A Protocol For The Management Of Opioid Dependence In .

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A Protocol for the Management of Opioid Dependence inTemporary Homeless Hotels during the COVID-19OutbreakAuthorsDr Emmert Roberts, Dr Michael KelleherVersion ControlVersionDate1.02.019 March 202023 March 20203.025 March 20204.02 April 2020Comments/ChangeAdded caution about using 1sedative agent – (i.e.methadone for opioiddependence andchlordiazepoxide for alcoholwithdrawal)Added recommendations toconsider buprenorphine asfirst line choice givenrespiratory comorbidity andreduced risk of overdoseAdded in comments fromSteve Taylor. Advised cautionwith regards UDS and updatednational picture of relaxedsupervised dispensing andpick up frequency1

Table of Contents1. Introduction . 32. Aims and Objectives . 33. Prescribing for Opioid Dependence on Admission to Hotel .3-54. Initiation of Opioid Substitution Treatment (OST) .5-64.1 Methadone Initiation . 54.2 Buprenorphine Initiation . 65. Naloxone . 66. Medication Storage . 67. Needle and Syringe Availability . 68. Overall Prescribing Flow Chart . 79. Appendices. 89.1 Length of Drug Detection Times in Urine . 89.2 ICD-10 Criteria for Opioid Dependence . 99.3 Clinical Opioid Withdrawal Scale (COWS). 109.4 Contraindications and Interactions with OST . 119.4 Signs and Symptoms of Opioid Intoxication . 122

1.IntroductionIt is vital to remember throughout any decision pertaining to opioid dependence treatment:OPIOID WITHDRAWAL IS NOT LIFE THREATENING –OPIOID TOXICITY IS LIFE THREATENINGThis document reflects the Drug Misuse and Dependence – UK Guidelines on ClinicalManagement 2017 ‘The Orange Guideline’The average pattern of drug misuse is likely to alter when an individual becomes unwell orenters a temporary homeless hotel. Although, clinicians should regard drug misusemanagement in temporary homeless hotels as equivalent to any other setting, there aresome particular differences they will need to take into account: Reduced availability of drugs and alcohol during the outbreak, leading to a risk ofintermittent intoxication and unanticipated withdrawalA potential change in injecting behaviour, and potentially much higher riskbehaviours due to the scarcity of injecting equipmentThe high volume and frequency of movement of people. At times with limited clinicalinformation availableThe risk of overdose on leaving the temporary homeless hotel due to diminishedopioid toleranceLimited continuous access for clinicians and therefore difficulty monitoring treatmentSignificant levels of co-morbidity2.Aims and Objectives To reduce drug related harmTo maintain tolerance to opioids, which reduces the risk of fatal drug overdoseTo reduce or prevent withdrawal symptomsTo continue community prescribed methadone or buprenorphine treatmentTo support wider recovery3.Prescribing for opioid dependence on admission to temporary homeless hotel When someone reports use of opiates upon admission to the temporary homelesshotel there are only three questions which need to be posed that relate to prescribing:1. Do I need to/can I safely prescribe continuation of opioid substitution therapy (OST)?If the answer is NO then:2. Do I need to/can I safely prescribe initiation of opioid substitution therapy (OST)?If the answer is NO then:3. Do I need to prescribe for symptomatic relief of opioid withdrawal?Question One:Do I need to/can I safely prescribe continuation of opioid substitution therapy (OST)?You need to confirm that the person is both:3

