Symptomatic Management of Opioid Withdrawal Guidelines

1. About this guideline
2. Assessment of Opioid Withdrawal Symptoms
3. Management of opioid withdrawal symptoms
4. Patients admitted on prescribed drugs for drug dependence
5. Discharge prescriptions
6. Contact Details for Drug Treatment Centres
7. Management of Drug-Dependent Patients

1. About this guideline

This is a guideline for the management of opioid withdrawal. We cannot provide or allow patients to use illegal substances while in our care. Formal detoxification is not being offered as our patients have medical conditions requiring treatment, which is a contraindication to opioid detoxification as outlined in the NICE Guidance, CG52 Drug misuse: Opioid Detoxification.

If the guidance is not applicable to a patient and further advice is required, or it is decided the patient is to commence treatment for their drug dependence then the Leeds Addiction Unit (LAU) should be contacted. The Leeds Addiction Unit Hospital Team provide a substance misuse service to the Leeds Teaching Hospital Trust (LTHT). The team consists of psychiatrists, registered general nurses (RGN) and registered mental health nurses (RMH). They can provide assessments on the ward and assist with management during hospitalisation. Their priority is to engage patients in appropriate treatment on discharge and thereby reduce pressure on hospital resources. Referral to the team can be made by contacting the team secretary on (0113) 295 1301. They would encourage early referral after admission. The LAU team are available 9am-5pm Monday to Friday.

In all cases where a patient cannot be treated for opioid withdrawal by following this guideline the senior doctors looking after the patient must be contacted for advice. If it is decided that input from LAU is required then it should be a senior doctor who contacts them.

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2. Assessment of Opioid Withdrawal Symptoms

It is important to recognise the differences between symptoms of opioid withdrawal and toxicity as some patients will use substances prior to presenting to hospital. The main symptoms of opioid withdrawal compared to opioid toxicity are outlined below.

Opioid Withdrawal Symptoms
If left untreated, withdrawal symptoms typically reach their peak 32-72 hours after the last dose of heroin and 4 to 6 days after the last dose of methadone. The duration of withdrawal from methadone is much longer than that from heroin, with symptoms that may not substantially subside for 10-12 days. The Clinical Opiate Withdrawal Scale gives more detailed information about assessing the severity of withdrawal symptoms. The symptoms of opioid withdrawal can include the following:

Opioid Intoxication Symptoms
Opioid intoxication can be recognised by the presence of the following symptoms:

Pregnant patients displaying symptoms of opioid withdrawal must be referred urgently to an obstetrician because opioid withdrawal during pregnancy can be dangerous for the mother and cause harm to the foetus.

Opioid withdrawal is not a life threatening condition, but opioid toxicity is. Patients suspected of opioid overdose, where there is an immediate threat to life, or a diagnosis of respiratory depression, should be treated with naloxone. The primary aim of naloxone treatment is reversal of the toxic effects of opioids so the patient is no longer at risk of respiratory arrest, airway loss, or other opioid related complication. Treatment should NOT aim to restore a normal level of consciousness, as in some circumstances this would be entirely inappropriate. Please refer to the current BNF, the National Poisons Information Service (see inside cover of BNF for contact number), or where available the Toxbase® poisons information website for guidance on naloxone dosages.

For opioid withdrawal, the severity of opioid withdrawal symptoms should be assessed, using the opioid withdrawal assessment scale (see below). This should be done when the patient presents to hospital and at frequent intervals until the symptoms are adequately controlled and remain stable.

Opioid withdrawal assessment
For each item, note the number that best describes the patient's signs or symptoms. Rate on just the apparent relationship to opioid withdrawal. For example, if heart rate is increased because the patient was jogging prior to assessment, the increase pulse rate would not add to the score.

(Adapted from the 'Clinical Opiate Withdrawal Scale (COWS)'.¹

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3. Management of opioid withdrawal symptoms

Drug Treatment
Drug treatment can be given in the form of opioid replacement or it can be managed symptomatically with non-opioid medication. The aim of drug treatment is to reduce the severity of opioid withdrawal symptoms so that the patient experiences no symptoms or only mild withdrawal symptoms. Medication should be titrated according to response bearing in mind that some symptoms may continue in the presence of other medical conditions (eg. vomiting and diarrhoea with gastroenteritis) and some symptoms may occur due to withdrawal from other substances in poly-drug users.

