Guidance and Protocols on the Clinical Management of
Drug and Alcohol Users
MANAGEMENT OF OPIATE DEPENDENCE ON MEDICAL &
SURGICAL WARDS
INTRODUCTION
Not every person who uses heroin or other opiates regularly is necessarily
dependent on opiates. The nature of the disorder (e.g.. problematic use,
dependence, etc) determines the treatment required. Even when dependence
on opiates is diagnosed the chronicity, nature, severity and level of problems
experienced may indicate different modes of treatment (e.g. detoxification,
maintenance, etc). An assessment of the three following areas is necessary to
determine what treatment, if any, is needed:
 Consumption
 Dependence
 Problems
Patients who are physically dependent on opiates may need substitute
prescribing to:
 Relieve the distressing symptoms of opiate withdrawal
 Minimise/stop injecting behaviour and therefore promote harm reduction
 Minimise/stop the use of illicit opiates
 Encourage positive treatment outcomes.
Some patients who are obviously opiate dependent may prefer symptomatic
treatment to substitute prescribing e.g. methadone.
If there is doubt about the degree of dependence it is advisable and safer not to
prescribe substitute medication initially but observe the patient until the signs
and symptoms of opiate withdrawal are evident
If opiate withdrawal is apparent the required dose of substitute medication is
titrated against presenting physical withdrawal symptoms in order to “stabilise”
the patients. This guidance and protocol provides a framework in which to work.
Be cautious in prescribing controlled drugs or other psychotropic medication
and do not discharge patients on substitute medication until you have an
agreed aftercare plan
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Guidance and Protocols on the Clinical Management of
Drug and Alcohol Users
ADMISSION GUIDELINES
On admission check if the patient is known to a drug prescribing service. If
currently on a prescription contact the prescriber and the community pharmacy
to confirm the last administered dose and the prescription details (ie. drug,
dose, frequency, and method of administration). If the patient is already being
prescribed treatment (e.g. methadone or buprenorphine) see later
History & Clinical Assessment
Assessment should balance the needs of the patient with those of the medical
practitioner. The doctor must ensure that an adequate assessment has been
made before prescribing symptomatic treatment, substitute opiates or other
controlled drugs. No doctor should feel pressurised into issuing medication until
he or she is satisfied that an appropriate assessment has been completed.
In patients who are seriously ill and unable to provide a history or whose
physical assessment is compromised by more serious problems treatment
decisions must consider the risks and benefits. It is probably safer to withhold
medication initially, assess repeatedly and administer small doses of medication
frequently. Some medication may need to be given parentrally.
Past and current (last 4 weeks) drug use
 Types and quantities of drugs taken (including concomitant alcohol
misuse)
 The duration of drug misuse (including alcohol and nicotine)
 Frequency of misuse and routes of administration
 Accidental overdose
 Periods of abstinence? If yes, triggers for relapse?
 Symptoms experienced when unable to obtain drugs?
Medical history
 Complications of drug use – abscesses, thrombosis, viral illnesses,
bacterial infections, chest problems, dental disease
 Hepatitis B, C status (if known)
 HIV status (if known)
 Last menstrual period (pregnancy test if appropriate)
 Operations, accidents, head injury
Psychiatric history
 Psychiatric admissions/outpatient attendance
 Any overdoses (accidental or deliberate)?
 Any previous episodes of depression or psychosis?
 Past and current treatment by GP with any psychotropics or analgesics.
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Guidance and Protocols on the Clinical Management of
Drug and Alcohol Users
Physical examination
 Signs of intoxication or withdrawal
 Needle marks
 Thrombosed veins
 Signs of complications of opiate use (abscesses, DVT etc)
Hematological investigations
 Full blood count
 Urea and electrolytes, creatinine, liver function tests
 Hepatitis B & C serology
 HIV antibody
Before any test, full informed consent should be obtained from the patient
Urine assessment
Urine analysis should be regarded as an adjunct to the history and examination
in confirming drug use, and should be obtained at the outset of prescribing and
randomly throughout treatment (request ‘Full Drug Screen’). Mouth swabs are a
useful alternative to laboratory urine testing and may be more acceptable to
patients. Ward based dip tests are useful for immediate confirmation of drug
use.
Results should be interpreted by an experienced clinician and in the light of
clinical findings, as false negatives and positives can occur. If results do not
correspond to the patient’s history, repeat the urine toxicology test/mouth swab
before taking any action, as laboratory errors can occur.
