Drug misuse

Short Text

Psychosocial interventions and opioid detoxification

Introduction

This pathway covers psychosocial interventions and opioid detoxification for drug misuse.
The pathway makes recommendations for the use of psychosocial interventions in the treatment of people who misuse opioids, stimulants and cannabis in the healthcare and criminal justice systems. It also covers treatment of people who are undergoing detoxification for opioid dependence arising from the misuse of illicit drugs. Opioid detoxification refers to the process by which the effects of opioid drugs are eliminated from dependent opioid users in a safe and effective manner, such that withdrawal symptoms are minimised.
This pathway should be used in conjunction with 'Drug misuse and dependence – UK guidelines on clinical management: update 2007', also known as the 'Orange Book', which provides advice to healthcare professionals on the delivery and implementation of a broad range of interventions for drug misuse, including those interventions covered in the present guideline. For more information visit The National Treatment Agency for Substance Misuse website.

Source guidance

The NICE guidance that was used to create the pathway.
Drug misuse: opioid detoxification. NICE clinical guideline 52 (2007)
Drug misuse: psychosocial interventions. NICE clinical guideline 51 (2007)
Naltrexone for the management of opioid dependence. NICE technology appraisal 115 (2007)

Quality standards

Quality statements

Needle and syringe programmes

This quality statement is taken from the drug use disorders quality standard. The quality standard defines clinical best practice in drug use disorders and should be read in full.

Quality statement

People who inject drugs have access to needle and syringe programmes in accordance with NICE guidance.

Rationale (Why is this important?)

Needle and syringe programmes can reduce transmission of blood-borne viruses and other infections caused by sharing injecting equipment. High quality programmes may reduce other harm associated with drug misuse, for example by advising on safer injecting practices, access to drug treatment and testing, vaccination and treatment for blood-borne viruses.

Quality measure

Structure
Evidence of local arrangements to ensure people who inject drugs have access to needle and syringe programmes in accordance with NICE guidance.
Outcome
a) Proportion of people who inject drugs who access needle and syringe programmes.
Numerator: the number of people who access needle and syringe programmes.
b) Incidence of blood-borne viruses among people who inject drugs.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for people who inject drugs to have access to needle and syringe programmes in accordance with NICE guidance.
Needle and syringe programme staff ensure people who inject drugs have access to needle and syringe programmes in accordance with NICE guidance.
Commissioners ensure they commission services for people who inject drugs to have access to needle and syringe programmes in accordance with NICE guidance.
People who inject drugs have access to needle and syringe programmes that are nearby, have suitable opening hours and provide injecting equipment and advice on reducing the risk of harm.

Source clinical guideline references

NICE public health guidance 52 recommendations 1-6.

Data source

Structure
Local data collection.
Outcome
a) Local data collection and Glasgow prevalence data from National Treatment Agency for Substance Misuse.
b) Local data collection.

Definitions

NICE public health guidance 52 defines the type of needle and syringe programmes which should be available.
NICE public health guidance 52 recommends that needle and syringe programme services should meet local need, for example they should take into account opening times, location and geography of the location (rural or urban) as well as the level of services needed.
NICE public health guidance 52 recommends that pharmacies, specialist needle and syringe programmes and other healthcare settings should be used to provide a balanced mix of the following services:
  • level 1: distribution of injecting equipment either loose or in packs with written information on harm reduction
  • level 2: distribution of 'pick and mix' injecting equipment plus health promotion advice
  • level 3: level 2 plus provision of, or referral to, specialist services.
Blood-borne viruses include hepatitis B, hepatitis C and HIV.

Equality and diversity considerations

A number of specific groups of injecting drug users may require special consideration as outlined in NICE public health guidance 52. These groups include:
  • homeless people, who are more likely to share needle and syringe equipment on a regular basis than others who inject drugs
  • women, whose drug use may be linked to specific behaviours and lifestyles that put them at an increased risk of HIV and hepatitis infections
  • users of anabolic steroids and other performance- and image-enhancing drugs
  • the prison population, which contains a higher than average number of injecting drug users.

Assessment

This quality statement is taken from the drug use disorders quality standard. The quality standard defines clinical best practice in drug use disorders and should be read in full.

Quality statement

People in drug treatment are offered a comprehensive assessment.

Rationale (Why is this important?)

People with drug use disorders have a better chance of recovery, and of maintaining recovery in the longer term, if their resources for recovery are assessed and tailored advice and support is provided.
An assessment is intended to identify needs and determine appropriate interventions and the key resources available and needed to support recovery and prevent relapse.

