PowerPoint: Support Clients on the Methadone Maintenance Program

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PowerPoint: Support Clients on the Methadone Maintenance Program

  1. 1. NURSING KNOWLEDGE + SUPPORTIVE ENVIRONMENT = GREAT PATIENT CARE Supporting Clients Methadone Maintenance Treatment
  2. 2. Case Study <ul><li>0400 ER -Andy, a 28 year old, was struck by a car at 0230, and you are the nurse assigned. His R leg & hip are bruised, and he is awaiting x-ray. He is rating his pain 9/10. </li></ul><ul><li>You have received an order for 3-5 mg morphine IV q15min for pain, and so far he has had 15 mg with no effect. </li></ul><ul><li>He is requesting more morphine, and he discloses to you that he is on a methadone maintenance treatment program, was previously addicted to heroin. </li></ul>
  3. 3. Immediate Comments / Questions? <ul><li>He is not getting any more morphine from me~! </li></ul><ul><li>… I wonder if I should have given him the 15mg morphine – will it interact with the methadone? </li></ul><ul><ul><li>Does the physician know ? </li></ul></ul><ul><li>It was probably his fault he got hit by a car! </li></ul><ul><li>How can I ever help this patient? </li></ul>
  4. 4. Agenda <ul><li>Nursing as an ‘art’ </li></ul><ul><li>Understanding the drug </li></ul><ul><ul><li>What is methadone maintenance treatment? </li></ul></ul><ul><ul><li>Interactions with other medications </li></ul></ul><ul><li>Pearls for practice </li></ul><ul><ul><li>A plan of care that works for all! </li></ul></ul><ul><ul><li>Safe practice </li></ul></ul>
  5. 5. The Code of Ethics It’s what we ‘nurse’ by! <ul><li>The Code of Ethics for RNs is structured around eight primary values, central to nursing practice: </li></ul><ul><ul><li>Safe, competent nursing care </li></ul></ul><ul><ul><li>Health and well being </li></ul></ul><ul><ul><li>Choice </li></ul></ul><ul><ul><li>Dignity </li></ul></ul><ul><ul><li>Confidentiality </li></ul></ul><ul><ul><li>Justice </li></ul></ul><ul><ul><li>Accountability </li></ul></ul><ul><ul><li>Quality practice environments </li></ul></ul>
  6. 6. The art….comes from knowledge <ul><li>“ In comes the nurse, to teach about and administer the medication, teach about the ache/pain/disease, prepare you for treatment or perform the needed procedure. Your next visit from the doc may be far away, but the nurse will be around.” </li></ul><ul><li>How can you implement this type of ‘giving care’ when you feel that you cannot trust your patient? </li></ul><ul><ul><li>The key is knowledge and understanding the methadone maintenance program </li></ul></ul>
  7. 7. “ Patients words” <ul><li>Participants in one study identified essential aspects of caring that nursing brought to relationships </li></ul><ul><ul><li>Communication </li></ul></ul><ul><ul><li>Physical care </li></ul></ul><ul><ul><li>Emotional support </li></ul></ul><ul><ul><li>Personal care </li></ul></ul><ul><ul><li>Maintaining connections </li></ul></ul><ul><ul><li>Personal attributes </li></ul></ul><ul><li>Emphasized the importance of friendliness - influenced how they formed therapeutic relationships </li></ul><ul><li>Important for nurses to believe in them and methadone as a treatment option. </li></ul>Wilson, MacIntosh & Getty, 2007
  8. 8. Knowledge & Skills <ul><li>Harm Reduction Principles </li></ul><ul><li>Methadone </li></ul><ul><ul><li>Pharmacokinetics </li></ul></ul><ul><ul><li>Pharmacodynamics </li></ul></ul><ul><li>Drug/Drug interactions </li></ul><ul><li>Administration </li></ul><ul><li>Side Effects / Adverse reactions </li></ul><ul><li>Patient Education </li></ul><ul><li>Can you spot withdrawal? </li></ul><ul><li>Would it be an appropriate time to taper off? </li></ul>
  9. 9. Harm Reduction <ul><li>“ It’s sad the way people look at you, even though you are trying to get help”… Linda, 45, MMT x10 yrs </li></ul><ul><li>Methadone maintenance program falls under the ‘harm reduction’ philosophy </li></ul><ul><li>Provides non-judgmental, client centered care </li></ul><ul><li>Provides a framework for treatment of substance misuse </li></ul>
