Welcome to the Turning Point Red Envelope!

Welcome to the Turning
Point Red Envelope!
Opiate Substitution Therapy – What we are trying to achieve
Drug misuse has the potential to affect both personal and public health. It
is therefore important that we treat individuals in order to reduce risks
and the possibility of harm to society. Examples of key interventions
include needle exchange services and substitute prescribing.
Substitution therapy forms a significant part of the treatment of opiate
dependent drug users. Appropriate methadone maintenance treatment is
a proven method of reducing the risk and harm associated with substance
misuse.
Pharmacists and pharmacies play a crucial role in the treatment and
prevention of drug abuse. Pharmacists often provide information & advice,
control the availability of certain medicines and provide harm reduction
services such as the provision of methadone and buprenorphine.
We have created this Red Envelope to help provide information and clear
guidance for any professionals involved in the provision of treatment for
our clients.
Contents
Contacting Us
1
When to Contact Turning Point
2
Contacting Key workers
3
Pharmacy Hints & Tips
4
Missed Doses
5
Intoxicated Patients
6
Changed or Superseded Prescriptions
7
Supervised Consumption
8-9
Dispensing Protocol Information
10-11
Prescribing Policy Information
12-14
Patient Holiday Guidance
15
Relevant Legislation & Guidance
16
Tel: 0300 123 1186
Email: EastKentEnquiries@turning-point.co.uk
39/41 Wincheap
Canterbury, Kent
Page 1
Contacting Us
 If you are located within the East Kent region and would like to contact
Turning Point, please use our SPOC (Single Point of Contact) number below:
0300 123 1186
 This telephone number provides 24/7 access to Turning Point and can be used
at any time, any day for whatever the reason. You will be put through to a
member of Turning Point staff and your call will be transferred to the relevant
person whenever necessary/possible.
Tel: 0300 123 1186
Email: EastKentEnquiries@turning-point.co.uk
39/41 Wincheap
Canterbury, Kent
Page 2
When to Contact Turning Point:
Situations where you must contact us as soon as possible
Patients who exceed the 3 day rule
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After a patient has gone THREE days without their regular opioid dose, they may have lost
their tolerance to the prescribed drug and so are at risk of overdose if the usual dose is then
taken/given. It is therefore important NOT to dispense the opiate substitution therapy (OST)
after this amount of time has passed.
If this situation presents, it is crucial that your local Turning Point service is made aware no
later than day four, BEFORE the patient is supplied with any medication.
See ‘Missed Doses’ section for more details.
Intoxicated patients
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There is risk of overdose if methadone is administered to a patient under the influence of
certain drugs and/or alcohol. The pharmacist may therefore deem it unsafe to
administer/provide patients with OST who are intoxicated.
The pharmacist must contact Turning Point as soon as possible if a patient presents to the
pharmacy intoxicated, especially if the patient’s dose of OST is not given.
See ‘Intoxicated Patients’ section for more details.
Concerns
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Although not an exhaustive list, the following concerns should be reported to Turning Point:
 Unacceptable behaviour when visiting the pharmacy
 Concerns about health, behavioural or other relevant problems seen in the patient
 Requests for help that the pharmacist is unwilling or unable to meet
 Child protection or other safeguarding concerns
Tel: 0300 123 1186
Email: EastKentEnquiries@turning-point.co.uk
39/41 Wincheap
Canterbury, Kent
Page 3
Contacting Key workers:
The Four-Way Agreement
 The ‘Four-Way agreement’ is a document used to clarify the rights and
responsibilities of parties involved in the client’s treatment, essential points of
contact and any issues associated with the prescribed medication, and is
signed by the Key Worker, Prescriber, Patient and Pharmacist. It should
provide basic information about a particular patient’s Key Worker, including
name and contact details.
If useful, you may use this section of the folder to file away
any completed four way agreements.
 It should be noted that a patient’s key worker may often change. If you are
unable to contact a certain key worker or have any questions, please don’t
hesitate to contact us using the 24/7 telephone number stated at the bottom
of this page and within the ‘contacting us’ section of this folder.
Tel: 0300 123 1186
Email: EastKentEnquiries@turning-point.co.uk
39/41 Wincheap
Canterbury, Kent
Page 4
Pharmacy Hints & Tips:
How to make supplying Opiate Substitution Therapy as easy as possible
for you and your team
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Check prescriptions on receipt, not when you need to start supplying from them. This allows time for
any mistakes or queries to be addressed.
