Drug Misuse and Dependence - Guidelines on Clinical Management

138 Pages·1999·0.76 MB·English

by  Department of Health, The Scottish Office Department of Health, Welsh Office , Department of Health and Social Services Northern Ireland

Department of Health
Scottish Office Department of Health
Welsh Office
Department of Health and Social Services,
Northern Ireland
DDrruugg MMiissuussee
aanndd DDeeppeennddeennccee ––
GGuuiiddeelliinneess oonn CClliinniiccaall
MMaannaaggeemmeenntt
Department of Health
Scottish Office Department of Health
Welsh Office
Department of Health and Social Services,
Northern Ireland
DDrruugg MMiissuussee
aanndd DDeeppeennddeennccee ––
GGuuiiddeelliinneess oonn CClliinniiccaall
MMaannaaggeemmeenntt
Published with the permission of the
Department of Health on behalf of
the Controller of her Majesty’s Stationery Office.
© Crown Copyright 1999
All rights reserved.
Copyright in the typographical arrangement and design is
vested in The Stationery Office Limited.
Application for reproduction should be made in writing in
the first instance to the Copyright Unit, Her Majesty’s
Stationery Office, St Clements House,
2-16 Colegate, Norwich NR3 1BQ
First published 1999
ISBN 0 11 322277 7
Drug Misuse and Dependence – Guidelines on Clinical Management
CONTENTS
Membership of the Working Group ix
Foreword
Previous Guidelines xiii
Terms of reference xiii
Who are the Guidelines for? xiii
What the Guidelines do not cover xiv
The nature of the Guidelines xiv
Evidence-based Guidelines xiv
The legal position of the Guidelines xv
Chapter 1
Introduction
1. The growth of drug misuse 1
2. Morbidity and mortality 2
3. Rights and responsibilities 2
4. The changing organisation of primary care 3
5. The new policy agenda 3
a) The Effectiveness Review 3
b) Tackling Drugs to Build a Better Britain 3
6. The generalist, specialised generalist and specialist 4
a) The generalist 5
b) The specialised generalist 5
c) The specialist 6
7. Evidence-based approach to care 6
a) Reducing the risk of infectious diseases and other medical and social harm 6
b) Reducing drug-related deaths 7
c) Reducing criminal activity 7
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Drug Misuse and Dependence – Guidelines on Clinical Management
Chapter 2
Treatment
1. Aims of treatment 9
2. The treatment setting: shared care and multidisciplinary working 10
a) The role of the general practitioner in shared care 11
b) The role of specialist services in shared care 12
c) Shared care guidelines 12
d) Monitoring group 13
e) Examples of good practice in shared care of drug misusers 14
3. Problems and challenges in multidisciplinary and shared care working 14
Chapter 3
Assessment
1. Aims of assessment 18
2. Diagnosis of drug abuse 19
a) Drug history 19
i) Reason for presentation 20
ii) Past and current (last 4 weeks) drug use 20
iii) History of injecting and risk of HIVand hepatitis 20
iv) Medical history 20
v) Psychiatric history 20
vi) Forensic history 21
vii) Social history 21
viii) Past contact with treatment services 21
ix) Other 21
b) Examination 22
i) Assessing motivation 22
ii) Assessing general health 22
iii) Assessment of mental health 23
iv) Assessment of social and family situation 23
c) Special investigations 23
i) Haematological investigations 23
ii) Urine assessment 23
iii) Hair analysis 24
3. Reporting to the Regional Drug Misuse Databases 24
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Drug Misuse and Dependence – Guidelines on Clinical Management
Chapter 4
The responsibilities and principles of prescribing for drug
dependence
The minimum responsibilities of the prescribing doctor-a summary 28
Prescribing 29
1. The responsibility of prescribing 29
2. Deciding whether to prescribe 29
3. Setting goals 30
4. Ending a failing treatment 31
5. The choice of drug 31
a) What to prescribe 31
b) Initiating prescribing 31
c) The route of administration 32
d) Prescribing injectable drugs 32
6. Record keeping 32
7. Dispensing 32
8. Issues for special vigilance 33
Chapter 5
The management of dependence and withdrawal
1. Withdrawal and detoxification 36
2. Opiates 36
a) Symptoms and signs of opiate withdrawal 37
b) Treatment of the withdrawal syndrome with substitute opiates 37
i) methadone – oral 37
ii) codeine-based drugs 38
iii) buprenorphine 38
c) Treatment of the withdrawal syndrome with non-opiate drugs 39
i) lofexidine 39
ii) clonidine 39
iii) naltrexone 40
iv) others 40
3. Benzodiazepines 40
a) Withdrawal syndrome 41
b) Prescribing 41
4. Stimulants 42
