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