• Summary
• Introduction
• Confidentiality
• Clients going away
• Contracting
• Urinalysis
• Typical drug clearance times
• Hair analysis
• ‘Manipulation’
• Terminating treatment
• Benzodiazepines
• Recreational drug use
• Problem alcohol use
• Worker supervision and support
• Transfer from injectable to oral methadone

Summary

• Many of the commonly experienced problems in methadone prescribing can be reduced by open, honest relationships and written contracts.

• Responsible use of urinalysis seeks to strike a balance in which the urine test is a positive corroboration for the written records of information given to the worker.

• Urinalysis has an important role in providing documentary evidence to support methadone prescribing at the start of treatment.

• The limitations mean that only limited weight should be given to the result of the initial urinalysis.

• Prescribing benzodiazepines to opiate users should only be undertaken by specialist prescribers, within clear guidelines.

• Problem alcohol use may contra-indicate methadone prescribing.

Introduction
This section covers some of the areas of methadone prescribing that all workers and services need to consider carefully. Preparation of policies and strategies to deal with these practical issues will greatly assist in the smooth and effective running of any prescribing service.

Confidentiality
There are a number of reasons why drug users may be anxious about people finding out about their opiate use which may include some or all of the list below.

Opiate users are often:

• Held in very low regard
• Worried by guilt feelings about their drug use
• Anxious because they have not told key professionals about their drug use before e.g. health visitor, GP or probation officer
• Aware that some professionals still believe that a heroin-using parent is a bad parent
• Concerned that friends and relatives will react to them differently if they find out about their opiate use.

These concerns and the level of anxiety are added to by the fact that:

• Heroin use is illegal.

For these reasons it is important to be clear with drug users about who will become aware of their methadone treatment. If information is to be passed on then the method and content of the disclosure needs to be explained clearly.

Fears about the lack of confidentiality within the NHS and other drug services is one of the areas cited by clients who are not in contact with services as a reason for not making contact. Being explicit with all clients about what confidentiality means to you and your agency will help reduce paranoia and anxiety among both the group who are in contact with your service and those who are not.

Clients going away
The practicalities of picking up a methadone prescription from the prescribing doctor and/or collecting the methadone itself can be restricting. Clients wanting to go away and requesting changes to their prescribing regime to accommodate this can be a major cause of friction. For this reason it is good practice to include a clause in the prescribing agreement that details how much notice is required for changes to be made in the regime and, if possible, what the parameters will be around accommodating employment or holidays.

If the client is leaving the country they may need an export licence: see Section 5: Methadone and the law.

As with all other aspects of prescribing it is important to weigh any possible risks – particularly those of overdose and illicit sale of methadone – against the therapeutic advantages of work or holiday.

Other possibilities for retaining some degree of control while allowing the travel or work plans to proceed are:

• Finding a pharmacy near the destination and arranging to post the methadone prescription there
• Arranging a temporary prescription with a doctor or prescribing service near the destination
• Checking with the local pharmacies and arranging evening methadone pick-ups.

However, in the end, it is important for the prescribing doctor not to feel pressured into making prescribing arrangements that may not be safe, and for the client to realise that sufficient warning must be given and that some negotiation has to take place before prescribing arrangements can be altered.

Contracting
The prescribing contract is not simply a set of rules the client must obey. Rather it is an agreement in which the client agrees to work with the prescribing service and in return the service agrees to prescribe methadone and provide an agreed level of support and help.

It should be borne in mind that there are few other areas of health care which require people to enter into contracts. A badly written contract that is simply a list of rules the client must obey can leave the client feeling devalued. Contracts should include the complaint procedures available to the client should they be dissatisfied with the service they receive.

It is important to read the contract to each client and discuss each issue in detail, not least because they may have literacy problems which they are reluctant to disclose.

In drawing up a contract it is important that if cessation of prescribing is mentioned as a response to behaviour, it is in terms that allow a measure of discretion or it is used only in circumstances in which there would be no doubt about the decision to stop prescribing.

This is particularly important with regard to clauses about illicit drug use as you may not want to respond to increases in drug taking and HIV risk behaviour by withdrawing treatment.

Components of a prescribing contract
The contract is usually between the prescribing doctor, client and drug worker.