a) General measures 42
b) Antidepressants 42
c) Substitute prescribing (dexamphetamine prescribing) 42
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Drug Misuse and Dependence – Guidelines on Clinical Management
Chapter 6
Dose reduction regimens
1. Methadone 45
a) Commencement dose 45
b) Stabilisation dose 46
i) first seven days 46
ii) subsequent stabilisation period 47
iii) slow reduction regimes 47
c) Drug reduction regime 47
2. Other Pharmacotherapies 48
a) Lofexidine community detoxification 48
b) Lofexidine detoxification regime 48
c) Dihydrocodeine 49
3. Benzodiazepines 50
a) Benzodiazepine reduction 50
b) Dispensing 51
4. Maintenance Prescribing 52
a) Introduction 52
b) Research evidence for methadone maintenance 53
c) The effectiveness of methadone maintenance 53
d) Conclusion 54
e) Dosing regime for methadone maintenance 54
5. Alternative opiate agonist agents 54
a) LAAM 54
b) Buprenorphine 55
6. Injectable prescribing for maintenance purposes 55
a) General issues 55
b) Injectable methadone 56
c) Diamorphine 57
7. Naltrexone 57
8. Summary – Prescribing for dependence and withdrawal: approval status by MCA 58
Chapter 7
Preventing relapse
1. Introduction 59
2. Consequences of non-compliance 60
3. Improving compliance 60
a) Assessment during treatment 60
b) Supervised consumption 61
c) Improving patient attendance 62
d) Naltrexone 62
4. Non-pharmacological approaches to relapse prevention 62
5. Broader approaches to psychosocial support and treatment 63
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Drug Misuse and Dependence – Guidelines on Clinical Management
Annex 1
Shared working with other professionals
1. Multiprofessional 65
Role of the:
2. Nurse 65
3. Drugs worker 66
4. Clinical psychologist 66
5. Community and hospital pharmacist 67
6. Social worker 68
Annex 2
Training for clinicians working with drug misusers
Training for the generalist 69
1. Introduction 69
2. Training for the wider Primary Health Care Team (PHCT) 69
3. Atraining curriculum for primary care 70
a) Delivery of training 70
b) Accreditation 70
4. Proposed curriculum for shared care training 70
Annex 3
Health and safety/managing challenging behavi o u r
1. Avoiding the violent or dangerous situation 73
2. GP surgery/A&E 73
3. Home visits 74
4. Information to patients 74
5. Needlestick injuries 75
a) Hepatitis B 75
b) Hepatitis C 75
c) HIV 75
Annex 4
Models of change
1. Anatural history and drug career perspective 77
2. The stages of change model applied to drug misuse 77
3. Using the Care Pathway Approach 78
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Drug Misuse and Dependence – Guidelines on Clinical Management
Annex 5
Pregnancy and neonatal care
1. Introduction 79
2. Management by a multidisciplinary team 79
3. Management of antenatal care 80
4. Effects of drugs on the foetus and baby 80
5. Maternal health problems 81
6. Management of labour 81
7. Neonatal withdrawal 81
8. Postnatal management 81
9. Postnatal planning meeting 82
10. Prescribing drugs for pregnant drug misusers 82
a) Opiates 82
b) Cocaine 83
11. Further reading 83
Annex 6
Young people and drugs
1. Consent to treatment and the under 18s: the legal position 85
2. Principles of good practice 86
3. The role of services 86
4. Prescribing medication 87
5. Data collection and monitoring 88
Annex 7
HIV, Hepatitis B and C
1. HIV 89
a) Prevalence 89
b) Testing 89
2. Hepatitis B 90
a) Immunisation 91
b) Further management 91
3. Hepatitis C 91
a) Testing 92
b) Further management 92
c) Further information 93
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Drug Misuse and Dependence – Guidelines on Clinical Management
Annex 8
Alcohol and drug misuse
1. Introduction 95
2. Detoxification 95
a) Vitamin B 96
b) Benzodiazepines 96
c) Disulfiram (Antabuse) 97
d) Acamprosate 97
3. Non-drug interventions 97
Annex 9
The criminal justice system
1. Police custody 99
2. The Probation Service 99
3. The new Drug Treatment and Testing Order (1998) 100
4. The Prison Service 100
5. Recommended reading 101
Annex 10
Accident and emergency
1. Introduction 103
2. Overdose and suicides 104
a) treatment 104
– naloxone administration 105
b) Management of other drugs 105
Annex 11
Mental health
1. Drug misuse and co-morbid mental illness 107
2. General considerations 107
3. Admission to a general psychiatric unit 108
4. The homeless and prison population 108
5. Continuing care 108
6. Risk assessment 108
7. The Care Pathway Approach (CPA) 108
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