| CRISM, 20187 |
|---|
| First- and second-line treatment options | |
- 1.
“Initiate opioid agonist treatment with buprenorphine–naloxone whenever feasible, to reduce the risk of toxicity, morbidity and death, and to facilitate safer take-home dosing.” (pE250)
| Strong recommendation, high quality evidence |
- 2.
“For individuals responding poorly to buprenorphine–naloxone, consider transition to methadone treatment.” (pE250)
| Strong recommendation, high quality evidence |
- 3.
“Initiate opioid agonist treatment with methadone when treatment with buprenorphine–naloxone is not the preferred option.” (pE250)
| Strong recommendation, high quality evidence |
- 4.
“For individuals with a successful and sustained response to methadone who express a desire for treatment simplification, consider transition to buprenorphine–naloxone, because its superior safety profile allows for more routine take-home dosing and less frequent medical appointments.” (pE250)
| Strong recommendation, moderate quality evidence |
| Alternative or adjunct treatment options | |
- 5.
“In patients for whom first- and second-line treatment options are ineffective or contraindicated, opioid agonist treatment with slow-release oral morphine (initially prescribed as once-daily witnessed doses) can be considered. Slow-release oral morphine treatment should be prescribed only by physicians with a Section 56 exemption to prescribe methadone, or following consultation with an addiction practitioner experienced in opioid agonist treatment with slow-release oral morphine.” (pE250)
| Strong recommendation, moderate quality evidence |
- 6.
“Offering withdrawal management alone (i.e., detoxification without immediate transition to long-term addiction treatment) should be avoided, because this approach has been associated with increased rates of relapse, morbidity and death.” (pE250)
| Strong recommendation, moderate quality evidence |
- 7.
“When withdrawal management (without transition to opioid agonist treatment) is pursued, provide supervised slow (> 1 mo) opioid agonist taper (in an outpatient or residential treatment setting) rather than a rapid (<1 wk) taper. During opioid-assisted withdrawal management, patients should be transitioned to long-term addiction treatment† to help prevent relapse and associated health risks.” (pE250)
| Strong recommendation, moderate quality evidence |
- 8.
“For patients with a successful and sustained response to opioid agonist treatment who wish to discontinue treatment (i.e., desiring medication cessation), consider a slow taper approach (over months to years, depending on the patient). Ongoing addiction care should be considered on cessation of opioid use.” (pE250)
| Strong recommendation, moderate quality evidence |
- 9.
“Psychosocial treatment interventions and supports should be routinely offered but should not be viewed as a mandatory requirement for accessing opioid agonist treatment.” (pE250)
| Strong recommendation, moderate quality evidence |
- 10.
“Oral naltrexone can also be considered as an adjunct medication if cessation of opioid use is achieved.” (pE250)
| Weak recommendation, low quality evidence |
| Adjunct harm-reduction strategies | |
- 11.
“Information and referrals to take-home naloxone programs and other harm reduction services (e.g., provision of clean drug paraphernalia), as well as other general health care services, should be routinely offered as part of standard care for opioid use disorders.” (pE250)
| Strong recommendation, moderate quality evidence |
| BCCSU/CRISM, 20176 |
|---|
| Approaches to avoid | |
- 1.
Withdrawal management alone (i.e., detoxification without immediate transition to longterm addiction treatment*) is not recommended, since this approach has been associated with elevated rates of relapse, HIV infection and overdose death. This includes rapid (< 1 week) inpatient tapers with methadone or buprenorphine/naloxone.” (p12)
| Strong recommendation, moderate quality evidence |
| Possible first-line treatment options | |
- 2.
“Initiate opioid agonist treatment with buprenorphine/naloxone whenever feasible to reduce toxicities and facilitate recovery through safer take-home dosing.” (p12)
| Strong recommendation, high quality evidence |
- 3.
Initiate opioid agonist treatment with methadone when treatment with buprenorphine/naloxone is not preferable (e.g., challenging induction).” (p12)
| Strong recommendation, high quality evidence |
- 4.
If withdrawal management is pursued, for most patients, this can be provided more safely in an outpatient rather than inpatient setting. During withdrawal management, patients should be immediately transitioned to long-term addiction treatment* to assist in preventing relapse and associated harms. See also #9. (p12)
| Strong recommendation, moderate quality evidence |
| Adjunct or alternative treatment options | |
- 5.
