Why did the College update standards for methadone maintenance treatment (MMT)?
The College updated standards for MMT in collaboration with PharmaCare and other stakeholders. To transition compounded oral methadone 1 mg/ml and provide coverage for methadone commercially available 10 mg/ml oral preparation. The standards were developed to facilitate a safe transition from the current compounded methadone to the methadone concentrate of 10 mg/ml and to ensure that patients have access to standardized pharmacy services for MMT in BC.
When can I no longer accept prescriptions for methadone 1 mg/ml for maintenance?
Effective February 1, 2014 all MMT prescriptions that are prescribed and started in February must be for methadone 10 mg/ml.
If you receive an old Controlled Prescription Form and it is prescribed in January and carries over or starts in February you may dispense methadone 1 mg/ml for maintenance until the prescription is complete or until February 28, 2014, whichever comes first.
Can I dispense methadone 1mg/ml for maintenance on or after March 1, 2014?
No. As of March 1, 2014 pharmacists are not permitted to dispense methadone 1mg/ml for MMT. Effective March 1, 2014 implementation of consistent dispensing standards will require all pharmacists to dispense only the commercially available oral preparation of methadone10mg/ml to support patient safety.
Can I accept a prescription for methadone for maintenance on the regular controlled prescription program (CPP) form?
Effective February 1, 2014, there will be only one form for MMT; all new prescriptions for methadone maintenance written in February must be on the new Methadone Maintenance Controlled Prescription Program form that is pre-printed with methadone 10mg/ml. Effective March 1, 2014, CPBC inspectors will be inspecting to ensure all MMT prescriptions are on the new MMT prescription pads.
Can I accept a prescription for methadone for pain on the Methadone Maintenance Controlled Prescription (MMT CPP) form?
No. Pharmacists may not accept prescriptions for methadone for pain on the Methadone Maintenance Controlled Prescription Program form. A Pharmacist may only accept prescriptions for methadone for pain that are written on the regular Controlled Prescription Program form
Can I still accept out-of-province prescriptions?
Yes. Pharmacists may choose to dispense methadone prescriptions from prescribing physicians in provinces other than BC. If there is any doubt regarding the authenticity of the out-of-province prescription, the pharmacist must contact the out-of-province prescribing physician to confirm the legitimacy of the prescription (including the prescriber’s exemption to prescribe methadone). When satisfied that the prescription is authentic, the pharmacist may dispense and process the prescription in the same manner as other prescriptions from out-of-province prescribers; only methadone 10 mg/ml may be dispensed.
What is the difference between prescribing date and start date?
The 'prescribing date' is the date the prescribing physician wrote the prescription while the 'start date’ is the date the prescribed therapy is to commence. If the 'start date' is blank the pharmacist may assume that the 'prescribing date' is the 'start date'. If the 'start date' overlaps with or leaves gaps from the existing prescription the pharmacist must seek clarification from the prescribing physician.
When can I dispense compounded methadone for maintenance after March 1, 2014?
The only situation where compounded methadone may be dispensed is when a commercially available 10mg/ml oral preparation is not available. Refer to CPBC's Policy Guide for MMT, Section 6.3 Compounding in Exceptional Circumstances. In order for the patient to receive coverage for compounded methadone when there is a supply shortage, the pharmacist must follow PharmaCare's procedures to report the shortage before dispensing compounded methadone. The pharmacist MUST compound and dispense methadone at 10 mg/ml only. Refer to PharmaCare Policy Manual, Section 5.11, page 14 Manufacturer Shortages. http://www.health.gov.bc.ca/pharmacare/pdf/5-6to5-12.pdf
Does Professional Practice Policy 66 apply to methadone for pain?
No. Professional Practice Policy 66, sets the standards for practice for methadone for maintenance only. We do not have any specific practice standards for pain other than regulations in place that apply to all medications.
Any questions regarding coverage must be directed to PharmaCare.
How can I safely and effectively measure small doses of methadone 10mg/ml volume?
