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Home > New clinical guidelines for management of opioid substitution in hospital setting.

Lyons, Suzi (2020) New clinical guidelines for management of opioid substitution in hospital setting. Drugnet Ireland , Issue 74, Summer 2020 , pp. 30-32.

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In December 2016, the Health Service Executive (HSE) launched its clinical guidelines for opioid substitution treatment (OST)1 in conjunction with the College of Psychiatrists of Ireland, the Irish College of General Practitioners, and the Pharmaceutical Society of Ireland. Appropriate policies and standard operating procedures for the delivery of inpatient OST are essential for patient safety when treating a person with an opioid dependency. 

Following the publication of those guidelines, it became apparent that there was a need for a specific set of guidelines covering inpatient aspects for the prescribing and dispensing of OST within the hospital setting.2 

Having identified the specific need for guidance within the hospital setting, the new document is an adjunct to Clinical guidelines for opioid substitution treatment. It is divided into seven sections, each covering the different aspects of OST treatment: the guiding principles; rehabilitation and psychosocial components of OST; principles and key operational stages of pharmacological interventions of OST; assessment of dependence and management of OST; drug testing; OST and associated health considerations; and specific treatment situations and populations.3,4 

A brief summary of the key points specific to the hospital setting is provided below. 

OST in hospital setting

  • The main objective of drug treatment in hospital is to stabilise drug misuse as quickly as possible in order to treat a drug-related or non-drug-related condition.
  • Occasionally, patients may use the opportunity afforded by a hospital admission to reduce their drug use or to complete a detoxification. This may be useful, but if unplanned, it is likely to result in relapse upon leaving hospital, in turn exposing the patient to a higher risk of overdose.
  • Transfer of care upon both admission and discharge require a coordinated response by treating staff.
  • Routine planned admissions to hospital are preferable.
  • Acute hospital settings and mental health inpatient units should have access to naloxone in case of opioid overdose.
  • Substitute opioids or other controlled drugs should only be prescribed following a comprehensive assessment. 

Assessment aims

1     Facilitate treatment of an emergency or acute problem or for an elective procedure to take place

2    Confirm the patient is taking drugs (history, examination, urinalysis)

3     Identify any complications of drug misuse and evaluate risk behaviours (blood-borne viral screening, nutrition, alcohol intake)

4     Consider psychiatric comorbidity. 

Patients currently being prescribed methadone or buprenorphine

Prescribing should be a straightforward continuation of the patient’s usual dose of OST while in hospital. Communication between the hospital and community is vital for safe patient care. The Central Treatment List (CTL) should be contacted to confirm that the patient is receiving OST. The CTL is available 9am–5pm, Monday to Friday, at 01 648 8638. 

  • Confirmation of the dose by the patient alone is not adequate.
  • Confirmation of the last dose received at the clinic should be sought by contacting the clinic or dispensing pharmacy directly. 

Patients not receiving OST

Where there is uncertainty about recent compliance, care must be exercised when initiating OST. Local drug treatment services should be contacted upon initiation to ensure continuity of care upon discharge. 

Initial dosing schedule for opioid-dependent patients admitted to hospital

  • OST should only be prescribed following an assessment.
  • Polydrug and alcohol misusers may develop multiple withdrawal syndromes, so these may need to be discerned in order to prioritise treatment.
  • Methadone may initially mask alcohol or benzodiazepine withdrawal symptoms.
  • Care should be exercised when prescribing additional drugs, such as sedatives, to individuals who may also be using illicit substances. Interactions between street drugs and psychotropic drugs should always be considered.
  • Clinicians should refer to a relevant text, such as Maudsley Prescribing Guidelines (2018).5
  • Where it is appropriate to initiate opioid substitution in hospital to reduce risk of withdrawal, methadone or buprenorphine can be used.
  • OST induction should always follow the methadone treatment protocol (MTP). However, close supervision in hospital may allow for a modified protocol.
  • Signs of intoxication, such as drowsiness, slurred speech, or pupil constriction, indicate the need to discontinue or reduce the dose of the drug.
  • Hospitals should contact the CTL before prescribing buprenorphine products to ensure continuity post-discharge, as HSE approval is required before buprenorphine products can be reimbursed in the community setting. 

Other drugs of misuse

Opioid-dependent patients in hospital may be taking other drugs and misusing alcohol. 

