Pharmacological Management of Substance Misuse. Prescribing Guideline

Transcription

1 Pharmacological Management of Substance Misuse in Community Prescribing Guideline Ref No: 1893 Version 4 Date: 25 October 2018 in Community Prescribing Guideline Page 1 of 15

2 Pharmacological Management of Substance Misuse in Community prescribing guidelines Partners in Care Document Ratification This is a controlled document and should not be altered in any way without the express permission of the author or their representative. Please note this document is only valid from the date approved below, and checks should be made that it is the most up to date version available. Document title: Purpose of document: in Community- Prescribing Guideline These prescribing guidelines outline the management of substance misuse experienced by adults in community, delivered by Torbay Drug and Alcohol Service. It is recognized that because of the potential and increased risk for drug misuse and diversion in these settings, it may sometimes be necessary and appropriate to prescribe an alternative medication(s) to those recommended in this document. Date of issue: 25 October 2018 Next review date: 25 October 2021 Version: 4 Last review date: April 2018 Author: Clinical Lead / Non Medical Prescriber Directorate: Operations Committee(s) approving the document: Care & Clinical Policies Sub-Group Clinical Director of Pharmacy Date approved: Links or overlaps with other 17 October 2018 in policies: Community policy 1893 Non-Medical Prescribing policy 0684 Substance misuse care coordination policy FP10/FP10MDA prescription SOP 1834 Medicines box SOP 1926 Does this document have training implications? If yes please state: Please select Yes No Does this document have financial implications? If yes please state: Is this document a direct replacement for another? If yes please state which documents are being replaced: Document Amendment History Date Version Amendment summary Completed by: 1 May Adaptation of existing DPT guideline Service Manager 1 September Periodic review Clinical Lead / Non Medical Prescriber 30 October Review date extended (6 months) Care and Clinical Policies Group in Community Prescribing Guideline Page 2 of 15

3 Pharmacological Management of Substance Misuse in Community prescribing guidelines 3 November Point 3.4 amended Pharmacy TSDFT 25 October Revised Care and Clinical Policies Group Clinical Director of Pharmacy in Community Prescribing Guideline Page 3 of 15

4 Pharmacological Management of Substance Misuse in Community prescribing guidelines Quality Impact Assessment (QIA) Please select Who may be affected by this document? Patient / Service Users Visitors / Relatives General Public Voluntary / Community Groups Trade Unions GPs NHS Organisations Police Councils Carers Staff Other Statutory Agencies Others (please state): Does this document require a service redesign, or substantial amendments to an existing? process? If you answer yes to this question, please complete a full Quality Impact Assessment. Are there concerns that the document could adversely impact on people and aspects of the Trust under one of the nine strands of diversity? Age Disability Gender re-assignment Marriage and Civil Partnership Pregnancy and maternity Race, including nationality and ethnicity Religion or Belief Sex Sexual orientation If you answer yes to any of these strands, please complete a full Quality Impact Assessment. If applicable, what action has been taken to mitigate any concerns? Who have you consulted within the creation of this document? Note - It may not be sufficient to just speak to other health & social care professionals. Patients / Service Users Visitors / Relatives General Public Voluntary / Community Groups Trade Unions GPs NHS Organisations Police Councils Carers Staff Other Statutory Agencies Details (please state): in Community Prescribing Guideline Page 3 of 15

5 Pharmacological Management of Substance Misuse in Community prescribing guidelines Contents 1 Introduction Statement/Objective Roles & Responsibilities Main body of the document Training Monitoring, Auditing, Reviewing & Evaluation References Distribution Appendices...16 and Mental Capacity Act Statement.. 20 Acknowledgement: Torbay and South Devon NHS Foundation Trust is thankful to Devon Partnership Trust for sharing this policy and allowing its adaptation for use within this organisation. 1 Introduction 1.1 Clinicians using this prescribing guideline must also refer to Trust Policy for the Clinical Management of Substance Misuse in Community 1.2 It is intended that this guideline will only be utilised by specialist prescribers working within the substance misuse field who have undertaken additional specific training (to at least RCGP level 2 certificate in substance misuse) or equivalent. 1.3 In non-emergency situations, other prescribers should always refer service users dependent upon illicit substances to the Torbay Drug and Alcohol Service (TDAS) within TSDFT for assessment and on-going clinical management. 2 Statement/Objective 2.1 The aim of these guidelines is to promote evidenced based, cost effective prescribing and support adherence to:- NICE CG 52 Drug Misuse: Opioid Detoxification (Mar 2010). NICE CG 120 Psychosis with co-existing Substance Misuses (Mar 2011). NICE TAG 114 Methadone and Buprenorphine (Jan 2007). NICE TAG 115 Naltrexone (Jan 2007). British Association for Psychopharmacology Updated Guidelines: evidencebased guidelines for the pharmacological management of substance misuse, harmful use, addiction and co-morbidity (2012). Department of Health Drug Misuse and dependence: UK guidelines & clinical management (July 2017) Medications in recovery: Re-orientating drug dependence treatment (NTA 2012) In Community Prescribing Community Page 4 of 15

