Drug misuse and dependence UK guidelines on clinical management

2007·0.57 MB·English

by  Department of Health, The Scottish Office Department of Health, Welsh Office , Department of Health and Social Services Northern Ireland

Drug Misuse prelim:Layout 1 05/10/2007 16:27 Page 1
Drug misuse
and dependence
UK guidelines on
clinical management
Recommended citation
Department of Health (England) and the devolved administrations (2007). Drug Misuse and
Dependence: UK Guidelines on Clinical Management. London: Department of Health (England), the
Scottish Government, Welsh Assembly Government and Northern Ireland Executive
Produced by the Department of Health (England), the Scottish Government, Welsh Assembly
Government and Northern Ireland Executive.
Last updated September 2007 (NHS England Gateway reference: 8828).
The text of this document may be reproduced without formal permission or charge for personal or
in-house use.
If your require further copies of this book, contact DH Publications Orderline / Prolog, quoting reference
UKCG07.
Email: [email protected]
Tel: [phone]
Fax: [phone]
Textphone: 08700 102 870 (8am to 6pm, Monday to Friday).
Copies are available in electronic form at www.dh.gov.uk/publications and from the
National Treatment Agency for Substance Misuse at www.nta.nhs.uk/publications
Contents
CONTENTS
CHAPTER 4: PSYCHOSOCIAL
COMPONENTS OF TREATMENT...............35
4.1 Key points...........................................35
WORKING GROUP MEMBERS
4.2 Principles of psychosocial
AND OTHER CONTRIBUTORS....................5
interventions.......................................35
Members of the working group.......................5
4.3 Psychosocial interventions –
User and carer representatives.........................5
evidence and models...........................37
Observers........................................................6
4.4 Psychosocial interventions and
Secretariat.......................................................6 different drugs of misuse ...................40
Reviews...........................................................6 4.5 Competencies to deliver
Other contributors...........................................6 psychosocial interventions...................40
4.6 NICE guideline on psychosocial
FOREWORD.................................................7
interventions.......................................41
Who are the Clinical Guidelines for?................7
4.7 References..........................................42
What are the 2007 Clinical Guidelines?...........7
Why update the Clinical Guidelines?...............7 CHAPTER 5: PHARMACOLOGICAL
NICE and the 2007 Clinical Guidelines.............7 INTERVENTIONS.......................................43
The status of the Clinical Guidelines................8 5.1 Key points...........................................43
Regulation and inspection...............................8 5.2 Prescribing..........................................43
The process for developing the 5.3 Induction onto methadone and
2007 Clinical Guidelines..................................9 buprenorphine treatment....................45
References....................................................10 5.4 Supervised consumption.....................50
5.5 Assessing and responding to
CHAPTER 1: INTRODUCTION...................11 progress and failure to benefit............52
1.1 Key points...........................................11 5.6 Opioid maintenance prescribing..........54
1.2 Drug treatment is effective .................11 5.7 Opioid detoxification...........................57
1.3 Drug misuse and drug treatment.........12 5.8 Naltrexone for relapse prevention........59
1.4 The impact of drug misuse 5.9 Benzodiazepines.................................60
on families and communities...............13 5.10 Stimulants ..........................................61
1.5 Models of drug treatment...................13 5.11 References..........................................62
1.6 References..........................................14
CHAPTER 6: HEALTH
CHAPTER 2: CLINICAL GOVERNANCE.....17 CONSIDERATIONS....................................65
2.1 Key points...........................................17 6.1 Key points...........................................65
2.2 Principles of clinical governance..........17 6.2 Blood-borne infections........................65
2.3 Doctors’ training.................................19 6.3 Preventing drug-related deaths...........71
2.4 Non-medical prescribing......................19 6.4 Alcohol...............................................72
2.5 Confidentiality, information 6.5 Tobacco..............................................73
sharing and child protection................21
6.6 References..........................................74
2.6 Involving patients................................23
2.7 Involving carers...................................23 CHAPTER 7: SPECIFIC TREATMENT
