Download Guidelines for the inpatient treatment of opiate addiction

Guidelines for the inpatient treatment of opiate
addiction
East London Foundation NHS Trust
November 2011
Guidelines for the inpatient treatment of opiate addiction. Final. Amended 02/11/11
1
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Document Control Summary
Title
Guidelines for the inpatient treatment of
opiate addiction
Purpose of document
To guide clinicians how tio treat opiate and
other illicit drug users in the in patient
situation
Electroninc file reference
(authors)
Electroninc file reference
(network or intranet)
Status
Version
Version 2
Author(s)
Name and position
Circulated to
Raymond Boakye, Lead Pharmacist
Specialist Addiction Service
Service managers and consultants of ELC
Specialist Addictions Services
Substance misuse clinical governance
group,Medicines Committee, Healthcare
Assurance Committee
Approved by
Second edition
02nd November 2011
Review date
02nd November 2013
All comments and ammendments to
Raymond Boakye, Lead Pharmacist
Specialist Addiction Service
Version Control Summary
Version
Date
1.0
April 2008
2.0
November 2011
Comments / changes
Max daily dose of methadone during
induction reduced to 50mg (flow chart &
page 14), example titration table added
(page 14), clarification on how to titrate
methadone (page 14)
Guidelines for the inpatient treatment of opiate addiction. Final. Amended 02/11/11
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Table of Contents
Section Topic
1.0
Summary flow chart
Page
number
4
2.0
Introduction
6
3.0
Development process including the staff
involved
6
4.0
Aim and Objectives
6
5.0
Target Population
7
6.0
Audience
7
7.0
Sources of Evidence (& search strategy)
7
8.0
Policy and Recommendations
8
9.0
Appendix 1 – Opiate withdrawal scale
18
Appendix 2 – Benzodiazepine withdrawal scale
19
10.0
References / Bibliography
20
11.0
Useful contact numbers for further advice
21
Guidelines for the inpatient treatment of opiate addiction. Final. Amended 02/11/11
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1.0 Summary
GUIDELINES FOR THE MANAGEMENT OF OPIATE
MISUSE AND DEPENDANCE
Monday to Friday 09:00 to 17:00 contact your local specialist addictions service for guidance on
prescribing or the Clinical Nurse Specialist for substance Misuse / Dual diagnosis team where
available
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Take a comprehensive history including:
Type of drug used
Daily drug intake and time of last use
Length of time of use at this level
Any periods of abstinence, history of withdrawal symptoms
Route of administration (IV, smoked, orally, nasally) if injecting, where. Examine sites of
injection – assess condition, are they fresh or old, any signs of infection
Daily cost of drug use, how use is funded
Are they currently in treatment with any service provider or in receipt of a prescription
Does the patient have a medical or psychiatric condition that requires admission?
Yes
No
Refer to CNS for substance
misuse or local specialist drug
service for outpatient support if
not already in treatment. If in
treatment refer back to the
prescriber.
Dipstick test urine (tests available in A&E) and send
a sample to lab for drug screen. Prescribing could
start on the basis of a single result so it is vital the
patient is assessed thoroughly
Does patient have opiate dependence?
Physical examination, interview (past
history of withdrawal symptoms) plus
urine result.
No
Yes
Does the patient have an active prescription in the community for an opiate substitution medication
(methadone or buprenorphine / Subutex)?
Yes
Can the community
prescriber or community
pharmacy confirm the
prescription?
No
No
Yes
Inform community prescriber of admission and have
them cancel any active prescription at the community
pharmacy. Continue prescription at community dose,
using twice daily dosing. You must factor in what they
have already had that day.
Assess the patient for signs and symptoms of substance misuse.
Injection marks, intoxication, reported drug use (amount and type),
withdrawal symptoms. Signs and symptoms of opiate withdrawal
include:
Dilated pupils, eyes watering, sneezing, gooseflesh, sweating,
abdominal cramps, feeling hot and cold, nausea, vomiting, diarrhoea,
tachycardia and hypertension.
Symptoms can take from 4 to 12 hours post dose to appear
(depending on the drug used) and peak at anything from 24 to 48
hours post dose
Guidelines for the inpatient treatment of opiate addiction. Final. Amended 02/11/11
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Note: Do not administer methadone to a
patient who is not opiate dependent, or who
appears drowsy or intoxicated.
Commence methadone mixture 1mg / 1ml at a
dose of 15mg every 12 hours up to a maximum
of 40 mg in the first 24 hours. If first dose of
15mg causes drowsiness reduce or withhold
the second dose. If daily dose of 30 mg holds
the patient maintain at this dose till discharge.
If dose is not keeping withdrawals at bay increase
by 10mg each day up to a maximum dose of 50mg
daily. Hold dose for 2-3 days before any further
increases. Consult a specialist for dosage increases
over 60mg. Split all daily doses into BD regime.
If night sedation is required use a short course of low dose zopiclone. Avoid prescribing benzodiazepines unless they were
being prescribed in the community and the prescription has been confirmed.
On Discharge
Do not prescribe any TTA’s for opiate substitution medication; the pharmacy will not supply them if you do.
Ensure the community prescriber is informed of the patient’s discharge and is able to restart prescribing. Fax or send
details of opiate substitution therapy doses at discharge.
If the community prescriber is unable to organise follow up immediately (for example at the weekend) patients’ may
have to return to the ward until the community prescriber can resume prescribing
Try to avoid discharging at the weekend.
