make a decision based solely on length of time in treatment; or following a request from the patient
• discuss patient presentation and stability with their dosing pharmacist
• to take a conservative approach to approving take away doses
• conduct and document regular risk assessments regarding the suitability of takeaway doses

Changes in patient risk factors that may destabilise treatment should prompt review of take away dosing arrangements.

Takeaway framework for South Australia

Supervised dosing at a 7 day pharmacy is recommended during the induction and stabilisation phase.

Take away doses may be considered during the maintenance phase depending on the individual patient’s level of risk.

Prescribers may consider a newly initiated patient, with very low risk factors to be stable enough to receive take away doses on Sundays and public holidays.

Prescribers are encouraged to use the risk assessment tool (PDF 155KB) to assist their assessment of, and to document the risk of allowing a patient to have take away doses.

Buprenorphine/naloxone (Suboxone)

Induction and stabilisation

Usually first 1-3 months of treatment

Supervised dosing (except in special circumstances)

Maintenance phase

Takeaway availability based on risk assessment

• High risk — Supervised dosing (except in special circumstances)
• Moderate risk — Maximum 4 take aways per week
• Low risk — Not more than 28 consecutive days unsupervised

Methadone

Induction and stabilisation

Usually first 3 months of treatment

Supervised dosing (except in special circumstances)

Maintenance phase

Takeaway availability based on risk assessment

• High risk — Supervised dosing (except in special circumstances)

• Moderate risk — Maximum 2 take aways per week (consider if supervised doses should be non-consecutive)

• Low risk — Maximum 4 take aways per week

No more than 4 consecutive days of take away methadone should be approved

Split dosing | Methadone Only

Only low risk patients, or exceptional circumstances (for example demonstrated rapid metabolism of methadone, pregnancy) should be considered for split dosing.

For split dosing of methadone, one portion (or both portions) of the total daily dose may be given as a take away dose. However, written approval from the DDU must be obtained before prescribing more than 4 consecutive days of take away doses per week, even when a patient is receiving split doses (see the MATOD frequently asked questions page).

Travel and interstate transfers

While, there is no specified limit on travel or temporary interstate transfer, prescribers should consider the potential risk of harm to the patient and others that may occur where large quantities of take away doses are approved. It is recommended prescribers:

• perform a risk assessment taking into account the lack of supervision; availability of secure storage; and the risk of diversion, misuse or illicit drug use,
• investigate alternative dosing arrangements, and
• that no more than 4 weeks are approved.

Short-term additional take away doses

Dosing at an alternative pharmacy is preferred however, where this is not possible, requests for short-term, additional take away doses may be considered in exceptional circumstances including;

• travel
• health or illness preventing the patient attending the pharmacy for dosing
• bereavement, family emergency
• temporary employment obligation.

Application must be made in writing (providing detail of the specific circumstances) and approval from DDU received before additional, short-term take away doses are prescribed.

Long-term stable patients

Long term, stable patients treated with methadone may be permitted more than the recommended number of take away doses; to a maximum of 6 doses per week. Prescribers must be satisfied that:

• the patient must has a demonstrated history of appropriate use of take away doses
• regular risk assessments have demonstrated the suitability of the patient for regular additional take away doses
• there is very low risk of harm to either patient or community associated with reduced supervision.

Application must be made in writing, and approval from DDU received, before additional takeaways are prescribed.

Important safety message

Due to risks of overdose and death associated with methadone and buprenorphine, it is important to appropriately counsel patients regarding the safe and secure storage of any prescribed take away doses. The methadone and buprenorphine not for kid's brochure (PDF 185KB) helps outline how to safely store medication and should be provided to all MATOD patients.