1.0 APPLICABLE TO Barnsley specialist Business Delivery Unit. Cmmunity Alchl & Substance Misuse Team Suth West Yrkshire Partnership NHS Fundatin Trust 2.0 RISK FACTORS Reduced piid tlerance and accidental verdse 3.0 PURPOSE T enable safe and effective discntinuatin f piids whilst minimising withdrawals. T ensure apprpriate aftercare arrangements are in place fllwing detxificatin t safeguard psitive treatment utcmes. 4.0 PERSON CENTRED CARE Clients shuld have the pprtunity t make infrmed decisins abut their care and treatment in partnership with healthcare prfessinals. Written infrmatin needs t be available and accessible t clients with additinal needs and t peple wh d nt speak r read English. 5.0 GENERAL PRINCIPLES The detxificatin duratin can vary frm 7 days up t as much as 12 weeks in the cmmunity. The regime shuld be tailred t individual need based n this prtcl Identificatin f suitable clients is critical, the fllwing clients may be suitable: Fully cmmitted t and infrmed abut the prcess Fully aware f high risk f relapse fllwing lss f piid tlerance Stable and supprtive envirnment Aftercare plans in place Physically fit fr the treatment with n cntraindicatins PAGE: 1 OF 15 DATE: 21 January 2014 REVIEW: 21 January 2016
CLINICAL PROCEDURE MANAUAL Stable mental health Felt t be respnsible fr their medicatin during the detxificatin Exclude dependence n ther substances, including benzdiazepines and alchl Clients presenting with cmplex issues wh require detxificatin may need inpatient facilities t safely achieve abstinence Risk assessment has been cmpleted t assess suitability described abve Preparatin has been agreed upn and is cmpleted prir t starting the detxificatin Liaisn with ther prfessinals invlved with the client s care is essential prir t detxificatin 6.0 PREPARATION: Determining readiness fr detxificatin, this can be the clinician s judgement r the Readiness t Change Questinnaire (Appendix 1) can be used. Cnsideratin f cping strategies ther than pharmactherapy Identificatin f a supprt persn and cnsider invlving the supprt persn in the care planning Planning aftercare, reinfrcing the imprtance f cntinued supprt t maintain abstinence Prvide infrmatin n self-help grups, e.g. NA, SMART and ther supprt grups Cnsidering previus detxificatin s, if applicable, and learning pints Discussin f physical and psychlgical aspects f piid withdrawal, and hw they may be managed Discuss lifestyle issues which may be relevant t piid detxificatin Balanced diet Hydratin Sleep hygiene Regular physical exercise Assessing risks PAGE: 2 OF 15 DATE: 21 January 2014 REVIEW: 21 January 2016
7.0 TREATMENT OPTIONS FOR DETOXIFICATION: 1. Lfexidine detxificatin this can be used frm either a prescribed piid, methadne r Buprenrphine, r frm herin 2. Buprenrphine - this can be used frm either a prescribed piid, methadne r Buprenrphine, r frm herin 3. Methadne detxificatin this can be used frm methadne maintenance r herin NICE, 2007b cncluded that detxificatin shuld be carried ut with the medicine n which the patient had been stabilised as neither methadne nr Buprenrphine were mre effective than each ther. Hwever, in clinical practice clients ften prefer t use Buprenrphine as they can reduce the dse faster than with methadne and the withdrawal symptms are less severe (client s reprts). When determining the starting dse, duratin and regimen f piid detxificatin, healthcare prfessinals, in discussin with the client, need t take in t accunt the fllwing: Severity f dependence, cnsider using Leeds Dependency Questinnaire (LDQ, Appendix 3) Pharmaclgical agents Duratin, up t 12 weeks in the cmmunity this includes preparatin, detxificatin and aftercare Ultra-rapid and rapid detxificatin is nt ffered due t the high risks assciated with sedatin in the cmmunity and the subsequent risk f death. PAGE: 3 OF 15 DATE: 21 January 2014 REVIEW: 21 January 2016