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Be cautious if prescribing opiate-based analgesia. Opiate dependent
patients may require more analgesia than normally encountered. If extra
opiate analgesia is required it is vital that a plan is devised regarding the
reduction and cessation of the extra opiate once it is no longer indicated
and before the patient is discharged. Consult the pain control team for
advice.
If a patient is found consuming alcohol, using illicit drugs, drug dealing on
the ward or if a patient leaves the ward for longer than 4 hours without
notification; discuss with the patient’s consultant regarding that patient’s
future care.
Patients with any kind of canula or parenteral lines fitted should not be left
to leave the ward unescorted for long periods of time.
IF IN DOUBT DO NOT PRESCRIBE. Opiate withdrawal is NOT life
threatening.
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2.0 Introduction
Drug users have the same entitlement as other patients to the services provided by
the National Health Service and it is the responsibility of all NHS staff to provide care
for both general health needs and drug-related problems of the same high standard
as that provided to non drug users, whether or not the patient is ready to cease using
drugs2. They are likely to present at acute or psychiatric hospital for a range of
conditions, which may or may not be related to their drug use. It is essential that they
be treated in a professional way.
Many drug users will require pharmacological interventions to prevent drug
withdrawal. The presence of withdrawal symptoms will often hinder clinical work, as
most drug users will be more concerned with impending withdrawal symptoms than
any other condition they may face. If there is a clinical nurse specialist in substance
misuse available then they should be the first point of call for all situations where a
drug user is admitted to a ward. Some sites have access to the dual diagnosis nurse
who will also be able to give general advice. If the local SAU is available they are an
invaluable source of advice as well.
This policy serves as a guideline for all staff in the management of opiate dependent
drug users, if there is no specialist help available.
3.0 Development Process
Members of the East London and the City specialist addictions services developed
this policy. Sources of reference included Drug Misuse and Dependence –
Guidelines on Clinical Management (DoH 2007), the Evidence-based guidelines for
the pharmacological management of substance misuse, addiction and co-morbidity:
recommendations of the British Association for Psychopharmacology, the previous in
patient policy written by Dr Annie McCloud, The Cochrane Library and clinical
experience. A full list of references is given at the end of this document
The development group included:
Raymond Yiadom Boakye – Lead Pharmacist ELCMHT Specialist Addictions
Services
Dr Ron Alcorn – Clinical Director East London and the City Specialist Addictions
Services & Consultant, Newham Specialist Substance Misuse Team (SSMT)
Dr Alex Verner – Consultant, Tower Hamlets Specialist Addictions Service (SAU)
Dr Sarah Metcalf – Consultant, Hackney Specialist Addictions Service (SAU)
Sharon Hawley – Service Manager, East London and the City Specialist Addictions
Services
Shameem Mir – Chief Pharmacist, East London Foundation Mental Health Trust
Deborah Morgan – Manager Hackney SAU
Dayo Agunbiade - Manager Tower Hamlets SAU
Gareth Ellaway- Acting Manager Newham SSMT
Mandie Wilkinson - Manager Blood Borne Virus Team
Ian Griffiths – Manager Healthy Options Team
4.0 Aim and objectives of the policy
Aim
 To ensure all opiate addicted patients are managed safely and consistently with
all their needs addressed.
Guidelines for the inpatient treatment of opiate addiction. Final. Amended 02/11/11
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Objectives
 To provide information for all clinical staff to enable them to manage opiate
addicted patients during their stay in hospital so that the patients’ medical,
physical or psychiatric problems can be treated effectively.
 To enable patients not in community based drug treatment services to engage
with such services on discharge.
 To maintain the treatment of patients prescribed in the community during their
stay in hospital.
 To minimise the risks associated with prescribing and administering opiate
substitution therapy.
5.0 Target Population
 This policy is intended for use with any opiate dependent drug user that presents
and is admitted to the hospital.
 The drug user may use opiates by any route but they must do so in a dependent
fashion as defined by ICD104.
 It does not apply to drug users addicted to non-opiate drugs such as crack
cocaine, alcohol and benzodiazepines that do not use any opiate drug in a
dependent manner.
 Polydrug users who also use opiates in a dependent manner are also targeted by
this policy.
 There is general reference to the treatment of other drug addictions towards the
end of this policy.
6.0 Audience
 This intended audience of this policy is medical, nursing and pharmacy staff
working with opiate addicted patients within the Trust.
7.0 Sources of Evidence
The recommendations of this document are based on the types of evidence in the
chart below. Those recommendations based on local clinical experience do not have
a letter following the statement, which indicates the lack of directly applicable studies
in the field of substance misuse.
Grade
A
Requires at least one randomised control trial as part of the body of
literature of overall good quality and consistency addressing the specific
recommendation)
B
Requires availability of well-conducted clinical studies but no randomised
clinical trials on the topic of recommendation
C
Requires evidence from expert committee reports or opinions and / or
Guidelines for the inpatient treatment of opiate addiction. Final. Amended 02/11/11
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clinical experience of respected authorities. Indicates absence of directly
applicable studies of good quality
8.0 Practice Recommendations
(Refer to flow chart above for summary)
8.1 Admission
 Every patient that is known to have a drug problem must be referred to the CNS
for substance misuse or another specialist drugs worker at the earliest
opportunity if there is one available.
 If not then the admitting doctor will have to assess the patient’s drug problem.
 The borough specialist addiction service can be contacted for advice.