A) Prescribed OSTB) Taking their prescribed OSTC) Cannot continue their prescription with their existing local service and need prescribing tobe taken overIn order to do this, you must confirm:1. The person reports receiving OST, and has not missed any doses in the last three days2. The pharmacist responsible for dispensing the OST or the prescriber responsible forprescribing OST confirms that the patient has a valid OST prescription3. The pharmacist responsible for dispensing OST confirms that the person has collectedtheir prescription as directed4. There are no clinical signs of opiate toxicity: intoxication, sedation or constricted pupilsNB This guidance is in light and in response to a national relaxation of supervisedconsumption and pick-up frequency rules regarding OST.Urine Drug Screening (UDS) should be kept to a minimum, as many people with opioiddependence have comorbid renal pathology which could lead to an increased risk ofCOVID19 transmission, where people are infected with the virus. If UDS are used theyshould be conducted using adequate Personal Protective Equipment (PPE)Only when all four of these conditions are met can you prescribe OST at the person’sregular maintenance dose. You must also always supply naloxone PRNDOSES SHOULD BE WITHHELD IF THERE IS ANY SIGN OFINTOXICATION/SEDATION/CONSTRICTED PUPILSIf the answer to question one is NO then proceed to question twoQuestion Two:Do I need to/can I safely prescribe initiation of OST?You need to confirm the person is both:A) Dependent on opioidsB) Suitable for OST treatmentIn order to do this, you must confirm:1. The person reports using opioids (heroin, methadone, buprenorphine etc.)2. The person meets ICD criteria for opioid dependence (see appendix 10.2)3. There is objective evidence of opioid withdrawal (e.g. using Clinical Opioid WithdrawalScale (COWS) (See appendix 10.3)Urine Drug Screening (UDS) should be kept to a minimum, as many people with opioiddependence have comorbid renal pathology which could lead to an increased risk ofCOVID19 transmission, where people are infected with the virus. If UDS are used theyshould be conducted using adequate Personal Protective Equipment (PPE)Only when all four of these conditions are met can you initiate a new prescription ofOST. For initiation regimens please see section 4. You must also always supplynaloxone PRN4

DOSES SHOULD BE WITHHELD IF THERE IS ANY SIGN OFINTOXICATION/SEDATION/CONSTRICTED PUPILSIf the answer to questions one and two is NO then proceed to question 3Question Three:Do I need to prescribe for symptomatic relief of opioid withdrawal?If you are unable to safely prescribe OST the following medications can be used tosymptomatically manage opioid withdrawal:4. Initiation of Opioid Substitution Treatment (OST):If you have determined that a person is suitable for initiation of OST your choices areto initiate methadone oral solution 1mg/1ml or buprenorphine sub-lingual tablet ororal lyophilisate, 2mg or 8mg.Discuss with the person if they have previously had either of these medications, andif so which they would prefer.In this setting buprenorphine should be considered the first line choice given the riskof COVID-19 respiratory co-morbidity, and the reduced risk of overdoseCaution is advised if prescribing 1 sedative agent i.e. OST for opioid dependenceand chlordiazepoxide for alcohol withdrawal4.1 Methadone Induction Regimen:If in withdrawal prescribe 1mg/1ml methadone mixture PO as a STAT dose; Neverprescribe as a PRN medicationDAY 1: First Dose: You can prescribe up to a maximum of 30mg on day oneIf tolerance is unclear or the amount of use is unclear start at 10mgIf a regular user of heroin, methadone or buprenorphine consider starting at 20mgIf an intravenous opiate user with fresh/recent track-marks consider starting at 30mgDoses above 20mg should be discussed with an experienced prescriber, there havebeen reports of iatrogenic deaths in opioid naïve people at doses of 20mg once daily5

Aim to titrate in 5-10mg increments every 3 daysIncrement should be no more than 10mg per dayWEEK 1: No more than a 60mg total daily dose, and no more than three doseincreases per weekThe target methadone OST maintenance dose in subsequent weeks is 60-120mgorally once a day.DOSES SHOULD BE WITHHELD IF THERE IS ANY SIGN OFINTOXICATION/SEDATION/CONSTRICTED PUPILS4.2 Buprenorphine Induction Regimen:People should normally have been heroin-free for around 12 hours and methadonefree for at least 24 hours before starting buprenorphineIf in withdrawal prescribe buprenorphine as a STAT dose; Never prescribe as a PRNmedicationDAY 1: First Dose: You can prescribe up to a maximum of 8mg on day oneIf tolerance is unclear or the amount of use is unclear start at 2-4mgIf a regular user of heroin, methadone or buprenorphine consider starting at 4mgIf an intravenous opiate user with fresh/recent track-marks consider starting at 4-8mgAim to titrate in 4mg increments every 3 daysWEEK 1: No more than 16mg total daily doseThe target buprenorphine OST maintenance dose in subsequent weeks is 12-16mgs/l od and up to 32mgDOSES SHOULD BE WITHHELD IF THERE IS ANY SIGN OFINTOXICATION/SEDATION/CONSTRICTED PUPILS5. NaloxoneAll people who are using opiates must have naloxone supplied.When they are due to leave the temporary homeless hotel they should be provided withnaloxone to take away (TTA)In the event of a suspected overdose anyone can administer naloxone for the purpose ofsaving a life without a prescription.Call an ambulanceCheck breathing and put in recovery positionGive 400 micrograms naloxone IM and repeat after 2-3 mins if not breathing6. Medication StorageAll OST are controlled drugs and a person’s supply should be stored in an individual’ssecure locked box on the premises, preferably in the persons room6