Quality measure

Structure
Evidence of local arrangements to ensure people in drug treatment are offered a comprehensive assessment.
Process
Proportion of people in drug treatment who receive a comprehensive assessment.
Numerator: the number of people in the denominator receiving a comprehensive assessment.
Denominator: the number of people in drug treatment.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for people in drug treatment services to be offered a comprehensive assessment.
Healthcare professionals offer people in drug treatment a comprehensive assessment.
Commissioners ensure they commission services that offer people in drug treatment a comprehensive assessment.
People in drug treatment are offered a full assessment of their drug use and needs in relation to recovery.

Source clinical guideline references

NICE clinical guideline 51 recommendations 1.2.2.1 and 1.2.2.3.

Data source

Structure
Local data collection.
Process
Local data collection. The National Drug Treatment Monitoring System collects data on all clients receiving specialist treatment for their problematic use of drugs; some aspects of the assessment of resources for recovery are collected, such as 'accommodation need', 'acute housing problems', 'housing risk', 'employment status', 'education' and 'paid work'.

Definitions

A comprehensive assessment should consider both drug use and resources for recovery and include:
  • treating the emergency or acute problem
  • confirming the person is taking drugs (history, examination and drug testing)
  • assessing the degree of dependence
  • assessing physical and mental health
  • identifying social assets, including housing, employment, education and support networks
  • assessing risk behaviour including domestic violence and offending
  • determining the person's expectations of treatment and desire to change
  • determining the need for substitute medication
  • obtaining information on any dependent children of parents who misuse drugs, and any drug-related risks to which they may be exposed.

Equality and diversity considerations

All assessments should be accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English. People who need a comprehensive assessment should have access to an interpreter or advocate if needed.

Families and carers

This quality statement is taken from the drug use disorders quality standard. The quality standard defines clinical best practice in drug use disorders and should be read in full.

Quality statement

Families and carers of people with drug use disorders are offered an assessment of their needs.

Rationale (Why is this important?)

Drug use disorders affect the entire family and the communities in which these families live. Families and carers of people with drug use disorders are often in need of support for themselves. An assessment is important to identify their needs and determine appropriate interventions for those needs that are unmet.

Quality measure

Structure
Evidence of local arrangements to ensure families and carers of people with drug use disorders are offered an assessment of their needs.
Process
Proportion of identified family members and carers of people with drug use disorders who are offered an assessment of their needs.
Numerator: the number of people in the denominator offered an assessment of their needs.
Denominator: the number of identified family members and carers of people with drug use disorders.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for families and carers of people with drug use disorders to be offered an assessment of their own specified needs.
Healthcare professionals ensure families and carers of people with drug use disorders are offered an assessment of their own specified needs.
Commissioners ensure they commission services that offer families and carers of people with drug use disorders an assessment of their own specified needs.
Families and carers of people with drug use disorders are offered an assessment of their own specified needs.

Source clinical guideline references

NICE clinical guideline 51 recommendation 1.1.2.1.
NICE clinical guideline 52 recommendation 1.1.2.1.

Data source

Structure
Local data collection.
Process
Local data collection.

Definitions

'Family members and carers' includes anyone affected by the person with the drug use disorder who approaches services, regardless of whether or not the person with the drug use disorder is in treatment.
An assessment should address the needs of the family member and carer and include those elements outlined in the National Treatment Agency for substance misuse guide Supporting and involving carers: a guide for commissioners and providers (page 13).
Family and carers’ needs include personal, social and mental health needs.

Equality and diversity considerations

All assessments should be accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English. People who need an assessment should have access to an interpreter or advocate if needed.

Blood-borne viruses

This quality statement is taken from the drug use disorders quality standard. The quality standard defines clinical best practice in drug use disorders and should be read in full.

Quality statement

People accessing drug treatment services are offered testing and referral for treatment for hepatitis B, hepatitis C and HIV and vaccination for hepatitis B.

Rationale (Why is this important?)

Blood-borne viruses can cause chronic poor health and can lead to serious disease and premature death. Rates of infection with blood-borne viruses are high among people with drug use disorders, specifically those who inject drugs. Vaccination can protect against hepatitis B and carrying out testing to diagnose infection with blood-borne viruses is the first step in preventing transmission and accessing treatment.

