PAIN AND/OR BENZODIAZEPINE MANAGEMENT 3002

Transcription

1 521 4 th Street Havre Montana Phone: Fax: POLICY AND PROCEDURE PAIN AND/OR BENZODIAZEPINE MANAGEMENT 3002 Policy: Pain and/or Benzodiazepine Management Contracts will be established for all non-cancer patients receiving opioid pain and anxiety/panic prescriptions for Bullhook Community Health Center providers for greater than three consecutive months. An evaluation by an Addiction Counselor must be completed within 30 days of the start of the contract. A pain and benzodiazepine management contract is a legally non-binding agreement between a patient and a provider outlining risks, responsibilities, and conditions of violation for patients who are prescribed chronic opioid or a benzodiazepine. A committee consisting of BCHC providers will be responsible for reviewing the related policies, pain and benzodiazepine contract violations, complex pain patients, mental health patients, and all requests for re-initiation of pain and benzodiazepine management contracts following violations. Purpose: Pain Management and Benzodiazepine Contracts will be established in order to provide safe and effective chronic pain and anxiety management for non-cancer patients receiving care at Bullhook Community Health Center, Inc. The goals of therapy for patients on chronic opioid and benzodiazepine therapy for non-malignant pain include: 1. Improving functionality and quality of life while minimizing drug related side effects. 2. Minimizing problems associated with abuse and diversion. Pain and/or Benzodiazepine Management Contracts do not carry an associated obligation on the part of the provider to supply a never-ending supply of opiate and benzodiazepine prescriptions. A copy of the current BCHC Pain and Benzodiazepine Management Contract is attached. Scope: BCHC providers, nursing staff, chronic pain and anxiety/panic patients on DEA Class II through V controlled substances. Review: This policy to be reviewed annually. Procedure: 1. All patients receiving daily (>30 doses per month) opioid pain medications or benzodiazepine medications for greater than three consecutive months from a BCHC Provider will be placed on a Pain and/or Benzodiazepine Management Contract. 2. All patients on Pain and/or Benzodiazepine Management Contracts will have a clearly identified primary care provider in the Electronic Health Record (EHR). 3. All contracts will be signed by the patient and the provider and subsequently scanned into the Electronic Health Record. The note title for the Pain and/or Benzodiazepine Management Contract will be Pain and/or Anxiety Contract. Hard copies of the Pain and/or Benzodiazepine Partners in Healthy Living

2 Management Contract will be provided to the patient. Pain and/or Benzodiazepine Management Contracts will be renewed on a 3 month basis. 4. Compliance tools including urine toxicology screening and pill audits will be used on a regular basis in order to reduce drug abuse and diversion risks. 5. Medical or Nursing staff may initiate the use of compliance tool at any time for patients on Pain and/or Benzodiazepine Management Contracts. 6. Compliance tools will be used on the following interval/schedule for patients on pain management contracts: a. At the initiation of therapy or contract b. At any time for cause or suspicion c. At random d. At a minimum of every 3 months for all patients on pain management contracts. 7. Patients on Pain and/or Benzodiazepine Management Contracts are obligated to comply with requests for urine toxicology screen sample submissions and pill audits in a timely manner. a. Patients called in by phone for pill audits or toxicology screening must present to BCHC the same business day as the request is made. b. Must have a working phone to be contacted c. Patients are not allowed to leave the health center unsupervised for any reason following a request to submit a urine sample for toxicology screening. Disregarding instructions to not leave the clinic unsupervised constitutes grounds for Pain and/or Benzodiazepine Contract violation and voiding of the Pain and/or Benzodiazepine Management Contract at the provider s discretion. d. If a Pain and/or Benzodiazepine Management Contract are voided for the first time, it shall not be re-initiated for a minimum of six months. Any subsequent violations and voiding of the Pain and/or Benzodiazepine Management Contract will result in forfeiture of Chronic Pain and Benzodiazepine Management treatment at the Bullhook Community Health Center, Inc. e. When a patient is in violation of the contract the medication may be tapered for no longer than 30 days. Providers are to note the taper and end date on the script and in the Medicine Module. Date: CHIEF EXECUTIVE OFFICER Date: CHIEF MEDICAL OFFICER Date: CHIEF DENTAL OFFICER Date: CHAIR, BOARD OF DIRECTORS Date: 02/20/2013 Approved Policy/Compliancy Committee Date: 02/27/2013 Approved - Board of Directors FOLLOW UP CHRONIC PAIN/BENZODIAZEPINE TEMPLATE

