Presentation from Dr Adam Winstock Consultant Psychiatrist and Addiction Specialist

1. Can you start people on OST without
a UDS positive for morphine?
Professor Adam R Winstock
Consulatnat Psychiatrist and Addiction Medicien Specilast

2. Currently to start someone you don’t know
on OST you need
• Assessment – history of use and physical examination – looking for IV
sites bit also to corroborate signs of either opioid intoxication of
withdrawal e.g. pupil size, droopy eyelids, sedation , sweatiness,
goose flesh , IV sites
• Usually you want a UDS positive for morphine or possibility
methadone or buprenorphine – from diverted street sources
• NOTE a positive UDS is not enough in isolation to determine whether
OST is appropriate
• Before starting someone of OST you are not only seeking to
dependence but also tolerance

3. The biggest risk starting someone on OST
• Is killing someone who is not tolerant to methadone – through too
rapid an induction – without daily monitoring
• For buprenorphine this is not a risk – the risk to avoid precipitated
withdrawal
• Basically a skilled / experience clinician can assess and diagnoses
opioid dependence with a level of confine that would leave mots
prescribers considered that they can prescribe buprenorphine .
• Methadone induction would be more risky in the absence of positive
UDS ….may be difficult to get prescribers to do this (first do no harm)

4. Low threshold approaches in CV19 times
would be
• Telehealth assessments
• Expanding assessment times
• Pref have someone who could look at patient physically if telehealth
• Preference for buprenorphine – s/l unsupervised or depot preparations
• Offer buprenorphine in preference to methadone because of OD risk during induction and
with diverted doses among those without tolerance
• Depot buprenorphine ideally suited to homeless population
• 1-4 weeks cover depending on dose and preparation
• Depot buprenorphine is highly acceptable
• Easy to offer on the street
• Methadone – even unsupervised may require more time to stabilise and concerns over large
volumes in circulation among those with no stable accommodation / place to store it