Drug Misuse Management in the Acute Hospital Setting Guidelines

Drug Misuse Management in the Acute Hospital Setting Guidelines This procedural document supersedes: PAT/T 21 v.1 Guidelines for the Management of Patients with Drug Misuse in the Acute Hospital Setting. Did you print this document yourself? The Trust discourages the retention of hard copies of policies and can only guarantee that the policy on the Trust website is the most up-to-date version. If, for exceptional reasons, you need to print a policy off, it is only valid for 24 hours. Author/reviewer: (this version) Date written/revised: July 2013 Approved by: Date of approval: 9 October 2013 Date issued: 17 October 2013 Next review date: October 2016 Target audience: Shane Peagram Drug and Alcohol Liaison Nurse Specialist DRI Policy Approval and Compliance Group on behalf of the Patient Safety Review Group Trust wide Page 1 of 63

Amendment Form Please record brief details of the changes made alongside the next version number. If the procedural document has been reviewed without change, this information will still need to be recorded although the version number will remain the same. Version Date Issued Summary of changes Author 2 17 October 2013 General restructuring of contents to improve access and flow of subject material. Contents presented to reflect National Drug Policy focus on Recovery. (DOH 2010) Clinical governance framework incorporating NICE QS23 (2012) New content - General guidance on prescribing by substance of misuse. New content Equity and diversity issues for Assessment. New content inclusion of contact details for Trust child Protection Nurses and Doncaster and Bassetlaw social services departments. New content Methadone Pharmacology. New content Buprenorphine Pharmacology New content Patients own supplies, linked to PAT/MM1B v.4 New content Pain management. Major revision Discharge planning, to reflect need for TTA doses of OST at weekends and holidays. New content APPENDIX 3 ICD 10 Dependency diagnosis. (WHO 1992) Revised content Summary card amended to reflect updated discharge planning arrangements. S. Peagram Page 2 of 63

Contents Page Section No 1 INTRODUCTION 6 2 PURPOSE 6 3 DUTIES AND RESPONSIBILITIES 6 4 4.1 4.2 4.3 4.4 5 5.1 5.2 5.3 5.4 5.5 5.6 6 6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8 7 7.1 7.2 7.3 7.4 8 8.1 8.2 8.3 8.4 9 9.1 9.2 9.3 9.4 9.5 9.6 GENERAL GUIDANCE Overview Rationale for prescribing Prescribing considerations Exceptional circumstances PRESCRIBING BY SUBSTANCE - OVERVIEW Opiates Benzodiazepines Alcohol Stimulants Cannabis New psychoactive substances ASSESSMENT Overview Equity and diversity Aims of a full assessment Urine screening Opiate withdrawal syndrome Opiate intoxication Drug using parents Cardiac assessment EXISTING COMMUNITY METHADONE / BUPRENORHINE PATIENTS Pre prescribing checks Out of hours Missed doses Administration ILLICIT OPIATE (HEROIN) USING PATIENTS Overview Precautions Choosing and appropriate opioid substitute Risk factors METHADONE PHARMACOLOGY Peak plasma concentration Peak clinical effects Duration of action (half life) Metabolism Excretion Dosing 8 8 8 9 9 9 9 10 10 10 11 11 11 11 11 12 12 13 14 15 16 16 16 17 17 18 18 18 18 19 20 21 21 21 21 21 22 22 Page 3 of 63

9.7 9.8 10 10.1 10.2 10.3 10.4 10.5 10.6 10.7 10.8 10.9 11 11.1 11.2 11.3 11.4 11.5 11.6 11.7 11.8 12 12.1 12.2 12.3 12.4 12.5 12.6 12.7 12.8 12.9 13 13.1 13.2 13.3 13.4 13.5 13.6 13.7 13.8 13.9 13.10 13.11 13.12 14 14.1 14.2 14.3 14.4 Equivalence Tolerance METHADONE INDUCTION PROCESS NEW STARTER Indication Precautions Contraindications Investigations Principles of safe induction Dosing Administration Risk factors Other points to consider BUPRENORPHINE PHARMACOLOGY Peak plasma concentration Peak clinical effects Duration of action (Half life) Metabolism Excretion Dosing Equivalence Tolerance BUPRENORPHINE INDUCTION PROCESS NEW STARTER Indication Precautions Contraindications Investigations Principles of safe induction Dosing Dosing Administration Risk factors for overdose Buprenorphine + Naloxone (Suboxone) Precipitated withdrawal OPIOD DETOXIFICATION Overview Consent Unsuitable populations Opiods and alcohol Opioids and benzodiazepines Methadone or Buprenorphine Lofexidine Clonidine Dihydrocodeine Other symptomatic medications Lofexidine dosing Lofexidine regime RELAPSE PREVENTION PRESCRIBING (NALTREXONE) Benefits Risks Investigations Dosing 22 22 23 23 23 23 23 24 24 25 25 25 26 26 26 26 26 26 26 26 27 27 27 27 27 28 28 28 28 29 29 29 30 30 30 30 31 31 31 31 32 32 32 32 33 34 34 34 34 34 Page 4 of 63

