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Surrey and Borders NHS Foundation Trust
Substance Misuse Services
Community Prescribing Guidelines October 2014
Community prescribing takes place within a context in which co-existing physical, emotional, social
and legal problems are addressed so far as possible. Prescribing, or pharmacotherapy, is therefore
an adjunct to psychological therapy, rather than an isolated intervention.
Community prescribing includes opiate substitution treatment, maintenance prescribing, opiate,
benzodiazepine and alcohol detoxification from alcohol, opiates or sedatives, (either gradual or
over a short period) or for relapse prevention.
The decision to prescribe for individuals with substance misuse problems is only made by the
prescriber after appropriate assessment at that point it time. Appointments should therefore be
made for prescribing assessments, not for prescribing per se.
Remaining in treatment for an adequate period of time is critical for treatment effectiveness. The
appropriate duration of treatment for individuals depends on their problems and needs, but
research indicates that for most people with drug dependence, the threshold of significant
improvement is reached after about three months in treatment, with further gains as treatment is
continued.
1
INDEX
Assessment for prescribing ............................................................................................................... 4
Choice of medication of opiate dependency ..................................................................................... 5
Prescription Housekeeping ............................................................................................................... 6
Prescribing Format ........................................................................................................................... 7
Dispensing ........................................................................................................................................ 8
Issuing Prescriptions ......................................................................................................................... 8
Reviewing Treatment ....................................................................................................................... 9
Failure to attend clinic/pharmacy ...................................................................................................... 9
Failure to collect medication from pharmacy .................................................................................... 9
Lost prescriptions ........................................................................................................................... 10
Medication Diversion ...................................................................................................................... 10
Reduction Regimes ......................................................................................................................... 10
Travel away from home .................................................................................................................. 10
Travel within the UK ........................................................................................................................11
Travel out of UK ............................................................................................................................... 11
Driving motor vehicles (appendix) ................................................................................................... 12
Continued substance use .................................................................................................................13
Fertility and Contraception ............................................................................................................. 14
Discontinuation of prescriptions ..................................................................................................... 14
Discontinuation process ...................................................................................................................15
Patients leaving the area/service ......................................................................................................15
Opiate Substitution Treatment (OST) ............................................................................................. 16
Choice of OST ................................................................................................................................. 16
Methadone ...................................................................................................................................... 17
Methadone equivalent doses .......................................................................................................... 18
Buprenorphine ................................................................................................................................ 19
Opiate detoxification ...................................................................................................................... 20
Non-Opiate Detoxification Medication ........................................................................................... 20
Benzodiazepines ............................................................................................................................. 21
Indications for a reduction prescription ........................................................................................... 22
Naltrexone ...................................................................................................................................... 24
2
Acamprosate .................................................................................................................................. 25
Disulfiram ....................................................................................................................................... 25
Lofexidine ....................................................................................................................................... 27
Lofexidine Schedule (one tablet = 0.2mg) ....................................................................................... 28
Pregnancy and Breastfeeding ......................................................................................................... 29
Methadone ..................................................................................................................................... 30
Buprenorphine ................................................................................................................................ 30
Depo-Provera ..................................................................................................................................31
Appendix 1 – QTc Prolongation........................................................................................................33
Appendix 2 – DVLA Guidance ......................................................................................................... 34
Drugs and Driving: blood concentration limits to be set for certain controlled drugs in a new legal
offence:........................................................................................................................................... 36
Drugs included in the new offence that might be used for medicinal purposes: ............................... 37
Please discuss the implications of this new law with any person who use our services who are taking
one of more of the above drugs: ...................................................................................................... 37
Appendix 3 – Opioids: Important Drug Interactions ........................................................................ 38
Appendix 4 – Benzodiazepine Withdrawal Scale ............................................................................. 40
Clinical observations ....................................................................................................................... 42
3
Assessment for prescribing

There is evidence of current dependence, confirmed on urine or saliva testing.

All clients should be registered with a local general practitioner, confirmed on NHS
Summary Care Record. Those without a GP should be asked to register within four weeks
of assessment or prescribing will not be continued.

Information regarding current substance misuse, medical and psychiatric history, details of
any medications currently being taken and of any known allergies should be available.

Written information on prescribed drugs and harm reduction should be given.
Consideration should be given to literacy and language.

Ensure and record that the client is competent to consent to treatment and has an
appropriate understanding of the effects side effects and hazards of any medications.

DVLA guidance on drugs, drinking and driving should be given.
The relevant pharmacist should be contacted and their agreement to dispense for the client
obtained. Clients requiring supervised consumption should be directed to a pharmacy that provides
this service and given a ‘Pharmacy Shared Care Contract’ to take to the pharmacy.
4
Choice of medication of opiate dependency
All individuals should be allowed to make an informed choice about the options available to them.
Consider the following factors when choosing which opiate substitute to use:

Patient experience and preference.

Level of current opioid use.

Any drug interactions if taking other drugs or medication.

According to evidence, methadone is more likely to retain patients in treatment.

Blockade effect of buprenorphine may be an advantage for some.

Safety, e.g. overdose risk (buprenorphine may have a lower risk of overdose).

Risks to others if medication taken e.g. children.
NICE recommends that, if both drugs are equally suitable, methadone should be prescribed as a
first choice.
Continuation of prescription from another service, including prison releases:

Written evidence of prescription including form, dose, interval.

Dispensing and if supervised consumption must be available.

Confirmation of when any existing prescription expires and the Pharmacy which is
dispensing should also be obtained.

Written confirmation should be sent to the previous community service, confirming that
prescribing now by SABP.
For Prison Releases

5
A prescription may be continued in consultation with a prescriber, for up to seven days,
while arrangements are made for the individual to see a prescriber for assessment.
Prescription Housekeeping

All prescription forms must be kept in a safe place, in accordance to Trust policy.
(PROCEDURE REF NO SABP/EXECUTIVE BOARD/0017/PROCEDURE10 Medicines Procedure:
FP10 - Prescriptions and ePACT prescribing data)
6

There should be a clear audit trail of prescription forms, including those voided, not
collected and cancelled.

The serial numbers of all prescriptions (whether printed, hand written and/or destroyed)
must be entered on a Prescription Record Sheet (electronic or paper).

The individual who prints the prescriptions should ensure they are not producing duplicate
or overlapping prescriptions, and that the prescription follows the agreed care plan. Care
should be taken to ensure that there is only one active prescription for each drug on the
computer system.

The specified pharmacy should be printed on the prescription and recorded in the notes.
This is not legally binding but allows checks on compliance and welfare if necessary.

The clinician who signs the prescription carries the responsibility for prescribing. Any
changes to dose, collection intervals or supervision should only be made in consultation
with the prescriber and should be brought to the attention of the prescriber prior to
signature.

