CLINICAL GUIDELINE FOR THE MANAGEMENT OF OPIATE DEPENDENT PATIENTS AT RCHT 1. Aim/Purpose of this Guideline

Transcription

1 CLINICAL GUIDELINE FOR THE MANAGEMENT OF OPIATE DEPENDENT PATIENTS AT RCHT 1. Aim/Purpose of this Guideline 1.1. These guidelines are aimed at Medical Staff at RCHT treating patients admitted that are dependent on heroin or receiving a community prescription for opiate dependence. 2. The Guidance 2.1. See over. Page 1 of 10

2 PATIENT REPORTS USE OF OPIATES AMOUNT OF OPIATES USED ROUTE OF ADMINISTRATION SHARES NEEDLES OR EQUIPMENT (RISK OF BLOOD BOURNE VIRUS INFECTION) IS THE PATIENT RECEIVING AN OPIATE MAINTENANCE PRESCRIPTION FROM ADDACTION? THESE GUIDELINES DO NOT COVER PREGNANCY OR PATIENTS UNDER 18 YEARS OLD YES NO CONTACT THE SUBSTANCE MISUSE LIAISON NURSE (BLEEP VIA EXT 1300) TO REQUEST DETAILS OF THE PRESCRIPTION (IF OUT OF HOURS CONTACT TO CONFIRM PRESCRIPTIONS) THESE PATIENTS CAN BE MAINTAINED ON THEIR NORMAL PRESCRIPTION WHILST INPATIENTS, AND FOLLOWED UP BY THIS TEAM ON DISCHARGE NB: REMEMBER METHADONE OVERDOSE IS POTENTIALLY FATAL, WHEREAS OPIATE WITHDRAWAL IS NOT. CUMULATIVE DOSES OF METHADONE MAY RESULT IN OVERDOSE. PATIENTS MAY PUSH FOR HIGHER DOSES, BUT THEIR PHYSICAL WITHDRAWL STATE SHOULD GUIDE PRESCRIBING (SEE COWS) NOT PATIENT PROTESTATIONS. PATIENTS WHO ARE OPIATE NIAVE CAN DIE AFTER EVEN SMALL (20-30mg) METHADONE DOSES. IF POSSIBLE A URINE TEST SHOULD BE COMPLETED TO CONFIRM PRESENCE OF OPIATES (IF THE PATIENT IS ACUTELY WITHDRAWING THIS CAN BE CONFIRMED WITHIN 2 HOURS IF REQUESTED AS URGENT) THE DUTY BIOCHEMIST CAN ADVISE ON URINE TESTING ON EXTENSION 2540 AND PAGER 2140 OUT OF IF URINE TEST IS POSITIVE FOR OPIATES, ASSESS HOURS THE PATIENT WITH CLINICAL OPIATE WITHDRAWL SCALE (COWS) IF THE PATIENT SCORES >20 PRN METHADONE TREATMENT SHOULD BE OFFERED TO MAINTAIN THE PATIENT WHILST THEY ARE INPATIENTS. METHADONE TREATMENT SHOULD BE GIVEN USING THE GUIDELINES ATTACHED! Page 2 of 10

3 2.2. METHADONE TREATMENT GUIDELINES 2.3. Methadone treatment should be given using the following guidelines: The patient should be assessed with the COWS. If they score >20 they should be given a starting dose of 10-20mgs (1mg=1ml). After four hours the patient should be assessed with the COWS and given a further 5-10 mgs if they score >20. This procedure should be repeated every four hours. (Maimum dose in the first 24 hours should be no higher than 40 mgs, ecepting patients with a current Addaction prescription) On day two total the amount of Methadone received in the first 24 hours, this should be prescribed as a daily dose for the rest of the patient s stay at RCHT If on day two the patient is still scoring >20 on the COWS assessment 4 hours after receiving prescribed dose, please seek medical advice and advice from the Substance Misuse Liaison Nurse as to further Methadone prescribing T.T.O s of Methadone should not be offered unless arranged previously with both the Psychiatric Liaison Team and Addaction. Patient s option of continued methadone prescription following discharge will be discussed with patient and Addaction If the patient refuses Methadone treatment the contact the Substance Misuse Liaison Nurse on 1300 to advice on possible alternatives With the above treatment monitor: COWS score for the first 24 hours. BP and TPR. GCS in any patients with reduced GCS Patients requiring high levels of opiate analgesia should have this titrated to their pain levels rather than with the above guidelines. If patients are receiving Methadone prescriptions from Addaction any opiate analgesia should be given in addition to their normal prescriptions For pregnant patients please seek senior medical advice and liaise with Addaction Consultant at the earliest opportunity Contact Andy Brooking, Substance Misuse Liaison Nurse 8am-4pm Monday Friday & the Psychiatric Liaison nurse on-call at weekends for advice on management of opiate dependent patients and counselling/referral to drugs services. Please read accompanying guidelines for COWS scoring. Page 3 of 10

