Consulted With: Post/Committee/Group: Date: John Crome Drug and Alcohol Liaison Emergency Care

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1 THE MANAGEMENT OF OPIOID WITHDRAWAL IN ADULT PATIENTS Type: Clinical Guideline Register No: Status: Public on ratification Developed in response to: Contributes to CQC Outcome number: 12 Best practice Consulted With: Post/Committee/Group: Date: John Crome Drug and Alcohol Liaison Professionally Approved By: Dr Timothy Lightfoot Divisional Director, Medicine & Emergency Care Version Number 1.0 Issuing Directorate Medicine &Emergency Care Ratified by: Document Ratification Group Ratified on: 19 th April 2018 Executive Management Board Sign Off Date June 2018 Implementation Date 12 th June 2018 Next Review Date March 2021 Author/Contact for Information Maria Richards, Principal Clinical Pharmacist, Acute Medicine Policy to be followed by (target staff) All clinical staff Distribution Method Intranet Related Trust Policies (to be read in conjunction with) Administration of Medicines to Inpatients Document Review History: Version Number: Authored/Reviewed by: Issue Date: 1.0 Maria Richards 12 th June

2 Index 1. Purpose 2. Scope 3. Introduction 4. Prescribing opioid substitution 5. Symptomatic relief and adjunctive therapy for withdrawal symptoms 6. Discharge from hospital 7. Contact numbers/further information and advice 8. Equality and diversity 9. Audit and monitoring 10. Communication 11. References 2

3 1.0 Purpose 1.1 To guide clinical staff involved in treating drug dependent patients in hospital who require ongoing management of their dependency, particularly out of hours when specialist advice will not be available from the Drug and Alcohol Liaison Team. 1.2 To promote safe and appropriate prescribing of opioid substitutes. 2.0 Scope 2.1 This guideline is intended for use by prescribers and nurses involved in the care of methadone/buprenorphine dependent patients who are admitted as an emergency to MEHT 2.2 This guideline covers adult patients (aged 18 years and above, excluding pregnant patients) who are admitted to MEHT requiring management of their drug dependency. 2.3 Substitute medication such as methadone, buprenorphine and/or symptomatic relief of opiate withdrawal should not be given to patients attending the Emergency Department for minor injuries or illness who are not being admitted to a ward. 2.4 For pregnant women, refer to MEHT Policy Drug and Alcohol Misuse in Pregnancy. 3.0 Introduction 3.1 Opioid withdrawal in itself is not life threatening and any presenting complaint should be treated first. However note that, left untreated, withdrawal could lead to self-discharges against medical advice. 3.2 Opioid withdrawal symptoms can usually be managed with adjunctive therapy and symptomatic relief and therefore should not normally require urgent supply of opioid substitution out of hours. 3.3 For patients who are already established on methadone or buprenorphine, due to the nature of these drugs, there is no need for an out of hours supply and the on-call pharmacist will not attend the hospital for these requests. Patients may be managed symptomatically as laid out in section Prescribing Opioid Substitution 4.1 An opioid substitute should not be prescribed without first confirming the treatment regime with an outside source -it should not be prescribed based only on information obtained from the patient or out of date documentation. 4.2 Ward pharmacy staff and / or the Drug and Alcohol Liaison Team (see section 7 below) may be able to assist in confirming prescriptions during office hours. 3

4 4.3 The community pharmacy and / or the community prescriber should be contacted to ensure they are aware of the patient s admission and that the prescription should be withheld during this time. 4.4 Where doses are unconfirmed and / or the patient is using illicit substances (rather than methadone or buprenorphine sublingual tablets), contact the Drug and Alcohol Liaison Team for advice. 5.0 Symptomatic Relief and Adjunctive Therapy for Withdrawal Symptoms 5.1 Objective signs of opioid withdrawal could start hours for methadone but could be 4-24 hours after last dose of opioid in cases of illicit substances. 5.2 Signs can include: yawning, lacrimation, sneezing, runny nose, raised heart rate, raised blood pressure, dilated pupils, diarrhoea, nausea, fine muscle tremor and clammy skin. 5.3 Several medications may be used to help relieve withdrawal symptoms: Symptom Diarrhoea Stomach cramps Nausea and vomiting (may also be useful for stomach cramps) Muscular pains & headaches Anxiety/agitation Insomnia Treatment Loperamide 4mg stat then 2mg after each loose stool (16mg max/day) for up to 5 days Mebeverine 135mg TDS Metoclopramide 10mg TDS (oral/im) for up to a max of 5 days Or Prochlorperazine 5mg TDS (oral) or 12.5mg BD (IM) Paracetamol/NSAIDs as per BNF Diazepam 5-10mg TDS PRN (or zopiclone 7.5mg ON for patients who have been dependent on benzodiazepines) Zopiclone mg ON PRN 6.0 Discharge from Hospital 6.1 Opiate substitution will not be supplied on TTAs except when there are extenuating circumstances. 6.2 Extenuating circumstances may include where a patient is being discharged at a weekend having missed their usual weekend prescription collection and their pharmacy is not open until Monday. In these rare cases, the minimum supply possible must be made and only up to their next due supply date (usually a Monday). Where possible, the dose for the day of discharge should be administered on the ward to limit the take home supply to only those days when a prescription is not available. 6.3 The community pharmacy and / or the community prescriber must be informed of the patient s discharge and when the last dose has been given in hospital. This is to ensure both that the patient cannot receive more than one 4

5 dose on a given day and to establish that the community pharmacy has a valid and appropriate prescription available. 6.4 If the patient has missed more than 3 days of their usual prescription, their community pharmacy will put them on hold and this cannot be reactivated again without their prescribing treatment agency/gp consent. 7.0 Contact numbers/further information and advice 7.1 Alcohol Liason Nurse Specialist ext 4804 mob Monday-Friday 7am-3pm 7.2 Open Road Monday-Friday 930am-5pm (7pm on Tuesdays) Essex STaRS As for Open Road 8.0 Equality and Diversity 8.1 MEHT is committed to the provision of a service that is fair, accessible and meets the need of all individuals 9.0 Audit and monitoring 9.1 Pharmacy will monitor all prescriptions for methadone or other opioid replacement therapy, and any concerns will be reported to the physician responsible for the patient and/or referred to the Drug and Alcohol Liaison Team. Similarly, any concerns from the Drug and Alcohol Liaison Team will be reported to the physician responsible for the patient Communication 10.1 A copy of this policy will be placed on the Trust s intranet References 11.1 Clinical Guidelines on Drug Misuse and Dependence Update 2017 Independent Expert Working Group (2017) Drug misuse and dependence: UK guidelines on clinical management. London: Department of Health 11.2 Methadone and Buprenorphine: Quick Reference Guide for Prescribing and Supply for Inpatients. North Essex Partnership University NHS Foundation Trust Guidelines for the Management of Adult Opiate Dependent Patients in the Acute Hospital Setting. Worcestershire Mental Health Partnership NHS Trust. 5