Rolling Hand Over (ROVER)

ROTATION: Addiction Medicine

Last REVIEW DATE: 05/08/2022

Last HEAD OF UNIT REVIEW DATE: Click here to enter a date.

NEXT HEAD OF UNIT REVIEW DUE DATE: Click here to enter a date.
(Default 2 years if no significant change)

Please update as required and send to [email protected]

CHECKLIST FOR NEW STARTERS

 read through this ROVER

 receive comprehensive unit orientation from unit supervisor/registrar within week 1
 ensure you have completed relevant EMR /First net training for the role.

TIPs

1. Organise access to the V:drive on the EH network early on your first day. If they ask you for a specific
location, ask for access to the folder in the V drive called ‘Drug Services’. This contains all of the relevant
templates for admissions and discharges.
Another way you may be able to access the V Drive is via Drive L: EH GroupShare > EH Mental Health

2. Wellington House is primarily paper-based. All orders for pathology and imaging are by paper however
results will appear on EMR

3. Check that your Safescript account is up and running which is handy to have from day one of the rotation.
This will allow you to establish or confirm any high-risk medications patients may be taking (e.g. opioids,
benzodiazepines

STAFF
UNIT STAFF & KEY CONTACTS CONTACT DETAILS
Clinical Director: Dr Matthew Frei, 0408 362 110
Dr Vicky Phan (Mondays and Fridays)
Consultants:
Dr Keri Alexander (Wednesdays and Fridays)
Dr Manu Bhatnagar
Registrars:
Dr Christina Ngo-Nguyen
HMO/Resident: according to roster This is you! 
Trudy Trice
Bed Manager
Ph: 47769
Unit NUM: Alex Lebani
Switchboard 46100 / #1
IT Help Desk 9092 670
GEOGRAPHY

ITEM LOCATION
Home ward Wellington House, 31-33 Wellington Road, Box Hill
Morning
meeting/handover Wellington House, Quiet Room @ 8:30am
point
End of shift
N/A- Can inform registrar within hours or consultant on call if needed
handover point
Your pager lives
No pager
here
Patient list WH Handover List prepared by nursing staff and provided during morning handover

Outpatient clinic Outpatient Clinic at Carrington Rd

RMO Quarters BHH

WEEKLY TIMETABLE at a glance

Mon Tues Wed Thurs Fri Sat/Sun

0830- 0830- 0830- 0830- 0830- Oncall for all EH, which
Handover at Handover at Handover at Handover at Handover at includes any day or night
Wellington WH WH WH WH shift every 1 in 3-4
House (WH) weekends*
0900-1700 0900-1700 0900-1130 0900-
0900- Admissions + Admissions + Admissions + Consultant
Consultant jobs jobs jobs WR
WR (join if
no morning 1130-1400 0900-1230
admission) Teaching + Admissions
12pm Intake + jobs
0900-1700 meeting
Admissions + (join to help 1230- Finish
jobs scribe for (Half day)
intake
meeting)

1400-1700
Admissions +
jobs

*For interest: if you have been activated to work > 10 hours, you are entitled to the next day off
Consultant ward round (Monday)

Preparation: Update bloods on patient list; use patient list template (Doctors > Documents > Handovers) to
print pre-prepared WR notes onto progress paper.

During: Usually conflicting admissions which require attention from the HMO on Monday morning. Join CWR
and assist with note taking or re-charting medications if available.

After: Paper round with the registrars about the plans made during the WR and important jobs to follow up

Consultant ward round (Friday)

Preparation: Briefly review all the patients on the ward and review of the patient’s admission blood tests,
print pre-prepared WR notes onto progress paper

During: Present patients to consultant (Dr Keri Alexander, assist with note taking or re-charting medications)

After: Jobs generated from CWR; ensure drug charts are updated for the weekend

JMO ROLE & RESPONSIBILITIES

Admissions
- There is an admission template to follow in the Admissions folder, which can be found at:
o V:/ Drug-Services -> 1 Clinical NEW -> Wellington House ->Doctors->Admissions (template
will be in this folder)
- Copy and paste all relevant information from CPF (Mental Health folder -> TPTTS or EHADS ->
medical/clinical review
o Useful to do this ahead of time to have an understanding of the patient prior to admission
and flag any issues that may arise
o Patients are currently needing a screening RAT test prior to admission, and have to wait for
roughly 20 minutes outside the facility for this to be completed, which is a good opportunity
to pre-prep the admission note
- Usually 2-3 admissions/d up to a max of 4/d
- The handover contains a list of planned admissions, but these are often subject to change
- The required history and exam during an admission is detailed by the admission template and, if
followed, ensures nothing important is missed