 Numbers for the three borough specialist services appear at the end of this policy.
 Where possible the specialist service or specialist nurse will offer appropriate
advice on treatment of the patient’s drug problem and provide support to the
patient and the medical team.
 Good liaison with the specialist team will help establish suitable continuing care of
the patient’s drug problem after they have been discharged.
8.2 Opiate Substitution Therapy
 The principle behind this treatment modality is to reduce the harm that drug use
inflicts on drug users.
 Within this are the aspects of reducing the amount of illicit drugs the drug user
must use to keep opiate withdrawals at bay, to reduce the frequency of injecting
and all of the inherent risks associated with that and to enable patients to break
the drug using life cycle many chronic users fall into (A).
 The theory is to change the illicit drug for a pharmaceutically pure opiate.
 The first line treatment is methadone1 (A). Methadone has the following benefits:
 It is long acting enabling once daily dosage (daily doses can be split into
two doses if necessary, a good practice in the in patient hospital setting);
its half-life is 24 to 36 hours.
 It is orally active, so drug users do not have to inject drugs.
 It is a full opiate agonist and will have the same pharmacological profile
as heroin (diamorphine), i.e. it will treat the opiate withdrawal syndrome.
 It has the best evidence base of all the therapies available1, 2.
 It does have some risks and should not be regarded as a completely safe
alternative. These risks include:
 It is toxic in overdose – like heroin – causing respiratory depression and
death.
 Its long duration of action means that the effect of the overdose will last
a lot longer. Naloxone, the opiate antagonist used to treat overdose has
a short duration of action hence it needs to be given as a continuous
infusion when used in methadone overdose, unlike in the heroin
overdose situation.
 It has cumulative pharmacokinetics. Methadone partitions into the fat
tissue and only when this is saturated do you see a steady blood
concentration of methadone, this process can take up to five days. In
practice this means that if doses are escalated too quickly then it is
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possible to overdose. For example if a patient were given 40mg on day
one then 80 mg on day two and 120 mg on day three, then the blood
level of methadone on day three would be higher in reality than the level
expected from that days dose. Therefore the patient would be at risk of
overdose.
In light of these risks it is vital that methadone is prescribed responsibly and
safely.
Remember that opiate substitution is essentially replacing one opiate with another
that has fewer risks, but none the less still carries some of the significant risks
associated with the opiate drug group.
The other drug commonly used for opiate substitution is Buprenorphine
(Subutex).
Temgesic is not licensed for use in opiate substitution therapy, unlike Subutex
and has different strengths of buprenorphine compared to Subutex.
8.3 Assessment 2, 5
 This is the most vital step. By the end of a good assessment the prescriber
should be able to decide if opiate substitution is indicated, what opiate to use,
how much and for how long.
 The first step is to take the patients history.
8.4 Patient History
Aim: To determine if the patient is currently using opiates, and if they are doing so in
a dependent fashion. Cover the following:
Drug History
 What they are using. Opiate substitution is only indicated in patients who
are dependent on opiates. People using cocaine, crack cocaine, cannabis,
alcohol, amphetamines or any other non-opiate drug of abuse on its own
should not be given methadone. Methadone would be indicated if the patient
was using a mixture of drugs including an opiate and were dependent on the
opiate.
 How they are using it, by injection, smoking, inhaling or some other route. If they
are injecting where are they injecting.
 The amount of opiate they use and how often they use it.
 When they started using the drug. How long they have used the drug.
 The patient’s experience of withdrawal symptoms, the patient should be able to
describe what they go through when withdrawing from opiates.
 Also enquire about other substances used; it may be necessary to prescribe
medication to deal with other substance misuse issues such as alcohol. Again
these other substances must be used in a dependent manner in order to warrant
a pharmacological intervention.
 Enquire about blood borne virus status (Hepatitis, B & C and HIV) find out when
they were last tested; they may want testing during their hospital stay.
Physical Examination
 Examine the state of any injection sites bearing in mind some may be in private
areas of the body.
 Look for evidence of drug use such as needle marks, track marks (thrombosed
veins). If they are injecting examine injection sites. If they are currently injecting
these will appear red and sore and they should be able to describe exactly
where they last injected.
 Look for signs of opiate withdrawal, however it may be necessary to initiate
methadone before the patient starts frank withdrawal symptoms. A dependent
patient should be able to describe past experiences of withdrawal from opiates.
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Look for signs of opiate intoxication (see below). Do not titrate doses of
methadone against signs of intoxication.
Table 1 Signs of opiate withdrawal 2, 5, 6
Early Signs
Intermediate Signs
Late Signs
Restlessness,
anxiety,
agitation,
discomfort, drug seeking behaviour /
craving
Yawning, sweats*, runny nose, runny
eyes, hot / cold flushes, dilated
pupils*, irritability, loss of appetite
Restlessness in legs whilst in bed,
insomnia, abdominal cramps, low
grade fever, nausea and vomiting,
increased pulse rate, diarrhoea*,
trembling, pale clammy skin with
goose bumps (piloerection)*, deep
aching pain in bones / muscles,
raised blood pressure*.
* Objective signs
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The withdrawal syndrome associated with heroin can start to appear 6 to 8
hours after the last use.
By 12 to 15 hours post dose the drug user will be feeling uncomfortable.
By 18 to 24 hours they will be very unwell with restlessness, difficulties sleeping
sweating, runny nose and runny eyes.
