Guest Post: Increased Access to Metadol-D and Guidance from BCCSU Jun. 12, 2019 BC Centre on Substance Use, Guest Post, Opioid overdose crisis

Guest Post: Increased Access to Metadol-D and Guidance from BCCSU

Recently, a decision was made by the Ministry of Health to provide coverage for the commercially available Metadol-D product (DIN 2244290) as an alternative for patients in the community who cannot take or are not benefiting from Methadose. As of May 28, 2019, Metadol-D (10mg/mL) is eligible for regular benefit coverage through PharmaCare. 

Patients and prescribers in BC will now have the option to choose between two formulations of benefit methadone – Methadose or Metadol-D – when starting opioid agonist treatment (OAT). Additionally, if patients are experiencing side effects or breakthrough withdrawal symptoms with one methadone formulation, they have the option to switch to the other formulation. Pharmacists, in collaboration with the patient’s care team, can help patients identify if they are not responding well to one methadone formulation and support patients during transitions as part of their opioid agonist treatment.

The majority of British Columbians currently prescribed methadone are taking Methadose. As described in our previous guest post, when Methadose was added to the provincial formulary in February 2014, some patients reported experiencing increased withdrawal symptoms (e.g., pain, nausea) or withdrawal symptoms that emerged earlier after taking a dose (i.e., in less than 24 hours) than with the compounded methadone formulation they had previously been taking. It was reported that for some people, the switch from the compounded formulation to Methadose had unintended but serious consequences, leading to re-initiation of illicit drug use, injection drug use, and/or high-risk income generating activities.(1-3)  The risks and harms that individuals have experienced have been compounded in the context of the opioid overdose crisis, Provincial Public Health Emergency and the toxic illicit drug supply.

Patients who have experienced challenges since the switch to Methadose may benefit from access to a safe, effective alternative methadone formulation, particularly if they have benefited from methadone in the past. As the  Provincial Public Health Emergency  continues in BC, the need to expand the scope and reach of evidence-based treatment interventions that are proven to reduce harm, including overdose deaths, remains critical. Providing patients and prescribers with choices for methadone-based OAT is one important step.

The BCCSU has developed a guidance document  to support prescribers, pharmacists, and patients in accessing Metadol-D. The guidance document recommends the prescriber contact the patient’s community pharmacy to notify them of changes to the formulation prescribed to a patient, and to ensure that Metadol-D is available and in stock. 

METADOL-D PRESCRIPTIONS MUST BE WRITTEN ON THE STANDARD BC METHADONE MAINTENANCE TREATMENT CONTROLLED PRESCRIPTION PROGRAM FORM
 

Metadol-D prescriptions can only be accepted when written using an original Methadone Maintenance Controlled Prescription form. The prescriber must write “Metadol-D” in the “Special Instructions” field. If these instructions are unclear or illegible, pharmacists should confirm with the prescriber.

As with any methadone prescription, pharmacists must ensure that the prescription is completed in full by the prescriber as outlined in the College of Pharmacists of British Columbia’s Professional Practice Policy-66 Policy Guide: Methadone Maintenance Treatment  (2013).

METADOL-D® IS SOLD COMMERCIALLY AS AN UNFLAVOURED 10MG/ML SOLUTION, AND MUST BE DILUTED TO 100ML IN A SUITABLE BEVERAGE BEFORE BEING DISPENSED TO A PATIENT. 

Because there will be potentially three different formulations of methadone stocked in some community pharmacies -1) cherry–flavoured Methadose; 2) sugar-free, unflavoured Methadose; and 3) unflavoured Metadol-D - it is critical that pharmacists exercise caution to ensure that no errors are made in preparing each patient’s dose.

Preparation Instructions:

• Premeasure the dose of Metadol-D 10mg/mL solution. 
• Prepare Tang, Crystal Light, or similar beverage crystals at full strength according to the manufacturer’s directions on the package. 
• Add a quantity sufficient (qs) of the full strength beverage to the premeasured dose of Metadol-D up to a total of 100mL.
• Each dose must be dispensed in individual appropriately sized container, and labeled in accordance with requirements. 
• In the sig field, include the dose in mg in a total of 100mL of juice, i.e., 40mg unflavoured Metadol-D in total (qs) 100mL of juice.

COLLEGE OPIOID AGONIST TREATMENT POLICIES AND GUIDELINES

Pharmacists should adhere to the College of Pharmacists of BC’s Professional Practice Policy-66: Opioid Agonist Treatment and accompanying PPP-66 Policy Guide: Methadone Maintenance Treatment when filling prescriptions for Metadol-D.

PATIENT SAFETY HIGHLIGHTS

• Under the Health Professional Act Bylaws, Schedule F, Part 1 - Community Pharmacy Standards of Practice, pharmacists must review each individual PharmaNet patient record, and resolve any medication-related problems prior to dispensing Metadol-D®.
• The automated drug usage evaluation (DUE) built into the PharmaNet system does not include methadone. Pharmacists must ensure they maintain their knowledge of potential drug interactions with Metadol-D. 
• As with all medications, pharmacists must counsel the patient on the risks (including common side effects) and benefits of taking their medication, and will need to be familiar with this information for Metadol-D®.
• Under the College of Pharmacists of BC’s Professional Practice Policy-66: Opioid Agonist Treatment, all pharmacy managers, staff pharmacists, relief pharmacists and pharmacy technicians employed in a community pharmacy that provides services related to Opioid Agonist Treatment are required to complete either the new OAT-CAMPP course or the College’s existing MMT training program until March 31, 2021 at which time the College’s MMT training program will no longer be available. (Learn more about the OAT training requirements transition period.)

BC CENTRE ON SUBSTANCE USE METADOL-D GUIDANCE WEBINAR

The BCCSU hosted a webinar on December 3 that reviewed available research, practice guidance, prescriber and patient perspectives on Metadol-D. The webinar recording can be accessed here:

Metadol-D: Clinical Implications and Patient Experience - Webinar

RESOURCES 

• Metadol-D® product monograph 
• A Guideline for the Clinical Management of Opioid Use Disorder (BCCSU)
• Opioid Agonist Treatment – College of Pharmacists of BC
• Methadone Maintenance Treatment (MMT) – College of Pharmacists of BC 
• How to use Naloxone to Save a Life

REFERENCES 

1. Greer, AM. et al. “Patient Perspectives of Methadone Formulation Change in British Columbia, Canada: Outcomes of a Provincial Survey.” Substance Abuse Treatment, Prevention, Policy 11 (2016): 3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4712495/
2. McNeil et al. Negotiating structural vulnerability following regulatory changes to a provincial methadone program in Vancouver, Canada: a qualitative study. Soc Sci Med. 2015; 133:168-176. https://www.ncbi.nlm.nih.gov/pubmed/25875323
3. Socias et al. Unintended impacts of regulatory changes to British Columbia Methadone Maintenance Program on addiction and HIV- related outcomes: an interrupted time series analysis. Int J Drug Policy. 2017; 45:1-8. https://www.ncbi.nlm.nih.gov/pubmed/2845404

BC Centre on Substance Use

The BC Centre on Substance Use (BCCSU) is a provincially networked organization with a mandate to develop, help implement, and evaluate evidence-based approaches to substance use and addiction. BCCSU seeks to improve the integration of best practices and care across the continuum of substance use through the collaborative development of evidence-based policies, guidelines, and standards. With the support of the Province of BC, BCCSU aims to transform substance use policies and care by translating research into education and care guidance, thereby serving all British Columbians.