Constipation All opioids do this. Will be made worse by lack of dietary fibre, fluid intake or exercise. Encourage fibre intake (fruit, cereals, vegetables), fluids, and regular exercise. Stimulant laxatives if necessary. Weight gain, particularly for Fluid retention caused by opioids – more likely on high doses Lower dose “ “ Eating more while in treatment; high salt intake Reduce fat and salt in diet, exercise regimen Poor sleep Dose too low and causing withdrawal at night Review maintenance dose and review other medications “ “ Dose too late at night, causing stimulation at time of peak effects Other drugs (particularly stimulants in the evening, such as coffee, nicotine, amphetamines) General anxiety or irregular sleep pattern Depressive illness Follow sleep hygiene recommendations “ “ Central sleep apnoea Assess and consider referral Amenorrhoea or oligomenorrhoea All opioids can do this May be related to lifestyle, stressors, poor diet, and general poor health Periods may return after cessation of heroin use, or following withdrawal from opioids. Address other causes Lowered sex drive More common with a high dose through effect on sex hormones Can be many other psychological factors (such as anxiety, poor relationship with partner, etc.) Review dose Consider investigation for opioid-induced hypogonadism Dental problems All opioids reduce saliva flow Poor diet, dental hygiene Encourage oral hygiene, dental floss and use of sugar free gum. Dental check-up. Reduce intake of sugary drinks and sweet food.
3. Quality framework 3.1 Assessment and treatment engagement The purpose of assessment is to identify patients’ determine their suitability for treatment and establish a treatment plan. A thorough assessment should precede all treatment and should involve comprehensive drug use, medical and psychosocial history, physical and mental state examination and, as clinically indicated, other appropriate investigations. Good assessment is essential to the continuing care of the patient. Not only can it enable the patient to become engaged in treatment but it can begin a process of change even before a full assessment is complete. The effectiveness of treatment can be expected to be greater if treatment is responsive to an individual’s of change and personal circumstance. Good care planning aims to deliver services that are patient-centred rather than centred on the service provider ().Care plans can facilitate patient access to an integrated selection of services and may prevent patient drop out. Assessment is the first stage of care planning. The primary purpose of assessment is to carry out a functional analysis and determine the best type of response (). However, the initial assessment is also a time when patient and clinician establish a therapeutic relationship. Hence the content and manner of assessment are both important. The general principles of assessment discussed in this section are applicable to all forms of treatment for alcohol and other drug use. The nature of opioid substitution treatment places some additional requirements on assessment of eligibility for this form of treatment. 3.2 Establishing and defining a therapeutic relationship For the prospective patient, the assessment interview is often a time of great vulnerability and expectation. The decision to seek treatment is frequently taken at a time of crisis. Many patients feel ambivalent about treatment, particularly substitution treatment, and entering treatment may be marked by a sense of failure and guilt. It is important for clinicians to demonstrate an accepting, non-judgmental approach to patients, being neither authoritarian nor overly intrusive. Patients are hesitant or reluctant to disclose their drug use or problems. Patients who are report discomfort, shame, fear, distrust, hopelessness, and the desire to continue using drugs as reasons they do not discuss addiction openly with their clinicians. Clinicians need to approach patients who have an addiction in an honest, respectful way, just as they would approach patients with any other medical illness or problem. It is important for clinicians to employ common sense, courtesy and an appropriate level of neutrality in establishing a relationship with patients. It is easy to present the impression of being excessively distant, remote and authoritarian in order to protect
