Record of Investigation Into Death
Coroners Act 1995
Coroners Rules 2006
I, Olivia McTaggart, Coroner, having investigated the death of
Jay Harli Lawrence
AT AN INQUEST held in Hobart on 2 March 2010 and 17 January 2011;
(a) Jay Harli Lawrence died on 10 February 2007 at the Royal Hobart Hospital, Liverpool Street, Hobart, Tasmania, aged 23 years.
(b) Mr Lawrence was born in Rockhampton in Queensland on 8 February 1984. He was unemployed and unmarried.
(c) Mr Lawrence died as a result of mixed drug toxicity (methadone, methylamphetamine and diazepam).
The inquest was held to investigate the death of Mr Lawrence to enable me to make findings, if possible, pursuant to the requirements of s28(f) of the Coroners Act 1995, that is, the identity of any person who contributed to the cause of death.
As a result of the evidence obtained before the inquest I am able to find that Mr Lawrence died on 10 February 2007 as a result of mixed drug toxicity. Toxicology results and the evidence generally allow me to find that Mr Lawrence had fatal levels of intravenously administered methadone in his blood and it was this methadone that was the primary cause of his death.
The evidence obtained before inquest also enables me to find that the day before his death, Mr Lawrence unlawfully obtained a supply of methadone prescribed to another person and intended for oral consumption by that other person. Mr Lawrence had never been lawfully prescribed methadone by any medical practitioner.
The evidence further allows me to find that after obtaining the methadone on 9 February 2007 he injected a portion of it in public toilets whilst he was in the centre of Hobart. The evidence also permits a finding that he injected a second quantity when he was at home later that evening.
During the course of the police investigation for the Coroner, it became apparent that two important matters that required determination by holding an inquest were:
(a) Who supplied Mr Lawrence with the fatal dose of methadone? The evidence in the investigation suggests that one Nigel Scott supplied Mr Lawrence with his own prescribed dose of methadone. However, Mr Scott in a statutory declaration denied that he supplied Mr Lawrence with methadone.
(b) Whether anyone was involved in injecting Mr Lawrence with methadone during the evening of 9 February 2007 or whether there were any other suspicious actions by any persons before his death? Two points arise in this regard. Firstly, the evidence disclosed two unusually positioned needle marks on the base of Mr Lawrence's neck that were not consistent with resuscitation attempts by ambulance officers. They also appeared not to be consistent with Mr Lawrence's own injecting practices where he would inject into his left arm. Secondly, Mr Lawrence was assaulted in his home before his death by one Gordon Blaschke. Whilst the medical evidence is that the assault did not cause or contribute to Mr Lawrence's death, the incident raised questions of whether any person was involved in harming Mr Lawrence before his death.
Regrettably the investigation and inquest were protracted. The police investigation was complex and required statutory declarations from numerous witnesses. Once the investigation was complete the inquest was listed for 2 March 2010. On that date three main witnesses gave evidence. They were Tiara Kelly (partner of Mr Lawrence), Nigel Scott and Kelly Woulleman (Mr Scott's partner). When they had given their evidence it became apparent that two other witnesses could give important eye witness evidence in respect of the issue of supply of methadone to Mr Lawrence. Those persons were Susan Risely and Peta Lee Jetson. Attempts were made to serve those persons with a summons to appear to give evidence.
Ms Jetson had relocated interstate and was living in shelter accommodation due to family violence issues. Whilst interstate police ultimately were able to contact her by telephone she would not release her address and could not be served with a summons. She indicated that she would cooperate by appearing on a video link. She did not co-operate by appearing on video link. Police subsequently lost contact with her due to her reluctance to be located.
In respect of Ms Risely, she also proved very difficult to locate and bring to court. On 18 March 2010 she was served personally with a summons to appear in court on 27 April 2010. However, she did not appear on that date. A warrant for her arrest was issued. For many months subsequently it appears that she avoided service due to a dislike of police. However, she was eventually arrested on 17 January 2011. On that date she gave a statement to police and also evidence on oath to the inquest. As will be discussed below her evidence ultimately was not helpful in resolving the important issues.