Quality measure

Structure
a) Evidence of local arrangements to ensure people accessing drug treatment services are offered testing for hepatitis B, hepatitis C and HIV, and referral for treatment if positive.
b) Evidence of local arrangements to ensure people accessing drug treatment services are offered vaccination for hepatitis B.
Process
a) Proportion of people accessing drug treatment services, not known to have hepatitis B, who receive testing for hepatitis B.
Numerator: the number of people in the denominator receiving testing for hepatitis B.
Denominator: the number of people accessing drug treatment services not known to have hepatitis B.
b) Proportion of people accessing drug treatment services who test positive for hepatitis B and are referred for treatment.
Numerator: the number of people in the denominator referred for treatment for hepatitis B.
Denominator: the number of people accessing drug treatment services who test positive for hepatitis B.
c) Proportion of people accessing drug treatment services, not known to have hepatitis C, who receive testing for hepatitis C.
Numerator: the number of people in the denominator receiving testing for hepatitis C.
Denominator: the number of people accessing drug treatment services not known to have hepatitis C.
d) Proportion of people accessing drug treatment services who test positive for hepatitis C and are referred for treatment.
Numerator: the number of people in the denominator referred for treatment for hepatitis C.
Denominator: the number of people accessing drug treatment services who test positive for hepatitis C.
e) Proportion of people accessing drug treatment services, not known to have HIV, who receive testing for HIV.
Numerator: the number of people in the denominator receiving testing for HIV.
Denominator: the number of people accessing drug treatment services not known to have HIV.
f) Proportion of people accessing drug treatment services who test positive for HIV and are referred for treatment.
Numerator: the number of people in the denominator referred for treatment for HIV.
Denominator: the number of people accessing drug treatment services who test positive for HIV.
g) Proportion of people accessing drug treatment services who are vaccinated against hepatitis B (either by the service or previously).
Numerator: the number of people in the denominator who are vaccinated against hepatitis B.
Denominator: the number of people accessing drug treatment services who are not known to have hepatitis B.

Outcome

Rate of hepatitis B infection in people with drug use disorders.
Rate of hepatitis C infection in people with drug use disorders.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for people accessing drug treatment services to be offered testing and referral for treatment for hepatitis B, hepatitis C and HIV, and vaccination for hepatitis B.
Healthcare professionals ensure people accessing drug treatment services are offered testing and referral for treatment for hepatitis B, hepatitis C and HIV, and vaccination for hepatitis B.
Commissioners ensure they commission services that offer people accessing drug treatment services testing and referral for treatment for hepatitis B, hepatitis C and HIV, and vaccination for hepatitis B.
People accessing drug treatment services are offered tests and, if needed, referral for treatment for hepatitis B, hepatitis C and HIV, and vaccination for hepatitis B.

Source clinical guideline references

NICE clinical guideline 51 recommendation 1.3.1.1.

Data source

Structure
a) and b) Local data collection.
Process
c), d) and g) Local data collection. The National Drug Treatment Monitoring System collects data on all clients receiving specialist treatment for their drug use; 'Hep C tested', 'Hep C intervention status', 'Hep C positive?', 'Referred for hepatology', 'Hep B vaccination count' and 'Hep B intervention status' are collected.
a), b), e) and f) Local data collection.
Outcome
Local data collection.

Definitions

The term 'accessing drug treatment services' is defined as being in contact with any drug service, including needle and syringe programmes.
Testing should not be performed only once. It should be repeated when necessary because a person's situation may change.
People with drug use disorders who are vaccinated against hepatitis B should receive the full course, which consists of 3 injections of hepatitis B vaccine over a period of 4 to 6 months.

Information and advice

This quality statement is taken from the drug use disorders quality standard. The quality standard defines clinical best practice in drug use disorders and should be read in full.

Quality statement

People in drug treatment are given information and advice about the following treatment options: harm reduction, maintenance, detoxification and abstinence.

Rationale (Why is this important?)

Appropriate information and advice about available treatment options will help people make informed choices about their treatment goals and the type of treatment and support likely to help them.

Quality measure

Structure
a) Evidence of local arrangements to ensure people in drug treatment are given information and advice about the following treatment options: harm reduction, maintenance, detoxification and abstinence.
b) Evidence of local arrangements for provision of all treatment options by local services.
Process
Proportion of people in drug treatment receiving information and advice about the following treatment options: harm reduction, maintenance, detoxification and abstinence.
Numerator: the number of people in the denominator receiving information and advice about the following treatment options: harm reduction, maintenance, detoxification and abstinence.
Denominator: the number of people in drug treatment.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for people in drug treatment to be given information and advice about the following treatment options: harm reduction, maintenance, detoxification and abstinence.
Healthcare professionals give people in drug treatment information and advice about the following treatment options: harm reduction, maintenance, detoxification and abstinence.
Commissioners ensure they commission services in which information and advice on the following treatment options are given to people in drug treatment: harm reduction, maintenance, detoxification and abstinence.
People in drug treatment receive information and advice about the following treatment options: treatment to help people reduce the risks of taking illegal drugs (harm reduction), taking a substitute drug (such as methadone or buprenorphine) for people dependent on opioids such as heroin (maintenance), reducing opioid use in a safe and effective manner (detoxification) or treatment to help people stop taking drugs (abstinence).

