Acute Management of People who use Drugs

This guideline is an abbreviated version of the full GGC guideline - Acute Management of People who use Drugs.

Opiates, cocaine and benzodiazepines are substances most commonly associated with harm across Greater Glasgow & Clyde. Many people who use drugs may also have a co-dependency or problematic use of alcohol. Referral should be made to the Acute Addiction Liaison Team as soon as possible following hospital admission. They will support treatment interventions. For contact details see Appendix 1 in the GGC guideline. Please note this service is not available at weekends and bank holidays and operates Monday-Friday, 9am - 5pm. Referrals can be made via TrakCare and out-of-hours referrals will be picked up on the next working day.

This guideline covers:

• Assessment / monitoring
• Opiate substitution treatment (OST) and withdrawal management
  • Discharge planning
• Benzodiazepine / hypnotic withdrawal management

Patients found in possession of illicit drugs in clinical area

If small quantities are found these should be disposed of by pharmacy. Larger quantities should be reported to the police.

Assessment / monitoring

• Establish history of drug misuse:
  • Drugs used, as well as the frequency and amount used
  • Route of use e.g. IV, smoked, ingested
  • Whether usage is increasing / decreasing
  • Recent use
  • Previous use
  • Treatment - previous or current* 
  • Tetanus immunisation status

*Current treatment should be confirmed with community pharmacies and/or the Alcohol & Drug Recovery Service (ADRS) teams to ensure there is no break in treatment. See Appendix 1 of the GGC guideline for contact information of the ADRS teams.

Undertake clinical examination and look for signs of withdrawal and examine injection sites. The patient's clinical state should be assessed symptomatically on an individual case basis. Assess whether the patient's clinical state is compatible with their declared use. Exclude other illnesses which may cause symptoms similar to opioid withdrawal.

Drug urinalysis (near patient testing / laboratory)

• A positive urinalysis indicates a drug has been taken but does not indicate when.
• Some of the new types of drugs, including novel benzodiazepines, cannot be tested for using standard urine tests. 
• Requests for laboratory testing to identify substances not detected by urine dip testing may be considered if clinically appropriate.

ECG

• This should be done for all patients, specifically to assess for a prolonged QTc interval and especially those on higher doses of methadone.
• Causes of QTc prolongation, other than methadone, should be considered and excluded, e.g. genetics, adverse drug effects (prescribed and non-prescribed), endocrine, metabolic.
• If the QTc interval is consistently prolonged on repeat ECGs, and reversible causes have been excluded, make referral to the Acute Addiction Liaison Team (see Appendix 1 for contact details) to discuss ongoing management.  

Blood Borne Virus (especially Hepatitis C and HIV)

• Offer Hepatitis C and HIV testing during admission (see the GGC BBV Testing, Diagnosis and Referral guidance).
• If a patient tests positive for Hepatitis C, refer to the treatment team specific to your hospital.
• The Failsafe Support Service will be notified of new HIV infections by the virology services and will link in with the testing clinical team. 

General management

• Flowchart Management of opiate misusers in hospital

Please note: If you are using multiple guidelines in the management of your patient, and prescribing from more than one guideline with similar medicines (e.g. centrally-acting medicines like benzodiazepines and haloperidol), ensure this is discussed with a senior or specialist as appropriate. This is to avoid the potentially additive effects of these medicines that may adversely affect the patient.

Opiate withdrawal can be distressing and can be a contributing factor to patients self-discharging from hospital against advice to remain. For the emergency management of opiate withdrawal symptoms, refer to Appendix 2.

Only prescribe OST when a full assessment, examination and investigations have been completed (see pathway). Refer to the Acute Addiction Liaison team (see Appendix 1 for contact details) as soon as possible.

The following OST are prescribed in NHSGGC:

• Methadone – usually 1mg/1ml oral solution
• Buprenorphine – oromucosal, Espranor^® tablet
• Buvidal^® – long-acting buprenorphine injection.

Commencing or re-initiating OST should always be undertaken with caution and support from the Acute Addiction Liaison Team.

Crisis management prescribing for opiate misusers

See the pathway for more detail.