2.8 References..........................................23 SITUATIONS AND POPULATIONS............75
7.1 Key points...........................................75
CHAPTER 3: ESSENTIAL ELEMENTS
7.2 Criminal justice...................................75
OF TREATMENT PROVISION....................25
7.3 Prisons................................................77
3.1 Key points...........................................25
7.4 Pregnancy and neonatal care..............80
3.2 Assessment, planning care and
7.5 Mental health.....................................83
treatment............................................25
7.6 Young people.....................................85
3.3 Delivery of treatment..........................28
7.7 Older current and ex-drug
3.4 Drug testing........................................29
misusers..............................................89
3.5 General health assessment at
7.8 Pain management for drug
presentation and in treatment.............31
misusers..............................................90
3.6 References..........................................33
7.9 Hospital admission and discharge .......91
7.10 References..........................................93
3
Drug misuse and dependence: UK guidelines on clinical management
ANNEXES..................................................97
A1 Doctors’ job titles and involvement
in drug treatment................................97
A2 Cardiac assessment and monitoring
for methadone prescribing..................98
A3 Writing prescriptions.........................100
A4 Travelling abroad with controlled
drugs................................................108
A5 Interactions.......................................109
A6 Marketing authorisations..................111
A7 Drugs and driving..............................114
A8 Injectable opioid treatment...............116
A9 Policy considerations for
under-18s.........................................119
A10 Useful documents.............................123
A11 Contacts...........................................125
GLOSSARY..............................................128
4
Working group
WORKING GROUP
Dr Brian Kidd
MEMBERS AND OTHER Consultant psychiatrist, NHS Tayside Substance
Misuse Services and Clinical senior lecturer in
CONTRIBUTORS
addiction psychiatry, University of Dundee
Dr Judith Myles
Members of the Clinical Guidelines
Senior lecturer in addictions, St George’s
on Drug Misuse and Dependence
University of London, and consultant psychiatrist
Update 2007 Working Group and clinical lead in addictions, South West
London and St George’s Mental Health NHS Trust
Professor John Strang (chair)
Professor of the addictions. Director of the Dr Rossana Oretti
National Addiction Centre, Institute of Consultant psychiatrist, Community Addiction
Psychiatry. Honorary consultant psychiatrist and Unit, Cardiff and the Vale NHS Trust
clinical director, addictions, South London and
Dr Duncan Raistrick
Maudsley NHS Foundation Trust
Consultant psychiatrist, Leeds Addiction Unit
Jayne Bridge
Dr Roy Robertson
Nurse consultant, Drug and Alcohol Directorate,
Edinburgh GP and reader, Division of Community
Mersey Care NHS Trust
Health Sciences, University of Edinburgh
Dr Dominic Connolly
Neil Steventon(representing carers)
Addiction psychiatrist, Community Addictions
Assist 2000
Services, Tyrone and Fermanagh Hospital
Heather Walker(representing Royal
Dr Edward Day
Pharmaceutical Society of Great Britain)
Senior clinical lecturer in addiction psychiatry,
Chief pharmacist, North East London Mental
Department of Psychiatry, University of
Health Trust
Birmingham
Ian Wardle
Dr Michael Farrell(representing Royal College
Chief executive, Lifeline Projects
of Psychiatrists)
Consultant psychiatrist, South London and Dr Nat Wright
Maudsley NHS Foundation Trust, and reader in Clinical director for substance misuse, HMP
addiction psychiatry, National Addiction Centre, Leeds, Leeds Primary Care Trust
Institute of Psychiatry, Kings College London
Dr Deborah Zador
Dr Clare Gerada(representing Royal College of Consultant physician in addictions, South
General Practitioners) London and Maudsley NHS Foundation Trust,
General practitioner (London practice) and and visiting senior lecturer, National Addiction
primary care lead for drug misuse Centre, Institute of Psychiatry
Dr Eilish Gilvarry
Conflicts of interests
Consultant psychiatrist in addictions,
Members of the working group registered any
Northumberland, Tyne and Wear NHS Trust
potential conflicts of interests with the National
Simon J Greasley(representing Association of Treatment Agency.
Nurses in Substance Abuse)
Clinical nurse specialist, The Kakoty Practice, User and carer representatives
Barnsley
Service user and carer representatives were
Dr Linda Harris supported and advised by national groups of
Clinical director, Wakefield Integrated Substance user and carer representatives respectively.