14.5 Loss of tolerance 35 15 15.1 15.2 15.3 15.4 15.5 15.6 15.7 15.8 15.9 15.10 GENERAL MANAGEMENT Ward management Drug related deaths Reducing drug related deaths Dealing with emergency overdose Sleeplessness Patients own supplies Pregnancy Mental capacity Illicit opiate use on top of prescribed medication Drug misusers not admitted to hospital and not in treatment 35 35 35 36 37 37 37 38 38 38 39 16 16.1 16.2 16.3 16.4 16.5 17 17.1 17.2 17.3 17.4 PAIN MANAGEMENT Overview Methadone and pain Buprenorphine (subutex / Suboxone) and pain Naltrexone and pain Peri operative pain DISCHARGE PLANNING TTO - Existing community patient Caution TTO - New starter Caution 43 43 44 44 44 18 TRAINING / SUPPORT 45 19 MONITORING COMPLIANCE WITH THE PROCEDURAL 45 DOCUMENT 20 DEFINITIONS 45 21 EQUALITY IMPACT ASSESSMENT 46 22 ASSOCIATED TRUST PROCEDUAL DOCUMENTS 46 23 REFERENES 46 APPENDICIES: Appendix 1 Clinical Governance Framework Clinical Guidelines 2007 49 Appendix 2 NICE quality standard 23 50 Appendix 3 Cardiac assessment and monitoring for methadone prescribing 51 Appendix 4 ICD-10 Diagnostic Guidelines Dependency 53 Appendix 5 Methadone assessment prior to administration of methadone 54 Appendix 6 Methadone Safety Care Plan 56 Appendix 7 Safer Injecting Care Plan 58 Appendix 8 Methadone summary card 60 39 39 41 42 42 43 Page 5 of 63

1. INTRODUCTION These guidelines are intended for both medical and nursing staff to act as a resource in the management of patients with drug misuse issues when prescribing for maintenance or detoxification. The main source of evidence used within these guidelines is taken form the Drug Misuse and dependence UK Guidelines on Clinical Management, (2007) and should be read in conjunction with, Guidance on methadone and buprenorphine for the management of opioid dependence (NICE) ; Drug misuse: opioid detoxification (NICE) ; Naltrexone for the management of opioid dependence (NICE); Guidance for the use of substitute prescribing in the treatment of opioid dependence in primary care (RCGP 2011): Medications in Recovery Re-orientating Drug Dependence Treatment (NTA 2012). 2. PURPOSE The purpose of these guidelines is to offer a comprehensive structure that will provide treatments within the context of the National Drug Strategy 2010 s overarching aims to: Reduce illicit and other harmful drug use: and Increase the numbers recovering from their dependence Our ultimate goal is to enable individuals to become free from their dependence [DOH 2010] 3. DUTIES AND RESPONSIBILITIES 3.1 DOCTORS RESPONSIBILITIES It is acknowledged that drug misusers have the same entitlement as other patients to the services provided by the National Health Service and it is the responsibility of all Doctors to provide care for both general health needs and drug-related problems, whether or not the patient is ready to withdraw from drugs. [DOH, 1999] All doctors must provide medical care to a standard, which could be reasonably, expected of a clinician in their position. The focus for the clinician treating a drug misuser is on the patients themselves. However, the impact of their drug misuse on other individuals especially dependant children and on communities should be taken into consideration. [DOH, 2007] 3.2 PRESCRIBERS RESPONSIBILITIES It is the responsibility of the prescriber (Doctor, NMP) to identify the purpose of prescribing e.g. maintain the continuity of existing community prescribing [sec 7] or to initiate new prescribing [sec 8]. Page 6 of 63