The agreement should include what each party agrees to do, which in most cases would include the doctor agreeing to:

• Provide a regular methadone prescription
• Liaise with the drug worker regarding the client’s progress
• Discuss alterations in the agreed prescribing regime with the drug worker and client

The drug worker agreeing to:

• See the client at agreed intervals
• Be available within an agreed time should the client request extra time
• Liaise with the prescribing doctor
• Review the programme with the client and doctor at agreed intervals

The client agreeing to:

• Attend appointments with the drug worker and doctor
• Accept full responsibility for the perscription and medication once issued
• Give adequate warning of plans to go away/request alterations to the prescribing regime
• Provide urine samples for drug screen when requested
• Reduce and minimise use of illicit drugs and to try and stop heroin use
• Use methadone for personal use and not sell or share any of the prescription
• Not to approach any other doctor for psychiatric medication during the treatment programme

And all parties agreeing that:

• They will not use abusive or threatening behaviour
• Any breach of the agreement will result in a review of the programme
• A serious breach may result in termination of the prescription regime.

Urinalysis
A urine drug screen that is opiate positive is an essential safeguard that should always be obtained at the outset of treatment. However, it is easy to over-emphasise the importance of urinalysis in methadone treatment. It cannot give a full picture of someone’s drug use (unless it is done daily – which is prohibitively expensive). It can only ever give a snapshot indication of drug use. It carries with it a number of dangers to the relationship between the prescriber/drug worker and client.⁹¹

The testing procedure
The urine specimen can be collected in a standard sterile pathology lab bottle and labelled accurately in the presence of the client.

The pathology lab form can be filled in by anyone but, unless there are special arrangements, must be signed by a doctor. The form would normally state: ‘receiving methadone treatment, full drug screen please’ although some services specify the drugs they want screened for e.g. ‘…please screen for methadone and other opiates, cocaine and amphetamine’.

The urine sample should be:

• Kept in the dark
• Refrigerated
• Tested as soon as possible.

The tests used
Most laboratories will use a relatively insensitive test first of all and, where a trace of a drug is found, follow it up with a more accurate test to confirm.

The tests used are:

• Thin layer chromatography
• Paper chromatography
• Gas chromatography
• EMIT scan.

The benefits of urinalysis
Urinalysis is used as part of methadone treatment to:

• Confirm heroin use prior to treatment commencing

and, once treatment has commenced, to:

• Confirm methadone is being taken
• Discourage illicit/additional drug use
• Assess illicit/additional drug use
• Inform treatment decisions such as allowing take-home doses, dose increases and reductions and removal from programmes
• Provide information to support research into prescribing programmes.

The value of urinalysis in these functions is largely unresearched and, in some respects, a flawed procedure. Its use in each of these functions is outlined below.

Urinalysis prior to treatment
A urine test prior to commencement of treatment is a standard feature of almost all methadone prescribing. It is a useful safeguard against accusations of irresponsible prescribing as it is good evidence of opiate use prior to commencement of treatment.

However it is only evidence of at least one dose of a drug having been taken in the last 24–72 hours: see the drug clearance times chart below. It gives no indication as to the quantity of drugs being used nor evidence as to how long the client has been using those drugs. And as it is widely known among drug users that a urine screen for drugs will be part of the assessment procedure they will generally ensure that the result is ‘opiate positive’.

The taking of a urine sample as part of the assessment procedure can easily convey to the client a message of distrust. It is therefore important to stress its role as a safeguard for the prescribing programme and as corroboration of the history given at assessment, rather than as a way of catching people out.

Confirming that methadone is being taken
This is an important part of the reason for testing urine for clients who can take their methadone home, and again forms useful documentary evidence against accusations of irresponsible prescribing.

Because methadone is a long-acting drug which is metabolised over a period of days, false negative urine screens are rare in clients who are taking their medication regularly – and should therefore be taken seriously and repeated as a further safeguard.

Confirmation that methadone is being taken requires a sample to be positive for both methadone and methadone metabolites.

Discouraging illicit/additional drug use
The extent to which the drug screening of urine samples deters illicit drug use is debatable, especially if the clients can predict when they are likely to be tested.

Although there are individual cases in which urinalysis can be helpful the extensive literature search carried out by Ward et al⁹¹ failed to find any studies that could demonstrate a reliable link between urinalysis (as part of a methadone maintenance programme) and reduced illicit drug use.

