Finding into death of Helen Maree Stagoll

Contributing factors

• diverted takeaway methadone dose prescribed to another person for opioid replacement therapy
• inadequate supervision and safety measures for takeaway methadone dosing
• reliance on client self-report for safety assessment
• lack of objective measures to verify stable accommodation and secure storage
• inability to detect ongoing drug diversion through current policy mechanisms
• policy changes in 2006 liberalizing takeaway dosing access
• liberal takeaway dosing criteria without adequate enforcement capacity

Coroner's recommendations

1. Review and strengthen policy oversight of takeaway methadone dosing suitability assessment
2. Provide subsidized random urine testing to support objective risk assessment
3. Expand research on annual frequency of supervised versus takeaway methadone doses dispensed in Victoria
4. Improve coronial data collection on methadone sources in fatal cases through data linkage with Department of Health
5. Encourage uptake of buprenorphine/naloxone as a safer alternative, including by requiring new clients to commence on this agent unless clinically contraindicated
6. Reduce maximum allowable weekly takeaway methadone doses without reducing buprenorphine/naloxone allowances
7. Consider shifting methadone dispensing to Section 85 of the National Health Act 1953 (Commonwealth) to improve geographic access and reduce financial incentives for diversion
8. Establish expert advisory group to evaluate benefits and harms of proposed policy changes