Practice dilemma: New patient wants methadone scrip

You feel unqualified to prescribe methadone to a patient. What should you do?

A GP’s view 

Dr Vasa Gnanapragasam, a GP in Sutton, Surrey  

Newly registered patients requesting methadone at their first visit to the practice are not unusual. If a clinician is not confident in prescribing methadone and has no training, then the GMC guidance suggests that you must recognise the limits of your professional competence.  

You should prescribe drugs or treatment, including repeat prescriptions, only where you have adequate knowledge of the patient’s health and medical needs.  

If you do not feel confident, you need to seek help from someone who knows. The duty psychiatrist needs to be involved in the management.  

He or she may or may not be of help, but at least they will know about the available local service provision.  

At times he or she might suggest an alternative scrip until his previous methadone prescriber can be contacted to verify the story and scrip.  

The local rehabilitation centre might be able to help with determining the nearest methadone prescriber.  

You must be clear in your discussion and documentation that your inability to prescribe methadone is purely clinical and not due to your personal beliefs and prejudice.  

The main point is that you must not act beyond your competence even if the local health planners have not made adequate provision for the care of methadone-dependent patients.  

Methadone prescribing is not core primary care, and if there is a demand for this service provision your primary care organisation might encourage you to develop this as an enhanced service.  

However you will need to be trained and clinically supported in this process. 

A medico-legal view  

Dr Marika Davies, medico-legal adviser, Medical Protection Society  

Your patient requires careful management of his methadone use and this should be provided by those who have the appropriate training to do so.  

According to GMC guidelines, in providing care you must recognise and work within the limits of your professional competence.  

If you do not feel confident in managing this patient’s methadone use, then you should explore alternative ways of ensuring this patient receives the treatment he requires. The drug rehabilitation centre that he attends should be able to assist or provide you with appropriate guidance.  

If you do prescribe methadone you must ensure that your prescribing is appropriate and responsible. You should also ensure that you are familiar with current guidance.  

A patient’s view  

Ailsa Donnelly, Patient Partnership Group  

I  would continue to prescribe  methadone at the current dose. If the patient has been taking this for two years, then it is presumably safe for the present and the potential effects of refusing to prescribe could be extremely serious.   

What was your source of information about the patient’s attendance at the rehabilitation centre and attempts to reduce his methadone? If you obtained this from the patient’s records, then consider contacting the previous GP and/or the rehabilitation centre for more information. If the patient wishes to reduce his dose, you need to talk to him to find out what problems occurred with previous attempts.   

Local advice and help regarding drug addiction and rehabilitation centres can be obtained from the Community Drug Team (CDT), and you should refer him as soon as possible.  

The CDT may also be able to offer you help regarding training. The Substance Misuse Unit at the RCGP has published downloadable guidelines on the use of methadone in primary care.  

The dilemma  

A newly registered patient has asked me to prescribe methadone. He occasionally attends a drug rehabilitation centre and is holding down a good job. However, he has been unable to reduce his dose of methadone for the past two years. I do not feel confident in prescribing methadone because I have had no training, but there does not seem to be a local alternative. 

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