The Bay of Plenty Addiction Service has been criticised for its handling of two methadone patients, one of whom died. Photo / 123RF
A man had been in a methadone programme for 30 years when he decided he wanted to voluntarily reduce his dose.
He wanted to end opioid substitution treatment (OST) entirely and, with the support of his dispensing pharmacy in Tauranga, began to gradually reduce his methadone dose.
But in May 2021, after 10 months of gradual reduction, the Bay of Plenty Addiction Service informed him his “lack of engagement” with the service meant he’d be subject to involuntary rapid withdrawal of methadone, which was implemented between August 7-14, 2021.
About six weeks later, the man died from “mixed drug toxicity”.
Post-mortem toxicology testing confirmed a level of methadone that “can be toxic to an individual who does not have a tolerance to the drug” as well as other drugs in his system.
Now, Health and Disability Commissioner Morag McDowell has found Health New Zealand, which runs the Bay of Plenty Addiction Service, was in breach of the Code of Health and Disability Services Consumers’ Rights.
It had involuntarily withdrawn the man, referred to in the findings as Mr A, without “reasonable grounds or exploration of all alternative strategies, at a dangerously rapid rate, and without appropriate advice or support”.
The HDC inquiry was conducted in conjunction with another case, from 2023, where a woman was taken off methadone and put on another treatment “under duress”, causing her “acute and unnecessary discomfort and distress”.
In both cases, Health NZ BOP was criticised for the clinical decisions and lack of communication with the methadone users.
Both decisions highlighted a letter from the HDC to the Director of Mental Health and Addiction Services, sent in October 2023, which expressed concerns that many OST services were being provided in a way that was “inconsistent with people’s rights under the code”.
It said OST consumers were not always “being respected as partners in their care and that treatment planning or decisions to amend or discontinue treatment were being made without consumers being involved in those discussions”.
Specific concern was expressed about the involuntary withdrawal of methadone, at rates far from gradual and for reasons unclear to consumers.
Mr A had decided he wanted to withdraw from the methadone programme entirely.
He didn’t like having to go to the pharmacy for medication every morning, finding it burdensome, but he was required to because of his “contentious use of cyclizine”, which meant he wasn’t eligible for “takeaway doses”.
Cyclizine is an antihistamine used to treat nausea or vomiting from motion sickness, which Mr A said he used for seasickness.
It can also enhance the effect of opioids and is regarded as a drug of abuse by people using methadone.
Mr A’s pharmacist, Mr B, was found in breach after he, during the period of voluntary withdrawal, gave Mr A reduced doses of methadone, at his request, without authorisation from the prescriber, Bay of Plenty Addiction Services.
The HDC found there were three occasions when Mr B dispensed a reduced dose without authorisation, and Mr B was found in breach of the code.
But the second breach was by Health NZ Hauora a Toi Bay of Plenty.
The possibility of involuntary withdrawal of Mr A’s treatment was first suggested at a medical review in November 2020.
Mr A’s use of cyclizine was discussed, and he was reminded that he needed to attend appointments while he remained in treatment.
A plan was suggested for monthly appointments, however, an adviser to the HDC, Dr Ivan Srzich, noted it wasn’t clear whether a plan for Mr A to attend more regular appointments was discussed in “any collaborative way”, nor did it appear “clinically warranted”.
Mr A was stable, undertaking a voluntary managed dose reduction, with no evident risks or challenging behaviours.
While the ongoing cyclizine use was not condoned, it did not raise clinical risks.
He’d been to nine face-to-face meetings in the 21 months before November 2020’s medical review, and with no “non-attendance” and no significant concerns.
The HDC said while it was important for OST service users to be “active participants”, in this case, it was known Mr A was already finding requirements “onerous“.
“It would appear counterproductive to suggest that Mr A increase contact,” McDowell said, concluding it seemed a “punitive approach” more likely to harm than help.
In May 2021, the Bay of Plenty Addiction Service told Mr A that his “very limited contact” had led them to conclude he was no longer willing or able to engage in the programme and his medications would be “withdrawn rapidly”.
Mr A then arranged an appointment with his case manager on May 21, 2021.
He said a rapid reduction of methadone was unrealistic and said his goal was to continue reducing his dose gradually until reaching zero.
He agreed to monthly appointments, attending medical review appointments, and ceasing cyclizine use.
But he didn’t make any further appointments, and missed two medical appointments – one in June, because he was unwell, and the second on August 2, which he later claimed was because he’d mixed up the dates.
