Home > External review of methadone treatment protocol makes wide-ranging recommendations.

Lyons, Suzi (2011) External review of methadone treatment protocol makes wide-ranging recommendations. Drugnet Ireland, Issue 37, Spring 2011, pp. 22-24.

PDF (Drugnet Ireland, Issue 37) - Published Version

 The results of the first external review of the Irish methadone treatment protocol were published on 20 December 2010.1 The HSE commissioned Michael Farrell, professor of addiction psychiatry at Kings College London, to conduct the review, assisted by Joe Barry, professor of population health medicine at Trinity College Dublin. This is the second review of the protocol; the Methadone Prescribing Implementation Committee carried out an internal review in 2005.2 

The terms of reference for the external review were to review the methadone treatment protocol with regard to:
·         maximizing provision of treatment, including detoxification, stabilisation, and rehabilitation;
·         clinical governance and audit;
·         effectiveness of referral pathways;
·         the enrolment and training of GPs, the criteria for Level 1 and Level 2 GPs, and the GP co-ordinator role;
·         the appropriateness and efficacy of urinalysis testing;
·         data collection, collation and analysis; and
·         engagement with the Department of Justice on the prescribing of methadone in Garda stations.
The review was informed by 69 written submissions and the conclusions of 38 oral hearings with stakeholders on the impact of the protocol. The main points of these inputs are outlined in chapter 5 and appendix 2 of the report. The authors state that the original protocol achieved its aims, especially in relation to improving both poor prescribing and the quality of independent practitioner practice. The current review covers a wide range of new issues, including: developing a model of service for rural Ireland, promoting better integration between and among services, the need to review benzodiazepine prescribing, changing the regime of urine testing and the need to deal urgently with methadone prescribing in Garda stations. 
The list of recommendations below, extracted in an abridged form from the published report, give an overview of the scope of the review. The full text of the recommendations is on pp. 33–36 of the report.
1. Maximising treatment provision and the efficacy of referral pathways
1.1. Requests for detoxification should have a defined time frame for response and should be reviewed as part of a service audit process.
1.2. There should be a mechanism to rapidly access treatment for the six months after detoxification to
ensure support if relapse occurs.
1.3. The redrafting of the methadone regulations to incorporate buprenorphine (alone or with naloxone) treatment should be completed to ensure a broader range of treatment options. To this end, the title needs to be changed and could be “The Opioid Treatment Protocol”.
1.4. Services with a focus on key workers and multidisciplinary work should be promoted and developed.
1.5. An integrated services approach should account for family, community and user groups and it is recommended that these voices get a more prominent place in the future planning and development of drug services.
1.6. There is an urgent need for a service model outside of Dublin that has a clear focus on rural aspects of service delivery.
1.7. In areas where the service currently relies on doctors travelling from Dublin, it is desirable that more permanent local medical input is organised in the near future for the purposes of continuity of service delivery.
1.8. The professional expertise of the adolescent services and the midwifery services should be used for developing an overall national strategy in these specific topics.
1.9. Implementation of a once-yearly brief instrument, such as the Treatment Outcome Profile, would provide important information on the performance of individuals and on the overall performance of the service. There is need to create a sense of progression and promote movement within and between services.
1.10. Services should use the full range of skills of the multidisciplinary team to ensure that health and social problems of drug users is evenly addressed.
1.11. The treatment of Hepatitis C Virus among drug users needs to be expanded further.
1.12. There is a need to develop a more structured and explicit care planning process. Everyone should have a clearly documented care plan that is regularly reviewed and updated, drawn up within the first three months of treatment.
1.13. The development of an electronic record of care planning is necessary if proper care planning is to be comprehensively implemented.
2. Clinical governance and audit
2.1. It is desirable that there be some option for flexibility around the appointment of HSE clinical directors and that the director has a background and training to the level recognised as an Addiction Specialist.
2.2. The lines of reporting and accountability for professionals in all of the services to be clarified.
2.3. Audit should now be developed across the full range of drug services where standards around practice could be reviewed.
2.4. The audit process should also be used to monitor treatment drop-out.
2.5. The development of joint guidelines that would enable benchmarks to be set against which future audits could be measured. Such guidelines should be developed by a joint working group of the College of Psychiatry of Ireland and the ICGP with input from relevant other professional groups.
