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Misuse of drugs and other substances

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1 Misuse of drugs and other substances
Implementing NICE guidance ABOUT THIS PRESENTATION: This presentation has been written to raise awareness of the NICE public health intervention guidance on substance misuse (PHI4) and two NICE clinical guidelines on drug misuse: psychosocial interventions (CG51) and opioid detoxification (CG52). This guidance has been written for the following audiences: Public health guidance – NHS and non-NHS practitioners and others who have a direct or indirect role in – and responsibility for – reducing substance misuse. Clinical guidelines – healthcare professionals and other staff who care for people who misuse drugs. Two NICE technology appraisals on drug misuse - methadone and buprenorphine (TA114) and naltrexone (TA115) for the management of opioid dependence - are also mentioned in the presentation. You may want to hand out copies of the quick reference guides at your presentation so that your audience can refer to them. The quick reference guides can be downloaded from: Clinical guidelines – and (this is a joint quick reference guide covering both guidelines) Public Health – or you can order printed copies – for more details, please see the notes of the ‘Access online’ slides at the end of the presentation. You can add your own organisation’s logo alongside the NICE and National Treatment Agency (NTA) logos. We have included notes for presenters amplifying the content of the slides: please feel free to adapt, amend or remove these as you see necessary. Where a slide refers to a particular piece of NICE guidance the reference number is included in the bottom right hand corner. The implementation tools symbol found on some slides in this presentation is used to clearly distinguish advice on implementing the recommendations of the guidance from the recommendations themselves. Slides with the tools symbol highlight suggested actions that may be useful when implementing recommendations. DISCLAIMER This slide set is an implementation tool and should be used alongside the published guidance. This information does not supersede or replace the guidance itself. 2007 NICE public health intervention guidance 4 Clinical guidelines 51 and 52

2 Joint working by NICE and the NTA
NICE has produced a suite of guidance on the misuse of drugs and other substances NICE and the NTA are working closely together to support the implementation of this guidance NOTES FOR PRESENTERS: The National Institute for Health and Clinical Excellence (NICE) is the independent organisation responsible for providing national guidance on promoting good health and preventing and treating ill health. NICE has produced a suite of guidance on the misuse of drugs and other substances. The National Treatment Agency for Substance Misuse (NTA) is a Special Health Authority which was created in The aim of the NTA is to ensure that there is more drug treatment, better treatment and fairer treatment available to all those who need it. This is the first time an organisation has been established to oversee the development of drug treatment services at a national level. Parallel structures have been established with the Welsh and Northern Ireland Assemblies. NICE and the NTA are working closely together to support the implementation of NICE guidance on substance misuse by delivering a range of resources and activities to support implementation. Details of these will be provided later in this presentation. The NTA has supported the development of the publication ‘Drug Misuse and Dependence - Guidelines on Clinical Management’ , also known as the ‘Orange book’, which is currently being updated and is due for publication in late This is aimed at clinicians who provide treatment to people who misuse drugs. It gives details of UK guidelines developed by an independent working group and is published by the Department of Health; it incorporates NICE guidance.

3 Changing practice NICE guidance is based on the best available evidence The Department of Health asks NHS organisations to work towards implementing NICE guidance Compliance with core and developmental standards will be monitored by the Healthcare Commission Service Improvement reviews NICE public health guidance and clinical guidelines aim to ensure that the promotion of good health and patient care are in line with the best available evidence of effectiveness and cost effectiveness. The guidance helps healthcare professionals and other staff in their work, but it does not replace their knowledge and skills. The Healthcare Commission assesses the performance of NHS organisations in meeting core and developmental standards set by the Department of Health in ‘Standards for better health’ issued in July 2004 and updated in April The implementation of NICE clinical guidelines forms part of the developmental standard D2. Core standard C5 states that nationally agreed guidance should be taken into account when NHS organisations are planning and delivering care. Core standard C5 states that healthcare organisations should ensure they conform to NICE technology appraisals. NICE public health guidance aims to ensure that promotion of good health and patient care in the NHS are in line with the best available evidence. Public health guidance helps healthcare professionals in their work, but it does not replace their knowledge and skills. NHS organisations meet DH standards for public health as set out in the seventh domain of ‘Standards for better health’ (updated in 2006). These include core standards C22 and C23 and developmental standard D13. Performance against these standards is assessed by the Healthcare Commission. The National Treatment Agency for Substance Misuse (NTA) and the Healthcare Commission agreed to work jointly in setting up a review process for substance misuse services. An improvement review is a review of a particular aspect of healthcare that is applied in every relevant organisation. Its aim is to encourage each organisation taking part to improve the quality of healthcare it provides to patients and the public. Each organisation taking part is given an assessment score that contributes to the Healthcare Commission’s overall summary of performance.

4 What this presentation covers
The suite of NICE guidance on the misuse of drugs and other substances Background Principles of person centred care/supporting families and carers Key recommendations Costs and savings Implementation support from NICE and the NTA NOTES FOR PRESENTERS: This presentation relates to a suite of guidance from NICE on the misuse of drugs and other substances – public health intervention guidance, clinical guidelines and technology appraisal guidance. It covers background, key recommendations, cost and savings that are likely to be incurred as a result of implementing the guidance, and implementation support that is available from NICE working jointly with the NTA.

