1.4 The CADAS teams do not provide a service for residents of Bournemouth or Poole.

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1 Pan Dorset Prescribing Protocol 1- Introduction 1.1 This policy provides guidance in relation to the Community Alcohol and Drug Service (CADAS). The service offers pharmacological interventions alongside psychosocial support for service users who are experiencing problems with alcohol or drug dependence. 1.2 The service is provided by two teams; CADAS East which covers the towns of Dorchester, Blandford, Gillingham, Shaftesbury, Wimborne, Ferndown, Christchurch, Wareham and Swanage and CADAS West which covers the towns of Weymouth, Portland, Bridport, Sherborne and Lyme Regis. The total populations and the treatment populations of these areas are approximately equal. 1.3 The teams are multidisciplinary including nurses, medical staff, social workers, support workers, administration staff and input from specialist addiction psychologists. The staff work in close partnership with other provider agencies, GP surgeries and all relevant statutory agencies with the aim of providing a seamless service from initial referral to discharge. 1.4 The CADAS teams do not provide a service for residents of Bournemouth or Poole. 1.5 In September 2007 the Department of Health (England), the Scottish Government, Welsh Assembly Government and Northern Ireland Executive published Drug Misuse and Dependence UK Guidelines on Clinical Management. Known commonly as the Orange guidelines They were developed concurrently with the National Institute for Health and Clinical Excellence (NICE) guidance on drug misuse treatment and are considered best practice. This policy refers closely to these guidelines and to the NICE standards. ( NB- the 2007 guidelines are currently being updated and are currently in draft consultation stage, this policy has been written based on these new guidelines and once ratified this reference will cite the 2016 version ) 1.6 In 2010 the government published a new drug strategy which acknowledged the usefulness of opiate substitution therapy (OST) in improving lives but also expressed an ambition to support a more recovery focused treatment model. The strategy suggests a number of outcomes that should inform best practice: Freedom from dependence on drugs or alcohol Prevention of drug related deaths and blood borne viruses A reduction in crime and re-offending Sustained employment The ability to access and sustain suitable accommodation Improvement in mental and physical health and wellbeing Improved relationships with family members, partners and friends

2 The capacity to be an effective and caring parent 1.7 Medications in recovery 2 nd Strang report. Published his government commissioned report on the use of medications in substance misuse treatment. This supported the ambition of strengthening the recovery capital of service users but also warned of the dangers of premature termination of treatment on the health and wellbeing of service users, their families and the wider community and acknowledged that there would always be a cohort of service users who would require longer term prescribing. 1.8 This policy is intended to support the ambition for recovery for everyone using the CADAS services whilst ensuring that the strong evidence base for harm reduction is retained as the foundation of a humane and compassionate service which affords respect and dignity to everyone using it. 2- Values and Principles of Treatment We believe that everyone has the ability to change while acknowledging that not everyone will take that opportunity during a particular episode of treatment. It is also our belief that it is not possible to predict those who will benefit from treatment or at what point they will benefit. Therefore we should treat everyone as if they will reach their full potential, even when they cannot believe it themselves. This principle of therapeutic optimism supported by the ethos of motivational interviewing will be at the heart of the CADAS Service. 2.2 We believe that service users should be at the centre of the assessment and care planning process including the choice of treatments and agreement of the expected outcomes The NHS constitution informs the values and principles of the service. CADAS makes a commitment to improving quality by developing staff, ensuring safety through rigorous governance and guaranteeing to provide an easily accessible service to all without discrimination. 2.4 The Care Act 2015 requires services to put the customer at the centre of the treatment journey and recognises that they are best placed to identify their own treatment needs 5 Pharmacological Interventions: (This section is a summary of the Clinical Guidelines which should be consulted for more detailed guidance 5.1 Opioid substitution Treatment (OST) Opioid substitution treatment has a well-established evidence base for the management of heroin dependence. It reduces drug related death, reduces the rate of transmission of Blood borne viruses and of other health problems associated with injecting and lifestyle. It also reduces the incidence of criminality and may be instrumental in beginning the process of recovery. Providing OST in the form of Methadone or

