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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: These slides were updated in December 2012 to include details of the NICE Quality standard, NHS Evidence and NICE Pathways. The guidance that this slide set is based on has not changed. This presentation has been written to raise awareness of the NICE public health intervention guidance on substance misuse (PH4) and two NICE clinical guidelines on drug misuse: psychosocial interventions (CG51) and opioid detoxification (CG52). The guidance is intended 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 referred to in this presentation. You may want to provide access to the NICE recommendations for your audience prior to, or during your presentation. NICE webview versions of the guidance may be helpful for this. You can add your own organisation’s logo alongside the NICE and National Treatment Agency (NTA) logos. We have included notes for presenters to provide further detail on 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. DISCLAIMER This slide set is an implementation tool and should be used alongside the published NICE guidance. This information does not supersede or replace the guidance itself. 2nd edition December 2012 NICE public health intervention guidance 4 Clinical guidelines 51 and 52

2 Guidance reviews CG51, CG52 and PH4
Guidance issue date: 2007 Review date: review recommendations CG51, CG52 and PH4 will not be updated at this time CG51: two clinical trials on contingency management are expected to publish results in 2012 and 2013 PH4: a future review may consider the broader prevention of substance misuse – including alcohol PRESENTER NOTES: CG51, CG52 and PH4 were initially published in 2007, and were reviewed in March 2011, in line with routine NICE practice. No factors were found that would invalidate or change the direction of the current NICE guidance recommendations. Factors affecting these decisions CG51: There was insufficient variation in current practice at this time to warrant an update of the current guideline. Stakeholders highlighted practice issues concerning the 12-step approach, inadequate incorporation of contingency management into routine practice, the impact of the roll-out of Improving access to psychological therapies (IAPT) workers and the Government’s new drug strategy. But it was decided that there was no significant new evidence in these areas at this time. CG52: Stakeholders highlighted practice issues concerning the use of injectable heroin or injectable methadone as an area not covered in the current guideline but a subject of recent clinical trials in the UK. They also highlighted the optimal duration of community detoxification, importance of the role of families in improving recovery. No significant new evidence was found in these areas at this time. PH4: It was recognised that increasingly interventions in practice are addressing both alcohol and drug use. In addition, whole family and ‘recovery’ approaches are concerned with a broader range of risk factors and vulnerability as the basis of an intervention. It was decided that the guidance should not be updated at this time, and it should be reviewed again in 3 years. NICE will liaise with the Department of Health about the possibility of a broader review of the prevention of substance misuse including alcohol (excluding tobacco), but with a narrower age range and greater focus on vulnerable populations. It is possible that any resulting guidance might supersede NICE PH4.

3 What this presentation covers
NICE Quality standard for drug use disorders NICE and the National Treatment Agency (NTA) Background Principles of person centred care/supporting families and carers Key recommendations NHS evidence and NICE pathway Find out more 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, an overview of the NICE Quality standard on drug use disorders, the underpinning NICE guidance, supporting NHS evidence and NICE pathway pages, and implementation support that is available from NICE and the NTA.

4 Quality standard for drug use disorders
Published: November Includes quality statements and indicators on: Needle and syringe programmes Assessment Families and carers Blood-borne viruses Information and advice Keyworking – psychosocial interventions Recovery and reintegration Formal psychosocial interventions and treatments Continued treatment when abstinent Residential rehabilitative treatment NOTES FOR PRESENTERS Key points to raise: This quality standard covers the treatment of adults (18 years or over) who misuse opioids, cannabis, stimulants or other drugs in all settings in which care is received, in particular inpatient and specialist residential and community-based treatment settings. This includes related organisations such as prison services and the interface with other services, for example those provided by the voluntary sector. More detail on the Quality standard for drug use disorders can be found via NICE quality standards are a set of specific, concise statements and associated measures. They set out aspirational, but achievable, markers of high-quality, cost-effective patient care, covering the treatment and prevention of different diseases and conditions. NICE quality standards are central to supporting the Government's vision for an NHS focused on delivering the best possible outcomes for patients. NICE quality standards enable: Health and social care professionals to make decisions about care based on the latest evidence and best practice. Patients and carers to understand what service they should expect from their health and social care provider. Service providers to quickly and easily examine the clinical performance of their organisation and assess the standards of care they provide Commissioners to be confident that the services they are purchasing are high quality and cost effective Additional information: The quality statements describe key markers of high-quality, cost-effective care for a particular clinical condition or pathway. These statements may address prevention, as well as elements of health and social care, and will promote an integrated approach to improving quality. Quality measures accompany the quality statement and aim to improve the structure, process and outcomes of health and social care. They are not a new set of targets or mandatory indicators for performance management. All quality measures are specified in the form of a numerator and a denominator which define a proportion (numerator/denominator). It is assumed that the numerator is a subset of the denominator population.

