Medication assisted treatment (MAT) (Guidelines)

It can be helpful to consider the assessment and management of Opioid Dependence as being a process, which consists of a number of ‘phases’.  One conceptual model of this, which comprises four phases, is illustrated in the table below.

It should not be presumed that progress through these phases is unidirectional, nor should the indicative timescales be considered ‘rigid’. Each individual patient must be assisted to undertake a recovery process that works for them.

Much of the rest of this guidance assumes that patients will proceed to introduction of MAT and a period of maintenance/stability. Some patients indicate a preference for (or may be more suitable for) introduction of MAT followed, quite quickly, by detoxification. In particular, this approach may be indicated for people who are between 16 and 18 years of age (OST should only be considered in those under the age of 16 by a specialist), those who have only a short history of opioid use (eg less than 6 months), or who are unconvincingly dependent (using very small amounts, using less than daily, mild or unobservable withdrawal signs/symptoms).

MAT Standard 1: All people accessing services have the option to start MAT from the same day of presentation.

Context: frustration about delays in commencing medication have been consistently identified by service users, as a significant barrier to efficient engagement into treatment. Previous targets (eg to commence treatment within three weeks of first presentation) were an initial attempt to ensure realistic and efficacious access to OST, and a marked improvement on the prior situation (where commencing medication may not happen for several months after referral). At the same time, the process of initiating and titrating people onto OST (Methadone in particular) is one of the highest risk periods in MAT for accidental overdose.

‘Establishing dependence’ previously required two consecutive positive drug tests taken at least a week apart (but within the same four week period), alongside eliciting an appropriate history of dependent drug use, and the identification, at physical examination, of ‘objective signs’ of drug misuse (e.g. injecting sites and/or features of withdrawal). Whilst acknowledging the very real need to remove barriers to induction into, and engagement with, treatment (OST), it is also necessary to maintain cognisance of the reasons for caution when undertaking ‘same day’ initiation of OST.

Within the context of NHS Highland it is relevant to draw attention to the physical and human geography, the state of infrastructure (including communications infrastructure) and the structure of health services generally (including community pharmacy provision). NHS Highland DARS has an absolute commitment to ensuring that, no matter where in the Highlands a person lives, they have access to the same high quality care and treatment for their substance use. NHS Highland DARS continues to work tirelessly to deliver care that is as consistent as possible across the whole region, but there will, inevitably, be some regional variation given the current circumstances – not all of which are within the gift of NHS DARS, the HADP or NHS Highland Health Board to change. Where, due to these circumstances, delivery of care cannot be identical, NHS DARS will continue to ensure that it is of the highest quality possible. It is, perhaps, in attempting to meet MAT 1 (same day prescribing) that these challenges are most apparent.

Overview of approach to ‘same day prescribing’.

Initial assessment/same day prescribing decision

• Undertake initial assessment including: history, examination and toxicology
• For people using opioids, the key goal of the first face to face assessment is to establish if it is safe and appropriate to start OST on that day. Advance telephone or video contact may support the initial assessment
• Assessment is an ongoing process that can be completed over time. There is not an expectation that the full psychosocial assessment will be completed at first attendance, or before OST is started.

The last 28 days (initial history taking)

• What substances are being used?
• What is the duration, amount and frequency of each substance used, including alcohol?
• Routes of drug administration used
• Urine or oral fluid drug screening

Establishing Diagnosis of Dependence

• Follow ICD-11 criteria for diagnostic requirements to confirm dependence
• A prescription for opioid substitute medication should normally only be considered if:
  • opioid use is regular: usually every day
  • there is convincing evidence of current opioid dependence
  • the assessment – including history, examination and toxicology – clearly supports the diagnosis and treatment need. Objective signs can be particularly useful e.g. evidence of injecting sites, opioid withdrawal etc. Tools such as the Clinical Opiate Withdrawal Scale (COWS) can help
  • the clinician is satisfied that the patient should be able to manage the prescribing regimen
  • it can be confirmed that the patient is not receiving an OST prescription from another source

 Additional Information

• Gather further information to support diagnosis of opioid use disorder and same day prescribing decision. Check:
  • for physical and mental health problems that may impact immediate prescribing decision
  • that it is safe to prescribe with other medications taken
  • Confirm with GP, Trakcare, patient. Speak to pharmacist/request medication review if there is any doubt
  • Medication can be stored safely / children cannot access. NB: OST is usually supervised for initiation / titration
  • Pregnancy status if appropriate
  • Driving status / DVLA / Does the person work at heights or have a need for concentration