For individuals responding poorly to buprenorphine/naloxone, consider transition to methadone. (p12)
| Strong recommendation, high quality evidence |
- 6.
“For individuals responding poorly to methadone, or with successful and sustained response to methadone desiring treatment simplification, consider transition to buprenorphine/naloxone.” (p12)
| Strong recommendation, moderate quality evidence |
- 7.
“For individuals with a successful and sustained response to agonist treatment desiring medication cessation, consider slow taper (e.g., 12 months). Transition to oral naltrexone could be considered upon cessation of opioids.” (p12)
| Strong recommendation, moderate quality evidence |
- 8.
“Psychosocial treatment interventions and supports should be routinely offered in conjunction with pharmacological treatment.” (p12)
| Strong recommendation, moderate quality evidence |
- 9.
“For patients wishing to avoid long-term opioid agonist treatment, provide supervised slow (> 1 month) outpatient or residential opioid agonist taper rather than rapid (< 1 week) inpatient opioid agonist taper. During withdrawal management, patients should be transitioned to long-term addiction treatment to prevent relapse and associated harms. Oral naltrexone can also be considered as an adjunct upon cessation of opioid use.” (p13)
| Weak recommendation, low quality evidence |
- 10.
“For patients who have been unsuccessful with first- and second-line treatment options, opioid agonist treatment with slow-release oral morphine (prescribed as once-daily witnessed doses) can be considered. Slow-release oral morphine should only be prescribed by experienced addiction practitioners who hold a Section 56 exemption to prescribe methadone or only after specialist consultation (e.g., RACE line). Practitioners who lack experience prescribing slow-release oral morphine for treatment of opioid use disorder, regardless of Section 56 exemption status, should consult with an experienced prescriber prior to initiating treatment.” (p13)
| Strong recommendation, moderate quality evidence |
- 11.
“Information and referral to take-home naloxone programs and other harm reduction services should be routinely offered as part of standard care for opioid use disorder.” (p13)
| Strong recommendation, moderate quality evidence |
| WHO, 201411 |
|---|
- 1.
“Health-care providers should ask all pregnant women about their use of alcohol and other substances (past and present) as early as possible in the pregnancy and at every antenatal visit.” (pxii)
| Strong recommendation, low quality evidence |
- 2.
“Health-care providers should offer a brief intervention to all pregnant women using alcohol or drugs.” (pxii)
| Strong recommendation, low quality evidence |
- 3.
“Health-care providers managing pregnant or postpartum women with alcohol or other substance use disorders should offer comprehensive assessment and individualized care.”
(pxii)
| Conditional recommendation, very low quality evidence |
- 4.
“Health-care providers should, at the earliest opportunity, advise pregnant women dependent on alcohol or drugs to cease their alcohol or drug use and offer, or refer to, detoxification services under medical supervision where necessary and applicable.”
(pxii)
| Strong recommendation, very low quality evidence |
- 5.
“Pregnant women dependent on opioids should be encouraged to use opioid maintenance treatment whenever available rather than to attempt opioid detoxification.” (pxii)
| Strong recommendation, very low quality evidence |
- 12.
“Pregnant patients with opioid dependence should be advised to continue or commence opioid maintenance therapy with either methadone or buprenorphine.” (pxii)
| Strong recommendation, very low quality evidence |
| APS-CPDD, 201410 |
|---|
| “When considering initiation of methadone, the panel recommends that clinicians perform an individualized medical and behavioral risk evaluation to assess risks and benefits of methadone, given methadone’s specific pharmacologic properties and adverse effect profile.” (p324) | Strong recommendation, low-quality evidence |
| “The panel recommends that clinicians educate and counsel patients prior to the first prescription of methadone about the indications for treatment and goals of therapy, availability of alternative therapies, and specific plans for monitoring therapy, adjusting doses, potential adverse effects associated with methadone, and methods for reducing the risk of potential adverse effects and managing them.” (p324) | Strong recommendation, low-quality evidence |
| “The panel recommends that clinicians obtain an ECG prior to initiation of methadone in patients with risk factors for QTc interval prolongation, any prior ECG demonstrating a QTc >450 ms, or a history suggestive of prior ventricular arrhythmia. An ECG within the past 3 months with a QTc <450 ms in patients without new risk factors for QTc interval prolongation can be used for the baseline study.” (p325) | Strong recommendation, low-quality evidence |
