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Prescribing Guideline Pharmacological Management of Substance Misuse PG20 These prescribing guidelines outline the management of substance misuse experienced by adults. It is recognised that because of the potential and increased risk for drug misuse and diversion in these settings, it may sometimes be necessary and appropriate to prescribe an alternative medication(s) to those recommended in this document. Document Control Version Date Issued 1.0 2006 2.0 October 2013 3.0 October 2014 4.0 December 2016 Target Audience/staff groups Ratifying group Date Ratified Implementation date Review date Author Name / Job Title / Email Dr Mary Rowlands; Consultant Psychiatrist [email protected] Roz Gittins; Lead Clinical Pharmacist (Specialist Services) [email protected] Chris Sullivan, Lead Clinical Pharmacist Health care professionals working in Devon Partnership NHS Trust. Drug and Therapeutics Committee November 2016 December 2016 October 2020 Document History Version Start date 1.0 1.1 Oct 2011 1.2 1.4 2.0 2.0 Apr 2013 Oct 2013 2.1 2.1 Aug 2014 Dec14 3.0 3.1 Oct 16 4.0 End date Author History 2006 MR MR New Guideline Revision of prescribing guidelines for alcohol and substance misuse (Ratified by Trust Addiction Services Governance Group 2010) to meet trust Prescribing guidelines format and inclusion of recent NICE guidance. Re-formatting of document alongside community policy. Comments from Drug Service and DTC received and incorporated. Document signed off following ratification at October DTC Review date extended from Oct15 to Dec 15 to allow for scheduled DTC review Update of version 2 to incorporate inpatient prescribing. Link to approximate equivalent dose converter updated (from UKMi to NICE CKS) Document ratified at DTC and signed off. Minor amendments following consultation with Shrublands Removal of lofexedine section – detoxes no longer performed within community or inpatient settings Ratified at DTC and signed off Oct 2013 Apr2014 RG RG KS KS Dec14 RG RG Dec14 KS Nov 2016 CS PG20 – Pharmacological Management of Substance Misuse Approved by Drugs and Therapeutics Committee: November 2016 Review date: October 2020 Page 1 of 12 Pharmacological Management of Substance Misuse Clinicians using this prescribing guideline must also refer to Trust Policy for the Clinical Management of Substance Misuse (P09). The aim of these guidelines is to promote evidenced based, cost effective prescribing and support adherence to: NICE CG 52 Drug Misuse: Opioid Detoxification (Mar 2010). NICE CG 120 Psychosis with co-existing Substance Misuses (Mar 2011). NICE TAG 114 Methadone and Buprenorphine (Jan 2007). NICE TAG 115 Naltrexone (Jan 2007). British Association for Psychopharmacology Updated Guidelines: evidence-based guidelines for pharmacological management of substance misuse, harmful use, addiction and co-morbidity (2012). Department of Health Drug Misuse and dependence: UK guidelines & clinical management (Sept 2007). These guidelines are NOT intended to replace prescribing information contained in the BNF or Summary of Product Characteristics. Psychological therapies and psychosocial interventions are integral to the successful treatment and must be used or offered alongside drug treatment, but are beyond the scope of these guidelines. Management of Poly-Drug Use In poly-drug use, stabilisation of the primary drug of choice may enable the person to cease other drugs without intervention. Otherwise treat as follows: StimulantsAlcoholBenzodiazepinesOpiates (e.g. if an opiate substitute is prescribed this should be held on the current dose whilst the benzodiazepine is reduced first). Stimulant/cannabis misuse does not require substitute prescribing: psychosocial support and symptomatic treatment should be provided. Substitute prescribing must be initiated in collaboration with specialist drug services. Management of Opioid Misuse Methadone (Maintenance/detoxification) Oral mixture 1mg/ml OR Oral mixture 1mg/ml sugar free If tablets prescribed this is off-label use and they have the greatest potential for injecting or diversion. Buprenorphine (Maintenance/detoxification) Sublingual tablets 400micrograms, 2mg, 8mg If tablets are crushed or if 200microgram strength (Temgesic®) prescribed this is off-label use. Inactivated if swallowed so therapeutic levels only achieved sublingually. Longer-term use may result in prolonged mild withdrawal symptoms on discontinuation. Alternate day dosing is off-label but may improve adherence (e.g. every 2 days give twice the daily dose, up to 32mg/dose). Lofexidine (Detoxification) Tablets 200micrograms Naltrexone (Maintaining abstinence) Tablets 50mg Once maintenance dose is achieved after repeated dosing, alternate day or three day a week (e.g. Mon 100mg, Wed 100mg, Fri 150mg) dosing is off-label but may improve adherence. Dose may be given BD with meals if for example nausea is a problematic side-effect. Management of Side-Effects / Symptoms in Opiate Misuse Avoid unnecessary pharmacological treatment: only treat if severe or “when required” (PRN): PG20 – Pharmacological Management of Substance Misuse Approved by Drugs and Therapeutics Committee: November 2016 Review date: October 2020 Page 2 of 12 the Side-effect Sedation Withdrawal symptoms occur before next dose Headache Nausea or Vomiting Constipation Weight gain Sleep difficulties Lowered sex drive Dental problems Anxiety Depression Abdominal Cramps Diarrhoea Muscle/Joint Pain Potential Causes and Management Options Opiate dose too high: lower the dose. Concomitant drug/alcohol use: review other medications being taken. Opiate dose too low: increase the dose. Changes in concomitant drug use: review other medications being taken. Check adherence. Withdrawal symptoms may include yawning, coughing, sneezing, runny nose/eyes, raised blood pressure/pulse, dilated pupils, cool/clammy skin, diarrhoea, nausea, fine muscle tremor, restlessness, irritability, anxiety, insomnia, depression, drug cravings and abdominal cramps. Common in buprenorphine initiation, particularly if dose is too high: usually mild and transient. Other causes of headache e.g. dehydration should be excluded. Consider use of paracetamol (oral) 500mg-1g up to QDS PRN. Common in opiate initiation and withdrawal, usually mild and transient. Avoid rapid dose changes and consider dose-reduction if persistent during initiation. Consider use of prochlorperazine (buccal) 3-6mg up to BD PRN. Very common in opiate use: encourage adequate dietary fibre, fluids and regular exercise. Particular issue at high doses of opiates and for women. Due to fluid retention and increased eating. Lower dose, reduce fat and salt in diet, ensure regular exercise regime. Dose too low and causing withdrawal at night. Dose too late at night causing stimulation at time of peak effects. Due to other drugs (particularly alcohol and stimulants in the evening, such as coffee, nicotine, amphetamines). Review maintenance dose and exclude other causes such as use of other medications. Advise on sleep hygiene and avoid hypnotic medication but as a last resort a time-limited course may be indicated. Refer to Trust Prescribing Guideline (PG02) for the Pharmacological Management of Insomnia. More common with high doses of opiates so review and consider lowering dose. Exclude other psychological factors (e.g. anxiety, poor relationship with partner). All opioids reduce saliva flow, exacerbated by poor diet/dental hygiene. Encourage teeth hygiene, dental floss, use of sugar free gum, regular dental checks and reduce intake of sugary drinks and sweet food. Management of substance misuse may unmask pre-existing anxiety which will need assessing in its own right. Refer to Trust Prescribing guideline (PG11) for the Pharmacological Management of Anxiety Spectrum Disorders. Management of substance misuse may unmask pre-existing depression which will need assessing in its own right. Monitor for severe persistent symptoms and suicidal ideation. Refer to Trust Prescribing guideline (PG03) for the Pharmacological Management of Unipolar Depression. Common during opiate withdrawal. Other causes of abdominal cramps should be excluded. Consider use of hyoscine butylbromide (Buscopan®) (oral) 10-20mg QDS PRN. Common during opiate withdrawal. Other causes of diarrhoea e.g. gastrointestinal infection should be excluded. Consider use of loperamide (oral) 4mg STAT then 2mg PRN after each loose stool, maximum dose 16mg/day. Common during opiate withdrawal. Other causes of pain e.g. physical trauma should be excluded. Consider use of paracetamol (oral) 500mg-1g up to QDS PRN. Opioid withdrawal is almost never a life threatening condition, whereas opioid toxicity is. Stabilisation / Maintenance of Opioid Misuse Both oral formulations of methadone and buprenorphine, using flexible dosing regimens are recommended options. The decision about which to use must take into account the person’s PG20 – Pharmacological Management of Substance Misuse Approved by Drugs and Therapeutics Committee: November 2016 Review date: October 2020 Page 3 of 12 preferences, history of opioid misuse, their commitment to a particular long-term management