7. Needle and Syringe AvailabilityAll people should be provided with sterile needles, syringes, foil and other injectingequipment (without the need to return used equipment)All people should be provided with sharps bins and advice on how to dispose of needles,syringes and equipment safely. These can be collected and disposed of by hotel healthcarestaff.7

8. Overall Prescribing Flow ChartOPIOID WITHDRAWAL IS NOT LIFE THREATENING – OPIOID TOXICITY IS LIFE THREATENINGPerson at admission says they use opiates (Heroin, Methadone, Buprenorphine etc.)Question One: Do I need to/can I safely prescribe continuation of OST?You need to confirm that the person is both:A) Prescribed OSTB) Taking their prescribed OST1. The person reports receiving OST2. Urine Drug Screen is positive for OST (methadone or buprenorphine)3. Dispensing pharmacist confirms that the patient has a valid OST prescription4. Dispensing pharmacist confirms no missed OST doses in the last three days (i.e. doses were supervised)Are all four conditions described above met?NO: MOVE ON TO QUESTION TWOYES: PRESCRIBE REGULAR DAILY OST DOSE PRN NALOXONEWITHOLD DOSE IF ANY SIGN OF INTOXICATION/SEDATION/CONSTRICTED PUPILSQuestion Two: Do I need to/can I safely prescribe initiation of OST?You need to confirm that the person is:A) Dependent on opioidsB) Suitable for OST treatment1. The person reports opioid use2. The person meets ICD criteria for opioid dependence3. Urine Drug Screen is positive for opioids (e.g. heroin)4. There are signs of opioid withdrawal (e.g. using Clinical Opioid Withdrawal Scale (COWS))Are all four conditions described above met?NO: MOVE ON TO QUESTION THREEYES: PRESCRIBE INITIATION OST DOSE PRN NALOXONEInduction OST RegimenBuprenorphine should be considered first line given the risk of COVID-19respiratory co-morbidity, and the reduced risk of overdoseBuprenorphine (Subutex )People should be heroin free for 12 hours andmethadone free for at least 24 hours before startingIf in withdrawal prescribe buprenorphine s/l as a STATdose; Never prescribe as a PRN medicationDAY 1: First Dose: Prescribe up to a maximum of 8mgIf tolerance unclear or amount of use unclear 2-4mgIf regular heroin or OST user consider starting at 4mgIf recent intravenous user consider starting at 4-8mgAim to titrate in 4mg increments every 3 daysWEEK 1: No more than 16mg total daily dose;Target buprenorphine maintenance dose 12-16mg s/l odMethadoneIf in withdrawal prescribe 1mg/1ml sugar free methadonemixture PO as a STAT dose;Never prescribe as a PRN medicationDAY 1: First Dose: Prescribe up to a maximum of 30mgIf tolerance unclear or amount of use unclear 10mgIf regular heroin or OST user consider starting at 20mgIf recent intravenous user consider starting at 30mgAim to titrate in 5-10mg increments every 3 daysIncrement should be no more than 10mg per dayWEEK 1: No more than a 60mg total daily dose;No more than three dose increases per weekTarget methadone maintenance dose 60-120mg PO odWITHOLD DOSE IF ANY SIGN OF INTOXICATION/ SEDATION/CONSTRICTED PUPILSCAUTION IF PRESCRIBING 1 SEDATIVE AGENT (E.G. CHLORDIAZEPOXIDE OST)Question three: Do I need to prescribe for symptomatic relief of opioid withdrawal?DiarrhoeaLoperamide 4mg PO STAT and 2mg PO after each loose stool;Normal dose 6-8mg PO od; Maximum 16mg PO/24oNauseaMetoclopramide 10mg PO tds PRN orProchlorperazine 5mg PO tds PRNMebeverine 135mg PO tdsStomach CrampsAgitation and InsomniaHeadache/PainDiazepam 5-10mg PO tds PRN orZopiclone 7.5mg PO on PRNParacetamol 1g PO qds PRN8