Administration of opioid substitution medication to known illicit substance users must be supervised. This can be achieved by getting the patient to talk or offering them a glass of water after the dose has been given to ensure the medication has been swallowed. This is common practice in the community. Urine testing can be carried out to confirm continued use of illicit substances for longer stay patients if necessary.

The patient should be provided with an information sheet and the planned management of their withdrawal symptoms explained. All patients should be offered contact details of local drug treatment services

The following provides guidance on the management of levels of opioid withdrawal. Medication should only be prescribed following suitable assessment of symptoms of withdrawal. Care should be exercised in any patient showing signs of respiratory disease, head injury, or liver disease.

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4. Patients admitted on prescribed drugs for drug dependence

Patients who are prescribed methadone or buprenorphine in the community should continue on their usual dosage provided no further contraindications or cautions are present e.g. severe hepatic impairment or renal dysfunction. Their usual prescription MUST be confirmed before a dose is given. Where possible the usual prescriber of the methadone or buprenorphine and the chemist who supplies the dose should both be contacted to be made aware the patient is currently an inpatient. If it is not possible to confirm the usual dose (e.g. at the weekend or overnight) the patient can be prescribed dihydrocodeine (as per above guidance) if clinically necessary until the dose can be confirmed. It is unlikely someone on methadone will start to withdraw if a dose is missed for a day.

The current dose of methadone or buprenorphine can be confirmed with the patient’s drug treatment centre, GP, Summary Care Record (SCR) or community pharmacist. Any dose a patient states should be confirmed with another source in case they have exaggerated the dose. When this has been done, it should be documented as “dose confirmed” both in the medical notes and on the drug chart. The ward pharmacist or pharmacy technician will usually do this as part of their medication history checks. It is also useful to ask the chemist what are the usual collection habits of the patient and when they last collected their prescription and wether they take a supervised or unsupervised dose. The patient should not be given a dose of methadone or buprenorphine unless the dose has been confirmed.

Methadone
The recommended, evidence based, maintenance dose for methadone is between 60-120mg however some patients need higher or lower doses.

Methadone has a long half life (normally 20-37 hours but can range up to 91 hours for some individuals). Because of this long half life, it is usually administered as a once daily dose. Some patients however, do prefer to split their dose and they should be enabled to do so in hospital. The time of administration should be negotiated with the patient and ward staff to reduce stress and anxiety.

If a patient misses 3 or more doses of methadone their tolerance can be lost. Patients may need their methadone re-titrating. Please seek advice from their usual prescriber or LAU if this occurs.

Buprenorphine
Buprenorphine maintenance is between 8-32mg (never above) and the usual range is between 8-16mg. If a patient is on a buprenorphine maintenance dose of above 8mg, opioid based analgesia may have limited effect as buprenorphine, a partial agonist, has a higher affinity for opioid receptors than almost every other opioid. NSAIDs should be considered first line for pain relief.

Buprenorphine may cause withdrawal symptoms if given to patients using other opioids, especially methadone (because of the long half life), and should not be given unless confirmed with an independent source, as mentioned above.

Non-Opioid Symptomatic Drug Treatments
These can be prescribed to alleviate individual symptoms. Non-opioid medication can be used as adjunct therapy when opioid replacement has been insufficient, or as an alternative to opioid replacement when high doses of opioid drugs should be avoided, e.g. severe liver impairment, acute respiratory depression, potential drug interactions (Refer to current BNF for full list of precautions/contra-indications).

Hyoscine-N-butylbromide
This can be prescribed for stomach cramps at a dose of 20mg (po) QDS

Loperamide or Co-phenotrope
These can be prescribed for diarrhoea.

