CD Instalment Prescriptions PDF

WEEK 15 Controlled Drugs Part 3: CD Instalment Prescriptions John Sherwood MRPharmS 6th November 2024 Slide 1 of 19 OSPAP MPHM15 Controlled Drugs: Instalment Prescriptions WEEK 15...

WEEK 15 Controlled Drugs Part 3: CD Instalment Prescriptions John Sherwood MRPharmS 6th November 2024 Slide 1 of 19 OSPAP MPHM15 Controlled Drugs: Instalment Prescriptions WEEK 15 Learning outcomes Define addiction and list the three components of being addicted to an opioid Understand ‘harm reduction’ and list the three principles Describe the legal requirements for a FP10MDA prescription and know what records to make Explain Home Office approved wording and know what scenarios are covered Describe what action to take when a patient’s representative wishes to collect their dose Be aware of clinical concerns, as well as legal issues, when a patient misses one or more doses of their opioid Slide 2 of 19 OSPAP MPHM15 Controlled Drugs: Instalment Prescriptions WEEK 15 What is ‘addiction’? A person is regarded as being an addicted to a drug ‘if, and only if, s/he, as a result of repeated administration, become so dependent on a drug that s/he has an overpowering desire for the administration of it to be continued’ There are three components of addiction: Physical dependence Psychological dependence Tolerance Slide 3 of 19 OSPAP MPHM15 Controlled Drugs: Instalment Prescriptions WEEK 15 Harm Reduction ‘Harm reduction’ is intended to reduce adverse effects of drug misuse as far as possible until the misuser has decided, or is able, to stop misusing the drug Three principles of harm reduction: Misuse of drugs is accepted but not approved of User should be treated as a normal human being Harm reduction need not necessarily lead to the longer-term goal of ridding the world of drug misuse Methadone or buprenorphine are used (although increasing evidence for other approaches such as diamorphine) Best used in conjunction with psychosocial support Programmes can be maintenance or detoxification A complete history is needed on entering a treatment programme to assess current drug use (usually done alongside toxicology screening) Prescribing is then tailored to the individual requirements Slide 4 of 19 OSPAP MPHM15 Controlled Drugs: Instalment Prescriptions WEEK 15 What can be prescribed to treat addiction? In England, the prescription form FP10MDA is used for instalment prescribing by both drug treatment centres and GPs A maximum of 14 days supply of any Schedule 2 CD, buprenorphine and diazepam can be prescribed for the treatment of addiction using the FP10MDA form Doctors may prescribe cocaine, diamorphine or dipipanone to treat addiction if they have a license from the Home Office (no license is needed to prescribe diamorphine or dipipanone for the treatment of pain) – refer to CD supply lecture Slide 5 of 19 OSPAP MPHM15 Controlled Drugs: Instalment Prescriptions WEEK 15 FP10MDA prescription requirements The same legal requirements as for any CD prescription In addition, the prescription must also include an ‘instalment direction’ which consists of two pieces of information: 1) Amount of medicine per instalment 2) Interval between each instalment It is a legal requirement that the instalment amount and the dose are specified separately on the prescription Prescriptions may also include certain Home Office approved wording (not a legal requirement) – see later The prescription must be marked with each date of dispensing The prescription does not have to specify a start date – if it does not, the first dispensing must be within 28 days of the appropriate date If a start date is specified, it must be complied with and the instalment directions run from that date Slide 6 of 19 OSPAP MPHM15 Controlled Drugs: Instalment Prescriptions WEEK 15 Pharmacy Stamp Age Title TitleForename, Forename,Surname Surname&&Address 1 Sarah Smith Address Graeme 19 Smith Balaclava Street D.o.B 28, Chester Sunderland Street Sunderland Number of day’s treatment N.B. Ensure dose is stated Endorsements Methadone liquid 1mg/mL Take 50mL daily Dispense 50mL each day starting on 6/11/24 Total quantity: seven hundred mL (700mL) Signature of Prescriber Date Jan