5 Guidance this presentation covers
NICE public health intervention guidance: ‘Interventions to reduce substance misuse among vulnerable young people’ (PHI4) NICE clinical guideline: ‘Drug misuse: psychosocial interventions’ (CG51) NICE clinical guideline: ‘Drug misuse: opioid detoxification’ (CG52) NICE technology appraisals on methadone and buprenorphine (TA114) and naltrexone (TA115) for the management of opioid dependence Note that the two technology appraisals are mentioned briefly during the presentation to raise awareness of the existence of this related guidance. The Department of Health publication ‘Drug Misuse and Dependence – guidelines for clinical management’ (often called the ‘Orange book’) is currently being updated by an independent working group supported by the NTA. It is the main clinical manual used by clinicians and incorporates all of the above NICE clinical guidance. It is due for publication in late 2007. We also refer to ‘Drug misuse and dependence – guidelines for clinical management: update 2007’ (the ‘Orange book’), as it incorporates NICE guidance

6 Background: why this guidance matters
Recent estimates indicate that there are around 327,000 people who misuse opioids and/or crack cocaine in the UK, with 280,000 of these misusing opioids People who misuse drugs may present with a range of health and social problems Drug misuse has a negative impact on physical/mental health and/or social functioning NOTES FOR PRESENTERS: A study published in 2006 by Hay and co-workers as part of Home Office online report 16/06 ‘Measuring different aspects of problem drug use’ estimated that around 327,000 people in the UK can be defined as ‘problem’ drug users (that is, they misuse opioids and/or crack cocaine). Of these, 280,000 misuse opioids. Drug misuse has a negative impact on health and/or social functioning, and may take the form of drug dependence, or be part of a wider spectrum of problematic or harmful behaviour People who misuse drugs can also present with a range of health and social problems other than dependence, which may include the following (particularly for opioid users): • physical health problems (for example, thrombosis, abscesses, overdose, hepatitis B and C, HIV, and respiratory and cardiac problems) • mental health problems (for example, depression, anxiety, paranoia, and suicidal thoughts). NICE has published guidance on a variety of mental health topics; these are listed in the ‘Further information’ section of the drug misuse quick reference guide. • social difficulties (for example, relationship problems, financial difficulties, unemployment and homelessness) • criminal justice problems.

7 Principles: Person-centred care
People who misuse drugs should be given the same care, respect and privacy as any other person. Treatment and care, and the information service users are given about it, should be culturally appropriate. It should also be accessible to people with additional needs, such as physical, sensory or learning disabilities, and to people who do not speak or read English. NOTES FOR PRESENTERS: These notes are taken from the clinical guidelines on drugs misuse but are relevant to the public health guidance when providing person centred care. Treatment and care should take into account service users’ needs and preferences. If service users do not have the capacity to make decisions, healthcare professionals should follow the Department of Health guidelines – ‘Reference guide to consent for examination or treatment’ (2001) (available from Since April 2007 healthcare professionals need to follow a code of practice accompanying the Mental Capacity Act (summary available from Good communication between staff and service users is essential. It should be supported by evidence-based written information tailored to the service user’s needs. Treatment and care, and the information service users are given about it, should be culturally appropriate. It should also be accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English.

8 Principles: Supporting families and carers
If the service user agrees, involve families and carers in decisions about treatment and care Offer family members and carers an assessment of their personal, social and mental health needs Provide information about : – impact of drug misuse on service users, families and carers – self-help and support groups for families and carers NOTES FOR PRESENTERS: It is very important to support the families and carers of people who misuse drugs and other substances. The recommendations in the clinical guidelines on drug misuse are summarised on this slide. For more information, please see the quick reference guide and ‘Understanding NICE guidance’, a version of the guidelines for people who misuse drugs, their families and carers and the public. If the service user agrees, involve families and carers in decisions about treatment and care. Discuss with families and carers the impact of drug misuse on themselves and other family members, including children. – Offer an assessment of their personal, social and mental health needs. – Give advice and written information on the impact of drug misuse. Where the needs of families and carers have been identified: – offer guided self-help (usually a single session with written material provided) – inform them about support groups – for example, self-help groups specifically for families and carers and facilitate contact. If families and carers continue to have significant problems, consider offering individual family meetings (normally at least 5 weekly sessions). These should: – provide information and education about drug misuse – help to identify sources of stress related to drug misuse – promote effective coping behaviours. The public health intervention guidance on substance misuse also includes recommendations on supporting the parents and carers of children and young people who are assessed to be at high risk of substance misuse, such as offering family-based programmes of structured support and group-based training in parental skills. These points are covered in more detail later in the presentation.

9 Public health guidance
Community-based interventions to reduce substance misuse among vulnerable and disadvantaged children and young people NOTES FOR PRESENTERS: ‘Every child matters’ and related documents state that all professionals working with children and young people should be trained to identify, assess and respond to those with drug use problems. They also state that PCTs, local authorities and drug (and alcohol) action teams (DA[A]Ts) should work together to identify vulnerable children and young people through the common assessment framework (CAF). NICE public health intervention guidance 4 March 2007 PHI4

10 Definition: ‘substance misuse’
Intoxication by – or regular excessive consumption of and/or dependence on – psychoactive substances, leading to social, psychological, physical or legal problems It includes problematic use of both legal and illegal drugs (including alcohol when used in combination with other substances) NOTES FOR PRESENTERS: This definition of substance misuse is taken from the NICE guidance. Substance misuse is defined as intoxication by – or regular excessive consumption of and/or dependence on – psychoactive substances, leading to social, psychological, physical or legal problems. It includes problematic use of both legal and illegal drugs (including alcohol when used in combination with other substances). PHI4

11 Definition: ‘vulnerable and disadvantaged’
Children and young people aged under 25 and at risk of misusing substances; among the most vulnerable are: those whose family members misuse substances those excluded from school, and truants young offenders those involved in commercial sex work NOTES FOR PRESENTERS: This definition of vulnerable and disadvantaged is taken from the NICE guidance. Vulnerable and disadvantaged children and young people aged under 25 who are at risk of misusing substances include: • those whose family members misuse substances • those with behavioural, mental health or social problems • those excluded from school, and truants • young offenders • looked after children • those who are homeless • those involved in commercial sex work • those from some black and minority ethnic groups Consistency of NICE guidance and ‘Drug Misuse and Dependence – guidelines for clinical management’ (the ‘Orange book’) Overall, there is consistency in references to young people, approaches and interventions. One difference, however, is the age cut-off adopted for ‘children and young people’ by the NICE public health guidance, which is 25 years (as opposed to 18 years used in the Orange book). NICE used the cut-off of 25 years as this was consistent with the government’s Public Service Agreement (PSA) targets to reduce illicit drug use in children and young people under 25.  Age 18 is used in the Orange book’, which is adopted by the Department of Health and legal framework. PHI4