8.0 LOFEXIDINE DETOXIFICATION Lfexidine is a nn-piid alpha-adrenergic agnist and is nt a cntrlled drug. It is licensed fr management f piid withdrawal. The dse needs t be built up ver time and lasts fr 7-10 days. Fr clients detxifying frm herin it is recmmended that the maximum daily use shuld nt exceed ½ gm, fr thse n methadne maximum dse 15 20mg and thse n Buprenrphine maximum dse 8mg. Detxifying frm mre than these amunts may lead t severe withdrawal symptms and ultimately relapse. An example f a Lfexidine regime is as fllws: N f tablets, 0.2mg Lfexidine Detxificatin day 8am 12pm 6pm 10pm Ttal Day 1 1 1 1 1 4 Day 2 2 2 2 2 8 Day 3 3 2 2 3 10 Day 4 3 2 2 3 10 Day 5 2 2 2 2 8 Day 6 2 1 1 2 6 Day 7 1 1 1 1 4 Day 8 1 0 0 1 2 Ttal tablets 52, the maximum daily dse f Lfexidine is 2.4mg PAGE: 4 OF 15 DATE: 21 January 2014 REVIEW: 21 January 2016
In additin the fllwing symptmatic medicatin is smetimes necessary: Diazepam 5mg tablets, maximum daily dse 20mg in divided dses, reduces anxiety and restlessness Buscpan 10mg tablets 1-2 tablets can be taken every 4-6 hurs, maximum 8 in 24 hurs, fr cramps Lperamide 2mg after each but f diarrhea Metclprmide 10mg fr nausea r vmiting, every 8 hurs Zpiclne 7.5mg ncte, maximum 7.5mg fr insmnia Paracetml r Ibuprfen fr aches and pains Mnitring is required during the detxificatin. The client shuld be seen at least 3 times during the first week f the treatment, ideally every day ver the first 3 days and less ften as the treatment prgresses. The reviews can either be in the clients hme r at the clinic base depending n circumstances and risk assessment. The reviews require a qualified member f staff in view f the physical health issues and necessary mnitring. It is recmmended that the medicatin is given n 2 separate prescriptins, day 1 and day 4, ideally this wuld be a Mnday and Thursday During the reviews the fllwing issues need t be explred: Severity f withdrawal symptms, the Shrt Opiate Withdrawal Scale (SOWS) can be used t mnitr this (Appendix 2) Side effects, especially drwsiness, dry muth and hyptensin. If systlic BP is <90 mmhg r has drpped by 30 mmhg frm baseline, r the pulse is belw 55 bpm the Lfexidine shuld be withheld. Treatment shuld be reviewed with the ptin t cntinue at a lwer dse r discntinue. Evidence f intxicatin At the end f the treatment the pssibility f cmmencing naltrexne shuld be discussed (see Guidelines fr Use f Naltrexne) PAGE: 5 OF 15 DATE: 21 January 2014 REVIEW: 21 January 2016
9.0 BUPRENORPHINE DETOXIFICATION Buprenrphine is a synthetic piid in the frm f a sub-lingual tablet, 0.4,2 r 8 mg tablets. It can be used t detxify frm herin, methadne r maintenance Buprenrphine (Subutex r Subxne). Herin maximum amunt fr a detxificatin is 1/2gm per day, higher amunts f herin use shuld cnsider a perid f stabilisatin first. Prir t starting the detxificatin the client shuld nt use herin fr at least 12 hurs. Methadne the dse shuld be reduced t 30mg daily and the client shuld be stable. Befre cmmencing the detxificatin the client shuld nt use methadne fr 36-48 hurs t avid precipitated withdrawal. The first dse f Buprenrphine shuld nt exceed 8mg, n the secnd day this can be increased t 16mg if necessary. It is recmmended t reduce a maintenance dse by 2mg every 1-2 weeks depending n the client. Once the dse is dwn t 8mg ne f the regimes can be used described belw. Buprenrphine this is similar t cnverting frm methadne described abve, initially a gradual reductin t 8mg and then ne f the reducing regimes can be implemented. a) Rapid dse reductin Day f detxificatin 1 8 2 6 3 6 4 4 5 4 6 4 7 2 8 2 9 0.8 10 0.8 11 0.4 12 0.4 Dse f Buprenrphine (mg) PAGE: 6 OF 15 DATE: 21 January 2014 REVIEW: 21 January 2016
