First reported 1 Nov 2013•Latest report 4 Mar 2024
Definition
What this concern includes
Includes failures of controls specifically dedicated to the safe use and management of methadone, including staff knowledge and training, recognition of intoxication and respiratory-depression risks, assessment of drug and alcohol interactions, initial-treatment medical review, monitoring, prescribing and escalation.
Not included
Excludes generic staff competence or training deficiencies that are not specifically tied to methadone treatment or methadone-related intoxication risks.
Excludes management of other medicines or substance-use risks unless methadone is the material shared safety concern.
Excludes general medication prescribing, administration or review failures where methadone-specific safety is not identified.
Excludes respiratory-depression hazards unrelated to methadone treatment or methadone-related intoxication.
Reports
9
Distinct published reports
Individual concerns
15
A report can raise multiple concerns
Date range
2013–2024
First to latest report issue date
Stated actions
23
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Department of Health and Social Care2
Belmarsh Prison1
Bromley Drug and Alcohol Service1
Dinnington Group Practice1
G4S1
General Medical Council1
General Pharmaceutical Council1
Haverhill Pharmacy1
National Police Chiefs’ Council1
Nestor Primecare Services Limited1
NHS England1
Nursing and Midwifery Council1
Oxleas NHS Foundation Trust1
Priory Group1
Public Health England1
Healthcare site3
Independent healthcare provider3
Health and care professional regulator2
Ministerial department2
NHS trust2
Executive agency1
Executive non-departmental public body1
Multi-service care provider1
National policing body1
Police force1
Prison operator1
Prison or young offender institution1
Type not available1
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
Inner West London
Concerns raised3
Failure to withhold or reduce methadone when patients show signs of sedation
Overreliance on subjective withdrawal symptoms rather than objective signs when assessing methadone need
Failure to account for reduced opiate tolerance and synergistic agents when prescribing methadone
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
Action
Update the national service specification using learning from the case to strengthen prescribing and supply of sedating medicines.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 6 March 2024.
Action
Revise and disseminate the withdrawal-treatment policy, including sedation safeguards, tolerance assessment, urine screening and clinical review requirements.
Stated by Oxleas NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 6 March 2024.
Action
Discuss the case in a prescriber reflective-practice forum, focusing on individual history, clinical signs, investigations and cautious methadone dosing.
Stated by Oxleas NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 6 March 2024.
Action
Follow national guidance on any revised opiate withdrawal scale and support implementing an approved change.
Stated by Oxleas NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 6 March 2024.
Action
Deliver case-based learning for prescribers on prioritising objective withdrawal signs over reported symptoms.
Stated by Oxleas NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 6 March 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
National guidance already addresses reduced opioid tolerance and reducing or withholding methadone when sedation is present.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
National standards and case-by-case clinical judgement are considered sufficient; NHS England will not mandate a particular withdrawal assessment tool.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Adopting an Opiate Withdrawal Scale requires national ratification and NHS England direction before it can become standard care.
Stated by Oxleas NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Suffolk
Concerns raised2
Failure to provide measuring equipment and instructions for accurate daily methadone dosing
Failure to dispense prescribed methadone in single daily dosage bottles
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Develop and publish COVID-19 guidance for drug and alcohol treatment providers addressing infection risks and medication dispensing arrangements.
Stated by Public Health EnglandStated completedThe respondent said that this action was complete when they made their response on 5 January 2021.
Action
Strengthen individualised risk-assessment requirements in subsequent iterations of published guidance before changing medication dispensing arrangements.
Stated by Public Health EnglandStated completedThe respondent said that this action was complete when they made their response on 5 January 2021.
Action
Reiterate to drug and alcohol treatment providers the need for individualised risk assessments before changing medication dispensing arrangements.
Stated by Public Health EnglandStated completedThe respondent said that this action was complete when they made their response on 5 January 2021.
Action
Continue supplying methadone in individual dose containers as the pharmacy’s standard procedure.
Stated by Haverhill PharmacyStated completedThe respondent said that this action was complete when they made their response on 5 January 2021.