strategy, and relative risks and benefits of each treatment. If both drugs are equally suitable, methadone should be prescribed as the first choice due to relative cost and evidence base. Estimates of the degree of dependence and tolerance are unreliable, and should never be the basis for starting doses due to the risk of overdose. Assessments should be based on the history of quantity, frequency and route of administration. Refer to Appendix 1, as a guide, for information on opioid dose equivalents, however titration against withdrawal and monitoring for intoxication is the safest way to achieve dose stabilisation. Concomitant medication, illicit drug and alcohol use must be taken into account. The Clinical Opiate Withdrawal Scale (COWS) (see Appendix 2) and / or clinical judgement of either drug withdrawal or side-effects including intoxication will be used prior to each dose change. The dose should be titrated to a level at which the individual is comfortable and is no longer using illicit substitutes: exceptionally high doses are rarely needed unless clinically indicated to retain the person in treatment and careful monitoring is required due to increased risk of opiate intoxication. If the individual continues to use illicit opiates consider stabilisation in an in-patient setting. START LOW AND GO SLOW BUT AIM HIGH ENOUGH TO STOP ILLICIT USE Methadone - Initial dose of 10-30mg/day (10mg-20mg/day if tolerance low or uncertain: experienced clinicians may use a maximum first dose of 40mg/day for confirmed heavy dependence with significant tolerance). Deaths have occurred following doses as low as 20mg. Steady state reached after 3-10days so for safety reasons dose titrated for 2-4weeks: if dose increase indicated during first 7 days, titrate dose upwards in increments of 5-10mg/day. The total weekly dose increase should not be >30mg above the initial dose. For optimisation of treatment after 7 days increase dose by 10mg every 4-7 days, usually up to a total daily dose of 60mg-120mg/day. Individuals prescribed methadone ≥100mg/day and/or with other risks of QT prolongation (e.g. concomitant medication, cardiac disease and electrolyte abnormalities) should have a baseline ECG performed and repeated 7 days after titration, with referral to a cardiologist if abnormalities are identified. If ECG is ‘normal’ but the risk of QT prolongation remains high, consider repeating at 6-12 monthly intervals. See Trust Guidance for QTc Interval Prolongation: Risk Factors and Medication. Buprenorphine To reduce the risk of precipitated withdrawal, ensure adequate time lapse between initiation and previous dose of opiate, (e.g. 6-12 hours after the last heroin dose) and administer first dose when starting to experience opioid withdrawal symptoms. Precipitated withdrawal is a transient effect commencing 30-90minutes, usually peaking within 3hours and then subsiding (in contrast to under replacement symptoms which characteristically begin later). Less severe symptoms may continue for the first 2-3 days due to the slow binding of buprenorphine. Buprenorphine will provide a blockade effect against other opioids at doses of ≥12mg/day. Steady state reached after 3-7days so dose can be rapidly titrated over 3 days, e.g.: Day 1 4-8mg Day 2 Increase by 2-8mg if withdrawal present. Day 3 Increase by 2-4mg if withdrawal present and 16mg has not been reached. Day 4 Usual range used to achieve abstinence is 12-16mg/day, with some needing up to 32mg/day. If onwards doses ≥16mg/day required, ≥7 days should lapse before dose change and minimum increments of 2mg/day every week. Methadone and buprenorphine are metabolised by cytochrome P450 enzyme system (CYP3A4 & CYP2D6) so there is a risk of interactions with other medication. Baseline LFTs should be ascertained prior to initiating treatment with buprenorphine, but if clinically well, do not delay starting if informed consent is provided (see P09, Trust Policy for the Clinical Management of Substance Misuse). If LFTs are normal, monitor regularly (e.g. 6 monthly). Caution required with all opiates if there is hepatic impairment, history of alcoholic liver cirrhosis, or hepatitis: medication should be reviewed (usually reduced or stopped); LFTs monitored and referred to hepatology if there are clinical signs of hepatic impairment. Hepatitis C may induce CYP enzymes, increasing first pass liver metabolism so requiring higher doses. Individuals with a recent history of PG20 – Pharmacological Management of Substance Misuse Approved by Drugs and Therapeutics Committee: November 2016 Review date: October 2020 Page 