Safe storage of methadone takeaway doses – a survey of patient practice
Dr Adam R. Winstock, Drug Health Services, Sydney South West Area Health Service, Locked Bag 4002, Ashfield, New South Wales 2131. Fax: (02) 9378 1338; e-mail: email@example.com
Objective: To determine current methadone takeaway storage practice among patients receiving supervised methadone treatment and takeaway doses at community pharmacies.
Methods: A cross-sectional survey was conducted in 2006 in Sydney, New South Wales. It addressed: safe storage of methadone takeaways; knowledge of risk of methadone ingestion by small children; and information provision from health care providers about the safe storage of methadone.
Results: Eighty-seven patients participated in the survey. The majority stored their methadone takeaways in a cupboard (48%) or secure cabinet (34%). All but one participant were aware of the risks of methadone ingestion by small children. Eighty-seven per cent had discussed safe storage of takeaways with a health professional.
Conclusions: Most patients receiving methadone takeaways store them safely and are aware of the risk that methadone ingestion poses to children.
Implications: Clinicians should ensure patients are adequately informed about safe takeaway storage and the risk of methadone ingestion by children.
Methadone is the most common medication used for the treatment of opioid dependence in Australia and internationally.1 In Australia, all methadone prescribed for opioid dependence is an oral liquid formulation in the ratio 5 mg/ml. Most clinical guidelines support daily doses of at least 50-60 mg to achieve optimal treatment outcomes.2–5 Because of the risks associated with the consumption of methadone by non-tolerant people and risks associated with diversion and injection,6–8 many Australian jurisdictions have advocated the routine provision of supervised dosing of methadone from either specialised clinics or community pharmacies. Such a response has been driven by research that identifies that the majority of illicit methadone is sourced from diverted takeaway doses.7,9 Guidelines vary over the provision of takeaway doses in different Australian jurisdictions, but in general are only provided following a period of stability in treatment and regular monitoring.9 In New South Wales (NSW), there are 37 public clinics and more than 600 community pharmacies providing methadone treatment. Public clinics focus on inducting and stabilising new-to-treatment clients. The majority of public clinics do not routinely provide takeaway doses. After a period of at least three months, if clients are considered stable, dosing may be transferred to a community pharmacy, where the possibility of receiving regular takeaway doses is available. NSW Health permits the prescribing of a maximum four methadone takeaway doses per week with a supervised dose required at least once every three days.2 In NSW, takeaway methadone doses are not required to be diluted by the pharmacist before dispensing to the patient.9
Perhaps the most tragic potential consequence of the provision of takeaway doses is the possibility that methadone may be consumed by a child. As a result of recent public and political concerns over a number of high-profile child deaths associated with methadone,10 NSW Health in collaboration with the NSW Department of Community Services (DoCS) has developed a patient information sheet describing the risks associated with the consumption of methadone by small children and advice on safe storage of takeaway doses.11 The occurrence of methadone-related deaths in children is rare and episodic. In NSW, there were no methadone-related child fatalities in 2004, while in 2005 there were three.10 One of these cases involved a takeaway methadone dose and one involved street-purchased methadone. The source of methadone in the third case was not determined. In the two-year period to June 2006 there were 12 non-fatal methadone-related presentations to hospitals in children.10 While the nature of ingestion (whether by accidental or intentional provision) is difficult to ascertain with confidence, good clinical assessment and accurate information provision should be an effective intervention to reduce accidental ingestion. With this consideration, the patient information sheet11 was recently provided to all patients on methadone treatment in NSW.
Prior to this information campaign, a survey was conducted exploring methadone takeaway storage among a group of patients receiving supervised methadone and takeaway doses from a community pharmacy.
Nursing unit managers at the five public opioid treatment clinics located in Sydney South West Area Health Service (SSWAHS) were asked to select up to three case managers from their clinic to take part in this study. Eligible patients were those who were case managed and prescribed to by the public clinic, but dispensed methadone (both supervised and takeaway doses) from a community pharmacy. Case managers were asked to survey all eligible patients attending the public clinic for clinical review during September 2006. No patients refused to participate in the survey.
Case managers were provided with a standard script to read to eligible patients outlining the nature of the survey and its purpose. A self-complete questionnaire was developed, derived from previous research exploring storage of methadone takeaways.12,13 The questionnaire addressed previous information provision about methadone takeaway storage, takeaway storage practice, and knowledge of risks to children associated with methadone takeaways. Following completion of the questionnaire, patients were provided with a pre-existing information sheet about appropriate methadone takeaway storage and child risk.
Ethical approval for this study was obtained from the SSWAHS Human Research Ethics Committee.
A total of 87 patients participated in the survey. The mean age was 38.0 years and 59% were male. The mean daily methadone dose was 84.2 mg (SD 34.4; range 15-165 mg). Participants were in receipt of a mean three takeaway methadone doses each week (SD 1.2; range 1-4).