| “The panel recommends that clinicians consider obtaining an ECG prior to initiation of methadone in patients not known to be at higher risk for QTc interval prolongation; an ECG within the past year with a QTc <450 ms in patients without new risk factors for QTc interval prolongation can be used for the baseline study.” (p325) | Weak recommendation, low-quality evidence |
| “The panel recommends against use of methadone in patients with a baseline QTc interval >500 ms.” (p327) | Strong recommendation, low-quality evidence |
| “The panel recommends that clinicians consider alternate opioids in patients with a baseline QTc interval $450 ms but<500 ms. If methadone is considered in a patient with a baseline QTc interval$450msbut<500ms, the clinician should evaluate for and correct reversible causes of QTc interval prolongation before initiating methadone.” (p327) | Weak recommendation, low-quality evidence |
| “The panel recommends that clinicians consider buprenorphine as a treatment option for patients treated for opioid addiction who have risk factors for or known QTc interval prolongation when an agonist/partial agonist is indicated.” (p327) | Weak recommendation, moderate-quality evidence |
| “The panel recommends that clinicians initiate methadone at low doses individualized based on the indication for treatment and prior opioid exposure status, titrate doses slowly, and monitor patients for sedation.” (p327) | Strong recommendation, moderate-quality evidence |
| “The panel recommends that clinicians consider those patients previously prescribed methadone, but who have not currently taken opioids for 1 to 2 weeks, opioid-naıve for the purpose of methadone reinitiation.” (p328) | Strong recommendation, low-quality evidence |
| “The panel recommends that for patients prescribed methadone, clinicians perform follow-up ECGs based on baseline ECG findings, methadone dose changes, and other risk factors for QTc interval prolongation.” (p329) | Strong recommendation, low-quality evidence |
| “The panel recommends that clinicians switch methadone-treated adults with a QTc interval $500 ms to an alternative opioid or immediately reduce the methadone dose; in all such cases, the panel recommends that clinicians evaluate and correct reversible causes of QTc interval prolongation, and repeat the ECG after the methadone dose has been decreased.” (p329) | Strong recommendation, low-quality evidence |
| “The panel recommends that clinicians consider switching methadone-treated adults with a QTc interval $450 ms but <500 ms to an alternative opioid or reducing the methadone dose. In patients in whom there are barriers to switching to alternative opioids, or who experience decreased treatment effectiveness with methadone dose reductions, the panel recommends that clinicians discuss with patients the potential risks of continued methadone. In all cases, the panel recommends that clinicians evaluate and correct reversible causes of QTc interval prolongation, and repeat the ECG after the methadone dose has been decreased.” (p329) | Strong recommendation, low-quality evidence |
| “The panel recommends that patients receiving methadone be monitored for common opioid adverse effects and toxicities and that adverse effects management be considered part of routine therapy.” (p330) | Strong recommendation, moderate-quality evidence |
| “The panel recommends face-to-face or phone assessment with patients to assess for adverse events within 3 to 5 days after initiating methadone, and within 3 to 5 days after each dose increase.” (p330) | Strong recommendation, low-quality evidence |
| “The panel recommends that clinicians obtain urine drug screens prior to initiating methadone and at regular intervals in patients prescribed methadone for opioid addiction.” (p330) | Strong recommendation, low quality evidence |
| “The panel recommends that clinicians use methadone with care in patients using concomitant medications with potentially additive side effects or pharmacokinetic or pharmacodynamic interactions with methadone.” (p330) | Strong recommendation, low-quality evidence |
| NICE, 201613 |
|---|
| “People who misuse drugs should be given the same care, respect and privacy as any other person.” (p40) | Not clear |
| “To enable people who misuse drugs to make informed decisions about their treatment and care, staff should explain options for abstinence-oriented, maintenance-oriented and harm-reduction interventions at the person’s initial contact with services and at subsequent formal reviews.” (p40) | Not clear |
“When making an assessment and developing and agreeing a care plan, staff should consider the service user’s:
medical, psychological, social and occupational needs history of drug use experience of previous treatment, if any goals in relation to his or her drug use treatment preferences” (p40)
| Not clear |
“Staff who are responsible for the delivery and monitoring of the agreed care plan should:
establish and sustain a respectful and supportive relationship with the service user help the service user to identify situations or states when he or she is vulnerable to drug misuse and to explore alternative coping strategies ensure that all service users have full access to a wide range of services ensure that maintaining the service user’s engagement with services remains a major focus of the care plan maintain effective collaboration with other care providers.” (p40)
