Department of Public Health, Environments & Society, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK.
University of Bristol, Oakfield Grove, Clifton, Bristol, BS8 2BN, UK.
Harm Reduct J. 2024 Nov 18;21(1):201. doi: 10.1186/s12954-024-01127-2.
Management of opioid withdrawal in hospital settings is crucial to improve treatment completion and health outcomes among patients who use opioids, such as heroin. Evidence-based clinical guidelines can support responsive provision of opioid substitution therapy (OST). In England there is no standardised application of guidance for substance dependence management across National Health Service (NHS) Hospitals. A recent review of NHS hospital policies identified varying approaches to managing opioid withdrawal and procedural barriers to timely medication.
To develop a clinical guideline for opioid withdrawal management in acute NHS hospital trusts to be tested and evaluated as part of the iHOST (Improving Hospital Opioid Substitution Therapy) research intervention.
We undertook a deliberative guideline development process. The University London College Hospital (UCLH) substance dependence guideline was used as a template, with key points of revision informed by evidence review, consultations with hospital staff and people with opioid dependence. A multidisciplinary working group deliberated evidence statements to develop recommendations. These were reviewed by an oversight committee comprising representatives from key stakeholder organisations. The team authored the guideline with iterative review by the oversight committee, key stakeholders and UCLH clinical governance committees.
Deliberation focused on three key domains: (1) identifying opioid dependence and promptly continuing existing OST prescriptions; (2) initiating or re-titrating OST; (3) ensuring safety and continuity of care at discharge. Changes to the UCLH guideline included removal of mandatory urine drug testing prior to OST; increasing initial methadone titration dose; and provision for a higher day-one titration dose when specific safety criteria are met. A new titration schedule for sublingual buprenorphine was incorporated. Discharge planning to ensure continuity of community care and reduce risk of opioid overdose was emphasised, with allowance for bridging prescriptions of OST and naloxone provision on hospital discharge.
The iHOST clinical guideline aims to remove procedural barriers to opioid withdrawal management for hospital inpatients. It is intended to be implemented by other NHS hospitals, which could improve access to OST and reduce discrepancies in treatment access and completion.
ISRCTN47320412 https://doi.org/10.1186/ISRCTN47320412 .
在医院环境中管理阿片类药物戒断对于改善使用阿片类药物（如海洛因）的患者的治疗完成率和健康结果至关重要。循证临床指南可以支持提供阿片类药物替代疗法（OST）。在英国，国民保健服务（NHS）医院没有针对物质依赖管理的标准化应用指南。最近对 NHS 医院政策的审查发现，管理阿片类药物戒断的方法各不相同，并且存在及时用药的程序障碍。
制定阿片类药物戒断管理的临床指南，以便作为 iHOST（改善医院阿片类药物替代疗法）研究干预的一部分进行测试和评估。
我们进行了一项审议性指南制定过程。伦敦大学学院医院（UCLH）的物质依赖指南被用作模板，关键修订点由证据审查、与医院工作人员和阿片类药物依赖者的协商以及对关键利益相关者组织的审查提供信息。一个多学科工作组审议了证据陈述，以制定建议。这些建议由一个监督委员会进行审查，该委员会由来自主要利益相关者组织的代表组成。该团队在监督委员会、主要利益相关者和 UCLH 临床治理委员会的反复审查下编写了该指南。
审议重点关注三个关键领域：（1）识别阿片类药物依赖并及时继续现有的 OST 处方；（2）启动或重新调整 OST；（3）确保出院时的安全和护理连续性。对 UCLH 指南的修改包括在开始 OST 之前取消强制性尿液药物检测；增加初始美沙酮滴定剂量；并在满足特定安全标准时提供更高的第一天滴定剂量。纳入了新的舌下丁丙诺啡滴定方案。强调出院前的社区护理连续性计划，以减少阿片类药物过量的风险，并允许在医院出院时提供 OST 和纳洛酮的桥接处方。
iHOST 临床指南旨在消除医院住院患者阿片类药物戒断管理的程序障碍。它旨在由其他 NHS 医院实施，这可以改善 OST 的可及性，并减少治疗可及性和完成方面的差异。
ISRCTN47320412 https://doi.org/10.1186/ISRCTN47320412 。
