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Appendices: 1.0 Brief protocol for initiating treatment with injectable hydromorphone and diacetylmorphine 2.0 Induction ProtocolsInjectable Hydromorphone Induction Schedule2.2. Injectable Diacetylmorphine (DAM) Induction Schedule2.3 Accelerated Injectable Hydromorphone Induction Schedule 3.0 Daily conversion doses for patients receiving diacetylmorphine of equivalent 4.0 Missed dose protocol 4.1 Missed dose protocol for diacetylmorphine and hydromorphone 4.2 Accelerated missed dose protocol for diacetylmorphine and hydromorphone 1.0 Brief protocol for initiating treatment with injectable hydromorphone and diacetylmorphineAssessment Check ListCriteria met for iOAT (injectable opioid agonist treatment)History (including history of current substance use) and physical examLaboratory Assessment: complete blood count (CBC), liver enzymes, renal function, international normalized ratio (INR), HIV (human immunodeficiency virus), Hepatitis A B C serology, rapid plasma reagin?(RPR), urine drug screen (UDS), Pregnancy test, CxR (Chest X-ray)Documentation of shared treatment goals between patient and provider: e.g., initial goals referring to reductions in drug use, from there build on other client centered goals (e.g., getting benefits, stable housing, going back to school, etc.). Ensuring there are goals beyond the pharmaceutical components of the treatment is important for measuring progress within the context of a chronic condition, specially considering high treatment retention in iOAT. Immunizations documented and updatedTB skin testContact the patient’s primary care provider Consent and treatment agreement reviewed and signedCheck provincial prescription database for patient’s treatment history (i.e. opioid agonist and other medications).Induction Protocols 3-Day Hydromorphone (HDM) Induction Schedule (Max HDM dose 90 mg)3-Day Diacetylmorphone (DAM) Induction Schedule (Max DAM dose 180 mg)Accelerated 3-Day Hydromorphone Induction Schedule (Max HDM dose 130 mg)Missed Dose ProtocolPrescribing physician to be informed if their patient misses one day of DAM/HDMIf a patient is absent for 1 or more days, an attempt to contact the patient or their place of residence should be made and documented.If a patient is absent less than or equal to 3 days, continue with prescribed dose (prescribed dose is not discontinued. If a patient is absent for more than 3 days and less than or equal to 7 days, follow “Missed Dose Protocol” (See below Section 3).“Accelerated Missed Dose Protocol” (See below Section 3) is now the standard default protocol (due to high tolerance to street opioids such as fentanyl)If a patient has been absent (e.g. vacation, hospitalization, incarceration, etc.) and on opioid agonist therapy treatment can be restarted by calling the physician on call for DAM/HDM dose.Reduced Dose ProtocolIf a patient has requested and received a reduced dose of DAM or HDM for 3 consecutive days (as a result of dose intolerance), the physician is to be contacted for a prescription adjustment as it may not be safe for the patient to have their full dose.Substitution If a patient is unable to attend the clinic, their DAM or HDM dose will be converted to either: Methadone, Slow Release Oral Morphine or Suboxone according to the “Conversion Table for Patients Engaged at Crosstown ClinicDiscontinuation of TreatmentPatients wishing to discontinue their treatment with DAM/HDM are advised to see their physician to discuss alternative treatment options to include but not limited to:MethadoneSuboxoneSlow Release Oral Morphine (SROM)Patients that are missing treatment days will have their treatment plans re-evaluated and will be offered all reasonable interventions. Providers should offer other options that are more acceptable to the client, for example intensifying care (increasing dose) or offering alternative OAT, such as a switch from HDM to DAM. Providence Crosstown Clinic has developed a join contract of rights and responsibilities for patients and health care providers. In cases where patients engage in behaviours that cause others to feel unsafe or uncomfortable (e.g. violence or threats of violence) patients may be offered alternative treatment (methadone, suboxone, SROM) and have their care transferred to another, more