A repeat prescription generated by nurses within Substance Misuse Teams is not deemed to
be transcribing as per Standard 3 of the Nursing & Midwifery Council (NMC) Standard for
Medicines Management (NMC, 2007).

There are occasional circumstances where substance misuse team staff will be required to
transcribe prescription information from faxed medicines charts/referral letters in order to
generate a prescription. In these cases it is the responsibility of the prescriber to check the
accuracy of the transcribed drug and dose details prior to signature.
Prescribing Format
Controlled Drug (CD) prescriptions do not have to be handwritten but they must be signed by the
prescriber. The date can be computer generated.
Prescriptions are only valid for 28 days. The 28 day period of validity runs from the date the
prescription was signed unless the prescriber has specified a start date on the prescription.
For instalment dispensing prescriptions, the first supply must be made within 28 days of the
appropriate date and the remainder of the instalments must be dispensed only in accordance with
the directions on the prescription.
Prescriptions for Schedule 2 and 3 drugs should also state:

The form (e.g. tablets) and where appropriate the strength of the preparation.

The total quantity of the preparation, or the number of dose units, in words and figures.

The daily dose.
Blue FP10MDA forms can only be used for interval dispensing of Methadone, Buprenorphine and
Diazepam. A maximum of 14 days can be prescribed on one form. The number of installments and
the intervals to be observed must be specified on the prescription.
Green FP10 forms are used for single collections of CD’s and all other medications. In the case of
installments not being collected on the correct day the wording below enables the pharmacy to
issue the remainder of the installment and prescription.
“If an installment prescription covers more than one day and is not collected on the specified day,
the total amount prescribed less the amount prescribed for the day(s) missed may be supplied.”
7
Dispensing
Supervised consumption is recommended for three months, although this period can be shortened
for those who stabilize prior to this.
Do not stop supervised consumption if:

A stable dose has not been reached.

There is continued and unstable drug misuse, including alcohol.

There is significant unstable psychiatric illness or risk of self-harm.

There are concerns about the safety of storage of medication at home where children are
present.

There is concern that the medicine may be diverted or used inappropriately.
Daily dispensing should then occur with gradual increase in the interval collection with stability and
progress in treatment.
Use of daily and/or supervised consumption should not be seen as a punitive measure but as an
adjunct to other treatment options for those finding it difficult to stabilize on medication.
Issuing Prescriptions
8

The individual person handing over the prescription must be deemed competent to
undertake the role and be absolutely certain it is being handed to the right patient. It is
good practice to ask for the name and date of birth if the client is not known to the
individual.

It is also their responsibility to assess the degree of intoxication of the client. Non-clinical
staff should always defer to clinical staff if they have any concerns at all.

If the client appears to be under the influence of alcohol, then the prescription should only
be given if a breath alcohol is <35 µg/100mls breath. If >35 µg/100mls breath, the client
should be asked to return at a later time.

If the client appears to be heavily under the influence of other substances then a discussion
with a senior member of staff should occur and be documented.

No prescriptions should be issued to individuals if they have not been seen by a member of
clinical staff for six weeks, unless a longer interval has been agreed and documented by the
prescriber.
Reviewing Treatment
Progress should be reviewed by a clinical worker regularly, looking at response to treatment in the
following areas:

Drug and alcohol misuse.

Physical and mental health.

Social functioning.

Offending and criminal justice.

Broader health and well-being.

Ongoing engagement in psycho-social support.
Risk assessment is an ongoing process. Any risks identified should be highlighted to the patient and
clearly documented in the case record.
Face-to-face prescriber review should occur at least annually, with shorter intervals in complex
cases, those new to treatment or where their situation has changed significantly.
Failure to attend clinic/pharmacy

When a patient on outpatient prescribing fails to keep clinical appointments on two
or more occasions, their case should be discussed at the team meeting. This should
also occur for patients regularly failing to pick up opiate medication from the
pharmacy.
Failure to collect medication from pharmacy
Missed Day
1
No action
2
May dispense if appropriate wording
3
May dispense if appropriate wording
Do not dispense, unless verified by
CDAT
CANCEL PRESCRIPTION
4
9
Pharmacy
Action
Titrating script any missed doses refer
prescriber
If fail to attend, inform CDAT
Client to discuss with keyworker.
Then may be appropriate to book
prescribing re-assessment appointment.
Lost prescriptions

Safe custody of the prescription and any dispensed medication is the responsibility of the
individual named on the prescription. The loss must be reported to the police by the service
user, and a crime number issued.

Lost prescriptions will only be replaced if a crime number is available and not if it is a
recurring event.
Medication Diversion

Third party information that an individual is selling or sharing their medication should be
addressed in a timely manner. The probity of the source should be noted.

Discussion at the Multi-Disciplinary Team (MDT) meeting should occur at how best to
address the issue and also how to manage the individual’s further treatment. The safety of
the source of the information should be taken into account in these discussions.
Reduction Regimes
The recommended maximum rate of reduction of medication is as follows. These are guidelines and
the individual should always be involved in any planning.
Medication
Maximum Reduction Rate
Methadone
5mg/week
Buprenorphine
2mg/week
Diazepam
5mg/week
Travel away from home
A minimum of two weeks’ notice is required.
10
Travel within the UK

For those who are dispensed daily +/- supervised consumption, collection can be arranged
at another pharmacy.

For those on less frequent collections, it may be possible to allow collection of medication
for the whole of the away period. These decisions will be made by the keyworker and
prescriber on an individual basis.
Travel out of UK
11

Prescriptions for travel abroad can only be issued for a total of four weeks.

Proof of travel must be provided prior to the issuing of prescriptions.

Travel for less than three months does not require a personal licence to enter or leave the
United Kingdom.

A letter should be provided, to confirm client’s name, travel itinerary, names of medication,
dosages and total amounts to be carried. The letter should be signed by the prescriber or
keyworker.

Other countries may have their own regulations for controlled drugs and prescription
medicines. This can be checked with the UK-based representatives of each country.
Driving motor vehicles (appendix)
It is the duty of the licence holder to notify the DVLA of any condition which may affect safe driving;
the DVLA is then legally responsible for deciding if a person is medically unfit to drive.
Prescribers should be familiar with the following publications:

For Medical Practitioners – at a glance guide to the current medical standards of fitness to drive
(DVLA, May 2014).

Confidentiality: Reporting concerns about patients to the DVLA or the DVA (GMC, 2009).
The person must have it made clear to them that:

Individuals must be informed that their driving may be impaired and that they have a legal
duty to inform the DVLA.

If they refuse to accept this advice they may wish to seek a second opinion.

Appropriate arrangements should be made to enable them to do so. They should be
advised not to drive until the second opinion has been obtained.