4 of 12 hepatic impairment, HCV antibody positive or alcohol misuse should have their LFTs rechecked at 12 weeks, then frequency to be determined by prescriber dependent on previous results (usually 3 monthly during treatment). In renal impairment dose changes are usually only required in end-stage renal disease. Transfer from Methadone to Buprenorphine: Do NOT transfer to buprenorphine until the methadone dose is ≤30mg/day. Methadone should be discontinued for at least 24-48 hours and wait for signs of withdrawal to occur prior to starting buprenorphine e.g.: Last methadone dose 20-30mg 10-20mg < 10mg Buprenorphine Day 1 4mg 4mg 2mg Buprenorphine Day 2 6-8mg 4-6mg 2-6mg Transfer from Buprenorphine to Methadone: Start methadone up to a maximum of 40mg/day, 24 hours after the last buprenorphine dose OR start 48 hours later if the 48 hour buprenorphine dosing schedule was being used. Residual buprenorphine may take up to a week to wash out, during which time it may block the full effects of methadone so titrate methadone dose gradually over at least 7 days. Buprenorphine dose <8mg 8-16mg ≥16mg First methadone dose <20mg 20-30mg 30-40mg Emergency Management of Opiate Intoxication Risk of overdose with opiates is increased during dose titration, in opiate naivety and with concomitant alcohol/poly-drug use (especially sedatives). A doctor must be contacted immediately if any degree of intoxication is observed. If severe symptoms of intoxication/severe drowsiness are observed: Call 999 immediately and request an ambulance in addition to calling a doctor (if available). Monitor and record respiratory rate every 10minutes and initiate CPR if appropriate. If naloxone is administered it will induce opiate withdrawal symptoms so the individual may be uncooperative, agitated and aggressive. Their capacity to accept treatment will depend on their level of alertness. Staff must give appropriate information to the ambulance about drug dependence and other medication, especially opiates. For inpatient management see Clinical Protocol for the use of naloxone in opiate overdose. Service users may be provided with naloxone for administration in cases of overdose under CP30 The Supply and Use of Naloxone to reduce drug related deaths associated with opioid overdose. The individual should be observed overnight in hospital to avoid a recurrence of opiate intoxication, as naloxone is shorter-acting than opiates. The high affinity of buprenorphine for opiate receptors results in the need to use very high doses of naloxone to reverse it (perhaps 10-30 times more than required for heroin), so resuscitation in intensive care may be needed. Mild intoxication: “Spaced out”, glazed response, pinpoint pupils: observe closely and record respiratory rate and level of sedation every 10minutes. Moderate intoxication: Nodding with efforts to hold up head: observe closely and record respiratory rate and level of sedation every 10minutes. Severe intoxication: Respiratory depression (<12 breaths/min with no signs of distress, may be unable to talk), sedated, bradycardia (slow heart rate<60 beats/min), hypothermia, hypotension, cyanosis. Therapeutic Plasma Level Monitoring / Drug Testing PG20 – Pharmacological Management of Substance Misuse Approved by Drugs and Therapeutics Committee: November 2016 Review date: October 2020 Page 5 of 12 There is no case for routine assays of plasma levels, but monitoring may be considered for: - Assessment of compliance. - Monitoring the effect of drug interactions. - Investigation of withdrawal symptoms despite high dose e.g. to identify fast-metabolisers. - Following a change in physical state e.g. pregnancy. - Considering splitting the dose i.e. for individuals who quickly reach peak plasma level concentrations from a single dose/where levels drop quickly causing withdrawal before the next dose e.g. a small takeaway evening dose can supplement the main supervised dose. Methadone has a linear but wide dose-plasma concentration relationship and does not plateau at high doses. In non-responders trough methadone levels of 400g/L for (R, S)-methadone or 250g/L for (R isomer)-methadone may be used as target values. Buprenorphine does not have a linear dose-plasma concentration relationship and plateaus at higher doses. Buprenorphine should test positive with drugs testing 20-37 hours post dose. Tolerance to Treatment and Missed Doses Tolerance varies between and within individuals, over time. Particular caution is required after periods of detoxification and release from prison. Missed doses can lead to loss of tolerance and prescribers