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Needle and syringe programmes

Short Text

Needle and syringe programmes

Introduction

This pathway makes recommendations on needle and syringe programmes for adults and young people who inject drugs including image- and performance-enhancing drugs. This includes young people aged under 16. The programmes covered include those provided by pharmacies and drugs services
The main aim of needle and syringe programmes is to reduce the transmission of blood-borne viruses and other infections caused by sharing injecting equipment, such as HIV, hepatitis B and C. In turn, this will reduce the prevalence of blood-borne viruses and bacterial infections, so benefiting wider society.
The pathway is for directors of public health, commissioners, providers of needle and syringe programmes and related services, and those with a remit for infectious disease prevention. In addition, it may be of interest to members of the public.

Source guidance

The NICE guidance that was used to create the pathway.
Needle and syringe programmes. NICE public health guidance 52 (2014)

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.

Service improvement and audit

These resources provide help with planning ahead for NICE guidance, understanding where you are now, and conducting improvement initiatives.

Pathway information

Needle and syringe programmes

Needle and syringe programmes supply needles and syringes for people who inject drugs. In addition, they often supply other equipment used to prepare and take drugs (for example, filters, mixing containers and sterile water). The majority of needle and syringe programmes are run by pharmacies and drug services. They may operate from fixed, mobile or outreach sites.
The main aim of needle and syringe programmes is to reduce the transmission of blood-borne viruses and other infections caused by sharing injecting equipment. Many also aim to reduce the other harms caused by injecting drug use and provide:
  • advice on safer injecting practices
  • advice on minimising the harm done by drugs, including image- and performance- enhancing drugs
  • advice on how to avoid and manage an overdose
  • information on the safe handling and disposal of injecting equipment
  • access to blood-borne virus testing, vaccination and treatment services
  • help to stop injecting drugs, including access to drug treatment (for example, opioid substitution therapy) and encouragement to switch to safer drug taking practices, if these are available
  • other health and welfare services (including condom provision).

Injecting equipment

The equipment supplied by needle and syringe programmes is regulated by a 2003 amendment to The Misuse of Drugs Act (2001). A Home Office circular on the supply of drug injecting paraphernalia clarifies that, in addition to needles and syringes, needle and syringe programmes may also supply:
(a) swabs
(b) utensils for the preparation of a controlled drug (that would include articles such as spoons, bowls, cups, dishes)
(c) acidifiers
(d) filters
(e) ampoules of water for injection.
In July 2013, the Home Office issued a written statement that it had accepted the advice of the Advisory Council on the Misuse of Drugs to allow for the lawful provision of foil by drug treatment providers. This is subject to the strict condition that it is part of structured efforts to get people into treatment and off drugs.

Updates to this pathway

16 April Minor maintenance update
8 April 2014 The needle and syringe programmes guidance for this pathway has been updated and the recommendations revised throughout this pathway.
11 March 2014 Minor maintenance update.
7 August 2013 Minor maintenance update.
12 December 2012 Added quality statement on needle and syringe programmes from the drug use disorders quality standard

Supporting information

Glossary

Workers from needle and syringe programmes deliver services away from the main venue.
The term 'drugs' is used in this pathway to mean: opioids (for example, heroin); stimulants (for example, cocaine) either separately or in combination (speedballing); novel psychoactive substances ('legal highs', for example, mephedrone); image- and performance-enhancing drugs (see below); and other drugs (for example, ketamine).
The term 'image- and performance- enhancing drugs' is used in this pathway to mean any substance injected with the intention of enhancing image or performance (except under medical supervision). It includes:
  • anabolic steroids, growth hormone and novel drugs (such as those that stimulate secretion of growth hormone, IGF-1 and analogues, and human chorionic gonadotrophin)
  • melanotans, bremelanotide, botulinum toxin and dermal fillers.
Low dead-space injecting equipment seeks to limit the amount of (potentially contaminated) blood that remains in the equipment after it has been used, by reducing the amount of 'dead space' it contains. It is believed that this may reduce the risk of transmission of infectious diseases among people who share injecting equipment.

Outreach services

Workers from drug and needle and syringe programmes go out and encourage people to use the service.
Workers from drug and needle and syringe programmes go out and encourage people to use the service.
Using more than one drug at the same time (although not necessarily in the same syringe). This practice is common among people who inject drugs. For example, people who use image- and performance-enhancing drugs often use one drug to enhance or counter the effects of another. They refer to this practice as 'stacking'.

Programmes based in community pharmacies

This recommendation is for community pharmacies that run a needle and syringe programme, regardless of the level of service they offer; coordinators of community pharmacy-based needle and syringe programmes; and local pharmaceutical committees.
Where someone collects needles, syringes and other injecting equipment from the needle and syringe programme on behalf of others.

Who should develop a policy for young people?

Directors of public health; commissioners and providers of needle and syringe programmes; commissioners and providers of young people's services; commissioners of young people's specialist substance misuse services; children's safeguarding boards.

Who should take action?