NB: If the urine test is negative for opiates and there is no evidence of opiate
withdrawal symptoms, the patient is very unlikely to be physically dependent
on opiates and should be reassessed in the light of this.
Breath Alcohol
If alcohol use/intoxication is suspected then breathalyse the patient and
interpret the reading in light of the patients reported daily consumption and last
reported drink.
Patient Assessment
Assessment should also take account of the sequlea of opiate use (i.e.
intoxication/withdrawal). It is important to note that intoxication with opiates
alone is not enough to diagnose dependence. However, withdrawal symptoms
suggest abstinence syndrome, which is one of the characteristics of
dependence.
If opiate dependence is still suspected after initial assessment but not confirmed
then reassess the patient 4 hours later.
Opiate withdrawal should be formally assessed using the Objective Opiate
Withdrawal Scale (OOWS – see appendix 1)
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Guidance and Protocols on the Clinical Management of
Drug and Alcohol Users
Opiate Intoxication: Signs And Symptoms
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Euphoria/relaxation
Constricted pupils (pinned)
Drowsiness
Feelings of well-being
Poor attention/concentration
Slurred speech
Opiate Abstinence Syndrome: Signs And Symptoms
Withdrawal from opiates is associated with a specific withdrawal syndrome.
Untreated heroin withdrawal typically reaches its peak 36-72 hours after the last
dose and symptoms will have subsided substantially after 5 days.
Untreated methadone withdrawal typically reaches its peak between 4 to 6 days
and symptoms do not substantially subside for 10 to 12 days.
Signs and symptoms are graded in their intensity and do not necessarily follow
a chronological order, however, below is a useful checklist (table 1) by which
you would expect to see withdrawal phenomena in the opiate dependent
patient.
Table 1. Times of appearance of abstinence signs in physically dependent
opiate addicts
Signs and Symptoms
Drug craving, anxiety, drug – seeking
Yawning, sweating, running nose, lacrimation
Increase in above signs and:
Dilated pupils, goose-flesh, tremors, hot/cold flushes, aching
bones/muscles, loss of appetite, abdominal cramps and irritability
Increase in intensity of above and:
Insomnia, increased blood pressure, low grade fever, increased
respiration, increased pulse rate, restlessness, nausea and vomiting
Increase in intensity of above and
Weight loss, diarrhoea, weakness, febrile, fetal position (curled up
on a surface), increased blood sugar
Source:
Ghodse
Hours after last dose
Heroin
Methadone
6
8
34-48
12
48-72
18-24
24-36
36-4days
36-4days
(1998)
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Guidance and Protocols on the Clinical Management of
Drug and Alcohol Users
TREATMENT OPTIONS
This guidance is not an exhaustive list of options for the management of opiate
use/dependence. The treatments identified have been selected with the
medical/surgical setting in mind. See care pathways (appendices 2 and 3)
The likely outcomes following assessment can be summarised as:
 Patient admitted on established community methadone
 Patient admitted with opiate dependence and in need of treatment
a) Patients whose admission is likely to be short term (days)
b) Patients whose admission is likely to be long term (week(s))
 Patient not opiate dependent
Patient admitted on an established community methadone programme
Contact the prescriber and the community pharmacy to check the last
administered dose and confirm prescription details (ie. drug, dose, frequency,
method of administration, last dose dispensed).
If there are no contraindications the dose should be administered as prescribed.
If there is any doubt as to when the patient last took a dose of methadone
withhold opiate medication until withdrawal symptoms appear. A single morning
dose is the preferred option but methadone can be given in divided doses to
help establish more sustained serum methadone levels, therefore making the
patient more comfortable. Never give methadone to any patient intoxicated
with opiates or other drugs including alcohol. Wait until the patient is
sober/non intoxicated before administering methadone.
The patient should be reassessed during the hospital admission. If there is
evidence of opiate withdrawal, opiate intoxication or continued illicit drug use
despite substitute prescribing an assessment should be requested from
specialist services.
The ward needs to liase with the community prescriber as early as possible so
the prescriber can cancel the existing community prescription and be prepared
to recommence the prescription on discharge. Continuation of the ward
prescription should be organised well in advance of discharge. NB community
services are mostly closed at weekends and Bank Holidays. Methadone doses
should always be converted to a single daily dose prior to discharge.
Cautions
Illicit opiate use “on top” of methadone prescription
If there is evidence of regular additional heroin use concurrent with a
methadone prescription restricting heroin use by admission may result in either
heroin being brought on to the ward to “help” control withdrawal phenomena or
the patient discharging themselves prematurely. In these circumstances the
patient’s methadone should be titrated as specified below.
