Patients admitted to Raigmore Hospital with opioid misuse

exp date isn't null, but text field is

These guidelines have been produced to promote consistency and good practice for patients admitted to Raigmore Hospital who are dependent on non prescribed opiates primarily heroin

Patients seen for treatment at A&E

A patient who attends A&E and is dependent on opiates who does not require admission to hospital, should not be prescribed opiate replacement therapy. They should be encouraged to refer themselves to their local drug and alcohol recovery service. Replacement doses of lost/stolen ORT should also not be provided.

Assessment
History of substance misuse

At the time of admission a full drug and alcohol history should be taken.  Clarify what other substances are being taken such as benzodiazepines, cocaine or gabapentinoids and what dose is being taken.

If alcohol dependence is suspected as well as opioid use, the detoxification from alcohol should take precedence.  Benzodiazepines prescribed in alcohol detoxification will help some of the symptoms associated with opioid withdrawal. 

Opioid withdrawal is uncomfortable but not life threatening, overprescribed opioid replacement is.

Every opportunity should be taken to provide patients with information on harm reduction eg naltrexone and other services and supports available within their area.

Contact Mental Health Liaison Team on ext 6224 if advice is required.

Establishing past and present contact with services will provide opportunities to confirm history of use.

In line with present guidance all patients should be asked about dependent children/ children in the household establishing –

  • names,
  • ages,
  • is parental drug or alcohol use impacting on them,
  • do they require extra support with the children,
  • are agencies already involved.

This needs to be handled particularly sensitively to support patients in being as open as possible.

Examination

Examination helps towards confirming history. All injection sites require to be examined and carefully documented. Identifying information regarding complications of drug use and of any current or previous injecting – including localised infections, abscesses, DVTs or damage to peripheral circulation or heart valves, as well as HIV, hepatitis B infection and vaccination, and hepatitis C status. It should also be noted if patients are smelling of alcohol, appear sedated or in withdrawal. (As per orange drug misuse and dependence guidelines 2017)

Signs of opioid withdrawal require to be carefully documented, see opioid withdrawal chart, Appendix 1 at end of document.

If a patients presentation is causing concern (aggressive, agitated, over sedated) do not assume this is caused by their drug misuse.  A full examination is required to exclude potential medical causes.

Investigation

Investigation depends on presentation and should be used to verify history and examination.

Blood alcohol levels – establish on admission by use of breathalyser and/or blood ethanol levels to ensure any alcohol problems are identified and treated if necessary.

Patients using drugs may at times find it difficult to provide an accurate history of their drug use, particularly if that results in impairment of consciousness or cognition.

On site instant urine screening for opiates can be particularly helpful in establishing:-

  • a baseline of use
  • confirming present drug use
  • or identifying drugs not declared in a patients history

but they have their limitations e.g. if a patient is prescribed and regularly taking co-codamol or other prescribed opioid medication an opioid test would be positive and therefore it could not confirm whether that individual is taking heroin.

Management on the ward

Any difficulties on the ward, contact MHLT

Datix must be completed as per NHS Highland policy for any disruptive, threatening/ aggressive or violent behaviour.

Treatment

If opioid dependency is established through a history of opiate misuse, signs and symptoms of opiate withdrawal and a positive urinary drug screen for opiates or 6-MAM (heroin), then the treatment will follow the guideline in the appendix.

  • Methadone Guidelines
  • Opioid Withdrawal Recording Chart
  • Prescription Chart - Methadone 
  • Services providing substitute prescribing

The patient will be made aware that methadone will not routinely be prescribed post discharge unless agreed by the Mental Health Liaison Team and the Drug and Alcohol Recovery Service.

If the patient is keen to continue with ORT on discharge, MHLT and Drug and Alcohol Recovery Service will work to try and facilitate this.

Patients already receiving substitute prescribing

If a patient is already receiving methadone/suboxone/subutex treatment in the community this should be continued where appropriate during their admission.

It is important to clarify who is prescribing for the individual as there are now a number of services where Opiate Replacement Therapy (ORT) is prescribed, see Appendix 4. 

In the first instance ask the patient who their prescriber and pharmacy are.  Raigmore Pharmacy or MHLT can provide advice.

Confirm with prescriber and community pharmacist at the earliest opportunity:-

  • Present dose of ORT
  • Dispensing arrangements – daily, supervised, unsupervised etc
  • If unsupervised dispensing, who collects ORT on their behalf
  • When was the last dose collected and how many days was this for - take into consideration if admitted on a Saturday they should still have Sunday’s dose at home but this requires to be confirmed with the patient as they may have used 2 days on the Saturday.
  • Are any other drugs being prescribed e.g. diazepam
  • Do they attend regularly or have they recently missed any days, if they have missed more than 72hours, they must re-titrate. MHLT can advise on dose reduction/re-titration.
  • Any other concerns with regards presentation e.g. alcohol use, sedation

It is important to inform the prescriber and community pharmacist when someone is admitted as this prevents use by others when the prescription is unsupervised, while providing the opportunity for ongoing liaison and discharge planning.

Discharge planning

Ensure patient is informed that tolerance level for opioids will be reduced due to admission to hospital and are at greater risk of overdose on discharge.

