Drug Misuse and Dependence: UK Guidelines

• The Drug Misuse and Dependence Guidelines were updated in September 2007.¹
• They are jointly produced by the Department of Health (England), the Scottish Government, the Welsh Assembly Government and the Northern Ireland Executive.
• They are intended to serve as a framework for all doctors working within the NHS and private health care system in the UK, including both doctors with no particular expertise in drug misuse and those who are providing care in specialist drug misuse services.
• They are based on current evidence and professional consensus.

The previous version of the Drug Misuse and Dependence Guidelines were published in 1999. Since then, a number of changes have occurred in the field of drug misuse and treatment:

• Recognition of drug misuse and investment in treatment has increased; greater numbers of people are now receiving treatment.
• Evidence and policy and guidance has expanded.
• Changes have occurred in GP contracts concerning drug treatment provision.
• Consensus on doctor competencies in substance misuse treatment has been established by the RCPschy and the RCGP.
• NICE has published guidance on drug misuse and its treatment:
  • Drug misuse: psychosocial interventions²
  • Drug misuse: opioid detoxification³
  • Drug misuse: methadone and buprenorphine⁴
  • Drug misuse: naltrexone⁵
  • Substance misuse: interventions to reduce substance misuse among vulnerable young people⁶

These updated Drug Misuse and Dependence Guidelines reflect these changes, as well as the increased prominence of drug misuse on the national agenda. NICE guidance is incorporated as appropriate. The difference in the status of NICE in England and Wales compared to Northern Ireland and Scotland should be remembered.

All significant published evidence has been included where possible but the guideline development committee acknowledges that 'although the evidence base for drug misuse treatment has improved, in many areas of drug treatment evidence was either lacking or was based on research from countries other than the UK.'

This article summarizes the key principles underpinning the Drug Misuse and Dependence Guidelines. Doctors should also be aware of the need to act in accordance with the separate legal obligations regarding the prescription of controlled drugs for the management of drug misuse.

• The rates of drug misuse and its associated morbidity and mortality in the UK are among the highest in the western world. Drug-related deaths due to overdose in the UK are among the highest in Europe.
• Drug misuse is more common in areas of social deprivation.
• Heroin is the most common main problem drug amongst adults although most drug misusers use a range of drugs and alcohol.
• Cannabis and alcohol are the main problem drugs in children under the age of 18.
• Drug treatment is effective, has an evidence base and is cost effective. It has an impact on levels of drug use, offending, overdose risk and spread of blood-borne viruses. Between a quarter and a third of those entering treatment achieve long-term sustained abstinence.
• Drug misusers may have multiple social and medical problems. Their mortality rates are higher.
• Drug misusers are particularly at risk from blood-borne infections. 21% of injecting drug users are thought to be infected with hepatitis B in the UK and 50% with hepatitis C. 1.3% of injecting drug users in England, Wales and Northern Ireland are HIV positive. HIV prevalence is thought to be increasing. Shared injecting equipment is thought to be responsible.
• Drug misuse has a serious impact on the families of the drug misusers, especially children of drug-using parents. Effective treatment of the parent can greatly improve the situation.
• GPs have a responsibility to provide general medical services to drug misusers. Local drug treatment systems should be based on local need and local partnerships can be formed and commissioned. GPs with a special interest in drug misuse can become involved in care.
• Good clinical governance systems will enable high quality care.
• There should be no prejudice or discrimination. Drug misusers have the same entitlement as other patients to the services provided by the National Health Service. Doctors must provide care for both general health needs and drug-related problems, whether or not the patient is ready to withdraw from drugs. This includes the provision of evidence-based interventions, such as hepatitis B vaccinations and providing harm-minimization advice.

• Specific training, supervision and competency is needed to work with drug misusers.
• Team-working across primary and secondary care is usually effective.
• National guidance should be followed and local policies and protocols made.
• Audit and review should be performed regularly.
• Patients should be involved in their own care.
• Families should also be involved as appropriate. Families may need support. The NICE guidelines give more detail about interventions that doctors can offer to carers.
• Risk management should include infection control procedures and immunisation of staff at risk of infection.
• The prescribing of medication for the treatment of drug misuse by health professionals other than doctors is increasing. This needs specific training and supervision.
• Adequate steps should be taken to protect the children of drug-misusing parents. Child protection procedures should be initiated if there are concerns.

• The needs of drug misusers should be assessed in terms of their health, social functioning and criminal involvement.
• A good initial assessment is essential. This may involve a multidisciplinary team. Good assessment is vital to the continuing care of the patient. It can enable the patient to become engaged in treatment and may begin a process of change even before a full assessment is completed.
• Confirmation of drug taking should be gained (through history, examination and drug testing).
• Any risks to their children should be assessed and child protection services involved as appropriate.
• Emergency or acute problems should be treated (for example access to clean needles and equipment).
• Testing for blood-borne infections should be arranged as appropriate.
• A physical and psychological health assessment should be carried out.
• Any ongoing criminal involvement or offences should be determined.
• The drug misuser's expectations and desire to change should be assessed.
• The degree of dependence and need for substitute medication should be assessed.
• An individual care and treatment plan should be drawn up and reviewed regularly.
• A named person should manage and deliver an individual's care (e.g. GP or drugs worker). They may be known as the 'keyworker'.
• Drug testing can help to monitor compliance and treatment outcome.