3 Subjective: This patient is here for review of opioid/benzodiazepine therapy for chronic pain/anxiety associated with for past years. The anticipated length of treatment is. MEDS: Opioids (Name/dose/frequency/daily maximum) Adjuncts (TCAs, Gabapentin, SSRI)(If not utilized, why?) NSAIDS (If not utilized, why?) OTC (capsaicin, Tylenol, Glucosamine)(If not utilized, why?) FUNCTIONAL STATUS: 1. The patient s functional status is: Good Fair Poor 2. Since the last visit, the patient s pain/anxiety is: Good Fair Poor 3. The patient s satisfaction with pain/anxiety treatment is: Good Fair Poor 4. Patient s relief of symptoms is %. 5. The activities that the patient has difficulty performing include: CO-MORBIDITIES:

4 1. Insomnia 2. Depression The patient reports the quality of their sleep is / is not a problem. PHQ-9 Screening has / has not been performed. If not, why? LIMITATIONS OF CURRENT THERAPY The current therapy plan has the following issues which affects compliance or effectiveness: Constipation Sedation Cognitive Breakthrough Pain Meds becoming ineffective Other (please specify) NON-PHARMACALOGICAL ADJUNCTS The patient is currently using the following adjunctive therapies to improve their functional status: Counseling, Support Groups Stretching, Yoga, Massage Exercise Music, Meditation, Prayer Relaxation, Distraction Physical Therapy PATIENT GOALS Has not tried to achieve goals Goals nearly achieved Goals exceeded No established goals (If not, why?) SCREENING FOR POTENTIAL ABERRANT DRUG-RELATED BEHAVIOR

5 None Requests early refills Reports lost/stolen medications Prescriptions obtained from other providers/er Excessive focus on opiate Multiple calls for meds/higher utilization Increasingly unkempt/impaired Abusing alcohol or illicit drugs Forging prescriptions Insists on medication by name Purposeful over-sedation Involvement in car or other accident Negative mood change OBJECTIVE: Vitals Physical Exam: General: Well-developed, well-nourished Female / Male patient in no acute distress. Alert and oriented x 3 HEENT: Heart: Lungs: Abdomen: Neuro: Psychology: Current pain level No Pain Worst Pain Imaginable Percent improvement with therapy % ASSESSMENT Chronic Pain

6 Anxiety Opioid Dependence 1. Patient is / is not benefitting from opioid therapy (improved function outweighs side effects) 2. Patient has / has not progressed toward goals 3. The level of function is stable / decreased / increased 4. The pain symptoms are stable / decreased / increased There is an opioid/benzodiazepine agreement and sold prescriber program in place. No violations suspected or reported since the last review. Plan Update sole prescriber as needed Meds: Labs: Continue present regimen Add/Adjust Adjuvant Therapy (Specify) Any adjustments or changes to present analgesics/anxiolytics (Specify) The risks, side effects, benefits of chronic opioid therapy have been discussed and an opportunity for questions provided. UA Drug Screening (if aberrant behavior) Goals: Selected by Patient (Specify 2 or 3) 1. Physical exercise, recreational activity, yard work or chores a. Will be performed minutes a day, days a week.