Mr Lawrence resided with his defacto partner, Tiara Kelly, and their two infant children, Jamia and Jayden, at 87 Rockingham Drive, Clarendon Vale. Mr Lawrence's mother, Rita Lawrence, had moved into the address with the family about three months before Mr Lawrence's death. Mr Lawrence was unemployed, but had most recently worked as a seasonal fruit picker.
It appears that since the age of 16 years Mr Lawrence had a history of illicit drug use. At the time of his death he was using cannabis on a daily basis.
Mr Lawrence had asthma and used an inhaler when required. Save for this, he had no significant medical issues. Mr Lawrence was not on the methadone program and was not known to Pharmaceutical Services Branch or Alcohol & Drug Service. There is no indication that in the months before his death that Mr Lawrence was obtaining any prescribed medication from medical practitioners.
Circumstances surrounding death:
In general terms I accept the evidence of Tiara Kelly regarding the events in the day before Mr Lawrence's death. Her original detailed statutory declaration was given to police on the day of his death, being 10 February 2007. Other evidence corroborates the main areas of Ms Kelly's evidence. Ms Kelly did not appear to have any particular reason to falsely implicate any person she named. In particular she did not appear to have any degree of connection with or animosity towards Mr Scott. She appeared at the inquest by video link. She now lives interstate.
On the other hand Mr Scott and Ms Woulleman maintained at inquest denials of supplying or knowledge of supplying Mr Lawrence. Their affidavits were made nearly 12 months after the death of Mr Lawrence and contained little detail. Their evidence to the inquest was also similar. Both had made an effort to remove themselves from the methadone program and appeared free of drugs. At the time of giving evidence Mr Scott was on parole and was required to be of good behaviour and not take illicit drugs. For reasons that I will discuss I reject their evidence that Mr Scott did not supply Mr Lawrence with methadone before his death. I find that he did supply Mr Lawrence with a "takeaway" dose of methadone in North Hobart on 9 February 2007. I find that Mr Lawrence of his own volition injected that methadone, and that it caused his death.
I find that on 9 February 2007 Susan Risely stayed at Mr Lawrence's residence at 87 Rockingham Drive with one of her infant children. Whilst Ms Risely was most unhelpful and evasive in her evidence, she did state positively that she stayed that evening with Mr Lawrence and Ms Kelly due to relationship problems she was having. I accept this was the case. Ms Kelly states that at 4.00am, Mr Scott attended their residence and collected Ms Risely. Both Ms Risely and Mr Scott denied that this occurred. Ms Risely states she caught a bus home later in the morning. Mr Scott indicated that he had collected Ms Risely, a good friend, from 87 Rockingham drive on other occasions but he did not collect her at that time. He did however acknowledge that he was with Ms Risely when he and Ms Woulleman caught a bus into town and then to North Hobart later that day. There appeared to be no good reason for Ms Kelly, in her statutory declaration on the day after Mr Lawrence's death, to make such an unusual statement that her house guest was collected at 4.00am if it was not correct. I can also not determine why Ms Risely and Mr Scott would deny it. It may have been associated with illegal actions. I find that Mr Scott did collect Ms Risely at an early hour from 87 Rockingham Drive. Not a great deal turns upon this finding except that it typifies the general lack of credibility in the way of blanket denials throughout questioning by Ms Risely and Mr Scott.
I find that at 12.00 midday on 9 February 2007 Mr Lawrence and Ms Kelly caught a bus from their home in Clarendon Vale to the home of Mr Scott and Ms Woulleman in Rokeby. I note Mr Scott was referred to by all witnesses as "Noddy". In her statutory declaration Ms Kelly stated:
"… Later that day, around 12 midday we went to Noddy's house at Rokeby. I don't know what street it's in, but it is past the church. We both went in and Noddy's girlfriend Kelly was there. It was weird whilst we were there and Kelly was not very talkative. I don't know Kelly's last name. We caught the bus to town with Noddy and Kelly. Noddy and Kelly were fighting about something. Jay told me he and Noddy were going to North Hobart to get methadone. I believe Noddy and Kelly are both on the methadone program and Jay was going to buy the methadone from Noddy."
