Guidance

Injectable opioid treatment: operating procedures

Published 19 March 2021

Applies to England

Introduction

Procedures and protocols that might be needed for injectable opioid treatment (IOT) include:

• accountability procedures for controlled drugs (including medicines preparation by nurses and pharmacists)
• administering medicines (buprenorphine tablets, methadone concentrate (10mg/ml), and modified release morphine sulfate capsules)
• extended observations, for example vital signs (see extended observation form)
• excessive sedation following injection
• injection routes (intravenous, intramuscular or subcutaneous)
• preparing injectable medicines (diamorphine 100mg powder ampoules and methadone ampoules)
• biological drug testing (not included here)

The following models reflect practice and procedures as they evolved in the IOT service at the South London and Maudsley NHS Foundation Trust (SLaM) as part of the Randomised Injectable Opiate Treatment Trial (RIOTT), and after its completion. They will need to be adapted to local circumstances as long as the adaptations conform to guidance and legislation.

Accountability procedures for controlled drugs: nurse preparation

Ordering and collecting controlled drugs

These are the steps you should take when ordering and collecting controlled drugs (CDs) from a pharmacy.

1. CDs are ordered as stock using the CD order book for requesting medicines.
2. CDs are signed out from the pharmacy by 2 registered nurses.
3. When the nurses receive the CDs, they must check that the medication is in a good condition and corresponds to the order in the prescription or CD requisition book.
4. CDs are then stored in the CD cupboard in the medication room.

Recording details in CD register

Steps for recording CD details when you receive them

These are the steps you should take to record details of CDs after you receive them from the pharmacy.

1. All CDs received and administered must be recorded in the controlled drug record book (CD register).
2. In an IOT service, you might need separate books for different CDs (for example diamorphine ampoules, methadone concentrate, methadone ampoules, buprenorphine tablets and modified release morphine capsules).
3. You must write the name, form and strength of the drug at the top of each page where indicated.
4. You should record the total quantity of drugs received in the CD register including a CD requisition number and record the:

• number of capsules for modified release morphine
• millilitres for methadone concentrate
• milligrams for diamorphine ampoules
• number of ampoules for methadone ampoules

Administering CDs

When administering controlled drugs, you must record the name of the patient, the amount administered and the time and date of administration in the CD register and 2 registered nurses should sign it. You should update the running stock in the CD register each time CDs are administered to individual patients.

Returning CDs to pharmacy

You must take any expired or obsolete CDs to the pharmacist to be discarded. The pharmacist should record the total amount of CDs returned in the CD register and adjust the running stock count accordingly. The discard should be checked and signed for by the pharmacist and registered nurse.

Corrections

You should mark any incorrect entries with an asterisk and explain them in a footnote, or cross them out using a single line. You should enter the correct details directly underneath the incorrect entry. You should use black pens for recording and red pens for corrections.

Checking CD stock

1. Every 24 hours, 2 nurses should check the running stock count in the CD register against the actual stock in the medication room CD cupboard, then record and sign this activity in the CD register.
2. If the numbers are different, you should recount the stock and check the CD register entries for possible errors and omissions. You should write any changes or comments in the CD register in red ink, and 2 nurses should sign these changes.
3. You should tell the IOT team leader and pharmacist as soon as possible if the numbers are still different after recounting and checking for errors.

Storing and transferring controlled drugs

Storing CDs

1. CDs should be stored in a room separate from the injecting room, and in an approved CD cupboard, secured by 2 separate keys: one to access the room and one to access the CD cupboard.
2. During injecting sessions, CDs should be stored in the CD cupboard in the injecting room, secured by 2 separate keys: one to access the medication cupboard and one to access the CD cupboard.
3. You should keep keys to the medication room and CD cupboards in a code operated safe outside of session times.
4. During the sessions 2 nurses should keep separate keys to ensure that both nurses are needed to access stored CDs at all times.

