Dr Clare Gerada discusses new guidelines from NICE, which offer advice on psychosocial interventions and the delivery of safe and effective care to opiate users

The NICE guidelines on psychosocial interventions, and opioid detoxification for opiate users were published in July 2007.1–4 The term opioid was used to indicate not only the naturally occurring opiates, which are derived from the opium poppy, but also their synthetic analogues such as methadone and pethidine. For the first time, NICE guidelines offer advice to clinicians about the safe and effective delivery of care to opiate users, albeit on only a small aspect of their care.

Development of the guidelines

The two guidelines were developed over many months, involving two separate committees, one on detoxification, chaired by a GP, and one on psychosocial aspects, chaired by a psychiatrist. The development groups for both sets of guidelines were drawn from a wide range of experts, including service users, individuals from non-statutory and statutory agencies, GPs, and psychiatrists.

Standard methods of grading research and recommendations were used in developing the guidelines. Where there was no available research evidence, not an infrequent finding in these subject areas, the guideline development groups made recommendations based upon expert consensus opinion.2,4

These new NICE guidelines on substance misuse offer greater treatment options for both patients and clinicians. They emphasise the importance of psychosocial interventions, and provide clinicians with the evidence for detoxification as a means of supporting their patients in abstaining from substance misuse.

Why do we need the guidelines?

Substance misuse is endemic in all parts of society and is a growing problem. Self-reported drug use among people aged 16 to 59 years in England and Wales for 2006 showed that approximately one in 10 had used illicit drugs in the previous year, and one in 20 had done so during the previous month.5

Substance misuse has a significant and profound impact on the health and social functioning of many individuals and their families. Drug users have an increased risk of premature death compared with their age-matched peers who did not take drugs. A long-term follow up of heroin addicts showed that they had a nearly 12 times greater risk of dying prematurely than the general population;6 for injecting users, the risk of premature death was even greater, at 22 times more than that for non-injecting drug users.7

People who take drugs often have multiple social and medical needs that have to be addressed, usually involving a wide range of health and social care professionals. The GP is an integral part of the treatment pathway and these new guidelines will provide him or her with support and also set out priorities for implementation. The guidelines provide GPs with up-to-date evidence-based treatment options that can be used in the management of opiate detoxification.

NICE implementation tools

NICE has developed the following tools to support implementation of its guideline on drug misuse: opioid detoxification and psychosocial interventions:

Costing tools
National cost reports and local cost templates for the guideline have also been produced.

  • costing reports are estimates of the national cost impact arising from implementation based on assumptions about current practice, and predictions of how it might change following implementation of the guideline.
  • costing templates are spreadsheets that allow individual NHS organisations and local health economies to estimate the costs of implementation taking into account local variation from the national estimates, and they quickly assess the impact the guideline may have on local budgets

They are now available to download from the NICE website: www.nice.org.uk.

NICE is also developing a slide set of key messages for local discussion, and audit criteria

Complications of heroin use

The multiplicity of problems associated with heroin use mean that it is important to attract, retain, and deliver effective and evidence-based treatments to these drug users. Specific complications apply to individuals who use heroin and other drugs, for example, crack-cocaine. These include:

  • complications secondary to injecting—overdose, abscess, blood-borne viruses, endocarditis
  • complications arising from the lifestyle of these drug users—unemployment, poor social networks, poor and/or inconsistent housing, involvement in crime
  • general complications—dental caries, poor diet, infertility, death from overdose.

Treatment

There were an estimated 181,390 individuals undergoing drug treatment in 2005–2006, with the most frequently reported main drug of misuse by patients over 18 years being heroin (64%).4 Cannabis was the most used drug in those aged under 18 (67%).5

It may seem a platitude to say so, but treatment works, and it is a vital message that needs to be heard by clinicians and policy makers. There are various treatment options available for treating opiate dependence and these should be made available to the patient. Treatment should aim for:8

  • reduction of psychological, social and other problems related to drug use
  • lessening of harmful or risky behaviour associated with the use of drugs, including sharing equipment
  • attainment of controlled, non-dependent, or non-problematic use
  • withdrawal from main problem drug(s)
  • abstinence from all drugs.