12 Key recommendations: children and young people
Develop a strategy Identify those at risk Provide community-based interventions NOTES FOR PRESENTERS: This NICE public health intervention guidance on substance misuse contains lots of recommendations about how care can be improved, but the experts who wrote the guidance have chosen key recommendations that they think will have most impact on care and are the most important priorities for implementation. The key recommendations fall into the three areas listed in the slide, and you can find them in your quick reference guide. We shall consider each in turn. Public health practitioners share the same need as clinical audiences for evidence-based, cost-effective solutions to: meet the challenges in their practice, and inform policies and strategies to improve health. Community-based interventions are defined as interventions or small-scale programmes delivered in community settings, such as schools and youth services. They aim to change the risks factors for the target population. There is more information on the treatment of drug misuse within the criminal justice system later in the presentation. PHI4

13 Develop a strategy Develop and implement a strategy to reduce substance misuse among the target population, as part of a local area agreement Target population Who should take action? Any child or young person under 25 who is vulnerable and disadvantaged Local strategic partnerships NOTES FOR PRESENTERS: What action should they take? Develop and implement a strategy to reduce substance misuse among vulnerable and disadvantaged people under 25, as part of a local area agreement. This strategy should be: based on a local profile of the target population developed in conjunction with the regional public health observatory. The profile should include their age, factors that make them vulnerable and other locally agreed characteristics supported by a local service model that defines the role of local agencies and practitioners, the referral criteria and referral pathways. PHI4

14 Any child or young person under 25 who is vulnerable and disadvantaged
Identify those at risk Use existing screening and assessment tools to identify the target population who are misusing – or who are at risk of misusing – substances Work with parents or carers, and other relevant professionals Target population Who should take action NOTES FOR PRESENTERS: Who should take action? Practitioners and others who work with vulnerable and disadvantaged children and young people in the NHS, local authorities and the education, voluntary, community, social care, youth and criminal justice sectors. In schools, this includes teachers, support staff, school nurses and governors. What action should they take? Use existing screening and assessment tools to identify vulnerable and disadvantaged children and young people under 25 who are misusing – or who are at risk of misusing – substances. These tools include the Common Assessment Framework and those available from the NTA. Work with parents or carers, education welfare services, children’s trusts, child and adolescent mental health services, school drug advisers or other specialists to: provide support (schools may provide direct support) refer the children and young people, as appropriate, to other services (such as social care, housing or employment), based on a mutually agreed plan. The plan should take account of the child or young person’s needs and include review arrangements. Any child or young person under 25 who is vulnerable and disadvantaged All who work with vulnerable and disadvantaged children and young people PHI4

15 Interventions: family support
Offer a family-based programme of structured support over 2 or more years, drawn up with the parents or carers and led by staff competent in this area Offer more intensive support to families who need it Target population Who should take action? Any child or young person aged 11–16 assessed to be at high risk of substance misuse Their parents or carers All who work with vulnerable and disadvantaged children and young people NOTES FOR PRESENTERS: Who should take action? Practitioners and others who work with vulnerable and disadvantaged children and young people in the NHS, local authorities and the education, voluntary, community, social care, youth and criminal justice sectors. In schools, this includes teachers, support staff, school nurses and governors. What action should they take? Offer a family-based programme of structured support over 2 or more years, drawn up with the parents or carers of the child or young person and led by staff competent in this area. The programme should: include at least 3 brief motivational interviews each year aimed at the parents/carers (motivational interviewing is described in more detail in slide 16) assess family interaction offer parental skills training encourage parents to monitor their children’s behaviour and academic performance include feedback continue even if the child or young person moves schools. Offer more intensive support (for example, family therapy) to families who need it. For more information on supporting families and carers, see slide 7 Implementation advice In terms of implementing this recommendation, the process could benefit from utilising existing children's services care coordinator roles or frameworks as part of the strategy developed (see slide 12). PHI4

16 Interventions: behavioural therapy
Offer the children group-based behavioural therapy over 1–2 years, before and during the transition to secondary school Offer the parents or carers group-based training in parental skills Target population Who should take action? Children aged 10–12 who are persistently aggressive or disruptive and assessed to be at high risk of substance misuse Their parents or carers Practitioners trained in group-based behavioural therapy NOTES FOR PRESENTERS: Who should take action? Practitioners trained in group-based behavioural therapy. What action should they take? Offer the children group-based behavioural therapy over 1 to 2 years, before and during the transition to secondary school. Sessions should take place once or twice a month and last about an hour. Each session should: focus on coping mechanisms such as distraction and relaxation techniques help develop the child’s organisational, study and problem-solving skills involve goal setting. Offer the parents or carers group-based training in parental skills. This should take place on a monthly basis, over the same time period (as described above for the children). The sessions should: focus on stress management, communication skills and how to help develop the child’s social-cognitive and problem-solving skills advise on how to set targets for behaviour and establish age-related rules and expectations for their children. PHI4

17 Interventions: motivational interviews
Offer one or more motivational interviews according to the young person’s needs. Each session should last about an hour. Target population Who should take action? NOTES FOR PRESENTERS: The target population – Vulnerable and disadvantaged children and young people aged under 25 who are problematic substance misusers, including those attending secondary schools or further education colleges Who should take action? Practitioners trained in motivational interviewing. Motivational interviewing is a brief psychotherapeutic intervention. For people who misuse substances, the aim is to help individuals reflect on their substance use in the context of their own values and goals and motivate them to change (adapted from the description by McCambridge and Strang in their 2004 ‘Addiction’ paper on the efficacy of single-session motivational interviewing in reducing drug consumption). What action should they take? Offer one or more motivational interviews according to the young person’s needs. Each session should last about an hour and the interviewer should encourage them to: discuss their use of both legal and illegal substances reflect on any physical, psychological, social, education and legal issues related to their substance misuse set goals to reduce or stop misusing substances. Note that the motivational interviews outlined in this public health intervention guidance are the same as the brief interventions focused on motivation outlined in the psychosocial interventions clinical guideline. Please see both pieces of guidance for more information. Reference McCambridge J, Strang J (2004) The efficacy of single-session motivational interviewing in reducing drug consumption and perceptions of drug-related risk and harm among young people: results from a multi-site cluster randomized trial. Addiction 99 (1): 39–52. Vulnerable and disadvantaged children and young people aged under 25 who are problematic substance misusers Practitioners trained in motivational interviewing PHI4

