Drug misuse and dependence

The Drug Misuse and Dependence Guidelines (often referred to as the "Orange Book" were updated in September 2017.¹ They are jointly produced by the Department of Health (England), the Scottish Government, the Welsh Assembly Government and the Northern Ireland Executive.

What are the drug misuse and dependence guidelines?

They are intended to serve as a framework for all doctors working within the NHS and private healthcare system in the UK, including doctors with no particular expertise in drug misuse and those who are providing care in specialist drug misuse services. They are based on professional consensus.

Of note, over the last two decades there have been major changes to delivery of health and social care. The devolution of responsibility to local areas, especially in England, continues to present risks and opportunities for drug treatment. The involvement of primary care varies substantially from area to area, so familiarity with guidelines may vary.

Also relevant to this topic is the following guideline, produced in 2012:

• Evidence-based guidelines for the pharmacological management of substance abuse, harmful use, addiction and comorbidity published by the British Association for Psychopharmacology (BAP) in 2012.²

See also the separate Assessment of Drug Dependence, Opioid Misuse and Dependence and Opioid Detoxification articles.

Background to the guidelines

The Drug Misuse and Dependence Guidelines, originally published in 1999, take on board the ever-changing epidemiology of drug misuse, changes in Government policy, the increasing involvement of GPs and competencies in substance misuse treatment.

The National Institute for Health and Care Excellence (NICE) has published guidance on drug misuse and its treatment. This includes, amongst others:

• Drug misuse: psychosocial interventions.³

• Drug misuse: opioid detoxification.⁴

• Drug misuse: methadone and buprenorphine.⁵

• Drug misuse: naltrexone.

• Substance misuse: interventions to reduce substance misuse among vulnerable young people.⁶

• Psychosis with co-existing substance abuse.⁷

The guidelines from the BAP were first published in 2004 and revised in 2012 to take account of developments principally from NICE. Unsurprisingly, they focus on the pharmacotherapy of substance abuse.

They deal in some detail not only with opioid abuse but also with benzodiazepines, tobacco, alcohol, ecstasy and other club drugs, cannabis and other substances of abuse.

These updated guidelines reflect these changes, as well as the increased prominence of drug misuse on the national agenda. NICE guidance is incorporated as appropriate. The difference in the status of NICE in England and Wales compared with Northern Ireland and Scotland should be remembered.

All significant published evidence has been included where possible but the Drug Misuse and Dependence Guidelines development committee acknowledges that: 'although the evidence base for drug misuse treatment has improved, in many areas of drug treatment evidence was either lacking or was based on research from countries other than the UK.'

This article outlines best practice based on a distillation of the current guidelines. Doctors should also be aware of the need to act in accordance with the separate legal obligations regarding the prescription of controlled drugs for the management of drug misuse.

Drug misuse and dependence guidelines: key points

• The BAP points out that various terms may be encountered in the literature, including drug dependence, drug addiction and substance abuse. The term drug misuse is used throughout this article but it is recognised that there is considerable overlap and some confusion in diagnostic terminology.²

• The rates of drug misuse and its associated morbidity and mortality in the UK are among the highest in the western world. However the proportion of drug misusers in treatment is also very high compared with other countries. Drug-related deaths due to overdose in the UK are among the highest in Europe.

• Drug misuse is more common in areas of social deprivation.

• Heroin is the most common main problem drug amongst adults, although most drug misusers use a range of drugs and alcohol.

• Cannabis and alcohol are the main problem drugs in children under the age of 18 years.

• Drug treatment is effective, has an evidence base and is cost-effective:
  

  • It has an impact on levels of drug use, offending, overdose risk and spread of blood-borne viruses.

  • Between a quarter and a third of those entering treatment achieve long-term sustained abstinence.

• Drug misusers may have multiple social and medical problems. Their mortality rates are higher.

• Drug misusers are particularly at risk from blood-borne infections:
  

  • 21% of injecting drug users are thought to be infected with hepatitis B in the UK and 50% with hepatitis C.

  • 1.3% of injecting drug users in England, Wales and Northern Ireland are HIV-positive.

  • HIV prevalence is thought to be increasing and shared injecting equipment is thought to be responsible.

• Drug misuse has a serious impact on the families of the drug misusers, especially children of drug-using parents. Effective treatment of the parent can greatly improve the situation.

• GPs have a responsibility to provide general medical services to drug misusers:
  

  • Local drug treatment systems should be based on local need, and local partnerships can be formed and commissioned.

