management of drug misuse
Successful 'management' may aim for stabilisation or abstinence from drugs. The term 'recovery' is a fluid one. It is defined by the drug consensus as "a process characterised by voluntarily maintained control over substance use, leading towards health and well-being and participation in the responsibilities and benefits of society" (UK Drug Policy Commission, 2008).
So far in this section we've identified that drug use is more common in homeless populations and that there are clear benefits in trying to improve and reduce illicit drug use. The next question is understandably 'how do I go about even starting this in primary care?'. Remember we are not trying to fix the whole spectrum of issues that go with drug misuse and dependence in a single consultation. We are aiming to build a trusting relationship with the patient to help them on their road to recovery. For more detail about how this might look in a consultation model in primary care, go to the ADDICTION TO PRESCRIPTION MEDICATION page to look at Longstaff & Schafer's model.
When thinking about how to manage drug misuse we can categorise interventions into community based treatment, specialist inpatient treatments and pharmacotherapy. I have then included a brief attempt at a possible consultation model that could be applied in the first presentation of drug misuse to primary care. Pharmacotherapy exists essentially for opioid dependence (chiefly heroin) and for treating co-existing problems such as depression and anxiety. Although illicit heroin use is rare compared to other drugs more commonly abused, its use is more common in homeless populations than in the general public, it has the greatest addictive potential and causes the most harm in terms of dependency, spread of blood borne viruses (through injecting) and death from overdose (RCGP, 2013).
No single method or model of treatment exists that works for everybody. The level of support needed will depend not he individual circumstances and whether or not the person has problem drug use or a full 'dependence syndrome', where use of the drug "takes up an overriding importance in the person's life" at the expense of other responsibilities (RCGP, 2013).
Community-based Treatments
These will exist in different forms across the country but will often compromise a core set up of: a drugs counsellor for advice, support, information and motivatiion; a nurse to help coordinate care; links with social workers; and access to groups to help combat isolation. They will usually be able to support access into group therapy programmes (i.e. 12-step groups) such as Narcotics Anonymous. Contrary to widely held belief, these 12-step orientated groups are not faith based and do not require religious belief but they do require one to admit to their own powerlessness over their problem and to ask the group for help. This is relevant because research has shown that the two biggest triggers for relapse into substance misuse are also two of the biggest risks factors for developing a problem in the first place: demoralisation and isolation (Miller & Harris, 2000).
Community based services will often also include access to psychological support in the forms of counselling (for individuals, families and couples), Cognitive Behavioural Therapy and Motivational Interviewing (using the FRAMES technique mentioned in the ALCOHOL section).
'In-patient' Treatments
Some people with full dependence syndromes may benefit from periods of supervised support or treatment in residential units. Often the only way for a patient to access these form primary care is to go through the community services (and this often requires motivation on their part to engage). Being in an residential setting removes some of the temptation and easy access to substances that might make relapse easier and withdrawal symptoms can also be managed (or masked) in a safe and controlled way. As with any substance misuse problem, however, the substance itself is only one piece of the problem and the residential settings can sometimes provide intensive input with regards to the psychological, behavioural and personal factors that help maintain a person's dependence.
Pharmacotherapy
By 'pharmacotherapy' in this section we mean the use Opiate Substitution Therapy (OST) in the management of opiate dependency. The medications we will consider are Methadone and Buprenorphine (Subutex) as Lofexidine and Naltrexone are being less commonly used in primary care at the time of writing. These can be used in different ways, depending on the aims of treatment: they can be used to facilitate WITHDRAWAL/DETOXIFICATION from all opiates or as MAINTENANCE THERAPY to help achieve some stability in the person's life, so that other issues can be addressed with the aid of psychosocial support. Whether used as 'detox' or maintenance, the principle aim of OST is to remove the physical and psychological effects of withdrawal whilst using a safer product under supervision from professionals, in order to reduce the harmful consequences of drug use and facilitate the process of recovery.
Methadone (a man-made opioid) has been described as 'the most researched medication in the world' and Buprenorphine (another man-made opioid) has been around since 1960. There is incontrovertible, consistent and strong evidence that long term treatment with Methadone and Buprenorphine reduce illicit drug use, risk of HIV, risk of death, crime and unemployment as well as improving social stabilisation, retention in employment and contributions to society (NICE, 2007; Mattick et al, 2003).