If the person continues to drive every reasonable effort should be made to persuade them
to stop. This may include telling their next of kin.
If it becomes clear that the person is continuing to drive, contrary to advice, relevant clinical
information should be passed immediately, in confidence to the medical advisor at DVLA.
12

Before giving information to the DVLA the person should be informed of the decision to do
so. Once the DVLA has been informed the person should have confirmation, in writing that
disclosure has been made.

The provision of advice in relation to alcohol, drugs and the responsibility to inform DVLA of
any impairment is provided in standard form to all clients.

Staff should discuss the effect of any drugs prescribed on driving and a note made of this
discussion.

Mileage expenses should not paid to people known to be unsafe who continue to drive.
Continued substance use
Alcohol use

20-50% of clients prescribed methadone also use alcohol. Evidence suggests that
continued prescribing in the face of alcohol misuse should follow a careful appraisal of risks
versus benefits together with interventions targeted at alcohol.

Those who regularly attend having consumed alcohol, or are judged to be dependent on
alcohol should be informed of the additional risks this poses in terms of general health and
overdose.

They should then be managed according to the appropriate alcohol treatment pathway.
Alcohol detoxification should be offered as appropriate.

Clients who refuse to address their alcohol use should have their Opiate Substitution
Treatment (OST) reviewed in line with the guidance on discontinuing OST on safety
grounds.
Opiate use
13

Ascertain whether use is in addition to taking prescribed medication properly or prescribed
medication being taken intermittently with illicit use. Is prescribed medication being stored
or diverted?

Reconsider reduced interval prescribing and the use of supervised consumption.

If collections are missed for logistic reasons, solutions should be explored and may include a
trial of less frequent collections.

Where medication is consumed daily but on top use continues then increase in dose should
be considered in the first instance.

If on top use is clearly hedonistic then the potential benefits of higher dose must be traded
against additional risk.

Consideration of changing to an alternative OST should preclude any discussions about
discontinuation if this is deemed safer.
Fertility and Contraception

Contraception is an important subject to discuss with women commencing treatment.
Many women cease ovulation during periods of uncontrolled drug use and resume ovulation
as they stabilise on opiate substitution treatment.

If this change is unexpected it can easily result in unplanned pregnancy. All females should
therefore be given advice about the risk of conception and suitable contraception.

It is desirable for the health and welfare of mother and baby that pregnancies should be
planned or at least delayed until the mother is healthier and life less chaotic.
Discontinuation of prescriptions
Involuntary withdrawal should be a last resort, and decisions relating to termination of treatment
should be initiated only after careful consideration and input from a number of other sources and
after all attempts have been made to solve any presenting issues, where appropriate.
Before any decision to withdraw OST is made, the key worker, prescriber or other relevant clinical
staff member must discuss the matter with the client and, wherever possible, written warnings
should be provided before the decision is made to withdraw treatment.
Situations that may lead to consideration of treatment discontinuation:
14

Failure to adhere to the safety requirements of the OST programme

OST is not considered an effective treatment (that is, the harm minimisation benefits of
OST are outweighed by the negative outcomes and elements of risk of continued
prescribing.

The individual takes regular overdoses or is frequently, significantly intoxicated from
psychoactive substance use, with concerns that prescribing may be increasing risk.

The client is threatening or violent towards staff, other clients, the prescriber or pharmacist.

Repeated failure to keep to the safety requirements of the OST provider.
Discontinuation process

All clients should be made aware of the situations that might lead to discontinuation of
prescribing at the outset of treatment.

Keyworker and/or prescriber should discuss the team view with the client and attempt to
reformulate the care plan.

Prescriptions should not be continued for more than six weeks without a face to face
review by a member of clinical staff.

Every effort should be made to see the client with flexibility of time and venue and the
client should be issued with a warning letter prior to discontinuation if this has not been
possible.

In patients for whom discontinuation may be needed, the reasons for this and specific
expected behaviours they can take to avoid discontinuation should be carefully discussed
and documented. It is often helpful to ask the client to sign that they have understood what
is written in the notes in this regard.

The reasons for discontinuation should be clearly documented including the parties
involved in the decisions.

The decision and rationale should be communicated in writing to the client, their GP and
any other agencies involved in their care and risk assessment updated.
Patients leaving the area/service
15

Where a patient attending the service and on medication wishes to leave the area the care
coordinator should facilitate both the transfer of care and prescribing if this is felt to be
appropriate.

The drug treatment service local to the patient’s new address should be contacted, details
of their referral processes obtained and a full report sent outlining the current treatment
plan as well as relevant past history.

Any prescribing arrangements required to cover the transition period should be agreed at a
team meeting.

Patients should not normally continue to receive prescriptions for a period in excess of two
weeks unless there is evidence that arrangements for transfer of care and prescribing
responsibility are still being made.
Opiate Substitution Treatment (OST)
The aims of an opioid treatment program are to:

Reduce or eliminate heroin and other illicit drug use by those in treatment.

Improve the health, psychological functioning and wellbeing of individuals and families.

Facilitate the social rehabilitation of those in treatment.

Reduce the spread of blood borne viruses (BBV) associated with injecting opioid use.

Reduce the risk of overdoses and deaths associated with opioid use.

Reduce the level of involvement in crime associated with opioid use.
Choice of OST

NICE, 2010 examined all the evidence pertaining to treatment of opiate dependence with
either Methadone or Buprenorphine. They concluded that:
‘Both methadone and buprenorphine in flexible dosing regimens are clinically effective and cost
effective, compared with no treatment, for maintenance therapy in the management of opioid
dependence.’

However, if both drugs are equally suitable for a person, then Methadone should be
prescribed as it is the cheaper drug. (NICE 2010)

Prescribing should form one element within a wider care plan, agreed with the client and
addressing physical, psychological and social needs. Good evidence exists for the effect of
motivational enhancement therapies, and a range of other psychosocial interventions
(Drug misuse and dependence – UK guidelines on clinical management DH, 2007).

16
Methadone and Buprenorphine should be administered daily, under supervision, for at least
the first three months. Supervision should be relaxed only when the patient’s compliance is
assured. Both drugs should be given as part of a programme of supportive care.
Methadone
Pharmacology








Methadone mixture sugar-free 1mg/1ml commonest.
Administered once daily.
Onset of effect ½ to 1 hour. Peak 2-4hours. Duration 24-36hours.
With regular dosing, duration may be up to 47hours.
Agonist at opiate µ receptors.
Methadone is a strong inhibitor of serotonin uptake.
Mainly metabolized by liver enzymes CYP3A4 and CYP2D6 meaning
extensive first pass metabolism.
Acidification of urine can increase clearance x3, and so reduce duration
of effectiveness.
Metabolism – fast and slow.
Indications

Opiate detoxification, stabilization and maintenance.
Investigations



Annual ECG.
Dose > 100mg/day.
Cardiac risk factors.
Other QTc prolonging medications.
Precautions

Hepatitis C infection may induce CYP enzymes so require increase in
dose.
Reduced does of methadone will need to be considered for patients
with prolonged QTc intervals ( >440ms for men, >470ms for women)
See appendix.
It is advisable to caution pregnant women taking methadone that the
use of heroin and cocaine has been shown to increase transfer of
methadone to the fetus (Malek A 2009).