In her evidence to the inquest Ms Kelly confirmed that she and Mr Lawrence had gone to Mr Scott's house that morning. She said "Jay was going to get methadone off them". Jay had told her of his intentions. He told her that it would cost $80. She said that Mr Scott and Ms Woulleman were there with their little girl. She believed Ms Risely and her child were also present. It would make logical sense that Ms Risely was there, having already been collected by Mr Scott earlier in the morning. However, her evidence was frank and factual, and contained good detail. She implicated Mr Lawrence in his involvement with illicit drugs in a forthright manner, and conveyed no intention to maliciously blame those supplying him.
I reject the evidence of Mr Scott and Ms Woulleman that there was no meeting with Mr Lawrence at their house. Ms Woulleman suggested that Mr Lawrence had been to her house on one occasion but denied it was at this time, and stated it was "during one evening". Generally her evidence disclosed that she had very little memory due to her drug and alcohol addiction. She also tended to give bland denials to matters that would be adverse to her. It was apparent that she and Mr Scott in their statutory declarations and evidence had discussed their account and were giving identical accounts that minimised their contact with Mr Lawrence and Ms Kelly on the day in question.
I find that Mr Lawrence and Ms Kelly caught a bus from their home in Clarendon Vale to Hobart and then to North Hobart. They were in the company of Mr Scott and Ms Woulleman. Both Mr Scott and Ms Woulleman were on the methadone program and were going to North Hobart to collect a prescription of methadone from the North Hobart Pharmacy. At this time, it was Mr Lawrence's intention to buy methadone from Mr Scott. I fully accept Ms Kelly's evidence that Mr Lawrence told her of his intentions, and she knew why she was accompanying him. Again I reject the accounts of Mr Scott and Ms Woulleman that they were not accompanied by Mr Lawrence and Ms Kelly on the bus to North Hobart. Ms Woulleman was very vague on the point and Mr Scott denies that he had ever been present in North Hobart in the company of Mr Lawrence and Ms Kelly. Again I reject his evidence.
Mr Scott and Ms Woulleman received their doses of methadone on 9 February. Both Mr Scott and Ms Woulleman were both at this time dispensed two 'take away' doses for 10 and 11 February 2007. They both admit they received these doses. Independent records from the Pharmaceutical Services Branch confirm that they received two takeaway doses each.
Ms Kelly gives a very detailed account of what happened when she and Mr Lawrence were in North Hobart with Mr Scott. Some of her evidence was eye witness evidence. She also gave some evidence that tended to be assumptions based upon what she believed was happening and what Mr Lawrence had told her. I must therefore approach her evidence with caution and analyse its reliability. I must also bear in mind that some of the details she was attempting to give were some three years after the event. I accept though that she has a genuine and relatively accurate memory of her movements and those of Mr Lawrence and Ms Jetson on that day.
I find in accordance with Ms Kelly's evidence that she and Mr Lawrence waited outside the pharmacy while Mr Scott and Ms Woulleman obtained their methadone. Ms Kelly states she first saw Ms Jetson outside the pharmacy. Ms Jetson states in her statutory declaration on 10 February 2007 that she met with Ms Kelly outside The Link, (Youth Health Services), in town. She did not mention seeing Ms Kelly in North Hobart, but did not exclude it. She said she did go there for her methadone and saw "Kelly and Noddy". I accept that Ms Kelly was accurate when she said she saw Ms Jetson in North Hobart. If she was not there herself she would likely not have known that she was there. Ms Jetson says that she was "aware that Jay had gotten the methadone from Noddy". Unfortunately Ms Jetson could not be tested on this statement for the reasons outlined above. It appears that Mr Lawrence told Ms Jetson of the source of the methadone when he was talking to her inside The Link whilst obtaining needles for injecting. In the circumstances I place some weight upon Ms Jetson's statement. It accords directly with Ms Kelly's evidence and was fresh in Ms Jetson's mind when she made the statutory declaration on the day of Mr Lawrence's death. Neither Ms Kelly, Mr Lawrence, nor Ms Jetson, appeared to have any grudge against Mr Scott that would cause them all to implicate him in the supply of methadone.