Misuse Services
Service user representatives
John Howard(representing service users)
Eliot Albert
Reading User Forum (RUF)
Sharyn Charlton
Dr Jenny Keen Andy Cornish
Clinical director, Primary Care Drug Misuse James Grieve
Services, Derby Gary Sutton
5
Drug misuse and dependence: UK guidelines on clinical management
Carer representatives Misuse and South London and Maudsley NHS
Patricia Boydell Foundation Trust
Dot Inger
Steve Taylor
Linda Moore
National Treatment Agency for Substance Misuse
Teresa Seymour
Christine Tebano Reviews
Jane White
A series of reviews was commissioned by the
NTA to advise the working group. In addition to
Observers
some obtained from members of the working
Yael Bradbury-Birrell
group, reviews were provided by:
Standards and Fitness to Practise Directorate,
Dr Neena Buntwal and Dr Sarah Welch
General Medical Council
Countywide Specialist Substance Misuse Service
Annette Dale-Perera
(Gloucestershire)
National Treatment Agency for Substance Misuse
Dr James Bell
Dr Nadine Harrison
The Langton Centre, Surry Hills, Australia
Primary and Community Care Directorate, the
Dr Franjo Grotenhermen
Scottish Government
Nova-Institut, Hürth, Germany
Sherife Hasan
Sarah Larney, Benjamin Phillips, Effat
Crime and Drug Strategy Directorate, Home
Merghati Khoei, Bradley Mathers and Kate
Office
Dolan
John Lenaghan
National Drug and Alcohol Research Centre,
Department for Social Justice and Local
University of New South Wales, Sydney
Government, Welsh Assembly Government
Dr Soraya Mayet
Rob Phipps and Ian McMaster
National Addiction Centre, London
Department of Health, Social Services and Public
Dr Louise Sell
Safety, Northern Ireland
Bolton, Salford and Trafford Mental Health NHS
Dr Stephen Pilling
Trust Substance Misuse Directorate
National Collaborating Centre for Mental Health,
Dr Kim Wolff
National Institute for Health and Clinical
King’s College London, National Addiction
Excellence
Centre, Institute of Psychiatry
Dr Mary Piper and David Marteau
Prison Health Policy Unit, Department of Health Other contributors
Dr Mark Prunty The working group sought some specific expert
Department of Health, England advice from beyond its membership and asked
some of these experts to help draft or revise
Deborah Smith
sections of the Clinical Guidelines. Experts
Public Health and Wellbeing Directorate, the
included:
Scottish Government
Dr Andrew Marsh and Richard Evers
Marion Walker
Toxicology Unit, Kings College Hospital, London
National Treatment Agency for Substance
Misuse and Berkshire Healthcare NHS Professor Graham Foster
Foundation Trust Centre for Gastroenterology, Queen Mary,
University of London
Dr Sarah Watkins
Department for Public Health and Health The working group would also like to thank the
Professions, Welsh Assembly Government many people who responded during the
consultation on the draft update to the Clinical
Secretariat
Guidelines, and the many others who
Dr Emily Finch contributed informally during the development
National Treatment Agency for Substance of the 2007 Clinical Guidelines.
6
Foreword
FOREWORD (cid:1) changes in contractual arrangements for
general practitioners who provide drug
treatment.
Who are the Clinical Guidelines for?
Drug Misuse and Dependence: UK Guidelines on NICE and the 2007 Clinical Guidelines
Clinical Management– hereafter referred to as
In 2004, the National Institute for Health and
the 2007 Clinical Guidelines – is intended for all
Clinical Excellence (NICE) was charged with
clinicians, especially those providing
developing a suite of guidelines and technology
pharmacological interventions for drug misusers
appraisals on various aspects of the treatment
as a component of drug misuse treatment.
and care of drug misusers. The 2007 Clinical
Guidelines were developed concurrently with the
What are the 2007
NICE suite of guidance on drug misuse
Clinical Guidelines?
treatment and NICE had observer status on the
This document updates and replaces Drug working group.
Misuse and Dependence – Guidelines on Clinical
NICE published technology appraisals in January
Management (UK health departments 1999) –
2007 on:
hereafter referred to as the 1999 Clinical
Guidelines. It has the same status across the UK (cid:1) methadone and buprenorphine maintenance
as the 1999 Clinical Guidelines.
(cid:1) naltrexone for relapse prevention.
The 2007 Clinical Guidelines provide guidance
NICE published its final clinical guidelines in July
on the treatment of drug misuse in the UK. They
2007 on:
are based on current evidence and professional
consensus on how to provide drug treatment for (cid:1) opioid detoxification
the majority of patients, in most instances. (cid:1) psychosocial interventions for drug misuse.
The 2007 Clinical Guidelines do not provide rigid NICE also produced public health guidance on
protocols on how clinicians must provide drug community-based interventions to reduce
treatment for all drug misusers. Neither does this substance misuse among vulnerable and
guidance override the individual responsibility of disadvantaged children and young people (NICE,
clinicians to make appropriate decisions in the 2007).
circumstances of the individual patient, in
The working group considered NICE clinical
consultation with the patient (and guardians and
guidelines and technology appraisals in drafting
carers if appropriate). In instances where
the 2007 Clinical Guidelines. The working group
clinicians operate outside the framework of this
interpreted and incorporated the NICE suite of
guidance, they should be able to demonstrate
guidance as appropriate, but the 2007 Clinical
the rationale for their decisions.