The pharmacist must measure the methadone dose using a calibrated device with an error rate of no greater than 0.1ml, which is equal to 1mg. All devices used to measure methadone should be distinctive and recognizable and should be used only to measure methadone solutions. Devices should be labelled with a “methadone only” label and a “poison” auxiliary label with the international symbol of the skull and cross bones. Pharmacists may contact their wholesaler for assistance to locate a product that meets the required specifications.
Can I dispense methadone 10 mg/ml to my patient in a syringe?
No. It has been deemed inappropriate to dispense methadone to former IV drug users in a syringe. If required the pharmacist may use a syringe with an error rate of no greater than 0.1ml, which is equal to 1mg, to measure small doses.
Do I have to dispense carries for methadone 10 mg/ml in individual bottles?
Yes, this is a new requirement due to the smaller volume of methadone. Each dose must be measured and dispensed in individually labelled, appropriately sized, child resistant containers. It is not acceptable to dispense multiple carries in one container and have the patient measure individual doses at home.
Do the patient and pharmacist need to sign to confirm the release of Methadone for Maintenance?
Yes. Prior to releasing the initial methadone prescription, the pharmacist and the patient must sign the Methadone Maintenance Controlled Prescription form in the space indicated on the bottom of the form to confirm the patient has received theinitial dose of the prescription. The patient and pharmacist must also sign the daily patient/prescription-specific log to acknowledge receipt of each witnessed ingestion dose, each partial dose and each take-home dose.
Neither the pharmacist nor the patient is permitted to pre-sign for future doses. The pharmacist must store the signed prescription and the patient/prescriptionspecific log together.
Is methadone 10 mg/ml available in other flavours? What if my patient cannot take Methadose?
Previously, only the cherry flavoured Methadose 10 mg/ml was covered by PharmaCare. However, a decision has been 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.
For more information, please refer to the following ReadLinks Guest Post: Increased Access to Metadol-D and Guidance from BCCSU
Do I have to be present to witness?
Yes. The pharmacist must follow the prescription release processes defined in CPBC's Policy Guide for MMT. The pharmacist must assess the patient and then must witness ingestion of the dispensed methadone followed by ingestion of water provided by the pharmacist. The pharmacist should then engage the patient in a brief conversation to ensure that the entire dose is ingested and to reduce the risk of diversion. This function cannot be delegated to a pharmacy technician or any other pharmacy support staff.*
*EXCEPTION: Due to COVID-19, while permitted by a section 56 exemption to the Controlled Drugs and Substances Act, amendments have been made to allow temporary authorizations for delivery of opioid agonist treatment by non-pharmacists. Pharmacists may now authorize a regulated health professional to deliver OAT, if they have the scope and competence to assess the patient and witness the ingestion of OAT (where required). Pharmacists may now also authorize pharmacy employees to deliver OAT to a patient on the pharmacist’s behalf, however this authorization should be reserved for exceptional circumstances where it is not possible for a pharmacist or regulated health professional to deliver the OAT drug. For additional information and requirements, please refer to PPP-71.
Can physicians still fax methadone prescriptions to pharmacies in an emergency situation and send the original at a later date?
Yes. Faxed Methadone Maintenance Controlled Prescription forms may only be accepted under extenuating circumstances and has been initiated following consultation between the patient's pharmacist and prescriber.
In this situation, the pharmacist must obtain written documentation from the prescriber prior to dispensing any medication. CPBC's Policy Guide for MMT includes a sample form titled, 'Emergency Fax Methadone Maintenance Controlled Prescription Form Documentation', the pharmacist may fax this form to the prescriber. The prescriber must fax documentation requesting the pharmacist to accept a faxed transmission of the MMT Controlled prescription form for the specified patient, with the prescription for MMT to the pharmacy. The prescriber must send the original prescription form to the pharmacy by the next business day or as soon as possible. A copy of the form is available in CPBC's Policy Guide for MMT, refer to Appendix 4; 'Emergency Fax Methadone Maintenance Controlled Prescription Form Documentation'.