Drug Misuse and Dependence : UK Guidelines on Clinical Management
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Drug misuse and dependence UK guidelines on clinical management Title: Drug misuse and dependence: UK guidelines on clinical management Recommended citation: Clinical Guidelines on Drug Misuse and Dependence Update 2017 Independent Expert Working Group (2017) Drug misuse and dependence: UK guidelines on clinical management. London: Department of Health Author: Clinical Guidelines on Drug Misuse and Dependence Update 2017 Independent Expert Working Group Publisher: Global and Public Health / Population Health / Healthy Behaviours / 25460 Document purpose: Guidance Publication date: July 2017 Target audience: Healthcare professionals Providers and commissioners of treatment for people who misuse or are dependent on drugs Professional and regulatory bodies Service users and carers Contact details: Alcohol, Drugs & Tobacco Division Public Health England [email protected] You may re-use the text of this document (not including logos) free of charge in any format or medium, under the terms of the Open Government Licence. To view this licence, visit www.nationalarchives.gov.uk/ doc/open-government-licence/ © Crown copyright Published to gov.uk www.gov.uk/dh Drug misuse and dependence UK guidelines on clinical management Prepared by Clinical Guidelines on Drug Misuse and Dependence Update 2017 Independent Expert Working Group Contents 1 Contents Preface 5 Professor Sir John Strang 5 Chapter 1: Introduction 9 Chapter 2: Essential elements of treatment provision 15 2.1 Key points 15 2.2 Assessment, planning care and treatment 15 2.3 Delivery of treatment 27 2.4 Drug testing 28 2.5 General health assessment at presentation and in treatment 31 2.6 Effective communication with primary and secondary care services 35 2.7 Organisational factors for effective drug treatment 35 2.8 Intimate partner violence and domestic abuse 43 2.9 Planning and contracting or commissioning services 44 Chapter 3: Psychosocial components of treatment 47 3.1 Key points 47 3.2 Introduction 47 3.3 Core elements underpinning effective delivery 51 3.4 Making psychosocial interventions effective 52 3.5 Interventions focused on social network and family, friends and carers 56 3.6 Medication and psychosocial interventions 57 3.7 Delivering psychosocial interventions 58 3.8 Resources and further reading 81 3.9 References 81 Chapter 4: Pharmacological interventions 83 4.1 Key points 83 4.2 Prescribing 84 4.3 Choosing an appropriate opioid substitute 88 4.4 Induction onto methadone and buprenorphine substitution treatment 90 4.5 Supervised consumption 101 4.6 Assessing and responding to progress and failure to benefit 104 4.7 Opioid maintenance prescribing 110 4.8 Opioid detoxification 115 4.9 Naltrexone for relapse prevention 118 4.10 Pharmacological management of dependence on other drugs 119 4.11 Resources and further reading 124 4.12 References 125 2 Drug misuse and dependence: UK guidelines on clinical management Chapter 5: Criminal justice system 127 5.1 Key points 127 5.2 Introduction 128 5.3 Criminal justice systems in the community 130 5.4 Prisons and other secure environments 133 5.5 References 160 Chapter 6: Health considerations 163 6.1 Key points 163 6.2 Blood-borne viruses and other infections 163 6.3 Preventing drug-related deaths 174 6.4 Naloxone 178 6.5 Alcohol in drug treatment 183 6.6 Smoking and respiratory function 187 6.7 Oral health 190 6.8 References 194 Chapter 7: Specific treatment situations and populations 197 7.1 General key points 197 7.2 Pain management 197 7.3 Dependence on prescribed and over-the-counter opioids 205 7.4 Misuse of or dependence on gabapentinoids 208 7.5 Hospitalisation 209 7.6 Pregnancy and neonatal care 220 7.7 New psychoactive substances and club drugs 225 7.8 Image and performance enhancing drugs 229 7.9 Coexisting problems with mental health and substance use 231 7.10 Young people 240 7.11 Older people 247 7.12 References 252 Annexes 255 A1: Working group members and other contributors 257 A1.1 Members of the working group 257 A1.2 User and carer representatives 259 A1.3 Observers 259 A1.4 Secretariat 260 A1.5 Reviews and synopses 260 A1.6 Other contributors 261 Contents 3 A2: Governance 263 A2.1 Quality governance 263 A2.2 Confidentiality and safeguarding 266 A2.3 Non-medical prescribing 269 A3: Marketing authorisations 271 A3.1 ‘Off-label’ or ‘unlicensed’ prescribing 271 A3.2 Young people 272 A3.3 References 272 A4: Writing prescriptions 277 A4.1 General considerations 277 A4.2 Patient safety 277 A4.3 Legal and good practice requirements 278 A4.4 Minor amendments 281 A4.5 Additional country-specific rules 281 A4.6 Other considerations 283 A4.7 Examples of what to write on a prescription 284 A4.8 Private prescriptions 291 A4.9 Resources and further reading 292 A5: Interactions 293 A5.1 Medicinal interactions 293 A5.2 Interactions with illicit drugs 294 A5.3 Resources