3 Buprenorphine prescribing is protective for the individual client and for the wider community. The goals of OST range between engagement in services to detoxification and abstinence, and the specific aims of treatment can include any or all of the following: reduce or prevent withdrawal symptoms break completely with all illicit opioid drug use and associated unhealthy risky behaviours and stabilise other drug intake and lifestyle reduce illicit opioid use with positive change in drug taking and risk behaviour encourage cessation of injecting help to maintain contact with clinicians and offer an opportunity to work with the patient further Service users should be able to access OST with the minimum of barriers to treatment and should be retained in treatment for as long as they are continuing to benefit from this intervention. A prescription for opioid substitute medication should normally only be considered if: opiates are being taken on a regular basis usually daily there is convincing evidence of current dependence (objective signs suggestive of dependence such as injecting sites can be helpful) but if there remains reasonable clinical doubt waiting to observe objective signs of opioid withdrawal syndrome will be essential the assessment (including history, examination and toxicology) clearly substantiates the diagnosis and the need for treatment the clinician is satisfied that the patient may be able to comply with the prescribing regimen the patient is not receiving an opioid prescription for management of dependence from another clinician Methadone and buprenorphine are both effective at achieving positive outcomes in heroin dependent individuals. Both are cost-effective and are recommended for the treatment and prevention of withdrawals from heroin and for maintenance programmes. Although there is some evidence that Buprenorphine may be safer during induction, there is also evidence that methadone is more effective in keeping people in treatment longer and may have a more beneficial effect longer term. Currently, there remains insufficient evidence to justify recommending one drug over the other and therefore service users should be informed of the pros and cons of each option prior to starting on an OST programme and their informed choice should be taken into account when deciding which medication should be used A number of clinical factors can be taken into account that can help the service user, with their key worker and prescriber, to decide which medication to opt for. These include: a patient s pre-existing preference for either drug where acceptable to the patient, the potential value of rapid induction on to higher dose buprenorphine to achieve full opioid blocking effect for an induction phase that has been assessed as particularly high risk, for example with high levels of injected heroin or injecting in to large veins previous substantial benefit from methadone maintenance previous substantial benefit from buprenorphine maintenance

4 specific safety concerns (e.g. with methadone, concerning potential diversion or previous overdose on it; and, with buprenorphine, previous disengagement from treatment on it) likely need for acute pain management, for example pending surgery, or chronic pain management (e.g. with advice of a pain clinic) using strong opioids other than buprenorphine different drug-drug interactions that should be taken into account when prescribing for patients taking other drugs or medication local pragmatic factors, such as lack of geographical availability of supervised consumption (which may favour buprenorphine in some cases) 5.2 Induction onto OST Induction onto methadone and buprenorphine treatment is the process of starting a patient on a suitable dose of a substitute opioid and optimising the dose. There are risks associated with starting OST and these are highest in the earliest stages of treatment particularly with Methadone. It is important that the initial titration of medication is done safely to avoid over sedation and possible overdose, but that it is completed as quickly as is safe to do so to avoid excessive withdrawals which may in turn lead to additional use of illicit opiates which also carries a risk of overdose. It may take two to four weeks (or more) to achieve an optimal dose with methadone. It usually takes less time with buprenorphine Risk factors for methadone- The first 4 weeks are the most risky time during induction onto methadone and this is exacerbated if the service user is also using benzodiazepines, alcohol and other illicit opioids. With methadone, toxicity is delayed, at least several hours after exposure, and this may often become apparent only after several days of treatment. The reason for the delayed toxicity is methadone s long but variable half-life, measured at between 13 and 50 hours with chronic administration. Variation can occur between individuals and within an individual. The half-life can be affected by other factors such as alcohol consumption or other drugs taken. It takes five half-lives, or 3-10 days, for patients on a stable dose of methadone to reach steady-state blood levels. The slower methadone is cleared, the longer it takes to reach steady state and the higher the steady state blood levels. During those 3-10 days, blood levels progressively rise even if patients remain on the same daily dose. A dose tolerated on day one may become a toxic dose on day three. Patients must therefore be carefully monitored and, if necessary, the dosage adjusted during the accumulation period. Patients should be informed of increasing effect of a dose as steady state is achieved so that they do not top-up excessively with street drugs. It is the responsibility of the CADAS practitioner to ensure that service users are given this information and that they understand the implications of it Peak methadone concentrations in the blood occur 2-4 hours after administration. As most deaths occur during sleep, induction patients should be advised against taking methadone during the evening. Daily assessment by a pharmacist using supervised consumption is the best safeguard against over-sedation in patient going undetected and all service users starting OST with CADAS services will begin on a supervised consumption regimen.