Source clinical guideline references

NICE clinical guideline 51 recommendation 1.1.1.1.
Drug misuse and dependence: UK guidelines on clinical management section 3.3.2, and paragraphs 4.3.1.1 and 4.3.1.3.

Data source

Structure
Local data collection.
Process
Local data collection. Contained within NICE clinical guideline 51 audit support (criteria for person-centred care), criterion 1.

Equality and diversity considerations

All information and advice about treatment 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. People with drug use disorders should have access to an interpreter or advocate if needed.

Keyworking – psychosocial interventions

This quality statement is taken from the drug use disorders quality standard. The quality standard defines clinical best practice in drug use disorders and should be read in full.

Quality statement

People in drug treatment are offered appropriate psychosocial interventions by their keyworker.

Rationale (Why is this important?)

Psychosocial interventions can improve the therapeutic relationship between the keyworker and the person with the drug use disorder. This can help to improve motivation, participation in treatment, the likelihood of recovery and prevention of relapse.

Quality measure

Structure
Evidence of local arrangements to ensure people in drug treatment are offered appropriate psychosocial interventions by their keyworker.
Process
Proportion of people in drug treatment who receive appropriate psychosocial interventions from their keyworker.
Numerator: the number of people in the denominator receiving appropriate psychosocial interventions from their keyworker.
Denominator: the number of people in drug treatment.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for people in drug treatment to be offered appropriate psychosocial interventions by their keyworker.
Keyworkers offer people in drug treatment appropriate psychosocial interventions.
Commissioners ensure they commission services that offer people in drug treatment appropriate psychosocial interventions from their keyworker.
People in drug treatment are offered psychosocial support by their keyworker, which may involve 'talking therapies' to help increase motivation and prevent relapse, and creating visual 'maps' to help support their treatment.

Source clinical guideline references

Drug misuse and dependence: UK guidelines on clinical management sections 3.3.2 and 4.2.1, and paragraphs 4.3.1.4, 4.3.1.5 and 4.3.1.6.

Data source

Structure
Local data collection.
Process
Local data collection. The National Drug Treatment Monitoring System collects data on all clients receiving specialist treatment for their problematic use of drugs; data on a range of psychosocial interventions are collected.

Definitions

Psychosocial interventions need to be appropriate to the service user's needs and circumstances. Drug misuse and dependence: UK guidelines on clinical management lists relevant interventions which can be offered by the keyworker. These include:
  • motivational interviewing
  • relapse prevention
  • goal setting and problem solving
  • brief motivational interventions
  • recovery planning.
All of the above can be supported through the use of mapping techniques.
The Drug misuse and dependence: UK guidelines on clinical management defines a keyworker as a key individual or clinician, for example a doctor, nurse or voluntary sector drugs worker who is in regular contact with the service user. If the person has complex needs it is important that the keyworker is a single named individual.

Recovery and reintegration

This quality statement is taken from the drug use disorders quality standard. The quality standard defines clinical best practice in drug use disorders and should be read in full.

Quality statement

People in drug treatment are offered support to access services that promote recovery and reintegration including housing, education, employment, personal finance, healthcare and mutual aid.

Rationale (Why is this important?)

People with drug use disorders have a better chance of recovery and reintegration, and maintaining recovery in the longer term, if they are supported to access services that promote recovery.

Quality measure

Structure
Evidence of local arrangements to ensure people in drug treatment are offered support to access services that promote recovery and reintegration, including housing, education, employment, personal finance, healthcare and mutual aid.
Process
Proportion of people in drug treatment who receive support to access services that promote recovery and reintegration.
Numerator: the number of people in the denominator receiving support to access services that promote recovery and reintegration.
Denominator: the number of people in drug treatment.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for people in drug treatment to be offered support to access services that promote recovery and reintegration, including housing, education, employment, personal finance, healthcare and mutual aid.
Healthcare professionals ensure people in drug treatment are offered support to access services that promote recovery and reintegration, including housing, education, employment, personal finance, healthcare and mutual aid.
Commissioners ensure they commission services that offer people in drug treatment support to access services that promote recovery and reintegration, including housing, education, employment, personal finance, healthcare and mutual aid.
People in drug treatment are offered support to help them recover and integrate back into the community, including getting help from housing, education, employment, personal finance and healthcare services and mutual aid.