7 REFERRALS 2. Relaxation Therapy a. will be performed days a week or as needed 3. Social religious services, maintaining friendships a. I will attend/visit times per month 4. Family quality time with family, communication a. I will visit/call family times per month 5. Vocational hobbies, education, sports fun job, volunteering a. I will have fun doing / times per month Physical Therapy Physical Medicine and Rehabilitation Behavioral Health Social Work Addiction Medicine (If aberrant behavior noted) Pain Clinic Other non-pharmacological adjunctive therapies (Specify) FOLLOW UP 1. Face to face visit in weeks 2. Refills by phone for next months I spent minutes with this patient and more than 50% was spent in counseling about pain, physiology, adjunctive therapy, risks and benefits of therapies. Patient Name: Date: Date of Birth: Gender: F M Marital Status: S M D W

8 Telephone Numbers: Home ( ) Work ( ) Home Address: City: State: ZIP: INITIAL PAIN ASSESSMENT By answering the following questions, you will help your physician better understand and treat your pain. When and how did your pain problem start? As far as you know, what is the cause of your pain? (i.e. the diagnosis) What doctors have you seen? When did you see them? What did they do? (For example, Doctor did physical exam, ordered tests, prescribed medication). Doctor s Name Month/Year Seen What was done? What tests and studies have been done? (For example, MRI, CT Scan, X-Rays) Tests & Studies Month/Year Done Results

9 On the diagram below, shade the area(s) where you feel pain, X the area(s) that hurt the most. What pain treatments or medications are you receiving now or have received in the past? (For example, pain medications, physical therapy, acupuncture, TENS, etc.) Circle the number next to the treatment to signify the amount of pain relief that treatment is providing or has provided. Treatment or No Complete Check if Medication Relief Relief Receiving now Circle the numbers below that best describe how pain has interfered with your daily functioning. General Activity

10 Does not interfere Completely interferes Mood Does not interfere Completely interfere Walking Ability Does not interfere Completely interfere Normal Work Routine Does not interfere Completely interfere Relations with Other People Does not interfere Completely interfere Sleep Does not interfere Completely interfere Enjoyment of Life Does not interfere Completely interfere Ability to Concentrate Does not interfere Completely interfere Appetite Does not interfere Completely interfere What level of pain do you think you could function with on a daily basis? No Pain Worst Pain Imaginable List the body sites where you experience pain and circle the words that best describe the pain at that site. Also, indicate the intensity of the pain and those things that make your pain better or worse. Use a separate sheet for each body site.

11 Body Site: Aching Sharp Penetrating Throbbing Tender Nagging Shooting Burning Numb Stabbing Exhausting Miserable Gnawing Tiring Unbearable Intermittent Continuous Circle the number that best describes your pain at its worst during the last month. No Pain Worst Pain Imaginable Circle the number that best describes your pain at its least during the last month. No Pain Worst Pain Imaginable Circle the number that best describes your pain on average during the last month. No Pain Worst Pain Imaginable Circle the number that best describes your pain as it is right now. No Pain Worst Pain Imaginable What sorts of things make this pain feel better? (For example, heat, rest, medicine)

12 What sorts of things make the pain feel worse? (For example, walking, standing, lifting) Current Opioid Misuse Measure (COMM) The Current Opioid Misuse Measure (COMM) is a brief patient self-assessment to monitor chronic pain patients on opioid therapy. The COMM was developed with guidance from a group of pain and addiction experts and input from pain management clinicians in the field. Experts and providers