Ms Kelly was a little unclear on where Mr Scott gave Mr Lawrence the bottle of methadone. She referred to the exchange happening in a telephone box and later an alleyway near the chemist. In her original statutory declaration she did not mention how the exchange occurred but said she kept a distance. I find that she did see Mr Lawrence with the bottle at a later stage but did not clearly witness where the actual exchange of the methadone for cash took place. It was certainly in the vicinity of the pharmacy.
Again I reject the evidence of Mr Scott that he did not supply Mr Lawrence. It would appear too that Ms Woulleman was closely aware of the movements and actions of Mr Scott. It is possible that Ms Woulleman was not aware of the supply by Mr Scott. There is no evidence of her direct involvement and it is not necessary to make a finding on her state of knowledge.
I find the sequence of events was as stated by Ms Kelly and other independent witnesses.
Mr Lawrence and Ms Kelly walked from North Hobart back to the CBD. Ms Kelly believed that Mr Lawrence was in possession of methadone at this time. They arrived in the city at around 3.00pm. Ms Kelly spoke to Ms Jetson near The Link in Liverpool Street and they had a conversation. Mr Lawrence had entered The Link.
Ms Jetson entered the Link and had a conversation with Mr Lawrence as discussed above. During this conversation, it appears that Mr Lawrence told Ms Jetson that he had got methadone from Mr Scott and was going to the Argyle Street toilets to 'shoot up'.
Mr Lawrence went to the Argyle Street car park toilets and injected himself with methadone. When he returned, Ms Kelly observed that he was obviously affected by methadone and was speaking very loudly. Ms Kelly convinced Mr Lawrence to catch a bus back to Clarendon Vale and Ms Jetson accompanied them. During this bus trip a witness, Peter Moore, described the three parties as appearing to be 'on something'.
I note that Ms Kelly gave evidence that Mr Lawrence had injected amphetamine ("speed") the day before he purchased methadone; and that one of the reasons for him doing so was to counteract the effects of "coming down" from the amphetamine. I accept this evidence.
Mr Lawrence and Ms Kelly returned home where their children and his mother were present. They were visited by friends Benjamin Pace and his partner Christie Williams. Mr Lawrence and his friends consumed alcohol and cannabis. Mr Pace stated in an affidavit for the investigation that Mr Lawrence told him that he had injected methadone in the toilet. Mr Pace stated that Mr Lawrence 'wasn't in a good way', that he was scratching his face, was drinking iced water and was 'in his own world'. Mr Lawrence was struggling to open his eyes and speak clearly. During this time a third friend, Will Smith, arrived and stayed for two hours. Mr Lawrence told Mr Pace that "the methadone knocks him around too much and that he wasn¡¯t going to take it anymore". Mr Pace believed that "he has injected 110ml of methadone" and "he had to go back in and clean his arm up too". Mr Pace did not know where Mr Lawrence got the methadone. Mr Lawrence and Mr Pace smoked three cones of cannabis after which Mr Pace reported that "he came (sic) better, so we could understand him and he could open his eyes and look at us".
Around 7.30pm the friends left the residence. Mr Lawrence and Ms Kelly fed their children and prepared them for bed. Mr Lawrence and Ms Kelly retired to bed around 9.30pm. Ms Lawrence and the children were already in bed.
Later in the evening at around 10.00pm, one Gordon Blaschke, a person known to Mr Lawrence, knocked on the front door of the residence. Mr Lawrence answered the door. Mr Blaschke punched Mr Lawrence three times to the face causing him to fall to the ground. Mr Blaschke immediately left the residence. Mr Lawrence had blood coming from his mouth as a result of the assault; he was shaken and vomited in the bathroom. He did not lose consciousness. Ms Kelly contacted police.
