Guidance

Part 2: supporting service users to start opioid substitution treatment (OST)

Published 21 July 2021

Applies to England

1. Assessment and engagement

1.1 Assessment for OST

Before prescribing opioid substitution treatment (OST) medicines you should work together with the prescriber and the service user to assess their current situation and agree an initial treatment and recovery care plan. Your role, ahead of the service user’s appointment with the prescriber, is to explore what the service user knows about OST, provide further information and get to know their needs and goals.

Learning about the service user

The assessment must be based on enough information to match the treatment to the service user’s needs and goals, and to address any risks. It’s up to the prescriber to make a clinical diagnosis of opioid dependence and to assess whether the service user is suitable for OST. But as a drug treatment and recovery worker, you can contribute to this, by:

• establishing a full history of the service user’s drug and alcohol use, including duration of use, frequency of use, route of administration, periods of abstinence, and response to previous treatments
• exploring any history of relevant physical and mental health difficulties that the prescriber will need to discuss in more detail
• asking the service user to describe their daily activities, social networks, and any offending history
• contributing evidence of opioid dependence including physical evidence (for example injection sites), investigations (such as drug screens), or information from significant others and involved professionals (with service user consent)
• asking the service user what they want to get from treatment and what sort of treatment they would prefer

Drug testing

You should use point-of-care drug screening tests (typically on urine or saliva) for initial assessment and to confirm drug use. We cover drug testing to confirm treatment compliance and monitor illicit drug use in part 3 of this guide.

A positive test for opioids does not diagnose dependence, because someone might have recently taken some opioids but not be a regular, dependent user. Similarly, a negative test does not exclude a diagnosis of dependence, because the test may give a false negative or the person may be due their next hit and the amount of opioid in their body at the time of the test may be too low to detect.

In situations of doubt or denial about a test result, it may be useful to repeat the point-of-care screening test or to send the sample off for a test to confirm the results (almost always through a laboratory). If test results do not match the service user’s reported use, this offers an opportunity to explore the person’s understanding and insight into their current drug use. It may also inform the degree of risk management needed during induction.

Providing information

As part of an initial appointment with a service user using opioids, you should do the following:

1. Explore what the service user already knows about OST. This includes the rationale for OST, expectations of them (such as attending daily for supervised doses during the stabilisation phase), support available and what they can expect from the medication and psychosocial interventions.
2. Fill any gaps in their knowledge about OST and correct any misconceptions.
3. Check and, where necessary, develop their understanding of the associated risks during induction. This includes the risks associated with using central nervous system depressant drugs (such as opioids, gabapentinoids, benzodiazepines and z-drugs) and alcohol.
4. Reassure the service user that the small increases in dose during induction are necessary for their safety. Many service users are anxious that they will not receive enough medication to feel comfortable. You should explain that blood levels of methadone rise during the first week of treatment and the rate of increase in dose is planned to manage this risk.
5. Provide the service user with overdose prevention advice, information, training and take-home naloxone supply. You can do this once they have started OST or before depending on the assessed likelihood of immediate risks.

Managing medication risks

Both you and the prescriber need to work with service users to manage medication risks such as safeguarding, drug driving and diversion.

Safeguarding
At the first appointment, you must emphasise the risks of someone else swallowing prescribed medication, particularly children. You should repeat this at other appointments. Safeguarding includes ensuring the service user stores their medication safely. If children are in the home, the service user must show that they understand the risks and are willing to make the changes needed to address them. These might include storing medications in locked boxes or otherwise restricting children’s access to the medication and preventing children from observing consumption to avoid copying behaviour.

Drug driving
Both drug use and OST can affect someone’s ability to drive. The prescriber should explain this to the service user and tell them that they should stop driving. The service user should also inform the Driver and Vehicle Licensing Agency (DVLA), who will almost certainly suspend the service user’s driving licence. This is true for someone who is opioid dependent whether they decide to start OST or not. If someone continues to drive against advice and is putting others at risk, the prescriber might decide to contact the DVLA themselves. Once someone is stable on OST, the DVLA can arrange a review to get their driving licence back. For more information on this, see the DVLA’s guidance on assessing people with drug and alcohol dependence for fitness to drive.

Diversion
Diversion is when an OST medication is given or sold to someone to whom it is not prescribed. This can be lethal. With your input, the prescriber should assess the risks of medicines being diverted and, if necessary, reduce these risks by recommending supervised consumption and drug testing.

Assessing a service user’s reaction to discussing these risks and safety measures should form part of your decision-making about dispensing and supervision arrangements. For example, it can help you decide whether someone is suitable for take-home medication.