The new guidelines from NICE concentrate on two aspects of treatment, which are psychosocial and detoxification treatments. Concentrating on these two aspects does not, however, undermine the importance of other aspects of care, especially maintenance treatment. Methadone is perhaps the best known substance for opiate substitution therapy and methadone maintenance treatment is one of the most thoroughly researched therapeutic modalities in the field of drug addiction, with many studies having a randomised double-blind design.9,10A long-term follow up of drug users in a number of different treatment modalities in England showed they had reduced drug use by 60% at 5-year follow-up, and arrests for violent and non-violent crime by as much as 50%—for every £1 spent on treatment, the saving to society as a whole was up to £18 on crime costs.11

Detoxification

The symptoms of heroin withdrawal, if untreated, reach a peak within 36–72 hours after the final dose and subside over about 5 days. In the guideline, opioid detoxification treatment refers to the provision of substitute medication such that an individual can cease using opiates with the minimum discomfort from withdrawal, thereby maximising their chances of maintaining abstinence. Options for detoxification include tapered doses of methadone or buprenorphine, or the alpha-2-adrenergic agonist, lofexidine.3

The period of detoxification is normally considered to last for up to 4 weeks in an inpatient/residential setting or for 12 weeks in the community. Periods longer than this should be referred to as maintenance treatment.3

Detoxification alone cannot be expected to result in long-term abstinence and should be combined with psychosocial support.3

Assessment for detoxification

People presenting for detoxification should be assessed to establish the presence and severity of opioid dependence and the use of other substances. If opioid dependence or tolerance is uncertain, confirmatory laboratory tests, such as urinalysis, should be used in addition to near-patient testing, for example, oral fluid and/or breath testing. Confirmation should particularly be sought when:3

  • a young person first presents for opioid detoxification
  • a near-patient test result is inconsistent with clinical assessment
  • complex patterns of drug misuse are suspected.

Advice and support

People who are dependent on opioids, and who have made an informed decision to give up taking them should be able to embark on a readily available treatment course. They should be given detailed information about detoxification and the risks involved in order to make that decision. This should include information on the following:

  • physical and psychological aspects of opioid withdrawal—how long it takes, how intense the symptoms are, and how they may be managed
  • non-pharmacological approaches that can be used to manage or cope with opioid withdrawal symptoms
  • development of intolerance to opioids that may develop after detoxification—this could result in an increased risk of overdose and death if the patient takes illicit drugs triggered by use of alcohol or benzodiazepines
  • availability of continued support and psychosocial and appropriate pharmacological interventions—these are important to help the opioid user remain abstinent, to treat any mental health problems associated with the withdrawal and detoxification process, and to minimise the risk of any adverse outcomes or death.3

Pharmacology to aid detoxification

The first-line treatment for opioid detoxification should be either methadone or buprenorphine. When deciding on which drug to use, the healthcare professional should take into account the service user’s preference and whether he or she is receiving maintenance treatment with methadone or buprenorphine, as opioid detoxification should normally be started using the same medication.

Lofexidine may be considered for people who have decided not to use methadone or buprenorphine for detoxification based on information they have been given, and where the decision is clinically appropriate. Lofexidine is also suitable for people who wish to undertake rapid detoxification and for use in those with mild or uncertain dependence, including young people.3

Clonidine and dihydrocodeine are not recommended by the guideline for routine use.

Community-based or residential detoxification

Initially, people who are considering opioid detoxification should be offered treatment in a community-based programme. There are, however, some people for whom this is not suitable. These include service users who:

  • have not had a beneficial outcome from previous formal community-based detoxification
  • have significant co-morbid physical or mental health problems and, therefore, require medical and/or nursing care
  • need multiple drug detoxification, such as those who also require alcohol and benzodiazepine detoxification
  • have significant social problems, which mean they will receive little benefit from community-based detoxification.3

Psychosocial interventions

Psychosocial interventions refer to a multitude of different approaches, many of which can be delivered in primary care. These include:2

  • addressing housing and employment needs
  • providing benefit advice
  • implementing talking therapies (including family, individual, and group therapies)
  • delivering information about self-help groups, such as those based on 12-step principles, for example, Narcotics Anonymous and Cocaine Anonymous
  • providing opportunistic brief interventions.