5 NICE and the National Treatment Agency (NTA)
NICE guidance was incorporated into ‘Drug misuse and dependence – guidelines on clinical management: update 2007’ (the ‘Orange book’) Contingency management demonstration sites NICE guidance and implementation tools Update December 2012 The Drugs Strategy (December 2010) and Healthy Lives, Healthy People (November 2010) set out a new vision of a locally-led, recovery oriented system, under which most drugs and alcohol services will in future be commissioned by local authorities through Directors of Public Health, supported by Health & Wellbeing Boards. Some functions of the National Treatment Agency are currently being transferred to Public Health England. PRESENTER NOTES: NICE and the NTA worked together to provide support for CG51, CG52 and PH4 at the time of the guidance launch. The NTA’s ‘Drug misuse and dependence; guidelines for clinical management’ (often called the ‘Orange book’) incorporates NICE guidance, as well as providing more detailed information for implementation. It is a widely accepted as a marker of good evidence-based practice. If there are areas of ambiguity between the Orange Book and NICE guidance, please refer to the NICE guidance. For more information on contingency management and demonstration sites, see Appendix C in either of the NICE drug misuse clinical guidelines. Other national standards/tools which could provide levers for implementing this guidance are: DANOS (Drug and Alcohol National Occupational Standards). In developing DANOS, Skills for Health worked with 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, as the set of quality standards for organisations in the sector. More information is available via the NTA website. Further information: 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.   

6 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 Please note that the two technology appraisals on the slide are mentioned briefly during the presentation to raise awareness of the existence of this related guidance. We also refer to ‘Drug misuse and dependence – guidelines for clinical management: update 2007’ (the ‘Orange book’), as it incorporates NICE guidance

7 Background 327,000 people use opioids and/or crack cocaine in the UK
People who misuse drugs may have a range of health and social problems Drug misuse has a negative impact on physical and mental health and 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, that they misuse opioids and/or crack cocaine. Of these, 280,000 people were estimated to misuse opioids. Drug misuse has a negative impact on health and social functioning. This may take the form of drug dependence, or it may form part of a wider spectrum of problematic or harmful behaviour. People who misuse drugs may present with a range of health and social problems other than dependence, which may include the following: • 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; • social difficulties, for example, relationship problems, financial difficulties, unemployment and homelessness; • criminal justice problems. Correct at This slide was not updated for the 2ndedition

8 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.

9 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 NICE clinical guidelines on drug misuse are summarised on this slide. 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 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.

10 Public health guidance
Community-based interventions to reduce substance misuse among vulnerable and disadvantaged children and young people NOTES FOR PRESENTERS: Please note that some of the mechanisms cited for the delivery of this guidance may have changed since the guidance first published, but the evidence base and the principles of the guidance recommendations still stand. ‘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

11 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

12 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 between 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). PHI4

13 Key recommendations: children and young people
Develop a strategy Identify those at risk Provide community-based interventions NOTES FOR PRESENTERS: The NICE public health intervention guidance on substance misuse contains recommendations about how care can be improved. The experts who wrote the guidance had chosen key recommendations that are likely to have the greatest impact on care and are important priorities for implementation. The key recommendations fall into the three areas listed in the slide. 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