Methadone is prescribed as a liquid, after guidance declared that tablets should no longer be used because of the risk they may be crushed and injected. Buprenorphine (Subutex) is a sublingual tablet. To be effective as an OST, both need to be given in adequate doses and evidence has shown this is typically 80-100mg per day for methadone and 8-32mg/day for buprenorphine (Mattick et al, 2003).
So far in this section we've identified that drug use is more common in homeless populations and that there are clear benefits in trying to improve and reduce illicit drug use. The next question is understandably 'how do I go about even starting this in primary care?'. Remember we are not trying to fix the whole spectrum of issues that go with drug misuse and dependence in a single consultation. We are aiming to build a trusting relationship with the patient to help them on their road to recovery. For more detail about how this might look in a consultation model in primary care, go to the ADDICTION TO PRESCRIPTION MEDICATION page to look at Longstaff & Schafer's model.
When thinking about how to manage drug misuse we can categorise interventions into community based treatment, specialist inpatient treatments and pharmacotherapy. I have then included a brief attempt at a possible consultation model that could be applied in the first presentation of drug misuse to primary care. Pharmacotherapy exists essentially for opioid dependence (chiefly heroin) and for treating co-existing problems such as depression and anxiety. Although illicit heroin use is rare compared to other drugs more commonly abused, its use is more common in homeless populations than in the general public, it has the greatest addictive potential and causes the most harm in terms of dependency, spread of blood borne viruses (through injecting) and death from overdose (RCGP, 2013).
No single method or model of treatment exists that works for everybody. The level of support needed will depend not he individual circumstances and whether or not the person has problem drug use or a full 'dependence syndrome', where use of the drug "takes up an overriding importance in the person's life" at the expense of other responsibilities (RCGP, 2013).
Community-based Treatments
These will exist in different forms across the country but will often compromise a core set up of: a drugs counsellor for advice, support, information and motivatiion; a nurse to help coordinate care; links with social workers; and access to groups to help combat isolation. They will usually be able to support access into group therapy programmes (i.e. 12-step groups) such as Narcotics Anonymous. Contrary to widely held belief, these 12-step orientated groups are not faith based and do not require religious belief but they do require one to admit to their own powerlessness over their problem and to ask the group for help. This is relevant because research has shown that the two biggest triggers for relapse into substance misuse are also two of the biggest risks factors for developing a problem in the first place: demoralisation and isolation (Miller & Harris, 2000).
Community based services will often also include access to psychological support in the forms of counselling (for individuals, families and couples), Cognitive Behavioural Therapy and Motivational Interviewing (using the FRAMES technique mentioned in the ALCOHOL section).
'In-patient' Treatments
Some people with full dependence syndromes may benefit from periods of supervised support or treatment in residential units. Often the only way for a patient to access these form primary care is to go through the community services (and this often requires motivation on their part to engage). Being in an residential setting removes some of the temptation and easy access to substances that might make relapse easier and withdrawal symptoms can also be managed (or masked) in a safe and controlled way. As with any substance misuse problem, however, the substance itself is only one piece of the problem and the residential settings can sometimes provide intensive input with regards to the psychological, behavioural and personal factors that help maintain a person's dependence.
Pharmacotherapy
By 'pharmacotherapy' in this section we mean the use Opiate Substitution Therapy (OST) in the management of opiate dependency. The medications we will consider are Methadone and Buprenorphine (Subutex) as Lofexidine and Naltrexone are being less commonly used in primary care at the time of writing. These can be used in different ways, depending on the aims of treatment: they can be used to facilitate WITHDRAWAL/DETOXIFICATION from all opiates or as MAINTENANCE THERAPY to help achieve some stability in the person's life, so that other issues can be addressed with the aid of psychosocial support. Whether used as 'detox' or maintenance, the principle aim of OST is to remove the physical and psychological effects of withdrawal whilst using a safer product under supervision from professionals, in order to reduce the harmful consequences of drug use and facilitate the process of recovery.
Methadone (a man-made opioid) has been described as 'the most researched medication in the world' and Buprenorphine (another man-made opioid) has been around since 1960. There is incontrovertible, consistent and strong evidence that long term treatment with Methadone and Buprenorphine reduce illicit drug use, risk of HIV, risk of death, crime and unemployment as well as improving social stabilisation, retention in employment and contributions to society (NICE, 2007; Mattick et al, 2003).