Where space allows, doses should be prepared, fully labelled, in advance and stored in the controlled
drugs cabinet to avoid undue delay or disruption to other processes when the patient presents to the
pharmacy.
It is reasonable for pharmacists to ask patients to allow sufficient time for daily doses to be prepared
in the morning before they present. For patients who need to attend first thing (e.g. because of work
or family commitments), it is recommended that the pharmacist encourage patients to notify the
pharmacy of this in advance so that their dose can be prepared first or ideally beforehand.
Offer privacy in your consulting room for the consumption of supervised medicines.
Offer a drink of water after supervised methadone (to ensure swallowing) or before supervised
buprenorphine (to speed up disintegration). Engage in conversation, again this helps to check
swallowing.
Patients in receipt of Opiate Substitution Therapy (OST) prescriptions who inject drugs may continue
to do so, especially in the first few months of treatment. Pharmacists should be reassured that ongoing substance use and injecting are assessed as part of clinical review. Pharmacists who are
concerned about the health of an on-going injector are encouraged to share their concerns with the
Turning Point prescriber.
Pharmacists who are part of Needle and Syringe Programmes (NSPs) should meet requests for
injecting equipment made by OST patients and accompany supply with appropriate advice about
reduction of overdose risks. All Turning Point hubs provide naloxone to people at risk of opiate
overdose. Patients should be referred to Turning Point for naloxone supply if appropriate.
Communication with locum pharmacists is crucial and often overlooked. It is important that locums
are made aware of any issues/changes regarding Turning Point service users to prevent any easily
avoidable mistakes from occurring.
Ensure that the ‘3 day rule’ is applied (see page 5).
Ensure you know how to respond to intoxicated people presenting for OST (see page 6).
The pharmacist may deem it necessary to reinforce any advice against driving and operating
machinery due to the sedative effects of the medication. For example when the dose is consumed on
the premises and the cautionary wording on the label may not be read by the patient. Similarly it is
expected that pharmacists will discuss and monitor for side effects where appropriate, reporting
these to prescribers, as appropriate.
Tel: 0300 123 1186
Email: EastKentEnquiries@turning-point.co.uk
39/41 Wincheap
Canterbury, Kent
Page 5
Missed Doses
 After a patient has gone THREE days without their regular opioid dose,
they may have lost their tolerance to the prescribed drug and so are at
risk of overdose if the usual dose is then taken/given. It is therefore
important NOT to dispense the medication after this amount of time has
passed before checking with the prescriber.
 If this situation presents, it is crucial that your local Turning Point service
is made aware no later than day four, BEFORE the patient is supplied
with any medication.
 The risks associated with methadone are higher compared to
buprenorphine; however there is as yet little evidence to suggest we
should implement different procedures for each drug. We therefore
apply the same ‘three day rule’ for both substances.
 It is also useful to notify Turning Point of any trends in missed doses e.g.
the patient always misses pick-up on one day of the week. Similarly if
patients miss ANY doses during titration, please inform us.
 If this situation presents at the weekend, or when Turning Point are
closed, pharmacists are advised to continue to follow this guidance (and
notify the 24 hour SPOC number ) unless their professional judgement
leads them to conclude that it is in the patient’s best interests to do
otherwise.
Tel: 0300 123 1186
Email: EastKentEnquiries@turning-point.co.uk
39/41 Wincheap
Canterbury, Kent
Page 6
Intoxicated Patients
 There is risk of OVERDOSE if methadone is administered to a patient
under the influence of certain drugs and/or alcohol. The pharmacist may
therefore judge it unsafe to administer/provide patients with
methadone who are intoxicated.
 It is important to remember that there may be risks associated with not
supplying the patient with their substitution therapy and so professional
judgement needs to be applied at all times.
 It may be appropriate for the pharmacist to ask the patient to return
later in the day when sober to reassess whether the dose can then be
given.
 The pharmacist must contact Turning Point as soon as possible if a
patient presents to the pharmacy intoxicated. When a dose is not given
Turning Point must be informed as soon as possible.
 If the dose is being withheld but the patient collects multiple doses at
once, it may be an idea to involve the patient’s family or friends (with
consent and using professional judgement).
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Remember: Always contact Turning Point.
Tel: 0300 123 1186
Email: EastKentEnquiries@turning-point.co.uk
39/41 Wincheap
Canterbury, Kent
Page 7
Changed or Superseded Prescriptions
 If there is a change in dose part way through a prescription, the pharmacist
should be advised by a recovery worker from Turning Point, over the
telephone.