The majority of participants (93%, n=81) reported that they always stored their takeaways in the same location. The most common location takeaways were stored were a cupboard or wardrobe (48%, n=42), or in a medicine cabinet or other secure box (34%, n=30). A minority of participants reported storing their takeaways in the fridge (7%, n=6). Further information on takeaway storage practices is provided in Table 1.
Table 1. Location and protective mechanism for storage of methadone takeaways.
|Cupboard/wardrobe||11 (10)||26 (23)||10 (9)|
|Medicine cabinet/other box||22 (19)||13 (11)||0|
|Fridge||1 (1)||2 (2)||3 (3)|
|Other (bag, on person)||0||0||10 (9)|
Forty-seven per cent (n=41) of participants had children under 16 years of age living with them. Forty-seven per cent (n=41) had children under 16 years of age who visited regularly or occasionally. Table 2 displays self-reported awareness of risks associated with methadone takeaways and the accessibility of stored takeaways by children, comparing the responses of participants living with children under the age of 16 with the responses of all participants.
Table 2. Self-reported risk awareness and accessibility of stored takeaways by children.
|Are your takeaways stored out of reach of small children?||92% (80)||100% (41)|
|Can the place where you keep your takeaways stored be locked by a key or combination lock?||62% (54)||71% (29)|
|Are you aware that very small amounts of methadone (as little as 1-2 mls) can be deadly to small children?||99% (86)||100% (41)|
|Do your children know where your takeaways are stored?||N/A||12% (5)|
|Have you told your children of the risks associated with your methadone?||N/A||68% (28)|
The proportion of participants who had discussed safe storage of takeaways with a case manager was 85% (n=74), with a doctor 80% (n=70), and with a pharmacist 62% (n=54). Thirteen per cent (n=11) reported that they had never discussed safe storage of methadone takeaways with a doctor, case manager or pharmacist.
Participants were asked to report what they did with their empty takeaway bottles. The majority reported that they threw them in the rubbish (85%, n=74) and 11% (n=10) returned them to where they were picked up. Sixty-seven per cent (n=58) reported that they rinsed the bottle out and 68% (n=59) removed the label before discarding.
The results suggest that the vast majority of people in receipt of methadone takeaways in this study are aware of the dangers that small amounts of methadone pose to small children and appear to take adequate precautions to ensure that takeaway doses are stored out of reach of children. Overall, 97% of participants reported either storing their takeaways in a place that could be locked or storing it out of reach of children. This compares favourably with results from other studies from the United Kingdom where 49%13 and 73%12 of patients were considered to store their methadone takeaways safely.
It was encouraging that more than 80% reported that the issue of safe storage had been discussed with either their prescriber or case manager, with 87% having discussed the issue with at least one heath care professional. That fewer patients had discussed the issue with their pharmacist is surprising given that pharmacists are typically responsible for dispensing takeaway doses. Although the current study was conducted prior to the recent NSW Health information campaign, the level of reported information provision is higher than the 31% of patients who reported being given advice on the safety of methadone in a recent UK study.12
The issue of what patients do with methadone takeaway bottles after the dose has been consumed is important for two reasons. First, unrinsed bottles may be placed with less care than full bottles and residual amounts of methadone may in some instances be of sufficient quantity to harm small children. That two-thirds of patients rinsed the bottle suggests that some patients may be aware of this risk. The second reason is confidentiality, a particular issue in rural or regional areas, where discarded bottles printed with the patient's name may be used to identify people as being in treatment. Patients should be advised to rinse empty methadone takeaway bottles and remove the label before discarding. Empty bottles can then be discarded anonymously and safely.
It would appear that methadone patients are appropriately informed about the risks of methadone ingestion by children and the vast majority take adequate precautions to ensure that takeaways are stored out of reach of children. However, the results suggest that there are some patients who store their methadone inappropriately and that not all patients had discussed the issue with a health care provider. In the event of a child ingesting even a very small amount of methadone, patients should be advised to call emergency services (000) immediately so their child can be assessed and monitored. Delays in accessing help because of fear of punitive reprisals must be challenged within health services. All children should be admitted to hospital and provided with an emetic only if alert.14 In those presenting with signs of an opioid overdose intramuscular naloxone is recommended.14
Methadone-related child fatalities are preventable through the careful assessment of patients, and prescribers should give the highest priority to ensuring the safety of children.2 The routine provision of information on methadone takeaway storage risk should be supported by a long-term commitment to the ongoing provision of accessible and credible information to patients, supported by local audit processes that may encourage the documentation of information provided to patients.
We would like to express our thanks to the patients, case managers, and nursing unit managers involved in this survey. Additional thanks to Anthony Jackson and Dr Jill Molan for the project management of the study, and Professor Robert Batey for his comments to improve this paper. This study was funded by Drug Health Services, Sydney South West Area Health Service, New South Wales.