 Decision on OST same day prescribing

• Can a diagnosis of opioid dependence be made today?
• Would the benefits of starting OST immediately likely outweigh the risks?
• Clinicians should not be pressured to start OST on the same day if there is insufficient information to safely initiate prescribing

Choice of opioid substitute (OST)

• Methadone and buprenorphine are available in NHS Highland. Table 1 compares them.
• Clinical staff involved in managing patients should ensure that they are familiar with prescribing guidance and can effectively discuss options with patients to allow choice in treatment
• If a medication is not offered, the rationale should be clearly explained to the patient and documented.
• Consider patient preference, treatment history, other medical conditions and medication, risk of overdose etc
• Discuss risk of precipitated withdrawal (and ways to avoid this) with patients starting buprenorphine
• Consider practicalities of administering Buvidal® injection if this is the agreed treatment option

 Starting OST on the same day

• Follow titration guidance for each product
• Ensure key worker aware of plan for ongoing titration and review; if this is not the prescriber

If starting OST on the same day is assessed as being inappropriate or unsafe, further assessment around need for OST and/or diagnosis of dependence should occur. Consider:

• other harm reduction and treatment options that could benefit the patient
• additional history, information or drug tests which might help treatment planning
• further assessment when the patient is in the early stages of withdrawal if acceptable to them

 Continue full assessment

• Continue with full assessment of physical health, mental health and social needs
• Same day prescribing does not do away with the need for a comprehensive physical, psychological and social assessment to be undertaken. This is essential and should be continued following the initiation of OST in a bid to improve quality and engagement in assessment when patients are more comfortable
• Provide overdose awareness, Naloxone, safer injecting equipment and BBV testing at initial assessment, or as soon as possible thereafter.

Table 1

Side-effects of methadone include constipation, reduced libido, headaches, sleeplessness, nausea/vomiting, and sweating. Side-effects vary from individual to individual. Many patients report a ’clouding’ effect, which is valued by some but not others. Methadone can cause respiratory depression, dizziness, dysphoria, pruritus, impaired sexual function, increased pressure in the biliary tract, urinary retention and hypotension. Specific concern relates to QT interval prolongation and the risk of torsade de pointes, particularly with ‘high doses’, or where other potentially QT prolonging medications are taken alongside methadone (eg antipsychotics).

Goal:

To establish the patient, as safely and quickly as possible, on a dose of OST that:

• Eliminates withdrawal symptoms
• Reduces the need to take additional illicit opioids
• Keeps side effects to a minimum
• Avoids toxicity

NB: The optimal dose is not necessarily the lowest dose that relieves withdrawal symptoms. It is a dose where the patient feels comfortable but not over-sedated, where cravings are managed and the focus on finding and using substances is reduced.  Insufficient dosing may increase the risk of additional substance use, reduce treatment effectiveness and increase risk of accidental overdose.

On initiation of OST:

• At least one urine or oral fluid drug test should have been performed. Near patient drug screens can be used to support same day prescribing.
• The increased risk of overdose when initiating methadone and buprenorphine should be discussed. Particularly the risk with other central nervous system depressants, including benzodiazepines, antidepressants, other opioids and alcohol. Patients should be encouraged to avoid use of other drugs and alcohol but to take extra care if this is unavoidable eg taking smaller amounts to assess the combined effect, only using ‘in company’ etc.
• Methadone and ECGs: Patients on medication known to prolong the QTc interval or with concerns about cardiac status (symptoms of chest complaints, dizzy spells or blackouts) should be considered for an ECG before commencing methadone.
• This should not stop methadone being offered within same day prescribing. Risks should be discussed with the patient and ECG arranged as soon as possible along with changes to other medications if indicated. If the patient is assessed as being at high risk for QT prolongation or torsade de pointes (see above) an ECG should be carried out and the patient referred to a cardiologist if abnormalities are identified. All patients receiving above 100mg methadone daily should have a baseline ECG and consider repeating annually.
• OST and liver function:
  • ‘Severe liver impairment’ has previously been identified as a situation requiring caution in offering Methadone (risk of medication accumulation and excess sedation), which may cause delays in initiating MAT if the patient requests Methadone, but LFTs are sought prior to commencing treatment. The relevant risks will need to be clearly examined and documented; commencing low dose Methadone (eg 10mg/mls) whilst awaiting blood test results may be an acceptable option.
  • Guidance commonly recommends BBV status and LFTs before starting Buprenorphine. This would exclude buprenorphine as an option for same day prescribing. There is some evidence that buprenorphine does not selectively cause abnormal liver function compared with methadone (3,4) and that patients with Hepatitis C have tolerated buprenorphine treatment. All patients should be offered rapid BBV testing early in treatment. LFTs should be conducted if there are any clinical concerns on hepatic function.