18 Clinical guidelines Drug misuse: psychosocial interventions (CG51)
Drug misuse: opioid detoxification (CG52) NICE clinical guidelines 51 and 52 July 2007 CG51 & 52

19 Clinical guidelines Identifying people who misuse drugs Assessment
Organising and developing care Identifying people who misuse drugs Assessment Key recommendations NOTES FOR PRESENTERS: These are key areas to consider when implementing the NICE clinical guidelines on Drug misuse: psychosocial interventions’ (CG51) and opioid detoxification (CG52). CG51 & 52

20 Organising and developing care
At initial contact/formal reviews, explain options for abstinence-oriented, maintenance-oriented and harm- reduction interventions Discuss with people who misuse drugs whether to involve families and carers in their assessment and treatment plans Ensure that there are clear plans to facilitate effective transfer of people who misuse drugs between services, to reduce loss of contact PRESENTER NOTES: At initial contact and at formal reviews, explain options for abstinence-oriented, maintenance oriented and harm-reduction interventions. Discuss with people who misuse drugs whether to involve families and carers in their assessment and treatment plans. Respect the service user's right to confidentiality. Ensure that there are clear and agreed plans to facilitate effective transfer of people who misuse drugs between services, to reduce loss of contact. All interventions for people who misuse drugs should be delivered by staff competent in delivering the intervention and who receive appropriate supervision. CG51 & 52

21 Identifying people who misuse drugs
In mental health and criminal justice settings, routinely ask service users about recent legal and illicit drug use: type, method of administration, quantity and frequency In settings such as primary care, general hospitals and emergency departments, consider asking people about recent drug use if they have symptoms that suggest the possibility of drug misuse PRESENTER NOTES In mental health and criminal justice settings (in which drug misuse is known to be prevalent), routinely ask service users about recent legal and illicit drug use, including type, method of administration, quantity and frequency. In settings such as primary care, general hospitals and emergency departments, consider asking people about recent drug use if they have symptoms that suggest the possibility of drug misuse, such as acute chest pain in a young person, acute psychosis, or mood and sleep disorders. CG51 & 52

22 Initial assessment When making the assessment and developing and agreeing a care plan, consider the service user’s needs, drug use and treatment history, goals and preferences Agree the care plan with the service user Use biological testing as part of a comprehensive assessment of drug use When making an assessment and developing and agreeing a care plan, consider the service user’s: medical, psychological, social and occupational needs history of drug use experience of previous treatment (if any) goals in relation to his or her drug use treatment preferences. When delivering and monitoring the care plan: agree the plan with the service user maintain a respectful and supportive relationship with the service user help the service user to: identify when he or she is vulnerable to drug misuse, and explore alternative coping strategies ensure that all service users have full access to a wide range of services remember the importance of maintaining the service user’s engagement with services review regularly the care plan of a service user receiving maintenance treatment to ascertain whether detoxification should be considered collaborate with other care providers. Use biological testing (for example, of urine or oral fluid) as part of a comprehensive assessment of drug use, but do not rely on it as the sole method of diagnosis and assessment. CG51 & 52

23 Assessment for opioid detoxification
Assess people presenting for opioid detoxification to establish the presence and severity of opioid dependence and use of other substances If opioid dependence or tolerance is uncertain, normally use confirmatory laboratory tests in addition to near- patient testing Near-patient and confirmatory testing should be conducted by appropriately trained healthcare professionals Assess people presenting for opioid detoxification to establish the presence and severity of opioid dependence and use of other substances, including stimulants, alcohol and benzodiazepines. Use urinalysis; other near-patient testing methods such as oral fluid or breath testing may also be considered. Clinically assess any signs of opioid withdrawal (consider formal rating scales only as an adjunct). Take a history of drug and alcohol misuse and any treatment. Take a history of physical and mental health problems and any treatment. Consider risks of self-harm, loss of opioid tolerance and the misuse of drugs or alcohol as a response to opioid withdrawal symptoms. Consider the person’s social and personal circumstances. Consider the impact of drug misuse on family members and any dependants. Develop strategies to reduce the risk of relapse, taking into account the person’s support network If opioid dependence or tolerance is uncertain, normally use confirmatory laboratory tests in addition to near-patient testing, particularly when: a young person first presents for detoxification a near-patient test result is inconsistent with clinical assessment complex patterns of drug misuse are suspected. Near-patient and confirmatory testing should be conducted by appropriately trained healthcare professionals in accordance with standard operating and safety procedures. CG52

24 Key recommendations Drug misuse: psychosocial interventions
Brief interventions Self-help Contingency management NOTES FOR PRESENTERS: As for the public health guidance, the key recommendations for clinical guidelines are those that are likely to have most impact on care and are the most important priorities for implementation. The key recommendations in the psychosocial interventions for drug misuse guideline fall into the three areas listed in the slide, and you can find them at the front of your quick reference guide. We shall consider each in turn. Introduction of programmes of contingency management, a formal psychosocial intervention, is a key recommendation. Other psychosocial interventions discussed in the guidance are behavioural couples therapy, cognitive behavioural therapy and psychodynamic therapy. CG51

