What is 'Safe titration'

[Alan J]

Dear All,

I would welcome exploring the views of fellow advocates, users and service providers as to what constitutes the optimum 'intitiation' dose to induct patients / potential users onto if uncertain of tolerance ?

Is 15mg pd per day appropriate? 30, 40 mg , or more? To what degree should we factor saftey and risk of diversion above percieved/reported need.

Remeber that a dose titration, performed properly, need not take weeks? A titration can be performed in day's, weels or months?

Pleeae relate you optimum procedures, without additional properties, pressure?

Best, Alan J.

[simon]

Alan,
What are your views ?.
We tend to increase rapidly on Subutex but more slowly on methadone.

[Alan J]

I tend to find that over zealous caution is a problem for a number of clients. We know from the evidence base that induction into treatment and dose assesment is a period which see's a lot of patients self discharge. Often I find due to the extended duration and discomfort experienced during the period between assesment, indiction, and titration to optimum dosing.

We know that given the right level of support and monitoring patient's can be rapidly titrated to a provisional 'optimum dose' with later fine tuning. This can be done with many patients at minimum risk of adverse outcome being outweighed by increased chances of retention and contiunuation in treatment.

Whilst I appreciate the difficulties this presents GP's and some shared care practices I fail to understand why Teir 3 services are unable to undertake fast titration where retention in treatment is a clinical priority.

Even GP's can perform relatively rapid titration when required. I suspect that it is often a matter of established practice, mores and custom (WE HAVE ALWAYS DONE IT LIKE THIS)

[simon]

Alan,
I suppose it depends on the set-up, we work in a bit of a different way, we treat our own patients and i am employed by the gp. Although we think of ourselves as part of shared care it is slightly different.
It is possible to assess and treat people within a day or two, however we are only a small service and of course we are restricted by how many staff we have treating our patients. That is to say there is me and one GP who work with our substance misuse patients. The other doctors and Nurses are involved in a more general manner. Sheer numbers in treatment will be a bar if we don't get more staff.
I see assesments as an ongoing thing, get the basics and the rest can be done as things progress.

[judith yates]

Younger, smaller and shorter term established opiate users I would start on 20 or 30mls methadone, and increase slowly and carefully, maybe by 5ml increments every three to four days, if needed. . ( or indeed try subutex, which if suitable is quicker and easier induction)

For higher dose, older and longer established users, (who  i expect ultimately to need at the very least 70mls-80mls methadone daily, and often up to 120mls or more daily) I may start on 40mls daily, and then try to get them as far as 70-80mls within 2 weeks, for the reasons you suggest, of engaging them quickly, avoiding drop outs, and avoiding too much heroin use on top of the script in the initial stages. . This group (often with a previous prescribing history, or at least a well documented long established habit) I start on 40mls daily,by supervised consumption,  then increase by 10mls every 3-4 days. (for example to 50mls from day 4, 60mls from day 7, 70mls from day 10 etc) this is within  the National Methadone prescribing guidelines, which suggest not more than 30mls increase in any one week.  I have colleagues who might increase them more quickly, sometimes by arrranging twice daily supervised consumption in the early stages.

One question which is being discussed by various GPs around the country at the present time, is whether for example a GP could safely write a blue script for 7 days (til their next GP appointment) with an automatic 5 or 10ml increase on day 4, leaving it to the patient to let the daily supervising pharmacist know if they do not want or need the increase. There are many who say this is unsafe practice, and somehow much safer if the GP sees the patient face to face, before each individual increase. There are others who feel the patient is really the only one who can safely judge whether thay need the extra 10mls, and the GP is not likely to be able to add much to the safety of the situation by actually looking at the patient each time (given that the pharmacist is looking at him/her each day) , which has the advantage of leaving the GP free to see someone else. Who knows which is correct? I don't at present.

Everybody of course want to work in the safest possible way, to avoid the terrible tragedy of death occuring at this dangerous induction time, just when somebody has found their way into treatment and is hopeful of a better future.

[simon]

I am cautious and try to increase as quick as i can as safely as i feel comfortable. we normally start on 30mg and increase every few days by 5mg, Judith has been doing this a lot longer than what we have and I am sure it is a lot to do with confidence of the prescriber.
I understand at one time locally gp's were told they must not prescribe methadone and a lot still remember this. They were told it was too dangerous for them to do it. Now gp's are being head hunted to prescribe and remember the danger stories what they were told some years ago.

[judith yates]

Hi Simon, I think we are in complete agreement. As i said above, I start many people on 30mls  (and a few on 20mls) increasing as you would at 5mls at a time, every few days (usually every 3 or 4 days) .

The higher doses mentioned are as i said for high dose users, with well documented long standing histories.(often they have been scripted in the past, and may be well known to me)

 I try to get everybody up to a comfortable dose which holds them as soon as I safely can, and the post above attempts to describe the lower and higher ends of the range.

