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 . 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 2 . 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 3 . 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 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 4 . 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. 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. Guidelines for the inpatient treatment of opiate addiction. Final. Amended 02/11/11 5 . 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 6 . 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 7 . 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 Guidelines for the inpatient treatment of opiate addiction. Final. Amended 02/11/11 8 . 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. Guidelines for the inpatient treatment of opiate addiction. Final. Amended 02/11/11 9 . 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 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 Guidelines for the inpatient treatment of opiate addiction. Final. Amended 02/11/11 10 . (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 Guidelines for the inpatient treatment of opiate addiction. Final. Amended 02/11/11 11 . 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. Guidelines for the inpatient treatment of opiate addiction. Final. Amended 02/11/11 12 . 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. Guidelines for the inpatient treatment of opiate addiction. Final. Amended 02/11/11 13 . 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 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. Guidelines for the inpatient treatment of opiate addiction. Final. Amended 02/11/11 14 . 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 15 . 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 16 . 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. Guidelines for the inpatient treatment of opiate addiction. Final. Amended 02/11/11 17 . 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 18 . 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 19 . 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 20 . 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 22 .
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