1. Developments in Community - Based Drug Treatments Lesley Peters lesley.peters@manchester.ac.uk

2. Overview 1. Facts and figures 2. Best practice evidence base 3. New developments

3. Extent of problem drug use Prison 130 000 annual through flow (HM Prison Service, 2003) n n 79 700 prison population (NOMS Oct 2006) n n 70 000 problem drug users annually n n 39 000 problem drug users at any one time (HM Prison Service, 2003) Community 288 000 problem drug users (Best, 2005) n 120 000 in treatment (NTA, 2006) 181 000 in contact with drug services 2005/06 (NTA, 2006)

4. Main drug of misuse From NDTMS data 2005/2006 (NTA 2006) n n heroin 66% n n crack cocaine / cocaine 11% n n methadone / other opiates 10% n n (cannabis 8%) Also in Tier 3 services n n benzodiazepines - poly drug use n n amphetamine - some primary users

5. Community based treatments 1 Opiate substitution treatment n n methadone n n buprenorphine Opiate detoxification n n methadone n n buprenorphine n n lofexidine Relapse prevention n n naltrexone

6. Community based treatments 2 Crack cocaine n n psychosocial interventions n n complementary therapies Benzodiazepines n n inter-service variation in prescribing policies n n diazepam reductions/de facto maintenance Amphetamine n n some dexamphetamine prescribing n n otherwise as for crack

7. Evidence for methadone maintenance Randomised controlled trials (Dole 1969, Gunne 1981, Newman 1979, Strain 1993, Vanichseni 1991, Yancovitz 1991) Cochrane review (Mattick et al 2003) TOPS (Hubbard et al 1989) NTORS (Gossop et al 1997,2001, 2003) Meta-analysis (Marsch 1998)

8. Evidence for methadone maintenance increased treatment retention reduced illicit heroin use reduced crime and imprisonment reduced injection related risk behaviour reduced HIV infection reduced mortality improved psycho-social well-being increased employment

9. Current guidance on methadone dose n n Department of Health clinical guidelines (1999) n n NTA Models of Care (2002) n n NTA Research into Practice briefing on MMT (2004) ‘consistent finding of greater benefit from maintaining individuals on a daily dose between 60mg and 120mg’ (higher doses in exceptional cases)

10. Evidence in relation to methadone dose Cochrane review of effectiveness of MMT at different dosages (Faggiano et al 2003) 21 studies - 11 RCTs, 10 CPS low: 1 - 39 mg med: 40 - 59 mg high: 60 - 109 mg methadone doses 60 – 100mg more effective than lower doses at - retaining patients - reducing heroin & (?) cocaine use during treatment

11. Effects of increasing methadone dose individuals on 80 mg (Caplehorn & Bell, 1991) likelihood of using heroin in treatment reduced by 2% for every 1mg increase in methadone dose. Odds of using heroin on 40mg, 2.2 x those on 80mg (Caplehorn et al 1993)

12. NTORS MMT - higher doses & retention in treatment predictive of reduced heroin use each milligram increase in methadone dose associated with 2% reduction in likelihood of regular heroin use (NTORS 2 year follow up, Gossop et al, 2001)

13. Optimising methadone maintenance More effective MMT n n higher doses n n maintenance orientation n n high quality counselling n n medical services n n good therapeutic relationship between client & keyworker n n low staff turn over n n higher retention rates (Ball & Ross 1991)

14. Buprenorphine in maintenance treatment 1 Cochrane review, Mattick et al, 2003 n n comparing buprenorphine to placebo or to methadone maintenance n n ‘buprenorphine is an effective intervention for use in maintenance treatment of heroin dependence, but it is not more effective than methadone at adequate doses’

15. Buprenorphine in maintenance treatment 2 Cochrane review, Mattick et al, 2005 n n comparing buprenorphine with methadone in flexible dosing regimes n n methadone 20 -120mg n n buprenorphine 2 - 16mg n n methadone maintenance better retention rates n n no difference in opiate use Recommended dose for buprenorphine maintenance 12 - 24mg daily