• Loperamide: 4mg (po) initially, then 2mg after each loose stool to a maximum of 16mg (8 capsules) in 24hrs.
• Co-phenotrope: 4 tablets (po) initially, then 2 tablets every 6 hours until diarrhoea controlled.

Paracetamol
This can be prescribed with or without NSAIDs to control muscular aches and pains & headaches at a dose of 500mg-1g QDS PRN.

Metoclopramide
This can be prescribed for nausea, vomiting & stomach cramps at a dose of 10mg (po) TDS.

Lofexidine
This is an alpha-2 adrenergic agonist that can be used to reduce the symptoms of noradrenergic hyperactivity.

• This is rarely used now and should not normally be prescribed.
• It should only be considered if there is input from LAU and with LAU nurse specialist involvement.
• Close monitoring of pulse & BP required prior to and during treatment.

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5. Discharge prescriptions

The prescribing responsibility for patients who usually receive methadone or buprenorphine prior to admission should be transferred back to the community at discharge. The hospital doctor should make sure arrangements are in place for a continued prescription prior to the patients discharge from hospital. The discharge should be well planned with a minimum of 24 hours notice, which allows time to arrange a new prescription should the current one have expired during the patients admission.

Methadone should not normally be supplied at discharge unless discussed with the Leeds Addiction Unit team or usual prescribing team. If it is the weekend and plans have not been successfully put in place then it is recommended that the supply of methadone or buprenorphine should only be supplied if thought clinically appropriate. If a supply is made it should be the minimum amount that will last until the patient can return to their usual prescriber.

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6. Contact Details for Drug Treatment Centres

1st point of contact:
Forward Leeds Hospital In-reach Team Leeds Addiction Unit
St James Hospital
(0113) 20 28596 (internal phone 28596)

2nd point of contact:
Forward Leeds
Armley Park Court,
9 Stanningley Road,
Leeds,LS12 2AE
(0113) 887 2477

Forward Leeds is a new service which includes the drug treatment centres at:

• Leeds and York Foundation trust
• DISC
• St Anne’s community Service
• St Martin’s Healthcare Service
• BARCA Leeds

York Street Health Practice (formerly NFA Health Care Team)
Please note that there is both a GP practice and Drugs treatment centre based here. Either team can and does prescribe opioid substitute medication.
68 York Street
Leeds, LS9 8AA
(0113) 295 4840

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7. Management of Drug-Dependent Patients

Information for Patients
Whilst you are under the medical care of The Leeds Teaching Hospitals NHS Trust we require agreement from you to follow a code of conduct so that treatment may be given to you in a safe and appropriate manner.

1. You have been admitted to hospital because you require further medical attention. During this time you must refrain from using any illegal drugs because this is not acceptable practice within the hospital and could be dangerous if we need to treat you with medication. Your urine may be tested to assist your management and for safety reasons medication may be withheld if we suspect use of illegal substances.
2. If you normally take prescribed medication, this will be continued provided that it is safe to do so and we have been able to confirm this information from your GP, community pharmacist or Leeds Addiction Unit.
3. Heroin and methadone withdrawal is not life-threatening, but if you feel unpleasant withdrawal symptoms you should inform the nurse or doctor who will make an assessment in order to decide on appropriate treatment. We will aim to treat your symptoms in a safe and appropriate manner. We may not be able to deal with your addiction issues and will not tolerate unreasonable demands for medication, but we can refer you to an appropriate organisation or give you their contact details, however, this does not confer you to preferential treatment at that organisation.
4. For safety reasons, you must obtain permission from the nurse in charge before leaving the ward area.
5. The Leeds Teaching Hospitals NHS Trust services cannot treat drug dependency and cannot supply medication for this purpose when you are discharged. We will supply medicines for medical conditions, and exceptionally, medicines that are requested by the GP or Leeds Addiction Unit.
6. All patients have the right to be treated in a respectful manner and receive the same standard of care. Behaviour that is found to be aggressive or offensive to other patients or staff will not be tolerated. This also applies to any visitors.
7. Any visitors who are suspected of supplying any illegal substances in the hospital will be asked to leave the ward.

Any breach to this code may result in you being discharged from the ward.

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