Opioid dependence (Formulary: CNS)

TAM (Treatments and Medicines) NHS Highland
NHS Highland

MHRA alert: Opioids: risk of dependence and addiction (September 2020) (www.gov.uk).
MHRA alert: Benzodiazepines and opioids: reminder of risk of potentially fatal respiratory depression (March 2020) (www.gov.uk).

For further information refer to the 2017 guidance Drug misuse and dependence: UK guidelines on clinical management (www.gov.uk) and Opiate misuse: Raigmore Hospital. National guidance recommends daily supervised consumption of methadone or buprenorphine or buprenorphine with naloxone for the first 3 months of treatment.

Pain management: for guidance on pain management in patients on long-term methadone, buprenorphine or buprenorphine with naloxone seek specialist advice.  The Maudsley Prescribing Guidelines* recommend that, for methadone prescribed patients requiring analgesia, non-opioid analgesia (eg paracetamol, NSAIDs) should be used in preference. If opioid analgesia is indicated (eg codeine, dihydrocodeine, morphine), the drug should be titrated accordingly against pain relief, with the methadone dose remaining constant to alleviate withdrawal symptoms.  Titrating the methadone dose to provide analgesia may be used in certain circumstances but should only be carried out by experienced specialists.  For further information see also ‘Pain and substance misuse; improving the patient experience’ at www.britishpainsociety.org.

*The Maudsley Prescribing Guidelines, 12th Edition, p437-438, David Taylor, Carol Paton, Shitij Kapur

Opioid conversions: for advice on conversions from opioids to methadone or buprenorphine contact Drug and Alcohol Services at Osprey House, Inverness tel: 01463 704000 (Raigmore Hospital Switchboard) or Argyll and Bute Addiction Team, Argyll and Bute Hospital, Lochgilphead, tel: 01546 602323. 

Dihydrocodeine (Opioid dependence) should only be prescribed to drug misusers by clinicians with appropriate specialist competencies. There is a small evidence base that dihydrocodeine can be used effectively for maintenance although none that it is superior to other opioid medicines. Dihydrocodeine tablets are difficult to supervise, are short-acting (so need frequent dosing) and can be easily diverted (Drug misuse and dependence. UK guidelines on clinical management).

Guidelines: Substance misuse (Guidelines)

BUPRENORPHINE

Therapy notes

Prescribers should be aware that buprenorphine preparations are NOT interchangeable.

Generic buprenorphine sublingual tablets are available at lower cost.

Guidelines:

Formulation and dosage details

Formulation:

Sublingual tablets (CD schedule 3) 400 micrograms, 2mg, 8mg

Dosage:

By sublingual administration, initially, 800 micrograms to 8mg daily (dividing the daily dose may be useful), adjusted according to response; maximum 32mg daily; withdraw gradually.

Notes:

In those who have not undergone opioid withdrawal, administer buprenorphine at least 12 hours after last use of opioid or when signs of withdrawal appear. For those receiving methadone, reduce the dose of methadone to maximum 30mg daily before starting buprenorphine. Start buprenorphine at least 24 hours after methadone.

Formulation and dosage details

Formulation:

Prolonged release injection (Restricted: specialist initiation only)

Buvidal® injections are available in formulations that can be given weekly or monthly, depending on the strength of the injection.

  • Weekly:
    Buprenorphine (50mg/mL): 8mg, 16mg, 24mg, 32mg prolonged release solution for injection pre-filled syringes (terminal half-life ranging from 3 to 5 days).
  • Monthly: 
    Buprenorphine (355.56mg/mL): 64mg, 96mg, 128mg prolonged release solution for injection pre-filled syringes (terminal half-life ranging from 19 to 25 days).

Dosage:

As per SMC2169: Treatment of opioid dependence within a framework of medical, social and psychological treatment. Treatment is intended for use in adults and adolescents aged 16 years or over.
SMC restriction: Use in patients in whom methadone is not suitable and for whom the use of buprenorphine is considered appropriate.

  • Local guidance under development. 

Formulation and dosage details

Formulation:

Oral lyophilisate tablet (Espranor®) 2mg, 8mg (Restricted: Specialist recommendation only)

  •  May ONLY be initiated in Primary Care under the recommendation of the Specialist

Place of therapy:

  • Specialist and Community settings: SECOND LINE buprenorphine oromucosal product after buprenorphine sublingual tablet or buprenorphine / naloxone combination sublingual tablet
  • Prison Service: FIRST LINE oromucosal buprenorphine product

Dosage:

As per SMC 1245/17: Substitution treatment for opioid drug dependence, within a framework of medical, social and psychological treatment. Treatment with buprenorphine oral lyophilisate is intended for use in adults and adolescents aged 15 years or over who have agreed to be treated for addiction. 

  • SMC Restriction: to patients in whom methadone is not suitable.  

Dosage: 

  • Oromucosal administration: the oral lyophilisate should be taken from the blister unit with dry fingers, and placed whole on the tongue until dispersed, which usually occurs within 15 seconds, and then absorbed through the oromucosa.
  • Swallowing should be avoided for 2 minutes.
  • The oral lyophilisate should be taken immediately after opening the blister.
  • Patients should NOT consume food or drink for 5 minutes after administration.