24 to 72 hours post dose the symptoms reach their peak with aches and pain in
the bones, muscles and joints, stomach cramps, vomiting and diarrhoea.
There after symptoms gradually fade away but it may be 7 to 10 days before the
drug user begins to feel well.
The withdrawal syndrome following cessation of methadone dosing has the
same features except it takes longer. Symptoms would begin 1 to 2 days post
dose and peak after 4 to 6 days. Symptoms can persist for 10 to 14 days and it
may be several days before the drug user starts to feel well again.
The withdrawal syndrome associated with buprenorphine is qualitatively less
intense than those associated with methadone and heroin. Symptoms may not
appear for 1 to 2 days post dose.
There is a psychological aspect to the withdrawal syndrome, which includes
symptoms like craving and responding to cues. This aspect can last for
unpredictable periods of time ranging from days to years.
 NB: the opiate withdrawal syndrome is very unpleasant but not life threatening. If
it is not managed adequately its presence will greatly hamper any other
interventions aimed at the patient and may cause the patient to self-discharge
against medical advice.
 However inappropriate use of medications such as methadone, benzodiazepines
and dihydrocodeine is potentially more dangerous.
The short opiate withdrawal scale is a validated scale that enables patients to
subjectively grade the severity of the main withdrawal symptoms (see appendix) that
they are experiencing.
Opiate intoxication
 Signs and symptoms include difficulty keeping the eyes open, head falling to one
side, drowsiness, reduced breathing rate / shallow breathing, constricted pupils
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(this symptom is always present in regular opiate users and only goes during
withdrawal).
In cases of overdose: Nausea and vomiting, constricted pupils, drowsiness,
reduced respiration, reduced heart rate, reduced systolic blood pressure and
reduced body temperature.
If the dose is large enough and the person is left untreated this could lead to
respiratory arrest and death.
Body Fluid Analysis
 This is a useful adjunct in the patient’s history and can be used to corroborate
information collected thus far.
 A positive result would be a prerequisite before starting the prescribed opiate and
would confirm the recent presence of opiates in the body.
 Analysis can be carried out by testing urine samples.
 Urine samples can be dipstick tested or sent to a laboratory. In the first instance
samples should be dipstick tested.
 There are dipstick tests available which can test for opiates, methadone, cocaine,
buprenorphine, amphetamine, cannabis and benzodiazepines.
Points to note regarding urine tests:
 Dilute samples of urine can give false negative results. Lab tests will
usually give the amount of creatinine in the sample and this will be a
guide of how dilute the sample is.
 If the patient drinks a large volume of liquid before they do the test this
will produce low concentration urine.
 The best sample is the first sample of urine passed in the morning.
 Some people give contaminated or substituted samples. A sample just
produced by the patient should be at body temperature and have a
normal colour. If it unusually cold or has an odd colour it may have been
tampered with.
 Many tests have a cut off point. This is the concentration below which
the test will disregard any of the metabolite it is testing for and show a
negative result.
 A positive result for an opiate urine test will mean that opiates have been
taken recently. Bear in mind simple opiate tests such as the dipsticks
and enzyme immuno-assay type tests cannot differentiate between
different opiates. If the client takes codeine, dihydrocodeine, morphine
or diamorphine (heroin) these tests will register positive. Some of these
opiates are found in over the counter preparations like co-codamol,
Paramol, Nurofen Plus and Kaolin and Morphine mixture.
 Opiate tests generally look for the presence of morphine and its
metabolites. These can be detected in the urine for up to 48 hours after
the last dose.
 A positive result on a methadone urine test will mean that the patient
has used methadone recently. Note methadone taken regularly in a
maintenance program could be detected in the urine up to 9 days after
the last dose.
 Urinalysis cannot give an indication of how much drug was taken.
 A negative result merely means the test did not detect any opiate or
methadone metabolites. It would be interpreted that the patient has not
used opiates or methadone recently.
 However there are plausible reasons why false negatives may occur:
The patient may be pregnant. During pregnancy hormones are released
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which speed up the metabolism of methadone. The urine may be dilute
– see earlier.
 In light of these facts urinalysis must be viewed in conjunction with the rest of the
assessment in particular the onset of withdrawal symptoms and cannot be relied
upon in isolation.
 The following table is a guide to how long drugs of abuse can be detected in the
urine once the user has stopped using the drug.
Approximate detectability of selected drugs in the urine2
SUBSTANCE
Amphetamines
Methamphetamine
Barbiturates
Short acting
Intermediate acting
Long acting
Benzodiazepines
Very short acting (half life 2 hours e.g. Midazolam)
Short acting (half life 2 to 6 hours e.g. Triazolam
Intermediate acting (half life 6 to 24 hours e.g. Temazepam,
Chlordiazepoxide)
Long acting (half life 24 hours, e.g. Diazepam, Nitrazepam)
Cocaine metabolites
Methadone (maintenance dosing)
Codeine, Morphine, Propoxyphene (heroin is detected as the
metabolite morphine)
Norpropoxyphene
Cannabinoids (Marijuana)
Single use
Moderate use (4 times per week)
Heavy use (daily)
Chronic heavy use
Methaqualone
Phencyclidine (PCP)
DETECTABLE FOR
48 hours
48 hours
24 hours
48 – 72 hours
7 days or more
Following 3 days dose
12 hours
24 hours
40 to 80 hours
7 days
2 – 3 days
7 – 9 days (approximate)
48 hours
6 – 48 Hours
3 days
4 days
10 days
21 –27 days
7 days or more
8 days (approximate)
 The street names of all drugs of abuse can be found at www.talktofrank.com in
the section “The A-Z of drugs”.