  10. 10. Harm reduction <ul><li>Reduces health related harms and consequences of substance misuse </li></ul><ul><ul><li>Encourages people to make better choices </li></ul></ul><ul><ul><li>Reduce risk of long-term health problems </li></ul></ul><ul><li>Abstinence is the best goal for drug treatment </li></ul><ul><li>Not always achievable </li></ul><ul><li>Harm reduction approach does not require cessation or reduction of drug use </li></ul><ul><li>“ continuum” for reducing different levels of harms </li></ul>Health Canada, 2001
  11. 11. Methadone Treatment Program <ul><li>Goes beyond just the drug; </li></ul><ul><ul><li>Interdisciplinary approach </li></ul></ul><ul><ul><ul><li>Counselling </li></ul></ul></ul><ul><ul><ul><li>Employment </li></ul></ul></ul><ul><ul><ul><li>Education </li></ul></ul></ul><ul><ul><ul><li>Housing </li></ul></ul></ul><ul><ul><ul><li>Access to other health services (ie, prenatal care, health promotion) </li></ul></ul></ul><ul><li>Most optimal treatment when patients are retained ‘long-term’ (months to years) </li></ul>
  12. 12. Outcomes <ul><li>Reduce misuse of drugs </li></ul><ul><li>Improved social health and productivity </li></ul><ul><li>Retention in treatment programs </li></ul><ul><li>Reduced needle sharing / reduced risk of infectious diseases (mortality / morbidity) </li></ul><ul><li>Reduction of spread of infectious diseases </li></ul><ul><li>Reduced crime </li></ul>Health Canada, 2001
  13. 13. Why Methadone? <ul><li>Substitution / maintenance therapy </li></ul><ul><ul><li>‘ swap’ one addiction for another </li></ul></ul><ul><li>Associated with the most positive outcomes related to opiate dependence </li></ul><ul><li>More clinically and cost effective than no-drug treatment modalities </li></ul><ul><li>‘ Gold standard’ for those with opiate dependence (Thomas, 2005) </li></ul>
  14. 14. Methadone <ul><li>Long acting synthetic opiate </li></ul><ul><ul><li>Metabolism ranges from as little as 4 hours to as many as 130 hour s </li></ul></ul><ul><ul><li>Binds to opiate receptors </li></ul></ul><ul><ul><ul><li>Reduces the rates of withdrawal and cravings </li></ul></ul></ul><ul><li>Long acting – no ‘euphoric’ effects </li></ul><ul><ul><li>Decreases rates of relapse </li></ul></ul><ul><ul><li>Provides cross tolerance, blocks the euphoric effects of other opiates </li></ul></ul><ul><ul><li>Non-sedating </li></ul></ul><ul><li>Long half life </li></ul><ul><ul><li>Half-life 15-60 hours </li></ul></ul><ul><ul><li>Can be administered once daily </li></ul></ul><ul><ul><li>Oral solution </li></ul></ul><ul><li>*Also recommended for pregnant women </li></ul>
  15. 15. Tolerance / Dependence <ul><li>As with any other opiate, tolerance will develop over repeated doses </li></ul><ul><li>Tolerance to analgesia, respiratory depression, nausea and sedation usually occur in the first week </li></ul><ul><li>No tolerance to constipation effects; may decrease in severity over time </li></ul>
  16. 16. <ul><li>Tolerance </li></ul><ul><li>Dependence </li></ul><ul><li>“ state of adaptation in which exposure to a drug induces changes that result in a lessening of one or more of the drug’s effects over time” </li></ul><ul><li>Indicated by the need for increasing or more frequent doses of med to maintain effect </li></ul><ul><li>It is not diagnostic of addiction </li></ul><ul><li>“ a state of adaptation that often includes tolerance, and if the medication is taken away unexpectedly (without weaning) then the patient will result in a state of withdrawal” </li></ul><ul><li>It is not diagnostic of addiction </li></ul>More on Tolerance / Dependence
  17. 17. Methadone does not: <ul><li>Therapeutic doses of methadone do not cause: </li></ul><ul><ul><li>Damage to any of the major organs or systems of the body - even in high dose, long-term use </li></ul></ul><ul><ul><li>Significant incoordination </li></ul></ul><ul><ul><li>Slurred speech </li></ul></ul><ul><ul><li>Congenital abnormalities in unborn children </li></ul></ul><ul><ul><li>Reductions in cognitive ability in the way alcohol does. </li></ul></ul><ul><li>Nor does it: </li></ul><ul><ul><li>Have any anti-convulsant effect - even at high doses </li></ul></ul><ul><ul><li>Effect levels of leuteinising and follicle stimulating hormones in women </li></ul></ul>
  18. 18. Long term ? <ul><li>The long-term toxic side effects of methadone (in fact all pharmaceutical opiates), if taken in hygienic conditions and in controlled doses, are few and (relative to the risks of alcohol, tobacco or illicit heroin use) benign. </li></ul>