should be kept informed of missed doses and must be informed after 3 consecutive missed doses for re-titration. The doses used for re-titration must take into account any potential loss of tolerance and ongoing illicit drug use when prescribed medication was not being taken. Management of Pain Control Consider use of non-pharmacological strategies and non-opioids e.g. paracetamol/NSAIDs/local anaesthesia. Before minor or intermediate elective surgery discuss with the anaesthetist. If opioid analgesia is indicated: For individuals taking full agonist opioids (e.g. methadone), opioid analgesia may be offered in addition to the usual opioid treatment dose but doses should be titrated according to response and respiratory function monitored. For individuals taking partial agonist opioids (e.g. buprenorphine), specialist advice should be sought. If the buprenorphine is continued, high doses of full agonist opioids will be required initially, with careful monitoring and anticipated dose reduction in the subsequent 36 to 72 hours. For individuals taking opioid antagonists (e.g. naltrexone), the opioid will be ineffective. Discontinue naltrexone 48-72hours before any procedure and for major elective surgery discontinue naltrexone 72hours beforehand. Relapse Prevention and Supporting Abstinence Naloxone Challenge Test can be considered prior to initiation of naltrexone, as opiate withdrawal can still occur despite a negative opiate urinalysis. Initiation of naltrexone without this test may be the preferred option if risk of relapse is high. The withdrawal effects that this challenge can provoke are less acute and shorter lived than those caused by oral naltrexone: if the person is opioid dependent withdrawal symptoms usually appear within 5 minutes and may last for up to 48 hours. Following negative urine test for opiates and in the absence of opioid withdrawal symptoms (COWS score <5, see Appendix 2) administer 400micrograms naloxone i/m or s/c. Observe the person following administration, and if they do not experience any withdrawal symptoms after a few hours, naltrexone can be given. PG20 – Pharmacological Management of Substance Misuse Approved by Drugs and Therapeutics Committee: November 2016 Review date: October 2020 Page 6 of 12 Naltrexone is a non-addictive, long acting competitive, opiate antagonist licensed for relapse prevention following detoxification. Naltrexone should only be administered under adequate supervision to people who are highly motivated to remain in an abstinence programme. They must be fully informed that opioid containing medication must not be taken with naltrexone and that an attempt to overcome the blockade can result in acute opioid overdose. It should be reviewed every 3 months and discontinuation should be considered if there is evidence of ongoing opiate misuse. It should be continued for at least 12 months and at the persons’ request up to a maximum of 24 months. Renal function should be taken at baseline and monitored every 3 months. LFTs must be taken at baseline and then repeated once a month for the first 4-6 months of treatment, then 3 monthly thereafter. Individuals with abnormalities should be tested every 2 weeks for the first 6 weeks then monthly thereafter. Naltrexone should not usually be started if AST is greater than two times the upper limit of normal and discontinued if greater than 3 times the upper limit. Individuals with minor LFT abnormalities have been treated with naltrexone without worsening of hepatic function. When venepuncture is difficult starting treatment without LFTs or in the presence of abnormalities may be considered but informed consent must be obtained (see Appendix 1 of Trust Policy for the Clinical Management of Substance Misuse (P09)). Relapse prevention with naltrexone is increasingly effective the more quickly it can be introduced. Treatment with naltrexone should not be initiated until the individual has been opioid free for a sufficient period of time. The person should be monitored for 60minutes after the first naltrexone dose and if withdrawal symptoms develop they should be treated symptomatically. Monitoring should include COWS scoring (see Appendix 2), blood pressure and pulse. Drug Heroin / other short acting opiate Methadone Buprenorphine 400micrograms ≥1week Buprenorphine ≤2mg for < 2weeks Buprenorphine >2mg Buprenorphine >4mg Naltrexone initiation 7 days minimum washout period before initiating naltrexone. Day 1=25mg/day, Day 2+=50mg/day. 14 days minimum washout period before initiating naltrexone. Day 1=25mg/day, Day 2+=50mg/day. 1 day minimum