Transferring CDs from the medication room to the injecting room

1. Two nurses should collect enough of the CD needed for the session from the medication room and transfer this to the CD cupboard in the injecting room in a locked carrier box.
2. At the end of each day 2 nurses should return all unused CDs to the medication room in a locked carrier box.

Accountability procedures for controlled drugs: pharmacist preparation

You can find details on ordering, receiving, supplying and recording CDs in the pharmacy in the latest Royal Pharmaceutical Society’s Medicine, Ethics and Practice guidance.

Ordering and collecting Controlled Drugs (CDs)

You can order CDs from the appropriate supplier using the local CD order procedure. This can be from an NHS pharmacy distribution service, pharmaceutical supply companies or direct from the manufacturer. If ordering from a community pharmacy, you must use the appropriate approved requisition form.

When you receive the order, it should be signed for. This process includes:

• checking the condition of the product
• checking the product and quantity delivered match both the order placed and the delivery note
• the driver and pharmacy staff receiving the order signing both the driver’s CD delivery sheet and the delivery note to record the transfer of responsibility for the CDs

The CDs and quantities should be double checked by pharmacy staff and placed in the approved CD cabinet in the pharmacy.

Recording details in CD register

All entries in the CD register must be:

• entered chronologically
• entered promptly on the day of the transaction or the next day
• in indelible ink
• unaltered

Steps for recording CD details

You must record all schedule 1 and 2 CDs that you receive and dispense or supply in the CD register.

Drugs should be recorded on separate pages of the CD register, with the name, strength and formulation of the drug at the top of each page. You must record the:

• date the supply was received
• name and address of who you received them from
• quantity received

Preparing doses from a multi-dose vial containing a powder

1. Prepare the aseptic worksheets. These must include:

• the batch number and expiry date for the starting materials
• the method of preparation
• the batch number and expiry date and time for the doses produced
• details of the patient and doses produced
• a sample label

2. You must record that you removed the multi-dose vial from the CD cabinet in the CD register as a supply to the pharmacy.

3. You should reconstitute the vial according to aseptic standard operating procedures (SOPs), within a laminar airflow cabinet or aseptic suite.

4. When reconstituting the powder, you must record the change of form from the powder to a liquid in the appropriate CD register section. You should note the pharmacy itself as the supplier of the liquid.

5. You should produce the required prescribed patient doses within the aseptic environment.

6. Label and check patient doses as they are produced and place them into tamper-evident packaging.

7. Store prepared doses in a locked standard pharmacy refrigerator and monitor the refrigerator according to SOPs.

Supplying CD to patients

When you supply the dose to the patient you must record in the CD register:

• the date and time of the supply
• the patient’s name and address
• the prescriber’s name
• the amount supplied
• the details of the person collecting the dose as the patient’s representative (if supplied via a healthcare worker)
• whether proof of ID was requested from the patient’s representative and what ID was provided

You should update the running balance of remaining stock in the CD register each time CDs are administered to individual patients.

Corrections

You must not cancel, alter or obliterate entries in the CD register. You should make any corrections as dated marginal notes or footnotes.

The person making amendments must identify themselves, for example by writing their name, initials or General Pharmaceutical Council number.

Checking CD stock

Balance checks of all CD stock must be undertaken by 2 people. You should do balance checks at least weekly, but more may be needed depending on the volume of CDs that you dispense. Balance checks should be recorded in the CD register. These entries should be signed and dated by the professionals undertaking them.

Destroying CDs

There are 2 scenarios where CDs need to be destroyed within an IOT facility.

1. The patient may leave their own medication return unused medication to be destroyed. This should be done according to local policies.
2. Expired or unused pharmacy CD stock (including expired doses that were produced but not collected by the patient).

Pharmacists must denature CDs before disposing of them. You should use an appropriate approved denaturing kit. In England and Wales, you can get an exemption to the licence needed to denature CDs (a T28 exemption) from the Environment Agency. You must register this exemption with the Environment Agency

An authorised person must witness the pharmacist destroying the CD. You must record the amount destroyed in the CD register, with the name of both the person destroying the CD and the witness. Denatured CDs should be disposed of according to local policies.