 The new prescription will then be sent to the pharmacy with a note advising of
the change, usually stapled to the prescription. Details of the change are also
normally given (i.e. increase, decrease, change of pick up days etc.).
 If the pharmacist has any unused prescriptions with the old instructions on
them, these must have a line put through them and be returned back to the
local Turning Point service. Any prescriptions changed part way through
should have the remaining pick up sections on the right hand side of the
FP10MDA crossed through and be sent for payment.
 Please ensure that any outdated or cancelled prescriptions are filed away
immediately and returned as quickly as possible to help avoid any potential
dispensing errors.
 The above points have been summarised in the diagram below:
Recovery worker from Turning Point will inform the pharmacist of
any dose changes associated with current clients/prescriptions.
New prescription sent to the pharmacy (with a note advising the
nature of the change).
Unused (superseded) prescriptions should be cancelled through and sent back
from the pharmacy to Turning Point as soon as possible.
Tel: 0300 123 1186
Email: EastKentEnquiries@turning-point.co.uk
39/41 Wincheap
Canterbury, Kent
Page 8
Supervised consumption
 When supervised consumption is requested on a prescription, the Opiate
Substitution Therapy (OST) must be consumed on the pharmacy premises
under the supervision of the pharmacist.
 Note: the pharmacist remains responsible for the supply if he/she chooses to
delegate supervision to another staff member.
 Supervised consumption should take place in a quiet, private area, normally
the consultation room.
 If the patient explicitly refuses privacy, it should still be offered periodically
where possible as the patient may change his/her mind. Supervision should
not take place in the dispensary.
 The pharmacist must be satisfied that the dose of OST has been consumed by
the patient.
 For methadone, it is recommended that the patient is offered a drink of water
AFTER taking their dose. This helps to confirm the swallowing of the
medication and helps reduce the methadone from sticking to teeth.
 For buprenorphine, it is recommended that the patient is offered a drink of
water BEFORE taking their dose. This is because buprenorphine is taken
sublingually and water helps to wet the oral mucosa and facilitates
disintegration/dissolution of the dosage form. It may take up to 10 minutes
for some formulations to be fully consumed, although the drug is reported to
be released sooner.
 Patients should be encouraged to participate in conversation in order to
reassure the supervisor that the dose has been taken.
Tel: 0300 123 1186
Email: EastKentEnquiries@turning-point.co.uk
39/41 Wincheap
Canterbury, Kent
Page 9
Supervised consumption
Stopping supervision:
 The stopping or relaxation of supervised consumption should be a stepped
process, commencing when a patient first stops taking doses observed by a
pharmacist but still remains on a regime that requires daily dispensing.
 After further progress is made, the frequency of dispensing may be reduced.
 Supervised consumption should only be stopped/relaxed if the prescriber is
certain that good compliance will be maintained and that it is safe to do so.
 Doses to be taken home should not usually be prescribed or given if (taken
from the DoH drug misuse and dependence guidelines):
 a patient has not reached a stable dose
 the patient shows a continued and unstable pattern of drug misuse
 the patient has a significant, unstable psychiatric illness or is
threatening self-harm
 there is continuing concern that the prescribed medicine is being, or
may be, diverted or used inappropriately
 there are concerns about the safety of medicines stored in the home
and possible risk to children
Supervised consumption is a two way process, it may be reinstated again at times of
instability. Pharmacists are well placed to identify times of instability and are
encouraged to share their concerns with prescribers.
Pharmacists are also well placed to identify concerns about vulnerable others such as
children. All pharmacies should have a safeguarding policy in place. Pharmacies are
reminded that any concerns about take home OST and risks to children should be
shared with the prescribing team. Pharmacists are expected to discuss safe storage
with any OST client on take away dosing.
Tel: 0300 123 1186
Email: EastKentEnquiries@turning-point.co.uk
39/41 Wincheap
Canterbury, Kent
Page 10
Dispensing Protocol
 Separate Standard Operating Procedures (SOPs) should be established for the
dispensing of instalment prescriptions for both methadone and
buprenorphine. These should already be in place within every pharmacy and it
is of the responsibility of the pharmacist to ensure that they are followed.
 It is a legal requirement that all daily dispensing of Schedule 2 controlled
drugs is entered in the CD register within 24 hours, in chronological order.
Best practice however recommends entry is done on the day of supply as soon
as possible.
 Remember: It is reasonable for pharmacists to ask patients to allow sufficient
time for daily doses to be prepared in the morning before they present. For
patients who need to attend first thing (e.g. because of work or family
commitments), it is recommended that the pharmacist encourage patients to
notify the pharmacy of this in advance so their dose can be prepared first.
