Psychosocial interventions and opioid detoxification for drug misuse: summary of NICE guidance

Why read this summary?

Drug misuse is an increasing problem that not only impairs the physical and mental health of people who misuse drugs but also negatively affects their families and wider society (for example, in its association with crime). Recently expanded drug services in the United Kingdom involve general practitioners to a considerable degree, who care for at least a third of opioid misusers in treatment. Many clinicians remain pessimistic, however, about the possible benefits of any treatment and how to engage drug users in treatment.¹ This article summarises two new NICE guidelines that identify the most effective, safe detoxification regimens for primary and secondary care, the most cost effective psychosocial interventions, and effective ways to promote patient engagement.^{2 3}

Recommendations

NICE recommendations are based on systematic reviews of best available evidence. When minimal evidence is available, a range of consensus techniques is used to develop recommendations. In this summary, recommendations derived primarily from consensus techniques are indicated with an asterisk (*).

Opioid detoxification

General principles

For all patients who are opioid dependent and have expressed an informed choice to become abstinent, services should:

• Offer detoxification as a readily available and effective treatment option;

• Provide detailed information about detoxification and the associated risks, including:

• • - The physical and psychological aspects of opioid withdrawal, including the duration and intensity of symptoms

  • - How such symptoms may be managed, including non-pharmacological approaches

  • - The loss of opioid tolerance after detoxification, and the ensuing increased risk of overdose and death from illicit drug use (this risk may be potentiated by alcohol or benzodiazepine use)

  • - The importance of continued support, and psychosocial and appropriate pharmacological interventions, to maintain abstinence, treat comorbid mental health problems, and reduce the risks of serious adverse events (including death) that may arise as a result of reduced opioid tolerance;

• *Offer a community based detoxification programme routinely, except to individuals who:

• • - Have not benefited from previous community based detoxification

  • - Need medical and/or nursing care because of significant additional physical or mental health problems

  • - Require complex polydrug detoxification (for example, concurrent detoxification from alcohol or benzodiazepines)

  • - Are experiencing considerable social problems that may substantially limit the benefit of a community based detoxification programme.

Pharmacological interventions

• Offer buprenorphine or methadone as first line treatment, depending on:

• • - Whether the patient is receiving maintenance treatment with either drug, as detoxification should normally be started with the same medication

  • - The service user's preference;

• Consider lofexidine, particularly for those with mild or uncertain dependence, but warn patients that this necessitates the use of adjunct medications to manage withdrawal symptoms such as nausea, vomiting and shivering as lofexidine may not sufficiently attenuate the noradrenergic storm, and that outcomes are likely to be no better than for buprenorphine or methadone;

• Do not use clonidine routinely because its outcomes are likely to be no better than for buprenorphine or methadone and because of the associated risk of hypotension;

• Do not use opioid antagonists (such as naltrexone) to precipitate or accelerate withdrawal as it seems to increase severity of withdrawal, necessitates the use of increased adjunctive medication, and no consistent evidence exists for improved long term outcomes;

• Do not routinely use drugs such as benzodiazepines, minor analgesics, or antidiarrhoeals to manage opioid withdrawal symptoms. This is to reduce the risks associated with specific drugs, drug interactions, and problems with adherence. Only use these medications when clinically indicated;

• Do not offer ultrarapid detoxification under general anaesthesia or heavy sedation (where the airway needs to be supported) owing to the risk of serious adverse events, including death.

Psychosocial interventions in drug misuse

Formal psychosocial interventions have not been widely used in UK drugs services, but the evidence reviewed by NICE shows that increased use of these interventions can bring real benefits.

Individual healthcare staff

• Offer opportunistic brief interventions focused on motivation to people in limited contact with services (for example, those attending a needle and syringe exchange or primary care settings). These interventions should:

• • - Comprise one or two sessions of 10-45 minutes' duration

  • - Express empathy with the service user; explore ambivalence about drug use and possible treatment options; and provide non-judgmental feedback aimed at increasing motivation to change behaviour;

• Routinely provide information about self help groups, often based on 12-step principles (for example, Narcotics Anonymous and Cocaine Anonymous).

Drug misuse services

• Consider introducing contingency management as part of a phased implementation programme led by the National Treatment Agency to reduce illicit drug use and/or promote engagement with services for people in methadone maintenance programmes or who misuse stimulants.

