1. Injectable Opioid Treatment in England Clinical Experience Rob van der Waal

2. The basics (1) F All Injectable diamorphine/ methadone administered under supervision F Oral supplement is necessary to ensure stability over 24 hours (take home available) 3Oral Methadone 3Slow Release Oral Morphine 3Buprenorphine

3. The basics (2) F Open all days, AM and PM sessions F Flexible dosing regimes available – converting Injectable to oral (partly or completely) 3To minimize the inconvenience of IOT 3To encourage patient choice 3To provide exit route

4. Assessment and Introduction to IOT F Establishing eligibility and feasibility F Trial period on oral medication followed by partial conversion to Injectables F Gradual titration of Injectable component and oral component! until patient is comfortable F Monitor and – if possible - manage problems (e.g. alcohol/ benzodiazepine use, injecting sites)

5. Stabilisation F Reduction/ cessation of street heroin use F Reduction/cessation of other street drug use F Develop safe injecting routine (site rotation etc) F Medium-long term care planning F If not successful patients move back to standard oral maintenance treatment

6. Medium – long term F Reduce/stop other street drug use F Reduction of injecting frequency and attendance F Increased focus on health and socio economic aspects in care planning F Exit or long term maintenance?

7. Flexible Dosing Example F Option ADiamorphine 200mg IV am Diamorphine 200mg IV pm Methadone oral 30mg F Option BDiamorphine 200mg IV / day Methadone oral 100mg F Option CMethadone oral 170mg

8. Monitoring pre and post dose F Routine – brief observation to establish 3if it is safe to proceed 3If there are complications post dose F Comprehensive - involves intermittent assessment of 3 vital signs (including pulse oximetry) 3 breath alcohol levels 3 UDS dipstick 3 rating of withdrawal/ sedation levels

9. Injecting F Hygiene Washing of hands, cleaning of sites before and after injection F Injecting sites Peripheral veins, muscles, no active inflammation F Injecting time Approximately 5 minutes once routine has been established

10. Injecting Problems and solutions F Poor veins limit intravenous injecting (IV) 3deep veins (e.g. groin) not allowed F Single site IM injecting (painful, infections) F The majority of patients now inject intra muscular (IM) or subcutaneously (SC) F And are required to rotate sites

11. Monitoring Problems F Severe post dose sedation related to 3Benzodiazepine use Not always evident prior to dosing 3Alcohol use 3Respiratory illness F It is easy to monitor alcohol use but benzodiazepine use is more costly, labor intensive and requires the patient to provide a urine specimen on the spot 3serious risk that can require immediate intervention (e.g. observation, oxygen naloxone)

12. Co morbidity F Due to daily attendance the clinic offers an excellent opportunity to administer other medication under supervision, for example when thee are concern about compliance F E.g. antidepressants, antipsychotics, mood stabilisers

13. Summary (1) F Diamorphine can be sufficiently rewarding to keep patients engaged in highly structured treatment F Structure (protocol, ritual) is a critical therapeutic component F Patients have made significant progress, some have moved back to standard oral treatment and have maintained the benefits

14. Summary (2) F When not successful, it is often due to other drug use (e.g. alcohol, poly drug use), health, socio- economic factors or simply because of patient choice F Resolving the above appears conditional to long term success