Morning all,following unanimous advice here,about a year ago,our local Out of Hours Centre no longer prescribes substitute opiate medication.
I would be grateful for any thoughts and advice re the Dos and Don'ts of symptomatic prescribing in OOH setting.
Thanks in anticipation.

George, Hope all is well. If you decide to not prescribe substitutes then all you are left with are the pretty useless throwaways- clonidine,ibuprofen and anti-emetics.Not much use and I know you know that. Difficult to get others on board and may be counter-productive to try. James.

Maybe:
2 days dose of Buscopan (hyoscine)(eg 6 daily =12)..people do tell me they find these helpful for stomach/muscle spasm type problems during "rattle".

1 days dose of imodium (loperamide) for diarrhoea..(eg 6)

one days dose of diazepam maybe (eg 4x5mg)
one days dose of night sedation of a less sexy, boring kind eg nitrazepam 2x5mg.

ibuprofen..for aches and pains (eg 400mg x6)

Although this lot would not kill someone if taken all together, it would take a pretty determined self-detoxer to get through with only this cocktail, but might get through another few hours, until usual prescriber available and might allow someone to feel cared about, maybe.

But...I think most people would be better advised to carry on with their usual smallest dose of heroin, and plan their detox in a non-emergency way "but I'll have to go out and mug someone..." well yes, that is a problem.

we give quinine for muscle cramps if the detox is being supervised, but I once had a GP patient who took 5 at once 'because cramps so bad', luckily didn't go blind but I'm v careful with these nowadys and would advise against use in OOH setting.

I would b v careful with the benzo's too - if word gets out...etc, plus danger of OD. Daily scripts would be a must for me (there is always some chemist open on a sunday/bank hol)

There is a kaolin mixture on its own (WITHOUT the morphine!!) that is said to be good for diarrhoea, pretty harmless stuff too.
Would it be worth preparing a sheet for OOH service to use to give to patients, detailing what each drug is for, with spaces for doctor to complete, how many been given and how often may be taken?
I wonder if there is scope for prevention here too - I imagine some of these are not self-detoxes but people who have forgotten to collect rx on a weekend (or been in custody). I now use the wording 'dispense saturday and sunday's doses on Fridays, or Sunday's dose on Saturday if DNA Friday' to avoid this.

susi

Thanks to all.
As I suspected,this is much more complicated than one might think.
Agree re no Quinine,no Kaolin AND Morphine,yes to Buscopan,Ibuprofen and Loperamide and antiemetics.
Must confess ignorance re Clonidine[presumably as Lofexidine ''equivalent''].
Agree re difficulties of getting others on board and double-edged nature of trying.
Sending a signal re OOH prescribing Benzos is clearly a worrisome isssue and if a doctor prescribes only a tiny dose of Diazepam and it is detected in a postmortem cocktail then it's a case of OOH-OH! for the prescribing doctor.
Think guidelines/spreadsheet for use in OOH a good idea[can be monitored by SCMG esp as OOH are members of our SCMG]and will try to prepare one---?to be in a future issue of Network.
Love the suggestion re writing the script to allow
for pick-up/dispensing difficulties at weekends,ultimately the cause of 99% of situations,rather than attempts at self-detox as Susi rightly points out.

Many thanks for advice on this one.
Presented local OOH service with written guidance,in pamphlet form,yesterday.

Substitute prescribing in exceptional[''never say never''] circumstances only---we have an on-call team till 1900hrs Monday to Friday and 0900-1200hrs on Saturdays to give advice and support re glitches and hitches affecting dispensing to our existing patients on Substitue medication.

Symptomatic prescribing along lines suggested by yourselves and existing local guidelines,flagging up avoiding Dihydrocodeine and other Codeine-based drugs,with advice of daily review to allay prescriber's concerns re overdose etc

Finally,special thanks,in the light of recent ''events'', to James who always provides constructive advice/support on the forum.

Hi George

Just noticed you mention Clonadine in your earlier comment - of all the "cocktails" we use on D5 (& some of the meds I am told we use have come as a suprise to me) we have always avoided clonadine due to it's potential to drop blood pressure.

Best regards for the new year to all

Declaration of Interest:
Malcolm is Director of Clinical Services at the Harrogate Clinic which incorporates Detox 5. Postings to the forum are not for marketing purposes

Dear George, Hope all is well. If I am the James you refer to can you clarify the "recent events" as I feel in the dark. Happy New Year. James.