Two people had their therapeutic methadone doses changed by Te Whatu Ora against their will, with one man dying of an overdose only six weeks later, according to two separate rulings by the Health and Disability Commissioner (HDC).
By Kate Green of RNZ
In one case, a pharmacy mistakenly gave one woman – known as Ms A – nearly double her normal dose because her name was similar to that on another prescription.
In the other case, a man who the report calls Mr A died of "mixed drug toxicity" in September 2021, six weeks after he was rapidly taken off methadone involuntarily by HNZ's Addiction Services in Bay of Plenty.
The case of Mr A
A had been on methadone as part of opioid substitution treatment for the past 30 years.
But in June 2020, he voluntarily began reducing his dose, with the goal of coming off it completely, as he was finding the conditions of the programme "burdensome".
Mr A was also a habitual user of cyclizine, an antihistamine known to enhance the effects of opioids, which he took for seasickness while fishing.
At an appointment in November 2020, he was reminded of the need to attend regular appointments despite reducing his methadone use, and "it was noted he would not commit to ongoing attendance".
In response, the frequency of his appointments was increased to monthly, which commissioner Morag McDowell found in her report to have been "counterproductive", considering he was already finding the programme "onerous".
After 10 months of "gradual recession", the report found, Addiction Services decided he was showing a lack of engagement with the service, as he was failing to attend appointments and decided his prescribed methadone dose "would be withdrawn rapidly unless engagement improved".
Between August 7 and 14, 2021, Mr A was discharged from the programme involuntarily, and his access to methadone cut off.
Six weeks later, he died from "mixed dose toxicity", with the drugs in his system including methadone, to which he would have decreased tolerance due to the withdrawal.
The commissioner noted Health New Zealand's approach seemed "punitive".
"I am highly critical that Mr A's treatment was withdrawn involuntarily contrary to accepted standards and practice, at a dangerously rapid rate, and without appropriate discussion of the risks of opioid overdose,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 A could re-engage with treatment or obtain support from a consumer advocate," she says.
It recommended Health NZ write an apology to Mr A's family.
In the report, Health NZ maintained monthly contact was a standard requirement under their protocols, and while in some cases clients could be encouraged to attend meetings by "holding doses", this would most likely have resulted in a complete withdrawal from methadone rather than a scheduled one, and "the risks and results of undertaking such a strategy may have been the same".
The commissioner is also critical of the pharmacist involved, who reduced A's dose on a number of occasions without signoff from Health NZ.
The pharmacy that employed them said it "would not be usual practice to decrease doses of methadone without authorisation from the prescriber".
The pharmacist claimed Health NZ had signed off on the change, and there were records to prove it, but those could not be produced, and the pharmacist had by now left that pharmacy.
The case of Ms A
In the second case published this week, a woman – known in the report as Ms A – had been receiving methadone as part of opioid substitution treatment since 2009.
In June 2023, Ms A was told by her case manager that due to the fact that she had recently injected some illicit opioids, along with some missed appointments and medical reviews, she should switch to buprenorphine.
When Ms A declined, HNZ began to reduce her dose of methadone, supposedly to reduce her risk of an overdose.
According to the report: "Once the dose reduction began, Ms A and her partner repeatedly told the service that she was not coping well physically or psychologically and that she was at risk of self-harming and of 'purchasing drugs and overdosing'. Ms A was not offered any physical or psychological support. Limited contact was initiated by the Addiction Service."
She switched to buprenorphine, but did not tolerate it well, and switched back.
Commissioner McDowell also criticised HNZ for then "delay[ing] optimisation of Ms A's treatment by requiring her to undergo unnecessary and onerous serum-level testing".
She recommended HNZ provide a written apology to Ms A.
It has also referred Health NZ Bay of Plenty to the HDC's director of proceedings to consider whether legal action was warranted, due to the severity of the departures from accepted standards.
Separately, in 2023, a case of mistaken identity saw her pharmacist at Unichem Greerton hand her the wrong prescription – a dose of 90mg of methadone rather than 40mg – because her first name was similar to that of another patient.
The commissioner said the error was caused by a "momentary lapse in attention", but if Unichem Greerton had had appropriate policies and procedures in place, it would have reduced the risk of such mistakes.
Unichem Greerton, quoted in the report, said it was disappointing that the dispensing error occurred and that it was sorry.
It assured the commissioner that methadone dispensing was "treated with utmost seriousness" and until this event it had maintained an eight-year record of no methadone dispensing errors.
Since the error it had made the following changes:
- Different patient dosages were now more clearly separated in the controlled drug safe.
- All pharmacists had discussed the importance of accurately identifying the correct dosage and name selected at the time of giving the dosage, and of taking enough time to do this carefully – even at busy times.
- Pharmacists had completed a refresher course on opioid substitution therapy.
- The pharmacy now had a double-check process, where a second dispensary staff member must double-check the patient against the dose.
- Notes are put on the files of patients with similar names.
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