Injectable Opioid Treatmentin England

Clinical Experience

Rob van der Waal

The basics (1)

All Injectable diamorphine/ methadone administered under supervision

Oral supplement is necessary to ensure stability over 24 hours (take home available) Oral MethadoneSlow Release Oral Morphine Buprenorphine

The basics (2)

Open all days, AM and PM sessions

Flexible dosing regimes available – converting Injectable to oral (partly or completely) To minimize the inconvenience of IOT To encourage patient choice To provide exit route

Assessment and Introduction to IOT

Establishing eligibility and feasibility Trial period on oral medication followed by

partial conversion to Injectables Gradual titration of Injectable component and

oral component! until patient is comfortable Monitor and – if possible - manage problems

(e.g. alcohol/ benzodiazepine use, injecting sites)

Stabilisation

Reduction/ cessation of street heroin use Reduction/cessation of other street drug use Develop safe injecting routine (site rotation

etc) Medium-long term care planning If not successful patients move back to

standard oral maintenance treatment

Medium – long term

Reduce/stop other street drug use Reduction of injecting frequency and

attendance Increased focus on health and socio

economic aspects in care planning Exit or long term maintenance?

Flexible Dosing Example

Option A Diamorphine 200mg IV amDiamorphine 200mg IV pmMethadone oral 30mg

Option B Diamorphine 200mg IV / dayMethadone oral 100mg

Option C Methadone oral 170mg

Monitoring pre and post dose

Routine – brief observation to establish if it is safe to proceed If there are complications post dose

Comprehensive - involves intermittent assessment of vital signs (including pulse oximetry) breath alcohol levels UDS dipstick rating of withdrawal/ sedation levels

Injecting

Hygiene• Washing of hands, cleaning of sites before and

after injection Injecting sites

• Peripheral veins, muscles, no active inflammation Injecting time

• Approximately 5 minutes once routine has been established

InjectingProblems and solutions

Poor veins limit intravenous injecting (IV) deep veins (e.g. groin) not allowed

Single site IM injecting (painful, infections)

The majority of patients now inject intra muscular (IM) or subcutaneously (SC)

And are required to rotate sites

MonitoringProblems

Severe post dose sedation related to Benzodiazepine use

• Not always evident prior to dosing

Alcohol use Respiratory illness

It is easy to monitor alcohol use but benzodiazepine use is more costly, labor intensive and requires the patient to provide a urine specimen on the spot serious risk that can require immediate intervention (e.g.

observation, oxygen naloxone)

Co morbidity

Due to daily attendance the clinic offers an excellent opportunity to administer other medication under supervision, for example when thee are concern about compliance

E.g. antidepressants, antipsychotics, mood stabilisers

Summary (1)

Diamorphine can be sufficiently rewarding to keep patients engaged in highly structured treatment

Structure (protocol, ritual) is a critical therapeutic component

Patients have made significant progress, some have moved back to standard oral treatment and have maintained the benefits

Summary (2)

When not successful, it is often due to other drug use (e.g. alcohol, poly drug use), health, socio- economic factors or simply because of patient choice

Resolving the above appears conditional to long term success