| Not clear |
| “Staff should discuss with people who misuse drugs whether to involve their families and carers in their assessment and treatment plans. However, staff should ensure that the service user’s right to confidentiality is respected.” (p74) | Not clear |
“Staff should ask families and carers about, and discuss concerns regarding, the impact of drug misuse on themselves and other family members, including children. Staff should also:
offer family members and carers an assessment of their personal, social and mental health needs provide verbal and written information and advice on the impact of drug misuse on service users, families and carers.” (p74)
| Not clear |
“Routine clinical questions
6.2.4.1 Staff in mental health and criminal justice settings (in which drug misuse is known to be prevalent) should ask service users routinely about recent legal and illicit drug use. The questions should include whether they have used drugs and, if so:
| Not clear |
“Routine clinical questions
In settings such as primary care, general hospitals and emergency departments, staff should consider asking people about recent drug use if they present with symptoms that suggest the possibility of drug misuse, for example:
| Not clear |
“Biological tests
Healthcare professionals should use biological testing (for example, of urine or oral fluid samples) as part of a comprehensive assessment of drug use, but they should not rely on it as the sole method of diagnosis and assessment.” (p80) | Not clear |
“Opportunistic brief interventions focused on motivation should be offered to people in limited contact with drug services (for example, those attending a needle and syringe exchange or primary care settings) if concerns about drug misuse are identified by the service user or staff member. These interventions should:
normally consist of two sessions each lasting 10–45 minutes explore ambivalence about drug use and possible treatment, with the aim of increasing motivation to change behaviour, and provide nonjudgemental feedback.” (p98)
| Not clear |
“Opportunistic brief interventions focused on motivation should be offered to people not in contact with drug services (for example, in primary or secondary care settings, occupational health or tertiary education) if concerns about drug misuse are identified by the person or staff member.
These interventions should:
normally consist of two sessions each lasting 10–45 minutes explore ambivalence about drug use and possible treatment, with the aim of increasing motivation to change behaviour, and provide nonjudgemental feedback.” (p98)
| Not clear |
| “For people at risk of physical health problems (including transmittable diseases) resulting from their drug misuse, material incentives (for example, shopping vouchers of up to £10 in value) should be considered to encourage harm reduction. Incentives should be offered on a one-off basis or over a limited duration, contingent on concordance with or completion of each intervention, in particular for:
| Not clear |
| “During routine contacts and opportunistically (for example, at needle and syringe exchanges), staff should provide information and advice to all people who misuse drugs about reducing exposure to blood-borne viruses. This should include advice on reducing sexual and injection risk behaviours. Staff should consider offering testing for blood-borne viruses.” (p113) | Not clear |
| “Group-based psychoeducational interventions that give information about reducing exposure to blood-borne viruses and/or about reducing sexual and injection risk behaviours for people who misuse drugs should not be routinely provided.” (p113) | Not clear |
| “Evidence-based psychological treatments (in particular, cognitive behavioural therapy) should be considered for the treatment of comorbid depression and anxiety disorders in line with existing NICE guidance for people who misuse cannabis or stimulants, and for those who have achieved abstinence or are stabilised on opioid maintenance treatment.” (p117) | Not clear |
| “Drug services should introduce contingency management programmes – as part of the phased implementation programme led by the NTA – to reduce illicit drug use, promote abstinence and/or promote engagement with services for people who primarily misuse stimulants.” (p148) | Not clear |
| “Cognitive behavioural therapy and psychodynamic therapy focused on the treatment of drug misuse should not be offered routinely to people presenting for treatment of cannabis or stimulant misuse or those receiving opioid maintenance treatment.” (p148) | Not clear |
| “Drug services should introduce contingency management programmes – as part of the phased implementation programme led by the NTA – to reduce illicit drug use and/or promote engagement with services for people receiving methadone maintenance treatment.” (p177) | Not clear |
“Contingency management aimed at reducing illicit drug use for people receiving methadone maintenance treatment or who primarily misuse stimulants should be based on the following principles.