washout period before initiating naltrexone. It may be considered Day 1=12.5mg/day, Day 2-8=25mg/day, Day 9+= clinically appropriate to 50mg/day. initiate naltrexone sooner due to a high risk of 4-6 days minimum washout period before initiating relapse and the person is naltrexone. Day 1=25mg/day, Day 2+=50mg/day. prepared to tolerate mild 5 days minimum washout period before initiating withdrawal symptoms. naltrexone. Day 1=25mg/day, Day 2+=50mg/day. Transition to naltrexone will precipitate withdrawal likely to be sufficient to require a lofexidine detoxification. Management of Benzodiazepine Misuse In early/mild dependence and if the benzodiazepine is being prescribed, minimal interventions such as advisory letters, provision of information, for both the individual and the prescriber should prompt review of their ongoing use. Illicit benzodiazepine use increases high risk behaviours and benzodiazepines should not be prescribed routinely in the treatment of substance misuse. Opiates including substitutes, alcohol and other sedative drugs combined with benzodiazepines will greatly increase the risk of respiratory depression and suppression of the gag reflex, a major factor in drug-related death. Where dependence is established, benzodiazepines should be gradually discontinued. There is no evidence that long-term maintenance prescribing of benzodiazepines reduces the risk of harm and their use for the management of benzodiazepine withdrawal and dependency is an off-license indication. Presence of physical dependence and the likely dependence syndrome must be determined prior to prescribing (usually dependent on daily therapeutic doses, without a break for > 3 months). PG20 – Pharmacological Management of Substance Misuse Approved by Drugs and Therapeutics Committee: November 2016 Review date: October 2020 Page 7 of 12 CIWA-B (see Appendix 3) can be used to assess and monitor withdrawal symptoms. If withdrawal symptoms occur, do not reduce the dose further until symptoms improve. In situations where the individual experiences intolerable/severe withdrawal symptoms, it may be necessary to increase the dose to alleviate symptoms before further reduction can be considered. Refer to Trust Prescribing Guideline (PG02) for the Pharmacological Management of Insomnia for additional guidance on benzodiazepine withdrawal and approximate equivalent doses (usually administered in four divided doses) may be found here: ≥20mg/day diazepam the recommended maximum rate of dose reduction is 5mg/fortnight. <20mg/day diazepam the recommended maximum rate of dose reduction is 2mg/fortnight. >30mg/day diazepam, gradually reduce to a dose of 30mg/day over a 6 week period or at a rate of 10mg/month (whichever is shorter) and then review. Diazepam Tablets 2mg, 5mg Oral solution (1mg/ml) may be used if there is a high risk of diversion. Tablets may also be crushed but this is off-license use. Oxazepam Tablets 10mg, 15mg Consider as an alternative to diazepam for individuals with severe hepatic impairment. Carbamazepine Modified release tablets 200mg May be considered instead of benzodiazepines to control withdrawal symptoms from high doses of benzodiazepines. Some individuals may not tolerate side effects (i.e. nausea, dizziness, diplopia), of the rapid dose increase necessary for detoxification. Carbamazepine is an enzyme inducer which may reduce the effect of other medication (e.g. when used with methadone, carbamazepine may decrease its’ effect but on cessation of carbamazepine, methadone plasma levels may rise, risking overdose). If a prescription for a benzodiazepine is to be issued, there must be a clear treatment plan, discussed and agreed between the prescriber and the individual, outlining the goals and time frame of the benzodiazepine withdrawal. Prescribing should be reviewed at least every three months, and more frequently during initial stages of treatment withdrawal. Where daytime drowsiness or intoxication are problematic, individuals may take the total daily dose in divided doses. In established hepatic impairment the decision to treat in these situations should be made with input from hepatology. A lower dose of diazepam or use of oxazepam (not hepatically metabolised) may be required. Following cessation of longer-term high dose benzodiazepine use (>50mg/day diazepam equivalence), abrupt withdrawal can cause seizures which can present weeks later. There is no need to match high self-reported illicit doses and equivalent doses ≥30mg/day of diazepam are rarely necessary. Doses of diazepam >30mg daily must only be prescribed after discussion