During titration:

• Regular contacts, phone, video call or face to face, should be planned during titration, at least twice weekly.
• Titration should pause if missed contacts or doses occur. The current dose should be maintained until review with the clinician occurs. If pharmacy attendance is erratic, it may be necessary to reduce or withhold further doses for safety until review can occur.

Role of the pharmacy:

• Supervised self-administration should be available to all patients to support induction.
• The pharmacy team should be asked to report ANY missed doses to the prescriber during the titration phase.
• Pharmacy staff should observe patients for symptoms of withdrawal, over-sedation and general presentation.
• It is important for clinicians to routinely obtain the feedback of the community pharmacist when reviewing the patient’s progress during titration.

All patients prescribed OST should be regularly offered naloxone. 

Titration with methadone:

• Methadone should be prescribed as 1mg/ml oral solution. This reduces risk of error during dispensing and administration
• Methadone has a variable half-life of 13 – 55 hours. Inappropriate dosing (starting too high, increasing too fast) in the first few days can result in overdose due to cumulative toxicity.
• START LOW AND GO SLOW: too high an initial dose and/or too rapid an increase adds to overdose risk due to the cumulative effect before steady plasma levels are reached.
• STARTING DOSE: Up to 30mg daily, based on assessment of the person’s opioid tolerance, frequency of use, route of administration, use of other drugs and withdrawal symptoms.
• MAXIMUM DOSE INCREASE IN 24 HOURS: 5mg to 10mg tailored to response. The full effects of the first dose are not experienced until at least day 3. There should therefore be a minimum of 3 days between each dose increase.
• MAXIMUM INCREASE OF DAILY DOSE IN 7 DAYS: 30mg
• USUAL THERAPEUTIC DOSE: for most this will fall between 60mg and 120mg daily
• It is important to ensure patients (and any carers present) can recognise and respond to symptoms of methadone toxicity.

Consideration for starting doses of methadone below 30mg:

• If tolerance is low or uncertain, a starting dose in the range of 10 to 20mg daily may be safer
• Lower doses should also be considered for the following patients:
  • Elderly patients
  • Use or co-prescription of other CNS depressant medication, drugs or alcohol
  • Drug interactions or co-morbidities eg respiratory disease, history of cardiac abnormalities, advanced heart disease, ischaemic heart disease, cardiac conduction issues, long QT syndrome or taking drugs that prolong QT
  • Hepatic impairment
• Clinicians should exercise extreme caution if patients present when significantly intoxicated. These patients would generally not be suitable to be started on the same day and should ideally be reassessed when not intoxicated.
• Given the nature of methadone as a full agonist and the overdose risks when used alongside other opioids or depressants, supervision during titration is recommended.

Titration with buprenorphine:

Please refer to alternate guidance for Buprenorphine oral products (see resources), and guidance for Long acting subcutaneous Buprenorphine depot (Buvidal®).

Use of other opioids as OST:

• Oral opioids other than methadone and buprenorphine, such as dihydrocodeine and slow-release oral morphine preparations are not licensed in the UK for the treatment of opioid dependence. They are not currently recommended for routine use in NHS Highland. In exceptional situations, their use may be considered by senior clinicians in NHSH DARS.

