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Q&As: Methadone and diacetylmorphine
On May 19, 2018, NPs gained the authority to prescribe methadone and diacetylmorphine under the Controlled Drugs and Substances Act (CDSA).
Why did the laws change?
Responding to the national opioid crisis, and following a national consultation, the Government of Canada changed the laws to increase health care access for Canadians needing treatment for substance use disorder.
Details of these changes can be found in the Canada Gazette, Part II published on March 21, 2018.
What are these drugs used for?
Methadone and diacetylmorphine are used to treat substance use disorder. Where clinically indicated, methadone is also used to treat pain (e.g., palliative care).
Why are methadone and diacetylmorphine so high risk?
Methadone and diacetylmorphine can cause addiction, overdose and death. There can also be dangerous side effects when taken in combinations with other drugs.
What other drugs can be used to treat substance use disorder?
There are other high-risk drugs used to treat substance use disorder. For example buprenorphine is a drug that NPs can prescribe already to treat substance use disorder. Please visit CNO’s resource page on controlled substances for information to reference when making evidence-informed decisions about controlled substances.
What are the practice expectations for NPs who prescribe methadone and diacetylmorphine?
Only NPs who have successfully completed College approved controlled substances education are authorized to prescribe controlled substances in Ontario, this includes methadone and diacetylmorphine.
Activities associated with controlled substances are high risk. As with any other activity or procedure NPs engage in, they are expected to have the knowledge, skill and judgment to prescribe methadone and diacetylmorphine in a safe, competent and ethical manner. NPs are expected to understand the unique risks associated with prescribing any controlled substance and incorporate relevant evidence-informed strategies to mitigate these risks.
- Having sufficient knowledge, skill and judgment to determine the appropriateness of performing the procedure at a given time for a particular client
- Applying knowledge, best evidence, skill, judgment and appropriate authority to make and act on decisions required during the procedure
- Assuming responsibility for their own professional development
- Declining to perform the procedure when it does not support safe and ethical client care
- Developing and implementing an appropriate follow-up and monitoring plan in collaboration with the client
- Incorporating evidence-informed strategies for assessing, managing and monitoring the risks of misuse, addiction and diversion and
- Consulting other health care professionals when encountering client care needs beyond the legal scope of NP practice, their individual competence, or when the client would benefit from the expertise of other health care professionals.
Do I need to complete specific education before prescribing methadone or diacetylmorphine?
At this time, there is no legal requirement for NPs to complete specific education before prescribing methadone or diacetylmorphine. However, additional resources are available to support NPs continuing competence and clinical decision making. For example the Opioid Dependence Treatment (ODT) Core course is an interprofessional course offered by the Centre for Addiction and Mental Health. This is the same course Ontario physicians and pharmacists take.
What do other regulators have in place?
Many other regulators, whose members have already been prescribing methadone, will continue to require methadone prescribers to complete specific education and follow specific guidelines. For example, the College of Registered Nurses of British Columbia requires NPs to meet specific requirements to prescribe opioid agonist treatment (p. 30). Also, the College of Physicians and Surgeons of Ontario requires specific education and clinical practice. Their notice describes the requirements for physicians choosing to prescribe methadone for opioid use disorder (not analgesia). They have excellent resources for methadone maintenance therapy. The Ontario College of Pharmacists also requires their members to have specific education when dispensing methadone
Can my clients access diacetylmorphine if I prescribe it?
Currently, diacetylmorphine can only be accessed through Health Canada’s Special Access Programme. It is not available through the Ontario Drug Benefit program.
Where can I access more resources about prescribing methadone or diacetylmorphine?
Visit the CNO’s controlled substances – resources and references web page for more information and tools to support your practice.