The programme should offer incentives (usually vouchers that can be exchanged for goods or services of the service user’s choice, or privileges such as take-home methadone doses) contingent on each presentation of a drug-negative test (for example, free from cocaine or non-prescribed opioids). If vouchers are used, they should have monetary values that start in the region of £2 and increase with each additional, continuous period of abstinence. The frequency of screening should be set at three tests per week for the first 3 weeks, two tests per week for the next 3weeks, and one per week thereafter until stability is achieved. Urinalysis should be the preferred method of testing but oral fluid tests may be considered as an alternative.” (p177)
| Not clear |
“Staff delivering contingency management programmes should ensure that:
the target is agreed in collaboration with the service user the incentives are provided in a timely and consistent manner the service user fully understands the relationship between the treatment goal and the incentive schedule the incentive is perceived to be reinforcing and supports a healthy/drugfree lifestyle.” (p177)
| Not clear |
| “Drug services should ensure that as part of the introduction of contingency management, staff are trained and competent in appropriate near-patient testing methods and in the delivery of contingency management.” (p177) | Not clear |
| “Contingency management should be introduced to drug services in the phased implementation programme led by the NTA, in which staff training and the development of service delivery systems are carefully evaluated. The outcome of this evaluation should be used to inform the full-scale implementation of contingency management.” (p177) | Not clear |
| “Behavioural couples therapy should be considered for people who are in close contact with a non-drug-misusing partner and who present for treatment of stimulant or opioid misuse (including those who continue to use illicit drugs while receiving opioid maintenance treatment or after completing opioid detoxification). The intervention should:
| Not clear |
| “All interventions for people who misuse drugs should be delivered by staff who are competent in delivering the intervention and who receive appropriate supervision.” (p178) | Not clear |
“For people receiving naltrexone maintenance treatment to help prevent relapse to opioid dependence, staff should consider offering:
contingency management to all service users behavioural couples therapy or behavioural family interventions to service users in close contact with a non-drug-misusing family member, carer or partner.” (p178)
| Not clear |
| “Staff should routinely provide people who misuse drugs with information about self-help groups. These groups should normally be based on 12-step principles; for example, Narcotics Anonymous and Cocaine Anonymous.” (p187) | Not clear |
| “If a person who misuses drugs has expressed an interest in attending a 12-step self-help group, staff should consider facilitating the person’s initial contact with the group, for example by making the appointment, arranging transport, accompanying him or her to the first session and dealing with any concerns.” (p187) | Not clear |
| “In order to reduce loss of contact when people who misuse drugs transfer between services, staff should ensure that there are clear and agreed plans to facilitate effective transfer.” (p193) | Not clear |
“Where the needs of families and carers of people who misuse drugs have been identified, staff should:
offer guided self-help, typically consisting of a single session with the provision of written material provide information about, and facilitate contact with, support groups, such as self-help groups specifically focused on addressing families’ and carers’ needs.” (p187)
| Not clear |
“Where the families of people who misuse drugs have not benefited, or are not likely to benefit, from guided self-help and/or support groups and continue to have significant problems, staff should consider offering individual family meetings. These should:
provide information and education about drug misuse help to identify sources of stress related to drug misuse explore and promote effective coping behaviours normally consist of at least five weekly sessions.” (p187)
| Not clear |
| “The same range of psychosocial interventions should be available in inpatient and residential settings as in community settings. These should normally include contingency management, behavioural couples therapy and cognitive behavioural therapy. Services should encourage and facilitate participation in self-help groups.” (p207) | Not clear |
| “Residential treatment may be considered for people who are seeking abstinence and who have significant comorbid physical, mental health or social (for example, housing) problems. The person should have completed a residential or inpatient detoxification programme and have not benefited from previous community-based psychosocial treatment.” (p207) | Not clear |
| “People who have relapsed to opioid use during or after treatment in an inpatient or residential setting should be offered an urgent assessment. Offering prompt access to alternative community, residential or inpatient support, including maintenance treatment, should be considered.” (p217) | Not clear |
| “For people who misuse drugs, access to and choice of treatment should be the same whether they participate in treatment voluntarily or are legally required to do so.” (p219) | Not clear |
“For people in prison who have drug misuse problems, treatment options should be comparable to those available in the community. Healthcare professionals should take into account additional considerations specific to the prison setting, which include:
the length of sentence or remand period, and the possibility of unplanned release risks of self-harm, death or post-release overdose”. (p224)
| Not clear |
| “People in prison who have significant drug misuse problems may be considered for a therapeutic community developed for the specific purpose of treating drug misuse within the prison environment.” (p224) | Not clear |
| “For people who have made an informed decision to remain abstinent after release from prison, residential treatment should be considered as part of an overall care plan.” (p224) | Not clear |
| NICE, 201412 |
|---|
| “Detoxification should be a readily available treatment option for people who are opioid dependent and have expressed an informed choice to become abstinent.” (p10) | Not clear |