  • Misuse of benzodiazepines or alcohol could lead to associated withdrawal symptoms and seizures.
  • Benzodiazepine prescribing should only be initiated once the level of dependence has been established through history taking and noting any symptoms of withdrawal. 

Within the inpatient setting, it is appropriate to provide a withdrawal regimen over one to four weeks, with a starting dose of diazepam no more than 30 mg daily, administered in divided doses. 

  • For useful tools and schedules, see the 2016 community detoxification guidelines issued by Ana Liffey Drug Project.6
  • Routine prescribing of benzodiazepines, Z-drugs, or gabapentinoids should be avoided while in hospital, especially the use of pregabalin as an anxiolytic.
  • Patients may also need a simultaneous detoxification from alcohol. 

Pain management

Management of patients if nil by mouth (NPO).7 

  • Specialist advice should be sought from the anaesthetist for perioperative and NPO instructions.
  • Postoperatively methadone should be restarted once the NPO instruction has been removed.
  • Should the NPO instruction remain postoperatively, both potential opioid withdrawal and pain should be managed using a conventional opioid, such as morphine injection/infusion. Intravenous methadone should not be used instead of the oral methadone due to differences in dose equivalence by route of administration.
  • If monitoring indicates the patient may be in opioid withdrawal or pain, referral to a specialist pain team may be required. 

Discharge from hospital

For drug misusers not previously in treatment, attendance at the emergency department or hospital admission may present a window of opportunity to put them in touch with other services. It is essential to link with services well in advance of discharge to ensure continuity of care. This is in line with the HSE Code of Practice for Hospital Integrated Discharge Planning. 

On discharge, the following information should be given: 

  • General health promotion advice
  • Contact details for further help, such as needle exchange, drug treatment services, or self-help groups. (Refer to the directory of services for your area on www.drugs.ie)
  • Advice on overdose prevention
  • Advice on reducing the risk of blood-borne viruses and hepatitis B vaccination
  • Advice on loss of tolerance in hospital. 

Where a patient is receiving an opioid prescription upon admission from the community, this should be continued on discharge with prescribing responsibility transferring back to the GP or HSE addiction clinic. Discharge planning is best done in collaboration with local drug treatment services, the GP, and the community pharmacy. 

On the day of discharge, confirm the following with the community services:

  • Patients should receive their substitution dose on the day of discharge; their clinic or GP and community pharmacy should be contacted to confirm they have received that day’s dose.
  • Details of other drugs prescribed while an inpatient should be provided.
  • Prior to discharge, confirmation should be provided that the patient is registered with a methadone-prescribing GP and a community pharmacy for continuation of OST.

 

1  Health Service Executive (2016) Clinical guidelines for opioid substitution treatment. Dublin: Health Service Executive. https://www.drugsandalcohol.ie/26573/

2  Health Service Executive (2020) Clinical guidelines for opioid substitution treatment: guidance document for OST in the hospital setting Dublin: Health Service Executive. https://www.drugsandalcohol.ie/31766/

3  Note that the prescription of OST in hospital settings is covered under the Misuse of Drugs (Supervision of Prescription and Supply of Methadone and Medicinal Products containing Buprenorphine authorised for Opioid Substitution Treatment) Regulations 2017. The regulations add certain buprenorphine medicinal products authorised for OST to the schedule of products that fall within the scope of these regulations. These regulations replace the Misuse of Drugs (Supervision of Prescription and Supply of Methadone) Regulations 1998 (SI No. 225 of 1998).

4  Lyons S (2017) New clinical guidelines for opioid substitution treatment. Drugnet Ireland, 62: 27–30. https://www.drugsandalcohol.ie/27752/

5  Taylor DM, Barnes TRE and Young AH (2018) The Maudsley prescribing guidelines in psychiatry, 13th edn. Chichester: Wiley Blackwell.

6  Ana Liffey Drug Project (2016) National community detoxification: methadone guidelines. Dublin: Ana Liffey Drug Project. https://www.drugsandalcohol.ie/26888/   

7  British Pain Society (2007) Pain and substance misuse: improving the patient experience. A consensus statement prepared by the British Pain Society in collaboration with the Royal College of Psychiatrists, the Royal College of General Practitioners and the Advisory Council on the Misuse of Drugs. London: British Pain Society. https://www.drugsandalcohol.ie/6343/  

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