- Substance use history:

o Timing of use – ask about time of first use, last use, frequency, when do you start using during
the day
o Amount
o Risks - different for each substance. Refer to the substance-specific guide at the end of this
document for a bit more info
o Route - IV, smoked, oral, etc. With IV use always ask where they inject (arms, neck, feet, groin)
and be sure to examine injection sites for signs of infection. Also ask if they have been
screened for BBVs and if not offer to do that for them during admission.

- Check all patients on Safescript.vic.gov.au prior to their admission for what they’re being prescribed
and ‘doctor shopping’
- Double check ORT (opioid replacement therapy) by calling up the patient’s pharmacy. This is
necessary for methadone to clarify their dosing and compliance i.e. Check their last dose

- Admission Plan:
 o Medical plan for admission (plans should have been formulated by intake staff prior to
admission and are not the HMO’s responsibility) – notes on CPF -> Mental Health -> TPETS ->
Clinical review, usually good patient summary under the intake nurse’s notes
o Contact the registrars or consultant on call to discuss the patients after admissions and
confirm the intake plan- highlight parts of the admission which defer from the points
outlined in the intake meeting/ CPF note as this may change the plan
o Let the Patient know what to expect on the ward and their initial management plan to
alleviate some of their anxiety. Flag with patients that benzodiazepines provided for
withdrawal are ceased on Day 6 of their admission.
- The CRAM is also part of the admission process and outlines patient safety and identifies risks,
CRAMs are needed on Admission and when patient is transferred back to us from ward or ED.

NB. Clients with suspected eating disorders

- For clients with suspected eating disorders; include in the plan:
- Day 1 and 2 UEC, CMP; daily ECGs for first 2 days (follow EH Objectify guideline if any
abnormalities)
- Monitor aperient usage
- Check oral hygiene, encourage to visit dentist for check-up if Hx of purging
- Support specific dietary needs on the wards
- Give Butterfly Foundation resource https://butterfly.org.au/ (phone 1800 33 4673/online/text
support for eating disorders/body image issues, links with GPs/psychologists/psychiatrists/dietitians)
- Refer for 291 assessment if previously undiagnosed / no current treating team (details on how to
refer for a 291 assessment can be found below).

NB. Admissions are an excellent opportunity to provide contraception counselling.

We are also currently able to offer Implanon insertions (must be performed by a doctor) and depot Provera
injections at Wellington House.

Completing the paperwork

These are documents you need to complete for all patients:
1. Admission document as outlined above
2. CRAM (Clinical Risk Assessment and Management) form
3. A resus form- usually full resus for everyone and sign at the bottom.
4. Medication charts (see below)
5. Check safe-script to confirm S11 medication. For methadone/suboxone always call dispensing
pharmacy to confirm dose and last day of dosing
6. Path slips- ensure patients are aware of which tests are being ordered and acquire consent for
these (Blood borne virus and/or STI screening in particular)

Med Charting

- Every patient has a standard set of regular and PRN medications written up.
- There is a sample chart in the doctor’s office that can use as a guide in the beginning. This template
also includes doses for PRN and front-loading/AWS diazepam/oxazepam
- All patients who are current smokers get charted nicotine replacement therapy (NRT). NRT options
at WH include patches, lozenges and inhalers. Recommend to remove patches over night as some
patients get nightmares from nicotine patches.