Ulrich 1.08.2024 For Dispenser No. of Prescns. Dr J.M Ulrich 350897 on form HEALTH CENTRE COUNCIL AVENUE WORTOON WN3 6SB TEL: 01914 733245 NHS 0155200001JS58 FP10 MDA0899 Slide 7 of 19 OSPAP MPHM15 Controlled Drugs: Instalment Prescriptions WEEK 15 Methadone Methadone is metabolized slowly (compared to other morphine-based drugs) and is also quite lipophilic, thus, it has a half life of around 22 hours (although this is variable) Given once a day Available in liquid form, tablets and injection Care is needed with liquid form: Methadone oral solution 1mg/mL Methadone oral solution sugar free 1mg/mL Methadone linctus 2mg/5mL Methadone oral solution concentrate 10mg/mL Methadone oral solution concentrate 20mg/mL Slide 8 of 19 OSPAP MPHM15 Controlled Drugs: Instalment Prescriptions WEEK 15 Buprenorphine (Subutex®) Buprenorphine is an opioid partial agonist Less sedating than methadone It can be used as substitution therapy for patients with moderate opioid dependence Care when dispensing Slide 9 of 19 OSPAP MPHM15 Controlled Drugs: Instalment Prescriptions WEEK 15 Supervision of patients in the pharmacy Pharmacists are sometimes required to supervise administration of methadone and Subutex to prevent the patient selling unused medicine and to ensure adherence Subutex tablets can take up to 10 minutes to dissolve and this has implications for both the patient and the supervising pharmacist Crushing buprenorphine sublingual tabs is outside the manufacturer’s marketing authorisation and this will render the product unlicensed A pharmacist may assume some liability for the supply of a product outside its licensed indication(s) The prescriber and the patient should agree to the tablets being crushed before administration and the patient should be informed of the risks and the benefits of crushing. Any crushing of tablets should be for the benefit of the patient, rather than the convenience of the pharmacist Slide 10 of 19 OSPAP MPHM15 Controlled Drugs: Instalment Prescriptions WEEK 15 Collection by a patient’s representative (1) - Unsupervised doses Where a third party collects a CD for a patient being treated for drug addiction, although not a legal requirement, it is good practice that a letter of authorisation from the patient is obtained on every occasion that the representative collects the medicine, and that the letter should be retained in the pharmacy. The prescription does not have to state the medication can be collected by a third party for this to be allowed The pharmacist needs to be satisfied that the letter is genuine It is good practice to insist on seeing the patient at least once a week, unless this is impractical This also applies if a patient is detained in police custody Slide 11 of 19 OSPAP MPHM15 Controlled Drugs: Instalment Prescriptions WEEK 15 Collection by a patient’s representative (2) – Supervised doses ‘Supervision’ is not a legal requirement/statement on a FP10MDA The pharmacist can contact the prescriber to see if they are agreeable to have the supply given to a representative rather than it being supervised Verbal confirmation by the prescriber is acceptable but this should be documented Confirmation from the prescriber is not necessary if the patient is in police custody as the administration of all schedule 2 and 3 CDs will be supervised by a healthcare professional The prescription and PMR should be annotated to show that the dose has not been supervised Slide 12 of 19 OSPAP MPHM15 Controlled Drugs: Instalment Prescriptions WEEK 15 Pharmacy Stamp Age Title Forename, Surname & Address Title Forename, Surname & Sarah Smith Yesterday (5/11) the patient failed 1 Address D.o.B 19 Graeme Balaclava Street Smith to turn up at the pharmacy to Sunderland 28, Chester Street Sunderland collect their first instalment. Number of day’s treatment N.B. Ensure dose is stated Endorsements Methadone Liquid 1mg/mL Today (6/11), the patient turns up Take 50mL daily Dispense 350mL on 5/11/24 and asking for a supply of methadone. 350mL on 12/11/24 Total quantity seven hundred mL (700mL) 1) Can you supply him with the full quantity of the first instalment? 