Misuse of drugs and other substances

Implementing NICE guidance

2007

NICE public health intervention guidance 4Clinical guidelines 51 and 52

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

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

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

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: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

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

Costs and savings per 100,000 population:

public health guidance

Recommendations with significant resource impact

Annual cost £

Motivational interviewing 2,683

Providing group-based behavioural therapy 1,800

Providing group-based training in parental skills 3,701

Providing family-based programme of structured support 15,274

Total cost impact 23,458

Costs and savings per 100,000 population: clinical guidelines

Recommendations with significant resource impactAnnual

cost/saving £

Behavioural couples therapy (psychosocial) 3,588

Prison care: anxiety and depression (psychosocial) 2,208

Prison care: behavioural couples therapy (psychosocial) 1,104

Increased provision of inpatient detoxification 22,032

Estimated cost of implementation 28,392

Savings

Savings attributable to healthcare 7,800

Potential societal savings (e.g. criminal justice) 70,000

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

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

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

Contingency management demonstration sites

• National Treatment Agency -led demonstration sites

• Appendix C NICE drug misuse clinical guidelines

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)

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

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/CG051 www.nice.org.uk/CG052

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