Dose





Initial dose of methadone should not exceed 40mg daily.
Experienced and competent clinicians with patients who are tolerant
and heavily dependent may use up to 40mg daily as a first dose.
Titrate up at a rate of 5-10mg/24hours.
Maximum dose increase of 20mg/week.
Aim to stabilize on dose that eliminates withdrawal symptoms and
craving to use illicit drugs without causing undue sedation.
Adverse Effects

Respiratory depression, nausea, vomiting, dizziness, mental clouding,
dysphoria, pruritus, impaired sexual function, constipation, urinary
retention and hypotension.
Pregnancy


Stability for mother and fetus is the primary aim.
Increased doses or split doses may be required in the third trimester
(29-40weeks) due to increased metabolism of methadone at this stage.
Breastfeeding should be encouraged, even if the mother continues to
use drugs, except where she uses crack cocaine or a very high level of
benzodiazepines.
Depressant effects enhanced by other CNS depressants.
Increasing risk of respiratory depression and hypotension.

Drug
interactions
17






Effects may potentially by Cytochrome P450 inhibitors such as anti-HIV
agents, macrolide antibiotics, ciprofloxacin and azole antifungals.
Effects may be reduced by enzyme inducing drugs such as rifampicin,
some HIV treatments, phenytoin and quetiapine.
Contra-indicated with citalopram and escitalopram.
Grapefruit juice can increase the blood levels and effects of methadone.
For full list see Appendix

Form
Methadone tablets may be prescribed in place of liquid methadone for
a temporary period for patients travelling (e.g. holidays). However, it
should be borne in mind that methadone tablets are not licensed for the
treatment of opiate addiction and they are associated with additional
risks.
Methadone equivalent doses
Dose equivalent of different opiates shown below. Derived through practical experience they are
rough approximations. Calculations are based on the equivalent Methadone dose that would
prevent withdrawal symptoms.
Name and Dose of Short Acting Opiate
Methadone Dose Equivalence
Pharmaceutical diamorphine
10mg
20mg
Morphine
10mg
10mg
Pethidine
50mg
5mg
DF118 (dihydrocodeine)
30mg
2-3mg
Codeine or codeine phosphate
30mg
2mg
Diconal (dipipanone)
10mg
4mg
Palfium (dextromoramide)
5mg
5-10mg
Fortral (pentazocine)
25mg
2mg
Codeine linctus, Gee’ s linctus, Collis
Brown
100ml
10mg
Approximately £10 worth of heroin = 10mg Methadone as a rough rule of thumb.
18
Buprenorphine
Pharmacology








Semi-synthetic opiate.
Partial agonist at µ receptors. Antagonist at κ receptors.
Sub-lingual tablets, poorly absorbed if swallowed.
Full blockage achieved at dose of 16mg.
Peak effect after 1-4hours.
Duration action 48-72hours at 16mg+ (less with lower doses).
Metabolized by CYP3A4.
Suboxone contains Naloxone – this is inactive if taken sublingually,
however can induce opiate withdrawals if taken IV or snorted.
Precipitate
withdrawal




Buprenorphine has a stronger affinity for opioid receptors than other
opiates and so will displace existing opiates causing withdrawal
symptoms.
Commence in the first 30-90 minutes.
Peak within three hours.
Treat with symptomatic medications and Lofexidine.
Indications

Opiate detoxification, stabilization and maintenance.
Investigations
Dose




LFTs in those with history of liver disease.
Prior to first dose, withdrawal symptoms should be present.
First dose at least 24 hours after methadone.
12-16 hours after short-acting opioids (oxycodone, heroin,
morphine).
Less for codeine, dihydrocodeine.
Up to 8mg can be taken in the first 24 hours, in divided doses to
allow full dissociation of other opiates from receptors.
Dose can be increased up to 16mg on the following day if needed.
Maximum dosage 32mg Buprenorphine, 24mg Suboxone.
Suboxone should be used if there is concern the patient is diverting
or misusing prescribed Buprenorphine.





Community Detoxification



Buprenorphine doses should be initially reduced by increments of
2mg.
From 4mg reductions may be in increments of 400-800 micrograms.
For those who persistently fail to start Buprenorphine in the
community, a short admission may be necessary to allow initiation
and titration in those who wish.
Adverse Effects

Common side effects include insomnia, dizziness, drowsiness,
headache and constipation.
Drug Interactions



Depressant effects enhanced by other CNS depressants.
May also cause respiratory depression and hypotension.
Effects may be potentiated by Cytochrome P450 inhibitors.
19
Cautions

Severe breathing problems including asthma.
Opiate Detoxification
Providing information, advice and support
Detoxification should be a readily available treatment option for people who are opioid dependent
and have expressed an informed choice to become abstinent.
In order to obtain informed consent, staff should give detailed information to service users about
detoxification and the associated risks, including:

Physical and psychological aspects of opioid withdrawal, including the duration and
intensity of symptoms, and how these may be managed.

Use of non-pharmacological approaches to manage or cope with opioid withdrawal
symptoms.

Loss of opioid tolerance following detoxification, and the ensuing increased risk of overdose
and death from illicit drug use that may be potentiated by the use of alcohol or
benzodiazepines.

Importance of continued support, as well as psychosocial and appropriate pharmacological
interventions, to maintain abstinence, treat comorbid mental health problems and reduce
the risk of adverse outcomes (including death).
Non-Opiate Detoxification Medication
Medication
LOPERAMIDE
Dose
2mg
Indication
Schedule
oral
Diarrhoea
4mg stat then 2mg after each loose
stool – Max16mg/24hrs
oral
Stomach
Cramps
Max qds
HYOSCINE
HYDROBROMIDE
(BUSCOPAN)
20mg
IBUPROFEN
400mg
oral
Aches &
Pains
Max qds
ZOPICLONE
7.5mg
oral
Insomnia
nocte
DIAZEPAM
5-10mg
oral
Agitation
Up to 30mg daily for 3 days only
20
Benzodiazepines
Benzodiazepine dependence occurs in two distinct populations

Therapeutic – Prescribed medication with dosage in therapeutic range.

Non-therapeutic – As part of poly-drug use, often with excessive doses.