2.6. There is a need to link major expansion in delivery of drug treatment to prisoners with the community based services.
2.7. The Pharmaceutical Society of Ireland demonstrated an interest in playing a part in improving the standards of prescribing of benzodiazepines. This work needs further development and should be undertaken as soon as possible in order to reduce poor benzodiazepine prescribing practice across all sectors of services in the HSE.
2.8. Recommendation 10 from the Report of the Benzodiazepine Prescribing Committee (2002)3 should be implemented.
3. Enrolment of GPs, training of GPs, the criteria for level 1 and level 2 GPs, and the GP Co-ordinator role
3.1. It should be an expectation that all trainees completing GP professional training have demonstrable competence to meet criteria for level 1.
3.2. There is a need to expand the number of level 2 general practitioners.
3.3. There should be a stated time limit for patients to be with level 2 GPs and GP Co-ordinators should ensure that the patient moves on to a level 1 GP within 12 months.
3.4. Level 2 GPs are requesting a change of the cap on numbers to be raised from 35 to 50. We recommend that this be done.
3.5. The cap on the number of patients with level 1 GPs should be abolished.
3.6. The roles of the GP Co-ordinators should be overhauled and the task of moving patients from level 2 to level 1 GPs be prioritised, in conjunction with local management.
3.7. The model of GP nurse liaison practitioners who work to both support and move patients on should be further developed.
3.8. As new structures evolve the National GP Co-ordinator post should be reviewed.
4. Urinalysis testing, its appropriateness and efficacy
4.1. Frequent urine testing should be stopped.
4.2. The supervision of urine testing should be eliminated except where there is a legal requirement for supervision and that oral fluid or temperature testing be used to indicate whether a fresh sample is being provided.
4.3. The technology behind oral fluid testing has improved substantially and it is now possible to undertake on site saliva testing.
4.4. The clinical guidelines jointly developed by the ICGP and the College of Psychiatry of Ireland should include an implementation plan for the move to less urine testing and a greater clinical focus on the use of the results of drug testing samples.
4.5. Consideration should be given to piloting one or two contingency management treatment programmes to assess their viability.
4.6. It would be desirable to introduce a mechanism for periodic monitoring of the levels of supervision of substitution treatment.
5. Methadone prescribing in Garda stations
5.1. There is a need for a fundamental review of the procedures and systems for medical assessment of people in Garda custody.
5.2. There is a need for clear and explicit guidelines for the management of opioid dependence while in Garda custody. A working group with a relevant range of stakeholders should be urgently established.
5.3. The overall health care input to Garda stations should be reviewed with consideration that operational responsibility and financial aspects of this service be transferred to become a responsibility of the HSE.
5.4. The doctors attending Garda stations should be at a minimum level 2 trained GPs.
5.5. Doctors attending users in Garda stations should have access out of hours to the CTL and should also be able to obtain information from Pharmacists on the last time of medication dispensing.
5.6. Garda stations should come under the protocol.
6. Data collection, collation and analysis
6.1. In developing a care planning approach, consideration should be given to the broader utility of this data monitoring with a view to some brief outcome monitoring process being built into this, where the status of an individual is systematically recorded on a once-yearly basis.
6.2. There should ideally be a systematic approach that enables wider data linkage through possible use of the PPS number that would enable ongoing mortality and other service utilisation analysis. Such work would help in tracking the pathways and careers of service users and provide valuable information on the long term outcomes of users.
6.3. There is a need for legislative change to allow the linkage of data from different data sources.
6.4. We recommend the establishment of a group comprising the main data controllers so that maximum use can be made of the data collected, in a secure and confidential environment with appropriate privacy protection
7. Other
7.1. Handwriting exemption procedures should be introduced.
7.2. Nurse prescribing of controlled drugs should be explored and if possible developed further in line with international practice.
7.3. There is a need for better linkage and for ensuring priority access of prisoners to community based treatment after release from prison from all Irish prisons.
1.     Farrell M and Barry J (2010) The introduction of the Opioid Treatment Protocol. Dublin: Health Service Executive. Available at www.drugsandalcohol.ie/14458
2.     Methadone Prescribing Implementation Committee (2005) Review of the Methadone Treatment Protocol. Dublin: Department of Health and Children. Available at www.drugsandalcohol.ie/5962
3.     Benzodiazepine Committee (2002) Report of the Benzodiazepine Committee. Dublin: Department of Health and Children. Available at www.drugsandalcohol.ie/5348

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