Methadone user in A&E

Structure: Methadone user in A&E

• Halo-Intro-Set the scene

• History of Methadone use

• Usage on top inc. risks

• Past Medical / Drug History

• Dependence

• Motivation

• Social History

• Management plan

Script: Methadone user in A&E

• “Hello, (NAME), my name is Dr.X, I understand you’ve come in today because you’re not feeling very well”

• “(NAME), I’d certainly like to help you, but I need to ask you some questions before I can make a decision on that”

• “What symptoms are you having at the moment?”

• “Why is it that you want Methadone at the moment?”

Script: Methadone user in A&E

• “When was the last time you took Methadone?”

• “You said you last took some 2 weeks ago, what’s been happening over the past couple of weeks?”

• “How long have you been on Methadone for? > “Who prescribed it for you?” > “How much are you on?”

Script: Methadone user in A&E

• “Do you use anything else on top of your Methadone?”

• “What do you take? > “How much?” > “How long have you been taking this for?”

• “How do you take the heroin?”

Script: Methadone user in A&E

• “Do you share your needles at all?”

• “Have you ever had any problems associated with injecting?” > “Some people get pain or infections at the sites they inject – has that happened?” > “Have you ever been in hospital because of blood clots in your legs? > “What about heart problems?”

• “Have you ever had a HIV test?” > “What about Hep C?”

Script: Methadone user in A&E

• “Have you ever managed to overdose on heroin?”

• “(NAME), is how you are currently feeling typical of what happens when you don’t take heroin?”

• “Have you had any reason to change the amount of heroin you need?” > “Do you need more to get the same effect?” > “How has this impacted on the rest of your life?”

Script: Methadone user in A&E

• “How much time do you spend time thinking about heroin?” > “Does it affect other things you might want to do in your day?”

• “Why are you on Methadone at the moment?” > “On a scale of 0-10 how motivated are you to come off heroin?”

• “I do see that you are in distress and I appreciate your patience with me, we are almost done”

Script: Methadone user in A&E

• “Who’s at home at the moment” > “Any children at the moment?”

• “Okay, if you don’t mind me asking, how do you fund your habit?” > “Ever been in trouble with the police?”

• “We can’t give you any methadone in the A&E department but we can give medications for the symptoms that you have at the moment – eg painkillers, buscopan, anti-diarrhoeal agents”

• “I do appreciate that but as a matter of medical safety for yourself I cant prescribe any methadone until I’ve liaised with the DASH service to confirm everything you’ve told me”

• “I’ll contact your key-worker as soon as possible so that your methadone prescription can be reinstated”

Overview

• True Opiates: Morphine, Codeine

• Semi-synthetics: Heroin

• True Synthetics: Fentanyl, Methadone

Signs of withdrawal

• <24 hours after last dose

• Last about a week

• Last about 7-10 days if on methadone withdrawal

• Can’t die from opiate withdrawal!

Management principles

Harm minimisation:

• Education on overdose-withdrawal

• IV to smoking

• BBV protection via safe sex/needle exchange

• Safer methods of injection

• Treatment of co-morbid illnesses

• Psychosocial – e.g. NA

Management principles

Detoxification/Substitution:

• Stop the opioid and allow withdrawal to run natural course

• Substituting a similar safer and less potent drug gradually decreasing the dose and stopping the drug

Management principles

Maintenance:

• Using a prescribed drug e.g. Methadone, Buprenorphine

Management principles

• Ongoing counseling and support are essential to controlling opioid addiction

• Withdrawal symptoms can be managed with methadone (20-80 mg/day).

Alternate Scenarios

• LINKED to Consultant presentation

• Opioid detoxification

• Methadone counseling

• Patient on Methadone but has relapsed back into opiate misuse

Structure: Opioid Detoxifcation

• Halo-Intro-Set the scene

• HPC: O,D,P,I

• Dependence

• Risks – Social / Forensic

• Past Medical / Past Psychiatric

• Harm minimisation > Substitution > Maintenance

• Management

Structure: Methadone relapser

• Halo-Intro-Set the scene

• HPC: O,D,P,I

• Dependence / Risks

• Past Medical / Drug / Psychiatric

• Issues with methadone

• Reassess motivation

• Management: Harm minimisation > Detoxification > Substitute

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