Transcript Presenter slides

Misuse of drugs and other
substances
Implementing NICE guidance
2nd edition December 2012
NICE public health intervention guidance 4
Clinical 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 2012
Includes quality statements and indicators on:
1
2
3
4
5
6
7
8
9
10
Needle and syringe programmes
Assessment
Families and carers
Blood-borne viruses
Information and advice
Keyworking – psychosocial interventions
Recovery and reintegration
Formal psychosocial interventions and treatments
Continued treatment when abstinent
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
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
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
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
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
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
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
Clinical guidelines
Drug misuse: psychosocial interventions (CG51)
Drug misuse: opioid detoxification (CG52)
NICE clinical guidelines 51 and 52
July 2007
CG51 & 52
Clinical guidelines
Organising and developing care
Identifying people who misuse drugs
Assessment
Key recommendations
CG51 & 52
Organising and developing care
• At initial contact/formal reviews, explain options for
abstinence-oriented, maintenance-oriented and harmreduction 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
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 nearpatient testing
Near-patient and confirmatory testing should be
conducted by appropriately trained healthcare
professionals
CG52
Key recommendations
Drug misuse: psychosocial
interventions
•
Brief interventions
•
Self-help
•
Contingency management
CG51
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
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
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
Key recommendations
Drug 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
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
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
Do not offer
ultra-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
Settings of care
• Community
• Residential
• Inpatient
• Criminal justice system
CG51 & 52
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
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
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
Provides details on
the provision of
needle and syringe
programmes for
adults who inject
illicit substances
Click here to go to
NICE Pathways
website
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 more
Visit 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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