Source clinical guideline references

NICE clinical guideline 51 recommendations 1.3.2.1 (key priority for implementation) and 1.3.2.2.
NICE clinical guideline 52 recommendation 1.1.1.6.
Drug misuse and dependence: UK guidelines on clinical management section 3.2.5 and paragraphs 4.3.1.2, 4.3.1.7 and 4.3.2.5.

Data source

Structure
Local data collection.
Process
Local data collection. The National Drug Treatment Monitoring System collects data on all clients receiving specialist treatment for their problematic use of drugs. Data on a range of recovery support interventions are collected.

Definitions

Definitions of support for housing, education, employment and healthcare should be taken from the National Drug Treatment Monitoring System dataset.
Mutual aid services include SMART (self-management and recovery training) recovery and those based on 12-step principles, for example Narcotics Anonymous, Alcoholics Anonymous and Cocaine Anonymous.
NICE clinical guideline 51 states examples of support that may be considered to assist people with drug use disorders to make initial contact with a self-help group. These include making appointments, arranging transport, accompanying people to their first session and dealing with any concerns. Support also includes the provision of information and advice.

Equality and diversity considerations

People in drug treatment should receive support to access services that promote recovery, tailored to their individual needs.

Formal psychosocial interventions and psychological treatments

This quality statement is taken from the drug use disorders quality standard. The quality standard defines clinical best practice in drug use disorders and should be read in full.

Quality statement

People in drug treatment are offered appropriate formal psychosocial interventions and/or psychological treatments.

Rationale (Why is this important?)

Evidence-based psychosocial interventions are effective in the treatment of people with drug use disorders. For the best chance of recovery a range of interventions should be provided to meet different needs.
Many people with drug use disorders have comorbid problems, particularly mental health problems that need concurrent or sequential interventions for treatment to be effective.

Quality measure

Structure
Evidence of local arrangements to ensure people in drug treatment are offered appropriate formal psychosocial interventions and/or psychological treatments.
Process
a) Proportion of people in drug treatment who receive appropriate formal psychosocial interventions.
Numerator: the number of people in the denominator receiving appropriate formal psychosocial interventions.
Denominator: the number of people in drug treatment.
b) Proportion of people in drug treatment who have comorbid depression or anxiety disorders who receive psychological treatments for those disorders.
Numerator: the number of people in the denominator receiving psychological treatments for those disorders.
Denominator: the number of people in drug treatment who have comorbid depression or anxiety disorders.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for people in drug treatment to be offered appropriate formal psychosocial interventions and/or psychological treatments.
Healthcare professionals offer people in drug treatment appropriate formal psychosocial interventions and/or psychological treatments.
Commissioners ensure they commission services that offer people in drug treatment, appropriate formal psychosocial interventions and/or psychological treatments.
People in drug treatment are offered psychosocial treatments including contingency management, behavioural couples therapy and/or psychological treatments that are suitable for their needs.

Source clinical guideline references

NICE clinical guideline 51 recommendations 1.4.1.4 and 1.4.2.1 (key priorities for implementation), 1.4.1.3, 1.4.4.1 and 1.4.6.2.
NICE clinical guideline 52 recommendations 1.5.1.2 and 1.5.1.3.

Data source

Structure
Local data collection

Process

a) and b) Local data collection. The National Drug Treatment Monitoring System collects data on all clients receiving specialist treatment for their problematic use of drugs. Data on a range of psychosocial interventions are collected.

Definitions

Formal psychosocial interventions
‘Formal psychosocial interventions’ have 3 aspects:
  • they need specific competencies to deliver them
  • they are supported by the relevant training and supervision
  • they are an enhanced level of intervention (above and beyond the standard keyworking platform).
Evidence based formal psychosocial interventions are listed in Drug misuse and dependence: UK guidelines on clinical management, NICE clinical guideline 51 and NICE clinical guideline 52. These should be appropriate to the needs and circumstances of the service user and include:
  • contingency management
  • behavioural couples therapy
  • community reinforcement approach
  • social behaviour network therapy
  • cognitive behavioural relapse prevention-based therapy
  • psychodynamic therapy.
Cognitive behavioural relapse prevention-based therapy and psychodynamic therapy should not be used as first-line psychosocial treatments. They may be reserved for individuals who have not benefited from first-line treatments such as brief interventions, contingency management and self-help groups, or in cases where clinical judgement suggests they may be appropriate in the particular circumstances of the case.
Psychological interventions
NICE clinical guideline 90, NICE clinical guideline 91 and NICE clinical guideline 113 recommend evidence-based psychological treatment, in particular cognitive behavioural therapy, for depression and anxiety.
The National Treatment Agency toolkits and resources for healthcare professionals and partners further outlines the effective delivery of psychosocial interventions for people with drug use disorders and with comorbid anxiety or depression.