25 Brief interventions Opportunistic brief interventions focused on motivation should be offered to people in limited contact with drug services if concerns about drug misuse are identified These interventions should: normally consist of 2 sessions each lasting 10–45 minutes explore ambivalence about drug use and possible treatment NOTES FOR PRESENTERS: Opportunistic brief interventions focused on motivation should be offered to people in limited contact with drug services (for example, those attending a needle and syringe exchange or primary care settings) if concerns about drug misuse are identified by the service user or staff member. These interventions should: normally consist of two sessions each lasting 10–45 minutes explore ambivalence about drug use and possible treatment, with the aim of increasing motivation to change behaviour, and provide non-judgemental feedback. See the quick reference guide for more information about brief interventions – for example, providing information about reducing exposure to blood-borne viruses. Note that the brief interventions focused on motivation outlined in this clinical guideline are the same as the motivational interviews outlined in the public health guidance. CG51

26 Self-help Staff should routinely provide people who misuse drugs with information about self-help groups These groups should normally be based on 12-step principles; for example: Narcotics Anonymous Cocaine Anonymous NOTES FOR PRESENTERS: Staff should routinely provide people who misuse drugs with information about self-help groups. These groups should normally be based on 12-step principles; examples include Narcotics Anonymous and Cocaine Anonymous CG51

27 Contingency management
Drug services should introduce contingency management programmes as part of the phased implementation programme led by the NTA Aim: to reduce illicit drug use and/or promote engagement with services for people receiving methadone maintenance treatment harm reduction for people at risk of physical health problems resulting from their drug misuse NOTES FOR PRESENTERS: Introducing contingency management Drug services should introduce contingency management programmes as part of the phased implementation programme led by the National Treatment Agency (www.nta.nhs.uk) to reduce illicit drug use and/or promote engagement with services for people receiving methadone maintenance treatment. Principles of contingency management Contingency management aimed at reducing illicit drug use for people receiving methadone maintenance treatment or who primarily misuse stimulants should be based on the following principles: The programme should offer incentives (usually vouchers that can be exchanged for goods or services of the service user’s choice, or privileges such as take-home methadone doses) contingent on each presentation of a drug-negative test (for example, free from cocaine or non-prescribed opioids). The frequency of screening should be set at three tests per week for the first 3 weeks, two tests per week for the next 3 weeks and one per week thereafter until stability is achieved. If vouchers are used, they should have monetary values that start in the region of £2 and increase with each additional, continuous period of abstinence. Urinalysis should be the preferred method of testing but oral fluid tests may be considered as an alternative. Contingency management to improve physical healthcare For people at risk of physical health problems (including transmittable diseases) resulting from their drug misuse, material incentives (for example, shopping vouchers of up to £10 in value) should be considered to encourage harm reduction. Incentives should be offered on a one-off basis or over a limited duration, contingent on concordance with or completion of each intervention, in particular for: hepatitis B/C and HIV testing, hepatitis B immunisation, tuberculosis testing. Implementing contingency management Drug services should ensure that, as part of the introduction of contingency management, staff are trained and competent in appropriate near-patient testing methods and in the delivery of contingency management. Contingency management should be introduced to drug services in the phased implementation programme led by the NTA, in which staff training and the development of service delivery systems are carefully evaluated. The outcome of this evaluation should be used to inform the full-scale implementation of contingency management to inform how contingency management can best be rolled out in the UK. For more information, see CG51

28 Key recommendations Drug misuse: opioid detoxification
Provide information, advice and support The choice of medication for detoxification Do not offer ultra-rapid detoxification Care settings for detoxification Types setting Choice of setting Criminal justice system NOTES FOR PRESENTERS: The key recommendations (that is, the priorities for implementation) for the opioid detoxification guideline fall into the four areas listed on the slide, and you can find them at the front of your quick reference guide. We shall consider each in turn. CG52

29 Provide information, advice and support
Detoxification should be a readily available treatment option for people who are opioid dependent and have expressed an informed choice to become abstinent In order to obtain informed consent, staff should give detailed information to service users about detoxification and the associated risks NOTES FOR PRESENTERS: Key recommendations: provide information, advice and support Detoxification should be a readily available treatment option for people who are opioid dependent and have expressed an informed choice to become abstinent. In order to obtain informed consent, staff should give detailed information to service users about detoxification and the associated risks, including: the physical and psychological aspects of opioid withdrawal, including the duration and intensity of symptoms and how these may be managed the use of non-pharmacological approaches to manage or cope with opioid withdrawal symptoms the loss of opioid tolerance following detoxification, and the ensuing increased risk of overdose and death from illicit drug use, which may be potentiated by the use of alcohol or benzodiazepines the importance of continued support, as well as psychosocial and appropriate pharmacological interventions, to maintain abstinence, treat comorbid mental health problems and reduce the risk of adverse outcomes (including death). Other related recommendations from the NICE opioid detoxification guideline Advise service users on aspects of lifestyle that need attention during detoxification, including diet, hydration, sleep and exercise. Encourage people considering self-detoxification to seek detoxification in a structured treatment programme or, at a minimum, to maintain contact with a drug service. Provide information about self-help (such as 12-step) and support groups (such as the Alliance) and consider facilitating engagement. Provide families and carers with information about detoxification and the settings in which it may take place. NB. Good communication between staff and service users is essential. It should be supported by evidence-based written information tailored to the service user’s needs CG52

30 The choice of medication for detoxification
Methadone or buprenorphine should be offered as the first-line treatment in opioid detoxification When deciding between these medications, healthcare professionals should take into account: current maintenance treatment with methadone or buprenorphine the preference of the service user NICE has produced two technology appraisals on: methadone and buprenorphine (TA114) naltrexone (TA115) NOTES FOR PRESENTERS: Key recommendation: the choice of medication for detoxification Methadone or buprenorphine should be offered as the first-line treatment in opioid detoxification. When deciding between these medications, healthcare professionals should take into account: whether the service user is receiving maintenance treatment with methadone or buprenorphine; if so, opioid detoxification should normally be started with the same medication the preference of the service user NICE has produced two technology appraisals on methadone and buprenorphine (TA114) and naltrexone (TA115) for the management of opioid dependence. More information is given about these later in the presentation. Additional supporting information on adjunctive medications When prescribing adjunctive medications during opioid detoxification, healthcare professionals should: only use them when clinically indicated, such as when agitation, nausea, insomnia, pain and/or diarrhoea are present use the minimum effective dosage and number of drugs needed to manage symptoms be alert to the risks of adjunctive medications, as well as interactions between them and with the opioid agonist. CG52