In all the conditions in which they are used, benzodiazepines tend to produce dependence
and withdrawal reactions therefore benzodiazepines should only be used for periods of up
to four weeks in non-dependent individuals.

There is no consensus evidence base for the management of benzodiazepine abuse and/or
dependence.
Benzodiazepine
Equivalent to 5mg diazepam
Alprazolam
Xanax
0.25mg-0.5mg
Chlordiazepoxide
Librium
15mg
Clobazam
Frisium
10mg
Clonazepam
Rivotril
0.5mg-1mg
Flunitrazepam
Rohypnol
0.5mg
Loprazolam
Dormonoct
0.5mg-1mg
Lorazepam
Ativan
0.5mg
Nitrazepam
Mogadon
5mg
Oxazepam
15mg
Temazepam
10mg
Triazolam
21
Trade Name
Halcion
0.25mg

When negotiating a structured reduction programme with a client it is often useful to
calculate the total quantity of Benzodiazepines used as an equivalent dose of diazepam so
an agreed baseline level of use can be determined from which to commence reduction.

Extra caution should occur in clients with hepatic dysfunction.
Indications for a reduction prescription

Individuals on long-term prescription on assessment although if possible, prescribing should
remain in primary care with guidance from CDAT.

Individuals stabilized on OST with a history if moderate to severe benzodiazepine
dependence syndrome. Use must be confirmed by at least two consecutive urine screens
positive for Benzodiazepines.

There is some evidence that reduction to 30-40mg diazepam can occur quite rapidly, and
some clinicians will only prescribe a maximum of 40mg.
Pharmacology





Enhances action of GABA.
Hepatically metabolized. Active metabolites.
Long half-life.
Accumulates in liver disease.
Reversed by flumazenil.
Indications for CDAT
prescribing

Benzodiazepine detoxification where there is a co-morbid, clear
(chronic and regular) dependency with opioids of at six months
duration.
Patients must have explored alternative ways of addressing their
benzodiazepine use.
2-3x urine samples positive for benzodiazepines, over the last few
months.
Evidence of withdrawal symptoms (see CIWA_B)
Relatively low dose brief detoxification is adequate for most.
Persistent use despite abstinence from other substances may
indicate the need for longer, slower withdrawal regime.
In a very small proportion, maintenance benzodiazepine
prescribing may be appropriate. This decision should be taken at
MDT and senior prescriber level.






Dose



All benzodiazepines should be converted to diazepam.
The initial daily prescribed dose should not exceed 30mg
diazepam.
Reduction should begin after a limited period of stabilization.
Adverse Effects



Short term drowsiness, sedation and ataxia.
Long term cognitive damage.
Be aware of the potential for paradoxical benzodiazepine
disinhibition.
Although this is thought to be an infrequent problem in most cases
(1%) groups at greater risk include those on high potency drugs
and those with pre-existing CNS damage or a history of aggression
or impulsivity (Paton, 2002).
Drug Interactions

CNS depressants effects may be enhanced if diazepam is used with
other centrally acting drugs.
22


23
Effects may be potentiated by cyto-chrome P450 inhibitors.
Effects may be reduced by cyto-chrome P450 enzyme inducing
drugs.

Medical review for decision to prescribe benzodiazepines.

Clear guidance to client regarding rationale for detoxification and discussion of regime.

Use CIWA-B to monitor reduction, every four weeks and decide further reduction.
APPENDIX CIWA_B.
Naltrexone
Pharmacology/
Information





Fully opioid antagonist.
Rapidly absorbed.
Displaces opioids from receptors precipitating withdrawals.
Blocks the effects of opioids.
Metabolized by liver.
Indications


Maintaining abstinence after opiate detoxification.
Maintaining abstinence after alcohol detoxification.
Investigations


Baseline LFTs the three monthly.
U&Es.
Dose

Initiate after patient has been opiate-free for 5-10days (confirm by
urinalysis).
Challenge – 25mg Naltrexone.
If tolerated, then maintenance dose 50mg daily.
Can be taken three times a week (Mon – 100mg, Wed – 100mg, Fri –
150mg).
Naltrexone is recommended for the prevention of relapse in
formerly opioid-dependent patients who are motivated to remain in
a supportive care abstinence programme. (NICE January 2007).
Prescribed for up to one year with concomitant psycho-social
intervention.





Opiate Antagonist Challenge




Adverse Effects


Drug Interactions
Further Information
24

Administer Naltrexone 25mg orally.
Monitor for opiate withdrawal for 2-3 hours. Signs and symptoms
may develop within five minutes and last up to 48hours.
Check BP and pulse. Request medical advice if BP 90/50 or 160/100
or if pulse 50 or 140.
Alternatively Naloxone (400 micrograms) intramuscularly or
subcutaneously can be used.
Side effects are common but tend to be transient and mild. GI
symptoms, anxiety, insomnia, poor appetite, headache and
increased sweating.
Patients should be made aware that Naltrexone can interfere with
pain relief and that they should let healthcare professionals know
they are taking it. These are cards available from the manufacturers
stating this fact.

Patients should be warned about taking opioid-containing
medicines such as in cough mixtures, some cold remedies and some
anti-diarrhoeals.
Significantly increases Acamprosate levels.


Avoid in hepatic and renal impairment.
Can cause constriction of the pupils (mechanism unknown).

Overdose can occur if individual takes enough opiate to overcome
blockade.
Acamprosate
Pharmacology/
Information



Reduces alcohol cravings.
Exact mechanism of action unknown but thought to antagonize
excitatory amino acids such as glutamate.
With counselling and social support.
Indications

Abstinence maintenance in alcohol dependence and harmful
alcohol use.
Investigations

None.
Dose



Ideally initiate at start of alcohol detoxification.
Two tablets (666mg) TDS in patients weighing 60kg or more.
Four tablets divided into three daily doses in patients <60kg. (two
tablets morning, one noon and one at night).
Adverse Effects

Diarrhea and stomach pain, headache, skin rash and sexual
problems.
Drug Interactions

Acamprosate levels may be slightly increased by Naltrexone.
Pharmacology/
Information

Blocks Acetaldehyde Dehydrogenase resulting in accumulation of
Acetaldehyde of alcohol taken.
Indications



Desire to maintain abstinence from alcohol.
Second line treatment.
Relatively stable personalities.
Investigations

None.

Flushing, nausea and vomiting, tachycardia, palpitations,
hypertension, headache if alcohol taken.
Have been fatalities.
Disulfiram
Dose
Adverse Effects

Drug Interactions
25
26
Lofexidine
Pharmacology/
Information


Alpha-2 adrenergic agonist.
Opiate withdrawal symptoms are from noradrenergic over activity.
Indications

Management of opiate withdrawal symptoms in a planned opiate
detoxification, clients with mild or uncertain dependence (NICE
2007) and those who have made in an informed and clinically
appropriate decision not to use OST.
They should live in a safe, stable environment and have a
responsible supporter.
A suitably trained staff member should monitor treatment and to
see the patient daily for at least the first three days.