 This information has not been included here as the list is vast and new names
join the list frequently.
Confirmation of prescribed medication used prior to admission
 Many patients will be under the care of a prescriber for the treatment of their
addiction in the community.
 This will usually be a GP in association with a community drug team (CDT) or for
the more complex drug user one of the borough specialist addiction services.
 In general if the patient is an injector or uses several different types of drug or has
a psychiatric diagnosis as well then it is likely that if they have a community
prescriber it will be one of the SAUs.
 There will also be a community pharmacy that dispensed prescribed medication
for the patient.
 It is vital that the community prescriber and pharmacist are informed of their
patient’s admission to hospital for a number of reasons:
 The community prescriber can confirm the dose of methadone or
buprenorphine prescribed in the community and hence save the medial
team the worry of having to do a full assessment.
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 If the community prescriber is not available the patient’s community
pharmacy can be contacted to confirm the dose.
 The prescriber will know not to give further prescriptions until the patient
has been discharged.
 The community pharmacist will cancel any current prescriptions they
have until the patient has been discharged and this has been confirmed
by the prescriber.
 If the community based clinicians are not contacted patients will go and
collect prescriptions and doses and in effect get double dosages.
 The ward will know when the patient last took their prescribed
medication. If more than three days has passed and the patient has not
used any opiates in that time then restarting methadone at the same
dose may not be safe. The decision depends on what the patient wants,
how they present and the hospital prescriber’s clinical judgement.
8.5 Prescribing opiate substitution therapies in hospital
 The two licensed medications for opiate substitution therapy available are
methadone and buprenorphine.
 Methadone has the larger research evidence base1 but buprenorphine has a
better safety profile.
 There are studies evaluating the use of buprenorphine in substance misuse and it
is well recognised as an effective treatment.
 However methadone is still considered the first line treatment because
buprenorphine initiation is more complex than methadone initiation.
Methadone prescribing
 Once there is a full assessment including a positive urine screen, objective signs
and symptoms of opiate dependence and the patient’s consent then it will be
appropriate to prescribe methadone.
Confirmed methadone prescription
 If the patient is prescribed methadone in the community and the dose has been
confirmed with the community prescriber or pharmacist and there has been no
break in methadone dosing then the community dose can be prescribed, if it is
clinically appropriate to do so. NB the patient’s medical condition may prevent
this.
 The patient’s dose should be split in half and given as a twice-daily dose, even if
they had it as a single daily dose in the community. This enables doses to be
withheld or delayed if the patient leaves the ward and returns intoxicated
 There are a number of methadone formulations available. The only one patients
will be prescribed is methadone mixture 1mg/1ml. The concentrated version,
injections and tablets are not to be prescribed, even if these were prescribed
pre-admission. The evidence suggests that the indications for tablets and
injectable methadone are limited 1,2.
Unconfirmed methadone prescription or patient not in drug treatment service
but has signs and symptoms of opiate dependence and an opiate positive
urine screen
 In most cases there will be only one urine screen carried out before prescribing
so it is vital that the patient is assessed for other signs and symptoms of
dependence.
 Prescribe methadone 1mg/1ml at a maximum dose of 15mg twice a day for day
one.
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Observe the patient for 1-2 hours post first dose2.
On day two if the client is not held by 30mg then assess to see if an increase is
required. The short opiate withdrawal scale can be used to guide the decision to
increase the dose (see appendix). The daily dose is increased by 10mg daily up
to a maximum of 50mg or until the dose holds withdrawal symptoms at bay for
24 to 36 hours2.
The underlying theme of questioning during the dose assessment is whether the
prescribed dose of methadone is preventing withdrawals symptoms for at least
24 hours. Doses of methadone should be titrated against this measure.
Once 50mg daily is reached hold the dose for 1-2 days at least then reassess
before increasing the dose further. Use the SOWS to get a better idea of the
severity of withdrawals. Try to correlate the dose and the time it was taken with
the time it took for withdrawal symptoms appear.
If the patient reports no symptoms fro 24 hours OR feeling able to wait for longer
than 24 hours between doses then they are on an adequate dose.
An example titration scheme is:
Day 1
Day 2
Day 3
Day 4
Day 5
Day 6
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30mg
40mg
40mg
50mg
50mg
60mg (if necessary)
An adequate dose of methadone will “hold” (i.e. prevent withdrawal symptoms)
for at least 24 hours. This is the aim of methadone prescribing. Doses should
always be titrated against signs of withdrawal and how long the patient is
comfortable on the current daily dose. Never titrate doses against signs of
opiate intoxication; this puts the patient at risk of methadone overdose. Doses
should only be titrated against withdrawal symptoms
The MHRA recently advised that doses of methadone above 100mg could be
associated with cardiovascular irregularities causing an increase in QT intervals.
Current advice is that all patients on high dose methadone - over 100mg, with
pre-existing medical conditions (such as heart disease or liver disease) or on
other medications that affect QT interval (such as the older antipsychotics) or on
medications that inhibit cytochrome CTP3A4 (such as fluoxetine, paroxetine,
erythromycin and ritonavir) need to have careful ECG monitoring11.
Methadone is cumulative so doses cannot be escalated rapidly. Hold doses for a
couple of days to allow the methadone to distribute throughout the body.