“In order to obtain informed consent, staff should give detailed information to service users about detoxification and the associated risks, including:
the physical and psychological aspects of opioid withdrawal, including the duration and intensity of symptoms, and how these may be managed the use of non-pharmacological approaches to manage or cope with opioid withdrawal symptoms the loss of opioid tolerance following detoxification, and the ensuing increased risk of overdose and death from illicit drug use that may be potentiated by the use of alcohol or benzodiazepines the importance of continued support, as well as psychosocial and appropriate pharmacological interventions, to maintain abstinence, treat comorbid mental health problems and reduce the risk of adverse outcomes (including death).” (p10)
| Not clear |
| “Service users should be offered advice on aspects of lifestyle that require particular attention during opioid detoxification. These include:
| Not clear |
“Staff who are responsible for the delivery and monitoring of a care plan should:
develop and agree the plan with the service user establish and sustain a respectful and supportive relationship with the service user help the service user to identify situations or states when he or she is vulnerable to drug misuse and to explore alternative coping strategies ensure that all service users have full access to a wide range of services ensure that maintaining the service user’s engagement with services remains a major focus of the care plan review regularly the care plan of a service user receiving maintenance treatment to ascertain whether detoxification should be considered maintain effective collaboration with other care providers.” (p10-11)
| Not clear |
| “People who are opioid dependent and considering self-detoxification should be encouraged to seek detoxification in a structured treatment programme or, at a minimum, to maintain contact with a drug service” (p11) | Not clear |
| “Service users considering opioid detoxification should be provided with information about self-help groups (such as 12-step groups) and support groups (such as the Alliance); staff should consider facilitating engagement with such services.” (p11) | Not clear |
| “Staff should discuss with people who present for detoxification whether to involve their families and carers in their assessment and treatment plans. However, staff should ensure that the service user’s right to confidentiality is respected.” (p11) | Not clear |
| “In order to reduce loss of contact when people who misuse drugs transfer between services, staff should ensure that there are clear and agreed plans to facilitate effective transfer.” (p11) | Not clear |
| “All interventions for people who misuse drugs should be delivered by staff who are competent in delivering the intervention and who receive appropriate supervision.” (p11) | Not clear |
| “People who are opioid dependent should be given the same care, respect and privacy as any other person.” (p11) | Not clear |
“Staff should ask families and carers about, and discuss concerns regarding, the impact of drug misuse on themselves and other family members, including children. Staff should also:
offer family members and carers an assessment of their personal, social and mental health needs provide verbal and written information and advice on the impact of drug misuse on service users, families and carers provide information about detoxification and the settings in which it may take place provide information about self-help and support groups for families and carers.” (p12)
| Not clear |
“People presenting for opioid detoxification should be assessed to establish the presence and severity of opioid dependence, as well as misuse of and/or dependence on other substances, including alcohol, benzodiazepines and stimulants. As part of the assessment, healthcare professionals should:
use urinalysis to aid identification of the use of opioids and other substances; consideration may also be given to other near-patient testing methods such as oral fluid and/or breath testing clinically assess signs of opioid withdrawal where present (the use of formal rating scales may be considered as an adjunct to, but not a substitute for, clinical assessment) take a history of drug and alcohol misuse and any treatment, including previous attempts at detoxification, for these problems review current and previous physical and mental health problems, and any treatment for these consider the risks of self-harm, loss of opioid tolerance and the misuse of drugs or alcohol as a response to opioid withdrawal symptoms consider the person’s current social and personal circumstances, including employment and financial status, living arrangements, social support and criminal activity consider the impact of drug misuse on family members and any dependants develop strategies to reduce the risk of relapse, taking into account the person’s support network.” (p12-13)
| Not clear |
“If opioid dependence or tolerance is uncertain, healthcare professionals should, in addition to near-patient testing, use confirmatory laboratory tests. This is particularly important when:
a young person first presents for opioid detoxification a near-patient test result is inconsistent with clinical assessment complex patterns of drug misuse are suspected.” (p13)
| Not clear |
| “Near-patient and confirmatory testing should be conducted by appropriately trained healthcare professionals in accordance with established standard operating and safety procedures.” (p13) | Not clear |
“Opioid detoxification should not be routinely offered to people:
with a medical condition needing urgent treatment in police custody, or serving a short prison sentence or a short period of remand; consideration should be given to treating opioid withdrawal symptoms with opioid agonist medication who have presented to an acute or emergency setting; the primary emergency problem should be addressed and opioid withdrawal symptoms treated, with referral to further drug services as appropriate.” (p13)
| Not clear |
| “For women who are opioid dependent during pregnancy, detoxification should only be undertaken with caution.” (p13) | Not clear |
| “For people who are opioid dependent and have comorbid physical or mental health problems, these problems should be treated alongside the opioid dependence, in line with relevant NICE guidance where available.” (p14) | Not clear |
“If a person presenting for opioid detoxification also misuses alcohol, healthcare professionals should consider the following.