Dose


Adverse Effects


The dose should be gradually increased from 0.2mgs qds to a
maximum of 0.6mg qds. Blood pressure monitoring should occur
after each increase in dose.
Similarly, the dose should be tapered off over 2-3days to prevent
the occurrence of rebound hypertension.
Side effects include drowsiness (6.6%), dry mouth (.3%),
hypotension (7.5%), bradycardia and rebound hypertension. Falls
in blood pressure and/or pulse rate are the most usual reasons for
intolerance.
May have a sedative effect thus advise not to drive or operate
machinery.
Caution

Caution in those with sever coronary insufficiency , recent
myocardial infarction, renal impairment and in people with marked
bradycardia (55 beats per minute). There have been reports of
asymptomatic QT prolongation during treatment with Lofexidine
or if taking other drugs known to cause QT prolongation.
Drug Interactions



Enhances sedative effects of alcohol, anxiolytics and hypnotics.
May enhance the effects of anti-hypertensive therapy.
Concomitant use of tricyclic antidepressants may reduce the
efficacy of Lofexidine.
Further Information

Safety in pregnancy and breast feeding is not established.
27
Lofexidine Schedule (one tablet = 0.2mg)
Day Number
Breakfast
Lunch
Dinner
1
0.2mg
0.2mg
2
0.2mg
0.2mg
0.2mg
0.2mg
3
0.4mg
0.2mg
0.2mg
0.4mg
4
0.4mg
0.4mg
0.4mg
0.4mg
5
0.6mg
0.4mg
0.4mg
0.6mg
6
0.6mg
0.6mg
0.6mg
0.6mg
7*
0.6mg
0.6mg
0.6mg
0.6mg
8*
0.6mg
0.4mg
0.4mg
0.6mg
9*
0.4mg
0.4mg
0.4mg
0.4mg
10
0.4mg
0.2mg
0.2mg
0.4mg
11
0.2mg
0.2mg
0.2mg
0.2mg
12
0.2mg
13



28
Bed
0.2mg
0.2mg
Note: Days 7,8 and 9 may need to be repeated for clients withdrawing from methadone.
Omit Days 6-8 if withdrawal is not severe.
A maximum does of 0.4mg qds may be sufficient for some individuals.
Pregnancy and Breastfeeding
29

Women who misuse substances and become pregnant have particular difficulties, so
attracting these patients into drug treatment services is vital.

Evidence demonstrate that the long-term outcome in women who enter methadone
treatment programmes during pregnancy is better in terms of their pregnancy, childbirth
and infant development, irrespective of continuing illicit drug misuse.

A medical review should be undertaken to assess physical and mental health, and discuss
treatment options.

If a partner is also using illicit opiates they too should be offered drug treatment.

Substitute prescribing can occur at any time in pregnancy and is lower risk than continuing
illicit use.

Methadone and Buprenorphine can be safely prescribed in pregnancy and will almost
always outweigh the risk of harm of heroin use.
Methadone
Pregnancy





Not a known teratogen and can reduce illicit drug use in
pregnancy.
Stability in pregnancy, with no illicit drug use in the first aim.
Maintain pregnant women on a dose sufficient to get benefit.
Methadone metabolism may increase in the third trimester
causing reduced levels and withdrawal symptoms, so dose may
need to be increased.
Is a risk of Neonatal Abstinence Syndrome, particularly in higher
doses.
Reduction in Pregnancy:
Breastfeeding



Rapid reduction should be avoided in pregnancy.
Slow reduction is preferable at a rate of 5mg or less/week.
Reductions should be led by the mother.

Methadone is excreted in the breast milk but this is not a
contraindication to breastfeeding. Methadone doses should be
kept as low as possible whilst breastfeeding.
Abrupt cessation of breastfeeding can result in Neonatal
Abstinence Syndrome, so mothers should be advised to slowly
wean from the breast.

Buprenorphine
Pregnancy



Breastfeeding



30
Buprenorphine is not licensed for use in pregnancy. However,
there is a consensus view that for women on Buprenorphine who
become pregnant, then it is safe and appropriate to continue
prescribing.
There is also a growing body of evidence of the safety of
Buprenorphine in pregnancy.
Neonatal Abstinence Syndrome can occur; however appears to
be lower incidence than with methadone.
Buprenorphine should not be used during breastfeeding.
There is currently limited data but research has demonstrated no
adverse effects in breastfeeding.
Low levels of Buprenorphine are found in breast milk however it
has poor oral bioavailability.
Depo-Provera
Indications

Long-acting reversible contraception.
Investigations

Pregnancy Test.
Contraindications



Pregnancy.
Current DVT or pulmonary embolus.
Unexplained vaginal bleeding, suspicious for a serious underlying
condition.
Diabetes with nephropathy, retinopathy, neuropathy, or vascular
complications.
Severe decompensated cirrhosis.
Liver tumours: hepatocellular adenoma and malignant
hepatoma.
Systemic Lupus Erythematosus with positive anti-phospholipid
antibodies; severe thrombocytopaenia.
History of or current breast cancer.
Sever side-effects from other Progestogen containing
medications.






For longer term use:




Dose



Adverse Effects

Timing




31
Significant multiple risk factors for arterial cardiovascular disease
(such as age, smoking, diabetes, hypertension and obesity).
Vascular disease including coronary heart disease presenting with
angina; peripheral vascular disease presenting with intermittent
claudication; hypertensive retinopathy.
Past history of ischaemic heart disease.
History of cerebrovascular disease, including transient ischaemic
attack.
Dosage single dose of 150mg every 12 weeks (the license allows
intervals of up to 12 weeks and five days).
Injections should be repeated at 12 week intervals although they
may be administered up to 14 weeks after the last injection.
This protocol is for a maximum of two consecutive injections,
while patients are assisted to access existing contraceptive
services. Deep intra-muscular injection slowly into the gluteal
muscle. The deltoid may be used if the patient refuses a gluteal
injection. (see Trust Protocol on intra-muscular and intravenous
injectables.)
Specifically discuss and document the possibility of menstrual
irregularities and amenorrhoea, weight gain (mean weight gain
of 3kg at two years use), skin and mood changes, slow return to
fertility (up to one year) and the effects on bone density.
General – Day 1-5 of menstrual cycle.
Amenorrhoea – Pregnancy Test.
Post-partum – up to 21 days post-delivery.
Miscarriage/Termination – same day.
Drug Interactions
32