In either case the prescriber must ensure that an adequate assessment has been carried out prior to prescribing. [sec 6] Where continuity of community prescribing is the goal; Confirmation of Drug, dose and time last taken should be established and documented. [sec 7.1] Missed doses and appropriate actions should be documented. [sec7.3] Discharge arrangements including Drug, dosage, take home quantities and date of next community prescribing agreed with the responsible community prescriber and documented. [sec17] Where initiation of treatment is the goal; Attention must be paid to the aim of treatment stabilisation abstinence detoxification [sec 8] The choice of treatment [sec 8.3] Discharge arrangements [sec 17] NOTE: While it is important to liaise with the relevant community Drug Team regarding ongoing treatments it is worth noting that their operational policies may be different from our own. In the event that a scenario should arise which is not covered within these guidelines the first point of contact should be the Drug and Alcohol Clinical Nurse Specialist Shane Peagram (DRI Blp 1491) Valerie Wood (BDGH Blp 2417) Methadone and buprenorphine should only be prescribed following liaison with the community drug team and there is a documented plan for continuation of treatment upon discharge. 3.3 NURSES RESPONSIBILITES It is the responsibility of nursing staff to ensure the safe administration of medicines as per PAT/MM 1. For existing community methadone / buprenorphine patients; Confirmation of Drug, dose and time last taken should be established and documented. [sec 7.1] Missed doses and appropriate actions should be documented. [sec7.3] Page 7 of 63

Discharge arrangements including Drug, dosage, take home quantities and date of next community prescribing agreed with the responsible community prescriber and documented. [sec 17] For new treatments; The presence of an opiate withdrawal syndrome should be assessed [sec 6.5] and documented. [Appendix 5] Where Methadone is prescribed, the Methadone Assessment Prior to Administration checks are completed [sec 6.6] and documented. [Appendix 5] Methadone and buprenorphine should only be prescribed following liaison with the community drug team and there is a documented plan for continuation of treatment upon discharge. 3.3 PATIENT RESPONSIBILITIES It is the patients responsibility to provide details of current treatment, prescriber and dispensing arrangements including any missed doses. Patients in possession of community dispensed medication must inform nursing staff. 4. GENERAL GUIDANCE 4.1 OVERVIEW Problematic drug users experience increased rates of morbidity and mortality due to their substance misuse, and although drug misuse exists in every sector of society, it is most prevalent in areas of social deprivation where individuals are more likely to experience poorer health outcomes, independent of substance misuse. (RCGP 2011) Generally, there is a greater prevalence of certain illnesses amongst the drug-misusing population, including viral hepatitis, bacterial endocarditis, HIV, tuberculosis, septicaemia, pneumonia, deep vein thrombosis, pulmonary emboli, abscesses and dental disease. (DOH 1999) 4.2 RATIONALE FOR PRESCRIBING For many people, prescribed treatment is an important part of their recovery journey. It is a component of a broader recovery-orientated system of health and social care and support that harnesses the full range of individual, social and community assets. Before deciding to prescribe, the clinician should be clear as to what the functions of prescribing are. A prescription can: Page 8 of 63

or Maintain current community prescribing. Reduce or prevent withdrawal symptoms from illicit drugs Offer an opportunity to stabilise drug intake and lifestyle whilst breaking with previous illicit drug use and associated unhealthy behaviours Promote a process of change in drug taking and high risk behaviour Help maintain contact and offer opportunity to work with the patient Achieve abstinence 4.3 PRESCRIBING CONSIDERATIONS Current community treatment plan The overall treatment plan for the individual client National and Locally agreed protocols The clinicians experience and competencies Discussion with member of a multi-agency team Advice, where necessary from a specialist in drug misuse Methadone and buprenorphine should only be prescribed following liaison with the community drug team and there is a documented plan for continuation of treatment upon discharge. 4.4 EXCEPTIONAL CIRCUMSTANCES Only in exceptional circumstances should the decision be made to offer substitute medication without specialist advice being sought i.e. a drug misuser presenting with opioid withdrawal in late pregnancy a patient with serious concomitant physical or psychiatric illness where withdrawal is complicating the clinical problems someone who is opioid-dependent and demonstrating withdrawal. Indeed, in such circumstances it is vital that the doctor fulfils their responsibilities by ensuring adequate assessment and appropriate management that facilitates the retention of the patient in treatment. (DOH, 1999). 5 PRESCRIBING BY SUBSTANCE - OVERVIEW 5.1 OPIATES Heroin users are the largest single group in treatment and use an especially tenacious, habit forming drug in the most dangerous ways. (NTA 2012) Page 9 of 63