• Dihydrocodeine oral up to 60mg four times daily (unlicensed use). Please discuss with acute addiction liaison nurses (see Appendix 1 for contact details).
• Dihydrocodeine can be given for the first 24-48 hours if OST is either inappropriate or there is a delay in initiating OST because:
  • Awaiting further assessment
  • Awaiting OST dose confirmation
  • It is a short-term admission
• In pregnancy avoid using dihydrocodeine. Seek urgent advice from local senior addiction medical staff, consultant obstetrician responsible for the woman’s antenatal care or maternity specialists (Blossom team, see the full GGC guideline, page 14, for contact details).
• Do not supply dihydrocodeine on discharge.

Take home naloxone guideline

See the GGC guideline, Take Home Naloxone in acute setting to individuals at risk of future opiate overdose.

Enhanced Drug Treatment Services (EDTS)

There are patients within NHSGGC receiving injectable diamorphine treatment and OST which is prescribed and dispensed within the EDTS premises. Contact EDTS (see Appendix 1) to confirm doses and for management advice whilst patient remains in hospital. In the out-of-hours period, patient’s withdrawal symptoms should be managed using the emergency guidelines, see Appendix 2.

Important note: under no circumstances should injectable diamorphine be continued in hospital as an OST. Opiates may still be given, however, for appropriate medical reasons.

Methadone

• Methadone taken regularly has a long half-life (14 to 72 hours - mean about 24 hours).
• It may be lethal in overdose or when given to patients who have lost their tolerance to opioids, or opioid naive patients.
• Caution should be exercised when commencing or re-introducing methadone. This should be done with the support of the Acute Addiction Liaison Team.
• If eGFR <10ml/minute/1.73m², reduce the dose by 50% and titrate according to response. 

Buprenorphine (Espranor^® tablets)

Caution should be exercised when commencing or re-introducing buprenorphine. This should be done with the support of the Acute Addiction Liaison Team (see Appendix 1). For further guidance see the full GGC guideline.

Buvidal^® (long-acting buprenorphine injection)

• Buvidal^® is a long-acting injectable formulation of buprenorphine which is available in either weekly or monthly depot-type preparations.
• If a patient who is currently maintained on Buvidal^® is admitted to an inpatient hospital site, it is important to ensure continuity of their treatment and care. Liaise with the Acute Addiction Liaison and ADRS teams (see Appendix 1)
• Alerts are placed on Clinical Portal by the ADRS team to advise that a patient is prescribed Buvidal^®.

Discharge Planning

• The Acute Addiction Liaison Team (see Appendix 1) will provide input and support to ensure a safe and robust discharge plan is in place for all patient’s referred to the service.
• Ensure all OST prescriptions are in place prior to discharge. No patients on OST should be discharged from hospital without confirmation of continuation of treatment in the community.
• Consider increased risks at weekends / public holidays. Weekend / public holiday discharge should be avoided, if possible, unless agreed discharge plan is in place for continuation of OST.
• If a patient needs to be discharged on opiate analgesia, this should be at the lowest effective dosage. If necessary, GPs can facilitate daily pick up of analgesia with OST.
• Prior to discharge, inform the community pharmacy when the last dose of OST was given in hospital.
• Communicate and confirm discharge plan with patient.
• Ensure the immediate discharge letter (IDL) is completed and authorised.

Benzodiazepine / hypnotic withdrawal

• Benzodiazepine withdrawal can cause potentially life-threatening seizures with other acute symptoms including: anxiety, tremor, insomnia, nausea and vomiting.
• Many patients attending community ADRS services are prescribed benzodiazepines as a maintenance prescription.
• Long-term benzodiazepine prescriptions should not be abruptly stopped.
• Street bought benzodiazepines are of varying strength and patients should be treated based on symptoms. This may require the prescribing of benzodiazepines.
• Refer to the benzodiazepine management pathway and contact the Acute Addiction Liaison Team (see Appendix 1) to discuss appropriate treatment options.
• If urgent advice is required outside normal office hours (Monday to Friday, 9am – 5pm) the ADRS Crisis Outreach Service (Glasgow City) can be contacted where there is a requirement to confirm OST, or if a patient is being discharged over a weekend or public holiday. See Appendix 1 for contact details.
• If the patient develops mental health symptoms, an additional referral to the Acute Mental Health Liaison Service (link active if connected to NHSGGC network) may be appropriate.

Guideline reviewed: May 2026

Page updated: July 2026