31 Do not offer ultra-rapid detoxification
Ultra-rapid detoxification under general anaesthesia or heavy sedation (where the airway needs to be supported) must not be offered This is because of the risk of serious adverse events, including death NOTES FOR PRESENTERS: Key recommendation: Do not offer ultra-rapid detoxification Ultra-rapid detoxification under general anaesthesia or heavy sedation (where the airway needs to be supported) must not be offered. This is because of the risk of serious adverse events, including death. See the NICE guideline for further information about ultra-rapid, rapid and accelerated detoxification (www.nice.org/CG052). CG52

32 Settings of care Community Residential Inpatient
Criminal justice system PRESENTER NOTES (This is not a key recommendation) Both drug misuse guidelines contain a number of additional recommendations relating to settings of care - please refer to the quick reference guide for more details. The same range of psychosocial interventions should be available in inpatient and residential settings as in the community. Residential psychosocial treatment should be considered for people who are seeking abstinence and who have significant comorbid physical, mental health or social problems. The person should have completed a residential or inpatient detoxification programme and have not benefited from previous community-based psychosocial treatment. Residential opioid detoxification should normally be considered for people who: have significant comorbid physical or mental health problems, or require concurrent detoxification from opioids and benzodiazepines or sequential detoxification from opioids and alcohol, or have less severe opioid dependence – for example, those early in their drug-using career, or who would benefit significantly from residential rehabilitation during and after detoxification. Inpatient detoxification should normally be considered for people who need a high level medical and/or nursing support for: significant and severe comorbid physical or mental health problems or concurrent detoxification from alcohol or other drugs. Inpatient and residential detoxification should be conducted with 24-hour medical and nursing support commensurate with the service user’s drug misuse and comorbid physical and mental health problems. Pharmacological and psychosocial interventions should be available to support treatment. Urgently assess people who have relapsed to opioid use during or after inpatient or residential treatment. Consider prompt access to alternative community, residential or inpatient support, including maintenance treatment. CG51 & 52

33 The choice of setting for detoxification
Staff should routinely offer a community-based programme to all service users considering opioid detoxification Exceptions may include service users who: have not benefited from previous formal community-based detoxification need particular medical and/or nursing care require complex polydrug detoxification are experiencing significant social problems NOTES FOR PRESENTERS: Key recommendation: The choice of setting for detoxification Staff should routinely offer a community-based programme to all service users considering opioid detoxification. Exceptions to this may include service users who: have not benefited from previous formal community-based detoxification need medical and/or nursing care because of significant comorbid physical or mental health problems require complex polydrug detoxification – for example, concurrent detoxification from alcohol or benzodiazepines are experiencing significant social problems that will limit the benefit of community-based detoxification. A further recommendation in the guideline (not a key recommendation) states that community detoxification should normally include: prior stabilisation of opioid use through pharmacological treatment effective coordination of care by specialist or competent primary practitioners psychosocial interventions, where appropriate, during stabilisation and maintenance. CG52

34 Settings: criminal justice system
Access to and choice of treatment for drug misuse should be the same whether people participate voluntarily or are legally obliged to do so Prisons Treatment options, including detoxification, should be comparable to those in the community Consider offering access to a therapeutic community for treating drug misuse in prison Consider residential treatment for people who have decided to remain abstinent after release PRESENTER NOTES There are special considerations for the treatment of drug misuse within the criminal justice system. Access and choice of treatment for drug misuse should be the same whether people participate voluntarily or are legally obliged to do so. Treatment options, including detoxification, should be comparable to those in the community. The following should be taken into account: length of sentence or remand period, and possibility of unplanned release risks of self-harm, death or post-release overdose for people receiving opioid detoxification, practical difficulties in assessing dependence and the associated risk of opioid toxicity early in treatment. Consider offering people with significant drug misuse problems access to a therapeutic community developed specifically for treating drug misuse in prison. Consider residential treatment as part of an overall care plan for people who have made an informed decision to remain abstinent after release. CG51 & 52

35 NICE technology appraisals
Methadone and buprenorphine for the management of opioid dependence (TA114) Naltrexone for the management of opioid dependence (TA115) NOTES FOR PRESENTERS: Technology appraisals are recommendations on the use of new and existing medicines and treatments within the NHS in England and Wales, such as: medicines medical devices (for example, hearing aids or inhalers) diagnostic techniques (tests used to identify diseases) surgical procedures (for example, repairing hernias) health promotion activities (for example, ways of helping people with diabetes manage their condition). Both of these technology appraisals were published in January The Secretary of State has directed that the NHS provides funding and resources for medicines and treatments that have been recommended by NICE technology appraisals normally within 3 months from the date that NICE publishes the guidance. Core standard C5 states that healthcare organisations should ensure they conform to NICE technology appraisals. TA114 & 115

36 Methadone and buprenorphine
Are recommended as options for maintenance therapy in the management of opioid dependence The choice of drug should be made on a case by case basis - methadone should where possible be first choice Administration should be daily and under supervision for at least the first 3 months NOTES FOR PRSESNTERS: Methadone and buprenorphine (oral formulations), using flexible dosing regimens, are recommended as options for maintenance therapy in the management of opioid dependence. The decision about which drug to use should be made on a case by case basis, taking into account a number of factors, including the person’s history of opioid dependence, their commitment to a particular long-term management strategy, and an estimate of the risks and benefits of each treatment made by the responsible clinician in consultation with the person. If both drugs are equally suitable, methadone should be prescribed as the first choice. Methadone and buprenorphine should be administered daily, under supervision, for at least the first 3 months. Supervision should be relaxed only when the patient’s compliance is assured. Both drugs should be given as part of a programme of supportive care. TA114