If the person is not alcohol dependent, attempts should be made to address their alcohol misuse, because they may increase this as a response to opioid withdrawal symptoms, or substitute alcohol for their previous opioid misuse. If the person is alcohol dependent, alcohol detoxification should be offered. This should be carried out before starting opioid detoxification in a community or prison setting, but may be carried out concurrently with opioid detoxification in an inpatient setting or with stabilisation in a community setting.” (p14)
| Not clear |
| “If a person presenting for opioid detoxification is also benzodiazepine dependent, healthcare professionals should consider benzodiazepine detoxification. When deciding whether this should be carried out concurrently with, or separately from, opioid detoxification, healthcare professionals should take into account the person’s preference and the severity of dependence for both substances.” (p14) | Not clear |
“Methadone or buprenorphine should be offered as the first-line treatment in opioid detoxification. When deciding between these medications, healthcare professionals should take into account:
whether the service user is receiving maintenance treatment with methadone or buprenorphine; if so, opioid detoxification should normally be started with the same medication the preference of the service user” (p14)
| Not clear |
“Lofexidine may be considered for people:
who have made an informed and clinically appropriate decision not to use methadone or buprenorphine for detoxification who have made an informed and clinically appropriate decision to detoxify within a short time period with mild or uncertain dependence (including young people).” (p14-15)
| Not clear |
| “Clonidine should not be used routinely in opioid detoxification.” (p15) | Not clear |
| “Dihydrocodeine should not be used routinely in opioid detoxification.” (p15) | Not clear |
| “Opioid detoxification refers to the process by which the effects of opioid drugs are eliminated from dependent opioid users in a safe and effective manner, such that withdrawal symptoms are minimised. This should be an active process carried out following the joint decision of the service user and healthcare professional, with continued treatment, support and monitoring. Detoxification should not be confused with stabilisation or gradual dose reduction.” (p15) | Not clear |
“When determining the starting dose, duration and regimen (for example, linear or stepped) of opioid detoxification, healthcare professionals, in discussion with the service user, should take into account the:
severity of dependence (particular caution should be exercised where there is uncertainty about dependence) stability of the service user (including polydrug and alcohol use, and comorbid mental health problems) pharmacology of the chosen detoxification medication and any adjunctive medication setting in which detoxification is conducted.” (p15)
| Not clear |
| “The duration of opioid detoxification should normally be up to 4 weeks in an inpatient/residential setting and up to 12 weeks in a community setting.” (p15) | Not clear |
| “Ultra-rapid and rapid detoxification using precipitated withdrawal should not be routinely offered. This is because of the complex adjunctive medication and the high level of nursing and medical supervision required.” (p16) | Not clear |
| “Ultra-rapid detoxification under general anaesthesia or heavy sedation (where the airway needs to be supported) must not be offered. This is because of the risk of serious adverse events, including death.” (p16) | Not clear |
“Rapid detoxification should only be considered for people who specifically request it, clearly understand the associated risks and are able to manage the adjunctive medication. In these circumstances, healthcare professionals should ensure during detoxification that:
the service user is able to respond to verbal stimulation and maintain a patent airway adequate medical and nursing support is available to regularly monitor the service user’s level of sedation and vital signs staff have the competence to support airways.” (p17)
| Not clear |
| “Accelerated detoxification, using opioid antagonists at lower doses to shorten detoxification, should not be routinely offered. This is because of the increased severity of withdrawal symptoms and the risks associated with the increased use of adjunctive medications.” (p17) | Not clear |
“When prescribing adjunctive medications during opioid detoxification, healthcare professionals should:
only use them when clinically indicated, such as when agitation, nausea, insomnia, pain and/or diarrhoea are present use the minimum effective dosage and number of drugs needed to manage symptoms be alert to the risks of adjunctive medications, as well as interactions between them and with the opioid agonist.” (p17)
| Not clear |
“Healthcare professionals should be aware that medications used in opioid detoxification are open to risks of misuse and diversion in all settings (including prisons), and should consider:
monitoring of medication concordance methods of limiting the risk of diversion where necessary, including supervised consumption.” (p17)
