Download Opiate Detox Guidelines

NHS Borders Addiction Service
NHS Borders
Clinical Guidelines
Dr Mike Kehoe
Consultant Psychiatrist in Addictions
September 2011
Procedure for Community Detoxification from Opiates with Prescribed
Lofexidine
Function:
To ensure safe and effective prescribing of Lofexidine and minimise the negative
effects of withdrawal from opiates.
Lofexidine is an alpha-adrenergic agonist drug that suppresses withdrawal over
activity of noradrenergic neurons. Thus it effectively suppresses autonomic signs of
withdrawal, but is less effective at suppressing symptoms of subjective discomfort. It
is a structural analogue of clonidine, but less sedating and less hypotensive.
Lofexidine is formulated as 200 microgram tablets.
Lofexidine is a treatment option for patients new to treatment who are seeking opioidsubstitution/ stabilisation treatment e.g. heroin dependent service users, opiatedependent service users using combinations of heroin and illicit methadone
(equivalent to less than 30ml methadone) and methadone- dependent service users
reduced/ stabilised at doses 30ml or less.
Lofexidine is a treatment option for community detoxification from heroin/
methadone as alternative to buprenorphine or continuing methadone reduction.
Lofexidine is a treatment option as a priority for younger heroin users, heroin smokers
and those not wanting or previously failed on methadone treatment. However longterm and regular intravenous users should also be included for consideration.
A stable, immediate social environment is highly desirable with a nominated
‘significant other’ present.
Location:
In service user’s homes, GP practices and NHS Borders premises.
Responsibility:
NHS Borders Addiction Service (BAS) staff and general practioners.
Exclusions criteria to consider when using Lofexidine treatment include:
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Service users with a diastolic BP below 50 mmHg and pulse rate above 120.
Hypersensitivity to Lofexidine or any other component of the tablet.
Severe respiratory and cardiovascular insufficiency.
Known history of QT interval prolongation.
Severe renal insufficiency.
Acute alcoholism or delirium tremens.
Acute mental health problems especially severe depressive illness and
suicidality.
Lofexidine is not licensed for use in pregnancy and during breast feeding or in
children under 18 years old.
Criteria for community detoxification using Lofexidine:
Completed a NHS Borders Addiction Service assessment that includes; mental health
assessment, physical health assessment, drug use history and life/ social history.
Confirmed as opiate dependent and must not be prescribed or taking illicit
benzodiazepines.
The results of a urine specimen taken before prescribing Lofexidine must be
available.
The service user will have provided a drugs diary of not less than one week old.
Team discussion to establish if Lofexidine prescribing is appropriate and the nature of
the continuing treatment programme from NHS BAS (medic and CPN). The service
user will have signed a contract which explains the procedure. A copy of this will be
placed in their notes. The respective GP will be contacted to discuss the case, the
proposed treatment and confirm agreement to undertake the prescribing request.
The community detoxification programme will be monitored by the CPN and BAS
staff and Lofexidine plus symptomatic relief medication prescribed by respective GP.
The regime is agreed and the prescription is issued for 10 days to be dispensed on a
daily basis by the pharmacist.
The pharmacy must have agreed in advance to dispense the Lofexidine in the
appropriate dosage. A telephone call to the community pharmacist indicating the
day’s requirements will facilitate the process.
It is essential that all service users undergoing this procedure are provided with a copy
of the Lofexidine information booklet and the contents discussed on Day 1 of the
procedure. Because of the time available it is also an opportunity to reinforce harm
reduction initiatives and undertake motivational work to promote continued
abstinence from illicit drugs. This will be done by the CPN. If appropriate to the case
the overdose dangers of returning to illicit drug use due to reduced tolerance
following detoxification must be discussed and documented in the notes.
Procedure:
Day 1
Ensure a current drug diary and recent drug screen result is available.
Have the service user complete the subjective opiate withdrawal scale (O.W.S.)
(appendix 1) and the dedicated CPN complete the objective O.W.S. (BP, pulse and
temperature).
The initial dose of Lofexidine will be 200- 400 micrograms twice daily, regardless of
quantity of current heroin use, based on objective and subjective OWS findings (doses
to be taken 12 hours apart). The service user or the CPN will pick-up the Lofexidine
at the pharmacist and the first dose will be taken in front of the CPN.
Following the initial dose the service user is observed closely for 90 minutes. They
will be checked for any signs of distress or light headedness and have their BP
checked at half–hourly intervals.
Day 2
CPN will visit the service user at home and the O.W.S. is completed.
If no signs of withdrawal are apparent then the total dose from Day 1 should be
repeated. If obvious withdrawal features are present then the total dose from Day 1
together with an increment of 200- 800 micrograms (1 -4 tablets) should be
administered (i.e. 1600 micrograms maximum in 24 hours to be given in 4 divided
doses and maximum single dose is 800 micrograms).
In all cases service users are monitored for 30 minutes by the CPN.