There is robust evidence showing that Opiate Substitution Therapy can significantly improve outcomes for most opioid dependent people. Treatment can reduce symptoms of dependence, and being in treatment can help to reduce associated difficulties. OST allows people the time, space and platform to make meaningful choices. OST: Prevents people dropping out of treatment. Suppresses illicit use of heroin. Reduces crime. Reduces the risk of BBV transmission Reduces risk of death. Exiting treatment prematurely can harm individuals, especially if it leads to relapse, which is also harmful to society. Coming off OST can lead to greater risk of relapse, BBVs and overdose; and that treatment orientated to rapid abstinence produces worse outcomes than treatment initially orientated to maintenance. (National Drug Strategy 2010) Prescribing options Methadone [sec 9] Buprenorphine [sec 11] Detoxification [sec 13] 5.2 BENZODIAZEPINES Benzodiazepines prescribed for benzodiazepine dependence should be at the lowest possible dose to control dependence and doses should be reduced as soon as possible. It is common to consolidate Benzodiazepine use to a single preparation i.e. Diazepam and divide doses evenly. Prescribing options Diazepam [BNF] Benzodiazepines should only be prescribed following liaison with the community drug team and there is a documented plan for continuation of treatment upon discharge. 5.3 ALCOHOL Acute alcohol withdrawal syndrome is a medical emergency and requires timely and appropriate intervention to prevent potentially life threatening complex symptoms. Prescribing options Chlordiazepoxide, Lorazepam, Diazepam, Midazolam For guidance on alcohol withdrawal management refer to PAT/T 25 5.4 STIMULANTS There are no licenced pharmacological treatments to eliminate the symptoms of withdrawal from stimulants (including cocaine). Page 10 of 63

Prescribing options There is limited evidence supporting the use of Dexamphetamine in the treatment of habitual amphetamine use. Treatment should only be considered by experienced practitioners within specialist drug treatment settings. Short term symptomatic relief of agitation with Anxiolytics may be considered i.e. Diazepam. [BNF] For psychosis short term management with Antipsychotics i.e. Haloperidol. 5.5 CANNABIS There are no licenced pharmacological treatments to eliminate the symptoms of withdrawal from cannabis. Short term symptomatic relief of agitation or insomnia with Anxiolytics may be considered i.e. Diazepam. [BNF] 5.6 NEW PSYCHOACTIVE SUBSTANCES New psychoactive substances (NPS) so called designer drugs or legal highs such as Mephadrone present a unique challenge as users might not know exactly which compound has been taken as many are sold under a variety of brand names. Prescribing options no substitute medications, consider symptomatic relief. In all cases of acute intoxication or poisoning TOXBASE should be consulted 6 ASSESSMENT 6.1 OVERVIEW Good assessment is essential to the continuing care of the patient. (DOH 2007), Furthermore, Assessment for recovery aims to deliver an informed understanding of the person s wishes, substance use, and the severity and complexity of clinical and other problems: and it needs to identify their strengths and key obstacles to their recovery. (NTA 2012) 6.2 EQUITY AND DIVERSITY All assessments should be accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English. People who need a comprehensive assessment should have access to an interpreter or advocate if needed. Page 11 of 63

