General Notes

The Drug Misuse and Dependence: UK Guidelines on Clinical Management Dec 2017, often called the Orange Book, contains guidance for clinicians treating patients with drug problems.  Prescriptions should only be considered after the patient has been fully assessed and has shown evidence of opioid dependence and motivation to stabilise their drug use.

Inpatient care of people who use drugs who are hospitalised for non-drug related treatment

If a person who uses drugs stable on a verified maintenance dose is admitted to hospital, this should be continued at the established dose after confirmation with the relevant prescriber and/or community pharmacist. The date of the last dose should ideally be confirmed by the Community Pharmacy due to the risk of overdose caused by rapid loss of tolerance as a consequence of missed doses.

If a history of drug use is given by a patient not on prescribed treatment, refer to hospital policy or discuss with Addiction Services. This should also include checking with the Substance Misuse Nurse Service in the hospital.

Pain relief for patients on methadone is best provided by non–opioid analgesics such as aspirin, paracetamol or NSAIDs. For severe pain, doses of opioids larger than normal may be required. For patients prescribed buprenorphine, contact substance misuse liaison nurses/addiction services for advice. Buprenorphine is an opioid receptor partial agonist with strong affinity for receptors and as such blocks the action of most opiates.

For patients that report issues who are not currently prescribed Opioid Agonist Treatment (OAT) please see guidance below for Acute Opioid Withdrawal.

Acute Opioid Withdrawal Symptoms

Preferred list (P)

SYMPTOMATIC RELIEF

  • Patients with mild or specific symptoms of opioid withdrawal, such as diarrhoea, nausea/vomiting or colic can be treated symptomatically with for example loperamide, prochlorperazine, mebeverine, NSAIDS or paracetamol.

 

Specialist initiation (S1)

OPIOID AGONIST TREATMENT (OAT)

  • OAT should only be used after seeking advice from the Addiction Service in patients with clinically confirmed opioid dependence and as part of a treatment plan.
  • A prescription for substitute opioids should not be initiated until the patient is fully assessed and a pharmacy is arranged to undertake supervision.
  • Dihydrocodeine is not recommended without specialist referral.

Opioid Agonist Treatment

Specialist initiation (S1)

METHADONE 1mg/ml oral solution

  • Dose should be adjusted to patient response as per NHSL guidelines.
  • Titrate dose gradually upwards (maximum of 10mg at a time and no more than 20mg per week) as required with supervised consumption until stable dose reached.
  • Initial dose should be in range of 20-40mg.
  • Tolerance quickly reduces with missed doses. The below should be used as a guide on reduction of dose dependent on days missed:
    • 1 or 2 days missed (not counting today) - no reduction in dose
    • 3 days missed (not counting today) - remain in treatment and reduce dose by 25%
    • 4 days missed (not counting today) - remain in treatment and reduce dose by 50%
    • 5 or more days missed (not counting today) - treat as induction. (This will not normally need a medical review, to be discussed with prescriber if significant risks are present).
  • Sugar-free formulations should only be prescribed in cases where there is a clinical justification.

BUPRENORPHINE

  • Buprenorphine may be prescribed as an alternative to methadone.
  • There are both long- and short-acting formulations of buprenorphine available which may be considered for prescribing. Comprehensive assessment by the specialist service, in collaboration with the patient, and in line with NHS Lanarkshire and national frameworks, will inform the most appropriate treatment/formulation option.
  • Initiation of buprenorphine should be delayed until clear signs of clinical withdrawal; this is at least 8 hours after last using heroin or 24-36 hours after using methadone.
  • If on methadone maintenance, the dose of methadone should usually be reduced to 30mg/day before switching to buprenorphine.
  • If buprenorphine is initiated while other opioids are still in the system, patients may experience precipitated withdrawal. This should take place by the specialist addiction services only and by prior agreement; transfers from higher doses of methadone may be planned with the lead medical practitioner for addiction services.

Prescribing Notes:

Take Home Naloxone for Prevention of Opioid Overdose

Preferred list (P)

NALOXONE (Prenoxad® 2mg/2ml solution for injection pre-filled syringes)

  • Non-medical setting: 400 micrograms intramuscularly repeated every 2-3 minutes alongside CPR if needed.
  • Each dose given in subsequent resuscitation cycles if patient not breathing normally, continue until consciousness regained, breathing normally, medical assistance available, or contents of syringe used up.
  • Prenoxad® comprises a plastic box containing one pre-filled syringe containing 2ml of 1mg/ml naloxone, two needles and a patient information leaflet.
  • The syringe is clearly calibrated to facilitate injecting up to five single 400 microgram naloxone doses.

NALOXONE nasal spray

Prescribing Notes:

  • Any patient at risk of opiate overdose (or their representative/carer), including all those on OAT, should be offered instruction in overdose prevention, basic life support and how to administer naloxone.

Naloxone for Treatment of Opioid Induced Respiratory Depression in Clinical Healthcare Settings

Preferred list (P)

NALOXONE 400 micrograms in 1ml injection

  • Used in clinical healthcare care settings for the treatment of respiratory depression. This preparation differs from the take home naloxone products above.

 

Opiate Detoxification

Detoxification is a specialist intervention and requires close monitoring and support. It should not be attempted by GPs without specialist addiction service involvement and can only be recommended as part of a structured care plan.

It will be considered for those who have been assessed as stable on prescribed opioid agonist treatment (OAT). The detoxification should be carried out at a rate the patient can tolerate to prevent relapse.

There is no current evidence to support a change of OAT as part of the detoxification process and treatment should be continued using a reducing regime. Adjunct therapy may be used in order to treat specific symptoms of withdrawal during detoxification.

Maintenance of Abstinence and Relapse Prevention

Preferred list (P)

SUPPORTIVE MEASURES

 

Specialist initiation (S1)

NALTREXONE

  • To be initiated under specialist supervision.
  • Patients must be completely free of opiates prior to initiation or precipitated withdrawal is likely.
  • Patients should be warned that an attempt to overcome opioid receptor blockade may result in acute opioid intoxication / overdose.

NHSL Joint Adult Formulary Key

To indicate the category of a formulary medicine, updated sections adopt the following key:

Preferred list (P): First-line formulary choices.

Total list (T): Alternative choices when preferred list options not effective/not tolerated, or not indicated.

Specialist initiation (S1): Specialist initiation, or on the advice of a Consultant or Specialist Practitioner in this therapeutic area. Continuation in primary care is acceptable.

Specialist use only (S2): Supply via hospital, Homecare Service or a hospital based prescription (HBP) for dispensing by community pharmacy. Not prescribed in primary care setting.

Editorial Information

Last reviewed: 31/01/2022

Next review date: 31/01/2025

Author(s): NHSL.

Version: Please refer to the introduction section for an explanation of the review dates above.

Approved By: ADTC

Reviewer name(s): ADTC.