Standard New Patient Medications

 Regular
o Multivitamin, 1 tab, PO, daily
o Magnesium, 1g, PO, BD
o Thiamine 100mg, PO, TDS (except load if EtOH withdrawal), for ETH withdrawal patients:
first 3 days: thiamine 300mg daily IM ( first dose today as stat dose)
 PRN
 o Paracetamol, 1g, PO, q4h, Max 4g, Pain, reduce to TDS if liver cirrhosis
o Ibuprofen, 400mg, PO, q6h, Max 1.2g, Pain, omit if history of gastric bleeding
o Buscopan, 10mg, PO, q6, Max 30mg, Abdo cramps
o Loperamide, 2-4mg, PO, q1h, Max 16mg, Diarrhoea
o Metoclopramide, 10mg, PO/IM, q6h, 30mg, N/V

o Nicotine Patch, 21mg/24hr, Top, Daily, Max 21mg, NRT

 If less than 10 cigarettes per day use 14mg/24hr
o Nicotine Inhaler, 15mg (1 inhaler), inh, q1h, Max 90mg, NRT
o Nicotine Lozenge, 2-4mg, PO, q1h, Max 60mg, NRT
o Melatonin, 2-4mg, PO, nocte, Max 4mg, sleep
o Coloxyl and Senna, 2 tab, PO, BD, Max 4 tabs, constipation

Medication tips
- Generally, patients over 65 or those with evidence of Chronic Liver Disease: use Oxazepam instead
of Diazepam for withdrawal
- It is important that the patients are told at the time of admission that they will only have
benzodiazepine for a max of 6 days for their symptom relief to avoid issues later on
o Clarify cease date and time on drug chart for PRN Benzodiazepines (usually on day 6, 9am)
o If the patient is on regular Diazepam in community clarify dose with patient and using
safescript/ GP documentation and make a clear plan for their regular BZD during and post
withdrawal
- Identification of “High risk” alcohol or GHB patients need to be front-loaded with Diaz or Oxaz for 3
doses every 2hrs (as per med chart template) on admission to avoid seizures/severe withdrawal Sx.
Only front load patients when their BAC is <0.1
- Ensure last dose and time of methadone given to patient is confirmed with their pharmacy before
prescribing
- If a patient is requiring long acting buprenorphine injections (LAIB) such as Sublocade or Buvidal
during admission, ensure a script is prepared and sent to BHH outpatient pharmacy as soon as
possible as delays with acquiring these injections are common. Call the pharmacy once this is sent to
confirm a date for when the injection will be in stock.

Deteriorating/ unwell patients

- During hours the HMO will often be the first point of call for nursing staff to review a potentially
deteriorating/ unwell patient
- The registrars will often be there for support or the on call consultant
- At Wellington House the only option for acutely unwell patients is to send them to ED. There is
limited scope for investigations, however bloods and ECGs can be performed at Wellington House.

Pathology & Imaging

Pathology
- Write a paper request slip
- Check results on EMR
- Generally WH nurses will take the bloods/ urine samples or organize an appointment at pathology
and escort them over
- HMOs can also help with bloods, in particular if there is a difficult bleed. The bloods then have to be
taken to pathology on the ground level of BHH
- Keep a track record of ordered pathology (especially Hep C viral load/ syphilis confirmatory testing)
so that you check if result is back (can take up to a week to come back)
 - Add on beta-HCG for women of child-bearing age
- Consider adding on metabolic screening (HbA1c, fasting glucose, fasting lipids) for clients at risk of
metabolic syndrome (e.g. from anti-psychotic medications)

Blood borne virus screening;

- Offered to all patients and encouraged in anyone with a history of IV drug use
- Pre-test counselling: advise them that they may not get there result from us and may need to get the
results from their GP after discharge
- Note- some diseases are notifiable diseases and if positive will require a notification to the
department of health
- STI testing: Chlamydia and gonorrhea PCR on first pass urine
- Bloods: FBE, UEC, LFTs, AST, anti-HCV (add on HCV PCR if positive), HBV serology, HIV serology,
syphilis serology
- NOTE: results for HCV PCR and syphilis confirmation can take 1 week to come back ( please keep a
list of patients to follow up results that are not back yet when writing DC summary and check
regularly). If they are not yet back by the time of discharge ensure to call the GP to chase the result
and include the phone number of BHH Pathology in the discharge summary.
- For syphilis: inform registrar on all preliminary positive results
- Follow up with pathology if results not back after 10 days
- Our ward secretaries Theresia and Tina can print out some pathology ordering stickers and stickers
with your provider details for ordering 

Imaging
- Ordered using yellow paper request slip
- Ensure nurses are aware so they can organize a time to escort the patient to radiology

Discharge- summaries and script

- The discharge summary template can be found here:

V:/ Drug-Services ->1 Clinical NEW -> Wellington House -> Doctors -> Discharges

- Save the template as the patient’s name and UR (like the admission note) in the relevant
year/month folder
- Use the completed discharge summaries as a guide for what details to include
- If a “291 assessment” (i.e. a formal evaluation and management plan by a psychiatrist that this
subsidized by the government) has been flagged as appropriate for the client, ensure that they are
given information for the GP to refer them to Dr Vicky Phan, Psychiatrist, 43 Carrington Road, Box
Hill. Also ensure to include these details in the discharge summary. In the interim, the client can be
offered Head to Health VIC resource (Ph: 1800 595 212) for mental health support.