Patients already on a substitute prescribing programme

Planned discharge - as soon as the discharge date is agreed:-

  • the prescriber/ CPN(A) requires to be informed to arrange ongoing prescriptions, provide them with a brief overview of treatment and physical condition.
  • Of particular relevance would be any restrictions regarding their mobility or other ongoing problems/ needs that may make it difficult for them to attend appointments or the chemist (pharmacy).
  • Although Osprey house is open Monday - Saturday, community based prescribers are not always available.

Unplanned discharge

  • should patients consider taking their own discharge they should be advised that immediate transfer of prescribing will not be possible.
  • Advise them that it is their responsibility to contact their prescriber/ CPN(A) as soon as practicable to arrange their next prescription.
  • Staff to contact prescriber/ CPN(A) at the earliest opportunity to advise them of unplanned discharge and provide update.

Advise the patient on the risk of decreased tolerance to opiates and risk of overdose if resuming opiate drug use.

Patients not previously on a substitute prescribing programme

Planned discharge - for those started on methadone in hospital, there will be no routine prescription of methadone on discharge unless specific arrangements have been made between The Mental Health Liaison Team (MHLT) and addiction services.

Unplanned discharge -  no opiate or benzodiazpeines will be prescribed for patients taking their own discharge against medical advice. The patients should be encouraged to contact local treatment services.

Those involved in the development of these guidelines

Marion Bethune, Mental Health Liaison Nurse, Raigmore Hospital
Dr David Gordon, Consultant Psychiatrist, New Craigs
Dr Grant Franklin, Consultant Physician, Raigmore Hospital
Stacey Beats, New Craigs Pharmacist
Kirsti Mjoseng, Raigmore Pharmacist
Dr Alex Keith, Consultant Psychiatrist, New Craigs

If clarification regarding these guidelines is required or specialist advice from either psychiatry or medicine is needed please contact either Dr David Gordon at New Craigs or Dr Grant Franklin at Raigmore Hospital.

Glossary
Abbreviation Meaning
MHLT Mental Health Liaison Team
ORT Opiate Replacement Therapy
CPN Community Psychiatric Nurse
CPN(A) Community Psychiatric Nurse in Addictions
Appendix 1 - Guidelines for the management of patients admitted to Raigmore Hospital with suspected opioid dependence

EXCLUDING PATIENTS ALREADY ON ORT

IMPORTANT

  • Do not prescribe methadone on an “as required” basis
  • Write on prescription “do not give if drowsy” in comments box on methadone prescription chart
  • Breathalyse and check alcohol levels
  • Do not give if patient is drowsy, sedated, ataxic, has slurred speech or is asleep
  • Do not give if patient has been absent from the ward or suspect illicit drug use
  • Do not allow patient to leave ward for 4hours after administration
  • Inform patient that methadone is not given on discharge unless arranged with community prescriber
  • If opioids are required for analgesia this will be in addition to this regime for managing patient’s opioid dependence.

Appendix 2 - Opioid Withdrawal Recording Chart

For recording chart see here

Appendix 3 - Prescription Chart - Methadone Mixture

For prescription chart click here

Appendix 4 - Services providing substitute prescribing

 Individuals GP practice with Community Psychiatric Nurse (Addictions) support.

Non enhanced services

These services are for patients who are registered with GP practices that do not prescribe methadone.

Inverness Drug and Alcohol Recovery Service
Substance Misuse Service
Royal Northern Infirmary
Inverness
Tel – 01463 706972

Osprey House Substance Misuse Day Services
Raigmore Avenue
Inverness
Tel 01463 716888

Badenoch and Strathspey Drug and Alcohol Recovery Service
Rathven
100 Grampain Road
Aviemore
PH22 1RH
Tel 01479 813400

Caithness Drug and Alcohol Recovery Service
CMHT Bankhead Road                             
Wick
Caithness
KW1 5LB
01955 606915

Caithness Drug and Alcohol Recover Service
CMHT Dunbar Hospital
Ormlie road
Thurso
KW14 7XE
01847 891224

Lochaber Drug and Alcohol Recovery service
Fort William Health Centre
Camaghael
Fort William
PH33 7AQ
01397 709830

Mid and East Ross Drug and Alcohol Recovery Service
County Community Hospital
Saltburn Road
Invergordon
IV18 0JR
01349 855677

Nairn and Ardersier Drug and Alcohol Recovery Service
Nairn Town and County Hospital
Cawdor Road
Nairn
IV12 5EE
01667 422786

Criminal Justice Substance Misuse Team DTTO Service
Criminal Justice Services
Inverness Justice Centre
Longman Road
IV1 1AH
01463 644900

Porterfield Prison – for patients recently released from prison confirmation of prescribing within prison can be obtained.
Duffy Drive
Inverness
Tel – 01463 229000

Drug and Alcohol Services Elgin
Drug and Alcohol Team                                
252 High Street                                              
Elgin
IV30 1BE
Tel – 01343 552211

Moray Council on Addictions (Voluntary)
As above

Studio 8
8 North Guildry Street
Elgin
IV30 1JR
Tel – 01343 543792

Editorial Information

Last reviewed: 30 April 2020

Next review: 30 April 2023

Approved By: TAM subgroup of ADTC

Reviewer Name(s): Consultant Psychiatrist

Document Id: TAM454