with and agreement by a Consultant Psychiatrist for Substance Misuse and inpatient stabilisation may be indicated. During benzodiazepine withdrawal: Depression may be a direct result of the withdrawal process or part of the underlying cause. An appropriate assessment of the depressive symptoms should occur. Refer to Trust Prescribing Guidelines for Unipolar Depression (PG03). Anxiety spectrum disorders should not routinely be managed with benzodiazepines. Refer to Trust Prescribing Guidelines for Anxiety Spectrum Disorders (PG11). Insomnia should not be managed with benzodiazepines. Promethazine may be useful short-term, alongside sleep hygiene measures. Refer to Trust Prescribing Guidelines for Insomnia (PG02). PG20 – Pharmacological Management of Substance Misuse Approved by Drugs and Therapeutics Committee: November 2016 Review date: October 2020 Page 8 of 12 Management of Substance Misuse in Pregnancy and Breastfeeding Women of childbearing age should be offered a pregnancy test, and advised to avoid pregnancy/breast-feeding whilst misusing substances. See Trust Prescribing Guideline (PG18) on the Pharmacological Management of Mental Health Conditions during Pregnancy and Breastfeeding. Click here to access. User-friendly Resources for Information about Managing Substance Misuse These web-based links are recommended sources for user-friendly information about treatment for the management of substance misuse: Choice and Medication website: http://www.choiceandmedication.org.uk/devon Includes printable summaries for medication used for substance misuse and an information leaflet for comparison of methadone vs. buprenorphine: http://www.choiceandmedication.org/devon/pdf/handyfactsheetmethadonevsbuprenorphine.pdf Patient.co.uk website: www.patient.co.uk Includes printable information for medication used for heroin replacement. Links to Manufacturer Patient Information Leaflet: http://www.medicines.org.uk/ Methadone Alliance: (020 7837 4379) www.m-alliance.org.uk Provides advocacy, training and helpline support for individuals accessing drug treatment services. Exchange supplies: http://www.exchangesupplies.org/shopdisp_P301.php Provides link to the methadone handbook: a complete guide to methadone and methadone treatment. Naltrexone cards are available from the Medicines Optimisation Team upon request. PG20 – Pharmacological Management of Substance Misuse Approved by Drugs and Therapeutics Committee: November 2016 Review date: October 2020 Page 9 of 12 Appendix 1 APPROXIMATE Equivalents These equivalences are to aid estimates of illicit drug use. They should never be used, instead of titrating the substitute dose against symptoms of intoxication and withdrawal. It is difficult to convert the reported use of street drugs, particularly as individuals may exaggerate without necessarily intending to manipulate the prescriber because of their addictive perception and anxiety, which may vary considerably depending on their available funds and the purity of what is available. City prices tend to be cheaper than in rural localities. Amphetamine: Street amphetamine sulphate averages 5% purity. Dexamphetamine is approximately twice as potent as amphetamine sulphate so actual equivalent, e.g. 4g of street amphetamine sulphate = ~actual dose of amphetamine sulphate = ~100mg dexamphetamine. Benzodiazepines: Refer to Trust Prescribing Guideline (PG02) for the Pharmacological Management of Insomnia for guidance of approximate equivalent doses. Opiates: UG Drug Codeine phosphate 15mg tablet Dextromoramide (Palfium®) 5mg tablet Dihydrocodeine (DF118) 30mg tablet Dipipanone (Diconal®) 10mg tablet Diamorphine 10mg tablet/ freeze-dried ampoule Morphine 10mg ampoule Pentazocine (Fortral®) 25mg tablet Pethidine 50mg tablet Buprenorphine dose 0.8-2mg 2-4mg 4-6mg 6-8mg 8-12mg 12-16mg 16-24mg 24-32mg Methadone dose 5-10mg 15-20mg 30mg 45mg 60mg ? ? ? Methadone dose equivalent 1mg 5-10mg 0-5mg 0-5mg 10 mg 10mg 2mg 5mg Dose of illicit ‘street’ heroin 0.1g (½ x £10 bag) 0.25g (1 x £10 bag) 0.5g (2 x £10 bags) 0.75-1g (4-5 x £10 bags) 1-1.5g (5-7 x £10 bags) 1.5-2g (7-10 x £10 bags or 1/16 oz; a “teenth” or 1.8g) 2-3g (10-15 x £10 bags; 1½ “teenths” or 2.7g) 3-4g (15-20 x £10 bags or ⅛ oz; an “eighth” or 3.5g) A £10 bag of heroin typically contains 0.2g heroin, but may contain as little as 0.1g or as much as 0.3g. If bought in larger quantities the cost is less, e.g. 0.5g = £20, 1g = £40, 1/16oz (=1.8g) = £60. Reduce approximated heroin dose by 1/3 if smoked rather than injected intravenously. PG20 – Pharmacological Management of Substance Misuse Approved by