6 3 Roles & Responsibilities 3.1 The Service Manager is responsible for the overall implementation of this guideline within specialist substance misuse services and for the monitoring of prescribing activity. 3.2 The Medicines Optimisation specialist pharmacist is responsible for providing the Service Manager with timely reports concerning the prescribing activity within the service, and highlighting any concerns with prescribing practices to the Service Manager. 3.3 All prescribers working within specialist substance misuse services are accountable for their prescribing actions in relation to this guideline and for working within its boundaries, and in exception, providing a clear and justifiable rationale for working outside of this guideline. 4 Management of opioid misuse 4.1 Prescribing options Methadone (Maintenance/detoxification) Oral mixture 1mg/ml OR Oral mixture 1mg/ml sugar free If tablets prescribed this is off-label use and they have the greatest potential for injecting / diversion. Buprenorphine (Maintenance/detoxification) Sublingual tablets 400micrograms, 2mg, 8mg If 200microgram strength (Temgesic ) prescribed this is off-label use. Inactivated if swallowed so therapeutic levels only achieved sublingually. Longer-term use may result in prolonged mild withdrawal symptoms on discontinuation. Alternate day dosing is off-label but may improve adherence (e.g. every 2 days give twice the daily dose, up to 32mg/dose). Lofexidine (Detoxification) Tablets 200micrograms Naltrexone (Maintaining abstinence) Tablets 50mg Once maintenance dose is achieved after repeated dosing, alternate day or three day a week (e.g. Mon 100mg, W ed 100mg, Fri 150mg) dosing is off-label but may improve adherence. Dose may be given BD with meals if for example nausea is a problematic sideeffect. In Community Prescribing Community Page 5 of 15

7 4.2 Management of Side-effects / Symptoms in Opiate Misuse Avoid unnecessary pharmacological treatment: only treat if severe / when required (PRN): Side-effect Potential Causes and Management Options Sedation Opiate dose too high: lower the dose. Concomitant drug/alcohol use: review other medications being taken. Withdrawal symptoms occur before next dose Opiate dose too low: increase the dose. Changes in concomitant drug use: review other medications being taken. Check adherence. W ithdrawal symptoms may include yawning, coughing, sneezing, runny nose/eyes, raised blood pressure/pulse, dilated pupils, cool/clammy skin, diarrhoea, nausea, fine muscle tremor, restlessness, irritability, anxiety, insomnia, depression, drug cravings and abdominal cramps. Headache Common in buprenorphine initiation, particularly if dose is too high: usually mild and transient. Other causes of headache e.g. dehydration should be excluded. Consider use of paracetamol (oral) 500mg-1g up to QDS PRN. Nausea/ Vomiting Common in opiate initiation and withdrawal, usually mild and transient. Avoid rapid dose changes and consider dose-reduction if persistent during initiation. Consider use of prochlorperazine (buccal) 3-6mg up to BD PRN. Constipation Very common in opiate use: encourage adequate dietary fibre, fluids and regular exercise. W eight gain Particular issue at high doses of opiates and for women. Due to fluid retention and increased eating. Lower dose, reduce fat and salt in diet, ensure regular exercise regime. Sleep difficulties Lowered sex drive Dental problems Dose too low and causing withdrawal at night. Dose too late at night causing stimulation at time of peak effects. Due to other drugs (particularly alcohol and stimulants in the evening, such as coffee, nicotine, amphetamines). Review maintenance dose and exclude other causes such as use of other medications. Advise on sleep hygiene and avoid hypnotic medication but as a last resort a time-limited course may be indicated More common with high doses of opiates so review and consider lowering dose. Exclude other psychological factors (e.g. anxiety, poor relationship with partner). All opioids reduce saliva flow, exacerbated by poor diet/dental hygiene. Encourage teeth hygiene, dental floss, use of sugar free gum, regular dental checks and reduce intake of sugary drinks and sweet food. Anxiety Management of substance misuse may unmask pre-existing anxiety which will need assessing in its own right. Depression Management of substance misuse may unmask pre-existing depression which will need assessing in its own right. Monitor for severe persistent symptoms and suicidal ideation. Abdominal Cramps Common during opiate withdrawal. Other causes of abdominal cramps should be excluded. Consider use of hyoscine butylbromide (Buscopan ) (oral) 10-20mg QDS PRN. Diarrhoea Common during opiate withdrawal. Other causes of diarrhoea e.g. gastrointestinal infection should be excluded. Consider use of loperamide (oral) 4mg STAT then 2mg PRN after each loose stool, maximum dose 16mg/day. Muscle/Joint Pain Common during opiate withdrawal. Other causes of pain e.g. physical trauma should be excluded. Consider use of paracetamol (oral) 500mg-1g up to QDS PRN. In Community Prescribing Guideline Page 6 of 15

