Emergency management of substance withdrawal in non-specialist in-patient settings

Emergency Management of substance Withdrawal in non-specialist in-patient settings.
Detoxification is not a treatment for addiction: These suggested management strategies are intended for
clients who are dependent on substances who have been admitted for another purpose into a non-specialist
setting.
Baseline Assessment.
1.
Assess for substance and alcohol use: quantity, route, length of use, dependence, withdrawal
symptoms, fits and DTs. Obtain informant history and objective information: physical examination
(eg for track marks,) urine drug screen and blood tests. Urine test should be taken and opiate
use confirmed before any opiate drug is prescribed. (See appendix 1 for more details on
assessment.)
Where possible use objective rating scales to measure symptoms (included or as obtainable from your local specialist service).
Remember opiate withdrawal is not life threatening but overdose with opiates in a non-tolerant individual is potentially fatal.
The aim of treatment is to relieve distress and prevent potentially harmful outcomes such as fits.
Where opiate users are detoxified before discharge they should be warned about their loss of tolerance to prevent accidental overdose.
Refer to alcohol management sheet for those clients.
Specific Drugs.
a)
Opiates.
If client claims to be on a script-do not prescribe until you have confirmation from prescriber (eg GP or Specialist drug team) and pharmacy that patient is on a script AND collecting it on a regular basis. If you commence prescribing, do so after discussion with prescriber only. Ensure all other prescriptions in the community are cancelled by the prescriber while you prescribe. Liase with community prescriber prior to discharge to ensure script continuity; issue TTH only in liaison with community prescriber.
Withdrawal symptoms for heroin: (Methadone similar pattern but over 14 up to 21 days, peak10-14,
depending on rapidity of reduction):
Early: (0-48hrs): Yawning: sniffling: goose flesh (cold turkey)
Middle Symptom Peak: ((3-4 days): Bone and muscle pain: (severe flu like symptoms)
Late: (5-7 days): Diarrhoea: Abdominal cramp (G1 symptoms.)
Symptomatic relief of withdrawal symptoms can be prescribed for clients experiencing mild to moderate
symptoms (see opiate withdrawal scale enclosed):
Abdominal cramps: BuscopanR 20 mg qds; SpasmonalR 60-120mg tds.
Diarrhoea: Loperamide 4mg initially then 2mg with each loose stool
Muscle and joint pain: Ibuprofen 400-600mg tds; ArthrotecR (diclofenac 50mg and misoprostol 200
micrograms) 1 tds; MovelatR gel applied topically qds; TransvasinR cream applied topically qds.
Severe withdrawal symptoms:
Symptomatic relief plus treat with Dihydrocodeine 60-90mg stat & Diazepam. 10mg stat. Assess 3hrs-if
objective symptoms present per opiate scale repeat DHC.
Do not write up on a regular basis. DHC is not licensed for this purpose.
Benzodiazepines.
Take a careful history to establish dependence, (use of Diazepam equivalent 60mg daily every day with no break for 3/12 or definite history of diazepam withdrawal related seizure in 40mg daily use.) Seek further advice from specialist service if these criteria are met,including benzodiazepine withdrawal scale.
If history of fits, prescribe 20mg Diazepam stat and seek further advice as above.
Depending on the likely duration stay of the individual, a short reducing course of diazepam could be prescribed to ease withdrawal symptoms.
Non-dependent use of diazepam should not be treated with “as required” diazepam.
Crack; cocaine; amphetamine; other stimulants.
No current evidence that any particular medication is of benefit is crash, depression or extinction phases.
Paranoid symptoms are usually of short duration and where troublesome responded to anti-psychotic medication (eg Haloperidol 2.5-5mg up to tds) for 2-3 days.
More florid psychoses need psychiatric assessment.
Polydrug use.
Seek advice-aim is to prevent more serious harm from fits. DTs. Psychosis and to withdraw
substitute drugs sequentially, starting with substances with shorter withdrawal duration, eg alcohol,
then opiates, then benzodiazepines.
Follow above advice re history of fits.

Source: http://www.peninsula-mrcpsych.org.uk/downloads/CT2_Addictions/Emergency%20Management%20of%20Substance%20Withdrawal%20Dr%20M%20Rowlands%2024th%20Jan%202014.pdf