Assessing illicit/additional drug use
However if someone can stop using for a few days prior to urine tests on a regular basis then they probably have a degree of control over their drug use. The issues around occasional drug use can therefore be addressed and systems that rely on urinalysis alone may miss this altogether.

If the client cannot stop using other drugs, even when they know a urine test is imminent, it is likely that they have not got much control over their drug use and this is an issue which needs addressing.

Informing treatment decisions
Urine screen results are commonly used to inform clinical decisions such as:

• Allowing take-home doses
• Increasing or decreasing the number of days’ take-home doses allowed
• Dose increases
• Dose reductions
• Removal from prescribing programmes.

However it is important that if a drug screen result is to be used in clinical decision making it is not the only indicator that is used.

Providing information to support research into prescribing programmes
Urine testing can give an indication for research purposes as to the illicit drug use of people receiving methadone, although its limitations (see above) mean that it is difficult to produce methodologically-sound conclusions on the basis of drug screening the urine of clients.

Because of this the interpretation of results may well depend on whether the reader is a drug user, drug worker, doctor, service funder, politician or researcher and whether or not they are hostile to or supportive of prescribing services.

Drawbacks of urinalysis
The research that has been carried out into the efficacy of urine testing has been unable to demonstrate that it is a reliably effective way of monitoring drug use. A therapeutic, open and trusting relationship in which the client is not afraid to disclose the true picture of their drug use is likely to produce a more accurate and productive indication of drug-using patterns.⁹⁰ However used in conjunction with a therapeutic relationship, psychological and other treatments, urinalysis may be useful in encouraging clients to meet appropriate goals related to controlling and reducing their illicit drug use.

The experience of many workers is that the more heavily methadone prescribing is policed, and the more the feeling of ‘them and us’ grows, the more ingenious the dodges become to avoid getting caught.

The ‘them and us’ syndrome can be countered through careful explanation of the test and the rationale for it. Most clients accept that some people are motivated to get methadone simply to sell it and that it is legitimate for services to use objective measures from time to time to check that they are providing an appropriate service. Clients also accept that many seek treatment to maximise drug consumption and that workers need objective tools to help determine what the real patterns of drug use are.

There are a number of ways clients can avoid getting a urinalysis result that is unfavourable, such as:

• Bringing in someone else’s urine in a small container kept under the arm (to keep it warm)
• Getting someone else in the toilets to provide a sample
• Adding water to the sample to dilute any unwanted metabolites.

The only reliable way of avoiding these is to supervise the production of the sample. This is a demeaning procedure for both client and staff member. However if the benefits are clear it may be worth while.

Typical drug clearance times
There is room on the chart below for you to fill in the values your pathology lab gives you according to the tests they perform, although they are unlikely to be much different from the values given.

Always remember that drug clearance times vary according to the:

• Dose of the drug taken
• Sensitivity of the tests used
• Ph value of the urine: more acidic urine tends to produce shorter clearance times
• Combination of drugs used: for instance stimulants increase the metabolic rate and therefore reduce drug clearance times.

Hair analysis
The hair can act as a ‘chemical tape recorder’, providing a record of drugs taken. It can be analysed centimetre by centimetre giving a clear picture of drug use over a period of months.

Hair analysis is commercially available in the UK. For most services it will complement rather than compete with urinalysis as it is rather expensive for routine use.

It is particularly valuable in:

• Monitoring people who are stable on methadone maintenance and who are seen only occasionally
• Assessing patients whose drug-using history is doubtful
• Monitoring levels of drug use over the long term.

Drug clearance times chart

Pros and cons of urine and hair analysis

‘Manipulation’
The history of drug users being seen as manipulative by health professionals is rooted in past conflicts between drug users and the medical establishment over drugs. For a long time doctors have had control over the commodity that can be the single most important thing in the life of a drug user. Society’s strong disapproval of the non-medical use of certain drugs, coupled with the historical desire of doctors to retain control of supply, has meant that control has been very tight.

Everyone who wants something will try different stratagems in order to get it – and the more they want it the more inventive they are inclined to be in the devices they employ. Furthermore if a strategy (however socially unacceptable) has worked once it is likely to be repeated.