9. AppendicesAppendix 9.1 Length of drug detection times in urineApproximate durations of detectability of selected drugs in urineDrug or its metabolite(s)Duration of detectability Codeine, dihydrocodeine, morphine, propoxyphene(Heroin is detected in urine as the metabolite morphine)48 hoursMethadone (maintenance dosing)2-4 daysBuprenorphine and metabolitesCocaine metabolite2-4 days2-3 daysCannabinoids:Single useModerate use (three times a week)Heavy use (daily)Chronic heavy use (more than three times a day)3-4 days5-6 days20 daysUp to 45 daysBenzodiazepines:Ultra-short acting (half-life 2h) (e.g. midazolam)Short-acting (half-life 2-6h) (e.g.triazolam)Intermediate-acting (half-life 6-24h) (e.g.temazepam,chlordiazepoxide)Long-acting (half-lie 24h) (e.g. diazepam, nitrazepam)Amphetamines, including methylamphetamine and MDMA12 hours24 hours2-5 days7 days or more2 days9

Appendix 9.2: ICD-10 criteria for opioid dependence 3 of the following 6 criteria in the past 12 monthsa) Desire or compulsion to take opioidsb) Difficulties to control opioid taking behaviourc) Physiological withdrawald) Development of tolerancee) Neglect of other things in favour of opioidsf) Persistent use despite evidence of harm10

Appendix 9.3 Clinical Opioid Withdrawal Scale ‘COWS’Clinician rated scale; 11 items; Maximum Score 480-45-1213-2425-36 36No evidence of withdrawalMildModerateModerately severeSevere11

Appendix 9.4 Contraindications and Interactions with OST OST in combination with any CNS depressant (e.g. alcohol, benzodiazepines,TCAs); risk respiratory depression/potential overdose Doses of 100mg methadone PO od are a risk factor for prolonged QTc; Patientsmay require ECG monitoringMedications which affect OST:Medicines which OST levelsMedicines which OST levelsCytochrome P450 inducers; OSTmetabolism; bioavailable OST; Potentialneed to OST doseCytochrome P450 inhibitors; OST metabolism; bioavailable OST; Potential need to OSTdoseINCREASE RISK OF WITHDRAWAL ANDOVERDOSEINCREASE RISK OF INTOXICATION ANDOVERDOSEAll OST: Barbiturates, Carbamazepine,Phenytoin, Rifampicin, St John’s WortOnly Methadone: Smoking, Antiretrovirals:abacavir, amprenavir, lopinavir, efavirenz,nevirapine, nelfinavir, ritanovirAll OST: Ciprofloxacin; Macrolide Abx;Fluconazole; Fluvoxamine ( /- Sertraline,Fluoxetine, Paroxetine); AmiodaroneOnly Methadone: Disulfiram, Verapamil,Grapefruit JuiceOnly Buprenorphine: Protease inhibitors (e.g.indinavir, saquinavir)12

Appendix 9.5 Signs and Symptoms of Opioid IntoxicationSIGNS OF OPIATE INTOXICATIONConstricted pupils (miosis)DrowsinessIntermittent dozingEyes closingOrthostatic hypotensionShallow BreathingBlue lips (cyanosis)Loud snoring13

A Protocol for the Management of Opioid Dependence in Temporary Homeless Hotels during the COVID-19 Outbreak Authors Dr Emmert Roberts, Dr Michael Kelleher Version Control Version Date Comments/Change 1.0 19 March 2020 2.0 23 March 2020 Added caution about using 1 sedative agent – (

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