  19. 19. Safety first <ul><li>According to the National Center for Health Statistics, and a 2006 series in the Charleston (WV) Gazette: </li></ul><ul><li>Medical examiners listed methadone as contributing to 3,849 deaths in 2004; up from 790 in 1999. </li></ul><ul><li>Approximately 82% of those deaths were listed as accidental, and most deaths involved combinations of methadone with other drugs (especially benzodiazepines ) </li></ul>
  20. 20. Drug / drug interactions <ul><li>Concomitant use of methadone with </li></ul><ul><ul><li>alcohol or </li></ul></ul><ul><ul><li>central nervous system depressants </li></ul></ul><ul><li>may further increase the risk for </li></ul><ul><ul><li>respiratory depression, </li></ul></ul><ul><ul><li>hypotension, </li></ul></ul><ul><ul><li>profound sedation, </li></ul></ul><ul><ul><li>coma </li></ul></ul>
  21. 21. Potential Drug Interactions <ul><li>Antibiotics </li></ul><ul><li>Antifungals </li></ul><ul><li>Antidepressants </li></ul><ul><li>Antiepileptics </li></ul><ul><li>Antiretroviral </li></ul><ul><li>Barbituates </li></ul><ul><li>All benzodiazepines </li></ul><ul><li>Amiodarone </li></ul><ul><li>Amitriptyline </li></ul><ul><li>Verapamil </li></ul><ul><li>Risperidone </li></ul><ul><li>Tobacco </li></ul><ul><ul><li>*Phenytoin and rifampin may increase methadone metabolism and cause drug-seeking behavior </li></ul></ul>
  22. 22. Methadone & Pain <ul><li>Patients receiving methadone will require higher and more frequent doses of pain medication </li></ul><ul><li>Theoretical risk that opiates & methadone can cause respiratory depression – however this is not usually demonstrated </li></ul><ul><ul><li>Tolerance to methadone develops quickly </li></ul></ul><ul><ul><li>Still need to monitor for respiratory depression </li></ul></ul>
  23. 23. Administration - back to Andy <ul><li>You have received orders, and are working with Andy to achieve a good level of pain control. It is now 0900, and pharmacy has called to inform you that you will have to give Andy his methadone dose at 1000. </li></ul><ul><li>To ensure safe administration; the nurse must perform the ‘6 rights’ </li></ul><ul><li>- right client, right route, right dose, right time, right medication and… Documentation. </li></ul><ul><li>Work with pharmacy to ensure the dose is ‘ Right ’. </li></ul>
  24. 24. Administration… <ul><li>Missed dose for 3 or more days should not be medicated until further assessment by the prescribing physician (College Physician & Surgeons of Ontario, 2005) </li></ul><ul><li>RN must ensure that they are aware of the amount and time of the patient’s last dose to avoid an overdose </li></ul><ul><ul><li>Verify with the client what the dose of methadone is </li></ul></ul><ul><li>Documentation is vital to ensure safety of administration and transfer of care </li></ul>
  25. 25. What if there is no pharmacy? <ul><li>The case study assumes you are in a large facility – what happens in a smaller community hospital? </li></ul><ul><li>Patients need to obtain the doses daily if they are not allowed to ‘carry’ – usually work closely with a pharmacist. </li></ul><ul><li>Nurses need to contact with the pharmacy where the patient visits to obtain their methadone (work with MD) </li></ul><ul><ul><li>Identify yourself and let the pharmacy know the patient will not be in to receive the methadone </li></ul></ul><ul><ul><li>If your patient misses a dose, when the drug becomes available, they should receive </li></ul></ul><ul><ul><li>Close monitoring for signs of withdrawal </li></ul></ul>
  26. 26. Side Effects <ul><li>Dry mouth </li></ul><ul><ul><li>good oral care is important (floss!) </li></ul></ul><ul><ul><li>Encourage water intake </li></ul></ul><ul><li>Bone ache </li></ul><ul><ul><li>May be a sign of withdrawal- ask physician to assess dosage </li></ul></ul><ul><li>Has been shown to slow metabolism </li></ul><ul><ul><li>Cause water retention / weight gain </li></ul></ul>
  27. 27. Adverse Effects <ul><li>Constipation </li></ul><ul><li>Hypoventilation </li></ul><ul><li>Miosis (pupil constriction) </li></ul><ul><li>Possibly: </li></ul><ul><li>Mood changes </li></ul><ul><li>Agitation </li></ul>