Guidelines cover the management and
Why update the Clinical Guidelines? treatment of drug misusers in a more wide-
ranging manner. These Clinical Guidelines and
UK guidelines for the clinical management of
NICE guidance should be taken together with
drug misuse were last revised in 1999. Since
other key documents to provide a
then there have been substantial developments
comprehensive picture of current clinical
in the evidence for drug treatment and clinical
guidelines on the treatment of drug misuse.
practice. These include:
It is important to note the different status of
(cid:1) greater recognition of and investment in the
NICE in England and Wales, Northern Ireland
importance of drug treatment and a massive
and Scotland.
expansion in the numbers receiving treatment in
the UK In England and Wales health professionals (and
their organisations) are expected to take NICE
(cid:1) an expanded evidence-base and resulting
guidance on health technologies and on clinical
policy and practice guidance
practice fully into account when exercising their
(cid:1) consensus on doctor competencies in clinical judgement. NICE guidance on public
substance misuse treatment (RCPsych and RCGP, health covers England only. In relation to the
2005) main types of guidance relating to drug misuse,
7
Drug misuse and dependence: UK guidelines on clinical management
Table 1 lists what NHS organisations are The status of the Clinical Guidelines
expected to do.
The 2007 Clinical Guidelines replace the
NHS Quality Improvement Scotland (NHS QIS) previous 1999 Clinical Guidelines. They have no
provides advice to NHSScotland on the suitability specific statutory status. However, any clinician
for Scotland of NICE advice and the status of not fulfilling the standards and quality of care in
NICE advice in Scotland varies according to the appropriate treatment of drug misusers as
product type. For NHS QIS-validated NICE set out in these guidelines will have this taken
multiple technology appraisals, NHSScotland will into account if, for any reason, their
take account of the advice and evidence from performance in this clinical area is assessed.
NHS QIS and ensure that recommended
medicines and treatment are made available to The General Medical Council states (GMC,
meet clinical need. This status applies to the 2006):
NICE multiple technology appraisals on (cid:1) You should be familiar with relevant
methadone and buprenorphine, and naltrexone.
guidelines and developments that affect your
NICE single technology appraisals and clinical
work.
guidelines currently have no formal status in
(cid:1) You must keep up to date with, and
Scotland and are for information only in
adhere to, the laws and codes of practice
NHSScotland.
relevant to your work.
In Northern Ireland the Department for Health,
(cid:1) You must provide effective treatments
Social Services and Public Safety reviews NICE
based on the best available evidence.
guidance for its applicability to Health and
Personal Social Services (HPSS) and decides
There are separate, defined legal obligations in
whether it should be endorsed for
relation to the prescribing of controlled drugs
implementation. NICE health technology
which clinicians should act in accordance with.
appraisals endorsed by the Department will be
In addition, doctors need to ensure that they act
treated as essential within the Quality Standards
within Home Office licensing arrangements for
for Health and Social Care. The NICE clinical
the prescription of diamorphine, dipipanone or
practice guidelines and public health guidance
cocaine for the management of drug misuse.
that have been endorsed will be regarded as
standards that the HPSS are expected to achieve Regulation and inspection
over time. As in England and Wales, it is
In England, the Healthcare Commission (HC) is
expected that endorsed NICE guidance will help
the inspection body for NHS and independent
health and social care professionals in their work
health care. It uses national guidance in this
but it does not override clinical responsibility for
context: NICE guidance is used in the HC annual
making decisions in specific circumstances.
health check, its programmes of review, and in
audit and assessment work. The joint HC and
NTA Improvement Reviews of drug treatment
also take into account NICE guidance and the
Type of NICE Recommendations for NHS Clinical Guidelines when setting criteria and
guidance organisations
benchmarking local commissioning partnerships
Clinical Review current management of and providers.
guideline clinical conditions and consider the
resources and time needed to Inspection and investigation of Welsh NHS
implement the guideline bodies and private and voluntary provision rest
with Healthcare Inspectorate Wales.