Storing controlled drugs

You should store CDs in the pharmacy in an approved CD cabinet. The CD cabinet should remain locked at all times when not in use and you should store the keys in an appropriate code-operated key cabinet.

Administering modified release morphine sulfate capsules

Equipment

To administer this drug you will need:

• a plastic cup
• modified release morphine sulfate capsules (200mg, 150mg, 120mg, 90mg, 60mg, or 30mg)

Preparing to dispense

1. All CD administering procedures are to be completed by 2 registered nurses.
2. Gather all equipment required and ensure the area is clear, quiet and uncluttered.
3. Check the form and drug dose against the prescription and the product information.
4. Check the expiry date and integrity of the medication (for example that the foil is not broken).
5. Check that the medication has not already been given.
6. Wash your hands with an antiseptic cleansing solution or with liquid soap and water using the 6 stage hand washing technique.

Dispensing capsules

1. Take the modified release morphine sulfate capsules box from the CD cupboard.
2. Take a strip of capsules from the box.
3. Push the capsules through foil into a plastic cup.
4. Place the strip back in the box and place the box back in the CD cupboard.
5. Give the cup with capsules to the patient.
6. Capsules should be swallowed whole. Provide water if required.
7. Observe that the patient takes all capsules.

Extended observations: vital signs

Equipment

For extended observations you will need:

• a sphygmomanometer
• a pulse oximeter or patient monitor
• an extended observation form

General procedure

1. Observe patients at baseline (before injection) and for 30 minutes after injection.
2. Patients should be seated or in a semi-supine position (lying on their back with their knees bent).
3. Record measurements on the extended observation form at baseline and at 3, 8, 15, 30 minutes after injection.

Blood pressure

1. Select which arm should be used to measure the patient’s blood pressure for the duration of monitoring.
2. Ensure the size of the sphygmomanometer cuff is suitable for the patient.

Pulse rate & peripheral oxygen saturation

1. Ensure that the fingernail is clean and free from dirt (and nail polish if applicable), and that the pulse oximeter sensor is also clean.
2. Check that the pulse oximeter signal is optimal (LED display).

Related documents and references

1. Local policy on management of medical devices.
2. The Royal Marsden Manual of Clinical Nursing Procedures (editors: Dougherty L and Lister S, 2015).

Excessive sedation following injection

The purpose of clinical safety procedures for administering prescribed opioids in the supervised injecting clinic is to prevent serious adverse reactions, such as excessive sedation. Factors that minimise the risk of serious adverse reactions include:

• daily attendance
• assessment before injecting (including alcohol breath testing)
• supervised administration of all medication (oral and injectable)
• adequate dosing of long-acting opioids, such as methadone
• strict policy on the use of benzodiazepines
• intramuscular injecting, as it is less likely than intravenous injection to produce overdose
• observation after dose increases or periods of unsupervised administration
• regular drug testing, which will help to prevent overdose and is an essential part of monitoring response to treatment

Daily supervised administration of prescribed injectable and oral opioids to tolerant patients does not present a risk of excessive sedation if doses are titrated gradually and patients do not misuse central nervous system depressants, such as benzodiazepines. You will usually see excessive sedation when patients have taken a combination of benzodiazepines or alcohol before dosing.

Clinical signs of excessive sedation include:

• change in consciousness level
• low blood oxygen saturation level (SpO2) (shown by pulse oximetry)
• cold clammy skin
• blue lips

If the patient is very drowsy but responds to verbal and physical stimulation, you should:

• observe the patient and check their vital signs
• engage the patient in a conversation
• tell the patient to breathe if SpO2 is low (pulse oximetry) as this usually increases oxygen levels

If these are not successful, then consider giving the patient oxygen at 15 litres per minute (l/min) via a non-rebreather face mask with reservoir (depending on their SpO2 levels) and contact a medical officer if SpO2 remains less than 85%.