8 4.3 Stabilisation / Maintenance of Opioid Misuse. The decision about whether to use Methadone or Buprenorphine must take into account the person s preferences, history of opioid/opiate misuse, their commitment to a particular long-term management strategy, and relative risks and benefits of each treatment. If both drugs are equally suitable, methadone should be prescribed as the first choice due to relative cost and evidence base. Estimates of the degree of dependence and tolerance are unreliable, and should never be the basis for starting doses due to the risk of overdose. Assessments should be based on the history of quantity, frequency, duration and route of administration. Titration against withdrawal and monitoring for intoxication is the safest way to achieve dose stabilisation. Concomitant medication, illicit drug and alcohol use must be taken into account. The Clinical Opiate W ithdrawal Scale (COWS) (see Appendix1) and / or clinical judgment of either drug withdrawal or sideeffects including intoxication will be used prior to each dose change. The dose should be titrated to a level at which the individual is comfortable and is no longer using illicit substitutes: exceptionally high doses are rarely needed unless clinically indicated to retain the person in treatment and careful monitoring is required due to increased risk of opiate intoxication. If the individual continues to use illicit opiates consider stabilisation in an in-patient setting. 4.4 Instigation and titration guidance Methadone - Initial dose of 10-30mg/day (10mg-20mg/day if tolerance low or uncertain: experienced clinicians may use a maximum first dose of 40mg/day for confirmed heavy dependence with significant tolerance). Deaths have occurred following doses as low as 20mg. Steady state reached after 3-10 days. If dose increase indicated during first 7 days, titrate dose upwards in increments of 5-10mg/day. The total weekly dose increase should not be >30mg above the initial dose. For optimisation of treatment after 7 days increase dose by 10mg every 4-7 days, usually up to a total daily dose of 60mg-120mg/day. Individuals prescribed methadone 100mg/day and/or with other risks of QT prolongation (e.g. concomitant medication, cardiac disease and electrolyte abnormalities) should have a baseline ECG performed and repeated 7 days after titration, with referral to a cardiologist if abnormalities are identified. If ECG is normal but the risk of QT prolongation remains high, consider repeating at 6-12 monthly intervals. Buprenorphine To reduce the risk of precipitated withdrawal, ensure adequate time lapse between initiation and previous dose of opiate, (e.g hours after the last heroin dose) and administer first dose when starting to experience opioid withdrawal symptoms. Precipitated withdrawal is a transient effect commencing 30-90minutes, usually peaking within 3hours and then subsiding (in contrast to under replacement symptoms which characteristically begin later). Less severe symptoms may continue for the first 2-3 days due to the slow binding of buprenorphine. Buprenorphine will provide a blockade effect against other opioids at doses of 12mg/day. Steady state reached after 3-7days so dose can be rapidly titrated over 3 days, e.g.: Day 1 4-8mg Day 2 Increase by 2-8mg if withdrawal present. Day 3 Day 4 onwards Increase by 2-4mg if withdrawal present and 16mg has not been reached. Usual range used to achieve abstinence is 12-16mg/day, with some needing up to 32mg/day. If doses 16mg/day required, 7 days should lapse before dose change and minimum increments of 2mg/day every week in Community Prescribing Guideline Page 7 of 15