Consult a specialist in substance misuse to review the patient if doses above
100mg are necessary.
Contact a specialist in substance misuse to review all opiate dependent patients
at the earliest opportunity.
Confirmed buprenorphine prescription
 Once the dose has been confirmed by the community prescriber it can be
prescribed as in the community.
 It should be prescribed as a single daily dose.
 Buprenorphine is a partial agonist with a high affinity for the opiate receptors in
the brain, higher than morphine and diamorphine (heroin). Hence it may
antagonise opiate pain relief administered during the patient’s stay in hospital.
This could impact on any surgical procedures that are required.
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Unconfirmed buprenorphine prescription
Buprenorphine will not be initiated whilst patients are in hospital. Initiation of
buprenorphine is not easy and requires the patient to be in withdrawal and is best left
to specialists in addiction.
If the assessment confirms the patient to have opiate dependence then they should
be started on methadone as above.
Summary of methadone prescribing
 Confirm the patient is opiate dependent before prescribing by completing a full
assessment including an interview, urinalysis, objective signs and symptoms,
and if possible confirmation with community based prescriber.
 If the dose is unconfirmed (i.e. the patient is a dependent opiate user but there
is no evidence that they are in treatment with a community based provider) start
the patient on methadone 15mg twice daily.
 Split the daily dose into twice daily regime. This is useful if patients use illicitly
whilst on the ward.
 Titrate the dose against signs of withdrawal; an adequate dose will hold the
patient for at least 24 hours.
 Only prescribe methadone mixture 1mg/1ml, do not use any other type of
methadone formulation.
 If the patient appears drowsy or intoxicated reduce, delay or omit the dose.
 Always write on the drug chart. If the dose was given sign the chart, if the
patient was not given the dose for some reason make that clear on the drug
chart. Some patients will try and get a double dose.
 Methadone is lethal in overdose causing death by respiratory depression.
Doses as low as 30mg can kill an opiate naïve adult, 5 to 10mg could kill a
child. The risks are increased if given with another respiratory depressant drug2
such as alcohol or benzodiazepines.
8.6 Overdose Guidance








The treatment for opiate overdose is the antagonist Naloxone.
Naloxone is a short acting drug with a half-life of approximately 4 hours.
It is given by the intravenous route. If that route is not accessible then it can be
given via the subcutaneous or intramuscular route but the clinical effect is
delayed.
The short half-life means that repeated injections are needed following opiate
overdose for example heroin.
The half-life of methadone is significantly longer and effects of an overdose can
last as long as 72 hours. Hence these patients will need to be observed for at
least 72 hours.
Hence in treating methadone overdose it needs to be given as an intravenous
infusion. The infusion is made up of 2mg Naloxone in 500ml of an infusion
solution, which is administered at a rate determined by the clinical response.
Bear in mind once Naloxone starts to take effect the patient will be in severe
withdrawals and may try to leave the ward prematurely.
Naloxone cannot displace buprenorphine from opiate receptors as
buprenorphine has a higher affinity. Hence Naloxone will at best only partly
reverse the effects of buprenorphine. However buprenorphine overdose is rare if
taken alone, it another opiate is used it will act as and antagonist or block the
effect of the second opiate. If it is taken with another depressant like alcohol or
benzodiazepine the safety profile is compromised. General supportive measures
would be taken.
Guidelines for the inpatient treatment of opiate addiction. Final. Amended 02/11/11
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
All ward staff should know what procedure to follow if the is a drug overdose on
the ward and where to obtain the required antidotes.
8.7 Detoxification
The decision to detoxify a patient from opiates should be a patient led decision. The
patient will require support from a substance misuse and counselling about the risks,
benefits and types of programmes available, how to go about getting into this type of
treatment and aftercare packages available. The key issue relating to detoxification
is:
 The risk to the patient should they relapse, many opiate overdoses and deaths
arise in cases where a patient has relapsed and uses pre-detoxification doses of
opiates to which they no longer have tolerance. 1,2,3
 Patients do better in treatment than out of treatment. There is a greater risk of
drug related morbidity and mortality in drug users out of treatment. If patients
have been detoxed they will be out of treatment and without adequate follow up
and aftercare there is a strong likelihood of relapse due to the psychological
aspects of dependence (such as craving) that will not have been addressed2.
 Evidence suggests that pharmacological detoxification with additional
psychosocial therapy is more effective than pharmacological detoxifications alone
in terms of treatment completion; compliance and results at follow up.
The decision to detoxify from opiates should not be taken by the clinician unilaterally.
8.8 Discharge







The inpatient team should try to co-ordinate the continuing treatment of the
patient’s opiate addiction. A community prescriber will continue treatment but
only if a referral has been made and enough notice has been given to carry out
this task.
If this is not done then there is a risk that there will not be a community
prescription available for the patient on discharge which may result in further
drug related harm and probable re-admission to the ward with similar
complications.
Patients must not be given take away methadone on discharge because of the
risk of diversion into the illicit drug market2
If methadone take away doses are prescribed the pharmacy department must
not dispense them.
For patients going on overnight leave doses of methadone can be given before
they depart as a single daily dose, once they return the dose can go back to a
split regime.
For patients going on several days leave they can return to the ward to collect
doses of methadone or in rare cases get take away doses (but this decision
should be taken after consultation with a specialist in substance misuse) or a
community pharmacy prescription can be organised for them to collect daily
doses in the community if the patients community prescriber agrees to this.