Contingency management

Contingency management refers to schemes that provide incentives contingent on an agreed desired behaviour, such as presentation of a drug-negative urine test, or completion of a hepatitis B immunisation programme. The incentives are usually in the form of vouchers that can be exchanged for goods or services of the patient’s choice, or privileges such as take-home methadone doses.1

Summary

These guidelines are not comprehensive. They are not a ‘how to’ manual on the management of opiate detoxification. They also do not give the GP dosages or other specific guidance. In addition, whether contingency management can routinely be provided in a primary care setting still needs to be determined, and it is likely that the methodological issues may make it impossible to carry out the necessary tests of compliance that contingency management will rely on. Nevertheless, GPs will have an important role to play, either as key workers themselves, or as part of the multiprofessional team working with the drug user.

The two NICE guidelines on drug misuse should be read in conjunction with the forthcoming publication ‘Drug misuse and dependence – guidelines on clinical management: update 2007’ also known as the ‘Orange Book’. This document is currently available to view as a consultation document at www.nta.nhs.uk.

Technology appraisals from NICE have been produced on methadone and buprenorphine,12 and naltrexone13 for the management of opioid dependence. NICE has also published public health intervention guidance on substance misuse in children and young people.14

written by Dr David Jenner, NHS Alliance PBC Lead

  • Effective treatment does produce health gain but also requires community infrastructure and near-patient testing
  • Drug misuse services are not as yet covered by PbR or the tariff
  • Complications of drug misuse impact on the PBC budget,
    e.g. hepatitis C, emergency medical admissions
  • PBC commissioners should seek to ensure an effective community substance misuse programme is provided
  • Sample tariff costs:
      • tariff price for emergency admission for poisoning:1 £657
      • tariff price for hepatology outpatient:1 £267 (new), £86 (follow-up)
  1. National Institute for Health and Care Excellence. Drug misuse—psychosocial interventions. Clinical guideline 51. London: NICE, 2007.
  2. National Collaborating Centre for Mental Health. Drug misuse—psychosocial interventions. Clinical guideline 51. London: NICE, 2007.
  3. National Institute for Health and Care Excellence. Drug misuse—opioid detoxification. Clinical guideline 52. London: NICE, 2007.
  4. National Collaborating Centre for Mental Health. Drug misuse—opioid detoxification. Clinical guideline 52. London: NICE, 2007.
  5. The Information Centre. Statistics on drug misuse: England, 2007. www.ic.nhs.uk
  6. Oppenheimer E, Tobutt C, Taylor C, Andrew T. Death and survival in a cohort of heroin addicts from London clinics: a 22-year follow-up. Addiction 1994; 89 (10): 1299–1308.
  7. Frischer M, Bloor M, Goldberg D et al. Mortality among injecting drug users: a critical reappraisal. J Epidemiol Community Health 1993; 47 (1): 59–63.
  8. Department of Health. Report of an independent review of drug treatment services in England: task force to review services for drug misusers. London: DH, 1996.
  9. National Treatment Agency for Substance Misuse. Methadone dose and methadone maintenance treatment. Briefings for drug treatment providers and commissioners. Research into practice briefing. London: NTA, 2004.
  10. Farrell M, Ward J, Mattick R et al. Methadone maintenance treatment in opiate dependence: a review. Br Med J 1994; 309 (6960): 997–1001.
  11. Godfrey C, Stewart D, Gossop M. Economic analysis of costs and consequences of the treatment of drug misuse: 2-year outcome data from the National Treatment Outcome Research Study (NTORS). Addiction 2004; 99 (6): 697–707.
  12. National Institute for Health and Care Excellence. Methadone and buprenorphine for the management of opioid dependence. Technology appraisal 114. London: NICE, 2007.
  13. National Institute for Health and Care Excellence. Naltrexone for the management of opioid dependence. Technology appraisal 115. London: NICE, 2007.
  14. National Institute for Health and Care Excellence. Community-based interventions to reduce substance misuse among vulnerable and disadvantaged children and young people. PHI4. London: NICE, 2007.G