9 4.5 Methadone and buprenorphine are metabolised by cytochrome P450 enzyme system (CYP3A4 & CYP2D6) so there is a risk of interactions with other medication. 4.6 Caution required with all opiates if there is hepatic impairment, history of alcoholic liver cirrhosis, or hepatitis: medication should be reviewed. In renal impairment dose changes are usually only required in end-stage renal disease. 4.7 Transfer from Methadone to Buprenorphine: 4.8 Do NOT transfer to buprenorphine until the methadone dose is 30mg/day. 4.9 Methadone should be discontinued for at least hours and wait for signs of withdrawal to occur prior to starting buprenorphine e.g.: Last methadone dose Buprenorphine dose 20-30mg 6-8mg 10-20mg 4-6mg < 10mg 2-6mg 4.10 Transfer from Buprenorphine to Methadone: 4.11 Induction of methadone up to a maximum of 40mg/day, 24 hours after the last buprenorphine dose OR start 48 hours later if the 48 hour buprenorphine dosing schedule was being used. Residual buprenorphine may take up to a week to wash out, during which time it may block the full effects of methadone so titrate methadone dose gradually over at least 7 days. Buprenorphine dose First methadone dose <8mg <20m 8-16mg 20-30mg 16mg 30-40mg 4.12 Emergency Management of Opiate Intoxication 4.13 Risk of overdose with opiates is increased during dose titration, in opiate naivety and with concomitant alcohol/poly-drug use (especially sedatives). A doctor must be contacted immediately if any degree of intoxication is observed. If severe symptoms of intoxication/severe drowsiness are observed: Call 999 immediately and request an ambulance in addition to calling a doctor (if available). Monitor and record respiratory rate every 10 minutes and initiate CPR if appropriate. If naloxone is administered it will induce opiate withdrawal symptoms so the individual may be uncooperative, agitated and aggressive. Their capacity to accept treatment will depend on their level of alertness. Staff must give appropriate information to the ambulance about drug dependence and other medication, especially opiates. The individual should be observed to avoid a recurrence of opiate intoxication, as naloxone is shorter-acting than opiates. The high affinity of buprenorphine for opiate receptors results in the need to use very high doses of naloxone to reverse it (perhaps times more than required for heroin), so resuscitation in intensive care may be needed. in Community Prescribing Guideline Page 8 of 15

10 Mild intoxication: Spaced out, glazed response, pinpoint pupils: observe closely and record respiratory rate and level of sedation every 10minutes. Moderate intoxication: Nodding with efforts to hold up head: observe closely and record respiratory rate and level of sedation every 10minutes. Severe intoxication: Respiratory depression (<12 breaths/min with no signs of distress, may be unable to talk), sedated, bradycardia (slow heart rate<60 beats/min), hypothermia, hypotension, cyanosis Tolerance to Treatment and Missed Doses 4.15 Tolerance varies between and within individuals, over time. Particular caution is required after periods of detoxification and release from prison. Missed doses can lead to loss of tolerance and prescribers should be kept informed of missed doses and must be informed after 3 consecutive missed doses for re-titration. The doses used for re-titration must take into account any potential loss of tolerance and ongoing illicit drug use when prescribed medication was not being taken Managed Withdrawal Programme 4.17 Managed withdrawal should normally last up to 2 weeks in an inpatient/residential setting or up to 12 weeks in the community. The detoxification regimen should be tailored to the individual taking into account potential risks and benefits, but will often start with the same medication that the individual is already prescribed. For example: Reduce methadone gradually (e.g. by 5mg every 1-2 weeks). Reduce methadone gradually to 30mg/day, then transfer to buprenorphine and steadily reduce. Reduce buprenorphine (e.g. initially by 2mg every 2 weeks with final reductions of 400micrograms) Lofexidine is a non-opiate for the management of opioid withdrawal symptoms. It may be considered for individuals with mild or uncertain dependence and in those with shorter drug and treatment histories who have decided not to use methadone or buprenorphine for managed withdrawal, or to withdraw within a short time period. Additional Lofexidine may be required up to a maximum of 2.4g/day to manage withdrawal symptoms; however it does not relieve stomach cramps and diarrhoea. Monitor for sedation, reduction in pulse and blood pressure: due to risk of hypotension. It should be omitted if the diastolic blood pressure is <55mmHg or if pulse rate <55bpm and further doses withheld until blood pressure and pulse rate return to baseline. Lofexidine should be discontinued gradually over at least 2-4 days, to avoid the risk of rebound hypertension associated with abrupt discontinuation Two hours after the first dose of lofexidine, opiate withdrawal symptoms may be significantly reduced, although in practice it may take 2-5 days to build the lofexidine dosage up to an effective level, when withdrawal symptoms are at their peak e.g: ) In Community Prescribing Guidelines Page 9 of 15

