Methadone is not to be prescribed for or supplied to patients in the ED
Background
- All patients should promptly receive appropriate analgesia to relieve their pain
- Opiates should be used, if necessary, to relieve symptoms of physically painful conditions (e.g. fractures) irrespective of whether the patient has a history of dependence or not
Please remember that
- For most heroin addicts general support, understanding of the symptomatology and encouragement is sufficient to alleviate acute withdrawal symptoms
- Symptomatic relief of withdrawal symptoms can be achieved without substitute opiate medication
- The severity of withdrawal symptoms is not directly related to the quantity of drugs previously consumed
- When assessing symptoms please identify observable signs rather than subjective symptoms
- Detoxification may be used in the in-patient wards but methadone must never be given in the Emergency department or CDU.
- Untreated heroin withdrawal typically reaches its peak 36-72 hours after the last dose and rapidly subside
- Withdrawal from opiates is associated with a specific withdrawal syndrome
Symptoms and signs of opiate withdrawal
| For each item, write in the number that best describes the patient's signs or symptom. Rate on just the apparent relationship to opiate withdrawal. For example, if heart rate is increased because the patient was jogging just prior to assessment, the increase pulse rate would not add to the score. Time: |
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| Resting Pulse Rate: (record beats per minute) Measured after patient is sitting or lying for one minute 0 pulse rate 80 or below 1 pulse rate 81-100 2 pulse rate 101-120 4 pulse rate greater than 120 |
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| Sweating: over past ½ hour not accounted for by room temperature or patient activity 0 no report of chills or flushing 1 subjective report of chills or flushing 2 flushed or observable moistness on face 3 beads of sweat on brow or face 4 sweat streaming off face |
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| Restlessness Observation during assessment 0 able to sit still 1 reports difficulty sitting still, but is able to do so 3 frequent shifting or extraneous movements of legs/arms 5 Unable to sit still for more than a few seconds |
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| Pupil size 0 pupils pinned or normal size for room ligh 1 pupils possibly larger than normal for room ligh 2 pupils moderately dilated 5 pupils so dilated that only the rim of the iris is visible |
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| Bone or Joint aches If patient was having pain previously, only the additional component attributed to opiates withdrawal is scored 0 not present 1 mild diffuse discomfort 2 patient reports severe diffuse aching of joints/ muscles 4 patient is rubbing joints or muscles and is unable to sit still because of discomfort |
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| Runny nose or tearing Not accounted for by cold symptoms or allergies 0 not present 1 nasal stuffiness or unusually moist eyes 2 nose running or tearing 4 nose constantly running or tears streaming down cheeks |
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| GI Upset: over last ½ hour 0 no GI symptoms 1 stomach cramps 2 nausea or loose stool 3 vomiting or diarrhoea 5 Multiple episodes of diarrhoea or vomiting |
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| Tremor observation of outstretched hands 0 No tremor 1 tremor can be felt, but not observed 2 slight tremor observable 4 gross tremor or muscle twitching |
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| Yawning Observation during assessment 0 no yawning 1 yawning once or twice during assessment 2 yawning three or more times during assessment 4 yawning several times/minute |
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| Anxiety or Irritability 0 none 1 patient reports increasing irritability or anxiousness 2 patient obviously irritable anxious 4 patient so irritable or anxious that participation in the assessment is difficult |
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| Gooseflesh skin 0 skin is smooth 3 piloerection of skin can be felt or hairs standing up on arms 5 prominent piloerection |
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| Score: 5-12 = mild withdrawal 13-24 = moderate withdrawal 25-36 = moderately severe withdrawal >36 = severe withdrawal |
Total Score Observers Initials |
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Management
Methadone is not to be prescribed for or supplied to patients in the ED
There are now satisfactory non-opiate treatments for opiate withdrawal. At CUH, please contact the liaison psychiatry team for advice. Drugs that should be considered include.
| Sign/Symtom | Treatment Option |
|---|---|
| Diarrhoea | Loperamide Oral: 4mg stat, then 2mg after each loose stool. Usual daily dose 6-8mg, maximum daily dose 16mg |
| Nausea and Vomiting | Prochlorperazine Oral: 5-10mg Intramuscular: 12.5mg, followed 6 hours later by an oral dose |
| Aches and Pains | Paracetamol: 1g QDS PO Ibuprofen: 400mg TDS PO |
| Agitation/Insomnia | Promethazine Oral: 25-50mg (max. 75mg/day) Intramuscular: 25-50mg |