[simon]

Judith,
I hear of people prescribing 80mls within a couple of days and this worries me. I do try and educate patients telling them how methadone works as best as I understand it.  I'm not sure rapid increases is  specialist knowledge or my ignorance.

Alan,
Come on tell us your view?.

[Alan J]

Dear Simon and Judith,

I found some of the idea's raised very interesting, especialy the one that would
allow patients a greater degree of control/input into the titration process. Currently titration is inhibited by concerns about safety, staffing levels to monitor progress and risk, often compounded when a patient is new to treatment or the practice/clinic.

A key objective of titration could summarised as being to determine and provide the optimum dose for the individual patient as safely,comfortably and quickly as practicably possible. The bottom line is that risk can be managed but never completely eliminated so it is important to take all reasonable measures with the patient so as to minimise the risk's associated with the titration process.
I emphasise the term reasonable to stress the importance of discussing the process with the patient so they understand it, how long it will take, and give them an opportunity to relate any problems this presents. For example, if they are working?
Attending college?Are disabled? Experiencing acute withdrawal,etc.

Such concerns are often compounded by additional issues, notably 'trust', particularly if a patient is new to treatment or new to a service/practice.
The conduct of the titration process can have a long term impact on the relationship between the individual patient and their treatment provider.

My own sense is that increasingly flexible practice hours,nurse and pharmacy prescribing offer ways of tackling this problem in the longer term. The idea Judith related is an example of just the kind of imaginative responce that could pave a way to resolving difficulties associated with over long titration procedures without compromising the patients safety.

I feel that users often feel particulalry disempowered and vulnerable during this period and will often, until optimum dosing is reached, be feeling the impact of full or partial withdrawal. Increased participation on the part of the patient would help
in that it would build trust, give them a sense of having some control and input into the process and that if in particular distress they feel that it will be responded to promptly.

In short, many problems could be resolved by increased patient involvement in the titration process, better understanding of why the process will take x long rather than y long, etc. That each patient's titration be managed on the indviduals presentation.That the process presents a unique opportunity to build trust, to help the patient become empowered and feel an active participant in the process and that the titration process is also a time of opportunity not soley one of risk.

This could be done as your own practice demonstrates within a reasonable time frame and need not require significant input in terms of staff or resources.


More to add but work calls, Best Alan J.

[Alan J]

Dear Judith, Simon, and all

I just had an observation to add which runs something like this....

Perhaps we have become overly focused on the 'problems' associated with the titration process and as a result have become 'snow blind'  and unable to recognise, to see and percieve this period as a time of unique opportunity.

Perhaps, if we collectively changed our mind set and mutualy (user and service provider alike), dispenced with recieved wisdom  and  recognised the potential offered by the titration period to build foundations for the future relationship between service provider and service user, the fundemental approach to the titration process will change.

Rather than a problem it could be transformed to a golden 'time', when the service user feels their needs are paramount, yes within limits but not so much limits as flexible bounds and and trail markers (?) which not only informs the patient about their rights & responsibilities but moreover help's them feel embraced as active and welcome participants in both titration and treatment pathway planning.

 In short, rather than this serving as a time when the treatment provider comses down from the mount of the 'team review', at a time when the dynamics of the relationship between patient and service become 'written in stone'and where 'scripts from on high' are handed down, it could be transformed to a space and time when user and service listen to each other, work together as 'equals' participating on a treatment planning process that is not set in stone but is rather holistic, repsonsive to changing need and circumstance, and is in reality and perception a process of empowerment and co-operperation towards mutualy agreed goals.

Perhaps this sounds like motivational thinking or a sales pitch. I hope not but readily admit to the 'idealism' I display. Idealism need not mean naivety indeed it could be founded upon realism. There is often mutual suspicion and mistrust between patient and service at this time, the actions of the service and the service user can create a relationship and dynamic under pinning a future relationship which could well determine the course and outcome of treatment responce, retention and outcome.

If titration is percieved to be a 'problem' period in the treatment process then perhaps "reviewing " it as a time of unique opportunity may lead to changes in the conduct of the process, indeed the process, itself. There may be no single solution to the problems this presents but I would contest that increased empowerment and knowledge on the part of the user will make for a shorter, more constructive and positive long term development of treatment pathway's by service user and service provider. In short this offers a proactive means to establish optimum treatment planning, development of relations between patient and service, alongside a host of other short, medium and long term benefits.

Anything that help's stop titration procedures that  outlast the users stay in care would be welcome by all and may save time, mutual frustration, harm and ultimately lives.