1.2 Engagement and re-engagement

At this early stage in OST, you play a vital role in building a supportive relationship with service users and helping them to stay in, and getting the most out of, treatment. This could include:

• discussing how important it is to be open with you about any ongoing illicit drug or alcohol use on top of the prescribed OST medicine
• discussing any issues with supervision, picking up from the pharmacy or any aspects of their treatment and affirming that you want to keep working with them to make treatment effective
• sending text reminders for appointments
• making sure you have up-to-date contact details for service users and their friends or family that you can contact if the service user drops out of treatment (in line with your confidentiality agreement with them)

2. Induction on to OST

Induction onto OST is the process of starting a service user on a suitable dose of a substitute opioid and gradually increasing it to a safe level where withdrawals are minimised and the use of illicit opioids reduces or stops. This is also called optimisation.

Induction should be monitored by the prescriber, or another doctor or suitably trained nurse or pharmacist, alongside the drug treatment and recovery worker. It may take 2 to 4 weeks (or more) to achieve an optimal dose of methadone. It usually takes less time with buprenorphine.

As the main point of contact for service users, you play a crucial role in responding rapidly to the service user’s concerns and needs about treatment. Examples include:

• managing any symptoms of withdrawal
• supporting them with any difficulties they have engaging with their treatment and recovery care plan
• addressing further harm from illicit drug use

In the first week, you should be checking in regularly to see how they are responding to their medication and if they need to increase their dose. It is your role to work with the prescriber to make sure that the service user gets the medication they need.

2.1 Medication risk factors

Methadone

In the first weeks of methadone treatment there is a slightly increased risk of death. After around a month in treatment, the risk falls to around half that of people not in treatment.

Over a period of a few days or more, methadone can accumulate in the body such that small doses can build to an amount that causes an overdose. Overdose is more likely if the service user also uses other depressant drugs, medicines or alcohol. For this reason, it is vital that methadone induction is done slowly and cautiously. This might lead to the service user thinking the treatment is not working and walking away. You need to explore these anxieties with them and remind them that this slower rate of induction is necessary to keep them safe.

A service user may also feel that they have been given a dose that is too low and may ‘top up’ with illicit methadone. Sometimes people who use heroin take illicit methadone at a high dose if they are unable to buy heroin. If a service user on OST has done this before, they might think the dose of illicit methadone that they took was the ‘right’ dose for them. And they might then be tempted to ‘top up’ their prescribed methadone to reach this dose. If they did this, they would put themselves at risk of overdose. So, you must explain the reasons for starting at a lower dose and building up slowly. The mantra ‘start low, go slow’ is useful to remember.

Buprenorphine

Buprenorphine has a lower risk of overdose than methadone as it does not accumulate in the same way. Also, it does not have some of the opioid effects that methadone has (buprenorphine causes less sedation and emotional numbing). Some people prefer these lesser effects of buprenorphine, but others do not. Buprenorphine can also cause withdrawal symptoms at the beginning.

With both medicines (but more so with methadone), using other depressant drugs, medicines or alcohol with OST medication can make an overdose more likely. Benzodiazepines, pregabalin and gabapentin have been especially associated with overdose, so it is important the service user tells you if they are taking any of these, whether as prescribed medicines or bought illicitly.

2.2 Service user response to dose

Buprenorphine and methadone are long-acting drugs. During induction onto OST, signs and symptoms of intoxication and withdrawal fall progressively, reducing the sensations that drive drug-seeking. This is the initial process of dose optimisation. If doses administered during induction are too high, the service user will be intoxicated. If doses are too low, they may not prevent withdrawal symptoms and drug cravings for the full 24 hours between doses.

Full dose optimisation involves helping the service user to stop using heroin (and other illicit opioids) completely. This is more likely with higher doses. National Institute for Health and Care Excellence guidelines on buprenorphine and methadone recommend daily doses of methadone between 60mg and 120mg daily, or daily doses of buprenorphine between 12mg and 16mg (though buprenorphine daily doses can go up to 32mg).

OST needs to be personalised and doses should be tailored according to individual need. Some service users will need lower doses and some will need higher doses, but service users are entitled to be informed about what is most likely to be effective.

How induction onto OST might feel for service users

While a lower dose may stop withdrawal symptoms, the service user might need a higher dose to minimise craving. In some cases, service users report withdrawal symptoms in the morning before taking their methadone, or more subtle withdrawal symptoms at other times, such as sleep disturbance.

You should consider these scenarios as they might suggest that methadone is not yet at the right dose and should be increased. Crucially, the service user might not completely stop using heroin until they are stabilised within the recommended dose range. The effective dose might be higher than the dose that helps the service user to ‘feel OK’. You need to explain this to service users, otherwise, they might want to stay on lower doses and will not benefit from stopping all heroin use.