4 2.10. Clinical Opiate Withdrawal Scale (Draft awaiting corporate approval) 2.11.For each item, circle the number that best describes the patient s signs or symptom. Rate on just the apparent relationship to opiate withdrawal. For eample, if heart rate is increased because the patient was jogging just prior to assessment, the increase pulse rate would not add to the score. Patient s Name: / / : Date and Time Reason for this assessment: Resting Pulse Rate: beats/minute Measured after patient is sitting or lying for one minute 0 pulse rate 80 or below 1 pulse rate pulse rate pulse rate greater than 120 Sweating: over past ½ hour not accounted for by room temperature or patient activity. 0 no report of chills or flushing 1 subjective report of chills or flushing 2 flushed or observable moistness on face 3 beads of sweat on brow or face 4 sweat streaming off face Restlessness: Observation during assessment 0 able to sit still 1 reports difficulty sitting still, but is able to do so 3 frequent shifting or etraneous movements of legs/arms 5 Unable to sit still for more than a few seconds Pupil size 0 pupils pinned or normal size for room light 1 pupils possibly larger than normal for room light 2 pupils moderately dilated 5 pupils so dilated that only the rim of the iris is visible Bone or Joint aches: If patient was having pain previously, only the additional component attributed to opiates withdrawal is scored 0 not present 1 mild diffuse discomfort 2 patient reports severe diffuse aching of joints/ muscles 4 patient is rubbing joints or muscles and is unable to sit still because of discomfort Runny nose or tearing: Not accounted for by cold symptoms or allergies 0 not present 1 nasal stuffiness or unusually moist eyes 2 nose running or tearing 4 nose constantly running or tears streaming down cheeks GI Upset: over last ½ hour 0 no GI symptoms 1 stomach cramps 2 nausea or loose stool 3 vomiting or diarrhea 5 Multiple episodes of diarrhea or vomiting Tremor: observation of outstretched hands 0 no tremor 1 tremor can be felt, but not observed 2 slight tremor observable 4 gross tremor or muscle twitching Yawning: Observation during assessment 0 no yawning 1 yawning once or twice during assessment 2 yawning three or more times during assessment 4 yawning several times/minute Aniety or Irritability 0 none 1 patient reports increasing irritability or aniousness 2 patient obviously irritable or anious 4 patient so irritable or anious that participation in the assessment is difficult Gooseflesh skin 0 skin is smooth 3 piloerrection of skin can be felt or hairs standing up on arms 5 prominent piloerection Initials of person completing Assessment: Total Score The total score is the sum of all 11 items Score: 5-12 = mild; = moderate; = moderately severe; more than 36 = severe withdrawal Page 4 of 10

5 2.12. CLINICAL OPIATE WITHDRAWAL SCALE (COWS) SCORE AND METHADONE ADMINISTERED DURING THE FIRST 24 HOURS OF MANAGEMENT OF OPIATE DEPENDENT PATIENTS AT RCHT Name of Patient... (Draft awaiting corporate approval) Address. Date of birth. CR Number. Day/Date/Time Commenced:.. day../../....hrs Consultant The administration of Methadone and continuing monitoring for the first 24 hours should follow this table. COWS Score (see reverse) Frequency of COWS observation Before first dose After first and of Methadone is subsequent required doses of Administration of Methadone Methadone 0-19 Two hourly Four hourly Nil 20 or greater Four hourly Four hourly 10-20ml DATE AND TIME COWS SCORE METHADONE DOSE 24 hours after commencing above assessments, total Methadone dose should be added up. This should then be prescribed as the patient's daily maintenance dose whilst they are at RCHT. Page 5 of 10

6 3. Monitoring compliance and effectiveness Element to be monitored Lead Tool Frequency Reporting arrangements Acting on recommendations and Lead(s) Change in practice and lessons to be shared Monitor the use of the guidelines The Substance Misuse Liaison Nurse No specific tool will be used the Substance Misuse Nurse will compare prescribing of Methadone against referrals to the service Monitor yearly Monitoring will be reviewed by the Substance Misuse Liaison Nurse in liaison with Community Substance Misuse Services The Substance Misuse Liaison Nurse will be responsible for acting on recommendations Required changes to practice will be identified and actioned within 6 months The Substance Misuse Liaison Nurse will be identified to take each change forward where appropriate. Lessons will be shared with all the relevant stakeholders 4. Equality and Diversity 4.1. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement Equality Impact Assessment The Initial Equality Impact Assessment Screening Form is at Appendi 2. Page 6 of 10