13 identified six key issues to determine if patients already on long-term opioid treatment are exhibiting aberrant medication related behaviors: 1. Signs and symptoms of intoxication 2. Emotional volatility 3. Evidence of poor response to medications 4. Addiction 5. Healthcare use patterns 6. Problematic medication behavior The COMM will help clinicians identify whether a patient, currently on long-term opioid therapy, may be exhibiting aberrant behaviors associated with misuse of opioid medications. In contrast, the Screener and Opioid Assessment for Patients with Pain (SOAPP) is intended to predict which patients, being considered for long-term opioid therapy, may exhibit aberrant medications behaviors in the future. Since the COMM examines concurrent misuse, it is ideal for helping clinicians monitor patients aberrant medication-related behaviors over the course of treatment. The COMM is: 1. A quick and easy to administer patient self-assessment items 3. Simple to score 4. Completed in less than 10 minutes 5. Validated with a group of approximately 500 chronic pain patients on opioid therapy 6. Ideal for documenting decisions about the level of monitoring planned for a particular patient or justifying referrals to specialty pain clinic 7. The COMM is for clinician use only. The tool is not meant for commercial distribution. 8. The COMM is NOT a lie detector. Patients determined to misrepresent themselves will still do so. Other clinical information should be used with COMM scores to decide if and when modifications to particular patient s treatment plan is needed. 9. It is important to remember that all chronic pain patients deserve treatment of their plan. Providers who are not comfortable treating certain patients should refer those patients to a specialist. COMM Please answer each question as honestly as possible. Keep in mind that we are only asking about the past 30 days. There are no right or wrong answers. If you are unsure about how to answer the question, please five the best answer you can.

14 Never Seldom Sometimes Often Very Often Never Seldom Sometimes Often Very Often 3002 Please answer the questions using the following scale 1. In the past 30 days, how often have you had trouble with thinking clearly or had memory problems? 2. In the past 30 days, how often do people complain that you are not completing necessary tasks? (i.e., doing things that need to be done, such as going to class, work or appointments) 3. In the past 30 days, how often have you had to go to someone other than your prescribing physician to get sufficient pain relief from medications? (i.e., another doctor, Emergency Room, friends, street sources) 4. In the past 30 days, how often have you taken your medications differently from how they are prescribed? 5. In the past 30 days, how often have you seriously thought about hurting yourself? 6. In the past 30 days, how much of your time was spent thinking about opioid medications (having enough, taking them, dosing schedule, etc.)? 7. In the past 30 days, how often have you been in an argument? 8. In the past 30 days, how often have you had trouble controlling your anger (i.e., road rage, screaming, etc)? Please answer the questions using the following scale 9. In the past 30 days, how often have you

15 needed to take pain medications belonging to someone else? 10. In the past 30 days, how often have you been worried about how you re handling your medications? 11. In the past 30 days, how often have others been worried about how you re handling your medications? 12. In the past 30 days, how often have you had to make an emergency phone call or show up at the clinic without an appointment? 13. In the past 30 days, how often have you gotten angry with people? 14. In the past 30 days, how often have you had to take more of your medication than prescribed? 15. In the past 30 days, how often have you borrowed pain medication from someone else? 16. In the past 30 days, how often have you used your pain medicine for symptoms other than for pain (i.e., to help you sleep, improve your mood, or relieve stress)? 17. In the past 30 days, how often have you had to visit the Emergency Room? SCORING INSTRUCITONS FOR THE COMM To score the COMM, simply add the rating of all the questions. A score of 9 or higher is considered a positive SUM OF ALL QUESTIONS Greater than or equal to 9 COMM INDICATION + (Positive)