11 Example lofexidine 7 day detoxification (e.g. from heroin or lower dose methadone): Day number Breakfast Lunch Dinner Bed 1 200micrograms 200micrograms 200micrograms 200micrograms 2 400micrograms 400micrograms 400micrograms 400micrograms 3 600micrograms 400micrograms 400micrograms 600micrograms 4 600micrograms 400micrograms 400micrograms 600micrograms 5 400micrograms 400micrograms 400micrograms 400micrograms 6 200micrograms 200micrograms 200micrograms 200micrograms 7 200micrograms micrograms Example lofexidine 14 day detoxification (e.g. from high dose methadone or buprenorphine): Day number Breakfast Lunch Dinner Bed 1 200micrograms micrograms 2 200micrograms 200micrograms 200micrograms 200micrograms 3 400micrograms 200micrograms 200micrograms 400micrograms 4 400micrograms 400micrograms 400micrograms 400micrograms 5 400micrograms 400micrograms 400micrograms 400micrograms 6 400micrograms 400micrograms 400micrograms 400micrograms 7* 400micrograms 400micrograms 400micrograms 400micrograms 8* 400micrograms 400micrograms 400micrograms 400micrograms 9* 400micrograms 400micrograms 400micrograms 400micrograms micrograms 400micrograms 400micrograms 400micrograms micrograms 200micrograms 200micrograms 400micrograms micrograms micrograms micrograms micrograms (*may be omitted if withdrawal symptoms are not severe.) 4.20 Relapse Prevention and Supporting Abstinence 4.21 Naltrexone is a non-addictive, long acting competitive, opiate antagonist licensed for relapse prevention following detoxification. Naltrexone should only be administered under adequate supervision to people who are highly motivated to remain in an abstinence programmer. They must be fully informed that opioid containing medication must not be taken with naltrexone and that an attempt to overcome the blockade can result in acute opioid overdose. It should be reviewed every 3 months and discontinuation should be considered if there is evidence of ongoing opiate misuse. It should be continued for at least 6 months and at the persons request up to a maximum of 12 months Relapse prevention with naltrexone is increasingly effective the more quickly it can be introduced. Treatment with naltrexone should not be initiated until the individual has been opioid free for a sufficient period of time. The person should be monitored for 60minutes after the first naltrexone dose and if withdrawal symptoms develop they should be treated symptomatically. Monitoring should include COWS scoring (see Appendix 1), blood pressure and pulse. Drug Heroin / other short acting opiate Methadone Naltrexone initiation 7 days minimum washout period before initiating naltrexone. Day 1=25mg/day, Day 2+ = 50mg/day 2+=50mg/day. 14 days minimum washout period before initiating naltrexone. Day 1=25mg/day, Day 2+=50mg/day. In Community Prescribing Guidelines Page 10 of 15

12 Buprenorphine 400micrograms 1week Buprenorphine 2mg for < 2weeks Buprenorphine >2mg Buprenorphine >4mg 1 day minimum washout period before initiating Naltrexone Day 1=12.5mg/day, Day 2-8=25mg/day, Day 9+=50mg/day. 4-6 days minimum washout period before initiating naltrexone. Day 1=25mg/day, Day 2+=50mg/day. 5 days minimum washout period before initiating naltrexone. Day 1=25mg/day, Day 2+=50mg/day. It may be considered clinically appropriate to initiate naltrexone sooner due to a high risk of relapse and the person is prepared to tolerate mild withdrawal symptoms. Transition to naltrexone will precipitate withdrawal likely to be sufficient to require a lofexidine detoxification Management of Benzodiazepine Misuse 4.24 In early/mild dependence and if the benzodiazepine is being prescribed, minimal interventions such as advisory letters, provision of information, for both the individual and the prescriber should prompt review of their ongoing use. Illicit benzodiazepine use increases high risk behaviour and benzodiazepines should not be prescribed routinely in the treatment of substance misuse. Opiates including substitutes, alcohol and other sedative drugs combined with benzodiazepines will greatly increase the risk of respiratory depression and suppression of the gag reflex, a major factor in drug-related death Where dependence is established, benzodiazepines should be gradually discontinued. There is no evidence that long-term maintenance prescribing of benzodiazepines reduces the risk of harm and their use for the management of benzodiazepine withdrawal and dependency is an offlicense indication. Presence of physical dependence and the likely dependence syndrome must be determined prior to prescribing (usually dependent on daily therapeutic doses, without a break for > 3 months) CIWA-B (see Appendix 2) can be used to assess and monitor withdrawal symptoms. If withdrawal symptoms occur, do not reduce the dose further until symptoms improve. In situations where the individual experiences intolerable/severe withdrawal symptoms, it may be necessary to increase the dose to alleviate symptoms before further reduction can be considered. Diazepam 20mg/day diazepam the recommended maximum rate of dose reduction is 5mg/fortnight. <20mg/day diazepam the recommended maximum rate of dose reduction is 2mg/fortnight. >30mg/day diazepam, gradually reduce to a dose of 30mg/day over a 6 week period or at a rate of 10mg/month (whichever is shorter) and then review. In Community Prescribing Guidelines Page12 of 15