• Following initiation and titration, most patients will have a period of maintenance as an important step towards recovery. The duration of maintenance will vary according to each patient’s needs.
• Maintenance does not prevent future abstinence from opioids. Each patient’s MAT goals should be regularly reviewed to ensure that treatment remains tailored to their needs. Areas of review should include:
  • Current drug and alcohol use
  • Physical and mental health
  • Opportunities to participation in, or support required to participate in, rehabilitation, counselling, relapse and other psychosocial support programmes
  • Progress with family relationships, training and employment
  • Housing
  • Offending and criminal justice
• Prescriber/Key Worker should link patients with the team most qualified to support in each area
• Patients may need to have more regular reviews initially. Frequency of review should be discussed and agreed between patient and clinician as treatment progresses.
• Supervised self-administration should be provided for a length of time appropriate to the patient’s individual needs and risks. Relaxation of supervised self-administration could be considered when:
  • The patient has reached their optimal daily dose of OST
  • Drug and alcohol use has stopped or significantly reduced
  • The patient’s mental health is stable and there is no risk of self-harm through overdose
  • Medication can be stored safely at home, particularly where children are present.
  • There are no concerns of diversion of medication
  • The barriers caused by supervised self-administration eg struggling to employment and education outweigh assessed risk of take home doses
• Clinicians should consider the positive features of supervision eg where daily structure and support of pharmacy staff could be beneficial.

Drug Testing During Maintenance

Random intermittent drug screening is a practical and cost-effective option for providing reliable information about an individual’s recent drug use.  Positive results are not a reason to exclude patients from treatment, rather an opportunity to discuss and reduce harm and review treatment and goals.  The patient’s reporting of drug use will influence the need to test.  It may be most useful where differences between reported use of substances and presentation are raising concerns regarding the risk of harm to the patient.

If the patient’s goals are not being met aim to:

• Increase the intensity of pharmacological and psychosocial support
• Ensure medication is at an optimal dose
• Consider changing to a different substitute medication
• Increase frequency and level of review
• Consider reinstating supervised self-administration to re-stabilise drug use
• If a relapse has occurred, try to discover what has triggered it. Help to develop techniques to regain progress, encourage participation in relapse prevention activities and counselling, training and employment etc.
• Consider the patient / clinician relationship and, if necessary, whether steps can be made to improve this.

Decisions to withdraw support using MAT should not be taken lightly.  MAT reduces risk of overdose, offending, BBV and potentially the risk to children or vulnerable adults in the home.  Every effort should be made to maintain engagement in treatment.

Principles of Maintenance for OST

• Range for maintenance doses:
  • For most patients this will fall between 60mg and 120mg daily.
  • For most patients this will fall between 12mg and 16mg daily. There is evidence of greater retention in treatment and protection against overdose of doses of Buprenorphine ≥ 8mg.
• Some patients may believe that intermittent lapses are due to lack of willpower when it is more likely that the dose of OST is too low. This may require some focused work if patients are not keen to increase the dose above the dose they feel “comfortable” with.
• The dose, frequency of dispensing and patient’s goals should be reviewed regularly ensure prescribing remains appropriate.
• Supervised self-administration is needed for a length of time appropriate to the patient’s needs and risks.

Missing doses of OST- particularly methadone - can lead to reduced opioid tolerance, increasing the risk of overdose.  The reason(s) for missed doses and actions taken in the interim should be considered.  Community pharmacists should contact prescribers if a patient has missed three or more doses of OST and are a source of information on current presentation.  Response should be tailored to each patient’s needs.   Best practice is to review patients, ideally face-to-face, before restarting.

Methadone

3 or 4 consecutive days missed

• Tolerance to opioids will begin to reduce (assuming no non-prescribed opioids taken)
• If there is convincing evidence of use of non-prescribed opioids and maintained tolerance, previous dose can be continued, otherwise
• Reduce the daily dose by 50% or to 30mg methadone, whichever is greater
• Re-titrate upwards by a maximum of 10mg methadone per day and 30mg per week.
• Where this occurs on a Thursday or Friday consideration should be given to using a 7-day pharmacy where available.

5 or more consecutive days missed

• Tolerance will have reduced after 5 days without methadone
• Restart at 30mg daily
• Re-titrate upwards by a maximum of 10mg methadone per day and 30mg per week.
• Where this occurs on a Thursday or Friday consideration should be given to using a 7-day pharmacy where available.

Buprenorphine

Please refer to alternate guidance on the use of oral Buprenorphine products and the use of long acting, subcutaneous buprenorphine depot (Buvidal®).

