Opiate Dependence

Overview

Opiate dependence leads to a wide range of medical, social and psychological harm (1)

People who misuse or are dependent on drugs (including heroin and other opioids in particular) have mortality rates of around 1-2% per year — an excess mortality that is 10–20 times greater than expected. 

People who are dependent on opiates have a greater risk of infection including:

• Skin infections and sepsis
• HIV - prevalence among injecting drug users in 2017 was 1.7% in England, Wales and Northern Ireland, 
• Hepatitis B - the proportion of people in the UK who inject drugs who have ever been infected with hepatitis B was 16% in 2017. 
• Hepatitis C - this is the most common blood-borne infection among people who inject drugs. Around half of injecting drug users in the UK are infected with hepatitis. There is a marked regional variation in the prevalence of hepatitis C: 52% in England.
• Tuberculosis
• Clostridium infections - such infections are associated with injecting into the skin or muscle (a technique known as 'popping'). 

People who inject drugs are more likely to get vascular complications such as:

• DVT and PE
• Superficial thrombophlebitis
• Venous and arterial thrombosis

People who use drugs are more likely to have social problems, including:

• Crime — it is estimated that half of all recorded crime is drug related. 
• Imprisonment.
• Effect on partner and children including child protection issues.
• Deprivation and social exclusion.
• Involvement in the sex trade.
• Homelessness.
• Loss of driving licence. 

People who use drugs are more likely to have psychological problems, including: 

• Craving and fear of withdrawal.
• Guilt.
• Anxiety. 
• Loss of memory or cognitive skills.

(1) Opioid Dependence: What are the complications - CKS (March 2021)

Who to Refer

Patients who are dependent on opiates will usually present in primary care requesting support or a script.

Prescribing of opiate substitution therapy should only be undertaken following assessment by a specialist drugs team. See details of referral routes below.

What to do before referral

Urine drug screen - BDP will now be able to dip test Urine Drug Screens at assessment so these are no longer needed with a referral.

Although not a requirement of referral the following should also be offered:

BBV screen - all patients should be offered screening for blood bourne virus (BBV) infections (HIV, hepatitis B and C) and baseline LFTs. If venous access is difficult then a BBV screen can be done via a blood spot test.

Immunisation- all patients should be offered a course of hepatitis B vaccination if not already completed. An accelerated vaccination schedule should be given in those patients not previously immunised. 

Referral for opiate substitution therapy

Opiate substitution therapy for adults is provided by collaboration between the NHS and local authorities. Referral pathways therefore differ across BNSSG.

Please see links to the relevant pages below:

Bristol

South Gloucestershire

North Somerset

Referrals for children (aged <18)

Prescribing advice

Orange Guidelines - these are the full national guidelines on OST initiation and prescribing (UK Clinical Guidelines on Clinical Management of Drug Misuse and Dependence)

The following sections are particularly useful for prescribers:

• Pharmacological interventions - Section 4, Pages 83 -113
• Initiation of methadone/buprenorphine - Secction 4.4,  Pages 90 - 100
• Methadone dosing Section - Section 4.4.7, Pages 97 - 98
• Buprenorphine dosing - Section 4.4.8, Pages 99 - 100

OST (re)start template on EMIS

There is an EMIS template that can be utilised for the initiation of OST – both new starts and restarts.The template is entitled ‘HHS opiate substitution therapy initiation’ and can be located in the ‘Templates from Homeless Health Service’ folder (via Protocols & Templates tab > One Care Published Templates & Protocols)

The template needs to be activated – this can be done by all BNSSG GP practices

For assistance locating template  please email - emis.optimisation@onecare.org.uk

Resources

Breaking Free (Bristol and South Gloucestershire only) - online resource for patients with alcohol and drug problems.

Alcohol Misuse

Non-opiate drug dependence

Resources for GPs Regarding Opioids and Chronic Pain (from Oxford University Hospital Trust) - this advice includes links to advice about opiod reduction in primary care.

Opioid Calculator (from Faculty of Pain Medicine (Australia and NZ) - link to app that can be downloaded.

Opioid Dependence - Clinical Knowledge Summaries (March 2021)

BNSSG Reducing and Stopping Opioids, Information for Patients leaflet - located in the Formulary section of Remedy but also available on the public facing ICB website here.

Helping primary care reduce harm from opioids 

The West of England AHSN have launched an easy-to-follow guide for primary care. The guide will support clinicians to identify patients at risk from opioid prescribing. It includes templates and ideas, as well as providing information on training and examples of best practice initiatives.  

Driving

DVLA guidance is available on drug or alcohol misuse and dependence (pg. 100).

GMC guidance is available on how to speak to a patient about driving, what to do if you’re unsure about their fitness to drive, and the steps to take if a patient continues to drive after you’ve advised them to stop.

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.