37 Naltrexone Is recommended as a treatment option in detoxified formerly opioid-dependent people Should only be administered under adequate supervision and as part of a programme of supportive care The effectiveness of using naltrexone as a treatment should be reviewed regularly NOTES FOR PRESENTERS: Naltrexone is recommended as a treatment option in detoxified formerly opioid-dependent people who are highly motivated to remain in an abstinence programme. Naltrexone should only be administered under adequate supervision to people who have been fully informed of the potential adverse effects of treatment. It should be given as part of a programme of supportive care. The effectiveness of naltrexone in preventing opioid misuse in people being treated should be reviewed regularly. Discontinuation of naltrexone treatment should be considered if there is evidence of such misuse. TA115

38 Costs and savings per 100,000 population: public health guidance
Recommendations with significant resource impact Annual cost Motivational interviewing 2,683 Providing group-based behavioural therapy 1,800 Providing group-based training in parental skills 3,701 Providing family-based programme of structured support 15,274 Total cost impact 23,458 NOTES FOR PRESENTERS: The estimated national annual changes in costs and savings arising from implementing the public health intervention guidance on interventions to reduce substance misuse among vulnerable young people are summarised in this table. It is recognised that implementation of the recommendations may take place over a number of years. The costs for individual health communities may need to be investigated at a local level. Benefits and savings Implementing the public health intervention guidance could lead to a reduction in costs associated with substance misuse. In Home Office online report 16/06, published in 2006, Gordon and co-workers estimated that the cost of class A drug use in economic and social terms in England and Wales in 2003/04 was around £15.4 billion. The costs per year per problematic drug user incurred by the health sector, by social care and due to drug-related death and crime are estimated to be between £11,800 and £44,000. Reference Gordon L, Tinsley L, Godfrey C et al. (2006) The economic and social costs of class A drug use in England and Wales 2003/04. In Singleton N, Murray R, Tinsley L editors. Measuring different aspects of problem drug use: methodological developments. Home Office Online Report 16/06. Home Office: London. Local costing template The local costing template produced to support this guidance enables organisations in England, Wales and Northern Ireland to estimate the impact locally and replace variables with ones that depict the current local position. For further information, please refer to the costing template and costing report for this guidance on the NICE website – details are given later in this presentation.

39 Costs and savings per 100,000 population: clinical guidelines
Recommendations with significant resource impact Annual cost/saving £ Behavioural couples therapy (psychosocial) 3,588 Prison care: anxiety and depression (psychosocial) 2,208 Prison care: behavioural couples therapy (psychosocial) 1,104 Increased provision of inpatient detoxification 22,032 Estimated cost of implementation 28,392 Savings Savings attributable to healthcare 7,800 Potential societal savings (e.g. criminal justice) 70,000 NOTES FOR PRESENTERS: The estimated national annual changes in costs and savings arising from implementing these clinical guidelines on drug misuse are summarised in this table – the guideline from which recommendation is taken is indicated in parentheses. It is recognised that implementation of the recommendations may take place over a number of years. The costs for individual health communities may need to be investigated at a local level. Benefits and savings It can reasonably be expected that improved care for people who misuse drugs, specifically opioids, will be reflected in significant savings to the criminal justice system and the NHS. In the ‘NTORS after five years’ report, published in 2001, it was estimated that for every extra £1 spent on the treatment of drug misuse, there is a return of £3 in the cost savings associated with lower victim costs of crime and reduced demands on the criminal justice system. The total savings through implementing the guidelines attributable to healthcare have been estimated as being £4.1 million. An additional £37.2 million of savings (national savings) to society have been estimated, but it should be highlighted that the majority of these savings will be outside the NHS in the criminal justice system. Note that the recommendation on the implementation of contingency management in the psychosocial interventions guideline has not been included in the costing work, since this will be part of a phased implementation programme led by the NTA. The guidance recommends that a number of demonstration sites are initially established, and implementing the contingency management recommendations in between 4 and 6 sites is unlikely to have material resource implications. Local costing template The local costing template produced to support this guidance enables organisations in England, Wales and Northern Ireland to estimate the impact locally and replace variables with ones that depict the current local position. For further information, please refer to the costing template and costing report for these clinical guidelines on the NICE website.

40 Costs and savings per 100,000: technology appraisals
TA114 Methadone and buprenorphine for the management of opioid dependence. Estimated cost £13,600 TA115 Naltrexone for the management of opioid dependence. Not thought to have significant resource implications TA114 Methadone & Buprenorphine The estimated cost of implementing this appraisal depends on the current prescribing of methadone and buprenorphine and the potential increase in the number of people that will receive buprenorphine over methadone following implementation of this guidance. Changes in prescribing following implementation of this guidance have been estimated following discussions with key clinicians. Current prescribing for this group of patients has been estimated as being 83% methadone and 17% buprenorphine. In the national cost calculation it is estimated that following implementation 70% of people engaged with prescribing services will receive methadone and 30% buprenorphine, although it should be noted that estimates of the future buprenorphine share ranged from 20 – 40%. TA115 Naltrexone The guidance on naltrexone for the management of opioid dependence (NICE technology appraisal guidance 115) is unlikely to result in a significant change in resource use in the NHS. Naltrexone is not widely used in the NHS. It is estimated that between 1500 and 2000 people are prescribed naltrexone[1], and a small proportion of this group will be receiving the drug for alcoholism and mental disorders rather than opioid dependence. Analysis of the Prescription Cost Analysis[2] (PCA) system suggests that use of naltrexone is decreasing [1] Assessment report section 8, based on current cost, estimated average dose and dose duration. [2] The PCA data are based on a full analysis of all prescriptions dispensed in the community, that is, by community pharmacists and appliance contractors, dispensing doctors and prescriptions submitted by prescribing doctors for items personally administered in England. The data do not cover drugs dispensed in hospitals, including mental health trusts, or private hospitals.

