Effective Interventions Unit
Integrated Care Pathways Guide 7:
Care of People with Drug Problems in Acute General Hospital Settings
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WHAT IS THE PURPOSE OF THIS GUIDE?
This is the seventh in a series of guides on developing and implementing Integrated Care Pathways (ICPs). This guide identifies the key issues in managing the care of drug users in a general hospital in-patient setting and aims to provide a framework for getting started locally.
This guide should be read in conjunction with the series of technical guides (1-4). It can be used as a framework for developing new ICPs or as part of a review process for existing pathways.
WHO SHOULD READ IT?
This guide should be of particular interest to those involved in the provision of care in general medical and surgical ward settings. It is primarily targeted at nurses, doctors and allied health professionals working in these areas that do not regard themselves as specialists in the treatment of drug misuse.
DEFINING THE CLIENT POPULATION
The focus of this guide is on opioid dependent patients/clients who are admitted to a medical or surgical unit for assessment, investigation or treatment of physical illness or injury. However the principles contained in this guide can be applied to people in similar settings who are dependent on other drugs such as benzodiazepines or alcohol.
Individuals will normally come in to hospital either as elective admissions, where they have been scheduled to undergo investigations or treatment, or emergency admissions in response to acute illness or injury (trauma). In the case of elective admissions there may be information about the nature and extent of the person's drug use and treatment in the pre-admission documentation but this cannot be taken for granted. In emergency admissions, the patient may be unable or unwilling to divulge their drug use in the first 24-48 hours.
This Guide contains information on:
Defining the client population
Mapping current practice
Issues to consider
Management of pain
Management of withdrawal
Management of 'difficult behaviours'
Next steps and other resources
Drug users who are on a substitute prescribing programme usually have set routines for taking their medicines. Often they will split their dose, taking half in the morning and half in the evening, or take it with a cup of tea or after something to eat. Disruption to this routine, such as 'drugs rounds' in the ward may cause upset and anxiety to some patients who might perceive a loss of control or experience a fear of withdrawal. This can potentially manifest itself in a way that can be regarded as 'difficult behaviour'.
In 2002/03 there were 4840 admissions (rate of 99:100,000) to general/non psychiatric hospitals in Scotland who had a diagnosis of drug dependence. 1 This may be an under-representation of the true number as many episodes might have been undetected or undiagnosed.
The National Electronic Library for Health holds a database of over 220 ICPs that are in use or under development in the U.K. Although ICPs are already widely used within general medical and surgical ward settings there are currently no ICPs on the database relating to the care of drug users in these settings.
It is important that general hospitals recognise a patient with an opioid dependence. After proper assessment and communication with the drug treatment service, patients should be able to continue their methadone medication whilst completing the medical treatment for which they entered the hospital. It is worth noting that general hospitals should not be considered as detoxification centres. The conditions in the hospital should simply favour the recovery and treatment of the medical problem. 2
MAPPING CURRENT PRACTICE
ICP Guides 2 and 6 provide information on process mapping. When reviewing current practice or evaluating current ICPs there are a number of questions to consider. These include:
Do current systems of care routinely screen for drug misuse during the assessment process?
What pharmacological and non-pharmacological interventions are provided for the management of pain in opioid dependent patients?
Are ward staff able to recognise the signs and symptoms of opioid withdrawal?
What is the current management approach to 'difficult behaviours'?
ICP development groups should assess the level of risk associated with the responses to these and other questions, as they relate to the safety of the individual patient as well as to other patients and staff.
ISSUES TO CONSIDER
This guide identifies and explores key management issues. These include:
Your development group may identify additional issues that you want to consider locally.
Ask the right questions
Look for non-verbal signs of pain
Use a suitable pain tool or chart
Examine the clues - physical, psychological, daily activities and normal functioning
Re-evaluate and plan care and treatment
Management of pain
Melzack & Wall (1999) stated that, "Pain responses can be affected by past experiences, cultural background, physical condition, emotional state and the proposed course of the disease". 3
Assessment of pain
For this reason it is important that the assessment of pain should be person-centred and individualised in terms of determining what kind of pain the patient is experiencing and identifying factors such as the onset, duration, intensity and frequency of their pain.
The Melzack McGill Pain Questionnaire is one example of a validated instrument for measuring pain, helping to identify the type of pain e.g. neuropathic or nociceptive pain, level of intensity and its impact on the individual's physical and psychological health.
"Street addicts who use opioids in the absence of pain develop tolerance and may need increasing doses to obtain the same effect". 4
For opioid dependent patients it is reasonable to consider the use of non-opiate drug therapies either as an adjunct or replacement to opiods. Neuropathic pain responds well to anti-depressant medication, such as amitriptyline, and anti-convulsant therapy, for example, gabapentin, carbamazepine and sodium valproate. 5 The ward team should consider consulting a pain specialist in the hospital or community for advice on appropriate strategies.