5 Opioids can affect cardiac conductivity which could, in some cases, result in a prolonged QTc interval. This risk is thought to be dose related but can also be exacerbated by the use of some prescribed medication and concurrent medical conditions such as heart or liver disease. Where risk factors have been identified and in all cases where more than 100mg of methadone per day is likely to be prescribed the service user should be referred for an ECG and their QTc interval monitored regularly throughout treatment and whenever an increase in methadone dose is considered Commencement dose for Methadone Methadone should normally be prescribed as a 1mg in 1ml oral solution. (Methadone tablets are not licensed for this purpose and should not be prescribed at induction due to an increased potential for diversion).the commencement dose should aim to achieve an effective level of comfort, both physical and psychological, while minimising the likelihood of overdose. The initial daily dose will be in the range of 10-30mg. If tolerance is low or uncertain then 10-20mg is more appropriate. With heavily dependent misusers who are tolerant, and where the clinician is experienced, with access to close supervision and skilled key-working support, a first dose can be up to 40mg. This should only be considered after consultation and with the agreement of the CADAS specialist Doctor All patients being inducted onto any OST medication should be offered or directed to overdose awareness training and provided with a supply of take home naloxone Optimal methadone dose Opiate-dependent patients being managed in the community should be offered frequent appointments at the beginning of treatment in order that their dose can be titrated against response. More frequent attendance allows for closer observation for any evidence of withdrawals or intoxication and can help identify evidence of changing risk. Communication with the community pharmacist during the period of induction may be helpful in assessing the dose response. Where doses need to be increased during the first seven days, the increment should be no more than 5-10mg on one day with a total weekly increase not exceeding 30mg above the starting day s dose. It is important not to under-dose patients who continue to use illicit opiates. There is a strong evidence base that higher OST doses are more effective After the first week, doses can continue to be increased incrementally. A total target dose of between 60 and 120mg a day may be required. It is important to achieve a level at which the patient reports feeling comfortable and, importantly, the dose at which the person is no longer using illicit heroin, which may be substantially higher. Caution needs to be exercised balancing any assessed risk with the need to optimise treatment effectiveness. It may take several weeks to reach the desired dose. There should be at least 3 days between each dose increase from the second week onward. The clinician will need to balance the risk of increasing the dose of methadone against the risk of continued heroin use and should seek advice from the CADAS specialist prescriber when required Methadone Tablets Prescribing methadone tablets will not normally be agreed, however it may be justified for specific circumstances, such as to reduce nausea and vomiting during pregnancy, to

6 reduce nausea when also in receipt of chemotherapy, during holidays abroad and where the prescription is being continued from another service. Where the prescription of methadone tablets is being considered advice should be sought from the CADAS specialist doctor and agreed within the MDT. 5.3.Risk Factors for Buprenorphine At low doses, buprenorphine is a potent opioid agonist, producing morphine-like effects. However, due to its mixed agonist-antagonist properties, increasing doses become self-limiting and do not produce more intense opioid effects. This may be one reason for preference for methadone by some patients. It is generally agreed that there is less risk of opioid overdose associated with the use of buprenorphine than with oral methadone, although the former has greater potential for misuse by injection and intranasally. However, as with methadone, concomitant use of buprenorphine with benzodiazepines, alcohol and other CNS depressant drugs can produce fatal opioid overdose, most commonly in individuals who lack opioid tolerance. Therefore, there is a risk of toxicity and the need for caution when initiating treatment with buprenorphine in someone misusing or co-prescribed CNS depressant drugs Commencement