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Drug misuse in over 16s: opioid detoxification

Key priorities for implementation: psychosocial interventions

Brief interventions

  • 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 non-judgemental feedback

Self-help

  • 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

Contingency management

  • Introducing contingency management:
    • drug services should introduce contingency management programmes – as part of the phased implementation programme led by the National Treatment Agency for Substance Misuse (NTA) – to reduce illicit drug use and/or promote engagement with services for people receiving methadone maintenance treatment
  • Principles of contingency management:
    • 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)
      • 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
      • 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
      • urinalysis should be the preferred method of testing but oral fluid tests may be considered as an alternative
  • Contingency management to improve physical healthcare:
    • 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:
      • hepatitis B/C and HIV testing
      • hepatitis B immunisation
      • tuberculosis testing
  • Implementing contingency management:
    • 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
    • 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

Key priorities for implementation: opioid detoxification

Providing information, advice and support

  • Detoxification should be a readily available treatment option for people who are opioid dependent and have expressed an informed choice to become abstinent
  • 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)

The choice of medication for detoxification

  • 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

Ultra-rapid detoxification

  • 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

The choice of setting for detoxification

  • 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 community-based detoxification

© NICE 2007. Drug misuse in over 16s: opioid detoxification. Available from: www.nice.org.uk/guidance/CG52. All rights reserved. Subject to Notice of rights.

NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication. 

First included: October 2007.