suitable site.2.0 Induction Schedules2.1 Injectable Hydromorphone Induction Schedule Session 1Session 2Session 3Total HDMDay 11. Give 10 mgWait 20 min2. If tolerated dose give 15 mgWait 20 min(Max dose 25 mg)1. Give 25mgWait 20 min2. If tolerated dose give 15 mgWait 20 min(Max dose 40 mg)1. Give 40mgWait 20 min2. If tolerated dose give 15 mgWait 20 min (Max dose 55 mg)Up to 120 mgDay 21. Administer 40% of total daily dose at Day 1 (Max dose 45 mg)Wait 20 min2. If tolerated dose give 15 mgWait 20 min(Max dose 60 mg)1. Give 60 mgWait 20 min2. If tolerated dose give 15mgWait 20 min(Max dose 75 mg)1. Give 75 mgWait 20 min2. If tolerated dose give 15mgWait 20 min(Max dose 90 mg)Up to 225 mgDay 3Administer the maximum tolerated amount from Day 2Wait 20 min(Max dose 90 mg)Administer the maximum tolerated amount from Day 2Wait 20 min(Max dose 90 mg)Administer the maximum tolerated amount from Day 2Wait 20 min(Max dose 90 mg)Up to 270 mgTotalUp to 615 mgFootnotes:If a patient has not attended all 6 sessions Day 1 and Day 2, they may continue with their induction on Day 3 with a physician orderPatient to see physician weekly for assessment to ensure a therapeutic dose has been metA small amount of each dose will be lost in the needle hubs and vials. It is necessary to add an additional 25mg to the prescription for each day (of both HDM and DAM) to counter this loss (e.g. total max day 1 dose becomes 145mg). On day 3, in the first session, and after waiting 20 minutes, patients may be given 15 mg more if the patient wishes and there is no intoxication. This dose would then be given for the remaining doses. Injectable Diacetylmorphine Induction ScheduleSession 1Session 2Session 3Total DAMDay 11. Give 15 mgWait 20 min2. If tolerated dose give 30 mgWait 20 min(Max dose 45 mg)1. Give 45mgWait 20 min2. If tolerated dose give 30 mgWait 20 min(Max dose 75 mg)1. Give 75mgWait 20 min2. If tolerated dose give 30 mgWait 20 min (Max dose 105 mg)Up to 225 mg Day 21. Administer 40% of total daily dose at Day 1 (Max dose 90 mg)Wait 20 min2. If tolerated dose give 30 mgWait 20 min(Max dose 120 mg)1. Give 120 mgWait 20 min2. If tolerated dose give 30 mgWait 20 min(Max dose 150 mg)1. Give 150 mgWait 20 min2. If tolerated dose give 30 mgWait 20 min(Max dose 180 mg)Up to 450mg Day 3Administer the maximum tolerated amount from Day 2Wait 20 min(Max dose 180 mg)Administer the maximum tolerated amount from Day 2Wait 20 min(Max dose 180 mg)Administer the maximum tolerated amount from Day 2Wait 20 min(Max dose 180 mg)Up to 540mg TotalUp to 1215 mgFootnote:If a patient has not attended all 6 sessions Day 1 and Day 2, they may continue with their induction on Day 3 with a physician orderPatient to see physician weekly for assessment to ensure a therapeutic dose has been metA small amount of each dose will be lost in the needle hubs and vials. It is necessary to add an additional 25mg to the prescription for each day (of both HDM and DAM) to counter this loss (e.g. total max day 1 dose becomes 250mg). On day 3, in the first session, and after waiting 20 minutes, patients may be given 30 mg more if the patient wishes and there is no intoxication. This dose would then be given for the remaining doses. 2.3 Accelerated Injectable Hydromorphone Induction ScheduleSession 1Session 2Session 3Total HDMDay 11. Give 20 mgWait 20 min2. If tolerated dose give 20 mgWait 20 min(Max dose 40 mg)1. Give 40 mgWait 20 min2. If tolerated dose give 20 mgWait 20 min(Max dose 60 mg)1. Give 60mgWait 20 min2. If tolerated dose give 20 mgWait 20 min (Max dose 80 mg)Up to 180 mg Day 21. Administer 40% of total daily dose at Day 1 (Max dose 70 mg)Wait 20 min2. If tolerated dose give 20 mgWait 20 min(Max dose 90 mg)1. Give 90 mgWait 20 min2. If tolerated dose give 20 mgWait 20 min(Max dose 110 mg)1. Give 110 mgWait 20 min2. If tolerated dose give 20 mgWait 20 min(Max dose 130 mg)Up to 330 mg Day 3Administer the maximum tolerated amount from Day 2Wait 20 min(Max dose 130 mg)Administer the maximum tolerated amount from Day 2Wait 20 min(Max dose 130 mg)Administer the maximum tolerated amount from Day 2Wait 20 min(Max dose 130 mg)Up to 390 mg TotalUp to 900 mgFootnote:If a patient has not attended all 6 sessions Day 1 and Day 2, they may continue with their induction on Day 3 with a physician orderPatient to see physician weekly for assessment to ensure a therapeutic dose has been metA small amount of each dose will be lost in the needle hubs and vials. It is necessary to add an additional 25mg to the prescription for each day (of both HDM and DAM) to counter this loss (e.g. total max day 1 dose becomes 205 mg). On day 3, in the first session, and after waiting 20 minutes, patients may be given 15 mg more if the patient wishes and there is no intoxication. This dose would then be given for the remaining doses. 