  • GPs with a special interest in drug misuse can become involved in care.

• Good clinical governance systems will enable high-quality care.

• There should be no prejudice or discrimination:
  

  • Drug misusers have the same entitlement as other patients to the services provided by the NHS.

  • Doctors must provide care for both general health needs and drug-related problems, whether or not the patient is ready to withdraw from drugs.

  • This includes the provision of evidence-based interventions, such as hepatitis B vaccinations and providing harm-minimisation advice.

Clinical governance: key points

• Specific training, supervision and competency is needed to work with drug misusers.

• Team-working across primary and secondary care is usually effective.

• National guidance should be followed and local policies and protocols made.

• Audit and review should be performed regularly.

• Patients should be involved in their own care.

• Families should also be involved as appropriate. Families may need support. The NICE guidelines give more detail about interventions that doctors can offer to carers.

• Risk management should include infection control procedures and immunisation of staff at risk of infection.

• The prescribing of medication for the treatment of drug misuse by health professionals other than doctors is increasing. This needs specific training and supervision.

• Adequate steps should be taken to protect the children of drug-misusing parents. Child protection procedures should be initiated if there are concerns.

Treatment provision: key points

• The needs of drug misusers should be assessed across the four domains of drug and alcohol misuse, health, social functioning and criminal involvement.

• Drug misuse treatment involves offering a range of psychosocial treatment and support interventions, not just prescribing.

• All GPs have a duty to provide basic medical services to people who are dependent on opioids and they should screen patients for drug misuse.

• A good initial assessment is essential:
  

  • This may involve a multidisciplinary team.

  • Good assessment is vital to the continuing care of the patient.

  • It can enable the patient to become engaged in treatment and may begin a process of change even before a full assessment is completed.

• Confirmation of drug taking should be gained (through history, examination and drug testing).

• Any risks to their children should be assessed and child protection services involved as appropriate.

• Emergency or acute problems should be treated (for example, access to clean needles and equipment).

• Testing for blood-borne infections should be arranged as appropriate.

• A physical and psychological health assessment should be carried out.

• Any ongoing criminal involvement or offences should be determined.

• The drug misuser's expectations and desire to change should be assessed.

• The degree of dependence and need for substitute medication should be assessed.

• An individual care and treatment plan should be drawn up and reviewed regularly.

• A consistent, named person should manage and deliver an individual's care (eg, the GP or drugs worker). They are known as the 'keyworker'.

• If detoxification and/or substitute prescribing are requested, after an initial assessment, GPs can refer to local specialist community drug services and there are usually locally agreed shared care guidelines. A care plan between the drug misuser and the service provider can then be drawn up.

• A GP may have a special clinical interest in the management of substance misuse in primary care and may be able to take more responsibility in the treatment of patients, particularly in complex cases.

• Drug testing can help to monitor compliance and treatment outcome.

• Aftercare support; and pathways for rapid re-engagement in treatment in the case of relapse are important to address risks of relapse and harm.

Psychosocial components of treatment: key points

• A keyworker with a good therapeutic alliance is best placed to provide psychosocial assessment and support.

• Counselling, cognitive behavioural therapy and supportive help (for example with housing and benefits) are examples of psychosocial treatment strategies.

• If the keyworker does not have the full range of competencies to deliver psychosocial interventions, other professionals may be involved.

• Common social problems among drug misusers include housing, employment and financial difficulties. Criminal convictions are also common.

• Mental health problems such as depression and anxiety can co-exist with drug misuse.

• In cannabis, hallucinogen and stimulant abuse (including cocaine), psychosocial interventions are the main treatment.

• For opioid, alcohol and polydrug misuse, they can be used in conjunction with drug treatment.

• Patients should also be advised about support groups such as Alcoholics Anonymous and Narcotics Anonymous.

• Some patients find that self-help approaches work for them and these should be discussed.

• In other countries, couple- and family-based interventions and contingency management have been found to be helpful. These approaches are not commonly used in the UK at present but they should be considered (provided the appropriate training has been received).

• The NICE guidelines support a number of formal psychosocial treatments and detail the evidence that supports them. These include brief motivational interventions, self-help groups and contingency management (eg, incentives contingent on each presentation of a negative drug test).

Pharmacological interventions: key points

See also the separate Substitute Prescribing for Opioid Dependence article.

• Methadone and buprenorphine are both effective as maintenance treatment and are recommended by NICE.