dose for Buprenorphine The two risks associated with the commencement of Buprenorphine are the risk of precipitated withdrawal ( due to the antagonist effect) and the risk of the service user dropping out of treatment. Service users should be advised that they need to be free of heroin (and other short acting opiates) for at least 12 hours prior to commencement of buprenorphine and should not have taken methadone for at least hours. Providing some flexibility in dosing over the first two days can also use (for example providing a number of 2mg tablets that can be divided across the first day or two) before instituting the recommended period of daily supervised consumption. Commencing doses should not be started on a Friday if this is avoidable. A cautious approach is to initiate treatment with 4mg on day one, then 8-16mg on day two and thereafter. An experienced and competent clinician may increase the starting dose to 8mg on day one, then 16mg on day two and thereafter increase the dose more slowly if necessary. In all cases, patients should be supported and encouraged, provided with information about precipitated withdrawal and informed that, if their discomfort is risking drop out of treatment, they could be reviewed early and treatment could be amended. If necessary that they can be switched to methadone as an alternative Optimal Buprenorphine dose Once a dose that does not precipitate withdrawal is achieved, rapid increase to recommended doses can be much quicker than is usually possible for methadone. Clinical judgement is required that takes into account all relevant factors in a particular case. Effective maintenance treatment with buprenorphine involves doses in the range of 12-16mg for most patients, with some needing up to 32mg. It makes sense to work towards this dose rapidly, so long as this does not produce side-effects or precipitated withdrawal. 5.3 supervised consumption Supervision of consumption by an appropriate professional provides the best guarantee that a medicine is being taken as prescribed. The principal reason for using supervision is to ensure the safety of the community and of the patient and to minimise the risk of toxicity. It should not be used or viewed as a punishment.

7 5.3.2 All service users commencing on OST will initially be expected to take this under supervised consumption and this will continue until a stable dose has been achieved Levels of supervision following the initial titration period should be based on an individual risk assessment. The risk assessment should include a review of compliance and individual circumstances, including whether the home environment is suitable for safe storage of medications. In some cases supervision will need to be for an extended period while for others it may be assessed as only being needed for a short period. Duration of supervision should be dependent on assessed clinical need and should not be applied in an arbitrary way When a patient restarts methadone or buprenorphine after a break, receives a significant increase in the dose or during periods of instability when tolerance may be reduced, daily dispensing with supervised consumption should be reinstated for a period of time and reviewed at regular intervals In exceptional cases e.g. where supervised consumption would interfere with working or where it is extremely difficult due to geographical location the MDT should be consulted and a plan should be agreed that will minimise risk to the individual and/or the community of less frequent unsupervised dispensing. 5.4 Relaxation of collection regimens Relaxation of requirements for supervised consumption and for instalment dispensing should be a stepped process in which a patient normally remains on daily dispensing with reduced supervision and progresses to less frequent instalment collection. The relaxation of supervision and collection can be seen as an important component of supporting further recovery in suitably stable clients and should be achieved in a stepped approach: Daily collection (supervised consumption) Daily collection (unsupervised consumption) Three times a week unsupervised collection (unsupervised consumption) Twice weekly collection (unsupervised consumption) Weekly collection (unsupervised consumption) No more than one week of take home doses should be supplied as a single instalment In order to protect patient and for community safety, take-home doses should not normally be prescribed where: the patient has not reached a stable dose the patient shows a continued and unstable pattern of drug misuse, including a significant excessive level of alcohol intake, the use of illicit drugs, benzodiazepines or other tranquillisers