Continued treatment and support when abstinent

This quality statement is taken from the drug use disorders quality standard. The quality standard defines clinical best practice in drug use disorders and should be read in full.

Quality statement

People who have achieved abstinence are offered continued treatment or support for at least 6 months.

Rationale (Why is this important?)

Continued treatment and support is designed to help an individual's chances of recovery by maintaining abstinence and reducing the risk of adverse outcomes (including death). A lack of support may lead people with drug use disorders to relapse.

Quality measure

Structure
Evidence of local arrangements to ensure people who have achieved abstinence are offered continued treatment and support for at least 6 months.
Process
Proportion of people who have achieved abstinence who receive continued treatment and support for at least 6 months.
Numerator: the number of people in the denominator who receive continued treatment and support for at least 6 months after being identified as drug free.
Denominator: the number of people who have achieved abstinence.

Outcome

Proportion of people who have achieved abstinence who are still abstinent at 6 months.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for people who have achieved abstinence to be offered continued treatment and support for at least 6 months.
Healthcare professionals offer people who have achieved abstinence continued treatment and support for at least 6 months.
Commissioners ensure they commission services that offer continued treatment and support for at least 6 months for people who have achieved abstinence.
People who have achieved abstinence (stopped taking drugs) are offered continued treatment and support for at least 6 months.

Source clinical guideline references

NICE clinical guideline 52 recommendation 1.4.2.1.

Data source

Structure
Local data collection.
Process
Local data collection.

Outcome

Local data collection.

Definitions

Support is defined as ongoing relapse-prevention interventions, access to peer support, provision of recovery-focused programmes such as education and interventions to address comorbid mental health problems.

Residential rehabilitative treatment

This quality statement is taken from the drug use disorders quality standard. The quality standard defines clinical best practice in drug use disorders and should be read in full.

Quality statement

People in drug treatment are given information and advice on the NICE eligibility criteria for residential rehabilitative treatment.

Rationale (Why is this important?)

Residential rehabilitative treatment provides a safe environment, a daily structure, multiple interventions and can support recovery in some people with drug use disorders who have not benefitted from other treatment options. For people with drug use disorders to make an informed choice about residential rehabilitative treatment, taking into account personal preferences, it is important they are aware of the NICE eligibility criteria.

Quality measure

Structure
Evidence of local arrangements to ensure that people in drug treatment are given information and advice on the NICE eligibility criteria for residential rehabilitative treatment.
Process
Proportion of people in drug treatment who receive information and advice on the NICE eligibility criteria for residential rehabilitative treatment.
Numerator: the number of people in the denominator receiving information and advice on the NICE eligibility criteria for residential rehabilitative treatment.
Denominator: the number of people in drug treatment.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for people in drug treatment to be given information and advice on the NICE eligibility criteria for residential rehabilitative treatment.
Healthcare professionals ensure people in drug treatment are given information and advice on the NICE eligibility criteria for residential rehabilitative treatment.
Commissioners ensure they commission services for people in drug treatment to be given information and advice on the NICE eligibility criteria for residential rehabilitative treatment.
People in drug treatment are given information and advice on the NICE eligibility criteria for residential rehabilitative treatment if they want to stop taking drugs, have other medical or social problems, have completed a detoxification programme and past psychosocial treatment has not been successful.

Source clinical guideline references

NICE clinical guideline 51 recommendation 1.5.1.2.

Data source

Structure
Local data collection.
Process
Local data collection.

Definitions

The eligibility criteria is listed in the NICE clinical guideline 51 which recommends residential treatment may be considered for people who are seeking abstinence and who have significant comorbid physical, mental health or social (for example, housing) problems. The person should be planning to complete a community, residential or inpatient detoxification programme and have not benefited from previous community-based psychosocial treatment.
Residential rehabilitative treatment is defined in the National Drug Treatment Monitoring System dataset as a structured drug treatment setting where residence is a condition of receiving the interventions.