Once SpO2 has returned to normal (more than 92%), and the patient appears alert, they will need to remain in the clinic for 30 minutes. If the patient remains alert without verbal stimulation, they can leave the clinic.

If the patient is unconscious and does not respond to verbal or physical stimulation you need to follow the steps below.

1. Call for help or an ambulance.
2. Place the patient in the recovery position.
3. Administer injectable naloxone between 0.4 milligrams (mg) and 2mg (suggest 0.8mg as starting dose) by intramuscular injection at intervals of 2 to 3 minutes to a maximum of 10mg, or nasal naloxone. Note the times of administration. If the patient’s respiratory function does not improve then question whether this is an opioid overdose. They may be unconscious for another reason.
4. Check the patient’s breathing.
5. If they are breathing, provide oxygen at 15 l/min using a non-rebreather face mask with reservoir.
6. If they are not breathing, ventilate artificially according to immediate life support (ILS) guidelines.
7. Continuously monitor the patient’s SpO2, pulse rate, blood pressure, respiratory rate and state of consciousness. This should be done by at least one nurse and until the patient’s condition becomes stable (defined as a return to normal parameters for 30 minutes without assisted ventilation or oxygen).
8. If cardiac arrest occurs, continue resuscitation according to ILS resuscitation guidelines.
9. Provide information to the ambulance crew (summary of the event, vital signs, drugs administered).
10. Patients may require medical monitoring for several hours after naloxone, as the effects of naloxone are short acting (between 30 minutes to 1 hour) and the effects of an opioid overdose may re-emerge (methadone has a half-life of 24 to 48 hours). Patients may need additional doses of naloxone.

Naloxone hydrochloride injection

All staff should know where naloxone is kept and how to use it. Naloxone is commonly provided in the community as:

• a 5 x 400 microgram (mcg) dose in a 2 millilitre (ml) prefilled syringe (1mg/ml )
• 2 intranasal devices (2 x 1.8mg/0.1ml)

In an IOT service it could also be available as 400mcg/ml ampoules.

Intravenous injection

Equipment

To administer IOT by intravenous injection you will need:

• a disposable tray
• a syringe (2.5ml Luer lock)
• a needle (orange, 25 gauge x 5/8 of an inch or brown, 26 gauge x 0.5 inches)
• an alcohol wipe
• an adhesive plaster
• gauze
• the CD register
• the prescription chart or a prescription dispensed in pharmacy and labelled for an individual patient

General points

1. All injections are self-administered by patients.
2. Intravenous injecting is only allowed if patients have sufficiently visible, accessible and undamaged peripheral surface veins and are assessed as competent injectors.
3. Patients with pre-existing vein damage resulting from long term injecting, can use intramuscular injection route instead.
4. Route of administration depends on the patient’s injecting plan and daily assessment by IOT nurses.
5. IOT nurses supervise all injections and advise patients on correct and hygienic injecting process.
6. Site rotation is important in vein management to avoid or minimise complications related to long term injecting.
7. Flushing (repeatedly drawing back blood in the syringe and re-injecting this into the vein) is not allowed.

Sites for intravenous injection

Intravenous injection is only allowed in the arms where there is no sign of active or recent inflammation.