Methadone is prescribed as a liquid, after guidance declared that tablets should no longer be used because of the risk they may be crushed and injected. Buprenorphine (Subutex) is a sublingual tablet. To be effective as an OST, both need to be given in adequate doses and evidence has shown this is typically 80-100mg per day for methadone and 8-32mg/day for buprenorphine (Mattick et al, 2003).
Starting OST
Please be aware that the following is not a comprehensive guide to OST prescribing. To safely prescribe OST a prescriber must have appropriate experience or have undergone training (such as the RCGP Certificate) and be working as part of locally enhanced agreement/equivalent. The Department of Health document 'Drug Misuse and Dependence: UK Guidelines on Clinical Management (2007)' is referenced heavily in the following information.
The national guidelines suggest that OST should only be considered when:
Examination and toxicology (to confirm opioid use) is important because there is real risk posed from initiating methadone to opiate naive people, especially if other CNS depressants such as alcohol or benzodiazepines are being abused.
The choice of OST agent will depend on a number of things, including the prescriber's confidence and the patient's preference or past experiences. For example, if someone feels or believes that methadone did not work for them before, it might not be likely to work next time around. The patient should also be referred to community pharmacist after a discussion with them, along with a letter. Remember that the relationship with the pharmacist (who will dispensing the medication) is important for patients and prescriber. A patient may not want to be referred to the pharmacy which is near their parent's house, for example. Issues like this might just add barriers to successful treatment.
Initiating OST is done incrementally, under close supervision from the community pharmacist and starts at low doses (typically 10-30mg/day methadone or 4-8mg/day Buprenorphine). Methadone builds up to a steady state over a number of days. This means two things: firstly, it will take a few days from the onset of treatment to know whether or not the dosing schedule is optimal (this can be difficult for patients who may be experiencing withdrawal); secondly, it means there is a risk of cumulative toxicity as the drug builds up over time. The risk of toxicity (overdose) from methadone is increased if people are using heroin, alcohol or benzodiazepines as well. Patients need to be carefully warned about the risks of using extra opiates on top of their methadone programme. Patients need to be reviewed daily for signs of opiate intoxication or withdrawal, so that their dose can be titrated. Any adjustments in the first week must be done with great caution Initiating buprenorphine is quite a lot quicker, with people often getting onto adequate doses within days.
It is normal for patients to have to take their medication under direct supervision from a community pharmacist, at least at the start of treatment. This policy has reduced deaths from opiate overdose. Typically this might go on for up to three months whereafter things might be relaxed if the prescriber is satisfied that compliance is likely to continue (this could be assessed by measures such as attendance at appointments, results of toxicology screens, abstinence from or large changes in drug use etc).
Summary
Click below to proceed to a brief outline of a consultation model that could be used during the initial meetings with a patient misusing drugs.
Please be aware that the following is not a comprehensive guide to OST prescribing. To safely prescribe OST a prescriber must have appropriate experience or have undergone training (such as the RCGP Certificate) and be working as part of locally enhanced agreement/equivalent. The Department of Health document 'Drug Misuse and Dependence: UK Guidelines on Clinical Management (2007)' is referenced heavily in the following information.
The national guidelines suggest that OST should only be considered when:
- opiates are being taken on a regular basis – usually daily
- there is convincing evidence of current dependence
- patients are motivated to change at least some aspects of their drug misuse
- the assessment (including history, examination and toxicology, drug diary) clearly substantiates the need for treatment
- the clinician is satisfied that the patient has the capacity to comply with the prescribing regimen
- the patient is not receiving a prescription from another clinician.
Examination and toxicology (to confirm opioid use) is important because there is real risk posed from initiating methadone to opiate naive people, especially if other CNS depressants such as alcohol or benzodiazepines are being abused.
The choice of OST agent will depend on a number of things, including the prescriber's confidence and the patient's preference or past experiences. For example, if someone feels or believes that methadone did not work for them before, it might not be likely to work next time around. The patient should also be referred to community pharmacist after a discussion with them, along with a letter. Remember that the relationship with the pharmacist (who will dispensing the medication) is important for patients and prescriber. A patient may not want to be referred to the pharmacy which is near their parent's house, for example. Issues like this might just add barriers to successful treatment.