Health and wellbeing boards; commissioners of drug, infectious disease, pharmacy and primary care services; directors of public health and public health practitioners whose remit includes needle and syringe programmes and infectious diseases.

Providing needle and syringe programmes

Providing needle and syringe programmes

Consult with communities and collate data

Consult with communities and collate data

Consult with communities and collate data

Consult with and involve users, practitioners and the local community

  • Involve the following when assessing the need for, and when planning, expanding or improving, a needle and syringe programme:
    • different groups of people who inject drugs (including both those who use a needle and syringe programme and those who don't)
    • under-represented groups, for example, young people and people from black and minority ethnic groups who inject drugs
    • families and carers of people who inject drugs
    • frontline workers in needle and syringe programmes, pharmacies and related services in the statutory, voluntary and private sectors.
  • Consult local communities about how best to implement new or reconfigured needle and syringe programmes. Promote the benefits of the service. For example, explain how these programmes have helped prevent an HIV epidemic in the UK and that they provide a route into drug treatment. Also explain that they may help reduce drug-related litter, by providing safe disposal facilities such as drop boxes and sharps bins.
For further recommendations on how to work with communities, see the community engagement pathway.

Collate and analyse data on injecting drug use

  • Regularly collate and analyse data from a range of sources (including data from Public Health England) to build reliable local estimates of the:
    • Prevalence and incidence of infections related to injecting drug use (for example, hepatitis C and bacterial infections) and other problems caused by injecting drug use (for example, number of people overdosing).
    • Types of drugs used and the numbers, demographics and other characteristics of people who inject, for example:
      • rates of poly-drug use
      • young people aged under 18 who are injecting, or being injected
      • people who inject image- and performance-enhancing drugs (this includes new cohorts of users, for example, of tanning agents and other image-enhancing drugs)
      • new psychoactive substance injectors
      • people who inject occasionally, for example, when they go to night clubs
      • other groups, such as men who have sex with men, ex-prisoners, sex workers or homeless people.
    • Number and percentage of injections covered by sterile needles and syringes in each of the groups identified above. (That is, the number and percentage of occasions when sterile equipment was available to use.)
    • Number and percentage of people who had more sterile needles and syringes than they needed (more than 100% coverage).
    • Number and percentage of people who inject drugs and who are in regular contact with a needle and syringe programme. (The definition of regular will vary depending on the needle and syringe programme user and the types of drugs they use.)
  • Map other services that are commonly used by people who inject drugs, for example, opioid substitution therapy services, homeless services and custody centres.

Quality standards

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Source guidance

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Develop a policy for young people

Develop a policy for young people

Develop a policy for young people

  • Develop and implement a local, area-wide policy on providing needle and syringe programmes and related services to meet the needs of different groups of young people aged under 18 (including young people under 16) who inject drugs.
  • Ensure the policy details how local services will achieve the right balance between the imperative to provide young people with sterile injecting equipment and the duty to protect (safeguard) them and provide advice on harm reduction and other services. It should take account of:
    • the young person's capacity to consent (Gillick competence)
    • the risks they face
    • the benefits of using services
    • the likelihood that they would inject anyway, even if sterile needles and syringes were not provided.
  • Make the governance responsibilities of drug services and safeguarding boards clear. The safeguarding board should approve the local policy.
  • Ensure the policy emphasises the need to provide young people with sterile injecting equipment. This should be provided as part of a broader package of care to meet their other health and social care needs, where possible. This is especially important for under-16s.
  • Ensure the policy is responsive to the needs of young people in the local area. The developers of the policy should take into account:
    • Provision of specialist young people's substance misuse services, including specialist provision of needle and syringe programmes for those under 18 (including young people under 16).
    • How to encourage young people to ask for advice and help from staff providing the services (as well as providing them with needles, syringes and injecting equipment).
    • How to assess service users:
      • their age
      • the degree or seriousness of their drug misuse
      • whether the harm or risk they face is continuing or increasing
      • the general context in which they are using drugs.
    • The skills, knowledge and awareness that staff need to provide services. This includes ensuring staff are trained to assess whether young people are competent to consent (Gillick competence).
    • The potential for using pharmacies to provide young people with needles, syringes and injecting equipment, if they also encourage the young person to make contact with specialist services.
    • That parental or carer involvement should generally be encouraged, with the consent of the young person. Where this is not possible (or appropriate), the policy should include strategies to address their needs.
    • The role of needle and syringe programmes as part of a range of services for young people that includes seamless transition from youth to adult services.
  • Ensure needle and syringe programmes aimed at young people who inject drugs implement all the recommendations in this pathway, not just those for young people.
  • Regularly review the policy.