Day 3
Service users should be given Day 2 dosage and an extra 200- 800 micrograms (1-4
tablets) if O.W.S. shows further opioid withdrawal. Therefore: 2400 micrograms
maximum in 24 hours to be given in 4 divided doses and maximum single dose is 800
micrograms.
Note- for those being inducted onto Lofexidine from methadone as opposed to heroin
(and other short acting opiates) prior to Day 1 methadone dose must be reduced to
less than 30ml. Ideally the last methadone dose should be 24- 48 hours before initial
dose of Lofexidine.
Once the CPN is satisfied with the procedure, the Lofexidine tablets for selfadministration will be handed over to the service user. Patients prescribed lofexidine
for opiate withdrawal will also receive the following medications as required
depending on symptoms:
 Ibuprofen 400mg for muscular aches and pain. Every 4-6 hours. Maximum
2.4g/ day.
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Zopiclone 7.5mg for withdrawal insomnia. Maximum 15mg in 24 hours.
Hyoscine butylbromide 20mg qds for stomach cramps. Maximum 80mg in 24
hours
Metoclopramide 10mg every 8 hours for nausea and vomiting. Maximum is
30 mg in 24 hours.
Loperamide 2mg for diarrhoea. Maximum 8mg in 24 hours.
Side Effects from Lofexidine:
If systolic BP drops below 90mm Hg or 30mm below baseline, or pulse drops below
55, lofexidine should be withheld until normal measurements are obtained. Service
users with a systolic BP below 90 mmHg can cautiously reintroduce up to a maximum
of 3 tablets bd or lower if they have dizziness at this dose. If in doubt consult the
BAS medic.
Duration of treatment is 7- 10 days and Lofexidine should not be stopped abruptly as
it may cause rebound rise in blood pressure. Reduce to a level at which the service
user has no side effects or if they need to stop Lofexidine completely stop over 3
days.
The importance of close supervision and observation of service users (BP, pulse,
adverse effects) undergoing Lofexidine detoxification cannot be overstated. Any
unexplained absences of service users should be a cause for concern and signs of
intoxication should prompt an urgent clinical evaluation.
Role of the Detox. CPN:
To provide a safe and effective home detoxification programme tailored to meet the
needs of the service user who wishes to become free from opiates. Throughout the
detox programme the nurse will undertake motivational work exploring issues relating
to lifestyle changes which will assist the service user in their goal for abstinence.
The home detox CPN will be seeing the service user every day for the first week,
alternate days for the second week and ensure further follow-up exists for the
following week.
A home detoxification patient satisfaction questionnaire will be issued after each
detoxification for completion and return to NHS Borders Clinical Audit Support
Team who will collate the results and an annual report will be produced.
Appendix 1: NHS BORDERS ADDICTION SERVICE
Opioid Withdrawal Symptoms Checklist
Name_____________________________________
D.O.B ________CHI _________
Please tick if you have been experiencing any of these symptoms in the past 24 hours.
TIME, DATE &
SIGNATURE OF
PRACTITIONER
S
U
B
J
E
C
T
I
V
E
1
2
3
4
5
6
7
8
9
Craving
Anxiety
Muscle Twitches
Hot/cold flushes
Aching bones and muscles
Loss of appetite
Irritability
Stomach cramps
Sleeplessness
O
B
J
E
C
T
I
V
E
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
Nausea
Vomiting/diarrhoea
Yawning
Sweating
Runny nose
Watering eyes
Gooseflesh
Restlessness
Pupil Size
Blood Pressure
Pulse Rate
Respiratory Rate
Temperature
Euphoria
Motor retardation
Sedation
Slurred speech
COMMENTS/REMARKS
(include starting dose and
any changes)
PUPIL SIZE (MM)
●1
●2
●3
● ●
4
5
● ●●
6
7
8
TIME OF APPEARANCE OF ABSTINENCE SIGNS
IN PHYSICALLY DEPENDENT OPIOID USERS
Grade of
abstinence
Signs
Hours after last dose
Heroin
Morphine
Methadone
0
Craving for drugs, anxiety,
drug seeking behaviour
4
6
12
1
Yawning, perspiration, running
nose, lachrymation
8
14
34-48
2
Increase in above signs plus
mydriasis, goose-flesh
(piloerection), tremors (muscle
twitches), hot and cold flushes,
aching bones and muscles,
anorexia, abdominal cramps,
irritability
12
16
48-72
18-24
24-36
24-36
36-48
3
4
Increased intensity of above
plus insomnia, increased blood
pressure, increased
temperature, increased
respiratory rate and depth,
increased pulse rate,
restlessness, nausea
Increased intensity of above
plus febrile facies, position
(curled up on hard surface),
vomiting, diarrhoea, weight
loss, spontaneous ejaculation or
eosinopenia, increased blood
sugar
N.B – Objective signs are those in italics. The remainder are subjective/require
clinical judgement or laboratory investigation