Procedure for intravenous injection

1. Patient washes their hands on entering the room.
2. Patient identifies a vein. Their choice of vein must be approved by IOT nurses.
3. Improve blood flow if necessary
4. Provide the patient with a disposable tray containing gauze, plaster, alcohol wipes, syringe with needle, and tourniquet.
5. Patient cleans the skin around the proposed injection site with alcohol wipe for a minimum of 30 seconds and allows to dry.
6. Patient applies tourniquet.
7. Patient positions needle at an adequate angle (45° or less).
8. Patient gently inserts the needle into the vein then checks that they have inserted correctly by vein by pulling back plunger gently. If blood is present, they can continue. If not, this is a failed attempt and the patient must move on to intramuscular injection.
9. Patient releases tourniquet and administers diamorphine gently over 10 to 30 seconds (in direction of blood flow).
10. The patient can withdraw the plunger gently halfway through the injection to check for patency of intravenous injection (check that the injection is still in the right place and solution flowing into the vein).
11. The patient withdraws the needle gently when all diamorphine has been administered.
12. The patient applies pressure on puncture site with gauze.
13. The patient applies plaster on puncture site.
14. The patient discards the needle and syringe in the sharps box.
15. The patient discards gauze and alcohol wipe in an orange clinical waste bag.
16. The patient washes their hands again before leaving the room.

Accountability

The following procedure is for nurses when there is no pre-dispensed dose prepared in pharmacy and labelled for an individual patient.

1. Nurses should sign the prescription card after administration of CD.
2. Nurses should enter details (for example date, quantity, name) in the CD register and update the running stock balance.
3. On each day at the end of the shift, you should check the CD register running stock balance against the actual stock in the CD cupboard.

Related documents and references

1. Local medicines management policy.
2. The Royal Marsden Manual of Clinical Nursing Procedures (editors: Dougherty L and Lister S, 2015).

Intramuscular injection

Equipment

To administer IOT by intramuscular injection you will need:

• a disposable tray
• a syringe (2.5ml Luer lock)
• a needle (23 gauge x 1 inch)
• an alcohol wipe
• an adhesive plaster
• gauze
• the CD register
• the prescription chart

General points

1. All injections are self-administered by patients
2. Patients should only inject in sites with no signs of active or recent inflammation.
3. Route of administration depends on the patient’s injecting plan and daily assessment by IOT nurses.
4. IOT nurses supervise all injections and may advise patients on correct and hygienic injecting process.
5. Site rotation is important in vein management to avoid or minimise complications related to long term injecting.

Sites for intramuscular injection

The Royal Marsden Manual of Clinical Nursing Procedures (editors: Dougherty L and Lister S, 2015) lists the sites in the table below for intramuscular injection. An illustration in this manual that has been adapted from a paper by Rodger and King (2000) is very helpful to identify the sites.

	Muscle	Factors	Volume to be injected
Arms	Deltoid muscle	Easy access	Not suitable for large amounts (up to 1ml according to Royal Marsden Manual, however in IOT it is regularly used for up to 2ml)
Buttocks	Dorsogluteal muscle (upper outer quadrant)	Low absorption rate and so can result in a build-up in the tissues	Up to 4ml per injection
Buttocks	Ventrogluteal muscle	Relatively free of major nerves and blood vessels	Up to 2.5ml per injection
Thighs	Rectus femoris muscle		Up to 5ml per injection
Thighs	Vastus lateralis muscle	No major blood vessels or significant nerve structures	Up to 5ml per injection

Procedure for intramuscular injection

1. Patient washes their hands when they enter the room.
2. Patient identifies the injection site according to injecting plan. Choice of site must be approved by IOT nurses.
3. Provide the patient with a disposable tray containing gauze, a plaster, alcohol wipes and a syringe with needle.
4. Patient cleans the skin around the injection site with an alcohol wipe for a minimum of 30 seconds and allows to dry.
5. Patient positions the needle at an adequate angle for injection (90° angle to the skin).
6. Patient gently but sharply inserts needle into the muscle (patient does not need to draw the plunger back like in intravenous injecting).
7. Ensure that approximately one-third of needle remains exposed out of the skin in case needle breaks, to help remove the broken needle.
8. Patient administers injection gently over 10 to 30 seconds (if there is resistance, advise the patient to pull out the needle and syringe, provide a new needle and use a different injection site).
9. Wait 10 seconds before removing the needle.
10. The patient swiftly removes the needle and syringe once all medication has been administered.
11. The patient applies pressure on puncture site with gauze.
12. The patient applies plaster on puncture site.
13. The patient discards the needle and syringe in the sharps box.
14. The patient discards the gauze and alcohol wipe in an orange clinical waste bag.
15. The patient washes their hands before leaving the room.