Discharge script
- If you need to write a script for opioid replacement therapy so that a patient is covered between
discharge and seeing their GP, be sure to include the following on the script:
o Type of ORT (eg. Methadone, suboxone)
o Dose (in numbers and words)
o To specific pharmacy (ring them to let them know it is happening and fax it over to them)
o Be specific about dates, eg. From 25/04/20 to 30/04/20 inclusive
o Always specify daily dispensing only
- Note: Buvidal and Sublocade doses should be mentioned with date given and date when next due
in the Discharge summary medications section
- Always ensure that the extra tables underneath where you have written the discharge medications
on the script are crossed off, per safe prescribing practice.
- N.B. Ensure that ‘PBS’ is ticked on your discharge script
- Acamprosate requires an approval number 5633 (otherwise this costs >$100 for patients
without a concession card).
- Naltrexone requires a PBS authority number (call 1800 888 333; the ‘hospital prescription
 number’ is the one found at the top of the pad)
- Ensure that scripts are written out to include over the counter medications for all of our Indigenous clients
as they are eligible for the ‘Close the Gap’ scheme.

Discharge medications include regular Diazepam or other S8:

- Recommend at least weekly dispensing (daily for any dose over 20mg diazepam daily)
- Indicate if for further weaning (recommend 10% per fortnight)
- Double check the discharge script with registrars if in any doubt

Discharge destinations
Some clients will wish to attend long-term rehabilitation on or after discharge.
Rehab facilities will have their own paperwork & rules regarding medications.
For example, Windana does not allow any benzodiazepine use 72-hours prior to admission. Diazepam is
usually ceased on day 6 for Wellington House clients; if they are planned only for a 7 day admission, discuss
the BZD cessation plan with a registrar/consultant. Windana’s medical team also prefer Sublocade to Buvidal
injections.
On the other hand, The Bridge Rehab program @ The Basin is able to accept clients discharging with
diazepam, to a maximum of 10mg/day.

Other medium-long rehabilitation destinations include:

- Quin House

Short term rehabs include:

- Western Health: Women’s Rehabilitation Program (6 weeks)

Thursday Intake Meeting

On Thursdays, there is an intake meeting from 12:30-2pm via Zoom.
If there are no admissions, join to help scribing -
Notes are saved with the ‘Clinical Review’ title in CPF > Mental Health > TPETS/AOD Tab

Intake Meeting Template:

[This will be forwarded from previous HMO via email for ease of access]

Sexual Health Specific Information

Active infection? Treatment

HCV Detectable HCV viral load [See HCV referral and treatment
pathway]
Syphilis TPPA reactive *Always speak to your
CLIA reactive registrar/consultant & seek
expert advice (Melbourne Sexual
Is there a reinfection? Health Clinic GP line or BHH ID)
- Presence of symptoms (swab prior to commencing treatment
lesion for TpPCR and DGI) for syphilis. Advocate for
- Asymptomatic reinfection (RPR treatment while IP given the
>4 fold rise in titre from baseline) increased risk of our client group
for self-discharging.

Treatment of early syphilis (< 2

years):
See eTG for updated treatment
plan

Treatment of late syphilis (> 2

years):
See eTG for updated treatment
 plan

Cx: Tertiary syphilis

Seek expert advice
Chlamydia Positive PCR See eTG for updated treatment
plan
[pregnant/anorectal
infection/PID]: Perform a test of
cure 3 weeks after treatment.
Gonorrhoea Positive PCR See eTG for updated treatment
plan

Perform a test of cure 2 weeks

after treatment.
Trichomonas vaginalis Positive PCR See eTG for updated treatment
plan
[If recurrent infection]: See eTG
for updated treatment plan

HELPFUL RESOURCES

Melbourne Sexual Health Centre for assistance on managing sexually transmitted infections. Call their GP
support line during office hours.
https://www.mshc.org.au/

TGA nicotine vaping product prescribers https://www.tga.gov.au/authorised-prescribers-unapproved-

nicotine-vaping-products – this is a list of GPs who are able to prescribe nicotine, which can be dispensed
from pharmacies. Write down this resource/GP prescriber in the area for clients who are currently vaping.