8 the patient has a significant, unstable psychiatric illness or is threatening selfharm there is continuing concern that the prescribed medicine is being, or may be, diverted or used inappropriately there are concerns about the safety of medicines stored in the home and possible risk to children 5.5. Failure to benefit from Treatment OST is shown to be beneficial to clients both in reducing harm and enabling recovery. It may take months or even years for service users to become stable and abstinent from illicit drug use and in some cases it can be difficult to balance the benefit received from OST against the risks associated with use of illicit drugs and/or alcohol on top of the prescribed medication A decision to temporarily or permanently exclude a patient from a drug treatment service or provide coerced detoxification should not be taken lightly. Such a course of action can put the patient at an increased risk of overdose death, contracting a bloodborne virus or offending. It may also increase the level of risk to children and vulnerable adults in the home There are various situations where reducing or withholding a prescription will be considered, however the guiding principles should always be to reduce the risk to the service user and to maintain them in treatment. Reducing or withholding a prescription should never be a punitive measure. If a service user is considered by the key worker or the prescriber to be at significant risk this should be discussed in the clinical section of the MDT and an action agreed within this meeting and communicated to the service user In all cases reduction or withholding of a prescription should be a last resort and it is recommended that the following actions are considered before this decision is reached: ensuring current medication is being offered at evidence-based optimal levels increasing intensity of support. increasing supervised consumption (which will also increase patient contact with health professionals who may be able to influence their drug use or risk behaviours) changing to another evidence-based substitute medication introducing additional psychosocial interventions 5.6 Missed Appointments Attendance at planned appointments is one of the cornerstones of safe prescribing. Every effort should be made by the keyworker to ensure that the service user attends all appointments. The use of reminder calls and texts prior to appointments may help reduce DNA s. The frequency of appointments should be agreed with the service user as part of the care planning process and should be stated on the care plan but should not be less than three monthly If a client has missed an appointment a call should be made where possible during the missed appointment time to rearrange. The new time and date should be recorded in the HALO contact notes along with the missed appointment. If it is not possible to contact the service user by phone on the day of the missed appointment a letter should be sent with a new appointment as soon as possible. The new appointment should be as soon after the missed appointment as keyworker availability allows.

9 5.6.3 If a second consecutive appointment is missed the same process as above should be followed and in addition the client should be advised that if a third appointment is missed this will be taken for discussion at the MDT Where a third consecutive appointment is missed, this should be discussed at the MDT and the risks considered. This discussion should be informed by relevant information from pharmacy and any other professionals involved. Where appropriate, risks should be mitigated by increasing frequency of collection or a change to supervised consumption. Where the MDT decides that the risks cannot be mitigated further and continuance of the prescription may do more harm than good, the prescription will be reduced over a 2 week period during which time the service user can arrange an appointment with the keyworker to review their care. A letter will be sent to inform the service user of this decision along with harm reduction information If there is a pattern of frequent missed appointments but these are not consecutive as described above, this should be reviewed as part of the care plan. If the keyworker believes that there are significant risks, the case should be presented at the MDT as above. 