Police attended the address at around 11.00pm and observed spots of blood on the front landing and injuries to Mr Lawrence consistent with the assault. Mr Lawrence instructed police not to pursue the assault matter. Mr Lawrence told police that he had 'two cones' before he went to bed and his behaviour was consistent with this. Police left the residence and Mr Lawrence stayed up for a couple of hours and then went back to bed with Ms Kelly.
Around 8.30am on 10 February 2007, Ms Kelly woke and could hear Mr Lawrence quietly snoring. She got out of bed and tendered to her children. When Ms Kelly came back into the bedroom at 9.00am she could hear that Mr Lawrence had stopped snoring. Vomit and white foam was around his mouth. Ms Kelly unsuccessfully tried to wake Mr Lawrence and called for Mrs Rita Lawrence to assist. Ms Kelly immediately tried to remove the vomit and white foam from his mouth. Mr Lawrence started gasping and Ms Kelly attempted to use the asthma inhaler on Mr Lawrence. Ms Kelly telephoned emergency services and commenced CPR with the assistances of Mrs Lawrence and ambulance personnel.
Tasmania Ambulance personnel attended the residence finding that Mr Lawrence unconscious and unresponsive. He was in cardiac and respiratory arrest. His Glasgow Coma Scale score was 3. Ambulance paramedics continued CPR and emergency intervention. Mr Lawrence did not regain consciousness and on arrival at the Royal Hobart Hospital Mr Lawrence was declared deceased. Tasmania Police attended the scene and an investigation commenced.
The evidence indicates that Mr Lawrence had never been on the methadone program and was not in recent times accustomed to using methadone regularly.
The Pharmaceutical Services Branch records indicate that before the time of Mr Lawrence's death there were reports of both Mr Scott and Ms Woulleman possibly diverting and misusing their takeaway doses of methadone. I accept that the police were the source of these reports but did not have sufficient evidence to sustain charges.
A post mortem examination of Mr Lawrence was conducted by Forensic Pathologist, Dr Ritchey. He determined the cause of death to be as a result of mixed drug toxicity (methadone, methylamphetamine and diazepam).
Toxicology of a post mortem blood sample revealed:
"methadone ¨C 0.4mg/ : within reported fatal range; methylamphetamine - 0.09mg/: therapeutic "illicit drug"; amphetamine ¨C present (refer methylamphetamine); diazepam ¨C 0.1 mg/ : therapeutic; nordiazepam ¨C present (refer diazepam); temazepam ¨C indicated (refer diazepam); THC ¨C present (illicit drug); THC-COOH ¨C present (refer THC)."
In his toxicology report forensic scientist Andrew Griffiths states:
"…advice indicates the deceased had injected methadone on the afternoon prior to his death and had also only begun administering methadone recently. These two factors are often the major cause of drug overdose fatalities involving methadone. The intravenous injection achieves a higher blood concentration than an orally administered drug…and a methadone intolerant individual can achieve toxic or fatal concentrations at blood concentration that is therapeutic for longer term users…Methadone fatalities often occur may hours after the drug was administered and whilst the person is sleeping. The presence of other drugs or alcohol is also a known contributing factor in reported methadone related deaths. Given all of these factors, there is a high potential for methadone/mixed drug poisoning in this case."
In his affidavit Dr Donald Ritchey reported that the autopsy revealed:
"…a well nourished, well developed man without natural disease or trauma to account for death. Toxicology testing of post mortem peripheral blood revealed the presence of multiple drugs including a fatal concentration of methadone (an opioid analgesic that is a strong central nervous system depressant) as well as methylamphetamine (a strong central nervous system stimulant) and diazepam (a sedative-hypnotic drug). The combination of drugs led to unconsciousness followed by respiratory arrest and death."
I accept Dr Ritchey's opinion as to the cause of Mr Lawrence's death.
I also accept Dr Ritchey's conclusion that trauma from the assault did not contribute to Mr Lawrence's death.