13 Oxazepam Tablets. 10mg, 15mg Consider as an alternative to diazepam for individuals with severe hepatic impairment 4.27 If a prescription for a benzodiazepine is to be issued, there must be a clear treatment plan, discussed and agreed between the prescriber and the individual, outlining the goals and time frame of the benzodiazepine withdrawal. Prescribing should be reviewed at least every three months, and more frequently during initial stages of treatment withdrawal. Where d a y t i m e drowsiness/ intoxication are problematic, individuals may take the total daily dose in divided doses. In established hepatic impairment the decision to treat in these situations should be made with input from hepatology. A lower dose of diazepam or use of oxazepam (not hepatically metabolised) may be required Following cessation of longer-term high dose benzodiazepine use (>50mg/day diazepam equivalence), abrupt withdrawal can cause seizures which can present weeks later. There is no need to match high self-reported illicit doses and equivalent doses 30mg/day of diazepam are rarely necessary. Doses of diazepam >30mg daily must only be prescribed after discussion with and agreement by the multidisciplinary team Depression may be a direct result of the withdrawal process or part of the underlying cause. Should depression or anxiety spectrum disorders re-emerge or be precipitated during withdrawal, assess severity of symptoms, (using recognized screening tools), and offer treatment according to level of need. Low level interventions can be delivered within substance misuse services; higher levels of need will require referral to Mental Health Services 4.30 Management of Substance Misuse in Pregnancy and Breastfeeding 4.31 Women of childbearing age should be offered a pregnancy test, and advised to avoid pregnancy/breast-feeding whilst misusing substances User-friendly Resources for Information about Managing Substance Misuse 4.33 These web-based links are recommended sources for user-friendly information about treatment for the management of substance misuse: Patient.co.uk website: Includes printable information for medication used for heroin substitute: last accessed 12/12/17 Exchange supplies: Provides link to the methadone handbook: a complete guide to methadone and methadone treatment: last accessed 12/12/17 In Community Prescribing Guidelines Page12 of 15

14 5 Training 5.1 All prescribers (GPwSpI s and NMP s) will receive appropriate training on local procedures and prescribing guidelines to ensure they are confident and competent to deliver clinical care to the standards described within this guideline. 5.2 The clinical evidence base and best practice guidance may change over time. It is therefore essential that all practitioners keep up to date with current practice. 5.3 Education and training requirements should be identified through Continuing Professional Development (CPD) and annual appraisals. Appropriate forms of learning to achieve these requirements (e.g. reflective practice, private study, formal courses) will be agreed between the individual and their line-manager and included in the Personal Development Plan. 5.4 Staff will be informed and, if necessary receive additional training when procedures are revised or amended and when new systems are introduced. 5.5 The Medical Director (Community TSDFT), Professional Leads and Managers will identify service specific training needs and, working together with the Training department, identify the options available to meet the education requirements of Trust staff within the resources and capacity available. Where additional resources are required, but not available, the risks associated with not providing training must be assessed and reported to the Risk Manager for inclusion on the Trust Risk Register. 5.6 All staff working in addiction services (clinical and non-clinical roles) should be aware of the symptoms of opiate intoxication and what to do in an emergency. Recommended links for further information: Leaflet: : (last accessed 11/12/17) (last accessed 11/12/17) 6 Monitoring, Auditing, Reviewing & Evaluation 6.1 The provision of community drug management will be subject to rigorous clinical governance arrangements. All aspects of the guidelines and practice will be scrutinised and agreed by the Trust governance group (Quality Safety and Performance meetings (QSP), MCDSG). 6.2 All near misses, serious and untoward incidents must be reported via the online incident reporting form found on the front page of the Trust intranet and the Trust Risk Incident Reporting Policy must be followed. 6.3 All Trust staff involved in the delivery of drug treatment will receive regular clinical and line management supervision in accordance with the Trust Supervision Policy. In Community Prescribing Guidelines Page13 of 15