Consider non-pharmacological interventions. "Some of the more simple interventions can have a very powerful synergistic effect when used with traditional methods of pain relief." 6 Examples of non-pharmacological interventions include Transcutaneous Electrical Nerve Stimulation (TENS), relaxation, heat pad and distraction techniques.
Management of withdrawal
In 1999 the Department of Health published Drug Misuse and Dependence: Guidance on Clinical Management. This stated that untreated heroin withdrawal typically reached its peak 36-72 hours after last dose and that symptoms will have subsided substantially after 5 days. Methadone withdrawal reaches its peak in 4-6 days and lasts 10-12 days. 7 The Guidance on Clinical management provides information on the signs and symptoms of withdrawal as well as a range of management strategies
Assessment of withdrawal
In 2003 the Effective Interventions Unit published A Digest of Tools Used in the Assessment process and Core Data Sets. This highlights the need for structured, consistent assessment using validated instruments that are designed for the task in hand. One of the instruments described in the Digest is the Severity of dependence scale, a short, easily administered scale which can be used to measure the degree of psychological dependence experienced by users of different types of drugs. It takes less than a minute to complete and requires no training to administer. The Digest is available at www.drugmisuse.isdscotland.org/eiu
If the patient is on a substitute prescribing programme the prescriber (GP or specialist drug service) and dispenser (community pharmacist) should be contacted to establish exactly when the last prescription was written, what the daily dose was and what arrangements were in place for dispensing. The date and time of last pick-up at the pharmacy should also be established and the pharmacist advised of the patient's hospitalisation.
"Urine analysis should be regarded as an adjunct to the history and examination in confirming drug use, and should be obtained at the outset of prescribing and randomly throughout treatment." 8
Locally agreed protocols should be developed for both the prevention and management of withdrawal based on the DoH Clinical Guidelines.
Management of difficult behaviours
As stated earlier, 'Difficult behaviours' describe a patient's response to internal factors (pain, fear, anxiety) or external factors (ward routine, noise, imminent treatment). These circumstances can create or heighten anxiety and physical discomfort, leading to the display of behaviours, which are often judged to be inappropriate.
Occasionally patients will react adversely to opioids such as morphine. "Even if a patient has been exposed to opioids previously it is important to bear in mind such things as nausea, vomiting, constipation and respiratory depression. Of note is the interaction with MAOIs causing central nervous system disturbances. Other interactions include those with cimetidine, mexiletine and some anti-fungals. The sedative effect of opioids can be exacerbated in those patients taking benzodiazepines. It is stressed that any possible drug interaction be confirmed with a current information source such as GP or dispensing pharmacist." 9
Patient and carer information
"It is not only important that treatment is accessed quickly but also that the patients and carers receive adequate information to allay their fears and reduce the psychological tension that arise from this condition." 10
A patient's version of the pathway, described in Guide 2, would contain information on the processes and procedures that the patient is likely to experience in the ward, as well as information about their individual care plan and, where appropriate, self-rating scales.
An ICP for the care and treatment of opioid dependant patients should be developed to run concurrently with the treatment of the physical illness or injury. It should identify the processes required to ensure that the patient is comfortable and pain free during and, where appropriate, following hospitalisation.
The table below sets out the issues discussed in this guide, highlights the interventions (processes) involved and identifies the resources (structures) required to achieve these.
Patient's pain is assessed using agreed process
Locally agreed multi-professional assessment process
Symptoms of pain are effectively managed
Pharmacological and non-pharmacological interventions are employed to manage pain
Nature of drug dependence and symptoms of withdrawal are assessed using agreed process
Assessment includes input from specialists in drug misuse as well as from ward staff
Information sharing protocol to be developed with community drug services
Symptoms of withdrawal are effectively managed
Pharmacological and non-pharmacological interventions are employed to manage withdrawal
Patient is well informed and feels involved in decision relating to the planning and delivery of their care
Patient has active and meaningful involvement in the planning and delivery of their care
Patient version of pathway is developed and implemented
Episode of care is effectively monitored
Agreed milestones, variances and outcomes are recorded appropriately on ICP documentation
Recording and monitoring system is agreed including roles and responsibilities of all involved
Episode of care is effectively evaluated
Evaluation system, including performance indicators, timescales and process are agreed before implementing the pathway
NEXT STEPS AND OTHER RESOURCES
All EIU documents referenced in this Guide and planned future ICP Guides can be viewed on the EIU website: www.drugmisuse.isdscotland.org/eiu
The EIU welcome comments on their work outputs.
Thanks to the EIU's Integrated Care Pathways Development Group,
Figure 8 Consultancy Services Ltd and others for contributing to this guide.
Effective Interventions Unit
Substance Misuse Division
St Andrew's House
Edinburgh EH1 3DG
Tel: 0131 244 5117 Fax: 0131 244 3311