• Take a full drug history, asking particularly about daily dependent use and withdrawal symptoms.
• Look at injection sites (for complications and also to confirm recent use).
• Ask about current/ past prescriptions for methadone, buprenorphine or dihydrocodeine, and whether supervised.
• If possible, confirm any opioid prescription with community pharmacy, GP and TRAK (check clinical notes on TRAK for specialist substance use service prescribing), including when last collected. If confirmed, continue prescription (sign amnesty form if not supervised - available from Ritson Clinic).
• Check recent drug screen results on TRAK or SCI store.
• Send urine sample (drugs of abuse) to RIE laboratory or do oral fluid swab.
• Search patient and any belongings if felt necessary (2 members of staff).
• Breathalyse unless confident no alcohol can have been taken.

Use COWS protocol to assess withdrawal

If obvious opioid withdrawals prescribe dihydrocodeine 120mg as “once only”. Symptomatic relief may also be prescribed.

Reassess after 4 hours or earlier if nursing concern. If COWS indicates moderate or severe withdrawal, prescribe a further dose of dihydrocodeine 120mg.

Repeat, but no more than dihydrocodeine 360mg in first 12 hours.

Do not give more than 480mg dihydrocodeine / 24 hours (120mg 4 x daily) before seeking advice from addiction services / senior medical colleagues.

Tips

• Never prescribe methadone without confirmation of prior prescription (including dose and when last taken).
• Never prescribe dihydrocodeine on an “as required” basis.
• Write on prescription - Do not give if drowsy / sedated / ataxic / slurred speech /asleep.
• Do not give if patient has been off ward and could have used drugs illicitly.
• Do not allow patient to leave ward for four hours after increase in dose.
• Inform patient that dihydrocodeine will not be prescribed on discharge, but that advice will be sought from specialist services for decision regarding any ongoing prescription.
• Any analgesia required (including opioid) should be prescribed in addition to this regime (although careful assessment must be made and alternatives preferred).
• Symptomatic relief - paracetamol, metoclopramide, loperamide, hyoscine butylbromide, NSAIDs.

Clinical Opiate Withdrawal (COWS)

Click here to view the form as a pdf that can be downloaded.