Time-limited methadone – guest blog by Paul Molyneux

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Paul Molyneux 2The topic of time-limited opioid prescriptions has been discussed before on Recovery Review. More recently, the issue has garnered increased attention after Liberal Democrat MP Norman Baker wrote to the ACMD on behalf of the Inter-Ministerial Group on Drugs. In the letter, Norman Baker requested that the ACMD review “whether the evidence supports the case for time-limiting opioid substitute therapy”.

Detox as default – ‘the revolving door’

Of equal interest, in a tender description for the “provision of clinical services to adults with substance misuse”, Slough Borough Council asks for a “suitably qualified organisation” to deliver a prescribing service that “includes reduction/detoxification as a default approach”. Although not explicitly stated, one wonders if time-limited prescriptions will be a feature of such a service which, a colleague jokingly suggested, might choose to name itself The Revolving Door.

“Enforced detoxification… causes relapse”

In relation to Norman Baker’s letter, it was requested that the ACMD report back to the Inter-ministerial Group by 3rd September. As far as I can tell, no report has been made available to the public (at the time of writing, at least). That being said, you only have to go as far back as November 2013 to get a flavour of the ACMD’s view (via its Recovery Committee) of time-limited opioid therapy:

“It is important to note that research is clear that enforced detoxification or time-limited opioid substitution treatment causes relapse and increased risk of harm to the individual and communities and is not recommended.” (ACMD, 2013).

Unless new evidence has come to light since then, it’s probably safe to assume that any new report will only echo the findings of the previous one.

Cost cutting dressed as recovery?

MethadoneBut where has the interest in time-limited prescribing come from? I’m not entirely sure. Is it out of concern that people will otherwise be ‘parked’ on methadone; or maybe a belief that it’s what clients want? Some have suggested that time-limited prescribing is a cost cutting initiative dressed up as recovery.

Perhaps in response to the current climate, the drugs charity Release published an article on their website in September. In it, they claim they are receiving increased reports of “people who have had their medication stopped because of seemingly petty reasons”. Indeed, they go on to say that they are supporting one individual in legal action against a drug service for stopping their prescription, apparently without a valid clinical reason.

Prescription at all costs?

Like Release and others, I too am worried about the apparent increase in prescriptions being stopped and the looming possibility of time-limited treatment. But is it ever right to stop a prescription? Like all medications, methadone isn’t risk free and a degree of monitoring is required. Despite this, have treatment providers been guilty of colluding with some clients to keep them on a prescription at all costs?

For instance, is it safe to continue to prescribe to a client who hasn’t been reviewed by a doctor for 18 months due to missing successive medical appointments? And what about the client who continually misses appointments only to turn up last thing every Friday to collect their prescription declaring that they can only stay a minute as they’ve got a taxi waiting outside?

Parallel in psychiatry

There is a parallel in psychiatry. Patients prescribed the anti-psychotic clozapine (Clozaril) are required to have regular blood tests due to the risk of agranulocytosis, a potentially life-threatening condition that severely lowers an individual’s white blood cell count. If a blood test is missed, a “clozapine prohibited” notice is issued and the medication stopped.

But where should drug services draw the line? There’s an interesting discussion taking place on the SMMGP forum. On it, one forum member extols the merits of how some Americans are prescribed methadone:

“I’m hoping we follow suit with USA personally [where] using on top means no script[.] [T]here MMT works, they can’t use on top.”

Comments like this concern me as, perhaps wrongly, I detect a hint of ideology creeping into the debate about the prescribing of methadone. As a nurse working in substance misuse, I’m already worried about the increasing politicisation of the addictions field.

Treading carefully

Of course, the discussion around time-limited ‘scripts takes place in the context of a sharp increase in drug related deaths in England and a significant increase in deaths related to opiates. It’s easy to get caught up in the numbers, but behind each death is a tragedy; one that was, perhaps, entirely preventable.

Whatever the downsides of methadone maintenance, it is undeniable that substitute prescribing has saved lives. So when making decisions about the future provision of drug services, let us tread carefully.

[Advisory Council on the Misuse of Drugs (2013) What recovery outcomes does the evidence tell us we can expect? Second report of the Recovery Committee, London: ACMD.]

    3 Responses to "Time-limited methadone – guest blog by Paul Molyneux"
    1. Anon says:

      Thanks for this interesting article and the link to the SMMGP forum.
      I wonder whether it makes sense to think of the population in need as being two separate groups: there is the (shirinking) group of newly presenting opiate users and there are the long term MMT patients.
      I think there is a reasonable case for saying that we should make every effort to avoid new patients getting onto long term MMT – our history of getting people onto methadone with no expectation on the part of the prescriber or the patient that we would help them to get further in recovery led in far too many cases to collusive relationships and a dreadully narrow range of choice for people. In part this was economically driven (methadone maintenance – despite reportts of the vast wealth flowing to GP’s and communinty pharmacists, is a cheap mass intervention. In part it was a simplistic interpretation of of harm reduction. I think that his group should be strenuously encouraged to take a route towards early abstinance, especially since we now have a better range of well understood pathways to abstinance in most areas. MMT should be very much a last resort for them.

      The latter group (the long term, gradually ageing MMT cohort) present, I think, the greatest challenge to our systems of care – we know relatively little about them and they are a very large group. Some English commissioners do seem to be promoting approaches which almost bully people off their prescriptions but I doubt that this is simple cost saving (leaving them “parked” was probably cheaper) – I imagine that it was born largely of a feeling that having large numbers of people just sitting there in the long term, especially with poor evidence of their outcomes, was incompatible with a recovery paradigm. Given better budgets and perhaps more insight and imagination, far better routes to recovery could be built for MMT patients.

      As this blog thoughtfully points out, there are no easy choices in this area.

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