• aims to reduce the risk of toxicity and overdose
• helps clinicians assess that patients are taking, and tolerating the prescribed dose
• should not be used or viewed as punishment
• is most appropriate at the start of treatment, during titration and during periods of instability or increased risk
• need for supervision should be clearly discussed from the outset
• decision making should consider possible impacts on patient safety and recovery
• Level of supervision and frequency of collection are informed by individual assessment of patient need versus risk(s)
• Primary care colleagues can contact drug and alcohol service for advice if needed
• Risk factors that may indicate a need for supervised administration include:
  • The patient has not reached a stable dose of OST
  • Continued and unstable pattern of drug or alcohol use including non-fatal overdose
  • Significant psychiatric illness or risk of self-harm
  • Concern that prescribed medication is being used inappropriately, diverted (self or under pressure from others) or lost
  • Concerns about the safety of medicines stored in the home and possible risk to children
  • Regular missed "take home" collections: a period of supervision may improve stability

Prior to prescribing thought needs to be given to:

• How medications are being stored at home, particularly if children are present.
• Effect of including the instalment instruction “If an instalment’s collection day has been missed, please still dispense the amount for any remaining days of that instalment” on prescriptions. Community pharmacists may not alert prescribers to variable attendance as quickly as they may otherwise do.

Lost or Spilled Instalments

• Consider risks and benefits of replacing doses
• Increasing frequency of pick up for the remainder of the instalment allows assessment for toxicity by the pharmacy before providing the next dose
• Regular occurrence should prompt review of instalment prescribing to ensure it remains appropriate to risk and need.

Community pharmacies have regular contact with patients and have information which can support decision making. 

Dispensing should be relaxed in a stepwise fashion and reviewed before each step, eg:

• Patients should be reviewed before relaxing dispensing to the next step
• One dose each week continues to be supervised
• Relaxation of dispensing should stop at the level that meets the patient’s needs and level of risk. It can be stepped up again if risk emerges
• Barring exceptional circumstances weekly instalments are the lowest instalment frequency recommended
• If risk factors increase, review of dispensing arrangements should form part of the overall patient review
• A move back to more limited dispensing or supervision is recommended unless there are clear indications the impact on patient care, outcomes or engagement outweighs identified risks.

Return to supervision risks overdose if the full dose is not being taken.

The following options are available.

Table 2

• If there is any uncertainty, seek advice of colleagues within the drug and alcohol service. E.g. during hub/cluster meetings or medical staff or senior clinical staff.

*Example of split supervised/take home re-titration.

Patient prescribed 100mg as a take home dose. 
Pharmacy staff can support process by assessing for signs of toxicity or over-sedation before further increases to the supervised component occur.

Table 4

Where the patient’s goal is stopping OST to be abstinent from all opioids, a supported plan should be agreed and include both preparation and post-treatment support to prevent relapse.

For a patient to give informed consent they need information on:

• The possible physical and psychological aspects of dose reduction, including duration and intensity of symptoms of withdrawal and options for managing these
• Available non-pharmacological approaches to manage and cope with withdrawal symptoms
• The importance of continued support to maintain abstinence and reduce the risk of adverse outcomes
• The importance of telling the prescriber if the reduction is proving too difficult. Dose reduction can be slowed down or stopped at any time until ready to continue
• The benefits that continued participation in psychosocial interventions and key working can have on successful outcomes
• That, as the dose of opioid is reduced, tolerance to previous doses is lost and any relapse into drug taking will carry a high risk of overdose
• For this reason it is important that overdose prevention work and naloxone supply is covered at this point.

Dose reduction in community based settings is suitable for most patients but exceptions may include those who:

• have experienced difficulties with previous care-planned dose reduction
• need medical and nursing care due to significant mental or physical health problems
• require complex poly drug detoxification
• have significant social problems, such as homelessness, that may limit the success of community based detoxification.

Reducing and stopping methadone

• Discuss and agree a plan for reduction with the patient. Consider pros and cons of setting specific targets such as frequency of reduction or an end date. For some this may cause a sense of failure and risk of disengagement if not achieved
• Aim to reduce the daily dose initially by around 5mg every 2 weeks. Most patients will tolerate a reduction in this range until reaching doses around 30mg daily
• Below 30mg, decreasing reductions to 1 to 2mg fortnightly may help
• Prolonged, slow reductions are not recommended – longer reductions are associated with a higher risk of relapse.
• When the patient has reached a daily dose of 30mg methadone or lower a switch to buprenorphine may help in completing the reduction plan. Some patients report this more tolerable.