Avon
Concerns raised1
Unsafe co-prescribing of clonazepam with methadone
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Request marketing authorisation holders to update clonazepam and methadone product information, including warnings about respiratory depression and delayed methadone effects.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 10 November 2019.
Action
Remind healthcare professionals through a Drug Safety Update article about respiratory-depression risks when benzodiazepines and opioids are co-prescribed.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 10 November 2019.
Action
Ensure development of a mental-health early-warning-score case study covering opioid use and over-sedation.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 10 November 2019.
Action
Develop prescribing guidance for mental health, endorsed by the Royal Pharmaceutical Society, with additional support, resources and learning materials.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 10 November 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Clinicians are responsible for prescribing decisions, including medication dosages and combinations.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
South Yorkshire (Eastern)
Concerns raised3
Lack of medical review during the initial phase of methadone treatment
Provision of a 7-day methadone supply to a methadone-naive patient
Failure to conduct a face-to-face consultation before prescribing methadone
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Stoke-on-Trent and North Staffordshire
Concerns raised1
Insufficient targeted training on drug and alcohol-related risks in custody
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Secure force training on drug and alcohol risks, including methadone intoxication and alcohol withdrawal.
Stated by Staffordshire PoliceStated plannedThe respondent said that this action was planned when they made their response on 15 April 2015.
Action
Provide mandatory first-aid induction training, including defibrillator, advanced airway, drug and alcohol risk training, with annual refresher training for detention officers.
Stated by G4S Care And Justice Services (UK) LimitedStated completedThe respondent said that this action was complete when they made their response on 15 April 2015.
Action
Examine opportunities to provide additional drug and alcohol risk guidance through an online learning management system.
Stated by G4S Care And Justice Services (UK) LimitedStated plannedThe respondent said that this action was planned when they made their response on 15 April 2015.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing guidance and training already address drug and alcohol risks, withdrawal, and referral for medical assessment where concerns arise.
Stated by College of Policing and DCC Nick EphgraveExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Inner South London
Concerns raised2
Failure to stop medicines when Methadone toxicity is considered
Lack of defined criteria and recording requirements for lowering blood pressure
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
County Durham and Darlington
Concerns raised1
Lack of staff competence and risk appreciation for patients with drug and alcohol problems receiving methadone
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6
Action
Complete an audit of medical staff competencies in specialist detoxification wards.
Stated by Priory GroupStated completedThe respondent said that this action was complete when they made their response on 27 November 2014.
Action
Transfer staff or provide additional training where competency gaps are identified.
Stated by Priory GroupStated completedThe respondent said that this action was complete when they made their response on 27 November 2014.
Action
Ensure full baseline physical health assessments at admission and increase physical-health complications in ongoing risk assessments.
Stated by Priory GroupStated in progressThe respondent said that this action was in progress when they made their response on 27 November 2014.
Action
Introduce a comprehensive training programme for Aspen Ward staff.
Stated by Priory GroupStated completedThe respondent said that this action was complete when they made their response on 27 November 2014.
Action
Source and arrange advanced-level training for Aspen Ward staff.
Stated by Priory GroupStated in progressThe respondent said that this action was in progress when they made their response on 27 November 2014.
Action
Integrate investigation lessons into Priory online training modules.
Stated by Priory GroupStated in progressThe respondent said that this action was in progress when they made their response on 27 November 2014.
South London
Concerns raised1
Unsafe provision of several days’ methadone supply at one time during public holidays
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Encourage services to use pharmacies open at weekends and bank holidays as medication collection bases for patients who have relapsed or miss doses.
Stated by United PharmacyStated plannedThe respondent said that this action was planned when they made their response on 31 March 2014.
East London
Concerns raised1
Failure to ensure methadone prescribers are fully informed of patients’ diagnosis, medication and treatment
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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Includes failures of controls specifically dedicated to the safe use and management of methadone, including staff knowledge and training, recognition of intoxication and respiratory-depression risks, assessment of drug and alcohol interactions, initial-treatment medical review, monitoring, prescribing and escalation.