2) Can you supply him with the Signature of Prescriber Date quantity of the first Jan Ulrich 1.11.2024 instalment, less the quantity For Dispenser No. of Dr J.M Ulrich 350897 that he missed yesterday (i.e. supply 300mL)? Prescns. on form HEALTH CENTRE COUNCIL AVENUE WORTOON WN3 6SB TEL: 01914 733245 NHS 0155200001JS58 FP10 MDA0899 Slide 13 of 19 OSPAP MPHM15 Controlled Drugs: Instalment Prescriptions WEEK 15 Home Office approved wording (1) Wording has been approved by the Home Office to allow the pharmacist some flexibility when making the supply due to various possible scenarios The approved wording is not included in legislation but the fact that the wording has been approved by the Home Office gives the pharmacist some degree of protection against the consequences of supplying against a strictly unlawful prescription The wording consists of five statements that can be used individually or combined An instalment prescription that contains wording different from that approved by the Home Office would not provide the dispensing pharmacist the security conferred by a prescription containing approved Home Office wording Slide 14 of 19 OSPAP MPHM15 Controlled Drugs: Instalment Prescriptions WEEK 15 Home Office approved wording (2) The five statements are: 1) Please dispense instalments due on pharmacy closed days on a prior suitable day 2) If an instalment’s collection day has been missed, please still dispense the amount due for any remaining day(s) of that instalment 3) Consult the prescriber if three or more consecutive days of a prescription have been missed 4) Supervise consumption on collection days 5) Dispense daily doses in separate containers Wording may not always be necessary, and it is up to the prescriber if they wish to include it on a prescription Slide 15 of 19 OSPAP MPHM15 Controlled Drugs: Instalment Prescriptions WEEK 15 What if a patient misses a dose? Generally, if a patient misses a daily dose, the prescriber should be made aware of this If, however, the patient misses three consecutive daily doses, then generally the prescription will be stopped and the patient will have to be reassessed by the prescriber. There is approved wording that covers this but usually the local Drug Treatment Centre will have a policy about this Generally, if a patient misses three or more consecutive doses they may have to be titrated back up to their ‘optimum’ dose and their current dose should not be dispensed, pending advice from the prescriber Slide 16 of 19 OSPAP MPHM15 Controlled Drugs: Instalment Prescriptions WEEK 15 Why dispense in daily dose bottles? Some patients will collect more than one day's doses at a time (e.g. see prescription on slide 13) The methadone may be supplied in several individual bottles each containing one day's dose or one bottle containing all the doses This is an important patient safety issue There are overdosing /underdosing concerns if patients measure their own dose from a multiple dose bottle There is also evidence of patients using measures such as baby’s bottles to measure doses - as little as 5ml of methadone can kill a baby if a residual amount is left in the bottle Dispensing daily doses is safer and good practice regardless of whether there is Home Office approved wording on the prescription Slide 17 of 19 OSPAP MPHM15 Controlled Drugs: Instalment Prescriptions WEEK 15 Disposing of methadone bottles Methadone bottles (stock bottles or patient dispensed bottles) should be rinsed and the liquid added to a CD denaturing kit (and the kit added to the pharmaceutical waste when full) – see CD Lecture Part 2 for disposal of CD liquids Liquid waste medicines must not be poured down the sink or toilet as a method of disposal It is not necessary to record the disposal of these rinsings Dispensing labels must be removed or obliterated before the clean, empty container is disposed of in the ‘ordinary’ waste Slide 18 of 19 OSPAP MPHM15 Controlled Drugs: Instalment Prescriptions WEEK 15 Preparing and dispensing extemporaneous methadone mixture Please refer to information included in the ‘Licensing’ lecture (next week!) Also see MEP (online – search ‘methadone’ then select ‘Extemporaneous methadone’) Slide 19 of 19 OSPAP MPHM15 Controlled Drugs: Instalment Prescriptions