Patients should not be discharged with codeine, dihydrocodeine, combination
analgesics containing opiates, benzodiazepines, zopiclone or zolpidem unless
indicated and following discussion with the specialist in substance misuse.
Guidelines for the inpatient treatment of opiate addiction. Final. Amended 02/11/11
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8.9 Other Drugs of Abuse
 In general if a patient is found to be misusing other non-opiate substances the
first point of reference for the ward staff will be the CNS substance misuse.
 Other drugs commonly encountered include crack / cocaine, alcohol,
benzodiazepines and amphetamines.
 Methadone is not indicated in the treatment of addiction to any of these
substances.
 What follows is brief guidance as to the treatment options of these other drugs.
They should only be used in the absence of the CNS substance misuse (i.e. out
of hours) as they do not replace the in depth work and advice the CNS substance
misuse will do with the patient.
8.61 Cocaine/crack cocaine/amfetamine




Substitute prescribing is not appropriate. There are several studies looking at the
use of other pharmacotherapies, none supports the use of pharmacological
interventions in cocaine dependence1 (A)
Studies have found that an abstinence-based psychosocial treatment approach,
linking counselling and social support has the greatest impact on cocaine/crack
misuse. (Standard of care)
When a patient exhibits persistent anxiety and/or agitation, in the first instance
focus on stress reduction procedures. If these are not effective, the patient is
clearly distressed and immediate relief is clinically indicated, it may be
appropriate to prescribe in terms of acute psychiatric emergency (rapid
tranquillisation, aggression, mania/hypomania and psychosis). This would be the
decision of the duty psychiatrist. It may be unclear as to whether the distress is
stimulant-induced or not. It would, therefore, be appropriate to prescribe in the
short-term (24-36hours) according to evident distress.
Dipstick a urine sample to test for cocaine/crack cocaine to inform clinical
opinion.
8.62 Benzodiazepines







Benzodiazepines are indicated for the short-term relief (2-4weeks) of anxiety that
is severe, disabling or subjecting the individual to unacceptable distress occurring
alone or in association with insomnia or short-term psychosomatic, organic or
psychotic illness.
The use of benzodiazepines to treat short-term mild anxiety is inappropriate and
unsuitable.
Benzodiazepines are only used, for short periods of time, to treat severe
insomnia.
Benzodiazepines are not licensed for the management of benzodiazepine
dependence.
Benzodiazepines are not indicated in the treatment of opiate withdrawal, the
abuse potential and the illicit market value of benzodiazepines makes them a
particular risk in this patient group.
The evidence suggests that long-term substitute prescribing of benzodiazepines
does not reduce the harm associated with their use although in a small proportion
of patients there may be benefits. There is increasing evidence that long-term
prescribing of more than 30mg diazepam a day (or equivalent) may cause harm.
Sudden cessation in the use of benzodiazepines can lead to a recognised
withdrawal state (see Withdrawal Chart) and a high risk of seizure, which could
lead to death.
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



Dipstick urine samples to test for benzodiazepine use, sequential positive
benzodiazepine positive urine tests will suggest dependence. The patient pattern
of use must also be investigated daily or near daily use would suggest
dependence; sporadic binges do not suggest dependence.
Prescribing is only appropriate when there is clear evidence of dependency –
patient’s history examination and sequential benzodiazepine positive urine
results.
Diazepam is the appropriate substitute medication for any benzodiazepine
dependence due to its long half-life.
In patients with severe hepatic impairment all benzodiazepines can precipitate
coma, therefore in this case Oxazepam should be used. Refer to an addictions
consultant for dosage advice. 15mg oxazepam is equivalent to 5mg diazepam.
Oxazepam is usually given in a four times daily regimen, but due to its short half
life withdrawal symptoms will be more likely.
Dosage




If there is evidence of on-going prescribing continue this regime.
Use the Withdrawal Scale, titrate dosage or ask for specialist opinion (SAU).
Evidence suggests that most detoxification regimes can begin with low to
moderate doses without any untoward effects. Doses over 40mg should not be
initiated without specialist advice.
If the patient appears drowsy, omit further doses.
Detoxification





The usual rate of reduction is 2mg of diazepam every two weeks.
History of seizures would require slower reduction and careful management. If
seizures develop then the dose should be held at previous dose prior to the
seizure and an even slower reduction planned.
A swift detox from dependent use would be 2.5mg diazepam per week.
A general rule of thumb is to plan the length of detox against the length of
dependent use e.g. 5 year dependent use of 20mg diazepam would indicate a 5
month detox of around 1mg per week, 9 year dependant use of 20mg would
indicate a 9 month detox of around 0.5mg per week.
Some clinicians prescribe larger decreases at the beginning of the detox and
slow down as the patient progresses through the detox.
8.63 Alcohol
Refer to the in patient alcohol policy
8.64 Overdose with other drugs



There are no antidotes for overdoses caused by the other drugs of abuse.
Treatment of these overdoses should be aimed at the presenting symptoms and
may include management of unconsciousness and management of acute
psychosis
The antidote for benzodiazepine overdose is flumazenil but this should only be
used on expert advice (an anaesthetist), as its use is hazardous.
