Drug addicts who are receiving methadone maintenance treatment should be given incentives, such as shopping vouchers, each time they test negative for the presence of drugs, to encourage them to keep off drugs, says a draft guideline on the psychosocial management of drug misuse by the NHS in England and Wales.
The draft guideline recommends that services for drug misusers should introduce contingency management programmes that use incentives to reduce illicit drug use and that improve engagement with those services among people undergoing methadone maintenance treatment. Incentives, which would usually be privileges such as access to a rapid dosing line, or vouchers, would be given each time a patient tests negative for the presence of drugs.
The guidance suggests that vouchers should have a value of £5 and should increase in value with each additional and continuing(?) period of abstinence.
Screening—probably by urinalysis—should be carried out three times each week for the first three weeks, twice a week for the next three weeks, and then once weekly until the patient has achieved stability.
The draft guideline also recommends the use of modest material incentives, such as shopping vouchers, to encourage specific harm reduction objectives, such as attending for hepatitis B and C and HIV testing.
The guideline aims to provide evidence based recommendations for the management in the healthcare and criminal justice systems of people who misuse opiates, stimulants, and cannabis. It was developed after a review of the available evidence by a committee from the National Collaborating Centre for Mental Health. The centre was commissioned by the National Institute for Health and Clinical Excellence (NICE), the organisation that advises the NHS on treatments.
The guideline development committee found evidence that contingency management is effective in reinforcing a range of behaviours, including abstinence from drugs, reducing drug use, and promoting engagement with psychosocial interventions. However, it warned that implementing such a programme in practice would need careful organisation.
Stephen Pilling, joint director of the National Collaborating Centre for Mental Health and facilitator of the NICE group, estimated that 50 000 addicts in England and Wales could take part in the scheme. He considered that it could help up to half of them stay off drugs.
“It [contingency management] provides a much better and positive way to relate to drug users than sometimes we have done in the past. I don't think it's bribery: I think it's an effective treatment that brings real benefit,” he said.
At a broader level, the draft guideline recommends that healthcare professionals should involve people who misuse drugs in decisions on their treatment, including options to promote and maintain abstinence and reduce harm.
People in limited contact with services, such as those who attend needle and syringe exchange services, should be offered opportunistic brief interventions. Family based or couple based interventions should be considered for people who are in close contact with a partner, family member, or carer and who continue to use illicit drugs when in opiate agonist maintenance treatment.
NICE has also published guidance on the management of opioid dependence. It recommends methadone and buprenorphine as options for maintenance therapy to manage opioid dependence, and it recommends naltrexone as a treatment option for detoxified, formerly opioid dependent people who are highly motivated to remain free of opioid use.
Methadone and buprenorphine should be administered daily, under supervision, for at least the first three months. Supervision should be relaxed only when the patient's compliance is assured.
Naltrexone should be administered only under adequate supervision to people who have been fully informed of the potential adverse effects of treatment. All three drugs should be given as part of a programme of supportive care.
Mr Pilling explained that the draft guideline was part of a series of new guidelines for the NHS on the management of drug misuse. He noted that the bulk of NHS treatment at present focuses on the use of substitutes, such as methadone for heroin addicts. “Substitute prescribing is very effective, but psychological and psychosocial interventions are not as well used in the UK as they might be.”
Contingency management is a very well researched strategy for positive reinforcement, Mr Pilling explained. He said evidence indicated that it could reduce illicit drug use by about 50% among people on methadone treatment programmes. Implementation programmes had shown that benefits achieved in trials continued in the longer term.
Drug Misuse—Psychosocial: NICE Guideline is at www.nice.org.uk/page.aspx?o=397260. Drug Misuse—Methadone and Buprenorphine and Drug Misuse—Naltrexone can be found at www.nice.org.uk.
