metadone di KKM

1. Dr Hj Mohd Ariff Mohd Noor
Pakar Perunding Psikiatri
HRPZ II, Kota Bharu
Pusat Latihan Bachok, 26 Mei 2010

2. General :
• To improve the health and quality of
life of persons with opiate
dependence through drug substitution
therapy.
OBJECTIVE

3. Specific:
• To reduce relapse among opiate dependent.
• To improve the physical and mental condition of opioid dependents.
• To reduce spread of infection through IVDU and sharing needles.
(e.g HIV, hepatitis B and C )
• To treat opiate dependents pregnant women.
• To improve psychosocial functioning, including ability to gain or
maintain employment and to improve their social adaptation and
integration into the society.
• To reduce criminal activities amongst opiate dependent.
OBJECTIVES

4. Opiate Dependent
Register
Inclusion
Consent
Initial Assessment
- Blood/urine
- Questionnaire
- Physical examination
DST
Counseling
Evaluations
Detox
2 / 52
1 / 52
Jika gagal
Lampiran 1
Lampiran 2

5. Lampiran 1
- No take away doses
DST
6 / 52
2 / 7 & Weekend doses
Daily
3 / 7 & Weekend doses
Urine negative
Regular follow-up &
Counseling

6. Lampiran 1
- No take away doses
DST
DOT
Daily
DOT
Urine negative
Regular follow-up &
Counseling
-No take away doses

7. Opiate dependent
Register,inclusion,personal
information
Consent
Initial assessment
- QOL, OTI
- P/E
- Blood/Urine

8. CRITERIA
• Inclusion
- Volunteer
- Drug dependent > 2years
- Proof of identity
- capable of informed
consent
- complication of opiate dependence
• Exclusion
- Age < 19
- Drug dependent <2 years
- Polysubstance abuse
- Abnormal LFT(more than 3x)
- ac. Med/psy disorder (severe/with
complication)

9. CRITERIA…additional inform
• Inclusion
- accept HIV negative
- non IVDU
• Exclusion
- No compromise if it is excluded
- Abn LFT
 Allow DOT if ALT >3fold with no
clinical significant finding & repeat LFT
in 2/52
 No DOT if ALT>5fold & repeat LFT in
2/52
 Exclude if clear clinical significant
finding.
- poor personal information (register but
waiting for include into the program)
- psy disorder with poor
supervision/compliance/
frequent admission/cognition

10. Consent…..inform about
 Emphasize on the rule
 Terminate if persistent against
the rule such as fraud,
violence toward staff
 No compromise on drug
dealing & theft/damage
property
 Not by proxy for takeaway
except able to show evidence
such letter from Doctor. Show
other evidence or bring family
if they want temporary
takeaway.
 To be taken preferably with
family
 Blood taking after consent

11. INITIAL ASSESSMENT
Questionaire
- WHOQOL
- Personal data
- OTI
- W0, W12, W24,W48
- W0 (on the day before DOT)
Physical examination
- sign intox,withdrawal,needle track
- medical problem e.g. liver disease
Blood
- LFT,HIV,Hep B,C
- after consent,3/12 first 1yr, then 6/12
Urine
- weekly 1st
1/12
-2 weekly for next 1/12
- randomly each month

12. Getting consent from pt and family

13. Mendaftar Nama Untuk Menentukan Nombor Giliran

14. Penilaian Semula Status Kesihatan Klien
Dengan Borang WHOQOL-BRIEF

15. Client sedang dinilai keberkesanan rawatan &
penilaian OTI oleh pegawai perubatan yg telah
diberi latihan

16. Sesi Kaunseling

17. INITIAL ASSESSMENT….blood
Blood
- LFT,HIV,Hep B,C
- after consent,3/12 first 1yr,
then 6/12
- HIV,Hep B,C once
assessment if positive
- TO BE TAKEN at least 1/52
before at initial DOT on the
same day (after consent)
- Blood is taken for selected
number of pts from same group
by different day of the week
monthly scheduled.

18. Saringan darah sedang
dilaksanakan.

19. Tempat Pemeriksaan urin

20. INITIAL ASSESSMENT….urine
Urine
- weekly 1st
1/12
-2 weekly for next 1/12
- randomly each month
- No need
randomly/month if
the individual show poor
behavioral performance.

21. Treatment effectiveness = Urine
Test result ?

22. Bahan sampingan penagih ditemui dalam “flush” tandas

23. ASSESSMENT BY THE PRESCRIBER
• Induction/stabilisation
– Patients are reviewed every 3
days or 2x a week for 2/52
(e.g.Sunday & Wednesday).
– Review PRN between those
days if withdrawal or
intoxication occur
– Highly supervised setting.
– No take home dose.