Men’s Shed https://mensshed.org/ a social program for men to partake in hobbies, increase social
networking and supports.

Family Drug Support (for family members, but can given to clients to pass-on): 1300 368 186

Quitline referral (can organise for Quitline to client on day of discharge/or give number for client to call) if
client’s goal is for tobacco cessation.

Macquarie University E-Pain Course: https://ecentreclinic.org/?q=PainCourse – A free online pain

management program designed to provide good information about chronic pain and to teach practical skills
for managing the impact of pain on day-to-day activities and emotional wellbeing.

Resources for Financial Strain

National Debt Helpline: 1800 007 007
MoneyCare (Salvation Army) referral (Handover to the nursing team to help the client put in a referral)
Detox specific information
- A basic framework for the common detoxes at WH are outlined below
- The information below is a good guide and will become very familiar over the first weeks of the
rotation (Don’t feel the need to commit all the below information to memory prior to commencing)
- As this information is just a guide it is still important to discuss the management plan with either a
registrar or a consultant.

Alcohol:

Thiamine
- Every patient is commenced on thiamine IM 300mg daily, first order on the day of admission write “
give now” or write as stat (then cease after 3 doses) and 100mg PO TDS ongoing
- If there is any concern regarding development of a potential Wernicke’s encephalopathy, we start on
therapeutic doses instead – 300mg IM TDS for 9 doses. Read up on your Wernicke’s and know how
to screen for this on examination: walking difficulties or any eye movement problems.
o Keep in mind that some patients may be intoxicated during admission ( if in doubt -> give
thiamine)

Diazepam or oxazepam for withdrawal

- Diazepam is the go-to for withdrawal management in most cases (oxazepam is used in chronic liver
disease). Most patients will be charted diazepam 5-20mg Q2H (max 120mg/daily) to cease at 9am on
the morning of their 6th day. (Day of admission is counted as Day 1.)
- Front-loading with diazepam (or oxazepam) - if there is a history of complicated withdrawals
(previous withdrawal seizures, delirium tremens, hallucinations, etc.), significant dependency (e.g.
drinking round the clock) or multiple previous withdrawals/detoxes, then you also front-load with
benzodiazepines. Front-loading is written up as three once off doses ( 20mg diazepam 2 hours apart)
– please refer to the sample medication charts to see how this is done. After front-loading is
completed, the usual PRN doses as per the AWS are used. Careful to front-load if a patient has a
history of morbid obesity or obstructive sleep apnoea- double check with registrar
- Benzodiazepines for withdrawal are only to be commenced when BAC <0.1
- If there is significant liver disease, oxazepam is used in place of diazepam as it avoids 1st pass
metabolism. Used for both front loading and PRN (refer to sample medication chart for dosing: 15-
60mg oxazepam q2hours , max 360mg, cease 9am day 6)
- To establish whether or not there is CLD for use of oxazepam, we can:
o Look at recent bloods. If ALT (if available) is at 3-5 times the upper limit of normal then we
use oxazepam. Also look at low platelet count as this may indicate portal hypertension.
o Ask about any history of cirrhosis or bleeding episodes – also used to stratify risk
o If no recent bloods and you suspect potential significant liver damage/Hx of cirrhosis, just
ask a senior
- When writing up your front-loading doses always make sure to specify:
o ‘omit if drowsy’, and commence when BAC <0.1

Opioids

Usually IV heroin or misuse of pharmaceutical opiates

Presentations for these patients vary but the most common I’ve come across are:

1. Patients not currently prescribed ORT, but looking to commence:

a. In these cases, we will generally try to offer suboxone over methadone as it’s safer
b. Only commence suboxone when the patient is in active opioid withdrawal (the patient will
help to guide you here – the first test dose of suboxone 2mg is usually given when they start
to feel uncomfortable with withdrawal symptoms / COWS > 11). Check out the COWS
(Clinical Opiate Withdrawal Scale) for a list of opioid withdrawal symptoms. Common
symptoms/signs you’ll see are pupil dilatation, piloerection, sniffles/sneezes/yawns,
 back/joint pain, restless legs, hot/cold flushes and GI upset.
c. Initial dosing for suboxone is usually charted as 2mg Q2H (up to a max of 32mg/24 hrs in
the first day. Once they’ve had a test dose and there have been no adverse effects, they’ll
usually continue the PRN dosing for 24 hours. After that we review and chart a regular dose
and up-titrate as appropriate from there.
2. Patients already on ORT and looking to change their dose or switch medication
a. We get quite a few patients who are already taking methadone and are looking to change
their dose or switch to suboxone. For transitioning from methadone to suboxone, we
generally utilise the micro-dosing protocol. See separate protocol. First day is 400mcg
Subutex , 4 doses at least 2 hours apart. Please always discuss with registrar/consultant
b. For patients wanting to increase or decrease their methadone dose, chat to the
registrar/consultant about a gradual titration plan.
3. Patients wanting to cease opioid use without ORT
a. We do have the occasional patient who wants to go withdraw from opioid use without using
ORT. In these cases, provide education about what to expect. The plan is essentially
symptomatic relief as outlined below tapering with suboxone.
b. Note we do NOT routinely prescribe benzodiazepines for withdrawal from opioids.
c. Give take home naloxone script as high risk of overdose after detox
d. Document that patient is choosing this against medical advice ( we always advice to change
to medium to long term ORT)

Symptomatic relief in opioid withdrawal

If patients feel uncomfortable during withdrawal, we can offer a few medications to ease this:
- Metoclopramide, Buscopan and Loperamide for the various kinds of gastrointestinal upset
- Pramipexole – chart this as 125mcg nocte, prescribed for restless legs.
- Clonidine – chart this as 50mcg QID PRN (max 200mcg). As an α2 -adrenergic agonist, it reduces
autonomic nervous system manifestations of opioid withdrawal. If you prescribe clonidine, be sure
to specify ‘omit if SBP <100mmHg’ on the chart and keep an eye on their BP. Review the ongoing
use/requirement for clonidine after a few days. If you cease it, be sure to review blood pressure for
48 hours for rebound hypertension.

Methamphetamine or cannabis:
- If a patient is using methamphetamine at least weekly, we regard this as physiologically dependent
and they will require PRN diazepam for withdrawal
- For both MA and THC – we generally prescribe PRN diazepam (5-10mg q4h max 60mg, cease day 6)

Benzodiazepines (both illicit and prescribed):

- Patients will be placed on a fixed weaning regimen with the registrar or consultant guiding you
- As previously mentioned, be sure to check SafeScript if you haven’t done so during admission
- This is often a challenging part of the job and clients are very aware of their benzodiazepine dose –
make sure you indicate on admission when their diazepam/oxazepam will cease and that their
benzodiazepines will be weaned (in the setting of significant use).

GHB:
- Depending on the pattern of use can be high risk with rapid onset, severe and prolonged withdrawals.
Make sure you take a detailed history of use outlining duration, frequency and amount per day in
particular.
- Always consult a registrar or consultant if you are admitting a patient for GHB detox but depending
on the pattern of use will require PRN +/- front-loading with diazepam, and usually baclofen.
- Generally:
o 5-20mg q2h , max 120mg, aim for light sedation ( cease day 6)
o Baclofen 10mg QID or 25mg QID (registrar to decide, generally above 40mls higher dose)
 o Consider to give regular diazepam e.g. 10mg TDS for first 7 days ( registrar to review), omit
if GCS<15, for patients taking more than 30mls daily
- If patient appears agitated during admission, consider giving 10mg diazepam plus 10mg baclofen
STAT

Polysubtance use
Many patients will be admitted for detox from more than one substance. This can get complicated, so be
sure to discuss the plan with your reg or consultant, at least in the beginning.

Anti-craving medication
Commencing or re-commencing patient on alcohol anticraving medications is a common occurrence.
Generally, the options are:

1. Naltrexone, 25mg day 1 then 50mg daily

2. Acamprosate, 666mg TDS

Note: Baclofen is also uncommonly used for anti-craving purposes (off-label use)

If you don’t have any recent bloods from the GP do these first before commencing. Naltrexone is not used in
liver impairment (if ALT 5 times upper limit of normal) and interacts with opioids (it is an opioid antagonist)
whereas Acamprosate is contraindicated in renal impairment. Disulfiram is no longer used for anticraving
in Australia.

