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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. A0062 OPIOID USERS – MANAGEMENT GUIDELINES V2 ISSUE DATE: JANUARY 2014 PAGE 1 OF 4 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 A0062 OPIOID USERS – MANAGEMENT GUIDELINES V2 ISSUE DATE: JANUARY 2014 PAGE 2 OF 4 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 A0062 OPIOID USERS – MANAGEMENT GUIDELINES V2 ISSUE DATE: JANUARY 2014 PAGE 3 OF 4 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 PAGE 4 OF 4 REVIEW DATE: JANUARY 2017