Women should be informed that the efficiency of progestogenonly injectable contraception is not reduced with concurrent use
of medication (including antibiotics and liver enzyme-inducing
drugs) and the injection intervals do not need to be reduced.
Appendix 1 – QTc Prolongation
Risk factors for QTc Prolongation
Modifiable



Electrolyte Disturbances (e.g. hypokalemia)
Bradycardia
Concomitant use of more than one drug that prolongs the QT interval
Non-modifiable






Female Sex
Age over 65 years
Congenital Long QT Syndrome
Cardiac Disease (e.g. congestive heart failure, ventricular hypertrophy)
Impaired hepatic/renal function (due to effects on drug metabolism)
Thyroid Disease (e.g. untreated hypothyroidism)
Common drugs that may cause prolongations QTc:
Antimicrobials
Erythromycin, Clarithromycin, Moxiflozacin, Fluconaole, Ketoconazole
Antipsychotics
All have some risk
Risperidone, Fluphennazine, Haloperidol, Pimozide, Chlorpormazine,
Quetiapine, Clozapine
Antiarrhythmics
Sotalol, Quinidine, Amiodarone, Flecanide, Dronedarone
Antidepressants
Citalopram/Escitalopram, Amitriptyline, Clomipramine, Dosulepin,
Doxepin, Imipramine, Lofepramine
Antiemetics
Domeperidone, Droperidol, Ondansetron/Granisetron
Others
Methadone
Protein kinese inhibitors
Some Antimalarials
Some Antiretrovirals
33
Telaprevir, Boceprevir – Hepatitis C Treatment
Appendix 2 – DVLA Guidance
DVLA Drugs and Driving
DRUG MISUSE AND
DEPENDENCE
Reference to ICD10 F10.1F10.7 inclusive is relevant.
CANNABIS
AMPHETAMINES
ECSTASY
KETAMINE
& other psychoactive
substances, including LSD
and HALLUCINOGENS
HEROIN
MORPHINE
METHADONE*
COCAINE
METHAMPHETAMINE
34
GROUP 1 ENTITLEMENT
ODL - CAR, M/CYCLE
GROUP 2 ENTITLEMENT
VOC – LGV/PCV
Persistent
use
of
or
dependence
on
these
substances, confirmed by
medical enquiry, will lead to
licence refusal or revocation
until a minimum six month
period free of such use has
been attained.
For Ketamine misuse, 6
months off driving, drug-free,
is required, and 12 months in
the case of dependence.
Independent
medical
assessment and urine screen
arranged by DVLA, may be
required.
Persistent
use
of
or
dependence
on
these
substances will lead to refusal
or revocation of a vocational
licence for a minimum one
year period free of such use
has been attained.
Independent
medical
assessment and urine screen
arranged by DVLA, will
normally be required.
Persistent
use
of,
or
dependence
on
these
substances, confirmed by
medical enquiry, will lead to
licence refusal or revocation
until a minimum one year
period free of such use has
been attained. Independent
medical assessment and urine
screen arranged by DVLA, may
be required. In addition
favourable
Consultant
or
Specialist report may be
required on reapplication.
Applicants or drivers complying
fully with a Consultant
supervised oral Methadone
maintenance programme may
be licensed, subject to
favourable assessment and,
normally,
annual
medical
review.
Applicants or drivers on an oral
Buprenorphine
programme
Persistent
use
of,
or
dependence
on
these
substances,
will
require
revocation or refusal of a
vocational licence until a
minimum three year period
free of such use has been
attained.
Independent
medical assessment and
urine screen arranged by
DVLA, will normally be
required.
In
addition
favourable Consultant or
Specialist report will be
required before relicensing.
Applicants
or
drivers
complying fully with a
Consultant supervised oral
Methadone
maintenance
programme
may
be
considered for an annual
review licence once a
minimum three year period
of
stability
on
the
BENZODIAZEPINES
The non-prescribed use of
these drugs and/or the use
of supra-therapeutic
dosage, whether in a
substance withdrawal or
maintenance programme
or otherwise, constitutes
misuse/dependence for
licensing purposes.
The prescribed use of these
drugs at therapeutic doses
(BNF), without evidence of
impairment, does not
amount to
misuse/dependence for
licensing purposes
(although clinically
dependence may exist).
35
may be considered applying
the same criteria.
There should be no evidence of
continuing use of other
substances, including cannabis.
maintenance programme has
been
established,
with
favourable random urine
tests and assessment.
Expert Panel advice will be
required in each case.
Persistent misuse of, or
dependence
on
these
substances, confirmed by
medical enquiry, will lead to
licence refusal or revocation
until a minimum one year
period free of such use has
been attained.
Independent
medical
assessment and urine screen
arranged by DVLA, may be
required.
In
addition
favourable
Consultant or Specialist report
may
be
required
on
reapplication.
Persistent misuse of, or
dependence
on
these
substances,
will
require
revocation or refusal of a
vocational licence for a
minimum three-year period.
Independent
medical
assessment and urine screen
arranged by DVLA, will
normally be required. In
addition
favourable
Consultant or Specialist
report will be required before
relicensing.
Drugs and Driving
Blood concentration limits to be set for certain controlled drugs in a new legal
offence:

The Department for Transport has introduced a new offence of driving with certain
controlled drugs above specified limits in the blood; this is likely to come into force on 2
March 2015.

The list of drugs includes some licensed medicines.

Anyone found to have any of these drugs in their blood above the specified limits will be
guilty of an offence, whether their driving was impaired or not. However, there is a medical
defence for people taking the drugs for medical reasons, if their ability to drive was not
impaired.

Advise patients to continue taking their medicines as prescribed.
A new offence of driving with certain controlled drugs above specified limits in the blood is
expected to come into force on 2 March 2015. These drugs include some prescribed medicines.
Anyone found to have any of the drugs above specified limits in their blood will be guilty of an
offence, whether their driving was impaired or not. A preliminary, non-specific roadside test may
be used to detect if an individual has any of the drugs in their body. To identify the particular drug
taken and quantify blood levels, a blood sample will be taken at a police station and sent for forensic
analysis.
The legislation provides a statutory “medical defence” for people taking the drugs for medical
reasons, if their driving was not impaired. The conditions of the medical defence state that the
individual is not guilty of an offence if:

The medicine was prescribed, supplied, or sold to treat a medical or dental problem, and

It was taken according to the instructions given by the prescriber or the information
provided with the medicine.
The individual may need to provide written evidence to satisfy the points above (e.g. the tear-off
section of a prescription or the medicine’s patient information leaflet).
If the individual’s driving is impaired, they can be found guilty of an offence under the current law,
which has no statutory medical defence and will not change.
36
Drugs included in the new offence that might be used for medicinal purposes:








Amphetamine*
Methadone
Morphine
Clonazepam
Diazepam
Lorazepam
Oxazepam
Temazepam
*Amphetamine will not be included in the current regulations to go before Parliament
in 2014 but it is expected to be included later in 2015 once a limit has been agreed.
Although only a few benzodiazepines and opioids are included in the list above, all
benzodiazepines and opioids can impair driving ability. The risk of driving impairment
is increased if the medicine is taken with alcohol. Warnings on the risks of driving
impairment are already in the patient information leaflet.
Advice for healthcare professionals:

Any condition that requires medicinal treatment may itself pose a risk to
driving ability if left untreated. Therefore it is important to advise people who
use our services to continue their treatment.
Advice to give to people who use our services taking any medicine:
 Continue taking your medicine as prescribed
 Check the leaflet that comes with your medicine for information on how your
medicine may affect your driving ability
 It is against the law to drive if your driving ability is impaired by this medicine
 Do not drive while taking this medicine until you know how it affects you
(especially just after starting or changing the dose of the medicine)
 Do not drive if you feel sleepy, dizzy, unable to concentrate or make
decisions, or if you have blurred or double vision
Please discuss the implications of this new law with any person who use our
services who are taking one of more of the above drugs:
There is an information leaflet for patients at:
http://www.mhra.gov.uk/home/groups/dsu/documents/publication/con437439.pdf
Further details of the new law and advice for healthcare professionals can be found at:
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/325275/healthcareprofs-drug-driving.pdf
37
Appendix 3 – Opioids: Important Drug Interactions
Opioid
Interaction
Examples
Opioids Affected
Mechanism
Effect
Other opioids
Benzodiazepines
Tricyclic
Antidepressant
Antipsychotics
Antihistamines
Alcohol
All
Increased CNS
depression
Addictive effect –
potentiation of
respiratory
depression.
Medicines that
increase opioid
levels.
Medicines that
increase opioid
levels
Cimetidine
Ciprofloxacin
Erythromycin
Clarithromycin
Fluconazole
Ketoconazole
Fluvoxamine and
possibly other
SSRIs
Methadone
Buprenorphine
Increased blood
levels of
methadone or
buprenorphine
by inhibition of
the enzyme
CYP3A4
Dose of
methadone or
buprenorphine
may need to be
decreased to
prevent toxicity or
overdose AND
may need to be
increased to
prevent
withdrawal
symptoms when
the enzyme
inhibitor is
stopped.
Medicines that
decrease opioid
levels
Anticonvulsants
(e.g.
barbiturates,
carbamazepine,
phenytoin) HIV
Medicines (e.g.
efavirenz,
nevirapine)
Rifampicin
Spironolactone
St John’s Wort
Methadone
Buprenorphine
Decreased blood
levels of
methadone or
buprenorphine
by induced of
enzyme CYP3A4
Dose of
methadone or
buprenorphine
may need to be
increased to
preventwithdrawal
symptoms AND
decreased to
prevent overdose
when the enzyme
inducer is stopped.
Opioids that act
as partial
agonists
Buprenorphine
and other partial
opioid agonists
Methadone
Diamorphine
Other full
agonists
Buprenorphine is
a partial agonist
and displaces
other opioids
from receptor
sites.
Can precipate
withdrawal
symptoms –
advise waiting
until opioid is
excreted
(confirmed by
presence of
withdrawal
symyptoms)
before taking
Other medicines
(and substances)
that depress the
CNS
38
buprenorphine.
Opioid
antagonists
Naltrexone
Naloxone – IV, IM
and SC
All
Naltrexone and
Naloxone are full
antagonists and
displace other
opioids from
receptor sites
Will precipitate
withdrawal
symptoms if taken
when agonist or
partial agonists
have recently been
taken
Medicines
affecting urine
pH
Vitamin C
Sodium
bicarbonate
(antacids)
Methadone
Affects excretion
of methadone –
increased
excretion in
acidic urine,
decreased
excretion in
alkaline urine
Increased
excretion may
cause withdrawal.
Decreased
excretion may
cause toxicity
39
Appendix 4 – Benzodiazepine Withdrawal Scale
Guide to the use of the clinical withdrawal assessment scale for Benzodiazepines
Person report:
For each of the following items, circle the number that best describes how you feel.
Do you feel irritable?
0
1
2
3
Not at all
Do you feel fatigued?
0
Very much so
1
2
3
Not at all
Do you feel tense?
0
0
Do you have any loss of appetite?
0
1
2
3
1
2
3
Do you feel you heart racing?
(palpitations)
0
Does your head feel full or achy?
0
1
2
3
1
2
3
1
2
3
0
1
2
3
40
4
Severe headache
1
2
3
Not at all
Not at all
4
Constant racing
Not at all
Do you feel anxious, nervous or
jittery?
4
Intense burning/numbness
No disturbance
0
4
No appetite, unable to eat
No numbness
Do you feel muscle aches or
stiffness?
4
Unable to concentrate
Not at all
0
4
Very much so
Not at all
Have you any numbness or burning
on your face, hands or feet?
4
Unable to function
Not at all
Do you have difficulties
concentrating?
4
4
Severe stiffness or pain
1
2
3
4
Very much so
Do you feel upset?
0
1
2
3
Not at all
How restful was your sleep last
night?
0
Do you feel weak?
0
Very much so
1
2
3
Very restful
0
Do you have any visual
disturbances? (sensitivity to light,
blurred vision)
0
Are you fearful?
0
1
2
3
1
2
3
Very much so
41
Not at all
4
Not at all
1
2
3
Not at all
0
4
Very much so
4
Very sensitive to light,
blurred vision
1
2
3
Not at all
Have you been worrying about
possible misfortunes lately?
4
Not at all
Not at all
Do you think you didn’t have
enough sleep last night?
4
4
Very much so
1
2
3
4
Very much so
Clinical observations
Observe behaviour for
sweating, restlessness and
agitation
0
None, normal activity
1
2
Restless
3
4
Paces back and forth,
unable to sit still
Observe tremor
Observe feel palms
0
No tremor
0
No sweating visible
1
Not visible, can be felt in
fingers
1
Barely perceptible
sweating, palms moist
2
Visible but mild
2
Palms and forehead
moist, reports armpit
sweating
3
Moderate with arms
extended
3
Beads of sweat on
forehead
4
Severe, with arms not
extended
4
Severe drenching sweats
Total Score Items 1 - 20
1 – 20
Mild withdrawal
21-40
Moderate withdrawal
41-60
Severe withdrawal
61-80
Very severe withdrawal
Source: Adapted from Busto, U.E., Sykora, K & Sellers, E.M. (1989). A clinical scale to assess
benzodiazepine withdrawal. Journal of Clinical Psychopharmacology, 9 (6). 412 - 416.
42