b) Gradual dse reductin Day f detxificatin 1-4 8 5-8 6 9-12 4 13-16 2.8 17-20 2 21-24 1.6 25-28 1.2 29-32 0.8 33-36 0.4 Dse f Buprenrphine (mg) Additinal medicatin is nt nrmally required but can be cnsidered n an individual basis. 10. METHADONE DETOXIFICATION There are tw main types f methadne detxificatin slw reductin and a frmal detxificatin regime. a) Slw reductin the usual rate is 5mg every 1-2 weeks, sme clients prefer this t be faster at the start and slwer at the end, the regime can be tailred t the individual. b) Frmal regime ver 28 days, prir t starting this regime the dse needs t be 25mg maximum; the fllwing reductin then cmmences: PAGE: 7 OF 15 DATE: 21 January 2014 REVIEW: 21 January 2016
Day f detxificatin 1-4 25 5-7 20 8-11 15 12-14 10 15-18 8 19-21 6 22-25 4 26-28 2 Dse f methadne (mg) Additinal medicatin is nt nrmally required but can be cnsidered n an individual basis. Mnitring f clients during either a Buprenrphine r methadne detxificatin is nt fixed and can be tailred t the needs f the individual, hwever, as a general principle weekly cntact is recmmended, this may be by telephne if nt pssible t have face-t-face cntact. During the reviews it is imprtant t cnsider withdrawal symptms, use f any herin r ther substances and mtivatin t cntinue with detxificatin. Pregnancy: Specialist midwives are available fr pregnant clients Detxificatin needs t be dne with cautin in pregnant clients, generally the safest time is during the secnd trimester and wuld invlve gradual reductin f methadne r Buprenrphine Lfexidine is cntra-indicated in pregnancy PAGE: 8 OF 15 DATE: 21 January 2014 REVIEW: 21 January 2016
11. RELAPSE PREVENTION AND AFTERCARE All clients shuld have the ptin f cmmencing ral naltrexne if safe t d s. Clients using Buprenrphine t detxificatin must have a minimum f 3 days ff Buprenrphine befre the first dse f naltrexne. Fr further infrmatin n use f naltrexne see Clinical Guidelines fr Use f Naltrexne. Naltrexne implants are nt licensed and therefre nt available n the NHS. Cnsider all ptins t supprt aftercare: Widening Hrizns Cre Prgramme Resettlement Team T4 Supprted Husing and flating supprt Service User Invlvement Mutual Aid SMART grups Recvery Enterprise Supprt fr carers Swanswell, Barnsley Beacn It is nt unusual fr clients t require supprt fr up t 6 mnths 12. REFERENCES 1. Drug Misuse and dependence : UK guidelines n clinical management; 2007 2. NICE (2007b) Drug Misuse: Opiate Detxificatin. NICE clinical guideline 52 3. NICE (2007c) Naltrexne fr the Management f Opiid Dependence. NICE technlgy appraisal 115 PAGE: 9 OF 15 DATE: 21 January 2014 REVIEW: 21 January 2016
APPENDIX 1 READINESS TO CHANGE QUESTIONNAIRE Subject name Date The fllwing questinnaire is designed t identify hw yu persnally feel abut yur using right nw. Please read each f the questins belw carefully, and then decide whether yu agree r disagree with the statements. 1 = Strngly disagree 2 = Disagree 3 = Unsure 4 = Agree 5 = Strngly agree Yur answers are cmpletely private and cnfidential 1. I dn t think I use t much 1 2 3 4 5 /P 2. I am trying t use less than I used t 1 2 3 4 5 /A 3. I enjy my using but smetimes I use t much 1 2 3 4 5 /C 4. Smetimes I think I shuld cut dwn n my using 1 2 3 4 5 /C 5. It s a waste f time thinking abut my using 1 2 3 4 5 /P 6. I have just recently changed my using habits 1 2 3 4 5 /A 7. Anyne can talk abut wanting t d smething 1 2 3 4 5 /A abut using, but I am actually ding smething abut it 8. I am at the stage where I shuld think abut using 1 2 3 4 5 /C less drugs 9. My using is a prblem smetimes 1 2 3 4 5 /C 10. There is n need fr me t think abut changing my 1 2 3 4 5 /P using 11. I am actually changing my using habits right nw 1 2 3 4 5 /A 12. Using less drugs wuld be pintless fr me 1 2 3 4 5 /P PAGE: 10 OF 15 DATE: 21 January 2014 REVIEW: 21 January 2016
