This is a plain English summary of an original research article
People who are dependent on opioids (such as heroin) should be prescribed substitutes (methadone or buprenorphine) when they are in hospital. This treatment helps prevent withdrawal symptoms (including sweating, muscle spasms and agitation). A review found that many hospital policies delay access to substitute opioids.
A lack of access to these substitutes may increase the risk of people discharging themselves early to obtain opioids in the community. This in turn may lead to worse illness and increased risk of death, the researchers say.
This study looked at NHS hospital policies on the management of opioid withdrawal. It found wide variation in policies but many created delays in access to substitute opioids. For example, some policies required lab tests to demonstrate recent use (which could take many hours) or input from specialist drug teams before prescribing. Some lacked clear guidance for doctors on how to start prescribing opioid substitutes or how to continue community prescriptions.
The study also looked at the UK’s Omitted and Delayed Medicines Tool, which informs hospitals’ lists of critical medicines. The tool did not consider opioid substitutes to be high risk if delayed or omitted, which was amended. The tool has since been withdrawn.
Building on this review, new policies to overcome barriers to the provision of opioid substitutes will be trialled at University College London Hospital from November 2022.
What’s the issue?
In 2016/17, more than 250,000 people in the UK were estimated to have used heroin or other illegal opioids. People who are dependent may receive substitute opioids from GPs or community drug treatment services. This treatment prevents withdrawal symptoms and can reduce people’s reliance on street opioids.
When people who use opioids go into hospital, national guidelines recommend that substitute opioids are started or continued to prevent withdrawal and allow people to receive treatment. A lack of substitute treatment, fear of withdrawal symptoms or the negative attitudes of healthcare professionals may prompt patients to discharge themselves early, against medical advice. Early discharge has been linked to readmission to hospital, overdose, and death.
However, clinicians are often concerned about prescribing substitute opioids because they are unsure of the safe dose for individuals.
National guidelines recommend that NHS trusts have local policies to ensure the timely prescription of substitute opioids in hospital. Before this study, there had been no comprehensive review of these policies.
The national Omitted and Delayed Medicines Tool is used locally to create lists of critical medicines. Medicines are considered critical if people are in danger when the drug is not given on time (delayed) or at all (omitted). The lists determine which drugs are stocked by individual hospitals.
This study examined whether policies in England delay or prevent the prescription of substitute opioids. It also examined how substitute drugs were classified in The Omitted and Delayed Medicines Tool.
The research team used the Freedom of Information Act to request local policies on the management of opioid withdrawal. They approached 135 trusts in England; most (86) provided relevant policies (101 in total). 1 in 3 trusts (33%) responded without a relevant policy (mostly because they had no policy in place). More than 1 in 4 (28%) policies were overdue a review.
The researchers analysed the policies’ content and compared them with national guidelines. They described 5 common barriers to the provision of substitute drugs.
1. Continuing community prescriptions in hospital
All hospital policies required confirmation of community prescriptions (in line with national guidelines) but few described how to do this other than by contacting community services, which might not be available on evenings and weekends. Only one policy included patient verification as an option; some explicitly stated that patients were not trustworthy. Some stated that no substitute opioids should be provided if verification was not possible; others suggested, regardless of confirmation, that substitute opioids could be started at a lower dose and gradually increased.
2. Starting new prescriptions in hospital
Most hospital policies said people could be started on substitute opioids (in line with national guidelines), but some provided no practical details on how to do so; a few prohibited it. Some advised treating withdrawal symptoms with different drugs (such as anti-sickness medications). Most policies required patients to display withdrawal symptoms (sweating, tremor) before substitute drugs could be given, and did not consider the psychological impact of withdrawal.
3. Continuing prescriptions after discharge
National guidelines state that this group should be encouraged to start or continue with substitute opioids in the community. In line with this, most policies said community drug treatment services should be told when someone is discharged to allow them to continue treatment. However, some policies contained no information on how treatment could be continued. Take home doses were limited when patients were discharged on weekends or bank holidays; one policy explicitly stated patients would need to refer themselves if they wished to continue with substitute opioids.