• Oral methadone maintenance treatment is associated with a reduction of drug-related behaviours with a high risk of HIV transmission but has less effect on a reduction in sexual risk taking.

• A drug combination of buprenorphine and naloxone (Suboxone®) is available:
  

  • It should be taken sublingually and, when done so, the naloxone does not interfere with the therapeutic effect of the buprenorphine.

  • If injected or taken intranasally, the bioavailability of the naloxone may increase.

  • The idea is that this discourages further misuse.

• Before prescribing, there needs to be evidence that patients are drug-dependent and that they are motivated to change.

• During drug induction, care should be taken not to prescribe too rapid an increase in dose. This can result in overdose. This risk is less with buprenorphine.

• Daily supervision of the taking of the medication should be carried out initially and the duration of this supervision should be assessed for each patient.

• Care should be taken to ensure medication is kept away from children. Appropriate measures should be taken.

• If patients are not responding to treatment, more intensive drug and psychosocial interventions may improve response. The full guidelines discuss common scenarios in failure to benefit and outline suggested management approaches.

• Methadone, buprenorphine and lofexidine are all effective for detoxification.

• If benzodiazepines are prescribed for dependence, this should be at the lowest possible dose and the dose should be reduced as soon as possible.

• Detoxification programmes should include a complete package including drug treatment and preparatory and post-detoxification support.

• Prescribing is the responsibility of the person signing the prescription.

• The British National Formulary has helpful information about prescribing, including guidance regarding dosages. It also contains the rules for controlled drug prescription under the Misuse of Drugs legislation.

• The full Drug Misuse and Dependence Guidelines also discuss dosing for methadone and buprenorphine in more detail. This includes their use for detoxification and maintenance treatment. Annexes discuss how to write a prescription, details about what to do when travelling abroad, drug interactions and a section on drugs and driving. A new offence of driving with certain specified controlled drugs in excess of specified levels in the body came into force in March 2015. This offence is an addition to the existing rules on drug-impaired driving and fitness to drive. The legislation also provides for a statutory 'medical defence' for this new offence, for patients taking their medicines in accordance with instructions. See 'Further reading', below.

• They also discuss the use of lofexidine for opioid withdrawal as well as that of naltrexone for relapse prevention.

• The BAP guidelines also address the issue of dosing, effectiveness of various treatments and withdrawal.

• There should be close liaison between the prescriber and the pharmacist.

• The aims of drug treatment should be clearly identified before initiation and may include:
  

  • Helping to combat withdrawal symptoms.

  • Helping to stabilise drug intake and provide an opportunity to change current lifestyle and illicit drug use and all of its associated risk-taking behaviours.

  • Relapse prevention and maintenance of abstinence.

  • Prevention of complications (eg, use of thiamine to prevent Wernicke's encephalopathy and Korsakoff's syndrome).

• The need for clear prescribing records to be kept.

Health considerations: key points

• All drug misusers should be screened for and offered vaccination against (where available) blood-borne infections, including hepatitis A, B and C and HIV.

• Treatment for these infections should be commenced if screening is positive.

• Other infections such as tuberculosis and tetanus should also be considered in drug misusers. Tetanus vaccination should be offered where indicated.

• Concurrent alcohol misuse should be assessed and help offered.

• Smoking cessation interventions should be commenced as appropriate.

• The risks of overdose and how to prevent and respond to it should be made clear to drug misusers and their families.

Specific treatment situations and populations: key points

The Drug Misuse and Dependence and the BAP guidelines also address specific treatment groups including:

• Pregnant women and babies affected by maternal drug misuse.

• Older drug misusers.

• Young drug misusers.

• Drug misusers with acute and chronic pain.

• Drug misusers being admitted to and discharged from hospital.

• Drug misusers with a dual diagnosis (with a co-existent mental health problem as a separate diagnosis).

• Drug misusers in the criminal justice system.

• Drug misusers who misuse gabapentinoids.

• Drug misusers who misuse "new psychoactive substances" or "club drugs".

• Drug misusers who misuse image and performance enhancing drugs.

They discuss the role of the clinician in each situation, as well as specific management and prescribing issues and the management of comorbid disorders.

Conclusion

These guidelines offer much more than guidance on prescribing. They guide the reader through the best practice points of the management of drug misuse and drug dependence and of the role of the GP in the holistic management of people who misuse drugs.

As with all interventions, pragmatic clinicians need to take a realistic view of the range of outcomes possible with this type of problem and with the particular patients for whom they are providing care. This is best achieved by providing tailored care with clear objectives.