Equality and diversity considerations

Residential rehabilitative treatment should be available for anyone meeting the eligibility criteria. The needs of people with children should be considered so that children are appropriately looked after while their parents enter residential rehabilitative treatment.
All information and advice about residential rehabilitation 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. People with drug use disorders should have access to an interpreter or advocate if needed.

Effective interventions library

Successful effective interventions library details

Implementation

Commissioning

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.

Education and learning

NICE produces resources for individual practitioners, teams and those with a role in education to help improve and assess users' knowledge of relevant NICE guidance and its application in practice.

Pathway information

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Updates to this pathway

8 April 2014 Minor maintenance updates
5 July 2013 Minor maintenance updates

Supporting information

Explanation of types of detoxification

The terms ultra-rapid and rapid detoxification refer to methods that shorten the duration of detoxification and thereby also the duration of withdrawal symptoms. In both ultra-rapid and rapid detoxification, withdrawal is precipitated at the start of detoxification by the use of high doses of opioid antagonists (such as naltrexone or naloxone). The essential distinctions between ultra-rapid and rapid detoxification are the duration of the detoxification itself and the level of sedation. Ultra-rapid detoxification takes place over a 24-hour period, typically under general anaesthesia or heavy sedation. Rapid detoxification may take 1–5 days, with a moderate level of sedation. Accelerated detoxification, which typically does not involve the use of heavy or moderate sedation, refers to the use of limited doses of an opioid antagonist after the start of detoxification to shorten the process without precipitating full withdrawal. All of these methods may help to establish the person on a maintenance dose of naltrexone for preventing relapse.
The levels of sedation used in ultra-rapid and rapid detoxification are defined in section 6.5.2 in the full guideline on opioid detoxification for drug misuse.
The risk to the person will be proportionate to the risk inherent in the use of different levels of sedation. In addition, the relatively high use of adjunctive medication associated with ultra-rapid and rapid detoxification exposes the person to risks associated with the use of the medications themselves and their potential interactions.

Glossary

The National Treatment Agency for Substance Misuse

Person who misuses or is at risk of misusing drugs

Person who misuses or is at risk of misusing drugs

NICE pathway on reducing substance misuse among vulnerable children and young people

View the 'Reducing substance misuse among vulnerable children and young people overview' path

Identification and assessment

Identification and assessment

Identification and assessment

Asking questions about drug misuse

In mental health and criminal justice settings (in which drug misuse is known to be prevalent), routinely ask service users about recent legal and illicit drug use, including 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, such as:
  • acute chest pain in a young person
  • acute psychosis
  • mood and sleep disorders.

Initial assessment

When making an assessment and developing and agreeing a care plan, consider the service user's:
  • medical, psychological, social and occupational needs
  • history of drug use
  • experience of previous treatment, if any
  • goals in relation to his or her drug use
  • treatment preferences.
When delivering and monitoring the care plan:
  • agree the plan with the service user
  • maintain a respectful and supportive relationship with the service user
  • help the service user to:
    • identify situations or states when he or she is vulnerable to drug misuse, and
    • explore alternative coping strategies
  • ensure that all service users have full access to a wide range of services
  • ensure that maintaining the service user's engagement with services remains a major focus of the care plan
  • review regularly the care plan of a service user receiving maintenance treatment to ascertain whether detoxification should be considered
  • maintain effective collaboration with other care providers.
Use biological testing (for example, of urine or oral fluid) as part of a comprehensive assessment of drug use, but do not rely on it as the sole method of diagnosis and assessment.

Quality standards

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Source guidance

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Brief interventions and self-help

Brief interventions and self-help

Brief interventions and self-help

At routine contacts and opportunistically (for example, at needle and syringe exchanges), provide information and advice to all people who misuse drugs about reducing exposure to blood-borne viruses.
  • Give advice on reducing sexual and injection risk behaviours.
  • Consider offering testing for blood-borne viruses.
Do not routinely provide group-based psychoeducational interventions that give information about reducing exposure to blood-borne viruses and/or about reducing sexual and injection risk behaviours.
If concerns about drug misuse are identified by the service user or a staff member, offer opportunistic brief interventions focused on motivation to people:
  • in limited contact with drug services (for example, those attending a needle and syringe exchange or primary care settings)
  • not in contact with drug services (for example, in primary or secondary care settings, occupational health or tertiary education).
These interventions should:
  • normally consist of two sessions each lasting 10–45 minutes
  • explore ambivalence about drug use and possible treatment, with the aim of increasing motivation to change behaviour, and provide non-judgemental feedback.
Routinely provide information about self-help groups.
  • These groups should normally be based on 12-step principles; for example, Narcotics Anonymous and Cocaine Anonymous.
  • Consider facilitating initial contact, for example by making the appointment, arranging transport and accompanying the person to the first session.
NICE has produced public health guidance on identifying and supporting under-25s who are misusing or are at risk of misusing substances. See the NICE pathway on reducing substance misuse among vulnerable children and young people.

