Borders Community Addiction Team



NHS Borders Addiction Service

NHS Borders

Clinical Guidelines

Dr Mike Kehoe Consultant Psychiatrist in Addictions

September 2011

Procedure for Community Detoxification from Opiates with Prescribed Lofexidine

Function:

To ensure safe and effective prescribing of Lofexidine and minimise the negative effects of withdrawal from opiates.

Lofexidine is an alpha-adrenergic agonist drug that suppresses withdrawal over activity of noradrenergic neurons. Thus it effectively suppresses autonomic signs of withdrawal, but is less effective at suppressing symptoms of subjective discomfort. It is a structural analogue of clonidine, but less sedating and less hypotensive. Lofexidine is formulated as 200 microgram tablets.

Lofexidine is a treatment option for patients new to treatment who are seeking opioid-substitution/ stabilisation treatment e.g. heroin dependent service users, opiate-dependent service users using combinations of heroin and illicit methadone (equivalent to less than 30ml methadone) and methadone- dependent service users reduced/ stabilised at doses 30ml or less.

Lofexidine is a treatment option for community detoxification from heroin/ methadone as alternative to buprenorphine or continuing methadone reduction.

Lofexidine is a treatment option as a priority for younger heroin users, heroin smokers and those not wanting or previously failed on methadone treatment. However long-term and regular intravenous users should also be included for consideration.

A stable, immediate social environment is highly desirable with a nominated ‘significant other’ present.

Location:

In service user’s homes, GP practices and NHS Borders premises.

Responsibility:

NHS Borders Addiction Service (BAS) staff and general practioners.

Exclusions criteria to consider when using Lofexidine treatment include:

• Service users with a diastolic BP below 50 mmHg and pulse rate above 120.

• Hypersensitivity to Lofexidine or any other component of the tablet.

• Severe respiratory and cardiovascular insufficiency.

• Known history of QT interval prolongation.

• Severe renal insufficiency.

• Acute alcoholism or delirium tremens.

• Acute mental health problems especially severe depressive illness and suicidality.

Lofexidine is not licensed for use in pregnancy and during breast feeding or in children under 18 years old.

Criteria for community detoxification using Lofexidine:

Completed a NHS Borders Addiction Service assessment that includes; mental health assessment, physical health assessment, drug use history and life/ social history.

Confirmed as opiate dependent and must not be prescribed or taking illicit benzodiazepines.

The results of a urine specimen taken before prescribing Lofexidine must be available.

The service user will have provided a drugs diary of not less than one week old.

Team discussion to establish if Lofexidine prescribing is appropriate and the nature of the continuing treatment programme from NHS BAS (medic and CPN). The service user will have signed a contract which explains the procedure. A copy of this will be placed in their notes. The respective GP will be contacted to discuss the case, the proposed treatment and confirm agreement to undertake the prescribing request.

The community detoxification programme will be monitored by the CPN and BAS staff and Lofexidine plus symptomatic relief medication prescribed by respective GP. The regime is agreed and the prescription is issued for 10 days to be dispensed on a daily basis by the pharmacist.

The pharmacy must have agreed in advance to dispense the Lofexidine in the appropriate dosage. A telephone call to the community pharmacist indicating the day’s requirements will facilitate the process.

It is essential that all service users undergoing this procedure are provided with a copy of the Lofexidine information booklet and the contents discussed on Day 1 of the procedure. Because of the time available it is also an opportunity to reinforce harm reduction initiatives and undertake motivational work to promote continued abstinence from illicit drugs. This will be done by the CPN. If appropriate to the case the overdose dangers of returning to illicit drug use due to reduced tolerance following detoxification must be discussed and documented in the notes.

Procedure:

Day 1

Ensure a current drug diary and recent drug screen result is available.

Have the service user complete the subjective opiate withdrawal scale (O.W.S.) (appendix 1) and the dedicated CPN complete the objective O.W.S. (BP, pulse and temperature).

The initial dose of Lofexidine will be 200- 400 micrograms twice daily, regardless of quantity of current heroin use, based on objective and subjective OWS findings (doses to be taken 12 hours apart). The service user or the CPN will pick-up the Lofexidine at the pharmacist and the first dose will be taken in front of the CPN.

Following the initial dose the service user is observed closely for 90 minutes. They will be checked for any signs of distress or light headedness and have their BP checked at half–hourly intervals.

Day 2

CPN will visit the service user at home and the O.W.S. is completed.