 An example SOP for the dispensing of methadone can be seen at the following
web address:
http://pharmacysop.com/PDF%20format%20SOP%27s/Dispensing%20Metha
done%20SOP.pdf
 The following page will give a brief overview of the dispensing of both
methadone and buprenorphine. It is your responsibility to ensure that all of
the steps mentioned (at the very least) are included in your pharmacy’s SOPs.
Tel: 0300 123 1186
Email: EastKentEnquiries@turning-point.co.uk
39/41 Wincheap
Canterbury, Kent
Page 11
Dispensing Protocol
1. Daily doses of methadone from FP10MDA should be prepared
as follows:
 Measure, double check and dispense in a suitable leak-proof container.
 Attach a dispensing label to container. This must state the patient name,
directions, quantity and date of supply. Use a new container each time.
 Ensure that any take home doses are fitted with child resistant closures
and clearly labelled as above.
 The pharmacist should mark the date and quantity prepared on the
prescription at the time of dispensing. These should be initialled as
supplied at the time of collection/supervised consumption. Missed doses
should be endorsed ‘Not dispensed’.
2. Daily doses of buprenorphine or other solid oral dosage forms
from FP10MDA should be prepared as follows:
 Count, double check and dispense in a suitable cardboard box.
 Attach a dispensing label to the box. This must state the patient name,
directions, quantity and date of supply.
 Ensure that any take home doses are also supplied in an appropriate
labelled box.
 The pharmacist should mark the date and quantity dispensed on the
prescription at the time of dispensing. These should be initialled as
supplied at the time of collection/supervised consumption. Missed doses
should be endorsed ‘Not dispensed’. All occasions on which a patient fails
to attend should be recorded on the prescription.
Tel: 0300 123 1186
Email: EastKentEnquiries@turning-point.co.uk
39/41 Wincheap
Canterbury, Kent
Page 12
Prescribing Policy Information
Aims and Objectives:
 To support clients to:
 recover from dependency
 reduce harm to themselves
 reduce harm to others
 achieve measurable positive change
 Offer clients an alternative to using illicitly obtained and ‘street’ drugs. This is an
important part of a client’s recovery plan and enables individuals to curtail/stop
their illicit drug use.
Before Prescribing:
 Before prescribing substitute medication, a comprehensive assessment and a
recovery/treatment plan are agreed with the client.
 When prescribing decisions regarding Opiate Substitution Therapy (OST) are
made, a risk assessment is done. Where appropriate this is shared with relevant
partner agencies, such as children’s social services.
Supervised Consumption:
 Turning Point will endeavour to ensure that supervised consumption is available
for all clients who need it for a length of time appropriate for their individual
situation. Current guidance recommends that this is usually around 3 months.
 This prescribing needs to be monitored by a doctor or non-medical prescriber
(NMP). It requires regular visits by the patient to a community pharmacy.
 See ‘Supervised Consumption’ section (page 9) for more information.
Tel: 0300 123 1186
Email: EastKentEnquiries@turning-point.co.uk
39/41 Wincheap
Canterbury, Kent
Page 13
Prescribing Policy Information
Methadone:
 Commencement dose:
 The use of other drugs is taken into account and heavy or binge drinking
may preclude or limit the prescribing of methadone depending on an
assessment of risk.
 If tolerance is low or uncertain the initial dose will usually be in the range
of 10-20mg.
 With heavily dependent misusers who are tolerant and where the
clinician is competent, a first dose can be up to 40mg. It is generally
considered unwise to exceed this dose.
 Most service users receiving prescribed methadone in the community must
have their methadone consumption supervised at their local pharmacy for the 3
months; this must then be reviewed regularly.
 Stabilisation dose:
 Dosage should be just sufficient to prevent withdrawal symptoms.
 Higher doses may be necessary for some clients who are free of physical
withdrawal symptoms but who feel unable to cope psychologically. This
will usually be established through thorough assessment, monitoring and
discussion with the Turning Point team and prescriber.
 Ideally community clients will be assessed daily during the first few days
to allow titration according to withdrawal symptoms, with dose
increments of 5-10mg daily if needed (with the totally weekly increase
not normally exceeding 30mg above the commencement dose).
 After the first week, subsequent increases should not exceed 30mg per
week up to a usual maximum dose of 120mg. Optimal doses are usually
between 60 to 120mg, however higher doses are sometimes needed.
