Misuse of drugs and other substances
Implementing NICE guidance
2nd edition December 2012
NICE public health intervention guidance 4Clinical guidelines 51 and 52
Guidance reviews CG51, CG52 and PH4
Guidance issue date: 2007
Review date: 2011
2011 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
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
Quality standard for drug use disorders
Published: November 2012Includes quality statements and indicators on:
1 Needle and syringe programmes 2 Assessment 3 Families and carers4 Blood-borne viruses 5 Information and advice 6 Keyworking – psychosocial interventions7 Recovery and reintegration 8 Formal psychosocial interventions and treatments 9 Continued treatment when abstinent 10 Residential rehabilitative treatment
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
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
We also refer to ‘Drug misuse and dependence – guidelines for clinical management: update 2007’ (the ‘Orange book’), as it incorporates NICE guidance
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
Correct at 2007. This slide was not updated for the 2ndedition
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.
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
Community-based interventions to reduce substance misuse among vulnerable and disadvantaged children and young people
NICE public health intervention guidance 4March 2007
Public health guidance
PHI4
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)
PHI4
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
PHI4
Key recommendations:children and young people
• Develop a strategy
• Identify those at risk
• Provide community-based interventions
PHI4
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
PHI4
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
Identify those at risk
Target population Who should take action
Any child or young person under 25 who is vulnerable
and disadvantaged
All who work with vulnerable and disadvantaged children
and young people
PHI4
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
Interventions: family support
Target population Who should take action?
All who work with vulnerable and disadvantaged children
and young people
• Any child or young person aged 11–16 assessed to be
at high risk of substance misuse
• Their parents or carers
PHI4
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
Interventions: behavioural therapy
Target population Who should take action?
Practitioners trained in group-based behavioural
therapy
• Children aged 10–12 who are persistently aggressive or
disruptive and assessed to be at high risk of substance misuse
• Their parents or carers
PHI4
Offer one or more motivational interviews according to the young person’s needs. Each session should last about an hour.
Interventions: motivational interviews
Target population Who should take action?
Practitioners trained in motivational interviewing
Vulnerable and disadvantaged children and young people aged under 25
who are problematic substance misusers
PHI4
Clinical guidelines
Drug misuse: opioid detoxification (CG52)
NICE clinical guidelines 51 and 52July 2007
Drug misuse: psychosocial interventions (CG51)
CG51 & 52
Organising and developing care
Identifying people who misuse drugs
Assessment
Key recommendations
CG51 & 52
Clinical guidelines
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 betweenservices, to reduce loss of contact
CG51 & 52
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
CG51 & 52
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
CG51 & 52
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
CG52
Key recommendationsDrug misuse: psychosocial
interventions
• Brief interventions
• Self-help
• Contingency management
CG51
Opportunistic brief interventions focused on motivation should be offered to people in limited contact with drug services if concerns about drug misuse are identified
Brief interventions
These interventions should:
• normally consist of 2 sessions each lasting 10–45 minutes
• explore ambivalence about drug use and possible treatment
CG51
Staff should routinely provide people who misuse drugs with information about self-help groups
Self-help
These groups should normally be based on 12-step principles; for example:
• Narcotics Anonymous• Cocaine Anonymous
CG51
Drug services should introduce contingency management programmes as part of the phased implementation programme led by the NTA
Contingency management
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
CG51
Key recommendationsDrug 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
CG52
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
Provide information, advice and support
CG52
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)
CG52
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
Do not offerultra-rapid detoxification
CG52
Settings of care
• Community
• Residential
• Inpatient
• Criminal justice system
CG51 & 52
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
The choice of setting for detoxification
CG52
Settings: criminal justice systemAccess 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
CG51 & 52
NICE technology appraisals
Methadone and buprenorphine for the management of opioid dependence (TA114)
Naltrexone for the management of opioid dependence (TA115)
TA114 & 115
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
TA114
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
TA115
NICE Pathway
Click here to go to NICE Pathways website
Provides details on the provision of
needle and syringe programmes for adults who inject illicit substances
NHS Evidence
Visit NHS Evidence for the best available
evidence on substance misuse
care
Click here to go to the NHS Evidence website
Find out moreVisit 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:
www.nice.org.uk/PHI004
www.nice.org.uk/CG051
www.nice.org.uk/CG052
www.nice.org.uk/TA114
www.nice.org.uk/TA115
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