1. Printing: This poster is 48” wide by 36” high. It’s designed to be printed on a large-format printer. Customizing the Content: The placeholders in this poster are formatted for you. Type in the placeholders to add text, or click an icon to add a table, chart, SmartArt graphic, picture or multimedia file. To add or remove bullet points from text, click the Bullets button on the Home tab. If you need more placeholders for titles, content or body text, make a copy of what you need and drag it into place. PowerPoint’s Smart Guides will help you align it with everything else. Want to use your own pictures instead of ours? No problem! Just click a picture, press the Delete key, then click the icon to add your picture. High dose methadone prescribing and medical review: a completed audit cycle in Midlothian 2012-14. 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 Method Results 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. Dr Rachel XA Petrie, Consultant Psychiatrist in Addictions, MBChB BSc(Hons) MRCPsych PhD Midlothian Substance Misuse Service, 1/5 Duke Street, Dalkeith, Midlothian EH22 1BG rachel.petrie@nhslothian.scot.nhs.uk Nov 2014 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. The case notes of patients on high dose methadone (defined as methadone ≥ 100mg/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. Discussion/Conclusions 20122014 Number of high dose prescriptions 2820 Mean age32 years35.5 years Mean dose129mg daily120mg daily Medical review in last 6 months? Yes 18/28 = 64% No 10/28 Yes 14/20 = 70% No 6/20 Co-morbid physical diagnoses clear? Yes 12/28 = 43% No 15/28 Unclear 1/28 Yes 15/20 = 75% No 5/20 Unclear 0/20 Co-morbid non- addiction psychiatric diagnoses clear? Yes 5/28 = 18% No 6/28 Unclear 17/28 Yes 8/20 = 40% No 9/20 Unclear 3/20 All prescriptions clear (including from GP)? Yes 14/28 = 50% No 14/28 Yes 10/20 = 50% No 10/20 ECG request last six months? Yes 9/28 = 32% No 19/28 Yes 7/20 = 35% No 13/20 ECG attended last six months? Yes 5/9 = 56% No 4/9 Yes 2/7 = 29% No 3/7 Unclear 2/7 Prolonged QTc?Yes 2/28 No 3/28 No 1/2 Result awaited 1/2 Prescription altered as result of prolonged QTc ECG? 1 of 2 who had prolonged QTc None Prescription altered for other clinical reason? 2 others who attended for ECG None 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 co-morbid 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.