If no signs of withdrawal are apparent then the total dose from Day 1 should be repeated. If obvious withdrawal features are present then the total dose from Day 1 together with an increment of 200- 800 micrograms (1 -4 tablets) should be administered (i.e. 1600 micrograms maximum in 24 hours to be given in 4 divided doses and maximum single dose is 800 micrograms).

In all cases service users are monitored for 30 minutes by the CPN.

Day 3

Service users should be given Day 2 dosage and an extra 200- 800 micrograms (1-4 tablets) if O.W.S. shows further opioid withdrawal. Therefore: 2400 micrograms maximum in 24 hours to be given in 4 divided doses and maximum single dose is 800 micrograms.

Note- for those being inducted onto Lofexidine from methadone as opposed to heroin (and other short acting opiates) prior to Day 1 methadone dose must be reduced to less than 30ml. Ideally the last methadone dose should be 24- 48 hours before initial dose of Lofexidine.

Once the CPN is satisfied with the procedure, the Lofexidine tablets for self-administration will be handed over to the service user. Patients prescribed lofexidine for opiate withdrawal will also receive the following medications as required depending on symptoms:

• Ibuprofen 400mg for muscular aches and pain. Every 4-6 hours. Maximum 2.4g/ day.

• Zopiclone 7.5mg for withdrawal insomnia. Maximum 15mg in 24 hours.

• Hyoscine butylbromide 20mg qds for stomach cramps. Maximum 80mg in 24 hours

• Metoclopramide 10mg every 8 hours for nausea and vomiting. Maximum is 30 mg in 24 hours.

• Loperamide 2mg for diarrhoea. Maximum 8mg in 24 hours.

Side Effects from Lofexidine:

If systolic BP drops below 90mm Hg or 30mm below baseline, or pulse drops below 55, lofexidine should be withheld until normal measurements are obtained. Service users with a systolic BP below 90 mmHg can cautiously reintroduce up to a maximum of 3 tablets bd or lower if they have dizziness at this dose. If in doubt consult the BAS medic.

Duration of treatment is 7- 10 days and Lofexidine should not be stopped abruptly as it may cause rebound rise in blood pressure. Reduce to a level at which the service user has no side effects or if they need to stop Lofexidine completely stop over 3 days.

The importance of close supervision and observation of service users (BP, pulse, adverse effects) undergoing Lofexidine detoxification cannot be overstated. Any unexplained absences of service users should be a cause for concern and signs of intoxication should prompt an urgent clinical evaluation.

Role of the Detox. CPN:

To provide a safe and effective home detoxification programme tailored to meet the needs of the service user who wishes to become free from opiates. Throughout the detox programme the nurse will undertake motivational work exploring issues relating to lifestyle changes which will assist the service user in their goal for abstinence.

The home detox CPN will be seeing the service user every day for the first week, alternate days for the second week and ensure further follow-up exists for the following week.

A home detoxification patient satisfaction questionnaire will be issued after each detoxification for completion and return to NHS Borders Clinical Audit Support Team who will collate the results and an annual report will be produced.

Appendix 1: NHS BORDERS ADDICTION SERVICE

Opioid Withdrawal Symptoms Checklist

Name_____________________________________ D.O.B ________CHI _________

Please tick if you have been experiencing any of these symptoms in the past 24 hours.

| | |TIME, DATE & SIGNATURE OF |

| | |PRACTITIONER |

| | |Heroin |Morphine |Methadone |

| | | | | |

|0 |Craving for drugs, anxiety, drug seeking |4 |6 |12 |

| |behaviour | | | |

| | | | | |

| | | | | |

|1 |Yawning, perspiration, running nose, |8 |14 |34-48 |

| |lachrymation | | | |

| | | | | |

| | | | | |

|2 |Increase in above signs plus mydriasis, |12 |16 |48-72 |

| |goose-flesh (piloerection), tremors (muscle | | | |

| |twitches), hot and cold flushes, aching bones | | | |

| |and muscles, anorexia, abdominal cramps, | | | |

| |irritability | | | |

| | | | | |

| | | | | |

|3 |Increased intensity of above plus insomnia, |18-24 |24-36 | |

| |increased blood pressure, increased temperature,| | | |

| |increased respiratory rate and depth, increased | | | |

| |pulse rate, restlessness, nausea | | | |

| | | | | |

| | | | | |

| |Increased intensity of above plus febrile | | | |

|4 |facies, position (curled up on hard surface), |24-36 |36-48 | |

| |vomiting, diarrhoea, weight loss, spontaneous | | | |

| |ejaculation or eosinopenia, increased blood | | | |

| |sugar | | | |

N.B – Objective signs are those in italics. The remainder are subjective/require clinical judgement or laboratory investigation

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