Sometimes, a service user may be unwilling to increase their dose into the recommended range because they intend to continue using heroin. This is likely to reduce the benefit that the service user gets from treatment and increase the risk of overdose. We’ll explore possible responses to this challenging scenario in part 2 of this guide.

3. Supervised consumption in early treatment

Methadone-related deaths reduced fourfold after supervised consumption was introduced in England and Scotland.

UK studies have shown that service users understand and value the role of supervised consumption but still consider it important to have the opportunity to move away from supervision as they make progress in treatment.

An unpublished review by Lambeth service user council of service user experiences of and views on supervised consumption found that 60% of service users either did not know or were not sure whether they could request a review of the decision for them to stay on supervised consumption. A fifth (20%) of service users said that the reasons for them being on supervised consumption had not been explained to them. Forty per cent did not know what changes might need to happen for them to stop supervised consumption.

Decisions on the appropriate level of supervision are made by the prescriber but the service user and the drug treatment and recovery worker are important partners in making them. You should explain to the service user that the main reason for supervision is for their safety because it minimises the risk of toxicity. It also increases the safety of their significant others and the community. It should not be seen or used as a punishment.

Levels of supervision should be based primarily on an individual risk assessment. But you should consider other practical things like:

• housing situation
• employment
• childcare
• pharmacy opening days and hours

Most new service users should be on supervised consumption for a period of time so that their progress can be monitored, and an ongoing risk assessment can be done. This risk assessment should cover the service user’s adherence to treatment and their individual and home circumstances. Supervision should be extended or ended after careful monitoring during the induction and stabilisation phase of OST.

The prescriber should review the clinical need for supervised consumption regularly in consultation with the multidisciplinary team, the service user and dispensing pharmacist. Long-term, daily supervised consumption is unlikely to be appropriate for a service user in regular, full-time work or education.

If a service user has moved on from daily dispensing, it should be reinstated temporarily (ideally with supervised consumption) whenever a service user:

• restarts methadone or buprenorphine after a break
• receives a significant increase in the dose
• has a period of instability when tolerance may be reduced

4. Harm reduction and overdose prevention

Delivering harm reduction responses and overdose prevention is a core aspect of your role as a drug treatment and recovery worker.

4.1 Safer injecting

The 3 main risks from injecting are:

• vein damage
• infection (bacteria and viruses)
• overdose

People who inject drugs can reduce their risk of overdosing by:

• taking a test dose of drugs to see how strong they are
• only injecting half a barrel at a time (similar to the test dose, seeing how strong it is before injecting the whole barrel)
• not mixing drugs in the same hit or using at the same time
• not drinking while using
• not injecting alone (it’s important to have other people there to call emergency services and administer naloxone if needed)

The person taking drugs can also massively reduce their risk by choosing to snort, swallow, smoke or ‘chase’ (inhaling) their drugs instead of injecting. This is because when injected, a large amount gets into the system very quickly increasing the risk of overdose.

You can read more about these risks, how to reduce them and what to do in an emergency in Routes to recovery from substance addiction: mapping user manual.

4.2 Overdose prevention and naloxone

Naloxone is a potentially life-saving medicine. It temporarily reverses the effects of an opioid overdose, including slow or stopped breathing. Naloxone is most commonly administered by intramuscular injection (in a muscle). Nasal preparations are also available.

Anyone can administer naloxone for the purpose of saving a life and drug services can supply naloxone without a prescription. Drug treatment and recovery workers, needle and syringe programme (NSP) staff and outreach workers are at the frontline of stopping opioid overdose deaths. You should offer overdose awareness training and naloxone to all opioid users you see in their work. You should routinely ask service users if they have naloxone, if they carry it, if they have used it and if they need to be resupplied.

4.3 Blood-borne viruses and other infections

NSP and OST reduce the risk of blood-borne virus (BBV) transmission. Vaccinations and diagnostic tests for hepatitis B, hepatitis C and HIV should be routinely and regularly offered to people who inject or have previously injected drugs. People should be supported to engage in treatment for BBVs.

Service users on OST should be offered vaccination against hepatitis B and testing for hepatitis C and HIV. Treatment for hepatitis C includes tablets to fight the virus, a test to see if the liver is damaged and lifestyle changes to prevent further damage. Treatment plans can be short (between 6 and 12 weeks) and the direct-acting antiviral medication available is easy to take and has very few side effects. You should positively promote treatment for hepatitis C as having the potential to vastly improve the service user’s quality of life.