4. Extra tests and input
National guidelines state that urine tests to confirm recent drug use can be used but are not essential. However, many policies required these test results before substitute opioids could be prescribed, and local labs could take hours or sometimes days to give results (unlike rapid point of care tests). Some policies required input from specialist drug teams before substitute opioids could be prescribed.
5. Stigmatising attitudes
Many policies were mistrustful of patients. A few advised clinicians watch people urinate to confirm they weren’t providing someone else’s urine for drug tests. Some policies said that people should not be allowed to leave the ward; one stated that people with a previous addiction may have ‘unreasonably high expectations’ of pain relief. Policies often used negative language such as ‘user’, ‘abuser’, or ‘addict’, and said that staff should have ‘a degree of suspicion’. A few policies required patients to sign a contract governing their behaviour when they were admitted; if broken, this could lead to their treatment being stopped.
The study also looked at the Omitted and Delayed Medicines Tool. Unlike opioids for pain management, the tool did not consider substitute opioids (to prevent withdrawal) to be critical if delayed or omitted.
Why is this important?
This was the first comprehensive review of hospital policies in England on the management of opioid withdrawal. It found wide differences in policies in different areas of the country. No policy said people with lived experience had been involved in its development.
Many policies created barriers to prompt provision of substitute opioids. When people are admitted at night or at weekends, many community drug treatment services can’t be contacted to confirm community prescriptions. Delays to accessing prescriptions can increase the risk of someone discharging themselves early, worsening illness, and death. This is a group who already experience considerable health inequalities.
Policies often directly or indirectly recommended treating people who use drugs with suspicion. This could reduce the willingness of people who use drugs to access healthcare. The researchers stress the need to challenge the stigma promoted by these policies.
The researchers believe the Omitted and Delayed Medicines Tool did not reflect the danger patients face when they discharge themselves from hospital. The researchers say the low-risk rating for substitute drugs probably contributed to hospital policies that did not prioritise the management of opioid withdrawal.
The researchers are not certain that all relevant policies were shared with them. Also, since the study did not examine practice, people may have received care that was better or worse than recommended in the policies.
Better local guidelines, informed by people with lived experience, are needed. They should improve the continuity between hospital and community care. For example, finding alternative ways to confirm prescriptions if community drug treatment services cannot be contacted.
This study led to the Improving Hospital Opioid Substitution Therapy (iHOST) project. The iHOST project aims to improve care for people dependent on opioids. The barriers identified in this study are informing the development of a policy template that trusts will be able to adapt for local use. This template will be improved during the iHOST study before being shared with NHS trusts by Autumn 2024.
Other iHOST resources include training materials for professionals, a helpline for people with opioid dependence, and a card patients can present to highlight their need for prompt access to substitute opioids. The programme will be trialed at University College London Hospital from November 2022, before expanding to Leeds and Staffordshire.
The researchers also reviewed the Omitted and Delayed Medicines Tool, in collaboration with people with lived experience of opioid dependence, and with the Specialist Pharmacy Service that developed the tool. The tool was changed substantially as a result. This demonstrates that organisations are open to change, which could improve the care received by people who use drugs. Ultimately, however, this tool was discontinued and a new tool is being developed.
You may be interested to read
This Alert is based on: Harris M, Holland A, and others. Barriers to management of opioid withdrawal in hospitals in England: a document analysis of hospital policies on the management of substance dependence. BMC Medicine 2022;20:151.
The NHS Addiction Provider Alliance campaign to reduce stigma towards people who use drugs: Stigma Kills.
The Release website, which advocates for drug policies that promote human rights and public health.
Why do people who inject drugs avoid seeking care?: Harris M, and others. Normalised pain and severe health care delay among people who inject drugs in London: Adapting cultural safety principles to promote care. Social Science and Medicine 2020;260:113183.
An article on drug-related deaths in the UK, and the need to challenge stigma: Rae M, and others. Escalating drug related deaths in the UK. British Medical Journal 2022;378:o2005.
Funding: The study was funded by the NIHR Health and Social Care Delivery Research programme.
Conflicts of Interest: Niamh Eastwood is Executive Director of the drug policy charity Release, which has received funding from Ethypharm (a company that produces drugs for opioid withdrawal). The late Gary Sutton also worked for Release.
Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.