16 Less than 9 - (Negative) As for any scale, the results depend on what cutoff score is chosen. A score that is sensitive in detecting patients who are abusing or misusing their opioid medication will necessarily include a number of patients that are not really abusing or misusing their medication. The COMM was intended to overidentify misuse, rather than to mislabel someone as responsible when they are not. This is why a low cut-off score was accepted. We believe that it is more important to identify patients who have only a possibility of misusing their medications than to fail to identify those who are actually abusing their medication. Thus, it is possible that the COMM will result in false positives patients identified as misusing their medication when they were not. The table below presents several statistics that describe how effective the COMM is at different cutoff values. These values suggest that the COMM is a sensitive test. This confirms that the COMM is better at identifying who is misusing their medication than identifying who is not misusing. Clinically, a score of 9 or higher will identify 77% of those who actually turn out to be at high risk. The Negative Predictive Values for a cutoff score of 9 is.95 which means that most people who have a negative COMM are likely not misusing their medication. Finally, the Positive likelihood ratio suggests that a positive COMM score (at a cutoff of 9) is nearly 3 times (3.48 times) as likely to come from someone who is actually misusing their medication (note that, of these statistics, the likelihood ratio is least affected by prevalence rates). All this implies that by using a cutoff score of 9 will ensure that the provider is least likely to miss someone who is really misusing their prescription opioids. However, one should remember that a low COMM score suggests the patient is really at low-risk, while a high COMM score will contain a larger percentage of false positives (about 34%), while at the same time retaining a large percentage of true positives. This could be improved, so that a positive score has a lower false positive rate, but only at the risk of missing more of those who actually do show aberrant behavior. COMM Cutoff Score Sensitivity Specificity Positive Predictive Value Negative Predictive Value Positive Likelihood Ratio Negative Likelihood Ratio Score 9 or Above PATIENT REASSESSMENT OPIOID ANALGESIC 4-A s+ CHART NOTE Patient Name Date CURRENT ANALGESIC REGIMEN

17 DRUG DOSE FREQUENCY COMMENTS REASSESSMENT NOTES ANALGESIC (Average/best/worst pain intensity; % pain relief) ADVERSE EVENTS (Type/severity) ACTIVITIES OF DAILY LIVING (Functional status/relationships/mood) ABERRANT DRUG RELATED BEHAVIORS (Type/severity) PATIENT REASSESSMENT OPIOID ANALGESIC 4-A s+ CHART NOTE MONITORING TESTS/REPORTS (Urine screens/pill counts/other) ASSESSMENT (Physical/psychological)

18 PHYSICAL EXAMINATION FINDINGS ACTION PLAN (Continue/adjust/discontinue therapy) COMMENTS SIGNATURE

19

20 OPIOID RISK TOOL (ORT) PATIENT FORM NAME DATE Mark each box that applies Female Male 1. Family history of substance abuse Alcohol [ ] [ ] Illegal Drugs [ ] [ ] Prescription [ ] [ ] Drugs 2. Personal history of substance abuse Alcohol [ ] [ ] Illegal Drugs [ ] [ ] Prescription [ ] [ ] Drugs 3. Age (Mark box if years) [ ] [ ] 4. History of preadolescent sexual abuse [ ] [ ] 5. Psychological disease Attention deficit hyperactivity disorder, obsessivecompulsive disorder, bipolar disorder, schizophrenia [ ] [ ] Depression [ ] [ ]

21 OPIOID RISK TOOL (ORT) PHYSICIAN FORM With item values to determine risk score NAME DATE Mark each box that applies Female Male 1. Family history of substance abuse Alcohol [ ] 1 [ ] 1 Illegal Drugs [ ] 2 [ ] 2 Prescription [ ] 4 [ ] 4 Drugs 2. Personal history of substance abuse Alcohol [ ] 3 [ ] 3 Illegal Drugs [ ] 4 [ ] 4 Prescription [ ] 5 [ ] 5 Drugs 3. Age (Mark box if years) [ ] 1 [ ] 1 4. History of preadolescent sexual abuse [ ] 3 [ ] 0 5. Psychological disease Attention deficit hyperactivity disorder, obsessivecompulsive disorder, bipolar disorder, schizophrenia [ ] 2 [ ] 2 Depression [ ] 1 [ ] 1 Low (0-3) Moderate (4-7) High (> or = 8) Scoring Totals [ ] [ ]

