UK guidelines on clinical management

1 Drug misuse and dependenceUK guidelines on clinical managementDrug misuse and dependenceUK guidelines on clinical managementPrepared by clinical guidelines on Drug Misuse and Dependence Update 2017 Independent Expert Working GroupYou 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 Crown copyright Published to : Drug misuse and dependence: UK guidelines on clinical managementRecommended 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 HealthAuthor: 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:GuidancePublication date: July 2017 (minor revisions November 2017) Target audience:Healthcare professionalsProviders and commissioners of treatment for people who misuse or are dependent on drugsProfessional and regulatory bodiesService users and carersContact details: Alcohol, Drugs & Tobacco DivisionPublic Health 1 ContentsPreface 5 Professor Sir John Strang 5 Chapter 1: Introduction 9 Chapter 2.

2 Essential elements of treatment provision Key points Assessment, planning care and treatment Delivery of treatment Drug testing General health assessment at presentation and in treatment Effective communication with primary and secondary care services Organisational factors for effective drug treatment Intimate partner violence and domestic abuse Planning and contracting or commissioning services 44 Chapter 3: Psychosocial components of treatment Key points Introduction Core elements underpinning effective delivery Making psychosocial interventions effective Interventions focused on social network and family, friends and carers Medication and psychosocial interventions Delivering psychosocial interventions Resources and further reading References 81 Chapter 4: Pharmacological interventions Key points Prescribing Choosing an appropriate opioid substitute Induction onto methadone and buprenorphine substitution treatment Supervised consumption Assessing and responding to progress and failure to benefit Opioid maintenance prescribing Opioid detoxification Naltrexone for relapse prevention Pharmacological management of dependence on other drugs Resources and further reading Refe re nce s 1252 Drug misuse and dependence: UK guidelines on clinical managementChapter 5: Criminal justice system Key points Introduction Criminal justice systems in the community Prisons and other secure environments References 160 Chapter 6: Health considerations Key points Blood-borne viruses and other infections Preventing drug-related deaths Naloxone Alcohol in drug treatment Smoking and respiratory function Oral health References 194 Chapter 7.

3 Specific treatment situations and populations General key points Pain management Dependence on prescribed and over-the-counter opioids Misuse of or dependence on gabapentinoids Hospitalisation Pregnancy and neonatal care New psychoactive substances and club drugs Image and performance enhancing drugs Coexisting problems with mental health and substance use Young people Older people References 252 Annexes 255A1: Working group members and other contributors Members of the working group user and carer representatives Observers Secretariat Reviews and synopses Other contributors 261 Contents 3 A2: Governance Quality governance Confidentiality and safeguarding Non-medical prescribing 269A3: Marketing authorisations Off-label or unlicensed prescribing Young people References 272A4: Writing prescriptions General considerations Patient safety Legal and good practice requirements Minor amendments Additional country-specific rules Other considerations Examples of what to write on a prescription Private prescriptions Resources and further reading 292A5: Interactions Medicinal interactions Interactions with illicit drugs Resources and further reading 295A6: Travelling abroad with controlled drugs General Travelling for less than three months Travelling for three months or more 303A7: Drugs and driving Key points Offences related to drug use and driving in the UK Driving licence requirements Risk assessment for driving Responsibilities of the prescribing clinician Information for patients References 310A8: Glossary 3114 Drug misuse and dependence: UK guidelines on clinical managementList of figuresBox 1: Full or comprehensive assessment of drug-using parents 19 Box 2: Principles for trauma-informed care 42 Table 1.

4 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 PrefaceProfessor Sir John StrangIt has been my great honour and pleasure to chair the independent expert working group updating the 2007 clinical guidelines .

5 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 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 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 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.

6 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 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 Drug misuse and dependence: UK guidelines on clinical managementPsychosocial 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.

7 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 have been positive developments in the greater availability of community-based psychosocial interventions and peer support and mutual aid for those in drug treatment. However, there are also areas of marked weakness, including inadequate provision of effective support for social integration, including for employment and housing, which are still poorly provided for this group. There have been major advances, including with some of the associated health complications such as the greatly improved treatment of chronic hepatitis C infection: it is our privilege to bring you updated guidance of these new treatments, and it is our collective responsibility to ensure that these new treatments are used to deliver health systems and services to serve these needs may be vastly different.

8 Earlier versions of the guidelines were written when the system was mostly divided between NHS secondary care prescribing and voluntary sector advice and support. Today the situation is very different, with NHS specialist providers much diminished and with major independent or third-sector agencies being the main providers of treatment in a variety of collaborative arrangements. But there is considerable variation between localities and between the different countries of the UK. Whatever the composition of commissioning and provision, the fundamental principles of the clinical guidelines remain crucial and will require careful attention to ensure improved reach, better quality and proper monitoring of benefit from the various evidence-based treatments which must be commissioned to address the clinical needs of the populations with healthcare success with falling numbers of young people currently developing heroin dependence, the morbidity, mortality and long-term needs of an ageing cohort of patients with long-term heroin dependence problems means that treatment is increasingly complex and that coordination between services is vital.

9 This includes ever greater integration with mainstream physical and mental healthcare. Furthermore, the huge number of new psychoactive substances with little-known long-term effects poses fresh challenges for are additional challenges such as the need for training of addiction specialists outside of, as well as within, the NHS. If adequate training of addiction specialists is not achieved, then it will be harder for policy makers and commissioners to deliver adequate care for patients with more severe and complex conclusion, I would like to re-state my immense gratitude to colleagues on the working group, to the advisory groups that supported the service user and carer representatives, and to the officials who supported us in this important preparation of the 2017 clinical 7 Finally, I am grateful to the Chief Medical Officers of England, Scotland, Wales and Northern Ireland for commissioning and supporting the update, and to Public Health England for providing secretariat Sir John Strang National Addiction Centre8 Drug misuse and dependence: UK guidelines on clinical managementChapter 1: Introduction 9 Chapter 1: About these Who are the clinical guidelines for?

10 Drug Misuse and Dependence: UK guidelines on clinical management hereafter referred to as the 2017 clinical guidelines are intended primarily for clinicians providing drug treatment for people who misuse or are dependent on drugs. Clinicians in this context are psychiatrists and other doctors, nurses, psychologists, pharmacists, keyworkers and other workers providing drug treatment, as well as health and social care professionals who provide limited periods of support for the treatment of drug misuse and dependence (such as during hospitalisations).The guidelines will also be useful to those commissioning drug treatment and to those considering or undergoing drug treatment, their family, friends and What are the 2017 clinical guidelines ?This document updates and replaces the 2007 edition of Drug Misuse and Dependence: UK guidelines on clinical management (DH & devolved administrations 2007) hereafter referred to as the 2007 clinical guidelines . It has the same status across the UK as the 2007 clinical 2017 clinical guidelines provide guidance on the treatment of drug misuse and dependence in the UK.