Ask the nursing staff to print off the relevant patient information sheets for naltrexone and Acamprosate.

COMMON CONDITIONS MANAGED BY UNIT

- Drug and alcohol dependence/abuse

- Most commonly including Ice/amphetamine, opioids (heroin, in particular), alcohol,
benzodiazepines and cannabis, GHB

USEFUL RESOURCES

Directline: Phone: 1800 888 236, 24 hour confidential alcohol and drug counseling and referral line. Clients
are given this number to access a pharmacy and GP in their area that can prescribe opioid replacement
therapy (limited number and access for both).

DACAS: Victorian Drug and Alcohol Clinical Advisory Service, 24 hour phone service for Health Professionals
(not for clients). Phone: 1800 812 804. To assist with diagnosis, clinical management and treatment options
for patients with drug and alcohol problems

Turning Point AOD guidelines:

Alcohol and Other Drugs (AOD) Withdrawal Guidelines (turningpoint.org.au)
Microdosing Protocol for 1 East and Wellington House

Day Total daily Dosing Regime Dosing Times ( 7a, - Methadone Adjuncts
dose (number of doses) 9pm)
1 1.6mg 400mcg q2-3h (x4) Depending on Full dose Pramipexole
(less if late admission time 0.125mg
admission) nocte,
diazepam 5-
10mg q4h PRN
2 3.2mg 800mcg QID Full dose Clonidine
50mcg TDS –
QID, Diaz 5mg
QID plus PRN,
As above
3 4.8mg 1200mcg QID 8/12/16/20 Full dose As above
4 6.4mg 1.6 QID 8/12/16/20 Full dose As above,
5 8mg 2 mg ( x4) 8/12/16/20 Full dose As above
6 16mg 8mg ( x2) mane and - stop Cease if no
midi, +/- LAIB in withdrawal
afternoon
Please wake patient for dosing
Dosing as charted ( +/- 10min), but can be withheld if patient unwell
Make sure that 30 tablets of 400mcg Subutex are ordered / in safe when new microdosing patient arrives
All patients should be charted for
1. Clonidine 50mcg QID : Withhold if systolic BP <105 or HR <60bpm ( Registrar review to cease day 6)
PLUS Clonidine 50mcg QID PRN for opioid withdrawal symptoms (Registrar review to cease day 6)
2. Diazepam 5-10mg q4h max 40mg in 24h for anxiety and opioid withdrawal, cease Day 5. Regular 5 or
10mg QID will be charted for days 2-5
3. Pramipexole 0.125mg, cease day 6
4. Paracetamol 1g QID pain, Ibuprofen 400mg TDS PRN for pain, Loperamide 2-4 mg PRN for stools or
abdominal cramps, Metoclopramide
5. Buscopan 10mg TDS ( cease day 6)
Nursing Observations with each medication administration:
- BP and Heart rate , withhold clonidine
- Fill out COWS withdrawal scale ( paper based ) TDS ( 8 am, midday, evening
- Enquire for headache, legs cramps, shivering, nausea, anxiety and offer symptoms
- Withhold buprenorphine dose if patients feels unwell / shivering / precipitated withdrawal until
further advice from registrar (please contact Vivian, including after hours)
Management of withdrawals:
- Opioid withdrawals symptoms with micro dosing regime are usually mild to moderate
- Usually occur 1-2h after buprenorphine dose
- Re –assure patient that he/she will get better within 2-3h
- Offer symptomatic management, especially diazepam (5- 10mg) for anxiety/agitation) and clonidine
50mcg PRN , loperamide for abdo cramps ( medical team to consider to change loperamide to
regular dosing , 2mg TDS)
- ask about headache, abdominal cramps, leg cramps, nausea and treat with Loperamide,
metoclopramide and paracetamol/neurofen accordingly.
- Many patients find a warm blanket or a hot shower helpful
- Patients may feel distressed and benefit from supportive nursing care to manage their anxiety
- Patients may experience cravings for opioids / risk of early discharge
- Get advice from registrar about next dose (next dose may get withheld until patient is better or dose
may get reduced)
What if patient is not coping with the mild to moderate withdrawal symptoms?
 1. Review if symptomatic management medications can be made regular, if there are any meds that
can be given to ease symptoms
2. Consider extra diazepam for anxiety
3. If not coping, then the protocol might need to be slowed down a bit:
a. Reduce the dose slightly but aim to maintain the same 24h buprenorphine dose as the day
before
b. Instead of increasing every day, increase every second day
4. Avoid dose increases over the weekend in very anxious patients or those who appear not to cope
well with withdrawal symptoms
5. Re-assure patients that some withdrawals are expected , to aim to continue dosing if symptoms are
manageable but can always slow down if symptoms are getting too challenging
6. Most symptoms occur between total daily dose of 3-8mg. Usually very mild symptoms only below
3mg and above 8mg
7. Avoid “ going back” in the dosing schedule more than 2 days but one could move back to the day
before and maintain this level for another day until increasing again
8. Consider slower increases in stronger withdrawal symptoms
Patient too sedated?
- Reduce or withhold Diazepam or other sedating meds ( e.g. Pregabalin/ Amitryptillin )
- Please call registrar Vivian ( 0422802912) to adjust schedule