41 Implementation support from NICE and the NTA
NICE implementation support tools NICE guidance incorporated into ‘Drug misuse and dependence – guidelines on clinical management: update 2007’ (the ‘Orange book’) Contingency management demonstration sites PRESENTER NOTES: NICE and the NTA have been working closely together to provide support for the guidance discussed in this presentation. Other national standards/tools which could provide levers for implementing this guidance are as follows. DANOS, which stands for Drugs and Alcohol National Occupational Standards. In developing DANOS, Skills for Health works very closely with the sector skills councils for social care, justice and other relevant sectors such as housing, education, youth work, training and employment. See the competences section of the Skills for Health website (www.skillsforhealth.org.uk) for more information. QuADS (Quality in Alcohol and Drugs Services), developed jointly by Alcohol Concern and Drug Scope, is widely used by alcohol and drug treatment services throughout England as the set of quality standards for organisations in the sector. More information is available on the NTA website. Implementation advice: The NTA ‘Assessing young people for substance misuse’ refers to the Fraser guidelines where young people under 16 can only consent to their own treatment if they are assessed as being competent to consent under the Gillick and Fraser guidelines.

42 Drug misuse and dependence – guidelines for clinical management: the ‘Orange book’
Updated version of 1999 guidelines Produced by an independent working group, and published by the Department of Health and devolved administrations Covers the whole treatment system and incorporates NICE guidance Evidence-based good practice No specific statutory status but marker of evidence- based good practice NOTES FOR PRESENTERS: ‘Drug misuse and dependence – guidelines for clinical management’ (often called the ‘Orange book’) was last updated in 1999. The production of the NICE suite of guidance on drug misuse and other drivers have led to its update. It is being updated by an independent expert working group informed by evidence and clinical practice and NICE guidance (It provides additional detail and covers areas outside the scope of the NICE guidance) supported by the NTA, and when agreed will be published and disseminated by the health departments of the four UK countries in late 2007. The Orange book incorporates NICE guidance, as well as providing more detailed information for implementation. It has no specific statutory status but is widely accepted as a marker of good evidence-based practice. Compliance with its recommendations is therefore used in criteria for NTA/Healthcare Commission Improvement Reviews of treatment for drug misuse and in future Healthcare Commission performance management. The guideline is also used by the General Medical Council and others in considering clinical practice. Defer to NICE guidance where there are areas of ambiguity between the Orange Book and NICE guidance.

43 Contingency management demonstration sites
National Treatment Agency -led demonstration sites Appendix C NICE drug misuse clinical guidelines In preparation for setting up the demonstration sites, a review of existing services that report the delivery of contingency management approaches has been undertaken by the NTA. More information will be provided by the NTA as the sites progress. This will give an indication of how the guidelines can best be implemented in England, taking into consideration costs, effects on benefits, and staff competencies. Please see NTA website for more information and activities being led by the NTA. For more information on contingency management and demonstration sites, see Appendix C in either of the drug misuse clinical guidelines. Introduction to contingency management Implementing contingency management in the NHS Establishing contingency management demonstration sites

44 Resources from NICE and the NTA: access online
From NICE (www.nice.org.uk) Costing reports and templates Implementation advice statement Audit criteria From the NTA (www.nta.nhs.uk) Service user leaflets ‘Drug misuse and dependence – guidelines on clinical management: update 2007’ (the ‘Orange book’) – incorporating NICE guidance Commissioning guidance (by November 2007) NOTES FOR PRESENTERS: The National Collaboration Centre for Mental Health are also providing complementary support for the NICE guidance, including: Service user and carer leaflets (jointly with the NTA) Royal College General Practitioner course updated to reflect guidance British Psychological Society – psychological toolkit The next two slides give details of website addresses for the individual NICE guidance – that is, the public health intervention guidance on substance misuse and the two clinical guidelines on drug misuse.

45 Public health guidance: access online
A quick reference guide for professionals and the public The NICE guidance – all of the recommendations, details of how they were developed and evidence statements NOTES FOR PRESENTERS: The guidance is available in a number of formats. You can download them from the NICE website, or order printed copies of the quick reference guide by calling the NHS Response Line on and quoting reference number N1187.

46 Clinical guidelines: access online
Quick reference guide (joint) – a summary NICE guidelines – all of the recommendations Full guidelines – all of the evidence and rationale ‘Understanding NICE guidance’ (joint) – a version for people who misuse drugs and their families and carers NOTES FOR PRESENTERS: These guidelines are available in a number of formats. You can download them from the NICE website, or order printed copies of the joint quick reference guide or joint ‘Understanding NICE guidance’ by calling the NHS Response Line on Quote reference number N1289 for the quick reference guide and N1290 for ‘Understanding NICE guidance’.

47 Technology Appraisals: access online
Quick reference guide – a summary Full guideline – all of the evidence and rationale ‘Understanding NICE guidance’ – a version for people who misuse drugs and their families and carers Implementation support tools NOTES FOR PRESENTERS: Implementation of TA114 on methadone and buprenorphine is supported by a costing report, which estimates the financial impact to the NHS of implementing the technology appraisal, and a costing template, which provide health communities with the ability to assess the likely local impact of the principal recommendations in the appraisal based on their population. There is no costing report and template for TA115 on naltrexone, as it was thought unlikely to result in a significant change in resource use in the NHS. The two technology appraisals are also supported by audit tools which assist healthcare organisations in determining whether the service is implementing, and is in compliance with, the appraisals. These can be found on the NICE website via the links provided below: Methadone and buprenorphine for the management of opioid dependence (TA114) – Naltrexone for the management of opioid dependence (TA115) – Implementation support tools: costing report and template (TA114) costing statement (TA115) audit criteria (both)


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