Finding into death of Phillip George Black

Contributing factors

• Inadequate clinical assessment for methadone suitability
• Failure to corroborate patient's reported opioid use
• Failure to obtain collateral history from previous prescribers or patient's partner
• Prescribing maximum permitted initial methadone dose (40mg) without sound clinical basis
• Inadequate review arrangements given high initial dose
• Patient had relapsed to occasional rather than daily heroin use, suggesting low opioid tolerance
• Concomitant benzodiazepine use not identified
• Failure to assess diabetes control and liver function before methadone commencement
• Patient over-stated frequency and quantity of heroin use to obtain higher methadone dose

Coroner's recommendations

1. That the Royal Australasian College of General Practitioners reminds its members who are methadone prescribers of the need to regularly review the National Clinical Guidelines and Procedures for the Use of Methadone in the Maintenance Treatment of Opioid Dependence to ensure that their practice accords with those guidelines, unless there is a sound and documented clinical basis for departure.
2. That Drugs and Poisons Regulation (Department of Health and Human Service, Victoria) considers amending the Victorian Policy for Maintenance Pharmacotherapy for Opioid Dependence to include a mandatory requirement that health practitioners prescribing methadone comply with the National Clinical Guidelines and Procedures for the Use of Methadone in the Maintenance Treatment of Opioid Dependence, unless there is a sound and documented clinical basis for departure.
3. That Drugs and Poisons Regulation considers amending the Victorian Policy for Maintenance Pharmacotherapy for Opioid Dependence to include a mandatory requirement that health practitioners prescribing methadone complete ongoing training in relation to the Victorian Policy and National Clinical Guidelines at regular intervals, and that compliance be audited.
4. That the Australian Health Practitioner Regulation Authority considers the circumstances in which Mr Black died, and takes whatever action it seems appropriate in relation to Dr D..