6.3 AIMS OF A FULL ASSESSMENT A comprehensive assessment should consider both drug use and resources for recovery and include: treating the emergency or acute problem confirming the person is taking drugs (history, examination and drug testing) (Table 1) assessing the degree of dependence (Table 2, 3 and 4 ) assessing physical and mental health identifying social assets, including housing, employment, education and support networks assessing risk behaviour including domestic violence and offending determining the person's expectations of treatment and desire to change determining the need for substitute medication obtaining information on any dependent children of parents who misuse drugs, and any drug-related risks to which they may be exposed. (Table 5 ) The clinician must ensure that an adequate assessment has been made before prescribing substitute opioids or controlled drugs. 6.4 URINE SCREENING Urine analysis should be regarded as an adjunct to the history and examination in confirming drug use, and should be obtained at the outset of prescribing and randomly throughout treatment (request Full Drug Screen). Results should always be interpreted in the light of clinical findings, as false negatives and positives can occur. If results do not correspond to the patient s history, repeat the urine toxicology test before taking any action, as laboratory errors can occur. If the urine test is negative for opioids, and there is no evidence of opioid withdrawal symptoms; the drug misuser is very unlikely to be physically dependent on opioids and needs to be reassessed in the light of this. Table 1 Drug detection times Drug Or Its Metabolite(s) Amphetamine/amfetamines, including methylamphetamine and MDMA Benzodiazepines Ultra-short-acting[half-life 2h] [e.g. midazolam] Short-acting [half-life 2-6h] [e.g. triazolam] Intermediate-acting [half-life 6-24h] [e.g. temazepam, Duration of Delectability 2 days 12 hours 24 hours 2-5 days Page 12 of 63

chlordiazepoxide] Long-acting [half-life 24h] [e.g. diazepam, nitrazepam] 7 or more Buprenorphine and metabolites 8 days Cocaine metabolite 2 3 days Methadone [maintenance dosing] 7 9 days Codeine, dihydrocodeine, morphine, propoxyphene 48 hours [heroin is detected in urine as the metabolite morphine] Cannabinoids Single use 3 4 days Moderate use [three times a week] 5 6 days Heavy use [daily] 20 days Chronic heavy use [more than three times a day] up to 45 days PAT/T 21 v.2 Detection times are only approximate and highly dependant upon dose, frequency, route of administration and urine excretion and concentration. 6.5 OPIATE WITHDRAWAL SYNDROME The onset of physical withdrawal symptoms is a key characteristic of opiate dependency and there presence is required to establish a diagnosis. Table 2 Opiate Withdrawal Syndrome Signs and Symptoms Heroin Methadone Drug craving, anxiety, drug seeking 6 hours - Yawning, sweating, running nose, lacrimation 8 hours 34-48 hours Increase in above signs and: Dilated pupils, goose-flesh, tremors, hot/cold flushes, aching bones/muscles, loss of appetite, abdominal cramps and irritability Increase in intensity of above and: Insomnia, increased blood pressure, low grade fever, increased respiration, increased pulse rate, restlessness, nausea and vomiting Increase in intensity of above and Weight loss, diarrhoea, weakness, febrile, foetal position (curled up on a surface), increased blood sugar 12 hours 18-24 hours 36-4days 48-72 hours 24-36 hours 36-4days Page 13 of 63

Table 3 Opiate Withdrawal Syndrome Objective signs of opiate withdrawal Yawning Coughing Sneezing Runny nose Lacrimation Raised blood pressure Increased pulse Dilated pupils Cool, clammy skin Diarrhoea Nausea Fine muscle tremor Subjective signs of withdrawal Restlessness Irritability Anxiety [The signs above may also be useful objective signs] Sleep disorders]depression Drug craving Abdominal; cramps Source: Ghodse (1998) The use of a clinical tool such as the Short opiate Withdrawal Scale is recommended to establish the presence of a physical withdrawal syndrome. The Short Opiate Withdrawal Scale is include as part of the Methadone Assessment Prior to Administration Tool [ Appendix 5 ]. 6.6 OPIATE INTOXICATION Mortality rates amongst Opiate users are 12 x higher than their none opiate using peers, and rise to 22 x higher for Intravenous drug users. The ability to identify and respond to acute opiate intoxication is key to maintaining patient safety. (DOH 2007) Table 4 - Opioid Intoxication SIGNS Euphoria/Relaxation Constricted pupils (pinned) Drowsiness Slurred speech Unsteady gait Smell (alcohol) SYMPTOMS Feelings of well-being Poor attention/concentration Slurred speech Methadone Pre Administration checklist and assessment The Methadone Pre Administration checklist needs completing by the person dispensing the initial dose (nurse, doctor or pharmacist) the same person should also assess patient, [sec 3.2,3.3] completing the pre administration checklist. [Appendix 5] The assessment should ensure that the patient is not showing evidence of intoxication due to opioids, alcohol or other drugs. (Table 4) Page 14 of 63