14 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 be taken? Please note that the principles of this recommendation still stand, although the partnerships or mechanisms for its local delivery may have changed since the guidance first published. 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

15 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? Please note that the principles of this recommendation still stand, although the partnerships or mechanisms for its local delivery may have changed since the guidance first published. 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

16 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 18) 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. PHI4

17 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

18 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

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

20 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

21 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

22 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 , 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 people 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

23 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 PRESENTER NOTES 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

24 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 PRESENTER NOTES 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

25 Key recommendations Drug misuse: psychosocial interventions
Brief interventions Self-help Contingency management NOTES FOR PRESENTERS: The key recommendations for clinical guidelines are those that are estimated to have the most impact on care and important priorities for implementation. The key recommendations in the psychosocial interventions for drug misuse guideline fall into the three areas listed in the slide. 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

26 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. Please 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

27 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

28 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

29 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 for implementation for the Opioid detoxification guideline fall into the four areas listed on the slide. We shall consider each in turn. CG52

30 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

31 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

32 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

33 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 relevant NICE Pathway or guidance page for 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

34 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

35 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

36 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, 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 2007. TA114 & 115

37 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

38 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

39 Click here to go to NICE Pathways website
Provides details on the provision of needle and syringe programmes for adults who inject illicit substances Click here to go to NICE Pathways website NOTES FOR PRESENTERS Key points to raise: If you are showing this presentation when in slideshow and connected to the internet, click on the orange button to go straight to the NICE Pathways website. NICE Pathways: guidance at your fingertips Our new online tool provides quick and easy access, topic by topic, to the range of guidance from NICE, including quality standards, technology appraisals, clinical and public health guidance and NICE implementation tools. Simple to navigate, NICE Pathways allows you to explore in increasing detail NICE recommendations and advice, giving you confidence that you are up to date with everything we have recommended. The NICE pathway can be found at Needle and syringe programmes (NSPs) Pathway Some of the recommendations in the NICE Pathway are also relevant to adults who inject non-prescribed anabolic steroids and other performance and image-enhancing drugs (PIEDs). While NSPs can help reduce the harm caused to people who inject drugs, the consequent reduction in the prevalence of blood-borne viruses benefits wider society. Other NICE Pathways include:

40 Click here to go to the NHS Evidence website
Visit NHS Evidence for the best available evidence on substance misuse care Click here to go to the NHS Evidence website NOTES FOR PRESENTERS: If you are showing this presentation when connected to the internet, click on the blue button to go straight to the NHS Evidence website topic page for drug misuse. There are also topic pages for alcohol treatment, alcohol misuse prevention, substance misuse prevention and over 80 other topics. For the home page go to

41 Find out more Visit www.nice.org.uk/guidance/QS23 for:
NICE Quality standard for drug use disorders NICE support for commissioners and others Information for people using NHS services for drug use disorders For NICE guidance and supporting costing and audit tools visit: NOTES FOR PRESENTERS: Please note that the NICE costing tools were first developed in 2007 to estimate the local costs and savings incurred from implementing the NICE guidance. These tools have not been updated. A NICE commissioning guide is available to support the Public health guidance PH18, Needle and syringe programmes. A link to this can be found on the PH18 guidance page. The National Collaborating Centre for Mental Health also provided support for this NICE guidance, including: Service user and carer leaflets (jointly developed with the NTA) Royal College General Practitioner course updated to reflect guidance British Psychological Society – psychological toolkit

42 What do you think? Did the implementation tool you accessed today meet your requirements, and will it help you to put the NICE guidance into practice? We value your opinion and are looking for ways to improve our tools. Please complete this short evaluation form. If you are experiencing problems accessing or using this tool, please NOTES FOR PRESENTERS: Additional information: This final slide is not intended to be part of the presentation. It asks for feedback on whether this implementation tool meets your requirements and whether it will help you to put this NICE guidance into practice: your opinion would be appreciated. To open the links in this slide set, right click over the link and choose ‘open link’. To open the links in this slide set right click over the link and choose ‘open link’


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