Reducing and stopping buprenorphine

The principles are the same as for methadone. For specifics, please see written guidance for the use of oral buprenorphine and for the use of long acting subcutaneous buprenorphine depot (Buvidal®).

It is possible to undertake planned detoxification with symptomatic relief only however OST should be encouraged as it is more likely to result in effective outcomes. It is also likely, especially in the last stages of reducing and stopping methadone or buprenorphine, that the patient will experience withdrawal symptoms. The following medication may be helpful (NB: lofexidine is not currently available in the UK):

Symptomatic Relief

Table 3

• Newly abstinent patients are at increased risk of overdose. Support focused on relapse prevention should be offered weekly and continued for at least 4 weeks after stopping OST. Patients should not be discharged during this time.
• Relapse to opioid use will usually require restarting of OST. Clinicians should ensure patients know how to access this quickly if it is needed and know how important it is in reducing risk and minimising any periods of relapse.
• Access to interventions focused on engagement in work-related activity and education or activities to replace lifestyles associated with drug use increases the likelihood of staying drug free. They should be offered and encouraged at all stages of treatment.
• Access to groups such as SMART recovery, Narcotics Anonymous and counselling services should also be highlighted.
• Integrated working with adult or child and family social work if needed should ensure that parents and children continue to receive necessary support.
• Patients remain at high risk of relapse on becoming opioid free. The aftercare phase is therefore a critical part of any abstinence focused care plan.

• Naltrexone is a long acting opioid antagonist.
• Taken on a regular basis after stopping opioids, it can assist in relapse prevention by blocking opioid receptors.
• Motivation is key but supervision of administration can aid successful outcomes.
• Naltrexone should be used only in combination with other forms of support for patients who have recently stopped taking opioids (OST or other).

Transfer to naltrexone

• Naltrexone will precipitate opioid withdrawal symptoms if given to someone who is taking, or has recently taken, an opioid
• Wait for at least 72 hours after last dose of oral buprenorphine or 7 days after the last dose of methadone to initiate naltrexone treatment
• A near patient urine test can be used to support the patient’s opioid free status if there is any doubt
• The initial dose of naltrexone is 25mg followed by 50mg daily. A three-times-a-week dosing schedule may be considered if it is likely to result in better compliance. (eg 100mg on Monday and Wednesday and 150mg on Friday)
• Naltrexone should be continued for at least 6 to 12 months

Caution with naltrexone

• Liver function tests are recommended before starting, one month post transfer and then six monthly. They are essential if patients have any signs of liver disease eg diagnosis of hepatitis
• Naltrexone should be discontinued if there is evidence of progressive hepatic impairment
• Naltrexone does not prevent the use of other classes of drugs, though there is evidence for reduced alcohol consumption for people with problematic alcohol use
• Absence of documented evidence means that naltrexone should only be given to pregnant or breastfeeding women when potential benefits outweigh the possible risks.

Full details of special warnings, precautions and interactions may be found in the Summary of Product Characteristics (see resources).

It is apparent that much drug related morbidity and mortality arises from the use of multiple substances concurrently. The use of potent central nervous system depressants/anxiolytics/hypnotics alongside opioids (prescribed or illicit) multiplies the risk of accidental overdose and death. There continues to be limited high quality evidence to guide the use of prescribed benzodiazepines, however the historical antipathy towards this approach may shift for pragmatic reasons.

The harm reduction benefits of OST are not immediately replicated with prescribed benzodiazepines. It is the effect of the medication itself (especially alongside other medications/substances) which confers risk, rather than the route of administration (cf. injecting of opioids). There are no steady release/once daily benzodiazepine preparations, thus supervision is not practical and diversion will remain a significant issue. We have no access to good alternatives which discourage the use of additional/illicit benzodiazepines ‘on top’ of prescribed medications.

Where people are using illicit benzodiazepines, the ‘ideal approach’ would be to engage them in broad non-pharmacological approaches, motivational interventions, identifying unmet mental health need (and addressing it) and advising practical approaches to gradually reducing benzodiazepine use. Where these approaches fail and/or significant additional risk is apparent (seizures, other severe benzodiazepine withdrawal phenomena, episodes of intoxication related delirium, near-fatal overdose, repeated overdose), there should be discussion with a senior clinician within DARS, about the potential appropriateness for a reducing Diazepam prescription. There are diverse views on the most appropriate starting dose, dispensing arrangements and rate of reduction. The Ashton Manual may be a useful guide. Clinical experience is generally dispiriting.