Guidelines for the inpatient treatment of opiate addiction. Final. Amended 02/11/11
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Appendix 1
SHORT OPIATE WITHDRAWAL SCALE
CLIENT: …………………………………………
Day of detox
Feeling sick
Stomach cramps
Muscle spasms or twitching
Feelings of coldness
Heart pounding
Aches and Pains
Yawning
Runny eyes
Difficulty sleeping
Muscle tension
PD
1
Weakness
Headache
Diarrhoea
Irritability/Agitation
Runny nose or sneezing
Any opiate drugs (y/n)
Any other drug (y/n)
Name & amount
of drug used
Blood Pressure
Pulse (per min)
Please rate your withdrawal symptoms each day:
DATE OF COMMENCEMENT:
2
3
4
0 = None
5
1 = Mild
6
7
8
9
10
11
12
2 = Moderate 3 = Severe
Adapted from Gossop M., Darke S., Griffiths P. et al Addiction 1995; 90: 607-614
Guidelines for the inpatient treatment of opiate addiction. Final. Amended 02/11/11
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Appendix 2
Benzodiazepine Withdrawal Scale
1 – Represents discomfort or experience of particular symptom.
10 – Represents unbearable experience of the symptom noted.
Symptoms
1
2
3
4
5
6
7
8
Anxiety Symptoms
Anxiety
**Sweating
** Nausea
Headache
Insomnia
**Blood pressure high
**Pulse high
**Resp high
Disordered Perceptions
Feelings of unreality
Abnormal body sensations
Abnormal sensation of movement
Hypersensitivity of stimuli
Major Complications
Psychosis
Epileptic Seizure
Scoring:
Anxiety symptoms
** = Objective benzodiazepine withdrawal measurement, other symptoms are
subjective to the patient and may/may not be included in the assessment.
1-3: 2-5mg diazepam 2 hour intervals for first 4hours, then 3hourly over
24hours, for next day prescribing take total at 24hours and split dose in half
for safety
4-6: 5-10 diazepam 2 hour intervals for first 4hours, then 3hourly over
24hours, for next day prescribing take total at 24hours and split dose in half
for safety
6-8: 10-15 2hour intervals for first 4 hours, then 3hourly over 24hours, for
next day prescribing take total at 24 hours and split dose in half for safety
Disordered perceptions
Psychiatric assessment needed
Major complications
Psychiatric assessment / treat symptoms
Guidelines for the inpatient treatment of opiate addiction. Final. Amended 02/11/11
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9
10
10.0 References, bibliography
1.
Evidence-based guidelines for the pharmacological management of
substance misuse, addiction and co-morbidity: recommendations of the
British
Association
for
Psychopharmacology.
Journal
of
Psychopharmacology 18(3) (2004) 293-335
2.
Drug Misuse and Dependence – Guidelines on Clinical Management
(DoH 2007),
3.
Addiction Medicine: An Evidence-Based Handbook.
Fingerhood. Lippincott William & Williams 2005.
4.
Oxford Handbook of Psychiatry. Oxford University Press 2005
5.
The Maudsley Prescribing Guidelines, 8th Edition. Taylor, Paton, Kerwin.
6.
Drug Addiction and Its Treatment. Gossop M. Oxford University Press
7.
Psychosocial and pharmacological treatments versus pharmacological
treatments for opioid detoxification. Amato L, Minozzi S, Davoli M,
Vecchi S, Ferri M, Mayet S. The Cochrane Database of Systematic
Reviews
2004,
Issue
4.
Art.
No.:
CD005031.
DOI:
10.1002/14651858.CD005031.
8.
Gowing L, Ali R, White J. Buprenorphine for the management of Opioid
withdrawal. The Cochrane Database of Systematic Reviews 2006, Issue
2. Art. No.: CD002025. DOI: 10.1002/14651858.CD002025.
9.
Petersen T., McBride A. Working with Substance Misusers. A guide to
theory and Practice. Routledge 2004
Rastegar,
10. Bazire S. The Psychotropic Drug Directory 2005, Lundbeck
11. MHRA. Current problems in pharmacovigilance. Vol 31(6), May 2006
Guidelines for the inpatient treatment of opiate addiction. Final. Amended 02/11/11
21
.
Useful contacts
Specialist Drugs and Alcohol Services (Tier 3) (Trust)
Tower Hamlets Specialist Addictions Unit 0208 121 5301
Hackney Specialist Addictions Unit – 0208 510 8629
Newham Specialist Substance Misuse Team - 0208 221 6000
CAMHS Specialist Substance Misuse Service (CSSS) – for under 19 year old
drug users - Tower Hamlets (via Lifeline) 020 7093 3007, Newham (via York
House) 020 7055 8400, Hackney (via Sub 19) 020 8525 4875
Community based Tier 2 Drug Services
Tower Hamlets Community Drug Team – 020 7790 1344
Hackney Community Drugs Team – 020 8985 3757
Newham Community Drugs Team – 020 8536 2121
Newham Healthy Options Team (Trust) – 020 7055 1500
Alcohol Specific Services
Alcohol Recovery Centre (ARC, Trust) (Hackney) 020 8958 3757
DASL (Newham) – 0208 257 3068
DASL (Tower Hamlets) – 0207 702 0002
National helplines
Narcotics Anonymous – 0207 730 0009
Alcoholics Anonymous - 0800 88 77 66
ADFAM - 0207 928 8900
Talk to Frank – 0800 776600
Guidelines for the inpatient treatment of opiate addiction. Final. Amended 02/11/11
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