Managing Inpatient Drug Withdrawal

Rationale

1. To prevent early discharge against medical advice due to opiate or benzodiazepine withdrawal symptoms and support secondary care colleagues to prescribe medications to reduce withdrawals until the patient can be referred to and assessed by the Drug and Alcohol Liaison Service (DALS) team.

Initial Assessment

1. What drug?
   • quantity used
   • frequency of use
   • operiod of use
   • who used with
2. Obtain Urine Drug Screen (UDS) and completion of point of care test (PCT) is recommended, where available, to confirm picture of drug use. Some drugs may not show up on PCT e.g. gabapentinoids and there is the potential for false positives (please seek advice if concerns re this).
3. If injecting drug user, complete physical check of injection sites to confirm use and check for infection such as swelling, heat/fever, redness, blistering, discharge, necrosis.
4. Is this classed as dependent use (using at least 3-4 times per week)
5. Are the drugs used prescribed or illicit?
6. Each drug should be addressed individually

Opiate Withdrawal

1. If there is an opiate prescribed, continue prescribed drug and adjust upwards as needed (dependent on Clinical Opiate Withdrawal Scale – COWS scale)
   • If no opiates are prescribed, prescribe dihydrocodeine PRN until assessed by DALS:
   • Starting dose 30mg QDS with 2 additional PRN doses
   • Period of adjustment 24-48 hours
   • Max dose 60mg QDS
   • Total up amount needed to achieve stability over 24 hours and convert to daily dose in 4 divided doses

*COWS may still be high due to withdrawal from other CNS depressants e.g. gabapentinoids, benzodiazepines.

*If patient is nil by mouth, then an equivalent dose of an alternative opiate should be prescribed.

Benzodiazepine Withdrawal

1. If reported use is within normal limits then calculate total daily dose, convert to diazepam equivalence and divide into QDS regime
2. · If unsure of quantity being used prior to admission, start PRN dosage regime
   • Diazepam 10-20mg QDS PRN + 2 additional PRN 10-20mg doses if needed
   • *Dose determined by level of use prior to admission. If low level use suspected then start with 10mg PRN regime, if high level use suspected then opt for 20mg PRN regime).
   • Max dose 120mg in 24 hours
3. Observe for over-sedation. Smaller doses can be given if required. Effects will be accentuated if prescribing other CNS depressants.

Discharge Planning

1. Patients can be provided with up to 24 hours worth of dihydrocodeine or diazepam on discharge. This should be a clinical decision based on each individual patient, taking into account:
   • whether they have a supply at home
   • how they source their drugs normally
2. This differs from advice for problem drinking where benzodiazepine medication is not usually supplied on discharge due to easily accessible supply of alcohol. THIS WILL NOT BE SUPPLIED BY GPs post discharge.
3. The DALS team should be contacted where possible so that harm reduction information can be provided around overdose, naloxone and post discharge support from services if not already know to addiction services.

Content by Sam Nairn – Approved at ADTC Jan 25, R/V Jan 27