5.7 Missed doses After more than three days without their regular prescribed dose of opioid, tolerance to the drug will have reduced, increasing risk of overdose if the usual dose is then taken. The risks of loss of tolerance are less with buprenorphine than with methadone When the key worker becomes aware that a service user has stopped collecting every effort should be made to contact them. If they have missed more than three days collection and telephone contact cannot be made within two days a letter should be sent advising them that their prescription has been suspended until they make contact and harm reduction information sent Repeated failure to pick up for one or two days at a time is of concern and three consecutive missed doses will require a review by the CADAS practitioner before dispensing recommences. This review is at the discretion of the practitioner who will need information on: Reason(s) for missed doses In order to exclude loss of tolerance, what drugs have been used during the lapse in dispensing amounts and frequency as accurately as possible by patient self-reporting What is known about the patient s current situation especially any current offending The pharmacist and/or key-workers own analysis of the situation and any specific safety concerns for the patient or security of the script The need for a full re-assessment is a possibility which should always be considered if there is doubt and there is a possibility of a significant drop in tolerance level If an assessment of substance use during this period suggests that the client has compensated for their lack of prescription by using illicit opioids, then it may be possible to re-instate the prescription safely at the same dose, however the CADAS keyworker should discuss the case with the prescriber. If no opioids have been used during this period, a re-assessment will need to be carried out and it is likely that a reduction (e.g %) may be made in the prescribed dose of medication, before building it back up

10 over the next 5-10 days. If the prescription is not collected for over 5 days it should be suspended until the client is reviewed by the prescriber Community Opioid detoxification Detoxification is usually thought of as being a clearly defined process supporting safe and effective discontinuation of opiates while minimising withdrawals. The process varies in duration from person to person, usually lasting about 28 days as an inpatient or up to 12 weeks as an outpatient The assessment process can establish whether a patient is suitable for detoxification. Detoxification alone is rarely successful especially at the first attempt. Patients who do not successfully detoxify should be offered seamless access back into maintenance or other treatment. The following factors can guide the clinician and patients opinions about whether they are suitable for detoxification: the patient is fully committed to and informed about the process the patient is fully aware of the high risk of relapse the patient is either in a stable and supportive social situation or able to go into one following detoxification the service user has clear plans for continuing support and treatment and these are in place There is clear evidence that coerced detoxification against a patient s express will is likely to lead to relapse and increased risks of harms such as overdose and bloodborne viruses some service users may prefer a slow reduction over a number of months or years. This should be supported by the keyworker as part of a care planned intervention. However, if there is evidence of a return to illicit drug use, this should trigger a review and consideration of a return to a therapeutic maintenance dose Community detoxification will normally be the first option for detox. CADAS will support community detox as described in the Community Opiate Detox pathway. 5.9 Community Alcohol Detoxification (CAD) CAD is indicated where a service user is drinking dependently, would like to stop drinking, and where an assessment has been completed and the criteria for a CAD has been met. A CAD will normally take place over 5-10 days with the support of CADAS keyworker worker, EDP support and with the involvement of aftercare services (ADCAP) Where a service user does not meet the criteria for a CAD but is declining an inpatient detox, the MDT must decide if the risks of offering a CAD are outweighed by the risks of the service user continuing to drink or of trying to detox without support. This decision should be recorded on the minutes of the MDT and on the HALO notes CADAS will support community alcohol detox as described in the Community alcohol Detox pathway 5.10 Relapse Prevention Medication (Opiates).

