Sector should reflect on methadone dispensing after overdose case
The “extremely sad case” of a patient’s methadone overdose provides pharmacy teams an “opportunity to reflect” on their substance misuse services, a patient safety lead has said.
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Matthew Colin Fitten was found deceased at his home in Haverhill, Suffolk on April 17 last year by a relative.
According to a coroner's report, toxicology analysis identified a toxic quantity of methadone in Mr Fitten’s blood at the time of his death, which the coroner attributed to his prescription changing from being dispensed three times a week in daily dose bottles, to once a fortnight, due to COVID-19 restrictions that had recently come into effect.
The coroner’s report said that, at the outset of the COVID-19 pandemic, the charity Turning Point, which was supporting Mr Fitten with his "drug dependency issues", was given guidance by Public Health England (PHE) “that individuals on opiate replacement treatment (methadone) should be moved off short-term (daily or tri-weekly) prescription collections to longer-term ones”.
Despite the patient's doctor stipulating that the methedone prescription still be dispensed in daily doses, when Mr Fitten went to his pharmacy on April 15, 2020, the methadone he was given was not in daily doses, but rather in bottles of 100ml, 156ml and 500ml, the coroner claimed.
Haverhill Pharmacy was contacted for comment, but had not responded by the time this article was published.
Due to his prescription being for single dose bottles, Mr Fitten was not given a measuring jug by his doctor to accurately measure out the 54ml of methadone he was supposed to take daily, according to the coroner’s report.
“This meant Matthew had a much larger quantity of methadone than he would normally have,” Nigel Parsley, senior coroner for the Suffolk area wrote in his report.
Mr Parsley offered a “probable” explanation for Mr Fitten’s death: “Due to a lack of a measuring jug, Matthew guessed his first dose from the larger methadone bottles, with tragic consequences.”
Mr Fitten would not have died "on a balance of probability" if he had either been given the daily doses of his methadone or a measuring jug and instructions on how to use it, Mr Parsley wrote in his report.
Despite risk mitigations put in place by Turning Point, his “access to increased quantities of methadone directly contributed to his death”, Mr Parsley wrote.
Lessons to learn and share
A spokesperson for the General Pharmaceutical Council told C+D that it has “opened an investigation into the regulatory concerns arising from the incident covered” and this investigation is “ongoing”.
Meanwhile, Janice Perkins, chair of the Community Pharmacy Patient Safety Group (CPPSG), told C+D that this “extremely sad” case “highlights the risks that reduced frequency of collections can create and provides important learnings that need to be shared to prevent similar occurrences in the future”.
Ms Perkins explained that providing substance misuse services during the initial months of the COVID-19 pandemic had posed “a number of challenges for community pharmacy” and the CPPSG had “worked through” some cases.
In these scenarios, the CPPSG had tried to “ensure a balance between patient safety, colleague safety and compliance with lockdown rules and best practice”, Ms Perkins explained.
Read her advice for pharmacy teams providing substance misuse services below.
What can pharmacy teams learn from this case?
“When dispensing methadone, pharmacists must follow best practice and take a patient-centred approach, which considers the individual needs and circumstances of the patient.
“It is imperative that patients receive sufficient counselling to enable them to understand changes to their prescription. Regular contact should be maintained to ensure any issues can be identified early and raised with the prescriber.
“We recommend a maximum seven days’ supply is issued per collection. It’s important to assess the benefits and the risk of any changes to prescribing frequency. This should take into account the patient’s circumstances and particularly the storage arrangements at home and their family situation, especially if they have children.
“To reduce the risk of error, in line with best practice medicine should always be supplied in single dosage bottles. If for any reason this is not possible then a suitable measure must be provided and the patient must be shown how to measure the correct volume.
“As lockdown restrictions ease, we also recommend the appropriateness of prescription changes are revisited and reviewed to further minimise risks and that the best treatment schedule is agreed between the patient, the prescriber and the pharmacy team. It’s important that changes are spread out across the week to help pharmacy teams manage their workload, order stock appropriately and maintain COVID-secure arrangements for all patients.”
Some positive takeaways
“On a more positive note, for some patients, the changes to the frequency of methadone collections as a result of the pandemic has been beneficial, improving quality of life, reducing the need to visit the pharmacy helping them to better manage their lives.
“Anecdotally, it has also removed some of the stigma that patients felt about feeling they were being treated differently due to their health condition. This is an opportunity for community pharmacy teams to reflect on the approach taken to supporting these patients and fully meet their, sometimes complex, needs in an empathetic and inclusive way.”
Source: Janice Perkins, chair of the Community Pharmacy Patient Safety Group (CPPSG)
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