Best, Alan   

[simon]

Alan,
i do agree with what you say, during a titration is when we probably see the most of a patient. It's a time to build a good strong therapeutic relationship. Within boundaries prescribing is a team effort. If any medication/treatment is to work then the patient needs to be empowered, they need to know what a drug does, how long it'll take to work, side effects, how long it needs to be taken for, even if it's forever.
There is definitely a partnership or should be. There are probably not many other areas where people prescribe that the patient should have such a big influence. If you go to see GP and they diagnose a chest infection and give you Amoxicillin 250mg for 7 days most people won't say sorry Doc. it'll take at least 500mg to shift it and 1o days prescription (Judith may tell us differently  ). I guess the 250mg would be what the evidence base may say and it would be right and proper to say you aren't getting 500mg for 10 days.
However if the evidence said prescribe 250mg and someone prescribed 125mg and patient knew this to be a kiddies dose and said this isn't nearly enough and the chest infection didn't go away and were told this is all you are getting. Would this patient be happy might they get aggressive?.

[Rokki]

Hi Alan and all

Here in the USA they start a new patient at no higher then 40 mgs the 1st day,unless of course they have transferrd from another provider. Marie Nyswander said it best when said "Listen to Your patients" As expressed here when a patient is involved with their own care they seem to feel better about the treatment they are receiving and will want to become more knowledgeable about methadone,the regs and how it works in our bodies. As we are all different the final outcome is never the same. What works for one patient could kill another. DR Payte says it best" How much methadone do you give a patient? ENOUGH!"  The increases should be larger as the dose increases. I believe 5 mgs is an insult to a patient when they ask for an increase. Studies show that after a patient reaches lets say 100 mg's the increases could be anywhere from 15 mgs on. ie: I take 120 mgs 3 x's a day so when I get an increase it's a 10 mg one but 3 x's a day so in esence it has been raised 30 mgs. I personally don't believe it matters whether we are young or old,patients shouldn't be confined to a Box theory,if they need an increase they should have it. We all know "There is No High Dose,No Low Dose,Only The Right Dose"

Lets try to remember that it's the patients saftey and recovery that is the most important thing and not our own butts or box like theorys

Thanks

Rokki
just my 2 cents

[simon]

Rokki,
Most interesting to read but i'm not sure that I could justify such dose increases I am all for giving people the dose that is needed and I am always challenging my own views.
I have been to coroners court a few times and wonder how I would justify to peers and family such increases if, God forbid a patient died whilst being given a drug introduced to them by me and at such doses.
I'm not saying it's wrong. Will be interesting to hear Judith's thoughts.
I am also in a position that may be watched carefully. I believe I was the first Nurse to prescribe controlled drugs to substance misuse patients and have to agree a clinical management plan with a Doctor before I prescribe. The Doctor I work with would not prescribe such high doses and therefore I can't.
I think such high doses would need specialist input and i'm not sure many consultants would prescribe such  large amounts of Methadone here but some will.
I would say it's not just my butt i'm watching it's the patients too I want happy patients incresed quick enough so they feel ok and are safe.

[Rokki]

Would you give a diabetic just enough insulin to keep from them from a coma? Or would you give them what their body required? When giving antibiotic's would you give a patient just enough to maybe get the virus,or would you give the patient what will work for them? Then why is methadone any different? Also,please remember that methadone content is twice the amount<I believe thats how it measures> in the UK then the forumla given here in the USA. I understand that methadone is not for everyone and sometimes patients will take more then they are used too. But if you keep a patient underdosed they will only stagnate in their recovery and maybe sell their doses to get "Well". Also split dosing works well for those with HCV and fast metabolizers. However Dr's are afraid to step outside the box due to STIGMA!  How can you expect a patient to do well with something if they are not getting the full amount of what They need,not what Joe Blow needs,but each patient as an Indiviual. It's thinking like that keeps users using and will kill them in the long haul as they search to get well.  I commend the work you do,but this IS medical care and patients should be treated with respect and dignaty and have what their body requires for them to mainitain some quality and stability of life. Like I said there are No Low Doise,No High Dose,Only The Right Dose.

I noticed when I was still taking neurontin and was taking 600 mg's 3 x's a day..No one blinked an eye cuz it's only a Number...However if say what my dose is with methadone people think I should be dead or sleeping all day...STIGMA...   I even have my Reg Dr saying "Its Only a Number" 

Take Care

Rokki

www.methadone.org

Methadone Is Medicine

[simon]

Rokki,
I'm all for giving people what they need and in regard insulin you would not recklessly increase a dose and risk the patients wellbeing/life and In my mind that is exactly the same with Methadone. A patient taking insulin will probably not be taking some they bought on the streets and taking some other oral medication that effects their production of insulin.
A diabetic is a good choice as many are poor with concordance you know this when you check the glucose levels and hba1c i guess the only thing similar in the substance misuse field would be a hair sample.
I expect that when i increase someones medication i do the best i can. There doesn't seem to be a magic formula for increasing methadone and a lot of guidlines are different. All patients are different, the guidelines are different and the prescribers are different, is it a wonder we ever reach a therapetic dose?.