• Contact Drug Liaison Nurses as soon as possible.
• Complete assessment (history, examination and investigation) and exclude other illnesses which may cause symptoms similar to opiate withdrawal.
• Always seek advice in pregnancy and breast-feeding from the PrePare Team or local Substance Use Service. See Useful phone numbers and contacts during working hours.
• If patients show signs of withdrawal, refer to COWS protocol as per Appendix 2. Remember symptoms of opiate withdrawal may appear objectively mild to an observer but be reported as subjectively severe by the patient. The patient’s description of symptoms may be sufficient to initiate treatment.

Suggested process for management of withdrawal symptoms:

Take urine test/oral fluid test (tox testing kits can be ordered through PECOS and labels through TRAK). See Appendix 3 for further information.

• Observe Clinical Opiate Withdrawal Scale measures. See Opioid dependence suspected or declared by patient
• Prescribe dihydrocodeine 120mg up to four times daily. If negative urine test (or cannot provide sample) do not prescribe opioids and consider symptomatic relief until lab test confirms opiate use
• This dose can be reduced or maintained during short admissions based on the clinical condition of the patient
• Do not supply dihydrocodeine on discharge

Please be aware that this is an unlicensed use of dihydrocodeine, but it is an established practice in the management of opiate withdrawals.

If titration and stabilisation with methadone or buprenorphine is appropriate, contact the Drug Liaison Nurse for further advice and assistance with facilitating ongoing prescribing arrangements with GPs, local Substance Use Services, and through-care planning. See Useful phone numbers and contacts during working hours.

Note: Do not initiate methadone or buprenorphine treatment without advice from specialist services and without arranging continuation of treatment on discharge.