Treatment and prevention

Treatment

Once a diagnosis of dependence has been made a treatment plan should be developed. The decision on which treatment course is chosen should be a collaborative one between the patient and doctor.
Depending on the complexity of the case and the skills and training of the prescriber this may be all under one doctor or it may involve a full network of clinicians, including GPs, addiction specialists, pain specialists, psychiatric specialists and acute services, or some point in between. Clear communication between all healthcare specialists involved in the patient’s care is vital as is clear documentation. It is important to note that many patients will recognise that they have an issue with prescription opioid dependence and will be willing to work in collaboration with their doctor to develop a treatment plan.

Usually one doctor should take over all prescribing of opioids and other potentially addictive drugs. If there is disagreement between the doctor and patient it may be beneficial if a different doctor who has not previously treated the patient takes over prescribing so that a new relationship and set of boundaries can be developed.
Information about the acute and chronic risks of opioids should be given to the patient.

Any underlying physical or psychiatric condition should be identified and appropriate treatment plans or referral made.

Principles of Opioid Substitution Treatment (OST)

If a diagnosis of dependence is made a decision needs to be reached regarding whether to maintain a patient on opioids or detoxify them. This decision involves multiple factors and should be made, where possible, in collaboration with the patient. The decision to maintain a patient versus detoxify can be influenced by factors that include: patient choice, a patient’s motivation, past drug and alcohol dependence, psychiatric and physical history, length of time on opioids, quality of life and social support. It may involve a meeting of multiple healthcare professionals involved in the case. The patient should be provided with as much information as possible so that they can make an informed choice. It may be important to record that the patient has the capacity (within the meaning of the Mental Capacity Act 2005) to make a decision.

Maintenance

If a decision is made to maintain a patient they should generally be transferred to a longer-acting, oral opioid. These include methadone and buprenorphine. Methadone and buprenorphine should be used cautiously in those with a history of respiratory difficulties, significant liver dysfunction and obstructive bowel conditions. Higher dose methadone is associated with prolonged QT syndrome.
Conversion tables should be treated with great caution. Conversion should only be undertaken with the support of a clinician experienced in opioid conversion and the use of methadone or buprenorphine. Advice should be sought from the local drug treatment provider.
It is advisable to consider a period of supervised consumption; however, a patient should not be converted to a fully supervised dose immediately as it places them at risk of overdose if they have been non-compliant.
The same doctor should regularly review the patient; the full range of treatment needs should be reviewed.
Consideration should be given to involving the patient in a wider addiction treatment programme. This may include, as an individual or in a group, motivational enhancement therapy, relapse prevention and/or mutual aid (including Narcotics Anonymous).
The patient should be regularly tested for the prescribed opioid and commonly used illicit substances. They should regularly be asked about alcohol and other drug use.

Detoxification

Detoxification will often be the preferred option. Usually this should take place on an outpatient basis (although residential treatment, either in an acute hospital or detoxification unit, is available throughout the UK). The options involve either conversion to a long-acting opioid as above or a gradual reduction in the dose of the currently prescribed opioid. This reduction should take place in collaboration with the patient.
If a patient chooses to detoxify, they should be warned of the risk of overdose if they relapse to opioid use.
In certain patients who have detoxified and do not need on-going opioids consideration should be given to prescribing naltrexone.

Naloxone

In those patients considered dependent and at risk of overdose, the provision of take-home naloxone with associated overdose training should be considered for both the patient and their family and carers.

There are risks of naloxone use in the frail and elderly due to increased adrenaline levels after use and it should be supplied (and administered) with caution. Doses should be administered conservatively in all patients.

Role of specialist drug and alcohol dependence treatment services

Every local area in the UK has a specialist addiction service; in England these are commissioned by local authorities, in Scotland and Wales by the NHS and in Northern Ireland by the Public Health Agency. These services should provide advice, assessment and support to other parties involved in the care of this patient group and, where appropriate, take over prescribing of opioids either looking towards detoxification or maintenance. In complicated patients it may be appropriate for these services to become the lead agency. Depending on the area they may be able to provide support regarding co-occurring mental health issues; however, in England psychiatric services are separately commissioned and provided.

Sources of Support

More information in Drug Misuse and Dependence: UK Guidelines on Clinical Management.

NHS Choices maintains a searchable directory of local drug and alcohol treatment services.

Further Reading

• Department of Health Drug Misuse and Dependence: UK Guidelines on Clinical Management. 2007
• National Institute for Health and Care Excellence. Technology appraisal 114. Methadone and buprenorphine for the management of opioid dependence. 2007.
• National Institute for Health and Care Excellence. Clinical guideline 52 Drug misuse in over 16s: opioid detoxification. 2007.
• National Institute for Health and Care Excellence. Technology appraisal 115 Naltrexone for the Management of Opioid Dependence. 2007.
• Vowles KE, McEntee ML, Julnes PS, et al. Rates of opioid misuse, abuse, and addiction in chronic pain: a systematic review and data synthesis. Pain 2015; 156: 569–576.

Prevention

• Assess patients comprehensively and appropriately prior to prescribing opioids.
• Prescribe within your expertise.
• Explore and treat any underlying psychological and social distress in line with appropriate NICE guidance.
• Treat underlying physical conditions causing pain in line with appropriate NICE guidance.
• Always agree clinical outcomes with a patient and set a time frame for clinical review.
• Always review the continued need for opioids on discharge from hospital. Have a clear plan regarding duration of treatment and communicate this clearly to primary care.
• If the reason for prescription of opioids or intended prescription are uncertain, discuss and consult with the initiating prescriber/specialist.
• Ensure effective communication between all prescribers involved in a patient’s care – refusal to allow healthcare professionals to communicate should in general lead to a refusal to prescribe.
• Temporary registered patients should be given at most three days’ prescription of medication to allow previous notes to be obtained.
• If in doubt regarding treatment options seek a specialist opinion for the relevant underlying condition.