22 ASSESSMENT AND MANAGEMENT OF PAIN IN THE END OF LIFE ADJUVANT ANALGESICS Titration Indication Drugs Typical Starting Dose Recommendations Spinal cord compression, malignant bone and nerve pain Dysesthetic and paroxysmal lancinating pain Neuropathic and musculoskeletal pain Bone pain Visceral pain Second-line treatment or neuropathic pain (used with anticonvulsant) Neuropathic pain refractory to anticonvulsants and opioids Postherpetic neuralgia Prednisone Dexamethasone Gabapentin Phenytoin mg PO, Daily In divided doses 4-16 mg PO, Daily In divided doses mg, PO 3 times daily mg PO, Daily Increase by mg every 1 to 3 days Carbamazepine 800 mg PO, Daily Increase every 3 days Lamotrigine 25 mg PO, Daily Increase by mg per day per week Topiramate mg PO, Daily Increase by 25-50mg per day per week Oxcarbazepin 300 mg PO, 2 times daily Increase by 300 mg every week Levetiracetam 500 mg PO, 2 times daily Amitriptyline Imipramine Increase to therapeutic Doxepin mg PO, dose of mg daily in Clomipramine Daily at bedtime divided doses Desipramine Nortriptyline Pamidronate 90 mg IV (over 2 hrs.), Octreotide Scopolamine Baclofen Lidocaine Capsaicin cream Monthly mg IV or SC, daily mg SC, daily 5 mg PO, 2 times daily 1-3 mg/kg IV, as loading dose (over 20 to 30 min), followed by infusion of mg/kg/hr % cream 4 times daily *Doses given are guidelines; actual doses should be determined on an individual basis Increase by 5 mg every 3 days to reach target dose of mg/24 hr.

23 ASSESSMENT AND MANAGEMENT OF PAIN IN THE END OF LIFE MANAGEMENT OF PAIN IN ADULTS ACCORDING TO THE WORLD HEALTH ORGANIZATION (WHO) LADDER Drug Typical Starting Dose and Route a WHO Step 1: Mild pain (score of 1-3 on a 10-point scale) Onset of Action Duration of Action (hr.) Aspirin 650mg PO 30 minutes 3-4 Acetaminophen 650mg PO 15 to 30 minutes 3-4 NSAIDs: Ibuprofen Naproxen Indomethacin Piroxicam mg PO mg PO 25-75mg PO 10-20mg PO Step 2: Moderate pain (score of 4-6 on a 10 point scale) Acetaminophen combinations: Plus Codeine Plus oxycodone Plus hydrocodone Codeine 60 mg PO 5-10 mg PO 10 mg PO mg PO 30 mg IV/SC 30 minutes 60 minutes 30 min to several hours Several hours 30 min Unknown 30 to 60 min to 45 min 4-6 Hydrocodone mg PO 30 to 60 min 4-8 Morphine b (immediate release) 5-15 mg PO 2-10 mg/hr. IV 4-15 mg SC 30 min 10 to 30 min 10 to 15 min Step 3: Severe pain ( score of >7 on a 10 point scale) Morphine (sustained release) mg PO 60 min 8-12 Oxycodone (immediate release) 5-10 mg PO 10 to 15 min 3-6 Oxycodone (sustained release) mg PO 30 min 12 Hydromorphone 2-4 mg PO to 30 min mg IV 2-4 Methodone 5-10 mg PO mg IV 30 to 60 min 4-8 Levorphanol 2-4 mg PO 10 to 60 min 6-8 Fentanyl mcg IV Transdermal patch (25 mcg/hr.) 5 to 10 min 12 to 24 hours Varies a Doses given are guidelines for opioid-naïve patients; actual doses should be determined on an individual basis. b Also used in Step 3 NSAIDs = non-steroidal anti-inflammatory drugs