Initiating OST is done incrementally, under close supervision from the community pharmacist and starts at low doses (typically 10-30mg/day methadone or 4-8mg/day Buprenorphine). Methadone builds up to a steady state over a number of days. This means two things: firstly, it will take a few days from the onset of treatment to know whether or not the dosing schedule is optimal (this can be difficult for patients who may be experiencing withdrawal); secondly, it means there is a risk of cumulative toxicity as the drug builds up over time. The risk of toxicity (overdose) from methadone is increased if people are using heroin, alcohol or benzodiazepines as well. Patients need to be carefully warned about the risks of using extra opiates on top of their methadone programme. Patients need to be reviewed daily for signs of opiate intoxication or withdrawal, so that their dose can be titrated. Any adjustments in the first week must be done with great caution Initiating buprenorphine is quite a lot quicker, with people often getting onto adequate doses within days.
It is normal for patients to have to take their medication under direct supervision from a community pharmacist, at least at the start of treatment. This policy has reduced deaths from opiate overdose. Typically this might go on for up to three months whereafter things might be relaxed if the prescriber is satisfied that compliance is likely to continue (this could be assessed by measures such as attendance at appointments, results of toxicology screens, abstinence from or large changes in drug use etc).
Summary
- Recovery from drug abuse is 'a process characterised by voluntarily maintained control over substance use, leading towards health and well-being and participation in the responsibilities and benefits of society'.
- Community-based support (such as 12-step programmes) are effective at offering support and motivation, which are important factors in avoiding relapse.
- Pharmacotherapy (OST) can be used to detoxify (withdraw) from opiates or to achieve stability in maintenance - both are evidence based to significantly reduce a number of harms associated with opiate dependence.
- To prescribe OST a prescriber must have suitable experience and training.
- The choice of OST agent depends on a number of things, including patient experience and preference.
- Doses of OST start low and are increased carefully under direct supervision at first.
Click below to proceed to a brief outline of a consultation model that could be used during the initial meetings with a patient misusing drugs.
References
Department of Health (England) and the devolved administrations (2007). Drug Misuse and Dependence: UK Guidelines on Clinical Management. London: Department of Health (England), the Scottish Government, Welsh Assembly Government and Northern Ireland Executive
Mattick R P, Breen C, Kimber J, et al. Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. The Cochrane Database of Systematic Reviews. Issue 4. 2003.
Miller W, Harris R. A simple scale of Gorski's warning signs for relapse. Journal of Studies on Alcohol. 2000; 61(5):759-65.
National Institute for Health and Clinical Excellence. Technology Appraisal Guidance 114 - Methadone and Buprenorphine for the Management of Opioid Dependence. 2007.
Royal College of General Practitioners. RCGP Guide to the Management of Substance Misuse in Primary Care. 2013 pp.35-47.
Royal College of General Practitioners. RCGP Guide to the Management of Substance Misuse in Primary Care. 2013 p.3.
UK Drugs Policy Commission. Policy Statement. 2008 - http://www.ukdpc.org.uk/wp-content/uploads/Policy%20report%20-%20A%20vision%20of%20recovery_%20UKDPC%20recovery%20consensus%20group.pdf
Department of Health (England) and the devolved administrations (2007). Drug Misuse and Dependence: UK Guidelines on Clinical Management. London: Department of Health (England), the Scottish Government, Welsh Assembly Government and Northern Ireland Executive
Mattick R P, Breen C, Kimber J, et al. Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. The Cochrane Database of Systematic Reviews. Issue 4. 2003.
Miller W, Harris R. A simple scale of Gorski's warning signs for relapse. Journal of Studies on Alcohol. 2000; 61(5):759-65.
National Institute for Health and Clinical Excellence. Technology Appraisal Guidance 114 - Methadone and Buprenorphine for the Management of Opioid Dependence. 2007.
Royal College of General Practitioners. RCGP Guide to the Management of Substance Misuse in Primary Care. 2013 pp.35-47.
Royal College of General Practitioners. RCGP Guide to the Management of Substance Misuse in Primary Care. 2013 p.3.
UK Drugs Policy Commission. Policy Statement. 2008 - http://www.ukdpc.org.uk/wp-content/uploads/Policy%20report%20-%20A%20vision%20of%20recovery_%20UKDPC%20recovery%20consensus%20group.pdf