Accountability

The following procedure is for nurses when there is no pre-dispensed dose prepared in pharmacy and labelled for an individual patient.

1. Nurses must sign the prescription card after administration.
2. Nurses must enter details in the CD register and update the running stock balance.
3. On each day at the end of the shift, you must check the CD register running stock balance against the actual stock in the CD cupboard.

Related documents and references

1. Local medicines management policy.
2. The Royal Marsden Manual of Clinical Nursing Procedures (editors: Dougherty L and Lister S, 2015).

Subcutaneous injection (‘skin popping’)

Equipment

To administer IOT by subcutaneous injection you will need:

• a disposable tray
• a syringe (2.5ml Luer lock)
• a needle (orange, 25 gauge x 5/8 of an inch or brown, 26 gauge x 0.5 inches)
• an alcohol wipe
• an adhesive plaster
• gauze
• the CD register
• the prescription chart

General points

1. All injections are self-administered by participants.
2. Patients should only inject in sites with no signs of active or recent inflammation.
3. Route of administration depends on the patient’s injecting plan and daily assessment by the prescriber and IOT nurses.
4. IOT staff supervise all injections and may advise patients on correct and hygienic injecting process.
5. Site rotation is important in vein management to avoid or minimise complications related to long term injecting.

Sites for subcutaneous injection

Patients use mainly arms and legs for subcutaneous injection.

Procedure for subcutaneous injection

1. Patient washes their hands when they enter the room.
2. Patient identifies the injection site according to their injecting plan. Choice of site must be approved by IOT nurses.
3. Provide the patient with a disposable tray containing gauze, a plaster, alcohol wipes and a syringe with needle.
4. Patient cleans the skin around the proposed insertion site with an alcohol wipe for a minimum of 30 seconds and allows to dry.
5. Patient gently pinches the skin up into a fold.
6. Patient inserts the needle into the skin at a 45° angle of and releases the grasped skin. Some patients insert into the skin at a 90° angle.
7. Patient administers injection gently over 10 to 30 seconds (if there is resistance, advise the patient to pull out the needle and syringe, provide a new needle and use a different injection site).
8. Wait 10 seconds before removing the needle.
9. The patient swiftly withdraws the needle and syringe once all medication has been administered.
10. The patient applies pressure on puncture site with gauze.
11. The patient applies plaster on puncture site.
12. The patient discards the needle and syringe in the sharps box.
13. The patient discards the gauze and alcohol wipe in orange clinical waste bag.
14. The patient washes their hands before leaving the room.

Accountability

The following procedure is for nurses when there is no pre-dispensed dose prepared in pharmacy and labelled for an individual patient.

1. Nurses must sign the prescription card after administration.
2. Nurses must enter details in the CD register and update the running stock balance.
3. On each day at the end of the shift, you should check the CD register running stock balance against the actual stock in the CD cupboard.

Related documents and references

1. Local medicines management policy.
2. The Royal Marsden Manual of Clinical Nursing Procedures (editors: Dougherty L and Lister S, 2015).

Nurse preparation of diamorphine single-use powder ampoules

Equipment

To prepare single use diamorphine ampoules you will need:

• alcohol wipes
• disinfectant wipes
• alcohol hand gel
• water and soap
• latex gloves (or latex free where there is an allergy)
• syringes (2.5ml, 3.5ml)
• needles (1.9 gauge x 2 inches)
• diamorphine ampoules: 5mg, 10mg, 30mg, 100mg, 500mg
• water for injection ampoules: 2ml, 5ml,10ml