24 MENTAL HEALTH AND ADDICTION SERVICES: BRIEF/SOCIAL DETOX UNIT Clinical Features of Opioid Withdrawal OPIOID WITHDRAWAL PROTOCOL - Detected & monitored using the Opioid Withdrawal Scale (OWS) Physical signs/symptoms Lacrimation, rhinorrhea, yawning, Dilated pupils, nausea/vomiting Diaphoresis, chills, piloerection, mild tachycardia and/or hypertension Myalgias, abdominal cramps, diarrhea Psychological Symptoms Onset & Duration of Symptoms Beginning <8hours from last opioid use (Peak within hours) Beginning 12 hours from last opioid use (Peak at 72 hours) Beginning hours from last opioid use (Peak at 72 hours) Anxiety and dysphoria Craving for opioids Restlessness, insomnia, fatigue Anxiety, fear of withdrawal, craving for drug, diaphoresis, chills, lacrimation, rhinorrhea, yawning Piloerection, anorexia, dilated pupils, anxiety, irritability dysphoria, restlessness, mild-moderate insomnia, tremor, mild tachycardia and/or hypertension, abdominal cramps Abdominal cramps, diarrhea, myalgias, muscle spasms, (especially in lower extremities), nausea, vomiting, diarrhea, severe insomnia, violet yawning NOTE: Methodone withdrawal may take longer to manifest clinically ( hours from last dose) than withdrawal from other opioids, but may persist 2-3 weeks or longer Physical withdrawal symptoms generally resolve by 5-10 days Psychological withdrawal symptoms (dysphoria, insomnia) may last weeks to months Complications of Opioid Withdrawal Opioid withdrawal is not life threatening in otherwise healthy individuals. However, the risk of serious medical complications is higher in pregnant women and neonates. Pregnancy associated risks: spontaneous abortion, pre-term labor Neonatal abstinence syndrome: seizures, death if not identified and treated There is a serious risk of flight, suicide (precipitated by anxiety, dysphoria), and overdose on relapse (because patients begin to lose their tolerance to opioids within 3 7 days after last use). IMPORTANT: Continually assess all patients for suicide risk Screen for pregnancy Warn patients about overdose if they resume opioid use at previous dose

25 MENTAL HEALTH AND ADDICTION SERVICES: BRIEF/SOCIAL DETOX UNIT Step 1: Symptomatic Protocol + Clonidine Symptomatic Protocol Target symptoms Drug Dosing guideline Nausea and vomiting Diarrhea Myalgias Anxiety, dysphoria, lacrimation, rhinorrhea Insomnia Clonidine Dose Clonidine 0.1 mg oral test dose Dimenhydrinate (Gravol) Prochlorperazine (Stemetil) Loperamide (Imodium) Acetaminophen (Tylenol) Naproxen (Naprosyn) Hydroxyzine (Atarax) Trazodone (Trazorel) If <91kg (or <200lbs) Clonidine 0.1 mg orally 4 times daily x 4 days Clonidine 0.05 mg orally 4 times daily x 2 days Clonidine mg orally 4 times daily x 2 days, then stop If >91kg (or >200lbs) Clonidine 0.2 mg orally 4 times daily x 4 days Clonidine 0.1 mg orally 4 times daily x 2 days Clonidine 0.05 mg orally 4 times daily x 1 day Clonidine mg orally 4 times daily x 1 day, then stop mg orally (orim) up to every 4 hours as needed 5-10 mg orally up to every 4 hours as needed 4 mg orally for diarrhea, then 2 mg orally as needed for loose bowel movements (Maximum dose 16 mg/24 hours) 325 mg 650 mg orally every 4 hours as needed (Maximum dose = 4000 mg/ 24 hours) 500 mg orally twice daily with meals for 4 days, then reduce to twice daily as needed mg orally three times daily as needed mg orally at bedtime x 4 days, then as needed for insomnia Monitoring Check blood pressure (BP) one hour later. If BP>90/60, if marked postural hypotension occurs or if HR(Heart Rate) <60 do not prescribe further Check BP prior to each dose and withhold dose if BP <90/60, if marked postural hypotension or dizziness occurs or if HR (Heart Rate) <60 Assess Opioid Withdrawal Score (OWS) at least every 24 hours: If after 24 hours the OWS is (suggesting moderate withdrawal symptoms) proceed to step 2 If after 24 hours, the OWS is >15 (suggesting severe withdrawal symptoms) proceed to step 3