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Guidance and Protocols on the Clinical Management of
Drug and Alcohol Users
Community Prescription not dispensed in the last 3 days
If patients miss methadone doses, for whatever reason, they need to be
reassessed for intoxication and withdrawal before methadone administration is
recommenced. It may be appropriate to reduce the dose by up to 30% if the
patient has not had methadone for 3 days, as their tolerance may be reduced.
Community Prescription not dispensed in the last 4-5 days
If a patient has abstained from methadone for 4 days or more, they will require
a full assessment before methadone is recommenced. Do not reinstate the
patient onto their original dose but retitrate methadone as prescribed below.
Dispensing arrangements for patients on discharge
This group of patients should not be issued with 7-day discharge prescriptions
for controlled drugs (e.g. Methadone). Discharge prescriptions should either be
for I or 2 days or if longer specify daily supervised consumption at a
prearranged community pharmacy
Patient admitted with opiate dependence and in need of treatment
The assessment process will help determine the treatment modality to follow.
This protocol suggests the use of two different approaches:
a) Symptomatic treatment/detoxification
b) Stabilisation on an appropriate dose of methadone or buprenorphine
The table below will help determine the appropriate treatment option:
Table 2: Guide to treatment
medical/surgical setting
for
patients
assessed
within
the
Symptomatic treatment/detoxification
Stabilisation on an appropriate dose of
methadone
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Short duration of opiate use
(e.g. 12-18 months)
Mildly – moderately opiate dependence
Younger age group
Willingness to detoxify
Medically fit to undergo detoxification
Considered for short admission (i.e. from
£30 heroin will require 7-10days
admission
May be more appropriate for those
smoking heroin
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May be appropriate for short duration
stabilisation if community prescriber
identified on discharge
(Needs admission to last 3-5 days)
More suitable for patients with extended
career of opiate dependence
Willingness to stabilise
More suitable for extended admissions in
which community prescriber can be
identified
May be more appropriate for intravenous
opiate user
NB those patients who fulfil the criteria for opiate stabilisation but whose
admission is likely to be too short to adequately or safely stabilise on
methadone should be treated symptomatically and referred to an external
treatment agency on discharge.
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Guidance and Protocols on the Clinical Management of
Drug and Alcohol Users
Symptomatic detoxification
Symptomatic treatment of withdrawal is most likely to be successful for patients
who are using less than 1 gram of heroin a day, have a short history of use, are
not using other illicit substances and have a mild degree of dependence. The
following drugs can be used as symptomatic treatment of withdrawal symptoms
– Hyoscine butylbromide (Buscopan) 20mg prn up to qds for stomache
cramps
– Lomotil 2 tablets prn up to qds or loperamide 2mg prn up to qds for
diarrhoea
– Ibuprofen 200-400mg tds/qds for bone/joint pain
– Trazodone 50-100mg nocte for insomnia
Withdrawal symptoms can be monitored using the Objective Opiate Withdrawal
Scale (OOWS) which provides a comparison over time (appendix 2).
Symptomatic detox may be carried on over 7-10 days
OPIATE WITHDRAWAL SIGNS AND SYMPTOMS
Objective Signs
(observable and not easily feigned)
 Increased blood pressure
 Increased pulse rate
 Increased temperature
 Piloerection (goose flesh)
 Increased pupil size
 Rhinorrhea
 Lacrimation
 Tremor
 Insomnia (Not Self-Report)
 Diarrhoea
 Vomiting (sometimes may be self – induced)
Subjective Symptoms
(not directly observable and easily feigned)
 Nausea
 Muscle (bone) aches
 Abdominal (stomach) cramps
 Irritability
 Anorexia
 Weakness/tiredness
 Restlessness
 Headache
 Dizziness/light headedness
 Sneezing
 Hot or cold flashes
 Drug craving
Cautions
The Detoxified Patient (Loss of Tolerance)
The patient should be warned of the risk of drug overdose on leaving hospital,
due to loss of tolerance. Accidental overdose is often due to reduction in
tolerance after period of abstinence (e.g. release from prison, discharge from
rehabilitation or hospital).
