Misuse of drugs and other substances

1. Misuse of drugs and other substances Implementing NICE guidance 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

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

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

5. Guidance this presentation covers 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

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.

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

9. Public health guidance • Community-based interventions to reduce substance misuse among vulnerable and disadvantaged children and young people 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) 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 PHI4

12. Key recommendations:children and young people • Develop a strategy • Identify those at risk • Provide community-based interventions 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 PHI4

14. 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 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 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 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? 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 • Organising and developing care • Identifying people who misuse drugs • Assessment • Key recommendations 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 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 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 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 CG52

24. Key recommendationsDrug misuse: psychosocial interventions • Brief interventions • Self-help • Contingency management 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 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 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 CG51

28. 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

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 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) CG52

31. Do not offerultra-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 CG52

32. Settings of care • Community • Residential • Inpatient • Criminal justice system 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 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 CG51 & 52

35. NICE technology appraisals Methadone and buprenorphine for the management of opioid dependence (TA114) Naltrexone for the management of opioid dependence (TA115) 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 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 TA115

38. Costs and savings per 100,000 population:public health guidance

39. Costs and savings per 100,000 population: clinical guidelines

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

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

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

43. Contingency management demonstration sites • National Treatment Agency -led demonstration sites • Appendix C NICE drug misuse clinical guidelines

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)

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 • www.nice.org.uk/PHI004

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 www.nice.org.uk/CG051www.nice.org.uk/CG052

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 • www.nice.org.uk/TA114 www.nice.org.uk/TA115