and further reading 295 A6: Travelling abroad with controlled drugs 303 A6.1 General 303 A6.2 Travelling for less than three months 303 A6.3 Travelling for three months or more 303 A7: Drugs and driving 305 A7.1 Key points 305 A7.2 Offences related to drug use and driving in the UK 305 A7.3 Driving licence requirements 306 A7.4 Risk assessment for driving 308 A7.5 Responsibilities of the prescribing clinician 308 A7.6 Information for patients 308 A7.7 References 310 A8: Glossary 311 4 Drug misuse and dependence: UK guidelines on clinical management List of figures Box 1: Full or comprehensive assessment of drug-using parents 19 Box 2: Principles for trauma-informed care 42 Table 1: A model of phased and layered interventions 50 Table 2: Signs of opiate withdrawal 86 Table 3: Responses to drug and alcohol misuse on top of an opioid prescription 109 Table 4: Approximate dosages equivalent to 5mg diazepam 122 Box 3: Naloxone and hostel scenario example 180 Box 4: Advice for achieving and maintaining good oral hygiene 193 Table 5: Special health needs of older people with substance use problems 249 Table 6: Marketing authorisations for medicines used in in adults 273 Table 7: Marketing authorisations for medicines used in in young people 275 Table 8: Examples of prescription writing 285 Table 9: Important interactions with methadone and buprenorphine 296 Table 10: Other clinically important interactions in substance misuse 300 Table 11: Some important interactions with HIV and hepatitis treatments 302 Preface 5 Preface Professor Sir John Strang It has been my great honour and pleasure to chair the independent expert working group updating the 2007 Clinical Guidelines. I am immensely grateful to the many colleagues who have served on the working group, or who have prepared documents and given evidence to us, and to the officials who have so actively supported us in our work. I am satisfied that this 2017 edition of the ‘Orange Book’ will help providers and commissioners to optimise the reach and effectiveness of the interventions they have the responsibility to deliver. The right treatment at the right time can be life-saving. It can also make a huge difference to the wellbeing and recovery of people with problems related to their drug use. Well-delivered treatment is greatly more effective than less competently delivered treatment. The Clinical Guidelines are designed to support you in meeting your responsibility to ensure evidence- based treatments are available and competently delivered. Guidelines guide – they are not intended to dictate the precise treatment for each patient. Rather, they are designed to guide the clinician and the commissioner in the provision of the right balance of interventions, which have the greatest likelihood to produce individual benefit and public good. The Clinical Guidelines also enable the clinician to assess whether a proposed treatment plan departs, and to what extent it departs, from evidence-based guidance on the specific treatment. As a general principle, the greater the extent to which a treatment plan departs from evidence-based guidelines, the greater the need to ensure that this departure from orthodox clinical practice is appropriate. Since my first involvement with the Clinical Guidelines more than a quarter of a century ago, the world of drug treatment has matured greatly, and so too has the manner in which we examine the available evidence. This is evident in the substantial and evidence-informed nature of the new 2017 Clinical Guidelines. Some of the problems individuals experience are new and require their own consideration, although many of the underlying principles of the provision of best care remain valid from previous iterations of the Clinical Guidelines. This is as we would expect it to be, since our knowledge grows incrementally with regard to the problems people experience and the ways in which we can help them to address these problems. Thus, some sections of the 2017 Clinical Guidelines contain new material, others echo earlier editions and others present updated revisions of earlier guidance. 6 Drug misuse and dependence: UK guidelines on clinical management Psychosocial and pharmacological approaches are considered within the Clinical Guidelines, as is the social context in which people experience their problems and are helped with their treatment and recovery. Pharmacological approaches remain extremely important and of clearly demonstrated efficacy and effectiveness for those with problems related to use of heroin or other opiates. But this approach is of limited relevance to treatment for those with problems related to use of other types of drug. For many who make contact with treatment services, it is also important to look broadly at the opportunity to address their psychological problems and the impact of past traumas, and to provide support to gain meaningful employment, stable housing, alongside family and other social support.