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Guidance and Protocols on the Clinical Management of
Drug and Alcohol Users
Stabilisation on methadone
Patients who are physically dependent on opiates may need methadone to
relieve the symptoms of opiate withdrawal. However, if there is doubt as to the
degree of dependency it is safer to withhold medication initially and observe the
patient until the clinical manifestations of withdrawal become clearer. Opiate
withdrawal may be very uncomfortable but is not dangerous or life threatening
Methadone is not an innocuous drug and inappropriate prescribing can:
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Cause fatal overdose
Simply increase a person's total drug consumption
Increase the drug-related chaos in a person's life
Supply the illicit market
Demoralise prescribing and other staff
Reduce respect for the prescribing agency among both drug users
and other helping agencies
Reduce the client's motivation and ability to achieve abstinence
Create opiate dependence
NEVER give methadone to a patient already intoxicated with opiates or
other drugs including alcohol
If opiate withdrawal is apparent the dose of methadone is titrated against
presenting physical symptoms to “stabilise”.
NEVER give more than 20mls (Methadone Mixture 1mg/1ml) as an initial
dose to patients not receiving a methadone prescription in the community.
4-hourly nursing/medical observation (TPR, signs of withdrawal and
intoxication) Objective withdrawal symptoms are assessed using OOWS
(see Appendix 2). Titrate the dose of methadone against observable opiate
withdrawal symptoms. Increase in increments of 5-10mg every 4-hours until
stabilisation is achieved.
The administration of methadone and subsequent increases should only
take place on evidence of objective physical withdrawal and NOT solely at
the request of the patient.
Although there will be a 4 hourly objective assessment of withdrawal
symptoms should the patient request a review of their medication the
assessment can brought forward
The total dosage needed to suppress withdrawal (but not cause intoxication)
throughout the first 24 hr period of stabilisation is the “stable dose” which
can be given either as a single dose or in divided doses, twice daily.
Subsequent dose increases should be either as a result of objective
withdrawal or on the advice of specialist services
The dose should be changed to once daily 2-3 days prior to discharge.
Most opiate addicts will be comfortably maintained on 40 – 60 mls daily
whist an inpatient. Some may require more.
If in any doubt contact the specialist substance misuse service
At present buprenorphine prescribing should only be initiated following advice
and assessment from specialist addiction services.
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Guidance and Protocols on the Clinical Management of
Drug and Alcohol Users
General Management:
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To avoid illicit drug use on the ward: ingestion of medication should be
observed; freedom to wander the hospital should be controlled; visitors
should be limited and regular urine samples should be taken.
Consideration should be given to placing the patient’s bed close to the
nursing station to facilitate observation
Some opiate users abuse other drugs. Concurrent dependence on alcohol
and sedative drugs (e.g. benzodiazepines/barbiturates) can cause severe
withdrawal symptoms and may require stabilisation on a sedative drug of the
same class (e.g. diazepam)
If detoxification is considered this should be discussed with members of the
SSMS Medical Staff first to assess suitability and regime
Special Situations
Insomnia
Insomnia can present a management problem. The patient and the team must
appreciate that difficulty sleeping is a feature of opiate withdrawal and therefore
as the titration of methadone progresses there will be a limited need for medical
treatment. Hypno-sedative medication e.g. benzodiazepines and the Z drugs
(Zimovane etc) are dependence producing and should be avoided
Night sedation may be given e.g. trazodone 50-100mg nocte but should be
limited to a few days and NOT be given as discharge medication. The use of
benzodiazepines should be actively discouraged unless there is evidence of
concurrent benzodiazepine dependence in which case advice should be sought
from specialist services.
Analgesic Needs:
Patients maintained on methadone because of their addiction may require
additional analgesia for pain depending on their medical condition or procedure.
If indicated, opiate analgesia can be given and the patient carefully observed for
signs of over-sedation. HOWEVER, the following drugs should be avoided, due
to their mixed agonist/antagonist affects.
 Pentazocine
 Buprenorphine
 Butorphanol
 Nalbuphine
Pre and Post Operative Pain Relief
Methadone may be given as per the patient’s usual requirements up to 3 hours
before surgery. Post operatively methadone should be continued at the same
dose (IM in split doses if necessary). Other opiates can be prescribed for
analgesia as if the patient were opiate naive and the dose titrated according to
the need for pain relief
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Guidance and Protocols on the Clinical Management of
Drug and Alcohol Users
Patients Prescribed High Dose Buprenorphine (Subutex)
Patients maintained on high dose buprenorphine have a reduced response to
opiate analgesia and may require larger doses of opiate analgesics than
patients not in buprenorphine treatment do. If opiates are required for pain
relief a temporary increase in buprenorphine dose may provide sufficient
analgesia. If opiates such as morphine are clinically indicated then the dose will
need to be closely monitored especially if buprenorphine is stopped, as there is
a risk of overdose
Pain relief should be carried out as per the Hull and East Yorkshire Hospital
Guidelines. The Pain Management Service can be contacted for advice if
necessary
Transfer of Methadone Prescription to Community Services
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Prior to initiating the methadone titration the ward will need to be assured
that they are able to transfer the prescription to the community prescriber.
