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Drug misuse is an increasing problem that not only impairs the physical and mental health of people who misuse drugs but also negatively affects their families and wider society (for example, in its association with crime). Recently expanded drug services in the United Kingdom involve general practitioners to a considerable degree, who care for at least a third of opioid misusers in treatment. Many clinicians remain pessimistic, however, about the possible benefits of any treatment and how to engage drug users in treatment.1 This article summarises two new NICE guidelines that identify the most effective, safe detoxification regimens for primary and secondary care, the most cost effective psychosocial interventions, and effective ways to promote patient engagement.2 3
NICE recommendations are based on systematic reviews of best available evidence. When minimal evidence is available, a range of consensus techniques is used to develop recommendations. In this summary, recommendations derived primarily from consensus techniques are indicated with an asterisk (*).
For all patients who are opioid dependent and have expressed an informed choice to become abstinent, services should:
Formal psychosocial interventions have not been widely used in UK drugs services, but the evidence reviewed by NICE shows that increased use of these interventions can bring real benefits.
In recent years drug treatment has focused on harm reduction rather than abstinence as a goal, but the evidence on detoxification makes clear that abstinence is an effective treatment option. Furthermore, although psychosocial interventions for drug misuse are not well developed, the evidence suggests that they can bring real benefits, in part through increasing the value of currently used treatments.
Contingency management has been little used in the UK, is open to misunderstanding by clinicians and the general public, and will require considerable training of staff and service development if it is to be introduced appropriately and effectively. It involves a new way of thinking, with the use of positive incentives instead of negative approaches such as the withholding of treatment. The evidence is that, particularly with this patient population, behaviour can be positively shaped with incentives, whereas threats and punishment have little influence. Overseas trials involving more than 5000 patients across more than 25 studies have consistently shown that such an approach reduces illicit drug use, is cost effective, and improves engagement in harm reduction and treatment programmes.
To tackle these challenges, it is proposed that the National Treatment Agency in the UK will establish a network of demonstration centres, which will develop materials to support a phased implementation of contingency management, support staff training and supervision programmes, and assess the relative value of different incentive systems.
A recent survey of inpatient detoxification identified the widespread use of a range of medications in detoxification.4 These included medications not found to be effective and/or requiring substantial adjunctive medications (for example, naloxone precipitated detoxification, clonidine). Recently the development and evaluation of psychosocial interventions for drug misuse has increased. However, few published data exist on the provision of psychosocial interventions for drug misuse in the UK. Recent evidence suggests that some interventions are not consistently provided.5
The guidelines recommend that contingency management should be used for the treatment of primary stimulant misuse and for illicit drug use in methadone maintenance treatment. The recommendations were based on the findings that contingency management had the most consistent evidence base of all psychosocial interventions for these groups.6 7 However, despite the strength of the evidence, this intervention is not widely used in the UK, with only a few services piloting such programmes.5 8
Drug misuse is associated with a greater risk of certain physical health problems (for example, hepatitis C). However, people who misuse drugs are often not aware they have these problems,9 or if they are aware, they are less likely to adhere to treatment. Contingency management was found to be much more effective than usual care or outreach in promoting identification and adherence to treatment of physical health problems. 10 11
The guidelines were developed according to NICE guideline methodology (see www.nice.org.uk/page.aspx?o=114219) by the National Collaborating Centre for Mental Health. The collaborating centre convened a development group of clinicians and patient and carer representatives for each guideline to oversee the work and develop the recommendations. The groups conducted extensive systematic reviews of the clinical and economic literature and assessed the quality of this literature. The guidelines went through an external consultation with stakeholders. The development groups assessed the comments, reanalysed the data where necessary, and modified the guidelines. NICE has produced four different versions of each guideline: a full version; a quick reference guide (which combines both guidelines); a version known as the “NICE guideline” that summarises the recommendations; and a version for patients and the public. All these versions are available from the NICE website (see www.nice.org.uk/CG051 and www.nice.org.uk/CG052). Future updates of the guidelines will be produced as part of the NICE guideline development programme.12
Evidence is lacking on a comparison of residential and community based settings, particularly for detoxification. Whether the substantially greater resources required for residential detoxification are associated with comparably better outcomes is still unclear.
Contributors: SP drafted the paper, and all authors contributed to its revision and the final draft. SP convened both guideline development groups. JS chaired the NICE guideline on psychosocial interventions, and CG chaired the NICE guideline on detoxification.
Competing interests: Both JS and CG have received funding from pharmaceutical companies and government agencies for advisory services, and both are members of the UK Department of Health Clinical Guidelines on Drug Misuse and Dependence Group.
Funding: The National Collaborating Centre for Mental Health was commissioned and funded by the National Institute for Health and Clinical Excellence to write this summary.
Provenance and peer review: Commissioned; not peer reviewed.