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Gloucestershire Hospitals
NHS Foundation Trust
TRUST GUIDELINE
OPIOID USERS ON THE WARD – MANAGEMENT GUIDELINES
FAST FIND:
This guideline works in conjunction with the following:
Acute Pain in Adults - Management Guidelines and action card PMG2 (Acute pain relief in
drug-dependent adults)
Action card OUM1 – Substitute Treatment With Methadone
Action card OUM2 – Use of Buprenorphine/Subutex/Suboxone
Turning Point Referral Form
Opioid Users Management Flowchart
Patient Information Leaflet – Methadone/Buprenorphine Prescribed Whilst an Inpatient
Useful Telephone Numbers Point Of Contact
1.
INTRODUCTION
These guidelines have been drawn up to advise doctors, nurses and pharmacists on managing patients
who have co-morbid opiate dependence. It gives guidance on prescribing substitute opiate medication
to manage their addiction and how to communicate with relevant substance misuse services.
2.
DEFINITIONS
Word/Term
Opioid
Opiate
3.
ROLES AND RESPONSIBILITIES
Post/Group
Consultant
Psychiatrist/Consultant
Anaesthetist
Medical staff
Pharmacists
Nursing staff
Alcohol liaison service
Turning Point
4.
Descriptor
Any synthetic narcotic that has opiate-like activities but is not derived from opium
Any drug derived from opium
Details
Review and maintenance of this guideline and related documents
Patient history taking
Arranging appropriate urine testing
Prescribing medication and clarifying compliance in the absence of the ward
pharmacist
Referring the patient to Turning Point on discharge
Checking and monitoring doctors’ adherence to prescribing regimes
Monitoring and checking drug interactions
Liaising with community pharmacies to ascertain patient compliance prior to
admission and providing post-discharge information
Monitoring patients using the opiate withdrawal chart, opiate sedation, pain
assessment and safe administration of medication
Testing urine for drugs
Providing advice on general management
Receiving referrals from GHT, providing advice and sharing prescribing information
PATIENT CARE PATHWAY
The Opioid Users Management Flowchart gives as overview of the care pathway for the management
of a patient who may be an opioid user. Use the notes below for more detailed information.
Where a patient is a known opioid user prior to admission, it is useful to clarify their current regime with
the prescriber and inform them that the patient is in hospital, and their likely length of stay.
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ISSUE DATE: JANUARY 2014
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REVIEW DATE: JANUARY 2017
4.1
Confirming a patient as drug-dependent
Medical staff are responsible for determining that the patient is drug-dependent before developing any
sort of management plan or prescribing any drugs. Methadone must NOT be prescribed without a drug
screen. Determine the patient’s status using the following methods:
History
Secondary evidence of drug
abuse
Urine and Drug Screening
The patient gives a clear history of daily opioid use (e.g. Heroin used daily)
Patient has used within the last 3 days.
Note:
If there have been 3 or more days of abstinence, there will be a loss
of tolerance and much of the withdrawal syndrome will have passed
Recent multiple injection sites
Note:
Drugs other than heroin may also be abused by injection, e.g. crack,
cocaine, amphetamines
May be carried out on the ward using the illicit drug multi testing screening
kit (e.g. Euromed)
Notes:
Kits are available from the Acute Care Units.
Patient must consent to a urine test – Methadone cannot be
prescribed if the patient is not tested
Results of urine screening must be documented in the patient’s notes
Urine screening has limitations as drugs leave the system at different rates. These are:





Heroin, Morphine and other opiates: 2-4 days (Buprenorphine and Methadone will not be
detected with the standard opiate screen. Separate tests for these substances are available, and
the presence of these drugs may be detected 5-7 days after last use)
Cocaine: 2-3 days
Amphetamines: 2-4 days
Cannabis: up to 1 month
Benzodiazepines: up to 2 weeks
Testing kits are held on ACUA and ACUC.
4.2
Checking current maintenance therapy and patient compliance
If the patient confirms they are currently prescribed Methadone or Buprenorphine, the ward pharmacist
is responsible for contacting the prescriber (Turning Point or GP) and confirming dose, compliance and
frequency of pick-up from prescriber. Out of normal office hours community pharmacist might be the
most available contact.
4.3



4.4





Prescribing
Prescribe Methadone according to action card OUM1
Prescribe Buprenorphine according to action card OUM2
Prescribe pain relief according to pain management guidelines action card PMG2
General patient management whilst on the ward
Concomitant benzodiazepine/alcohol and other drug use is not uncommon. Exercise extreme
caution when prescribing benzodiazepines as many patients exaggerate the amount they use and
the combination of opioids and benzodiazepines can be dangerous
Controlled Drugs can only be prescribed by a Medical Practitioner or suitably qualified non medical
prescriber (see POPAM)
Do not give opioids and/or other sedatives if patient respiratory rate is less than 10, or sedation
score is more than 2
Ensure opioid withdrawal score is recorded on the EWS chart
See action card OUM1for use of Methadone and action card OUM2 for use of
Buprenorphine/Subutex/Suboxine
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REVIEW DATE: JANUARY 2017
4.5
Managing withdrawal
The symptoms and signs of opioid withdrawal are caused by:



Noradrenergic storm – raised heart rate, blood pressure and respiratory rate; flu-like “cold turkey”
symptoms including agitation/anxiety
Hyperalgesia/pain sensitivity
Dysphoric mood changes
The time of onset of withdrawal symptoms depend on the drug taken – see table below
Drug
Pethidine
Codeine phosphate/
Morphine/Heroin
Methadone
Buprenorphine
Onset of symptoms after
last dose
2-6 hours
6-8 hours
Peak intensity
8-12 hours
36-72 hours
Duration of withdrawal
syndrome
4-5 days
7-10 days
24-48 hours
24-72 hours
3-7 days
3-7 days
6-7 weeks
1-2 weeks
The table below helps with deciding the severity of withdrawal symptoms and changes to treatment
required:
MILD
(score 1 for each item)
Runny nose
Nausea
Mild anxiety
Yawning
Loss of appetite
Tremors
Goose bumps
Sneezing
MODERATE
(score 2 for each item)
Irritability/agitation
Vomiting
Severe anxiety
Hot and cold flushes
Muscle cramps
Tachycardia
Mild/moderate hypertension
Tachypnoea
Pyrexia
Abusive behaviour
Loss of direct eye contact/dilated pupils
SEVERE
Score 3 for each item)
Severe muscle spasm
Dehydration
Panic attacks
Severe agitation
Aggressive behaviour
Diarrhoea
Gastro-intestinal spasm
Note: Opiate withdrawal is unpleasant, but not life threatening
See the Useful Contacts list or contact Turning Point via their single point of contact number, available
on the internet.
5.
PATIENT DISCHARGE
Follow the guidance on the Opioid Users Management Flowchart ensuring that all relevant information
is passed to the CSSMS or the patient’s GP as appropriate.
6.
TRAINING
See Training Needs Analysis document.
7.
MONITORING OF COMPLIANCE
Criteria (objective
to be measured)
Monitoring
methodology
Lead
responsible
Timescales
Reporting arrangements
Appropriate
treatment and
management of
opioid-dependent
patients
Review of patient
data
Mental Health
Liaison Team
Under
construction
Discussed at Mental Health
Liaison Team meetings and
information shared with
Turning Point where
appropriate
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ISSUE DATE: JANUARY 2014
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REVIEW DATE: JANUARY 2017
OPIOID USERS ON THE WARD – MANAGEMENT GUIDELINES – DOCUMENT PROFILE
DOCUMENT PROFILE
REFERENCE NUMBER
CATEGORY
VERSION
SPONSOR
AUTHOR
ISSUE DATE
REVIEW DETAILS
ASSURING GROUP
APPROVING GROUP
APPROVAL DETAILS
EQUALITY IMPACT
ASSESSMENT
CONSULTEES
DISSEMINATION DETAILS
KEYWORDS
RELATED TRUST DOCUMENTS
A0062
Clinical
2
Sock Koh, Consultant Anaesthetist
Dr Karen Williams, Consultant Psychiatrist, Dr Sheila West,
Consultant Anaesthetist
(technical authoring support, Kym Ypres-Smith)
January 2014
January 2017 – review by Consultant Anaesthetist
Trust Policy Assurance Group
Mental Health Liaison Team
Policy application: 17/01/2014
TPAG approval: 23/01/2014
N/A
Pharmacy, Turning Point, Liver specialist nurse, Consultant
Gastroenterologist
Upload to Policy Site; global email; cascaded via divisions
Opioid, opiate, drug dependent, addict, drug, detox, heroin
Action cards:
Action card OUM1 – Substitute Treatment With Methadone
Action card OUM2 – Use of Buprenorphine/Subutex/Suboxone
Turning Point Referral Form
Opioid Users Management Flowchart
Patient Information Leaflet – Methadone/Buprenorphine
Prescribed Whilst an Inpatient
Useful Telephone Numbers Point Of Contact
OTHER RELEVANT DOCUMENTS
EXTERNAL COMPLIANCE
STANDARDS AND/OR
LEGISLATION
POPAM
Acute Pain in Adults - Management Guidelines and action card
PMG2 (Acute pain relief in drug-dependent adults)
Drugs and pregnancy guideline
Medicines Act 1968
A0062 OPIOID USERS – MANAGEMENT GUIDELINES V2
ISSUE DATE: JANUARY 2014
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REVIEW DATE: JANUARY 2017