Quality standards

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Source guidance

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NICE pathway on needle and syringe programmes

View the 'Needle and syringe programmes overview' path

Supporting families and carers

Supporting families and carers

Supporting families and carers

Discuss with families and carers the impact of drug misuse on themselves and other family members, including children.
  • Offer an assessment of their personal, social and mental health needs.
  • Give advice and written information on the impact of drug misuse.
Where the needs of families and carers have been identified:
  • offer guided self-help (usually a single session with written material provided)
  • inform them about support groups – for example, self-help groups specifically for families and carers – and facilitate contact.
If families and carers continue to have significant problems, consider offering individual family meetings (normally at least five weekly sessions). These should:
  • provide information and education about drug misuse
  • help to identify sources of stress related to drug misuse
  • promote effective coping behaviours.

Quality standards

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Source guidance

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Principles of care

Principles of care

Principles of care

To enable people who misuse drugs to make informed decisions about their treatment and care, staff should explain options for abstinence-oriented, maintenance-oriented and harm-reduction interventions at the person's initial contact with services and at subsequent formal reviews.
Discuss with people who misuse drugs whether to involve families and carers in their assessment and treatment plans. Respect the service user's right to confidentiality.
Ensure that there are clear and agreed plans to facilitate effective transfer of people who misuse drugs between services, to reduce loss of contact.
All interventions for people who misuse drugs should be delivered by staff competent in delivering the intervention and who receive appropriate supervision.
People who misuse drugs should be given the same care, respect and privacy as any other person.

Quality standards

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Source guidance

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Settings of care

Settings of care

Settings of care

Community, inpatient and residential settings

The same range of psychosocial interventions should be available in inpatient and residential settings as in the community. These should normally include contingency management, behavioural couples therapy and cognitive behavioural therapy. Services should encourage and facilitate participation in self-help groups.
Consider residential treatment for people who are seeking abstinence and who have significant comorbid physical, mental health or social problems. The person should have completed a residential or inpatient detoxification programme and have not benefited from previous community-based psychosocial treatment.
Urgently assess people who have relapsed to opioid use during or after inpatient or residential treatment. Consider prompt access to alternative community, residential or inpatient support, including maintenance treatment.

Criminal justice system

Access to and choice of treatment for drug misuse should be the same whether people participate voluntarily or are legally required to do so.

Prisons

Treatment options, including detoxification, should be comparable to those in the community.
When choosing treatment, take into account:
  • length of sentence or remand period, and possibility of unplanned release
  • risks of self-harm, death or post-release overdose
  • for people receiving opiate detoxification, practical difficulties in assessing dependence and the associated risk of opioid toxicity early in treatment.
Consider offering people with significant drug misuse problems access to a therapeutic community developed specifically for treating drug misuse in prison.
Consider residential treatment as part of an overall care plan for people who have made an informed decision to remain abstinent after release.

Quality standards

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Source guidance

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Maintenance treatment with methadone and buprenorphine

Maintenance treatment with methadone and buprenorphine

Maintenance treatment with methadone and buprenorphine

Methadone and buprenorphine (oral formulations), using flexible dosing regimens, are recommended as options for maintenance therapy in the management of opioid dependence.
The decision about which drug to use should be made on a case by case basis, taking into account a number of factors, including the person's history of opioid dependence, their commitment to a particular long-term management strategy, and an estimate of the risks and benefits of each treatment made by the responsible clinician in consultation with the person. If both drugs are equally suitable, methadone should be prescribed as the first choice.
Methadone and buprenorphine should be administered daily, under supervision, for at least the first 3 months. Supervision should be relaxed only when the patient's compliance is assured. Both drugs should be given as part of a programme of supportive care.
These recommendations are from Methadone and buprenorphine for the management of opioid dependence (NICE technology appraisal guidance 114).

Implementation tools

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Source guidance

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Paths in this pathway

Pathway created: January 2013 Last updated: April 2014

Copyright © 2014 National Institute for Health and Care Excellence. All Rights Reserved.

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