Examples:
Patient experiencing stronger withdrawal on Day 3 after the morning dose, e.g. shivering, feeling unwell,
nausea
Day Total daily Dosing Regime Dosing Times ( 7a, - Methadone Adjuncts
dose (number of doses) 9pm)
1 1.6mg 400mcg q2-3h (x4) Depending on Full dose Pramipexole
(less if late admission time 0.125mg
admission) nocte,
diazepam 5-
10mg q4h PRN
2 3.2mg 800mcg QID Full dose Clonidine
50mcg TDS –
QID, Diaz 5mg
QID plus PRN,
As above
3 4.8mg 1200mcg QID 8/12/16/20 Full dose As above
3.2mg 1200, 8am -> unwell New schedule, Consider
Midday: 400mcg gives the patient making PRNs
PM: 800mcg extra time to regular
Nocte: 800mcg recover from
withdrawal
symptoms and
then maintains the
gains from day
before
4 4.8mg 1200mcg QID Day 3 is now given
a day late but body
would have had
another day to
adjust
5 4.8mg 1200mcg QID Day 4 is now
repeated to give
more time to
adjust
6 6.4mg 1.6 QID 8/12/16/20 Full dose As above,
7 6.4mg 1.6 QID 8/12/16/20 Full dose As above,
8 8mg 2 mg ( x4) 8/12/16/20 Full dose As above
9 16mg 4mg q2h +/- LAIB in 8/10/12/14 stop Cease if no
afternoon or next withdrawal
day

DRAFT HEP C HMO Referral and Treatment Pathway (JAN 2021)

 Addiction Medicine
HepC Clinic Contact (Nurse) – Caroline Day 0418 599 728; [email protected]

Admission: Pt unknown HCV Positive Admission: Pt known HCV Positive

Order bloods: Order bloods:
FBE, UEC, LFT, AST, Coags FBE, UEC, LFT, AST, Coags
HIV, HBV, HCV serology HIV, HBV
And write: take extra tube for HCV viral load HCV viral load, HCV genotype
and HCV genotype, add on if HCV positive

Patient HCV Ab Positive with detectable viral load

Calculate APRI score:
https://www.hepatitisc.uw.edu/page/clinical-calculators/apri

Organise Liver USS – PLEASE CALL U/S after

sending fax to book appointment
(Screening for HCC and Cirrhosis)

No obvious cirrhosis and low Medical comorbidities/high Evidence of cirrhosis

APRI Score APRI score, no obvious cirrhosis

Discuss treatment plan with HMO emails HepC Clinic Nurse

Addiction Registrar Consider referral to HepC with results and patient history
team for advice (Specifically include social
history, medication list, medical
conditions – in particular
epilepsy)

HepC Clinic Nurse/Doctor

provides treatment
recommendation and follow up
plan

Pt discharged Give script to Healthsmart (near zouki) -

before treatment pharmacy takes 1-2 days to order in!
(Note this is an outpatient script – there is a cost to the pt of
about $40 or $6 if heathcare card. Please make sure pt is aware.
Also note, order meds early – can take 1-2 days to arrive)

Send referral on CPF to Liver Clinic (aka. CLEAR Clinic) for

HepC OP F/U
(Note: GP F/U is an option if the GP is happy to managed HCV)