16. Opioid detoxification 1 n n Methadone at tapered doses for the management of opioid withdrawal, Cochrane Review, (Amato et al, 2005) n n No difference between methadone and other pharmacotherapies

17. Opioid detoxification 2 n n Buprenorphine for the management of opioid withdrawal, Cochrane Review, Gowing et al, 2006 n n ‘Buprenorphine is more effective than clonidine for the management of opioid withdrawal. There appears to be no significant difference between buprenorphine and methadone in terms of completion of treatment, but withdrawal symptoms may resolve more quickly with buprenorphine.’

18. Relapse prevention: naltrexone n n naltrexone and behavioural treatment significantly reduced probability of re- incarceration (Kirchmayer et al. 2002) n n oral naltrexone effective treatment if retention rate adequate (Johansson et al, 2006)

19. Treatment of cocaine dependence n n Cochrane reviews - all negative antidepressants dopamine agonists carbamazepine auricular acupuncture n n psychosocial interventions most promising

20. Psychological therapies 1 n n evidence base for MMT based on studies which included counselling n n improved MMT outcomes with addition of a range of psychosocial interventions e.g. medical/psychiatric care, social work, family therapy, employment counselling (McLellan et al, 1993)

21. Psychological therapies 2 Effectiveness of psychological therapies in drug misusing clients (Wanigaratne et al, 2005) Opiates n n substitution treatment plus any psychosocial intervention Stimulants n n CBT / relapse prevention / motivational interviewing

22. New Guidelines NICE clinical guidelines (due July 2007) n n Drug Misuse: opiate detoxification of drug misusers in the community and prison settings n n Drug Misuse: psychosocial management of drug misusers in the community and prison settings NICE Technology Appraisals (due March 2007) n n Methadone and buprenorphine for the treatment of opiate drug misuse n n Naltrexone as a treatment for relapse prevention in drug misuse

23. Treatment Effectiveness n n NTA Treatment Effectiveness strategy launched June 2005 n n improving client’s journey through treatment n n improving local drug treatment systems - waiting times - 3 weeks for voluntary referral - retention targets - 12 week target - care planning - wrap around services - housing, education, employment - drug free routes

24. Buprenorphine / naloxone combination Suboxone buprenorphine : naloxone 4:1 4 week double blind study open label study, take home doses, opiate free urines 35% to 67% over 6 months Fudala et al, 2003

25. Sustained release buprenorphine Subcutaneous injection 58mg buprenorphine lasted upto 6 weeks reduced withdrawal, reduced craving, blocked effect of opiates Sobel et al, 2004

26. Depot naltrexone n n subcutaneous implants n n intramuscular injection - - monthly injections - positive results alcohol and heroin dependence - increased retention; 60%+ in heroin users (Garbutt et al, 2005; Comer et al,2006)

27. New treatments for cocaine dependence Modafinil and Behavioral Therapy Dackis et al, 2005 Modafinil 33% abstinent for > 3 consecutive weeks Placebo 13%

28. New treatments for cocaine dependence Disulfiram and CBT Carroll et al, 2004

29. Cocaine vaccine TA - CD generates antibodies cocaine - antibody complex too large to cross blood brain barrier cocaine antibodies persist for months ethical debates Martell et al, 2005

30. Take Home Naloxone 1 n n opiate antagonist n n reverses respiratory depression of heroin overdose n n given by injection n n naloxone may be ‘given by anyone for the purpose of saving life in an emergency’ Medicines for Human Use (Prescribing) (Miscellaneous Amendments) Order 2005

31. Take Home Naloxone 2 n n target high risk situations n n train users, peer group, carers in administration of naloxone and general overdose training n n distribute to users, friends and family n n named patient basis

32. Mini-jet naloxone 400 micrograms per 1 ml

34. Watch this space !