Quality standards

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Source guidance

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Commission services to meet local need

Commission services to meet local need

Commission services to meet local need

Health and wellbeing boards, commissioners of drug, infectious disease, pharmacy and primary care services and directors of public health should:
  • Ensure the results of consultation and data analysis (see Consult with communities and collate data and Develop a policy for children under 16 in this path) inform the local joint strategic needs assessment.
  • Commission a range of generic and targeted needle and syringe programmes to meet local need, based on these results. For example, ensure services are offered at a range of times and in a number of different locations. Take the geography and demographics of the area into account (for example, whether it is an urban or rural area). Targeted services should focus on the specific groups identified.
  • Ensure services aim to be accessible and:
    • Increase the proportion of people who have more than 100% coverage (that is, the number who have more than 1 sterile needle and syringe available for every injection).
    • Increase the proportion of people who have been tested for hepatitis B and C and other blood-borne viruses (including HIV) in the past 12 months (see the hepatitis and C testing pathway for further information).
    • Increase the proportion of each group of people who inject drugs who are in contact with a needle and syringe programme.
    • Ensure syringes and needles are available in a range of sizes and at a range of locations throughout the area.
    • Encourage identification schemes (involving, for example, the use of coloured syringes).
    • Offer, and encourage the use of, low dead-space injecting equipment.
    • Provide advice and information on services that aim to: reduce the harm associated with injecting drug use; encourage people to stop using drugs or to switch to a safer approach if one is available (for example, opioid substitution therapy); and address their other health needs. Where possible, offer referrals to those services.
  • If applicable, commission outreach or detached services for areas where there are high levels of drug use or populations that do not use existing needle and syringe programmes.
  • Promote needle and syringe programmes to groups that may be under-represented among those who use them, for example, club-drug injectors and people who inject image- and performance-enhancing drugs
  • Develop plans for needle and syringe disposal, in line with Tackling drug-related litter (Department for Environment, Food and Rural Affairs 2005). Include the provision and disposal of sharps boxes for the safe disposal of needles. Consider providing public sharps bins (drop boxes) in areas where drug-related litter is common. Work with members of the local community, people who inject drugs and the local police service to agree the location for drop boxes.
  • Commission integrated care pathways for people who inject drugs so that they can move seamlessly between the full range of services, including treatment services.

Quality standards

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Source guidance

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Provide a mix of services

Provide a mix of services

Provide a mix of services

Health and wellbeing boards and commissioners of drug, infectious disease prevention, pharmacy and primary care services should:
  • Use pharmacies, specialist needle and syringe programmes and other settings and approaches to provide geographical and demographic coverage. Examples of other settings and approaches that could be used include: custody centres, sexual health services, outreach and detached services. Provide a mix of the following levels of service to meet local needs:
    • Level 1: distribution of injecting equipment either loose or in packs, suitable for different types of injecting practice, with written information on harm reduction. (For example, telling people about specialist agencies, or giving them details about safer injecting practices, including how to prevent an overdose.)
    • Level 2: distribution of 'pick and mix' (bespoke) injecting equipment and referral to specialist services plus health promotion advice. (This includes advice and information on how to reduce the harms caused by injecting drugs.) Some level 2 services might also offer additional services, such as blood-borne virus testing or vaccination.
    • Level 3: level 2 plus provision of, or referral to, other specialist services (for example, specialist clinics, vaccinations, drug treatment and secondary care). See specialist programmes including those based in community pharmacies in this pathway.
  • Establish links and referral pathways between the different levels of service to promote integration and to share learning and expertise.
  • Coordinate services to ensure testing for hepatitis B and C and other blood-borne viruses is readily available to everyone who uses a needle and syringe programme (see the hepatitis B and C testing pathway for further information).
  • Coordinate services to ensure injecting equipment is available at times, and in places, that meet the needs of people who inject drugs. For example, it may be appropriate to provide out-of-hours vending machines for groups that would not otherwise have access to services – or not at the time that they need them. (The location of these machines would need to be considered carefully and their use would need to be regularly monitored.) Another example would be to encourage pharmacies with longer opening hours to provide needles, syringes and other injecting equipment.
  • Ensure services offering opioid substitution therapy also make needles and syringes available to their service users, in line with the National Treatment Agency Models of care for treatment of adult drug misusers: update .

Quality standards

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Source guidance

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Monitor services

Monitor services

Monitor services

Health and wellbeing boards, commissioners and providers of needle and syringe programmes and public health practitioners whose remit includes needle and syringe programmes and infectious diseases, should:
  • Collect data on service usage as follows:
    • All services should monitor the number and types of packs or equipment they distribute.
    • Specialist services should, where possible, collect more detailed data on: the amount and type of equipment distributed, the demographic details of the person who is injecting, along with details of their injecting practices and the drugs they are injecting (see 'Collate and analyse data on injecting drug use' under Consult with communities and collate data in this path). Practitioners should only ask for these details if they are confident it will not discourage the person from using the service.
  • Ensure a local mechanism is in place to aggregate and analyse the data collected on at least an annual basis. Aim to build up a picture of injecting practices in the local area and how this may be changing over time. This data should be used as part of the collecting and analysing data process (see 'Collate and analyse data on injecting drug use' under Consult with communities and collate data in this path).
  • Ensure local service use data are available, in anonymised form, for relevant national bodies and research units (for example, Public Health England).

Quality standards

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Source guidance

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Paths in this pathway

Pathway created: December 2011 Last updated: April 2014

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