It is not so long since the only way any doctor could be persuaded to write an opiate prescription for an ‘addict’ was if s/he was made to believe that the person genuinely wanted to give up drug use forever, and that the only thing that would help was a detoxification to help with the initial withdrawals. Clearly in these circumstances anyone who wanted a prescription, regardless of their true intentions, knew that their only hope was to spin the old ‘I want to get off’ yarn. The failure of these ‘detoxes’ has been a formative experience for many doctors.

With the advent of more flexible prescribing this problem has been reduced. Most drug services have found that any increase in flexibility and understanding is met with a corresponding reduction in ‘manipulative’ strategies to obtain the desired treatment.

The limit to flexibility is that the prescribing must not increase drug-related harm. Drug users may still employ techniques to persuade the providers of treatment to do things that will not be helpful to them.

However opportunities for manipulation with its resulting friction and dissatisfaction will be minimised if we:

• Are clear and realistic about our treatment aims
• Communicate effectively with our colleagues
• Have clear written agreements with our clients
• Encourage our clients to have an overt agenda
• Try and offer appropriate and effective treatment.

Terminating treatment
Methadone is not a treatment that works for everyone. In addition to people who are too chaotic in their drug use to meet the requirements made by prescribing programmes there will always be the occasional person succeeding in getting a methadone prescription who:

• Is not suited for treatment
• Convinces the assessor to prescribe more methadone than is necessary
• Gives a fictitious history to receive an inappropriate treatment duration
• Is unable to achieve any of the treatment goals.

It is often easier to identify these clients after they have been started on a prescribing programme rather than before and the review procedures should take this into account.

Treatment may be terminated if:

• It is doing more harm than good – with no prospect of this changing
• There has been a serious breach of contract e.g. violence towards staff
• There have been repeated breaches of contract e.g. non attendance at appointments.

Termination of treatment is a serious step, especially if there may be a return to high-risk behaviours as a result. Prescribing staff must be certain that it is a necessary intervention.

It is important that the criteria for removal from methadone prescribing are understood by all concerned and that they are applied fairly and without discrimination. Where possible clients should receive verbal and written warnings prior to removal from treatment. Other options that fall short of permanent removal, such as suspension of prescribing, may be considered.

Where possible entry criteria for returning to methadone treatment, including the earliest date a referral will be considered, should be made clear to the client.

Benzodiazepines
Use of benzodiazepines is, for many heroin users, part of the opiate-using culture. They are seen as relatively benign drugs that can be taken without withdrawal effects. This may be because benzodiazepine withdrawals could be mistaken for opiate withdrawals.

Benzodiazepines are sometimes used by opiate users to help them sleep, although often in doses far in excess of the normal therapeutic range. They are also used during the day when the user has no intention of sleeping to achieve the following effects:

• Creating a feeling of not being part of the rest of the world
• Causing complete amnesia of the time spent intoxicated
• Increased confidence
• Feeling ‘drunk’
• Potentiating the effects of alcohol
• Reducing the severity of opiate withdrawal symptoms.

The relationship between benzodiazepines and methadone is twofold:

• Requests for methadone prescription are frequently accompanied by a request for a concurrent benzodiazepine prescription
• People on methadone will often continue to use illicit benzodiazepines when they have stopped using illicit opiates.

The main problems are that:

• The therapeutic value of benzodiazepines in terms of sleep promotion is lost after only 2–4 weeks of treatment
• When taken in excess they can cause chaotic, high-risk behaviour with memory loss of events while intoxicated
• Their use contributes to higher levels of HIV/hepatitis risk behaviour
• The withdrawal syndrome – which includes agoraphobia and panic attacks – can be distressing and trigger further drug use.

As they are not controlled drugs it may not be possible for services to arrange dispensing of any less than a week’s supply at a time - and there is often a high risk of them all being consumed in the first 24 hour period. It is therefore difficult to prescribe benzodiazepines using the rationale of harm reduction.

Methadone prescribing services that operate a non-benzodiazepine prescribing policy may:

• Be at less risk from accusations of irresponsible prescribing
• Reduce requests for benzodiazepines
• Promote discussion and insight into benzodiazepine use

but they will not meet the needs of people with genuine benzodiazepine dependency or be able to take advantage of the short-term therapeutic benefits when their use is clinically indicated.