  28. 28. Withdrawal <ul><li>Signs & Symptoms of Withdrawal: </li></ul><ul><ul><li>S – salivation </li></ul></ul><ul><ul><li>L – lacrimation </li></ul></ul><ul><ul><li>U – urination (increased) </li></ul></ul><ul><ul><li>D – defecation (diarrhea) </li></ul></ul><ul><li>Early Signs (8-12 hrs): Diaphoresis, nausea, yawning, lacrimation , </li></ul><ul><li>tremor, rhinorrhea, irritability, dilated pupils, resp. rate, pulse>90 </li></ul><ul><li>Severe Signs (12-48 hrs): Insomnia, elevated T,P,R,& BP, nausea, </li></ul><ul><li>vomiting, abdominal cramps, chills, diarrhea , muscle twitching, dilated pupils </li></ul>
  29. 29. Tapering – is now a good time? <ul><li>Admission to hospital in an acute scenario is not an appropriate time to taper or decrease the methadone dose </li></ul><ul><li>Awareness of methadone, drug/drug interactions; risks associated with toxicity with acute illness </li></ul><ul><ul><li>If concerned – call primary methadone provider! </li></ul></ul><ul><li>If over 3 days have lapsed, notify primary provider, patient will be reassessed for need upon discharge, as loss of tolerance may have occured </li></ul>
  30. 30. Patient Education <ul><li>Reassure ‘Andy’ that his history will not prevent pain management measures </li></ul><ul><li>The usual dose of methadone should be maintained </li></ul><ul><li>Work with Andy on a clear plan for pain management </li></ul><ul><ul><li>set goals for all team members to work towards </li></ul></ul><ul><ul><li>Discuss expectations for discharge and continued medications </li></ul></ul>
  31. 31. Mythbusters <ul><li>Methadone is a cure for addiction </li></ul><ul><ul><li>It is not a cure </li></ul></ul><ul><ul><li>It is a tool that helps repair the damage caused by dependence </li></ul></ul><ul><li>People on methadone are still addicts </li></ul><ul><ul><li>Methadone is a medication- just like insulin and blood pressure medications </li></ul></ul><ul><ul><li>Treatment allows for re-instatement of normal daily activities, such as work, school, family/child care </li></ul></ul>
  32. 32. Discharge – team effort <ul><li>Notify the primary provider of any additional prescriptions that have been written </li></ul><ul><ul><li>Especially opiates, benzodiazepines </li></ul></ul><ul><ul><li>Medications should be dispensed with methadone, daily </li></ul></ul><ul><ul><li>These medications will show up on any urine screens and provider should be aware </li></ul></ul><ul><li>Connect Andy with social work if needed </li></ul><ul><ul><li>Will he need home care for dressing changes? </li></ul></ul><ul><ul><li>Does he have coverage for antibiotics, etc </li></ul></ul><ul><ul><li>What is the plan for follow up? </li></ul></ul>
  33. 33. Clinical Pearls <ul><li>Find out how long your patient has been on methadone </li></ul><ul><ul><li>Have they developed a ‘tolerance’ ? </li></ul></ul><ul><ul><li>Has their dose recently been adjusted up/down? </li></ul></ul><ul><li>Ensure methadone is labelled properly </li></ul><ul><ul><li>Did it come already prepared? </li></ul></ul><ul><li>Ensure the client takes all methadone (observe) </li></ul><ul><li>Missed doses must be clearly documented </li></ul>
  34. 34. Leadership <ul><li>Nurses are first contact – knowledge of MMT is essential </li></ul><ul><li>Knowledge building – your own & others </li></ul><ul><ul><li>Learn more about methadone in other populations (elderly, pregnancy, HIV/HepC) </li></ul></ul><ul><ul><li>Association between stigma, discrimination and outcomes among those on MMT </li></ul></ul>
  35. 35. Thank you!
  36. 36. References: <ul><li>Wilson, K., MacIntosh, J., Getty, G. 2007. Tapping a tie: successful partnerships in managing addictions with methadone. Mental Health Nursing. 28; 977-996 </li></ul><ul><li>Health Canada.2001. Reducing the harm associated with injection drug use in Canada. Health Canada: Ottawa. http://www.hc-sc.gc.ca/hl-vs/alt_formats/hecs-sesc/pdf/pubs/adp-apd/injection/injectiondrug-eng.pdf </li></ul><ul><li>The Charleston Gazette 2006 The Killer Cure. </li></ul><ul><li>Increases in Methadone-related Deaths: 1999-2004 http://www.cdc.gov/nchs/products/pubs/pubd/hestats/methadone1999-04/methadone1999-04.htm </li></ul>

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