SCORING THE READINESS TO CHANGE QUESTIONNAIRE The Precntemplatin items are numbers 1, 5, 10, and 12, the Cntemplatin items are numbers 3, 4, 8 and 9 and the actin items are numbers 2, 6, 7 and 11. All items are t be scred n a 5-pint rating scale ranging frm: -2-1 Strngly disagree Disagree 0 Unsure +1 Agree +2 Strngly agree T calculate the scre fr each scale, simply add the item scres fr the scale in questin. The range f each scale is 8 thrugh 0 t +8. A negative scale scre reflects an verall disagreement with items measuring the stage f change, whereas a psitive scre represents verall agreement. The highest scale scre represents the Stage f Change Designatin. Nte: If tw scale scres are equal, then the scale farther alng the cntinuum f change (Precntemplatin Cntemplatin Actin) represents the subject s Stage f Change Designatin. Fr example, if a subject scres 6 n the Precntemplatin scale, 6 n the Cntemplatin scale and 2 n the Actin scale, then the subject is assigned t the Cntemplatin stage. PAGE: 11 OF 15 DATE: 21 January 2014 REVIEW: 21 January 2016
Nte that psitive scres n the Precntemplatin scale signify a lack f readiness t change. T btain a scre fr Precntemplatin which represents the subject s degree f readiness t change, directly cmparable t scres n the Cntemplatin and Actin scales, simply reverse the sign f the Precntemplatin scre (see belw). If ne f the fur items n a scale is missing, the subject s scre fr that scale shuld be pr-rated (ie multiplied by 1.33). If tw r mre items are missing, the scale scre cannt be calculated. In this case the Stage f Change Designatin will be invalid. Scale Scres Readiness t Change Precntemplatin Scre Precntemplatin (reverse scre) Cntemplatin Scre Cntemplatin (same scre) Actin Scre Actin (same scre) Stage f Change Designatin (P,C, r A) Ref: Rllnick S, Heather N, Gld R, & Hall, W (1992) B J Add. 87 743-754 PAGE: 12 OF 15 DATE: 21 January 2014 REVIEW: 21 January 2016
APPENDIX 2 SHORT OPIATE WITHDRAWAL SCALE (GOSSOP 1990) Name. Starting day (1) Rate each symptm n 0-3 scale (Nil = 0, Mild = 1, Mderate = 2, Severe = 3) Day 1 2 3 4 5 6 7 8 9 10 Feeling sick Stmach cramps Muscle spasms Feeling cld/gse flesh Sweating Heart punding Muscular tensin Aches and pains Weakness Yawning Running eyes Difficulty sleeping TOTAL SCORE PAGE: 13 OF 15 DATE: 21 January 2014 REVIEW: 21 January 2016
APPENDIX 3 Leeds Dependency Questinnaire (Raistrick, Bradshaw, Tber, Weiner, Allisn, & Healy; 1994) Here are questins abut the imprtance f alchl and/r ther drugs in yur life. Think abut yur drinking/ther drug use in the last tw weeks and answer each questin by ticking the clsest answer t hw yu see yurself. Never Smetimes Often Nearly always 1. D yu find yurself thinking abut when yu will next be able t have anther drink (drug)? 2. Is drinking (drug use) mre imprtant t yu than anything else yu might d during the day? 3. D yu feel yur need fr drink (the drug) is t strng t cntrl? 4. D yu plan yur days arund getting alchl (the drug) and drinking (using the drug)? 5. D yu drink (use the drug) in a particular way in rder t increase the effect it gives yu? 6. D yu drink (use the drug) mrning, afternn and evening? 7. D yu feel yu have t carry n drinking (drug use) nce yu have started? 8. Is getting the effect yu want mre imprtant than the particular drink (drug) yu use? 9. D yu want t drink (use the drug) mre when the effect starts t wear ff? 10. D yu find it difficult t cpe with life withut alchl (drugs)? PAGE: 14 OF 15 DATE: 21 January 2014 REVIEW: 21 January 2016
T find ut yur scre, simply add up the numbers frm each f yur answers. Interpretatin Ttal LDQ scre 0 N dependence 1 10 Lw t mderate dependence 11 20 Mderate t high dependence 21 30 High dependence This scre is t be used as a guide t yur level f dependence ver the tw weeks r s. It des nt indicate whether yur cnsumptin is at risky levels r the extent f ther alchl r drug use related prblems. PAGE: 15 OF 15 DATE: 21 January 2014 REVIEW: 21 January 2016