15 6.4 Community drug management completed by Trust staff will be reviewed as part of clinical and managerial supervision arrangements to ensure that policies are being adhered to and specific service evaluations will be conducted where a need is identified. 6.5 TDAS Governance Group, (QSP meetings) will advise the Trust s Clinical Effectiveness Lead on audits, relating to the management of substance misuse, to be included in the Trust s Annual Clinical Audit programme. 6.6 Audits will be conducted to ensure Trust-wide adherence to this policy, and related policies, procedures and prescribing guidelines covering the management of substance misuse, to ensure that all personnel involved with any aspect of the service are aware of them and have received the necessary training. This will be managed within an agreed annual audit programme through the Trust Governance Group and the Trust Audit and Effectiveness Group. 6.7 There will be regular reviews of prescribing reports (quarterly) to ensure safe and evidence based prescribing. 7 References BAP (2012) Guidelines: Lingford-Hughes AR, Welch S, Nutt DJ Evidence based guidelines for the pharmacological management of substance misuse, harmful use, addiction and comorbidity: recommendations from the British Association for Psychopharmacology, Journal of Psychopharmacology 0(0) Department of Health Drug Misuse and dependence: UK guidelines & clinical management (July 2017) NICE (2010) Drug Misuse: Opioid Detoxification.NICE clinical guideline 52. London: National Institute for Health and Clinical Excellence. NICE (2007) Methadone and Buprenorphine for the Management of Opioid Dependence. NICE technology appraisal guidance 114. London: National Institute for Health and Clinical Excellence. NICE (2007) Naltrexone for the Management of Opioid Dependence. NICE technology appraisal guidance 115. London: National Institute for Health and Clinical Excellence. RCGP (2011) Guidance for the use of substitute prescribing in the treatment of opioid dependence in primary care. Royal College of General Practitioners. Strang, Medications in recovery re-orientating drug dependence treatment. National Treatment Agency for Substance Misuse. In Community Prescribing Guidelines Page 14 of 15

16 8 Distribution 8.1 A copy of this clinical guideline will be distributed to:- All prescribers within Torbay Drug and Alcohol Service The Medical Director/CD accountable Officer for TSDFT 9 Appendices 9.1 Appendix 1: Clinical Opiate Withdrawal Scale (COWS) and Monitoring Form 9.2 Appendix 2: CIWA-B: Benzodiazepine Withdrawal Schedule Rating Scale and Monitoring Form In Community Prescribing Guideline Page 15 of 15

17 Appendix 1 Clinical Opiate Withdrawal Scale (COWS) and Monitoring Form Symptom Score Resting Pulse Rate: Measured 0 pulse rate 80 2 pulse rate after the resting for 60secs 1 pulse rate pulse rate >120 Sweating: After 30mins not due 0 no report of chills/ flushing 2 flushed/observable facial moistness to room temperature/activity 1 subjective report of chills/flushing 4 sweat streaming off face Anxiety or Irritability: 0 none 2 person obviously irritable/ anxious 1 person reports increasing irritability or anxiousness 4 person so irritable/ anxious that assessment difficult Restlessness: Observation 0 able to sit still 3 frequent shifting or arm/leg during assessment 1 reports difficulty sitting still but able movements to do so 5 unable to sit still at all Pupil Size: Taking into account 0 pupils less then /normal sized 2 pupils moderately dilated room lighting 1 pupils larger than normal for room 5 pupils dilated so that only the rim of Runny nose and tearing: Not accounted for by allergies/cold symptoms Yawning: Observation during light (>3mm) 0 Not present 1 Nasal stuffiness or unusually moist eyes 0 no yawning assessment 1 yawning once/twice GI upset: Over the past 30mins 0 no GI symptoms 1 stomach cramps 2 nausea/loose stool Tremor: Observation of 0 no tremor outstretched hands 1 tremor can be felt but not observed Gooseflesh skin: 0 skin is smooth 3 piloerection of skin can be felt Myalgia or Arthralgia: Taking 0 Not present into account any pain 1 Mild diffuse discomfort experienced prior to opiate withdrawal. the Iris is visible 2 Nose running or frank tears 4 Nose constantly running or tears streaming 2 yawning three or more times 4 yawning several times/ minute 3 vomiting or diarrhoea 5 multiple episodes of vomiting or diarrhoea 2 slight visible tremor 4 gross tremor or muscle twitching 5 prominent piloerection 2 Reports severe diffuse aching of joints/ muscles 4 Person rubs joints/muscles and unable to sit still due to discomfort Add up the score from all 11 items to provide a maximum score of 48. Use of this scale is at the prescriber's direction to confirm severity of withdrawal: the trend should be downwards. Name: NHS Number: Date of Birth: Date Time Resting Pulse Rate (0-4) Sweating (0-4) Anxiety or Irritability (0-4) Restlessness (0-5) Pupil Size (0-5) Runny nose or tearing (0-4) Yawning (0-4) GI upset (0-5) Tremor (0-4) Gooseflesh skin (0-5) Myalgia or Arthralgia (0-4) Total Score Score: 5-12 = mild withdrawal = moderate withdrawal >24 = severe withdrawal Clinical Opiate Withdrawal Scale (COWS) and Monitoring Form Page1 of 1