• Contingency management should include:

• • - Incentives such as vouchers or privileges, contingent on each presentation of a drug negative test result (for example, free from cocaine or non-prescribed opioids); such vouchers may be exchanged for goods or services, and privileges to increase the service user's choice (for example, use of take-home methadone doses); vouchers should have monetary values that start at about £2 (€3; $4) and increase with each additional, continuous period of abstinence;

  • - Drug tests (three tests a week for the first three weeks, two tests a week for the next three weeks, and once weekly thereafter until stability is achieved); urine analysis is the preferred method of testing, but oral fluid tests may be used as an alternative.

• For those at risk of physical comorbidity from drug misuse, consider material incentives (such as shopping vouchers of up to £10 in value) on a one-off basis or over a limited duration, contingent on concordance with specified harm reduction activities, particularly for:

• • - Hepatitis B or C and HIV testing

  • - Hepatitis B immunisation

  • - Tuberculosis testing.

Overcoming barriers

In recent years drug treatment has focused on harm reduction rather than abstinence as a goal, but the evidence on detoxification makes clear that abstinence is an effective treatment option. Furthermore, although psychosocial interventions for drug misuse are not well developed, the evidence suggests that they can bring real benefits, in part through increasing the value of currently used treatments.

Contingency management has been little used in the UK, is open to misunderstanding by clinicians and the general public, and will require considerable training of staff and service development if it is to be introduced appropriately and effectively. It involves a new way of thinking, with the use of positive incentives instead of negative approaches such as the withholding of treatment. The evidence is that, particularly with this patient population, behaviour can be positively shaped with incentives, whereas threats and punishment have little influence. Overseas trials involving more than 5000 patients across more than 25 studies have consistently shown that such an approach reduces illicit drug use, is cost effective, and improves engagement in harm reduction and treatment programmes.

To tackle these challenges, it is proposed that the National Treatment Agency in the UK will establish a network of demonstration centres, which will develop materials to support a phased implementation of contingency management, support staff training and supervision programmes, and assess the relative value of different incentive systems.

Current practice and what's new

Current practice

A recent survey of inpatient detoxification identified the widespread use of a range of medications in detoxification.⁴ These included medications not found to be effective and/or requiring substantial adjunctive medications (for example, naloxone precipitated detoxification, clonidine). Recently the development and evaluation of psychosocial interventions for drug misuse has increased. However, few published data exist on the provision of psychosocial interventions for drug misuse in the UK. Recent evidence suggests that some interventions are not consistently provided.⁵

What's new in the guidelines?

The guidelines recommend that contingency management should be used for the treatment of primary stimulant misuse and for illicit drug use in methadone maintenance treatment. The recommendations were based on the findings that contingency management had the most consistent evidence base of all psychosocial interventions for these groups.^{6 7} However, despite the strength of the evidence, this intervention is not widely used in the UK, with only a few services piloting such programmes.^{5 8}

Drug misuse is associated with a greater risk of certain physical health problems (for example, hepatitis C). However, people who misuse drugs are often not aware they have these problems,⁹ or if they are aware, they are less likely to adhere to treatment. Contingency management was found to be much more effective than usual care or outreach in promoting identification and adherence to treatment of physical health problems. ^{10 11}

Further information about the guidance

Methods

The guidelines were developed according to NICE guideline methodology (see www.nice.org.uk/page.aspx?o=114219) by the National Collaborating Centre for Mental Health. The collaborating centre convened a development group of clinicians and patient and carer representatives for each guideline to oversee the work and develop the recommendations. The groups conducted extensive systematic reviews of the clinical and economic literature and assessed the quality of this literature. The guidelines went through an external consultation with stakeholders. The development groups assessed the comments, reanalysed the data where necessary, and modified the guidelines. NICE has produced four different versions of each guideline: a full version; a quick reference guide (which combines both guidelines); a version known as the “NICE guideline” that summarises the recommendations; and a version for patients and the public. All these versions are available from the NICE website (see www.nice.org.uk/CG051 and www.nice.org.uk/CG052). Future updates of the guidelines will be produced as part of the NICE guideline development programme.¹²

Future research and remaining uncertainties

Evidence is lacking on a comparison of residential and community based settings, particularly for detoxification. Whether the substantially greater resources required for residential detoxification are associated with comparably better outcomes is still unclear.

Related NICE guidance

• National Institute for Health and Clinical Excellence. Interventions to reduce substance misuse among vulnerable young people. London: NICE, 2007. (Public health intervention guidance) (www.nice.org.uk/PHI004)

• National Institute for Health and Clinical Excellence. Methadone and buprenorphine for managing opioid dependence. London: NICE, 2007. (Technology appraisal) (www.nice.org.uk/TA114)

• National Institute for Health and Clinical Excellence. Naltrexone for the management of opioid dependence. London: NICE, 2007. (Technology appraisal) (www.nice.org.uk/TA115)