Patients who appear intoxicated with CNS depressant drugs should not be given their usual dose of methadone but be reassessed at a later time when they are no longer intoxicated. If intoxication mild the patient may be given a delayed or reduced dose but only after being reviewed by the prescriber. The Pre Administration Methadone Assessment Checklist needs completing prior to every dose [Appendix 5] 6.7 DRUG USING PARENTS A third of drug misusers in treatment have child care responsibilities. NTA (2009) Table 5 Child Protection Considerations The following should be taken into consideration: Effect of drug misuse on functioning, for example, intoxication, agitation Effect of drug seeking behaviour, for example, leaving children unsupervised, contact with unsuitable characters. Impact of parent s physical and mental health on parenting How drug use is funded, for example, sex working, diversion of family income. Emotional availability to children Effects on family routines, for example, getting children to school on time Other support networks, for example, family support. Ability to access professional support Storage of illicit drugs, prescribed medication and drug-using paraphernalia With consent, information should be gathered from other professionals If risk of significant harm to a young person is found, involve other professionals according to local child protection requirements. Referral to Social Services in Doncaster 01320 736636 Referral to Social Services in Bassetlaw 01777 716161 For more information or advice about Child Protection Policies and Procedures within BDGH contact Safeguarding Team, Named Nurse for Children on ext 4090. PAT/PS 10 - Safeguarding and Promoting the Welfare of Children. Page 15 of 63

6.8 CARDIAC ASSESSMENT Methadone and QT prolongation The Medicines and Health Care Product Regulatory Agency [MHRA] recommended in 2006 that patients with the following risk factors to QT interval prolongation are carefully monitored whilst taking Methadone: heart or liver disease, electrolyte abnormalities, concomitant treatment with CVP 3A4 inhibitors, or medicines to cause QT interval prolongation. In addition any patient requiring anymore than 100mg of methadone per day should be closely monitored. Further information is included in the product information. Clinicians must make a balanced judgement for each patient according to the MHRA guidance [and any later expansion or revision] Monitoring, will usually include checking other medications, general monitoring of cardiovascular disease, liver function tests and urea and electrolytes. As the risk factors for the QT interval prolongation increase, e.g. high methadone dose or multiple risk; clinicians will need to consider ECGs. The MHRA recommendation, suggests that an ECG might be considered before induction onto methadone, or before increases in methadone dose and subsequently after stabilisation at least with doses over 100 mg per day and in those with substantial risk. [APPENDIX 3] 7 EXISTING COMMUNITY METHADONE / BUPRENOPHINE PATIENTS Good communication between hospital and community team is essential to ensure safe management of the admission and discharge of existing community treatment. 7.1 PRE PRESCRIBING CHECKS Prior to prescribing Methadone or Buprenorphine the following safety checks need confirming and documenting. Drug type and strength (i.e. Methadone 1mg/1ml) Daily dose Pick up frequency (daily, 3 x weekly, 2 x weekly, weekly) Community Pharmacy Date last collected Missed doses [sec7.3] Prescribing agency / keyworker Amount and whereabouts of any community supplies brought to hospital by the patient. [sec15.6] Page 16 of 63