Where people are receiving benzodiazepines through their General Practitioner, NHSH DARS would not offer to ‘take over’ the prescription; we may have a role in supporting the patient during a reduction plan and offering advice and support to the prescriber.

Being in treatment is, of itself, protective against drug-related death. Clinicians can help to reduce drug-related deaths in their patients by:

• discussing harm reduction strategies to reduce risk of overdose and supply naloxone as soon as possible, and at regular intervals during OST treatment.
• providing prompt access to OST with full support to achieve dose optimisation.
• Considering Buprenorphine as a treatment option in patients with COPD and/or where current risk of overdose is particularly high (eg frequent overdose, significant polysubstance use)
• making patients aware of the higher risk of overdose during induction onto opioid treatment and after periods of loss of tolerance (including missing prescribed doses for a few days or more)
• providing carefully supported exit from OST including a period of aftercare support and planning after stopping OST.
• making patients aware of the dangers of using OST in combination with other drugs, especially benzodiazepines, alcohol, gabapentinoids and other sedating drugs (including prescribed drugs). Considering these risks when making prescribing decisions
• educating patients that the use of their OST by others is extremely dangerous.
• providing education and training or referring families/carers to overdose awareness training and naloxone supply
• Identifying and supporting individuals with an increased risk by virtue of complex medication regimes, multiple diagnoses, social isolation and/or risk of suicide.

Naloxone

• Naloxone is an opioid antagonist and is licensed for use in community settings to reverse the effects of suspected opioid overdose whilst the ambulance arrives
• Systematic reviews conclude that provision of naloxone to patients can be effective and there is also evidence for the effectiveness of training family members or peers in how to administer the medicine.
• Naloxone should be proactively recommended to all patients attending services and is available from all drug treatment services including clinical teams.

It is available in two formats, Prenoxad intramuscular injection and Nyxoid nasal spray (currently non-formulary).  It can be prescribed for dispensing by community pharmacy and planned discharge from hospital or supplied using NHS Highland Guidance or PGD.

• Medication Assisted Treatment (MAT) is more than just OST and should include a comprehensive psychosocial plan tailored to the person’s individual needs.
• Staff should ensure they remain up to date on the interventions available in their area, as well as being familiar with other services available across the Highlands and available elsewhere through NHS Highland.
• One resource that may aid keyworkers is the node-link mapping approach designed by the National Treatment Agency for Substance Misuse illustrated in the publication Routes to Recovery via the Community. This offers a structured and visual set of tools likely to support people with and without cognitive impairment to engage more fully with treatment.

As a brief summary, many of the people seen in DARS require practical help engaging with other statutory and non-statutory bodies including (but not limited to): housing providers, local authorities, social work, other branches of healthcare, Women’s Aid, employers, the DVLA, schools, family members, solicitors, criminal justice services, financial institutions, debt collection agencies, Citizens Advice Bureau.

Many will benefit from non-NHS care providers, including residential rehabilitation services, twelve step/peer support organisations, local/national counselling agencies (eg Addictions Counselling Inverness, APEX, SMART Recovery).

Despite the relatively recent introduction of a clinical psychologist within NHS Highland DARS, provision of/access to psychological therapy remains suboptimal and there continue to be recognised barriers to this group of patients receiving equitable access to general Mental Health services. Due to the very high level of co-morbidity in our client group, continuing to advocate on their behalf and assisting them to engage with statutory and non-statutory mental health agencies, will remain a key part of successful recovery.

NHSH DARS is implementing a number of different approaches to responding rapidly to near fatal overdoses and assertive outreach to individuals otherwise identified as being at high risk of drug related harm/death (eg recent liberation from prison, recent detoxification from OST, recent discharge from hospital or residential rehabilitation). The aim is to engage and induct high risk individuals into treatment as rapidly as can be managed, and maintain them in treatment.

The approaches being taken vary to an extent depending upon the catchment and the structure of the local team. In Inverness city, the response is being led by the Senior Nurse Practitioner, InverNess Engagement Service (NES) (Rapid Response Pathway to reduce drug related deaths in Highland).

• DARS: Drug and alcohol recovery service
• MAT: medication assisted treatments
• OST: Opioid substitution therapy