24. ASSESSMENT BY THE PRESCRIBER
• Maintenance Phase
– Patient should be seen:
• Weekly for 2 week.
• Fortnightly – 2 months.
• Monthly – after that.
– Allow take away not more
than 3 days
– Preferably with family
supervision.

25. ASSESMENT TAKEAWAY
Takeaway
 Not mandatory if urine result
persistent negative
 Avoid from giving takeaway
 Unlikely involve with gang or
came with outsider
 Busy and comitted with work
especially involve with people
 Never seen with “hang around”
 Don’t empathy/sympathy

26. TAKEAWAY cont…
Takeaway
 Suspended if
 urine persistently positive
 Share with others
 Selling to others
 Bring the bottle to their friend’s house
 Bring back bottle of the similar identity
 Strictly warning or suspend takeaway if
repeatedly bring suspicious ‘friend’

27. Client sabar menunggu,tabiat lama yg
perlu dibuang, BAGAIMANA
MENANGANINYA ????

28. Initial Assessment
1/52
DST
2/52
Counselling GAGAL
Evaluation
Detox?Detox??

29. How to plan…
• Review pt
• Blood specimen
• OTI
• Urine
• Counselling
• ….if possible all plan are systemic,well
organised, time consuming and
predictable

30. APPROACH
• Identify group
MO only looking at clinical aspect. MO came to
review according to their turn because has to
review other activities.
• The committee would arrange time table base
on MMT GUIDELINE FOR
1) review client according the group
2) blood specimen taken /OTI/QOL
3) urine test
• All procedure done before review by MO and
then dispensing by pharmacist

31. Sun/dilihat
oleh MO
Mon/*OTI/
Dilihat oleh
MO
Tue/
consent
&blood Ix
Wed Thurs/
dilihat oleh
MO
22/10
1
29/10
1 1
5/11
1 1
12/11
1 2
19/11 1,2 2
26/11
2 2
3/12
1,2 3
10/12 2, 3 3

32. Sunday/ dilihat oleh
MO
Mon/
dilihat oleh MO &
OTI
Wed/
Pengambilan
darah
18/2 PH 3,9,11 7*
25/2 4,8,10 11 9(28/2)
4/3 5,6, 3 9*
11/3 1,2,7 10.11 10 (14/3)
18/3 3 10*
25/3 4,8,11
1/4 5,6,9 11 (4/4)
8/4 1,2,7 11
3,9

33. Kump
1
Kump
2
kump
3
Kump
4
kump
5
1/12 Urine
2/12
3/12
Sun 4/12
5/12
Tue 6/12 urine urine
7/12 urine
8/12 urine

37. Panduan kakitangan

38. Client dimaklumkan tarikh awal jumpa doktor

40. Peraturan lebih ketat lagi ….agar client tidak berkeliaran

41. Masa pendispensan yg ketat dan mesti
dipatuhi oleh client

42. Client baru dapat peluang minum ubat

43. Pegawai Farmasi di bilik
pendispensan

44. Repeater Pump give better time management

45. Each group either….
• To be reviewed by MO
• For Urine test
• QOL/OTI
• Blood investigation
• And end up medication dispensed by
Pharmacist.

46. Patient
Registered
Blood test Urine test
Dispensed
Methadone
Review by
MO/Sp/C
QOL/OTI
Gp 1 Gp 3,4
Gp2
Gp 5 Gp 6
Flow Chart

47. Working committee meet at least 3 monthly
– LATERAL & STRATEGIC THINKING

48. Menyusun Keputusan Ujian Makmal
dan borang OTI/QOL untuk dihantar
ke JKN/KKM

49. File lama/pasif (kiri) dan file baru/aktif (kanan)

50. Rekod client mengikut kumpulan dalam simpanan

51. Conclusion
• Systematic
• Traceable - personal file
- the procedure schedule &
its defaulter
- result test & its defaulter
• Better time management
• Easy to arrange work plan
• Predictable
• Enforce the rule and be assertive

52. Substance & Consultancy Unit
Ministry of Health
LITHUANIA, MAC 2005

53. KOTA BHARU, MAC 2006

54. “Bio-Psycho-Social” model
Biological
Psycho-cognitive Socio-environmental
MODELMODEL
Spiritual

55. Treatment effectiveness = Urine
Test result ?

56. Maintaining abstinence Response
Functional,Quality of Life,
Remission
Functional
and
Social Autonomy
Recovery
What is successful treatment ?
Improvement of Dependency?

57. Perjalanan masih jauh
TERIMA KASIH….kita jumpa lagi

58. THANK YOU…