| Not clear |
“Staff should routinely offer a community-based programme to all service users considering opioid detoxification. Exceptions to this may include service users who:
have not benefited from previous formal community-based detoxification need medical and/or nursing care because of significant comorbid physical or mental health problems require complex polydrug detoxification, for example concurrent detoxification from alcohol or benzodiazepines are experiencing significant social problems that will limit the benefit of communitybased detoxification.” (p18)
| Not clear |
| “Residential detoxification should normally only be considered for people who have significant comorbid physical or mental health problems, or who require concurrent detoxification from opioids and benzodiazepines or sequential detoxification from opioids and alcohol.” (p18) | Not clear |
| “Residential detoxification may also be considered for people who have less severe levels of opioid dependence, for example those early in their drug-using career, or for people who would benefit significantly from a residential rehabilitation programme during and after detoxification.” (p18) | Not clear |
| “Inpatient, rather than residential, detoxification should normally only be considered for people who need a high level of medical and/or nursing support because of significant and severe comorbid physical or mental health problems, or who need concurrent detoxification from alcohol or other drugs that requires a high level of medical and nursing expertise.” (p18) | Not clear |
| “Following successful opioid detoxification, and irrespective of the setting in which it was delivered, all service users should be offered continued treatment, support and monitoring designed to maintain abstinence. This should normally be for a period of at least 6 months.” (p18-19) | Not clear |
“Community detoxification should normally include:
prior stabilisation of opioid use through pharmacological treatment effective coordination of care by specialist or competent primary practitioners the provision of psychosocial interventions, where appropriate, during the stabilisation and maintenance phases” (p19)
| Not clear |
| “Inpatient and residential detoxification should be conducted with 24-hour medical and nursing support commensurate with the complexity of the service user’s drug misuse and comorbid physical and mental health problems. Both pharmacological and psychosocial interventions should be available to support treatment of the drug misuse as well as other significant comorbid physical or mental health problems.” (p19) | Not clear |
“People in prison should have the same treatment options for opioid detoxification as people in the community. Healthcare professionals should take into account additional considerations specific to the prison setting, including:
practical difficulties in assessing dependence and the associated risk of opioid toxicity early in treatment length of sentence or remand period, and the possibility of unplanned release risks of self-harm, death or post-release overdose.” (p19)
| Not clear |
| “Contingency management aimed at reducing illicit drug use should be considered both during detoxification and for up to 3–6 months after completion of detoxification.” (p20) | Not clear |
“Contingency management during and after detoxification should be based on the following principles.
The programme should offer incentives (usually vouchers that can be exchanged for goods or services of the service user’s choice, or privileges such as take-home methadone doses) contingent on each presentation of a drug-negative test (for example, free from cocaine or non-prescribed opioids). If vouchers are used, they should have monetary values that start in the region of £2 and increase with each additional, continuous period of abstinence The frequency of screening should be set at three tests per week for the first 3 weeks, two tests per week for the next 3 weeks, and one per week thereafter until stability is achieved. Urinalysis should be the preferred method of testing but oral fluid tests may be considered as an alternative.” (p20-21)
| Not clear |
“Staff delivering contingency management programmes should ensure that:
the target is agreed in collaboration with the service user the incentives are provided in a timely and consistent manner the service user fully understands the relationship between the treatment goal and the incentive schedule the incentive is perceived to be reinforcing and supports a healthy/drug-free lifestyle.” (p21)
| Not clear |
| “Drug services should ensure that as part of the introduction of contingency management, staff are trained and competent in appropriate near-patient testing methods and in the delivery of contingency management.” (p21) | Not clear |
| “Contingency management should be introduced to drug services in the phased implementation programme led by the National Treatment Agency for Substance Misuse (NTA), in which staff training and the development of service delivery systems are carefully evaluated. The outcome of this evaluation should be used to inform the full-scale implementation of contingency management.” (p21) | Not clear |
