Drug misuse : Opioid : detoxification THE NICE GUIDELINE DRUG MISUSE Opioid detoxification National Clinical Practice Guideline Number 52 National Collaborating Centre for Mental Health commissioned by the National Institute for Health & Clinical Excellence published by The British Psychological Society and The Royal College of Psychiatrists © The British Psychological Society & The Royal College of Psychiatrists, 2008 The views presented in this book do not necessarily reflect those of the British Psychological Society, and the publishers are not responsible for any error of omission or fact. The British Psychological Society is a registered charity (no. 229642). All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Enquiries in this regard should be directed to the British Psychological Society. British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library. ISBN-: 978-1-85433-469-5 Printed in Great Britain by Alden Press. Additional material: data CD-ROM created by Pixl8 (www.pixl8.co.uk) developed by National Collaborating Centre for Mental Health Royal College of Psychiatrists’ Research and Training Unit 4th Floor, Standon House 21 Mansell Street London E1 8AA www.nccmh.org.uk commissioned by National Institute for Health and Clinical Excellence MidCity Place, 71 High Holborn London WCIV 6NA www.nice.org.uk published by The British Psychological Society St Andrews House 48 Princess Road East Leicester LE1 7DR www.bps.org.uk and The Royal College of Psychiatrists 17 Belgrave Square London SW1X 8PG www.rcpsych.ac.uk Contents CONTENTS 1. EXECUTIVE SUMMARY 8 1.1 General considerations 9 1.2 Assessment 11 1.3 Pharmacological interventions in opioid detoxification 12 1.4 Opioid detoxification in community, residential, inpatient and prison settings 14 1.5 Specific psychosocial interventions 16 1.6 Research recommendations 17 2. INTRODUCTION 18 2.1 National guidelines 18 2.2 The national opioid detoxification for drug misuse guideline 21 3. INTRODUCTION TO DRUG MISUSE 23 3.1 Drug misuse and opioid dependence 23 3.2 Epidemiology of drug misuse 25 3.3 Aetiology and maintenance of drug misuse 26 3.4 The course of drug misuse 27 3.5 The pharmacology of opioids 28 3.6 The public health impact of drug misuse 28 3.7 Identification and assessment of drug misuse 30 3.8 The aims of the treatment and management of drug misuse 31 3.9 The development of detoxification services 34 3.10 Current care and treatment in the NHS 35 3.11 The experience of drug misuse – personal perspectives 38 3.12 Impact of drug misuse on families and carers 44 3.13 Economic impact of drug misuse 45 4. METHODS USED TO DEVELOP THIS GUIDELINE 47 4.1 Overview 47 4.2 The scope 47 4.3 The Guideline Development Group 48 4.4 Clinical questions 49 4.5 Systematic clinical literature review 51 4.6 Systematic economic literature review 61 4.7 Stakeholder contributions 63 4.8 Validation of this guideline 63 3 Contents 5. ASSESSMENT AND TESTING 64 5.1 Introduction 64 5.2 Clinical assessment in the management of detoxification 64 5.3 Drug testing 67 5.4 Psychometric assessment tools 72 6. PHARMACOLOGICAL AND PHYSICAL INTERVENTIONS IN OPIOID DETOXIFICATION 76 6.1 Introduction 76 6.2 Pharmacological interventions in detoxification 78 6.3 Overall clinical summary of pharmacological interventions in detoxification 120 6.4 Clinical practice recommendations 120 6.5 Ultra-rapid, rapid and accelerated detoxification using opioid antagonists 122 6.6 Clinical practice recommendations 144 6.7 Physical and complementary interventions during detoxification 144 7. PSYCHOSOCIAL INTERVENTIONS IN OPIOID DETOXIFICATION 146 7.1 Introduction 146 7.2 Current practice 147 7.3 Definitions 148 7.4 Outcomes 150 7.5 Databases searched and inclusion/exclusion criteria 150 7.6 Studies considered 150 7.7 Psychosocial interventions in combination with detoxification 156 7.8 Clinical summary 156 7.9 Literature review of health economics evidence 157 7.10 Economic modelling 157 7.11 Clinical practice recommendations 169 8. SETTINGS FOR OPIOID DETOXIFICATION 170 8.1 Introduction 170 8.2 Inpatient and community-based settings 172 8.3 Unassisted/self-detoxification 180 8.4 Prison-based detoxification 182 9. APPENDICES 185 10. GLOSSARY 244 11. REFERENCES 252 12. ABBREVIATIONS 269 4 Guideline development group members GUIDELINE DEVELOPMENT GROUP MEMBERS Dr Clare Gerada (Chair, Guideline Development Group) General Practitioner, Lambeth Primary Care Trust, London Primary Care Lead for Drug Misuse at the Royal College of General Practitioners Mr Stephen Pilling (Facilitator, Guideline Development Group) Joint Director, The National Collaborating