| Step 1 – Triage |
- Referral: Online, phone, family/professionals, or self-referral.
- Triage Assessment: Assess opioid dependence using Clinical Opiate Withdrawal Scale (COWS).
- Substance History: Check for illicit/prescribed opioid use, polysubstance use.
- Risk Factors: Assess for overdose risks, including benzodiazepines and alcohol.
- Case Record: Completed by the Single Point of Contact worker.
- Naloxone Offer: Provide Take Home Naloxone (THN) training and supply.
- Safe Storage: Discuss safe storage for opioid medications.
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| Step 2 – Personalised Assessment |
- Medical Review: Confirm opioid dependence via urine/saliva drug testing and prescription history.
- Polysubstance Use: Adjust induction plan for alcohol, benzodiazepines, gabapentinoids.
- Medication Choice: Discuss options:
- Buprenorphine: Faster titration, lower overdose risk.
- Methadone: Better retention, requires slow titration.
- Informed Consent: Discuss medication risks, overdose prevention, and treatment expectations.
- Prescriber Appointment: Arrange a face-to-face prescriber consultation ASAP.
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| Step 3 – Induction & Titration |
- Buprenorphine Induction:
- Day 1: 8mg
- Day 3: 16mg
- Monitor for precipitated withdrawal.
- Methadone Induction:
- Start at 20-30mg.
- Increase by 5-10mg every 3 days.
- Max weekly increase: 30mg.
- Avoid exceeding 60mg in first 2 weeks due to overdose risk.
- Supervised Consumption: All inductions must be supervised.
- Weekly Titration Monitoring:
- Assess withdrawal symptoms.
- Check for missed doses (if ≥3 days missed, review required).
- Monitor sedation/over-sedation.
- Review ongoing illicit opioid use.
Titration Checklist
As a minimum, the following information should be determined at the review. Please then email the information to the prescriber for consideration and to make a decision as to whether a change in the treatment plan is to be made.
Regular check-ins: Regular check-ins during the titration period are essential.
- Drug screen result:
- Self-declared use of any drugs in the last 7 days:
- Self-declared use of any alcohol in the last 7 days:
- Contact with pharmacist: Any missed collections?
- Other medicines: Are they taking any other medicines at the moment (if so, which ones)?
- Side effects: Are they experiencing any side effects (especially sedation)? If yes, please give details.
- General appearance: How do they appear today?
- Other relevant information:
- Next clinical review: Has the next clinical review been booked?
Note: Ensure to email the Script Department to post out future scripts once the patient is on the optimal dose.
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- Follow-Up: Arrange the next medical appointment during induction, in line with medic direction, no later than 6 months after.
- Alcohol Pathway: For cases with alcohol and an AUDIT score ≤15 (and meeting other criteria), refer to the dedicated Alcohol pathway for further advice.
- Unsuccessful Induction: Consider alternative MAT or supervised consumption.
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| Step 4 – Ongoing Case Management |
- Post-Induction Contact: Weekly face-to-face during induction.
- Ongoing Review:
- 4-6 week check-ins post-induction.
- 12-week risk review and naloxone re-supply.
- 6-monthly medical and BBV screening.
- Annual safe storage, home visit (if required).
- Dual Dependencies: Arrange a nursing review before medication adjustments.
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| Disengagement & Missed Doses |
- Missed 1-2 Days: Clinical judgment required.
- Missed 3 Days: Suspend prescription pending review.
- Missed 4-14 Days: Assessment before re-titration.
- Missed 14+ Days: Full prescriber re-assessment required.
- Assertive Outreach: Proactive engagement to reduce overdose risk.
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