I note that Mr Blaschke was charged with assaulting Mr Lawrence. However police did not proceed with the charge. It appears that this was due to Ms Kelly and other witnesses being unwilling to give evidence.
I have given careful consideration to needle marks located upon Mr Lawrence's body. There were two needle puncture marks located to left side of Mr Lawrence's neck. Needle puncture marks were also present on inside of the right and left elbow. The ambulance records state there were also "trac (sic) marks on arms" presumably from past intravenous drug use.
Ms Kelly and Mr Pace provided evidence that Mr Lawrence injected in the arm. Ms Kelly states he always injected into his left arm. Mr Pace reported that during the evening Mr Lawrence stated that he had to go back in and "clean up his arm". However, it is more difficult to determine whether he also injected himself in the neck. It is quite possible that he did so, leaving two puncture marks.
The needle puncture marks to the elbows are consistent with ambulance attempts or resuscitation. According to an affidavit supplied by Peter Hampton, intensive care paramedic, who viewed photographs of the puncture marks to Mr Lawrence's left and right elbow, the marks are consistent with intravenous access sites for patients in cardiac arrest. In Mr Hampton's opinion the two marks to the neck were not consistent with intravenous access by ambulance personnel. Mr Hampton stated:
"I would doubt that a second attempt following a failed attempt would be done on the same side so close together. A failed external jugular IV normally bleeds easily to a degree that would be messy, this would be problematic for a successful second attempt in that immediate location. There did not appear to be any external blood or subcutaneous blood clots in the vicinity of the two neck marks. From viewing the photographs I feel that these marks would be from something else, not our treatment on the day."
The neck puncture marks are consistent with the possibility of Mr Lawrence having injected himself to the neck. As he was right handed he would be able to reach the left side of his neck. It is also possible that he asked someone else to inject him; although I am satisfied that Ms Kelly did not inject him. She denies ever injecting him and I accept her evidence. It is unlikely that anyone else injected him. I am not able to make a positive finding on how the marks came to be on his neck. I am satisfied however, that, apart from the assault by Mr Blaschke upon him, there were no suspicious circumstances indicating that he was harmed by any other person before his death.
I am also satisfied that he did not intend to deliberately take his life. There is no evidence that he was contemplating suicide.
For the reasons stated I am satisfied that Mr Lawrence recklessly injected a large quantity of methadone. The effects of that substance, combined with other substances in his system, tragically caused his unintended death.
Whilst I am satisfied that Mr Scott supplied him with the methadone, Mr Lawrence ultimately injected the drug of his own volition.
In concluding this report, I convey my sincere condolences to Mr Lawrence's family.
The issue of the illicit supply of take away doses of medication:
The issue of the abuse of prescribed takeaway doses of methadone by those on the methadone program has been the subject of comments and recommendations by coroners. This case particularly highlights the consequences of prescribing takeaway doses of methadone, particularly to those who are suspected of unlawfully supplying their doses to others.
In 2008 Coroner Stephen Carey made the following comments in a finding:
"In an investigation finding published on 6 February 2007 which dealt with another case in which the illicit use of take-away doses of methadone had caused death, I made a number of recommendations. In summary, I considered that if as certain evidence suggested, the Alcohol and Drug Service believed that the rate of prescription of take-away doses of methadone was too high then steps ought to be taken to reduce it. Options that may have been considered were to establish explicit and rigorous rules concerning the access to take-away doses, or providing that a request for take-away doses be sanctioned by an expert panel independent from the prescriber. It was apparent that there was a need to ensure that an appropriate balance was achieved between the encouragement of rehabilitation of certain individuals by providing for the ability to be prescribed take-away doses and the alternate being the opportunity to divert those doses for illicit use.