Technology Fund and resource medicines and
appraisal treatment recommended usually In Scotland, there are different organisational
within three months of NICE arrangements for the governance of different
issuing guideline
NHS and independent services. NHS boards are
Public health Review current practice and responsible and accountable for the quality of
guideline consider the resources and time NHS services provided directly or secured by
(England) needed to implement the guideline
contract. Services in the independent healthcare
sector required to register with the Scottish
Table 1: Expectations of NHS organisations in England
Commission for the Regulation of Care (‘the
and Wales in relation to NICE guidance
8
Foreword
Care Commission’) are regulated by it and are evidence-base for a range of drug misuse
expected to provide care and treatment that treatment-related issues, including: prison drug
reflects the relevant NHS QIS standards, and treatment; drugs and driving; injectable opioid
reflects good practice based on relevant treatment; methadone and buprenorphine dose
research-based studies, audit reports, standards, induction; drug testing and its use in practice;
guidelines and evidence-based treatments. drug treatment for young people; treatment of
substance misuse in pregnancy; cardiac
The Regulation and Quality Improvement
assessment and monitoring for methadone
Authority (RQIA) is the independent health and
prescribing. Reviewers were asked to provide
social care regulatory body responsible for
recommendations to be considered by the
monitoring and inspecting the availability and
working group and to rate both their
quality of health and social care services
recommendations and the evidence behind
delivered by Health and Personal Social Services
them in line with established systems.
(HPSS) bodies and the independent sector in
Northern Ireland. The working group also considered the key
messages from NICE guidance and other
The process for developing relevant research and guidance. The working
the 2007 Clinical Guidelines group then, by a process of consensus, came to
a view of the best available evidence from
In 2006, the Department of Health (England)
whatever source. The working group considered
and the authorities of the devolved
rating its recommendations and the evidence
administrations tasked the National Treatment
supporting them in line with common current
Agency for Substance Misuse (NTA) with
practice for guidelines. However, it decided
supporting an independent working group to
against this on the basis that the Clinical
update Drug Misuse and Dependence –
Guidelines have traditionally – and usefully –
Guidelines on Clinical Management(UK health
provided consensus opinion which draws
departments, 1999). It was agreed that it would
extensively on clinical experience as well as on
still be sensible to issue a single set of guidelines
published research. By doing this it is able to
for the whole of the UK that would provide a
make recommendations on important subjects
skeleton framework of best practice from which
beyond those with a substantial research
the devolved administrations could develop their
evidence base and in a way that is of practical
own guidance on locally appropriate variations
use to clinicians. The strength of the working
in policy and practice. The terms of reference of
group’s recommendations and its opinion on the
the working group were to update the 1999
quality of the supporting evidence is indicated by
Clinical Guidelines in 2007.
judicious wording of the recommendation and
The chair of the 1999 (and 1991) guidelines of the accompanying text.
working group, Professor John Strang, was
Members of the clinical guidelines working
invited to again chair the group. The NTA
group were fully involved in the consultation
convened and provided a secretariat for the
process, which was conducted by the NTA. All
independent working group and separate user
consultation responses were collated and fed
and carer advisory groups.
back to the group at regular intervals during the
The working group included members who consultation period. The group was asked to
brought a wide range of individual expertise, comment on key issues arising and their advice
continuity with previous guidelines, and taken into account when redrafting the
representation of key groups of stakeholders. document. A meeting of the working group was
These included addiction psychiatrists, general held to discuss topics that were the focus of
practitioners, nurses, pharmacists, service user most consultation comment, or where more
and carer representatives. The service user and discussion or consensus was required. Issues
carer representatives were supported by their amended or clarified as a result of the
own advisory groups. Government departments, consultation process included child protection
the NTA and others had observer status. and blood-borne infections. Greater emphasis
has been put on child protection and clinicians’
Development of the updated guidelines began
responsibilities to maximise opportunities to
with the commissioning of a series of reviews to
identify and prevent harm to both the children
advise the working group on the current
of drug-misusing parents and young drug
9
Drug misuse and dependence: UK guidelines on clinical management
misusers themselves. In relation to blood-borne
infections, much greater detail on hepatitis C
has been included and information has been
added on bacterial infections that may be an
increasing problem in drug misusers.
The 1999 Clinical Guidelines noted that “there is
currently, with some exceptions, a limited
amount of rigorous reviews in this area”.
Although the evidence base for drug misuse
treatment has improved, the working group
found that, in many areas of drug treatment,
evidence was either lacking or was based on
research from countries other than the UK.
References
GMC (2006) Good Medical Practice: Guidance
for Doctors. London: General Medical Council.
NICE (2007) Community-Based Interventions to
Reduce Substance Misuse Among Vulnerable
and Disadvantaged Children and Young People.
Public Health Intervention Guidance 4. London:
NICE.
RCPsych and RCGP (2005) Roles and
Responsibilities of Doctors in the Provision of
Treatment for Drug and Alcohol Misusers.
Council Report CR131. London: Royal College of
Psychiatrists and Royal College of General
Practitioners.
UK health departments (1999) Drug Misuse and
Dependence – Guidelines on Clinical
Management. London: The Stationery Office.
10