Information provided by the patient may not be reliable and needs corroborating with the community pharmacy and community drug team and documenting. Liaise with the community prescriber as early as possible so that the community prescriber can cancel the existing community prescription and be prepared to recommence the prescription on discharge of the patient. 7.2 OUT OF HOURS Where there is evidence of acute opioid withdrawal and it is not possible to corroborate the patients information i.e. outside of pharmacy hours, Bank holidays etc., Opioid Substitution Therapy medications can be prescribed with the following precautions. Assess the patient [Section 6] Evidence onset of withdrawal syndrome using Short Opiate Withdrawal Scale. [Appendix 5] Methadone 1mg/1ml (PRN) 5 10mg 4hrly Max 40mg in 24 hrs Methadone Assessment Prior to Administration checklist to be completed prior to every dose. [Appendix 5] TO BE INCLUDED ON RE PRINT AMMEDMENT Confirm community dose at earliest possible opportunity and review patient in light of findings. CAUTION Patients presenting out of hours in receipt of existing community opiate substitution therapy may have been dispensed advanced supplies for Weekends and Bank Holidays. This may be in their possession. Patients do not always disclose this information on admission. Every effort should be made to establish the whereabouts of patients own supplies and reassure the patient that continuity of treatment will be maintained throughout admission and upon discharge. [sec3.2 sec 3.3 sec15.6] 7.3 MISSED DOSES OST is reif patient has missed OST doses, for whatever reason, they will need to be reassessed for intoxication and withdrawal before OST administration is recommenced. [sec 6.5] [sec 6.6] Where patients miss OST doses they may use illicit opiates or other drugs including central nervous system depressants such as alcohol and benzodiazepines. When OST doses are missed for 3 days or more days, tolerance to opioids may be reduced placing patients at increased risk of overdose when introduced. Page 17 of 63

Table 6 Action to be taken in the event of Missed doses Number of days missed One day Two days Three days Four days Five days or more Action to be taken No change in dose If no evidence of intoxication administer normal dose. Administer half dose in discussion with prescriber. Patient must see prescriber. Recommencement at 40mg half dose which ever is the lower. Regard as a new medication. (Australian Gov, 2000) 7.4 ADMINISTRATION In order to maintain patient safety and reduce drug related deaths [sec 15.3] an assessment of intoxication [sec 6.6] is required prior to administration. The Drug and Alcohol Service Methadone Assessment Prior to Administration Checklist [Appendix 5] needs completing immediately before each administration. 8 ILLICIT OPIATE (HEROIN) USING PATIENTS 8.1 OVERVIEW Patients who are physically dependent on opioids may need OST to relieve the distressing symptoms of opiate withdrawal whilst in hospital. Failure to address the patients dependency may result in continued used of illicit opioids i.e. heroin within the ward environment or premature discharge from hospital. 8.2 PRECAUTIONS Do not give in to undue pressure to prescribe immediately. Take time to assess the patient. Remember a patient who is experiencing withdrawal symptoms may not be able to co-operate fully with medical or surgical treatment. A patient suffering from abstinence withdrawal will present with objective and subjective withdrawal. [See tables 2 and 3] For safety s sake rely more on objective signs of opioid withdrawal.[see tables 2 and 3] Page 18 of 63

Poly-drug and alcohol misusers may develop multiple withdrawal syndromes and hospital doctors will need to differentiate these to prioritise treatment. Methadone may initially mask alcohol and benzodiazepine withdrawal symptoms. Exercise particular care in cases of respiratory disease, head injury and liver diseases. It is important to be extremely careful when prescribing additional drugs such as sedatives. It may be necessary, in some cases, to contact the relevant pain control team for further advice on improving pain control. If a urine test is negative for opioids and there is no evidence of opiate withdrawal symptoms, the drug misuser is very unlikely to be physically dependent on opiates and should be reassessed in the light of this. It is not appropriate to offer OST to patients who do not meet the diagnostic criteria for opioid dependency. [Appendix 4] If there is doubt about the degree of dependence it is advisable and safer to withhold prescribing of substitute medication initially and observe the patient until the physical manifestations of opioid withdrawal are evident.[armstrong, 2003] 8.3 CHOOSING THE APPROPRIATE OPIOID SUBSTITUTE Opioid substitution Therapy should only be considered following liaison with the community drug services. Appropriate arrangements for exit prescribing will need to be in place to ensure a seamless transfer of care back into to community The clinical need for prescribing should always be paramount [sec 4.2] [sec 5.1] [Appendix 4] Methadone and buprenorphine are both approved for the treatment and prevention of withdrawals from opioids. Both are approved for maintenance and detoxification programmes (NICE 2007a) NICE recommends the if both drugs are equally suitable, methadone should be prescribed as the first choice. because: Its clinical effectiveness is supported by extensive research. It alleviates opioid withdrawal symptoms. It is taken orally, thus reducing the risk of injection. The dose can be carefully titrated to the optimal level. Blood levels can be kept stable, thus eliminating post dose euphoria and pre dose withdrawal. Page 19 of 63