Checklist of actions:

1. As soon as possible, confirm the dose of MAT with the prescriber and dispensing pharmacist.
2. Ask about current illicit use of all substances as well as alcohol and smoking.
3. Send urine for toxicology screening.
4. Check U&Es in all sick patients including magnesium.
5. Patients on methadone should have an ECG (risk of QT prolongation).
6. Look for signs of intoxication or withdrawal & document. Consider the use of the COWS scale - see Opioid dependence suspected or declared by patient.
7. Where appropriate, give usual MAT even if fasting for surgery (sugar free formulation). If the usual dose corresponds to a particularly large volume e.g. methadone >100mls, check with anaesthetist pre-theatre.

Analgesia advice (See Key points):

• similar principles to elective admission.
• Use oral route where possible and use simple analgesia where appropriate. Some non-opioid analgesics can be given SC/IV/IM/PR if necessary.
• Estimate the likely ‘as required’ opioid dose, using an appropriate opioid conversion tool e.g. the West of Scotland Pain Calculator.
  • Err on the side of caution and reduce the equivalent dose by at least 25% - 50% - this can be increased if necessary later.
• Most patients on MAT will not require more than 20mg of oral morphine for ‘as required’ analgesia.
• Assess pain / function and withdrawal symptoms daily.
• Review opioid analgesia daily including dose and route of administration with a plan to wean opioids as soon as possible.
• If at all unsure about opioid prescribing, contact the Inpatient Pain Team or the anaesthetist on call via switchboard.

Lack of oral route

To avoid withdrawal, MAT should be replaced.

• Methadone: Consider administering via NG tube for methadone.
• Buprenorphine: Consider whether sublingual buprenorphine can still be given.
• If MAT is omitted for three days or more do not restart usual dose without specialist advice.

If there is no enteral route available / unable to continue usual MAT, subcutaneous morphine can be given regularly (4 hourly) as a short-term measure. Seek specialist advice as soon as possible.

If considerable doses are required or the oral route is likely to be unavailable for >24hrs, a PCA or an IV infusion can be considered. Always use a dedicated PCA pump as these are tamperproof.

Note: Any patient with an IV morphine continuous infusion requires HDU care. PCA’s can usually be managed on the ward with hourly observations.

It is uncommon following an opioid conversion calculation that patients need a PCA pump with a bolus of more than 2-3mg or a continuous infusion of morphine above 1-3mg/hr.

If pain remains problematic, call the Inpatient Pain management Team or anaesthetist on call.

Discharge facilitation

Aim to discharge on admission dose of MAT with a clear plan of reducing analgesia communicated to the patient, pharmacist and GP. Liaise with the community pharmacist to restart usual dispensing of MAT. Inform Community Addictions Team if needed.

Consider whether the patient requires daily dispensing of their analgesia and be aware of the risk of the patient taking all their analgesia at once. Any concerns, contact the Drug Liaison Service.