3.0 Daily conversion doses for patients receiving diacetylmorphine of equivalent Injectable Diacetylmorphine daily dose (mg)Oral Methadone daily dose (mg)SROM (mg)Injectable Hydromorphone daily dose (mg)lowhighlowhighlowhigh202050102140205510011204160201051502130618025155200314081100302052504150101120352553005160121140403053506170141160503554007180161180604054508190181200654555009110020122070505550101110221240755556001111202412608060565012113026128080655700131140281300857057501411503013209075580015116032134095805850161170341360100855900171180361380100 905950181190381400100955100019120040142010010051050201210421440100105511002112204414601001105115022123046148010011551200231240481500100120024125050152010012002512605215401001200261270541560100120027128056158010012002812905816001001200291300601620100120030131062164010012003113206416601001200321330661680100120033134068170010012003413507017201001200351360721740100120036137074176010012003713807617801001200381390781800100120039140080182010012004014108218401001200411420841860100120042143086188010012004314408819001001200441450901920100120045146092194010012004614709419601001200471480961980100120048149098110001001200491500 Footnote: SROM: slow-release oral morphineConversions have been determined with the goal of maintaining the average degree of saturation of the opiate receptors by opiates in order to prevent withdrawal symptoms while also avoiding over-dosage. 4.1 Missed dose protocol for diacetylmorphine and hydromorphone Prescribed HDM/DAM Dose mgSession 1 (1/3 Rx Dose) Session 2 (+15% Rx Dose mg)) Session 3 (+15% Rx Dose mg)) Session 4 (+15% Rx Dose mg) Session 5 (+15% Rx Dose mg) Session 6 Prescribed Dose mg4013.319.325.331.337.340.04515.021.828.535.342.045.05016.724.231.739.246.750.05518.326.634.843.151.355.06020.029.038.047.056.060.06521.731.441.250.960.765.07023.333.844.354.865.370.07525.036.347.558.870.075.08026.738.750.762.774.780.08528.341.153.866.679.385.09030.043.557.070.584.090.09531.745.960.274.488.795.010033.348.363.378.393.3100.011036.753.269.786.2102.7110.012040.058.076.094.0112.0120.013043.362.882.3101.8121.3130.014046.767.788.7109.7130.7140.015050.072.595.0117.5140.0150.016053.377.3101.3125.3149.3160.017056.782.2107.7133.2158.7170.018060.087.0114.0141.0168.0180.019063.391.8120.3148.8177.3190.020066.796.7126.7156.7186.7200.021070.0101.5133.0164.5196.0210.022073.3106.3139.3172.3205.3220.023076.7111.2145.7180.2214.7230.024080.0116.0152.0188.0224.0240.025083.3120.8158.3195.8233.3250.026086.7125.7164.7203.7242.7260.027090.0130.5171.0211.5252.0270.028093.3135.3177.3219.3261.3280.029096.7140.2183.7227.2270.7290.0300100.0145.0190.0235.0280.0300.0310103.3149.8196.3242.8289.3310.0320106.7154.7202.7250.7298.7320.0330110.0159.5209.0258.5308.0330.0340113.3164.3215.3266.3317.3340.0350116.7169.2221.7274.2326.7350.0360120.0174.0228.0282.0336.0360.0370123.3178.8234.3289.8345.3370.0380126.7183.7240.7297.7354.7380.0390130.0188.5247.0305.5364.0390.0400133.3193.3253.3313.3373.3400.0Accelerated missed dose protocol for diacetylmorphine and hydromorphonePrescribed HDM/DAM Dose mgSession 1 (50% Rx Dose mg) Session 2 (75% Rx Dose mg)) Session 3 (100% Rx Dose mg)) 402030404522.533.7545502537.5505527.541.2555603045606532.548.7565703552.5707537.556.2575804060808542.563.7585904567.5909547.571.259510050751001105582.511012060901201306597.51301407010514015075112.51501608012016017085127.51701809013518019095142.5190200100150200210105157.5210220110165220230115172.5230240120180240250125187.5250260130195260270135202.5270280140210280290145217.5290300150225300310155232.5310320160240320330165247.5330340170255340350175262.5350360180270360370185277.5370380190285380390195292.5390400200300400Footnote:Physician to be contacted to initiate accelerated missed dose protocol ................
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