11 Naltrexone - Naltrexone is an opioid antagonist which, when taken regularly, blocks the effects of opiates. It can be helpful following detoxification in enabling a patient to maintain abstinence. In the UK naltrexone is only licensed for use orally Naltrexone is likely to be more effective if the service user is also engaged with ongoing psychosocial support Due to the potentially hepatotoxic nature of naltrexone, liver function tests should be conducted before and during naltrexone treatment. Following induction monitoring should be continued for 3 months by the keyworker before being handed over to the GP If opioids have been used recently then severe and prolonged withdrawal symptoms will result if naltrexone is administered. A drug screen should be offered prior to commencement and if there is any uncertainty as to whether the service user has used opiates they should be given advice about the likely reaction if they have opioids in their system. Naltrexone should not be taken if the drug screen is positive to opiates or methadone Following a negative urine or oral fluid test for opiates the service user is given a single dose of naltrexone (25mg) orally. If the they do not experience any withdrawal symptoms after a few hours a 50mg tablet of naltrexone can be given. Patients can be commenced on naltrexone within a few days of finishing a buprenorphine detoxification and 24 to 36 hours after the last withdrawal symptoms have been experienced for methadone detoxes (usually 7-10 days after the last methadone dose). The usual maintenance dose is then 50mg a day It is good practice to give patients a card indicating that they are maintained on naltrexone. The risk of opiate overdose is increased if the person uses again after a period of abstinence and therefore overdose awareness advice and written information should be given service user when commencing on naltrexone. Naloxone should be provided to the service user and/or partner or family Relapse prevention medication (alcohol) Relapse prevention medication can be a useful adjunct to psychosocial interventions for those who have completed a community or in-patient detox. The CADAS keyworker should discuss these medications as an option with service users prior to detox and again when the detox is coming to an end. Where the service user is admitted to an inpatient unit for detox the medication should be started prior to discharge if possible Disulfiram (Antabuse) - Disulfiram is a tablet which if taken daily interferes with the metabolism of alcohol. If alcohol is taken whilst taking disulfiram, there is a build-up of acetaldehyde which is toxic and which gives rise to a reaction directly related to the amount of alcohol taken. The reaction is characterised by flushing, nausea, palpitations and, more seriously, arrhythmias, hypotension and collapse If using disulfiram, treatment should be started at least 24 hours after the last alcoholic drink consumed and where the service user is alcohol free. The usual dose is 200mg per day. If a dose of 200mg (taken regularly for at least 1 week) does not cause a sufficiently unpleasant reaction to drinking, consider increasing the dose to a maximum of 400mg per day in consultation with the service user Before starting treatment with disulfiram, test liver function, urea and electrolytes to assess for liver or renal impairment. Check the SPC for warnings and contraindications in pregnancy and in the following conditions: a history of severe mental illness, stroke, heart disease or hypertension.

12 Disulfiram will normally be prescribed by the service users GP. Further support from CADAS will be offered for 3 months. Service users will be encouraged to engage with other community support provided by EDP, ADCAP or fellowship meetings Warn service users who are considering taking disulfiram, and their families and carers that: The interaction may also be triggered by hidden alcohol found in food, perfume, aerosol sprays etc. There is a risk of rapid and unpredictable onset of the rare complication of hepatotoxicity; advise service users that if they develop a fever or jaundice they should stop taking disulfiram and seek urgent medical attention Acamprosate. There is evidence that taking Acamprosate in combination with psychosocial support can reduce cravings following detox. It should be started as soon as possible after the detox has finished and is usually prescribed at a dose of 1998mg (666mg three times a day). If the service user weighs less than 60kg, and then a maximum of 1332mg should be prescribed per day. Acamprosate can be taken for up to 1 year after detox but can be prescribed for longer for those who continue to benefit. It should be stopped if drinking persists 4-6 weeks after starting the drug. It will usually be initiated by the GP after recommendation by CADAS and service users who are started on Acamprosate should continue to be monitored by CADAS keyworker for 3 months after commencement Naltrexone for alcohol. Naltrexone is an opioid-receptor antagonist but is useful as an adjunct in the treatment of alcohol dependence after a successful detox. The initial dose is 25mg per day with the aim of increasing to a maintenance dose of 50mg per day if this is tolerated. Service user s should be advised about the blocking impact on opioidbased analgesics and their attention should be drawn to the information card given with the medication Naltrexone can be initiated by the service users GP on advice from CADAS following discussion at the MDT. Oral naltrexone should usually be prescribed for up to 6 months, or longer for those benefitting from the drug and who wishes to continue on it. It should be stopped if drinking persists 4-6 weeks after starting. It is not necessary to continue with regular blood tests routinely, but it should be considered for older people, for people with obesity, for monitoring recovery of liver function and as a motivational aid for service users to show improvement. If the service user feels unwell they should be advised to stop the oral naltrexone immediately.