Centre for Mental Health Director, Centre for Outcomes, Research and Effectiveness, University College London Consultant Clinical Psychologist and Deputy Head of Psychology Services, Camden and Islington Mental Health and Social Care Trust Mrs Pauline Bissett Chief Executive, Broadway Lodge Mr Neil Connelly Service User Representative, Voluntary Support Worker, Littledale Hall Therapeutic Community, Lancaster Dr Paul Davis Consultant Lead Clinical Psychologist and Head of Psychology for Substance Misuse Services, Camden and Islington Mental Health and Social Care Trust Ms Vivienne Evans Carer Representative Chief Executive, Adfam Dr Emily Finch Addiction Psychiatrist, South London and Maudsley NHS Foundation Trust Clinical Team Lead, National Treatment Agency for Substance Misuse Professor Robert Forrest Consultant in Clinical Chemistry and Toxicology, Sheffield Teaching Hospitals NHS Foundation Trust Dr Eilish Gilvarry Clinical Director, Newcastle Drug and Alcohol Unit, Newcastle upon Tyne Mr David Harding-Price Team Coordinator, Community Mental Health Team, Skegness, Lincolnshire Mr Paul Hawkins Service User Representative Ms Sarah Hopkins Project Manager, The National Collaborating Centre for Mental Health (2006–2007) 5 Guideline development group members Ms Rebecca King Project Manager, The National Collaborating Centre for Mental Health (2005–2006) Mr Ryan Li Research Assistant, The National Collaborating Centre for Mental Health Dr Anne Lingford-Hughes Reader in Biological Psychiatry and Addiction, Academic Unit of Psychiatry, University of Bristol Addiction Psychiatrist, Avon and Wiltshire Mental Health Partnership NHS Trust Dr Nicholas Meader Systematic Reviewer, The National Collaborating Centre for Mental Health Ms Jan Palmer Nurse Consultant, Clinical Substance Misuse Lead, Offender Health Mrs Kay Roberts Pharmacist; Chairman, PharMAG Ms Poonam Sood Research Assistant, The National Collaborating Centre for Mental Health Ms Sarah Stockton Information Scientist, The National Collaborating Centre for Mental Health Dr Clare Taylor Editor, The National Collaborating Centre for Mental Health Mr Loukas Xaplanteris Health Economist, The National Collaborating Centre for Mental Health 6 Acknowledgements ACKNOWLEDGEMENTS The Guideline Development Group for Drug Misuse: Opioid Detoxification and the National Collaborating Centre for Mental Health (NCCMH) review team would like to thank the following people: Those who acted as advisors on specialist topics or have contributed to the process by meeting with the Guideline Development Group: Dr Ed Day, University of Birmingham Professor Michael Gossop, Institute of Psychiatry Dr Kim Wolff, Institute of Psychiatry Editorial assistance Emma Brown 7 Executive summary 1. EXECUTIVE SUMMARY KEY PRIORITIES FOR IMPLEMENTATION The following recommendations have been identified as recommendations for implementation. Providing information, advice and support ● Detoxification should be a readily available treatment option for people who are opioid dependent and have expressed an informed choice to become abstinent. See section 3.7. ● In order to obtain informed consent, staff should give detailed information to service users about detoxification and the associated risks, including: – the physical and psychological aspects of opioid withdrawal, including the duration and intensity of symptoms, and how these may be managed – the use of non-pharmacological approaches to manage or cope with opioid withdrawal symptoms – the loss of opioid tolerance following detoxification, and the ensuing increased risk of overdose and death from illicit drug use that may be potentiated by the use of alcohol or benzodiazepines – the importance of continued support, as well as psychosocial and appropriate phar- macological interventions, to maintain abstinence, treat comorbid mental health problems and reduce the risk of adverse outcomes (including death). See section 3.7. The choice of medication for detoxification ● Methadone or buprenorphine should be offered as the first-line treatment in opioid detoxification. When deciding between these medications, healthcare professionals should take into account: – whether the service user is receiving maintenance treatment with methadone or buprenorphine; if so, opioid detoxification should normally be started with the same medication – the preference of the service user. See section 6.3. Ultra-rapid detoxification ● Ultra-rapid detoxification under general anaesthesia or heavy sedation (where the airway needs to be supported) must not be offered. This is because of the risk of serious adverse events,