COVID-19: Supplying methadone to housebound patients due to self-isolation or shielding

31 Mar 2020

A number of pharmacies have raised concerns about how to manage patients who require supervised administration of medicines (e.g. methadone, buprenorphine) in the pharmacy during the Coronavirus (COVID-19) pandemic. This also extends to how to manage such patients when they are in isolation or shielding in their homes as preventive measures.

We have covered the key considerations regarding the supply of methadone, and similar medicines, to housebound patients during the COVID-19 pandemic to prevent and/or reduce risk of infection while supporting patient care.

 

Managing risks while providing patient care

We understand that there may be occasions when you may have to operate outside your established procedures to ensure continued patient care. The key consideration in everything is patient safety. This can be achieved by ensuring a risk-assessed approach to decision-making and good record keeping. This is especially important so that if required, you are able to demonstrate your sensible approach to decision-making to uphold continued patient care.

Each patient must be risk assessed on a case-by-case basis, in consultation with the prescriber, to ensure that the risk of infection is mitigated as much as possible, while providing the patients with the care they need in the safest way possible.

It is not appropriate to make a blanket decision to not supply any methadone (or instalment prescription item) by delivery service to housebound patients. Patients under treatment for substance misuse are more vulnerable. They have taken the decision to seek support to help them recover and it is important that their recovery be supported. They may also be at higher risk due to other co-existing health conditions such as hepatitis C for example. Disruption to their treatment may increase their vulnerability and has the potential to impact on not just themselves, but also others in their family, which may include children.

·     Weigh up the risks of making the supply by delivering the medicines versus not supplying – what are the risks to the patient, and/or their family members of making the supply or not? Clinical as well as practical considerations?

·     Is it appropriate to supply and deliver potentially large quantities of such medicines (for example fortnightly prescriptions)?

·     Consider the potential for the patient (or others in their home) to overdose. There are child protection issues – what if a vulnerable child finds methadone lying about in the house?

·     Delivery drivers carrying a large quantity of methadone (or other instalment prescription item) are putting themselves at risk of robbery and other crime.

·     What to do about the requirement to supervise the administration?

Supervising administration or not?

This is not a legal requirement; it is a good practice recommendation to support treatment. Therefore, where a prescription calls for supervised administration but it is not possible to do so, pharmacists may still proceed with supplying the treatment without supervision. When this happens, ideally, the prescriber should be contacted to advise them of the situation, and contemporaneous records made on the patient’s PMR to record the actions taken and decisions made.

Based on the outcome of your risk assessment of each patient, you can make a decision regarding each patient about whether to continue to supervise administration of their medicine, or whether toe risks of doing so outweigh the potential benefits.

It is advisable to liaise with the prescriber to omit the supervision requirement from future prescriptions for such patients until this requirement can be followed again.

In Northern Ireland pharmacists have been advised to stand down arrangements for supervised opioid substitution treatment (OST) effective from 19 March 2020. Pharmacies should liaise with local Trust OST keyworkers to make appropriate arrangements for safe supply. This is particularly important in the instance of a client who is currently self-isolating. Read letter

Supplying medicines to a representative

Where supplies of medicines such as methadone and buprenorphine are to be made to the patient’s representative, a letter of authorisation should be obtained from the patient, at each collection where possible, for their representative to collect on their behalf. However, whether a letter of authorisation has been obtained or not, the patient should be contacted to confirm the supply to their representative.

Key considerations

There are key considerations involved in delivering medicines instalment prescription items, regardless of whether it is supervised or not. These include:

·     Methadone (or other instalment prescription item) may not be delivered by pharmacies as part of their usual delivery service; before starting this, risk-assess the patient in consultation with their prescriber / local Drug and Alcohol Team:

o     Ensure there is close liaison with prescribing teams

o     Consider other methods in which the patient can obtain the methadone, for example, a representative coming to collect

o     Consider whether another pharmacy is better suited for the patient to travel to

·     Undertake a risk assessment in consultation with their prescriber / local Drug and Alcohol Team before starting such a delivery service in which a clear, robust process, with safeguards, are in place

o     Consider who will deliver the methadone – the delivery driver or pharmacist

o     Record potential risks in delivering

o     Consider how you will ascertain the methadone has reached the patient – see advice published on delivering medicines during COVID-19 outbreak

·     For supervised patients, following the joint risk assessment with the prescriber, work through the process and have them amend the prescription accordingly

·     Record all conversations with any parties (for example, GP, drug clinic) and decisions made on the PMR

o     Add discussion of concerns, for example, patient’s stability, vulnerable children at home

·     If you need to close, then patients with instalment prescriptions would need to be signposted to another pharmacy

o     This is a good reason why a shorter duration of prescription, post-dated, can be issued to the patient so there is continuity of care

o     See the Continued Pharmacy Services document

Ensure your delivering medicines standard operating procedure (SOP) is reviewed and updated before initiating the home delivery service for such medicines.

NPA Professional Indemnity statement

When considering delivery to a supervised methadone patient, treat each case differently. The pharmacy needs to talk to the GP and prepare a risk assessment and the best way forward. Members must write detailed notes of their discussions with the GPs and record these notes/risk assessments against the patients’ PMRs.

Although, it is not a legal requirement to provide supervision, ideally new prescriptions should be requested without this requirement. In terms of deliveries, it is best that these should be for as little of the methadone delivered, as frequently as possible.

For further information, advice and support, please contact us:

Telephone: 01727891800

Email: pharmacyservices@npa.co.uk