Note: If the oral lyophilizate, or saliva containing buprenorphine are swallowed, the buprenorphine will be metabolised and excreted and have minimal effect. For further information, see the national guidelines for buprenorphine treatment.

BUPRENORPHINE WITH NALOXONE

Therapy notes

Formulation and dosage details

Formulation:

Sublingual tablets (CD schedule 3) 2mg/500 micrograms, 8mg/2mg, 16mg/4mg

Dosage:

See SMC 2316: substitution treatment for opioid drug dependence, within a framework of medical, social and psychological treatment. The intention of the naloxone component is to deter intravenous misuse. Buprenorphine/naloxone is indicated in adults and adolescents over 15 years of age who have agreed to be treated for addiction.
SMC restriction: to those patients in whom methadone is not suitable and for whom the use of buprenorphine is considered appropriate.

and SMC 355/07:substitution treatment for opioid drug dependence, within a framework of medical, social and psychological treatment. 
SMC restriction: to those patients in whom methadone is not suitable and for whom the use of buprenorphine is considered appropriate.

METHADONE

Therapy notes

MHRA advice: Drugs and driving: blood concentration limits to be set for certain controlled drugs in a new legal offence (December 2014) (www.gov.uk).

Formulation and dosage details

Formulation:

Oral solution (CD schedule 2) 1mg/mL

Dosage:

Initially 10 to 30mg daily, increased by 10mg daily until no signs of withdrawal or intoxication, usual dose 60 to 120mg daily. Higher doses may be used in consultation with specialist units.  Usual maximum weekly increase should not exceed 30mg.

Notes:

In patients with recognised risk factors for QT-prolongation, or in case of concomitant treatment with drugs that have a potential for QT-prolongation, ECG monitoring is recommended prior to methadone treatment, with review on dose stabilisation. In patients without recognised risk factors for QT-prolongation, ECG monitoring is recommended before dose titration above 100mg/day.

In methadone overdose when using naloxone be aware of its short duration of action.

NALTREXONE HYDROCHLORIDE

Therapy notes

Formulation and dosage details

Formulation:

Tablets 50mg (s)

Dosage:

Commence under specialist supervision, Day 1, test urine to confirm patient is opioid and methadone-negative, give 25mg then observe for an hour. If tolerated, subsequent doses can be increased to 50mg daily as a maintenance dose.  

Notes:

Check liver function before starting naltrexone and at 3-monthly intervals for one year.

Warn patients taking naltrexone that an attempt to overcome the block could result in potentially fatal opioid intoxication.

NALOXONE

Therapy notes

BNF

Important safety information: Safe practice

  • Doses used in acute opioid overdose may not be appropriate when there is risk of acute withdrawal (e.g. chronic opioid use), or when a continued therapeutic effect is required (e.g. postoperative use, palliative care).

Guidelines - NHS Highland:

Formulation and dosage details

Formulation:

Nasal spray unit dose (Nyxoid®) 1.8mg/0.1mL FIRST LINE OPTION

Dosage:

Opioid overdose

  • Licensed for use in individuals aged 14 years and above.
  • In a life-threatening emergency, such as a suspected opioid overdose, it may be administered to individuals of any age, as an off-label intervention to save life.
  • An opioid overdose can be identified by a combination of signs and symptoms such as: pinpoint pupils, difficulties in breathing such as slow/uneven breathing or no breathing, not responding to a loud noise or touch, blue or purple fingernails or lips and unconsciousness.

Supply for ‘Take Home Naloxone’:

  • Anyone at risk of overdose
  • A family member or friend of a person at risk of overdose
  • An outreach worker for a homelessness service whose clients include people who use opioids

Dosage: 

  • After administration: Monitor until help arrives.
  • Stay with the person. Watch for an improvement in breathing, and their response to sound and touch
  • If the person is unconscious and not breathing normally, give basic life support (such as CPR) if you are trained to do so.
  • Be aware: even if they wake up, they may become unconscious again, and stop breathing

Formulation and dosage details

Formulation:

Nasal spray unit dose 26mg/0.1mL (1.26mg) SECOND LINE OPTION

Dosage:

Opioid overdose

  • Naloxone 1.26mg Nasal Spray, is licensed for use in individuals aged 16 years and above.
  • In a life-threatening emergency, such as a suspected opioid overdose, it may be administered to individuals of any age, as an off-label intervention to save life. 
  • An opioid overdose can be identified by a combination of signs and symptoms such as: pinpoint pupils, difficulties in breathing such as slow/uneven breathing or no breathing, not responding to a loud noise or touch, blue or purple fingernails or lips and unconsciousness.

Supply for ‘Take Home Naloxone’:

  • Anyone at risk of overdose
  • A family member or friend of a person at risk of overdose
  • An outreach worker for a homelessness service whose clients include people who use opioids

Dosage:

  • After administration: Monitor until help arrives.
  • Stay with the person. Watch for an improvement in breathing, and their response to sound and touch
  • If the person is unconscious and not breathing normally, give basic life support (such as CPR) if you are trained to do so.
  • Be aware: even if they wake up, they may become unconscious again, and stop breathing

Editorial Information

Document Id: F106