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Drug Misuse and Dependence

Scope of the guidance

This item offers guidance on the clinical management of drug misuse in the UK, reflecting the changes that have occurred in treatment over the past eight years and incorporating recent NICE guidance. The guidelines are based on current evidence and professional consensus.  They are intended for all clinicians, especially those providing pharmacological interventions as a component of drug misuse treatment. Chapters in the source material cover clinical governance; treatment provision; psychosocial treatment; pharmacological interventions; health considerations; specific treatment situations and populations.

Source

Department of Health (England), Scottish Government, Welsh Assembly Government and Northern Ireland Executive. Drug Misuse and Dependence - UK Guidelines on Clinical Management. London: National Treatment Agency for Substance Misuse, 2007. www.smmgp.org.uk/download/clinical/clinicalguidelines.pdf

Key points

1. Entitlement to health care

Drug misusers are entitled to high quality NHS services just as anyone else is. GPs must  provide general medical services and take into account the implications of the drug misuse in its widest sense when offering advice and treatment. All GPs undertaking substitute prescribing for opiate abusers should complete Part 1 of the RCGP’s certificate in the management of drug misuse in primary care. Part 2 is recommended for those wishing to undertake more specialised community substance misuse work.

2. Services for drug misusers

Effective services for drug misusers involve clinicians working together in primary care, secondary care or across both sectors; professionals must be appropriately competent, trained and supervised. Most areas have support agencies providing key worker services to misusers; it is becoming common for drug agency workers to see patients within the GP surgery, with the GP available to offer medical support and prescribing. Some primary care organisations offer special contracts for GPs to work with services in this way – in England, a locally enhanced service. Shared care should be the normal manner in which prescribing occurs. It should be unusual for most GPs to initiate prescriptions for opiate substitutes unless patients have support from specialist agencies and the prescribing is occurring within the context of an agreed care plan.

3. Goals of treatment

The main goals of treatment of drug misuse can be considered as a hierarchy:

•  reduce health, social, crime and other problems relating to drug misuse
•  reduce health, social, crime and other problems not directly due to drug misuse
•  reduce harmful or risky behaviours – e.g. sharing injection equipment
•  attain controlled, nondependent, non-problematic drug use
•  abstain from all drugs

For many patients, long-term prescribing of opiate substitutes and support will be required before abstinence is a possibility.

4. Providing care - assessment and planning care

• Screening by urine testing indicates if drugs have been ingested over few days prior to the test; mouth swab testing detects drugs taken over previous 24-48 hours. Hair testing indicates if drugs use over preceding months, but is less good at detecting recent use; it is more complicated than urine or mouth swab testing and restricted to specialist laboratories. Drug testing can be used in the initial assessment and confirmation of drug use, confirming treatment compliance, and monitoring illicit drug use.
• Assessment may require more than one consultation. The needs of all drug misusers should be assessed across four domains: drug and alcohol misuse, health, social functioning, criminal involvement.
• Risks to dependent children should be assessed for all drug-using parents. All drug misusers entering structured treatment should have a care or treatment plan which is regularly reviewed. GPs and practice nurses are well placed to undertake some of this assessment and care.

5. Psychosocial interventions

•  Treatment for drug misuse should always involve a psychosocial component
•  Psychosocial interventions are the mainstay of treatment for the misuse of cocaine and other stimulants, as well as for cannabis and hallucinogens
•  Self-help and mutual aid, especially the 12-Step approach (eg Narcotics Anonymous) have been found to be highly effective for some individuals. Patients seeking abstinence should be signposted to them.

6. Pharmacological interventions

• Methadone or buprenorphine used at the optimal dose range are effective medicines for maintenance treatment
• Dose induction should aim to achieve an effective dose, while exercising caution about the inherent risks of too rapid an increase. With methadone, induction may take up to four weeks. Dose induction with buprenorphine may be carried out more rapidly with less risk of overdose.
• Patients must be made fully aware of the risks of their medication and of the importance of protecting children from accidental ingestion. Prescribing arrangements should aim to reduce risks to children.
• Clinicians should optimise patient care for those not benefiting from treatment, usually by providing additional and more intensive pharmacological and psychosocial interventions.
• Benzodiazepines prescribed for benzodiazepine dependence should be at the lowest possible dose to control dependence and doses should be reduced as soon as possible.
• There are no effective pharmacological treatments to eliminate the symptoms of withdrawal from stimulants (including cocaine). Psychosocial interventions are the mainstay of treatment.

When substitute prescribing is used, there are risks of overdose. The risk is particularly high for situations when the patient has reduced or no tolerance to a previously tolerated dose of opiate:

• patients recently leaving prison
• patients in the first few days of a methadone programme
• patients using street drugs again after a period of abstinence
• the patient who has not taken their regular methadone for three days or more then takes the same dose
• where other sedatives such as alcohol or benzodiazepines are also used

7. Health considerations

Reducing potential harm due to overdose, blood-borne viruses and other infections should be a part of all patient care. All drug misusers should be offered:

• vaccination against hepatitis B, and against hepatitis A where indicated
• counselling, testing and, if required, treatment for hepatitis C and HIV infections
• interventions for alcohol misuse
• smoking cessation interventions
• cervical screening for women
• contraception
• advice regarding safe sex
• check BMI and offer advice regarding healthy eating

8. Treating specific populations of drug misusers

• Strike a balance with pregnant women between reducing the amount of prescribed drugs in order to reduce foetal withdrawal symptoms, and the risk of the patient returning to or increasing their misuse of illicit drugs
• People with severe mental health problems should have high quality, patient-focused care integrated with mental health services
• Drug treatment goals for young people who regularly misuse substances should be to reduce immediate harm from substance misuse, stabilise the young person and enable them to move to abstain from illegal drug misuse
• Older drug users may have underlying problems caused either by complications of lifelong drug (and alcohol) misuse or by problems associated with substitute treatment
• Drug misusers in acute pain: consider non-opioid analgesia for mild to moderate pain; use of opioids for severe pain will depend on whether the person is taking full agonist opioids such as methadone, partial agonist opioids such as buprenorphine, or opioid agonists such as naltrexone (when opioid analgesia will be ineffective) – read more about this in section 7.8 of the source document 
• Drug users in chronic pain (back pain, arthritis and headache being most common): non-pharmacological interventions options such as cognitive behavioural therapy should be considered (if available), as well as pharmacological interventions – a joint approach from medical, primary care, psychiatric and pain services is in patient’s best interests.

Practical tips for the busy GP >>

EGP 1. May 2008