26 MENTAL HEALTH AND ADDICTION SERVICES: BRIEF/SOCIAL DETOX UNIT Step 2: Symptomatic Protocol + IntensifiedClonidine Intensified Clonidine Dose Monitoring If <91kg (or <200lbs): Clonidine 0.2 mg orally 4 times daily x 4 days Clonidine 0.1 mg orally 4 times daily x 2 days Clonidine 0.05 mg orally 4 times daily x 1 day Clonidine mg orally 4 times daily x 1 day, then stop If >91kg (or >200lbs): Clonidine 0.3 mg orally 4 times daily x 4 days Clonidine 0.2 mg orally 4 times daily x 1 day Clonidine 0.1 mg orally 4 times daily x 1 day Clonidine 0.05 mg orally 4 times daily x 1 day Clonidine mg orally 4 times daily x 1 day, then stop Check BP prior to each dose and withhold dose if BP >90/60, if marked postural hypotension or dizziness occurs or if HR >60 Assess Opioid Withdrawal Score (OWS) at least every 24 hours: If after 24 hours at step 2, the OWS is >15 (suggesting severe withdrawal symptoms) proceed to step 3 Step 3: Symptomatic Protocol + Intensified Clonidine + Phenobarbitol Intensified Clonidine + Phenobarbitol Clonidine dose Monitoring If <91kg (or <200lbs) Clonidine 0.2 mg orally 4 times daily x 4 days Clonidine 0.1 mg orally 4 times daily x 2 days Clonidine 0.05 mg orally 4 times daily x 1 day Clonidine mg orally 4 times daily x 1 day then stop If >91kg (or >200lbs) Clonidine 0.3 mg orally 4 times daily x 4 days Clonidine 0.2 mg orally 4 times daily x 1 day Clonidine 0.1 mg orally 4 times daily x 1 day Clonidine 0.05 mg orally 4 times daily x 1 day Clonidine mg orally 4 times daily x 1 day, then stop Phenobarbital dose: Phenobarbital mg orally twice daily as needed for anxiety and sedation Check BP prior to each dose and withhold dose if BP <90/60, if marked postural hypotension occurs or if HR <60 Assess Opioid Withdrawal Score (OWS) at least every 24 hours Monitoring Hold dose in presence of marked sedation, hypotension (BP <90/60), dizziness, ataxia, listlessness Stop if rash develops Step 4: Refer to a methadone prescribing physician Methodone 10mg orally 3 times daily for 3-4 days, then taper by 10mg/day (5mg/day on final day).

27 SHORT OPIOID WITHDRAWAL SCALE Symptom Not Present Mild Moderate Severe Feeling sick Stomach cramps Muscle spasms or twitching Feeling cold Heart pounding Muscular tension Aches and pains Yawning Runny/watery eyes Difficulty sleeping Add scores for total score: Compare total score to table below to guide withdrawal management Score Suggested withdrawal treatment 0 10 Mild Withdrawal; symptomatic medication only Moderate withdrawal; symptomatic or opioid medication Severe withdrawal; opioid medication Management of mild opioid withdrawal Patients should drink at least 2-3 litres of water per day during withdrawal to replace fluids lost through perspiration and diarrhea. Also provide vitamin B and vitamin C supplements. Symptomatic treatment and supportive care are usually sufficient for management of mild opioid withdrawal. Management of moderate to severe opioid withdrawal Same as for management of mild withdrawal, but with the addition of clonidine or opioid medications such as buprenorphine, methadone or codeine phosphate. Opioid withdrawal management using clonidine Clonidine is an alpha-2 adrenergic agonist. It can provide relief to many of the physical symptoms of opioid withdrawal including sweating, diarrhea, vomiting, abdominal cramps, chills, anxiety, insomnia, and tremor. It can also cause drowsiness, dizziness and low blood pressure. Clonidine should be used in conjunction with symptomatic treatment as required. It should not be given at the same time as opioid substitution.