Insofar as the misuse and abuse of methadone illustrated by this case, I note that there is presently before interested persons and professional bodies within Tasmania a draft "Tasmanian Opioid Pharmacotherapy Program Policy and Clinical Practice Standards (2008) for the use of Buprenorphine and Methadone in the treatment of opiate dependents (TOPP)". I understand that this provides a conservative and clinical risk management approach to the use of Pharmacotherapy treatment for those persons dependent upon opiate products. This program provides for the use of Buprenorphine rather than methadone as it is at least two orders of magnitude less likely to be associated with an opiate toxicity related death. I also understand that the use of take-away doses would be significantly curtailed and a detailed clinical risk assessment approach would apply to all persons on the program and any person identified as a risk would not receive take-away doses"
In 2009 Coroner Chris Webster stated:
"Death relating to illicit overdose of drugs remains a problem within the community. The illicit use of morphine and methadone within Tasmania appears to remain at a high level. Anecdotal evidence suggests that a large portion of legally obtained drugs are being diverted into the illicit market due to the financial gains available."
In 2009 Coroner Carey stated:
"It is my further recommendation that any decision made to authorise the use of "takeaways" be continuously reviewed by clinical assessment and by consideration of information provided by the patient and by other health professionals regarding the patient's living and social circumstances. Assessment of clinical stability and of any patient and public safety issues should form a routine part of clinical assessment each time the patient is reviewed by his/her prescriber. Such review will enable the prescribing physician to consider his/her assessment of the patient's need for "takeaway" doses in the light of any change in the patient's circumstances including his/her domestic arrangements."
I adopt these comments and urge all methadone prescribers to remain vigilant in prescribing takeaway doses of methadone.
The new draft prescribing guidelines (TOPP) referred to above have still not come into force.
Clinical Director of Alcohol and Drug Services, Dr Adrian Reynolds, has provided for this investigation a summary of the new prescribing guidelines referred to in Coroner Carey's comments above. He states:
"The Alcohol and Drug Service has reviewed the Tasmanian Methadone Policy 2000, and has developed a (new) 'Tasmanian Opioid Pharmacotherapy Policy and Clinical Practice Standards' (referred to as the TOPP), in accordance with National policy. This document remains in draft form and is currently going through an internal stakeholder review before going out to external stakeholders for comment, prior to its publishing.
The National Opioid Pharmacotherapy Policy 2007 states that methadone and Buprenorphine should be consumed under direct supervision, but that under certain circumstances it may be appropriate for authorisation of takeaway doses, and further that individual jurisdictions may vary in the limits applied to takeaway doses.
The new Tasmanian Opioid Policy and Clinical Practice Standards will restrict the number of methadone and Buprenorphine takeaway doses to no more than two (2) in any week and these takeaway doses will be provided only when there is very good evidence of clinical stability and evidence that this medication can and will be safely stored by the patient and taken only as directed by their prescribing doctor.
More specifically, a patient will be allowed a maximum of one methadone or Buprenorphine takeaway dose each week after demonstrating three months of continuous clinical stability, as well as a need for and capacity to benefit from such takeaway dose privileges. A patient may be granted two takeaway doses each week but not on consecutive days, when they have demonstrated six months of continuous clinical stability.
These takeaway dose privileges will be removed immediately and for at least three months when there is evidence of poor treatment compliance or other behaviour that is assessed as placing the patient or the public at risk. Where there is evidence that a patient is clinically unstable and at risk, they will be clinically monitored more closely and when willing and within the constraints of available professional resources, will be engaged in appropriate counselling to assist them in addressing their life problems including unsanctioned alcohol or other drug use where this is the issue of concern. Detailed risk assessment and risk management guidelines and clinical management strategies are described in the TOPP. Following the completion and publishing of the TOPP, attention will then focus on training and on networking with, supervising and mentoring prescribers and other health professionals involved in the opioid pharmacotherapy program.
The TOPP includes a risk and protective framework that requires an evaluation of the safety of the home environment as well as the safety of children who may be affected by their parents substance use. The legislation section of the TOPP will also highlight the reporting requirements around neglect and harm to children in accordance with the Children Young Persons & Their Families Act."
I support this revised policy and encourage all those involved to efficiently pursue its implementation in the hope that there will be a reduction in the number of deaths involving the abuse of takeaway doses of methadone.
DATED: 22 September 2011 at Hobart in Tasmania.