Positive reinforcement The process by presentation of a stimulus, usually pleasant (e.g. the drug itself), increases the probability of a response. Rapid opioid detox A general term for procedures involving the use of opioid antagonists to induce withdrawal from opioids (See 2.2.3) Receptors Brain structures which bind particular drugs; the effects of a drug are experienced when the drug has attached itself to its corresponding receptor Recovery capital The sum total of all the personal, social, and community resources a person can draw on to begin and sustain his recovery from drug and alcohol problems () Relapse Return to problematic use of alcohol or drugs. ShOWS Short Opiate Withdrawal Scale (See Appendix 2) SOWS Subjective Opiate Withdrawal Scale (See Appendix 2) Takeaways Doses of medication provided for administration away from the dosing point; administration of takeaways may or may not be supervised by a responsible adult. See also unsupervised dosing. (See 2.3.6) Tolerance Requiring higher doses of the drug to experience the same effects Unsanctioned Usually referring to use of drugs that is not in accordance with a medical prescription Unsupervised dosing Refers to takeaway of medication that are administered without supervision by a responsible adult. See also Takeaways. (See 2.3.6) Withdrawal Signs and symptoms associated with cessation of a substance on which a person is dependent. Appendix 1: Definitions of opioid dependence Diagnostic and Statistical Manual of Mental Disorders After a major review, the latest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has now been released. (See ) DSM-IV had separate diagnoses of substance and dependence which have been combined in DSM-5 into a diagnosis for substance use disorder. The DSM-5 substance use disorder criteria are nearly identical to the DSM-IV substance abuse and dependence criteria combined into a single list, with two exceptions. The
Benzodiazepines 1-10 days depending on half-life 3-6 days, longer in some people Anxiety, insomnia, muscle aching and twitching, perceptual changes, feelings of unreality, depersonalisation, seizures. Stimulants 8-36 Several days, occasionally 2-3 weeks Lethargy, depression, irritability, hyperphagia, anhedonia, dysphoria, desire for sleep increased. Cannabis Usually days Weeks Irritability, anxiety, insomnia, anorexia, sweating, muscle spasms, headaches. From NSW Methadone Maintenance Treatment Clinical Practice Guidelines. Used with permission. Appendix 6: of intoxication with commonly used drugs Class of drug Intoxication Overdose Opioids (e.g. methadone, heroin, morphine) Constriction of pupils Itching/scratching Sedation/somnolence Lowered blood pressure Slowed pulse Hypoventilation Loss of consciousness Respiratory depression Pinpoint pupils Hypotension Bradycardia Pulmonary oedema Alcohol Relaxation Disinhibition Impaired coordination Impaired judgement Decreased concentration Slurred speech Ataxia Vomiting Disorientation/confusion Respiratory depression Loss of consciousness Loss of bladder control Benzodiazepines (e.g. diazepam, oxazepam, alprazolam, flunitrazepam) Disinhibition Sedation Drooling Incoordination Slurred speech Lowered blood pressure Dizziness Stupor/coma Ataxia Confusion Respiratory depression Stimulants (e.g. amphetamines, cocaine) Hyperactivity Restlessness Agitation Anxiety/nervousness Panic Acute paranoid psychosis Seizures Cardiac arrhythmias
dilation of pupils Elevated pressure Increased pulse Raised temperature Sweating Tremor Myocardial ischaemia Hypertensive crisis Cerebrovascular accidents Hyperpyrexia Dehydration Cannabis Relaxation Decreased concentration Decreased psychomotor performance Impaired balance Conjunctival inflammation Paranoid psychosis Confusion Agitation Anxiety/panic Hallucinations From NSW Methadone Maintenance Treatment Clinical Practice Guidelines. Used with permission. Appendix 7: Detection times for selected drugs in urine on information supplied by SA Pathology, Frome Rd, Adelaide] Drug Time* Alcohol 4-24 hours Amphetamine-like substances: including amphetamine, methamphetamine, ecstasy (MDMA) 2-4 days Benzodiazepines acting Long-acting (high-level misuse) 1-3 days 1-2 weeks (up to 6 weeks) Buprenorphine (sublingual) 1-2 weeks Cannabis (50 µg/L screen cut-off) Occasional Chronic, very use 1-3 weeks 4-6 weeks (may be up to 12 weeks) Cocaine metabolites 2-4 days Monoacetylmorphine (heroin metabolite) 12-24 hours Methadone 3-4 days Opiates: codeine, morphine 2-4 days Oxycodone 1-2 days *Times are estimates only. Detection times for an individual may vary with specific drug, dose and metabolism.
101 storage, 59 tetanus, 52 therapeutic communities, 73 therapeutic relationship, 30, 155 tolerance, 15, 21, 24, 77, 98, 99, 104, 105, 117, 149, 153, 189, 190 treatment goals, 9, 64 treatment planning, 12, 155, 157 chronic pain, 15, 151 clinical review, 47 coordination, 12 duration, 67 patient perspective, 12, 66, 92 review, 14, 36, 42, 159 selection of treatment approach, 12, 45, 66, 91, 96, 114, 118, 130, 132, 138 unsupervised dosing, 24, 32, 61 urine drug screening, 36, 160 'dipstick' methods, 36 directly observed, 37 limitations, 36, 46, 205 uses, 10, 36 vaccination, 52, 147 withdrawal, 32 assessment, 18, 191 precipitated by antagonists, 46, 47, 115, 116, 201 precipitated by buprenorphine, 21, 25, 27, 29, 34, 79, 99, 103 protracted, 84 signs and symptoms, 83, 88, 111, 134, 203