Tel: 0300 123 1186
Email: EastKentEnquiries@turning-point.co.uk
39/41 Wincheap
Canterbury, Kent
Page 14
Prescribing Policy Information
Buprenorphine:
 Buprenorphine offers an alternative opiate substitution to methadone in people
who are motivated to stop using opiates altogether. It is an opioid partial
agonist and so can be used as a substitution therapy in patients with moderate
opioid dependence. However on top use can still result in overdose.
Buprenorphine may improve mood and is safer on its own in overdose hence it
has a role in the longer-term treatment of selected cases, namely:
 the patient is at high risk of overdose
 where methadone causes general unease or discomfort or unacceptable
side effects
 the patient is sensitive to methadone or one of the other ingredients in
the medicine
 Induction Procedure:
 clients must be informed that they should not use heroin for at least 8-12
hours and should expect to be experiencing some symptoms of
withdrawal prior to starting buprenorphine
 the safest option is dose titration against the dosage of street opiates,
starting low to avoid precipitated withdrawal and increasing rapidly
 Stabilisation (dose titration procedure):
 day 1: Up to 4mg (n.b. BNF first day max is 4mg but second dose may be
given 4 hours later if showing no evidence of precipitated withdrawal).
 day 2: Increase by 2-8mg if withdrawal present. Decrease if there are
signs of intoxication
 day 3: Increase day 2 dose by 2-8mg if withdrawal present. Decrease day
2 dose if signs of intoxication
 stable dose range is 4-24mg per day. Maximum dose is 32mg
Tel: 0300 123 1186
Email: EastKentEnquiries@turning-point.co.uk
39/41 Wincheap
Canterbury, Kent
Page 15
Guidance for Patient Holidays
If travelling within the UK:
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Patients on daily supervised consumption must have a pharmacy identified in the
area being visited. Daily supervised consumption must be arranged if possible or if
not, daily pick up must be arranged by the key worker.
Patients on daily pick up or twice weekly pick up should continue this arrangement
with a pharmacy identified in the area being visited.
Patients on weekly pick up may be given the prescribed medication in one
instalment to take away with them. The amount should not exceed 1000mg of
methadone.
If travelling outside of the UK:
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The patient must demonstrate that a flight/travel has been booked by providing
evidence such as a valid ticket or booking confirmation containing the name of the
patient.
The holiday duration should not be longer than TWO WEEKS.
A letter signed by the prescribing doctor detailing the medication the patient is
carrying should be issued to the patient.
Certain countries will also not allow the import of certain drugs into their country,
the patient should check this requirement with the appropriate consulate
http://www.homeoffice.gov.uk/publications/alcohol-drugs/drugs/druglicences/embassy-list
Further information can also be found on this website:
http://indro-online.de/travel.htm
Safe Storage Boxes:
 It may be necessary to recommend the use of a safe storage box while the patient is
away on holiday, especially if children are present or the patient is staying in less
secure accommodation (e.g. tents). Safe boxes are available from Turning Point.
Tel: 0300 123 1186
Email: EastKentEnquiries@turning-point.co.uk
39/41 Wincheap
Canterbury, Kent
Page 16
Relevant Guidance
 Drug Misuse and Dependence: UK Guidelines on Clinical Management
2007: http://www.nta.nhs.uk/uploads/clinical_guidelines_2007.pdf
 NICE Drug Misuse guidance & guidelines page:
https://www.nice.org.uk/guidance/health-protection/drug-misuse
 NICE Pharmacological Interventions in Opioid Detoxification for Drug
Misuse treatment pathway: http://pathways.nice.org.uk/pathways/drugmisuse#path=view%3A/pathways/drug-misuse/pharmacologicalinterventions-in-opioid-detoxification-for-drug-misuse.xml&content=viewindex
 NICE (2007) Drug Misuse – Opioid detoxification clinical guidance:
https://www.nice.org.uk/guidance/cg52
 Non-medical prescribing, patient group directions, and minor ailment
schemes in the treatment of drug users, NTA, 2007:
http://www.nta.nhs.uk/uploads/nta_non_medical_prescribing_1207.pdf
 NICE (2010) Pregnancy and complex social factors: a model for service
provision for pregnant women with complex social factors:
https://www.nice.org.uk/guidance/cg110
For Pharmacy Teams:
CPPE open learning package on Substance Use & Misuse:
https://www.cppe.ac.uk/learningdocuments/pdfs/substanceuse_ol.pdf
Tel: 0300 123 1186
Email: EastKentEnquiries@turning-point.co.uk
39/41 Wincheap
Canterbury, Kent