Preparation

1. Use a ‘no-touch’ technique. Avoid touching areas that you might contaminate with bacteria, such as syringe tips, needles, vial tops.
2. Gather all equipment needed, and ensure area is clear, quiet and uncluttered.
3. Clean the surface you are using to prepare the ampoules using disinfectant wipes.
4. Check that the form, drug dose and diluent are the same as what is stated on the prescription and the product information.
5. Check the expiry dates of all drugs, ingredients and equipment to be used.
6. Check that all packaging is undamaged.
7. Peel wrappers from needles and syringes. Do not push needles and syringes through wrappers as this will contaminate them.
8. Check route of administration matches the prescription.
9. Check that the medication has not already been given.
10. Wash your hands with an antiseptic cleansing solution or with liquid soap and water (using the 6 stage hand washing technique).
11. Wear gloves to avoid contaminating the injection being prepared and to protect against accidental skin contamination.

Withdrawing water for injection into a syringe

1. Swab the neck of the plastic water ampoule using an alcohol wipe and allow to dry.
2. Snap open the neck of the water ampoule.
3. Select an appropriate syringe and put needle on.
4. Using a ‘no-touch’ technique, carefully withdraw the required volume into the syringe.
5. Tap the syringe lightly to concentrate any air bubbles.

Reconstitution and drawing up of diamorphine ampoules

1. Ampoules can only be reconstituted and drawn up after the patient has been assessed.
2. Swab the neck of the diamorphine ampoule using an alcohol wipe and allow it to dry.
3. Snap open the neck of the diamorphine ampoule.
4. Inject the required volume of water for injection into the vial.
5. Wait until powder completely dissolves and draw up the required volume of diamorphine liquid using the same needle.
6. Discard the needle in a sharps box and fit the required needle for injection.
7. Remove gloves and wash your hands.

Any leftover reconstituted diamorphine that is not used should be discarded immediately into a CD destruction kit and recorded in the CD register as ‘DOOP’ (Destruction of old pharmaceutical waste) by 2 staff, at least one being a nurse.

Empty diamorphine ampoules should be discarded in a sharps box.

Nurse preparation of methadone ampoules

Equipment

To prepare methadone ampoules you will need:

• cleaning wipes
• alcohol wipe
• alcohol hand gel
• water and soap
• latex gloves (or latex free where there is an allergy)
• syringes (2.5ml, 3.5ml)
• drawing up needle (1.9 gauge x 2 inches)
• methadone ampoules 10mg/ml; 25mg/ml; 50mg/ml

Preparation

1. Use a ‘no-touch’ technique. Avoid touching areas that you might contaminate with bacteria, for example syringe tips, needles, vial tops.
2. Gather all equipment needed and ensure the area is clear, quiet and uncluttered.
3. Clean the surface you are using to prepare the ampoules.
4. Check that the form, drug dose and diluent are the same as what is stated on the prescription and the product information.
5. Check the expiry dates of all drugs, ingredients and equipment to be used.
6. Check that all packaging is undamaged.
7. Peel wrappers from needles and syringes. Do not push needles and syringes through wrappers as this will contaminate them.
8. Check route of administration matches the prescription.
9. Check that the medication has not already been given.
10. Wash your hands with an antiseptic cleansing solution or liquid soap and water (using the 6 stage hand washing technique).
11. Wear gloves to avoid contaminating the injection being prepared and to protect against accidental skin contamination.

Drawing up methadone ampoules

1. Ampoules can only be opened and drawn up after the patient has been assessed.
2. Swab the neck of the methadone ampoule using an alcohol wipe and allow to dry.
3. Snap open the neck of the methadone ampoule.
4. Select an appropriate syringe and attach the needle (1.9 gauge x 2 inches).
5. Using a ‘no touch’ technique, carefully draw up the contents into the syringe.
6. Tap the syringe lightly to concentrate any air bubbles.
7. Discard the drawing-up needle in the sharps container and attach an appropriately sized needle for injecting.
8. Empty methadone ampoules should be discarded in a sharps box.
9. Remove gloves and wash your hands.