7 Appendi 1. Governance Information Document Title Date Issued/Approved: 27 Nov 13 Guidelines for the Management of Opiate Dependent Patients at RCHT Date Valid From: 27 Nov 13 Date Valid To: 27 Nov 16 Directorate / Department responsible (author/owner): Andy Brooking (Substance Misuse Liaison Nurse) Contact details: Brief summary of contents Suggested Keywords: Target Audience Eecutive Director responsible for Policy: Page 7 of 10 Guidelines for the management of opiate dependent patients at RCHT with Methadone prescribing advice and opiate withdrawal symptom assessment scale. Heroin, Methadone, Opiate detoification, IVDU RCHT PCH CFT KCCG Medical Director Date revised: 27 Nov 13 This document replaces (eact title of previous version): Approval route (names of committees)/consultation: Divisional Manager confirming approval processes Name and Post Title of additional signatories Signature of Eecutive Director giving approval Publication Location (refer to Policy on Policies Approvals and Ratification): Document Library Folder/Sub Folder Guidelines for the Management of Opiate Dependent Patients at RCHT Senior Medical & Nursing staff in all admission areas Addaction Specialist Substance Misuse Consultant Not Required {Original Copy Signed} Internet & Intranet Clinical/Pain Intranet Only Links to key eternal standards Care Quality Commission Outcomes 4 & 9 Related Documents: ALCOHOL DETOXIFICATION AND

8 Training Need Identified? CHLORDIAZEPOXIDE (CDZ) ADMINISTRATION GUIDELINES No Version Control Table Date Versio n No Aug 06 V1.0 Original ratification May 10 V2.0 Nov 13 V3.0 Summary of Changes Full review, no changes made to original document. Full review, CDAT details changed to Addaction. Changes Made by (Name and Job Title) Andy Brooking (Substance Misuse Liaison Nurse) Andy Brooking (Substance Misuse Liaison Nurse) Andy Brooking (Substance Misuse Liaison Nurse) All or part of this document can be released under the Freedom of Information Act 2000 This document is to be retained for 10 years from the date of epiry. This document is only valid on the day of printing Controlled Document This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the epress permission of the author or their Line Manager. Page 8 of 10

9 Appendi 2. Initial Equality Impact Assessment Form Name of Name of the strategy / policy /proposal / service function to be assessed (hereafter referred to as policy) (Provide brief description): Guidelines for the Management of Opiate Dependent Patients at RCHT Directorate and service area: Psychiatric Is this a new or eisting Policy? Eisting Liaison Name of individual completing Telephone: assessment: Andy Brooking 1. Policy Aim* Who is the strategy / policy / proposal / service function aimed at? These guidelines are aimed at Medical Staff at RCHT treating patients admitted that are dependent on heroin or receiving a community prescription for opiate dependence. 2. Policy Objectives* The safe and appropriate treatment of opiate dependent patients at RCHT 3. Policy intended Outcomes* 4. *How will you measure the outcome? 5. Who is intended to benefit from the policy? 6a) Is consultation required with the workforce, equality groups, local interest groups etc. around this policy? The safe and appropriate treatment of opiate dependent patients at RCHT Regular auditing of the use of the guidelines All Medical Staff at RCHT and all patients admitted to RCHT with opiate dependence No b) If yes, have these *groups been consulted? C). Please list any groups who have been consulted about this procedure. 7. The Impact Please complete the following table. Are there concerns that the policy could have differential impact on: Equality Strands: Yes No Rationale for Assessment / Eisting Evidence Age Page 9 of 10

10 Se (male, female, transgender / gender reassignment) Race / Ethnic communities /groups Disability - learning disability, physical disability, sensory impairment and mental health problems Religion / other beliefs Marriage and civil partnership Pregnancy and maternity Seual Orientation, Biseual, Gay, heteroseual, Lesbian You will need to continue to a full Equality Impact Assessment if the following have been highlighted: You have ticked Yes in any column above and No consultation or evidence of there being consultation- this ecludes any policies which have been identified as not requiring consultation. or Major service redesign or development 8. Please indicate if a full equality analysis is recommended. Yes No 9. If you are not recommending a Full Impact assessment please eplain why. These guidelines are for use with All patients admitted to RCHT with opiate dependence Signature of policy developer / lead manager / director Date of completion and submission Names and signatures of members carrying out the Screening Assessment Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead, c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa, Truro, Cornwall, TR1 3HD A summary of the results will be published on the Trust s web site. Signed Date Page 10 of 10