Drugs and Therapeutics Committee: November 2016 Review date: October 2020 Page 10 of 12 Appendix 2 Clinical Opiate Withdrawal Scale (COWS) and Monitoring Form Symptom Resting Pulse Rate: Measured after the resting for 60secs Sweating: After 30mins not due to room temperature/activity Anxiety or Irritability: 0 1 0 1 0 1 Restlessness: Observation during assessment 0 1 Pupil Size: Taking into account room lighting 0 1 Runny nose and tearing: Not accounted for by allergies/cold symptoms Yawning: Observation during assessment GI upset: Over the past 30mins 0 1 Tremor: Observation outstretched hands Gooseflesh skin: of Myalgia or Arthralgia: Taking into account any pain experienced prior to opiate withdrawal. 0 1 0 1 2 0 1 0 3 0 1 Score pulse rate ≤80 2 pulse rate 81 –100 4 no report of chills/ flushing 2 subjective report of chills/flushing 4 none 2 person reports increasing irritability 4 or anxiousness able to sit still 3 reports difficulty sitting still but able to do so 5 pupils less then /normal sized 2 pupils larger than normal for room 5 light (>3mm) Not present 2 Nasal stuffiness or unusually moist 4 eyes no yawning 2 yawning once/twice 4 no GI symptoms 3 stomach cramps 5 nausea/loose stool no tremor 2 tremor can be felt but not observed 4 skin is smooth 5 piloerection of skin can be felt Not present 2 Mild diffuse discomfort 4 pulse rate 101-120 pulse rate >120 flushed/observable facial moistness sweat streaming off face person obviously irritable/ anxious person so irritable/ anxious that assessment difficult frequent shifting or arm/leg movements unable to sit still at all pupils moderately dilated pupils dilated so that only the rim of the Iris is visible Nose running or frank tears Nose constantly running or tears streaming yawning three or more times yawning several times/ minute vomiting or diarrhoea multiple episodes of vomiting or diarrhoea slight visible tremor gross tremor or muscle twitching prominent piloerection Reports severe diffuse aching of joints/ muscles Person rubs joints/muscles and unable to sit still due to discomfort Add up the score from all 11 items to provide a maximum score of 48. Use of this scale is at the prescriber's direction to confirm severity of withdrawal: the trend should be downwards. Name: _________________________ Date of Birth: ____________ NHS Number: ____________ Date Time Resting Pulse Rate (0-4) Sweating (0-4) Anxiety or Irritability (0-4) Restlessness (0-5) Pupil Size (0-5) Runny nose or tearing (0-4) Yawning (0-4) GI upset (0-5) Tremor (0-4) Gooseflesh skin (0-5) Myalgia or Arthralgia (0-4) Total Score Score: 5-12 = mild withdrawal 13-24 = moderate withdrawal >24 = severe withdrawal PG20 – Pharmacological Management of Substance Misuse Approved by Drugs and Therapeutics Committee: November 2016 Review date: October 2020 Page 11 of 12 Appendix 3 CIWA-B: Benzodiazepine Withdrawal Schedule Rating Scale and Monitoring Form For each of the following items please circle the numbers which best describe the severity: (0=least severe, 4=most severe) 1. Observe behaviour for restlessness and agitation. 0 1 2 (no symptoms, normal activity) (restless, unable to sit still) 3 4 (frequent pacing) 2. Do feel you have difficulties concentrating? 0 1 (no difficulty) 3 4 (unable to concentrate) 3 4 (unable to eat) 3 4 (constantly) 3 4 (severe headache) 3 4 (very much so) 2 (some difficulties) THIS FORM IS INCLUDED IN THIS 3. Do you have any loss of appetite? DOCUMENT FOR INFORMATION 0 1 2 ONLY (no loss) (no appetite) FOR A COPY OF THIS FORM, 4. Do you feel your heart racing (palpitations)? PLEASE DOWNLOAD PG20b 0 1 2 FROM THE MEDICINES (not at all) (occasionally) OPTIMISATION PAGES OF THE DEVON PARTNERSHIP TRUST 5. Does your head feel full or achy? INTRANET 0 1 2 (not at all) CLICK HERE TO ACCESS 6. Do you feel anxious, nervous or jittery? 0 1 (not at all) 2 Add up the score from all 6 questions to provide a maximum score of 24. Name: _________________________ Date of Birth: ____________ NHS Number: ____________ Date Day 1 (Week 1) Day 2 (Week 1) Day 3 (Week 1) Day 7 (Week 1) Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 08:00 10:00 12:00 14:00 Time 16:00 18;00 20:00 22:00 This scale is at the prescriber's discretion to confirm severity of withdrawal. It can be used as a once-only score. Otherwise the aim is to reduce score initially over the first 3 days and review clinical need for further scoring to check that the trend is downwards. PG20 – Pharmacological Management of Substance Misuse Approved by Drugs and Therapeutics Committee: November 2016 Review date: October 2020 Page 12 of 12