• A keyworker with a good therapeutic alliance is best placed to provide psychosocial assessment and support.
• Counselling, cognitive behavioural therapy and supportive help (for example with housing and benefits) are examples of psychosocial treatment strategies.
• If the keyworker does not have the full range of competencies to deliver psychosocial interventions, other professionals may be involved.
• Common social problems among drug misusers include housing, employment and financial difficulties. Criminal convictions are also common.
• Mental health problems such as depression and anxiety can co-exist with drug misuse.
• In cannabis, hallucinogen and stimulant abuse (including cocaine), psychosocial interventions are the main treatment.
• For opioid, alcohol and polydrug misuse, they can be used in conjunction with drug treatment.
• Patients should also be advised about support groups such as Alcoholics Anonymous and Narcotics Anonymous.
• Some patients find that self-help approaches work for them and these should be discussed.
• In other countries, couple and family based interventions and contingency management have found to be helpful. These approaches are not commonly used in the UK at present but they should be considered (provided the appropriate training has been received).
• The NICE guidelines support a number of formal psychosocial treatments and detail the evidence that supports them. These include: brief motivational interventions, self-help groups and contingency management (ae.g. incentives contingent on each presentation of a negative drug test).

• Methadone and buprenorphine are both effective as maintenance treatment and are recommended by NICE.
• A newer drug combination of buprenorphine and naloxone (Suboxone) is available. It should be taken sublingual and when done so the naloxone does not interfere with the therapeutic effect of the buprenorphine. However, if injected or taken intra-nasally, the bioavailability of the naloxone may increase. The idea is that this therefore discourages further misuse.
• Before prescribing, there needs to be evidence that patients are drug dependent and that they are motivated to change.
• Care should be taken during dose induction not to prescribe too rapid an increase in dose. This can result in over-dose. This risk is less with buprenorphine.
• Daily supervision of the taking of the medication should be carried out initially and the duration of this supervision should be assessed for each patient.
• Care should be taken to ensure medication is kept away from children. Appropriate measures should be taken.
• If patients are not responding to treatment, more intensive drug and psychosocial interventions may improve response. The full guidelines discuss common scenarios in failure to benefit and outlines suggested management approaches.
• Methadone, buprenorphine and lofexidine are all effective for detoxification.
• If benzodiazepines are prescribed for dependance, this should be at the lowest possible dose and the dose should be reduced as soon as possible.
• Detoxification programmes should include a complete package including drug treatment and preparatory and post-detoxification support.
• Prescribing is the responsibility of the person signing the prescription.
• The British National Formulary has helpful information about prescribing including guidance regarding dosages. It also contains the rules for controlled drug prescription under the Misuse of Drugs legislation.
• The full Drug Misuse and Dependence Guidelines also discuss dosing for methadone and buprenorphine in more detail. This includes their use for detoxification and maintenance treatment. Annexes discuss how to write a prescription, details about what to do when travelling abroad, drug interactions and a section on drugs and driving.
• It also discusses the use of lofexidine for opioid withdrawal as well as those of naltrexone for relapse prevention.
• There should be close liaison between the prescriber and the pharmacist.
• The aims of drug treatment include:
  • Helping to combat withdrawal symptoms.
  • Helping to stabilise drug intake and provide an opportunity to change current lifestyle and illicit drug use and all of its associated risk taking behaviours.
• Clear prescribing records should be kept.

• All drug-misusers should be screened for and offered vaccination against (where available) blood-borne infections including hepatitis A, B and C and HIV.
• Treatment for these infections should be commenced if screening is positive.
• Other infections such as TB and tetanus should also be considered in drug misusers.
• Concurrent alcohol misuse should be assessed and help offered.
• Smoking cessation interventions should be commenced as appropriate.
• The risks of overdose and how to prevent and respond to it should be made clear to drug misusers and their families.

• The guidelines also address specific treatment groups including:
  • Pregnant women
  • Older drug misusers
  • Young drug misusers
  • Drug misusers with acute and chronic pain
  • Drug misusers being admitted to and discharged from hospital
  • Drug misusers with a dual diagnosis (with a distinct mental health problem as a separate diagnosis)
  • Drug misusers in the criminal justice system
• They discuss the role of the clinician in each situation as well as specific management and prescribing issues and the management of comorbid disorders.

In conclusion, these Guidelines offer much more than guidance on prescribing. They guide the reader through the best practice points of the management of drug misuse and drug dependence.

As with all interventions, pragmatic clinicians need to take a realistic view of the range of outcomes possible with this type of problem and with the particular patients to whom they are providing care.