If the patient does not have a current community prescriber then contact
should be made with the specialist addiction services
Prior to discharge the ward team and the specialist addiction services will
negotiate the transfer date of the prescription to the appropriate service (GP,
Community Drug and Alcohol Team etc).
Where the patient is medically fit enough to present to a community clinic
they will be asked to attend a clinic appointment.
Where the patient is not medically fit enough to attend a community
appointment they will be supported at home. It is the responsibility of the
nominated addiction worker who assessed the patient on the ward to
ensure the smooth transition to community prescribing.
Where the patient has demonstrated consistent poor compliance during their
hospital admission a decision to prescribe or not to prescribe may need to
be made in the community. This may result in a re-assessment of the case.
Community prescriptions will be via supervised daily consumption initially.
Dr D J Armstrong, Clinical Director Trust Addiction Services
Mr T Phillips, Consultant Nurse Trust Addiction Services
Humber Mental Health Teaching NHS Trust
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Guidance and Protocols on the Clinical Management of
Drug and Alcohol Users
Appendix 1
Objective Opiate Withdrawal Scale (OOWS, Handlesman et al, 1987)
Name:
Unit Number:
Objective Opiate Withdrawal Scale (OOWS)
Date: __________________________________________________
Observe the patient during a 5 minute observation period then indicate a score for each
of the opioid withdrawal signs listed below (Items 1-13). Add the score for each item to
obtain the total score
Sign
Measures
Yawning
0 = no yawns
1 = ≥ 1 yawn
Rhinorrhoea
0 = < 3 sniffs
1 = ≥ 3 sniffs
Piloerection (Observe
0 = absent
1 = present
Perspiration
0 = absent
1 = present
Lacrimation
0 = absent
1 = present
Tremor (Hands)
0 = absent
1 = present
Mydriasis
0 = absent
1 = ≥ 3 mm
Hot & Cold Flushes
0 = absent
1 = shivering/huddling for
Score
(AM)
Score
(PM)
arm)
warmth
Restlessness
0 = absent
1 = frequent shifts of position
Vomiting
0 = absent
1 = present
Muscle twitches
0 = absent
1 = present
Abdominal cramps
0 = absent
1 = holding stomach
Anxiety
0 = absent
1 = mild-severe
TOTAL SCORES
Range 0-13
Rater’s name: __________________________________________________
Rater’s Designation: _____________________________________________
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Guidance and Protocols on the Clinical Management of
Drug and Alcohol Users
Appendix 2
Treatment Options for Patients already on a Community Prescription of
Methadone
Opiate use identified by
history, clinical examination
or urinalysis
Patient already on a
community prescription for
methadone or buprenorphine
Check details with
community prescriber and
pharmacist
Check for signs of
withdrawal or intoxication
Take urine for drug screen
Patient intoxicated
Withold prescription until
sober /non intoxicated
Patient not intoxicated
Last community
prescription issued
within 3 days
Last community
prescription issued
up to 3 days ago
Continue prescription
Request liaison
assessment if patient is
unstable
Assess for withdrawal
/intoxication
Reduce prescribed
methadone dose by up
to 30%
Last community
prescription issued
>3 days ago
Retitrate
See appendix 4
Reassess daily
Repeat urine drug
screen
Request specialist
assessment if patient
unstable
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Guidance and Protocols on the Clinical Management of
Drug and Alcohol Users
Appendix 3
Treatment Options for Patients not on a Community Prescription
Opiate use identified by
history, clinical examination
or urinalysis
Patient not on a community
prescription
Assess severity of dependence
 History
 Physical examination
 Urinalysis
 OOWS
Assess for use of other drugs
including alcohol
Day1
Titrate onto methadone over 24
hours + symptomatic treatment if
required
Day 2 onwards
Prescribe total dose given in the
first 24 hours (stable dose)
symptomatic treatment if required
Reassess daily
Repeat urine drug screen
Request specialist assessment if
patient unstable
Symptomatic detoxification
(see table 2)
 Hyoscine
butylbromide
 Lomotil or
loperamide
 Ibuprofen
 Trazodone
Reassess daily
Repeat urine drug screen
Request specialist assessment if
patient unstable
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