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High dose methadone prescribing and medical review: a completed audit cycle in Midlothian 2012 High dose methadone prescribing and medical review: a completed audit cycle in Midlothian 2012 -14. Dr Rachel XA Petrie, Consultant Psychiatrist in Addictions, MBCh. B BSc(Hons) MRCPsych Ph. D Midlothian Substance Misuse Service, 1/5 Duke Street, Dalkeith, Midlothian EH 22 1 BG Results Background QTc prolongation on the ECG is associated with arrhythmias and sudden cardiac death. Methadone is a risk factor for QTc prolongation on the ECG, with a possible dose-dependent action, but the overall risk is low 1. However, patients on high dose methadone often have other QTc risk factors. These include co-morbid diagnoses and other commonly prescribed psychotropic medications. This is one reason why regular medical review of patients on high dose methadone is important within Addiction services. No robust system was in place within our service to ensure this. Aims • To establish a baseline of current practice of medical reviews in high dose methadone patients (2012). • To feedback data on current practice to keyworkers, and to make recommendations for improvement • To re-audit the same parameters in the same service (2014) in order to establish whether this had led to any quality improvement. Method The case notes of patients on high dose methadone (defined as methadone ≥ 100 mg/day), were reviewed to collect the following data at baseline (2012): • Number of patients on high dose methadone; age • dose • whether medical review within last 6 months • co-morbid conditions • other prescribed drugs (including GP prescriptions) • whether ECG requested • whether patient attended for ECG • whether ECG QTc was prolonged • whether prescription altered as a result of ECG (or other reason) These results (along with QTc education) were presented to keyworkers. It was recommended that all high dose patients were offered and ECG and 6 monthly medical reviews. The same data was collected for re-audit in 2014. Prolonged QTc? Nov 2014 Discussion/Conclusions The results are summarised in the table below. The total number of high dose prescriptions is around 10% of the total number of patients in our service. Compared to 2012, the re-audit in 2014 shows a reduction in the number of high dose methadone prescriptions and a reduced mean daily dose. A slightly higher percentage were medically reviewed within 6 months, and there was better recording of comorbid conditions and other prescriptions. There were a few more ECG requests but attendance for ECG remained poor. Few patients had QTc prolongation in either baseline or repeat audit. Prescriptions changes were more often made for other clinical reasons rather than as a direct result of ECG. 2012 Number of high dose 28 prescriptions Mean age 32 years Mean dose 129 mg daily Medical review in last Yes 18/28 = 64% 6 months? No 10/28 Co-morbid physical Yes 12/28 = 43% diagnoses clear? No 15/28 Unclear 1/28 Co-morbid non. Yes 5/28 = 18% addiction psychiatric No 6/28 diagnoses clear? Unclear 17/28 All prescriptions Yes 14/28 = 50% clear (including from No 14/28 GP)? ECG request last six Yes 9/28 = 32% months? No 19/28 ECG attended last six Yes 5/9 = 56% months? No 4/9 rachel. [email protected] scot. nhs. uk 2014 20 35. 5 years 120 mg daily Yes 14/20 = 70% No 6/20 Yes 15/20 = 75% No 5/20 Unclear 0/20 Yes 8/20 = 40% No 9/20 Unclear 3/20 Yes 10/20 = 50% No 10/20 Yes 7/20 = 35% No 13/20 Yes 2/7 = 29% No 3/7 Unclear 2/7 No 1/2 Result awaited 1/2 None Yes 2/28 No 3/28 Prescription altered 1 of 2 who had as result of prolonged QTc ECG? Prescription altered 2 others who attended None for other clinical for ECG reason? This completed audit cycle has led to several improvements in quality of care. Both patients and keyworkers are more informed of the potential cardiac risks of a high dose methadone prescription. The importance of regular medical review/discussion within the Addictions service is more recognised. Consequently, the opportunity for medication review to ensure safest prescribing is now more routine for these patients. At re-audit, there were fewer high dose prescriptions, a reduced mean daily dose. Recording of co-morbid conditions and other prescriptions also improved. It is recognised that updated GP prescription information is important and it is likely that improving IT systems will help this. All these factors are highly relevant in relation to safe prescribing. Medical review and discussion appropriately leads to ECG requests. As expected, the data shows that attendance for ECG is poor in this population. ECG monitoring of all high dose methadone patients is therefore impractical, and is probably of dubious benefit 1. These data confirm that prescription changes are more often made for other clinical reasons rather than as a direct result of ECG. This is in line with the Maudsley Prescribing Guidelines 1 which state that “prescribing should be such that the need for ECG monitoring is minimised”. Cardiac and other risks can be reduced through other clinical strategies at medical review. It is intended that this audit will be repeated over time and in other geographical areas in the Substance Misuse Directorate within NHS Lothian. Bibliography 1. Maudsley Prescribing Guidelines (9 th ed). Taylor D. , Paton C. , Kerwin R. (2007) Informa healthcare: 116 -119.