On August 3, he was told he would be discharged involuntarily, at a rate of 5mg per day until he reached zero.
On August 5, he contacted Bay of Plenty Addiction Service to say the reduction was “unfair and cruel”.
The rate of reduction was slowed to 2mg per day.
But McDowell accepted the advice of Dr Srzich that the involuntary discharge was not appropriate and was a “moderate departure” from accepted practice.
Srzich noted that the decision was contrary to the NZ OST Guidelines and Health NZ’s BOP OST Pathway, which provide that involuntary discharge should be undertaken only as a “last resort” owing to the risks to the service user, including the increased risk of fatal overdose.
Srzich said a client’s challenging engagement does not warrant involuntary withdrawal.
There was also inadequate support and advice given to Mr A, including no discussion about the risk of overdose, no mention of the provision of Naloxone to manage possible opioid overdose.
“It appears that Mr A was offered medication for relief from withdrawal symptoms, but it is not clear what this was,” McDowell said.
“Dr Srzich considered that the limited support offered to Mr A during the withdrawal process was a mild to moderate departure from accepted practice. I accept this advice.”
As a result of the deficiencies identified in Health NZ’s care of Mr A, he experienced acute and unnecessary distress.
Six weeks after his treatment was withdrawn rapidly, Mr A died from a mixed-drug overdose, including methadone to which he would have decreased tolerance.
“I am highly critical that Mr A’s treatment was withdrawn involuntarily contrary to accepted standards and practice, at a dangerously rapid rate, and without appropriate discussion of the risks of opioid overdose, management of possible opioid overdose, or how Mr A could re-engage with treatment or obtain support from a consumer advocate,” McDowell said,
In another case, Ms A had been receiving methadone as part of OST since 2009, and had been registered with BOPAS since late 2019.
She was told she’d need to switch to buprenorphine, used for maintenance therapy, because of her recent IV use of illicit opioids.
She was told if she didn’t, she would have her methadone involuntarily reduced.
Later in 2023, she complained to the HDC about her methadone dose being involuntarily reduced on two occasions, and that she’d been made to undergo unnecessary methadone blood tests.
McDowell found Health NZ BOP was in breach in Ms A’s case too, after it failed to have “adequate oversight and communication systems” in place to ensure decisions regarding her treatment were based on “complete and correct information”.
There had been a degree of “coercion” to have her agree to an alternative treatment, buprenorphine, when she didn’t want to, and had “no reasonable opportunity to challenge that decision”.
As a result of Health NZ BOP’s care, Ms A experienced “acute and unnecessary discomfort and distress”.
McDowell was “highly critical” that a first dose reduction was implemented without the opportunity for medical review, at a dangerously rapid rate, and without appropriate discussion of risks, withdrawal management strategies, and physical and psychological support options.
It had also delayed treatment by requiring her to undergo “unnecessary and onerous serum-level testing”, by way of blood tests.
The HDC also found that Unichem Greerton had accidentally given Ms A another patient’s dose.
The pharmacist had mistakenly taken the wrong prescription from the controlled drug safe, as the other patient shared a “similar name”.
The dose had been 90mg of methadone, rather than Ms A’s prescribed dose of 40mg.
The pharmacist, Mr B, noticed the error and informed and apologised to Ms A.
He checked on her condition, reported the incident to the Addiction Service, and provided advice. The pharmacy investigated and documented the incident.
McDowell said while the dispensing error was in part caused by the pharmacist’s “momentary lapse in attention”, the pharmacy should have had appropriate policies and procedures in place, as per OST guidelines.
The pharmacy has since implemented a number of changes to enhance patient safety, including a “double check” process for the methadone programme.
The HDC recommended that both cases were used as a basis for developing education/training for the OST service, with reference to World Health Organization’s guidance.
It’s recommended that it focus on a number of areas of the OST service, including ongoing methadone dosing, planned withdrawal, involuntary cessation, measuring serum levels, and managing problematic substance use.
There have been training recommendations made for OST staff, both current and future, and a recommendation to consider if the current Health NZ Bay of Plenty OST team’s prescribing psychiatrist become a member of the National Association of Opioid Treatment Providers (NAOTP), or, alternatively, advise that they are already a member.
The HDC also recommended that written apologies be provided to the family of Mr A, and to Ms A.
Hannah Bartlett is a Tauranga-based Open Justice reporter at NZME. She previously covered court and local government for the Nelson Mail, and before that was a radio reporter at Newstalk ZB.