Many clients are willing to ‘trade’ their benzodiazepine request for extra methadone. A regime of 5mg methadone for 10mg temazepam/5mg diazepam to a maximum of 25% above the assessed methadone need, based on opiate use alone, is used by some services. This is not always appropriate and is thought by some to be flawed in terms of logic, especially as methadone will have little or no effect on benzodiazepine withdrawals. Some services offer a diazepam detox running alongside methadone treatment for the first few weeks to give people a realistic chance of coming off.

If a client remains adamant that they need prescribed benzodiazepines it is reasonable to start the methadone prescribing and to require them to remain in treatment for a period of extended assessment prior to a decision being made on prescribing benzodiazepines.

Recreational drug use
Most people on methadone prescriptions continue to take other drugs in addition to their methadone, particularly cannabis.

The test which needs to be applied is not that of abstinence but rather of the treatment aims. If the additional drug use is not compromising the treatment aims then it should not jeopardise the continuation of prescribing. If it is threatening the treatment aims then the care plan may need to be adjusted in order to achieve those aims before termination of treatment is considered. Problematic additional opiate use is discussed in the next section: Prescribing for groups with special needs: People who ‘use on top’.

It is important that prescribing services are clear among themselves and with clients on what the treatment aims are and what the response will be to recreational drug use.

Problem alcohol use
A significant minority of people on methadone prescriptions have a concurrent alcohol dependence. Alcohol and methadone potentiate each other and thus the risks of overdose are greatly increased when people are drinking heavily in addition to using methadone. Alcohol is thought to be a contributing factor in many of the methadone overdoses.

Some clients alternate between opiates and alcohol and for these people methadone is often helpful because while on methadone alcohol consumption falls or stops. It is those who have a dual dependency that present the biggest problems to prescribing services.

Additional services that may be offered to reduce risk and increase appropriateness of treatment include:

• Supervised consumption of methadone
• Breathalysing prior to dispensing of methadone
• Hospital or community alcohol detoxification prior to commencement of (or during) methadone treatment
• Liver function tests and other health investigations
• Concurrent dispensing of disulfiram (Antabuse) – started in hospital to reduce risks
• Discussion of alcohol consumption as a specific item on the care plan
• Residential rehabilitation.

Worker supervision and support
Clinical supervision is a key issue in providing effective methadone prescribing services. Opiate users present in many different ways and present unique challenges in the needs they have.

In order to offer an equitable, consistent and sustainable service clinicians must have access to supervision which allows them to discuss both the clinical and personal issues that are raised for them in their work.

Clinicians involved in working with opiate users also benefit from the support and opportunities to develop practice through:

• Conferences
• Regional drug workers fora
• Special interest groups
• Journal clubs
• Specialist training.

Transfer from injectable to oral methadone
There are a number of reasons why both the clinician and the client may want to transfer from a prescription of oral and injectable methadone to oral only. These include:

• Vein damage being exacerbated by continued injection
• A desire to move away from illicit drug-using patterns
• Pressure from partner or family
• Recognition that stopping injecting is a precondition to successful detox
• Agency or purchaser policy requires everyone on methadone treatment to receive oral methadone.

The transfer from injectable to oral methadone can be a very difficult and slow process which is one of the reasons many services choose not to prescribe injectables and instead try and stabilise clients on oral methadone from the start.

The process is one of a negotiated reduction in the injectable portion of the prescription and a simultaneous increase in the oral portion. Sometimes this process can be made easier by increasing the oral portion of the prescription by a little more than the reduction in the injectable methadone. For instance a client on 1x10mg ampoule per day may be given an extra 15–20mg oral methadone to replace it.

During this process it is important to check injecting sites regularly and encourage the client to use counselling and psychological support services.

Sometimes, as with detox, the best approach is to agree with the client prior to any changes that the process is an experiment, with the option to return to the original dose/route remaining open. This removes the pressure on both worker and client to see the process in terms of sucess or failure and for clients to resist change for fear they might be giving something up forever.

The transfer is more likely to be successful (in terms of avoiding a relapse to injecting illicit drugs) if it takes place in gradual steps. For people with a long history of injecting, full transfer to oral medication can take up to two years. Towards the end of the process, when nearly all the ampoules have been ‘converted’ into oral methadone, the client may continue to have one injecting day per script cycle, and this final phase can be the longest. Relapses need to be expected and dealt with as learning experiences.