18 Appendix 2 CIWA-B: Benzodiazepine Withdrawal Schedule Rating Scale and Monitoring Form For each of the following items please circle the numbers which best describe the severity: (0=least severe, 4=most severe) 1. Observe behaviour for restlessness and agitation. 0 (no symptoms, normal activity) 1 2 (restless, unable to sit still) 2. Do feel you have difficulties concentrating? 0 (no difficulty) 1 2 (some difficulties) 3 4 (frequent pacing) 3 4 (unable to concentrate) 3. Do you have any loss of appetite? 0 (no loss) 1 2 (no appetite) 3 4 (unable to eat) 4. Do you feel your heart racing (palpitations)? 0 (not at all) 1 2 (occasionally) 3 4 (constantly) 5. Does your head feel full or achy? 0 (not at all) (severe headache) 6. Do you feel anxious, nervous or jittery? 0 (not at all) (very much so) Add up the score from all 6 questions to provide a maximum score of 24. Name: Date of Birth: NHS Number: Time Date 08:00 10:00 12:00 14:00 16:00 18;00 20:00 22:00 Day 1 (Week 1) Day 2 (Week 1) Day 3 (Week 1) Day 7 (Week 1) Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 This scale is at the prescriber's discretion to confirm severity of withdrawal. It can be used as a once-only score. Otherwise the aim is to reduce score initially over the first 3 days and review clinical need for further scoring. Benzodiazepine Withdrawal Schedule Rating Scale and Monitoring Form Page1 of 1

19 The Mental Capacity Act 2005 The Mental Capacity Act provides a statutory framework for people who lack capacity to make decisions for themselves, or who have capacity and want to make preparations for a time when they lack capacity in the future. It sets out who can take decisions, in which situations, and how they should go about this. It covers a wide range of decision making from health and welfare decisions to finance and property decisions Enshrined in the Mental Capacity Act is the principle that people must be assumed to have capacity unless it is established that they do not. This is an important aspect of law that all health and social care practitioners must implement when proposing to undertake any act in connection with care and treatment that requires consent. In circumstances where there is an element of doubt about a person s ability to make a decision due to an impairment of or disturbance in the functioning of the mind or brain the practitioner must implement the Mental Capacity Act. The legal framework provided by the Mental Capacity Act 2005 is supported by a Code of Practice, which provides guidance and information about how the Act works in practice. The Code of Practice has statutory force which means that health and social care practitioners have a legal duty to have regard to it when working with or caring for adults who may lack capacity to make decisions for themselves. The Act is intended to assist and support people who may lack capacity and to discourage anyone who is involved in caring for someone who lacks capacity from being overly restrictive or controlling. It aims to balance an individual s right to make decisions for themselves with their right to be protected from harm if they lack the capacity to make decisions to protect themselves. (3) All Trust workers can access the Code of Practice, Mental Capacity Act 2005 Policy, Mental Capacity Act 2005 Practice Guidance, information booklets and all assessment, checklists and Independent Mental Capacity Advocate referral forms on icare Infection Control All staff will have access to Infection Control Policies and comply with the standards within them in the work place. All staff will attend Infection Control Training annually as part of their mandatory training programme. The Mental Capacity Act in Community Prescribing Guideline Page1 of 1

20 Clinical and Non-Clinical Policies Data Protection Torbay and South Devon NHS Foundation Trust (TSDFT) has a commitment to ensure that all policies and procedures developed act in accordance with all relevant data protection regulations and guidance. This policy has been designed with the EU General Data Protection Regulation (GDPR) and Data Protection Act 2018 (DPA 18) in mind, and therefore provides the reader with assurance of effective information governance practice. The UK data protection regime intends to strengthen and unify data protection for all persons; consequently, the rights of individuals have changed. It is assured that these rights have been considered throughout the development of this policy. Furthermore, data protection legislation requires that the Trust is open and transparent with its personal identifiable processing activities and this has a considerable effect on the way TSDFT holds, uses, and shares personal identifiable data. Does this policy impact on how personal data is used, stored, shared or processed in your department? Yes No If yes has been ticked above it is assured that you must complete a data mapping exercise and possibly a Data Protection Impact Assessment (DPIA). You can find more information on our GDPR page on ICON (intranet) For more information: Contact the Data Access and Disclosure Office on dataprotection.tsdft@nhs.net, See TSDFT s Data Protection & Access Policy, Visit our Data Protection site on the public internet. In Community Prescribing Guideline New Data Protection Regulation Page1 of 1