Drug misuse in over 16s: opioid detoxi cation

Clinical guideline Published: 25 July 2007

http://www.nice.org.uk/guidance/cg52

Drug misuse in over 16s: opioid detoxi cation (CG52)

Your responsibility

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.

Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.

Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Drug misuse in over 16s: opioid detoxi cation (CG52)

Contents

Overview …………………………………………………………………………………………………………………………………………………………. 4 Who is it for? ……………………………………………………………………………………………………………………………………………………………….. 4 Introduction ……………………………………………………………………………………………………………………………………………………. 5 Key priorities for implementation ………………………………………………………………………………………………………………. 6 1 Guidance ………………………………………………………………………………………………………………………………………………………. 8 1.1 General considerations ………………………………………………………………………………………………………………………………………. 8 1.2 Assessment …………………………………………………………………………………………………………………………………………………………… 10 1.3 Pharmacological interventions in opioid detoxi cation ………………………………………………………………………………. 12 1.4 Opioid detoxi cation in community, residential, inpatient and prison settings ………………………………………. 16 1.5 Speci c psychosocial interventions …………………………………………………………………………………………………………………. 18 2 Research recommendations …………………………………………………………………………………………………………………….. 21 2.1 Adjunctive medication during detoxi cation …………………………………………………………………………………………………. 21 2.2 Comparing inpatient or residential and community detoxi cation …………………………………………………………… 21 Appendix: Contingency management – key elements in the delivery of a programme ……………………. 22 Finding more information and resources ………………………………………………………………………………………………….. 27 Update information……………………………………………………………………………………………………………………………………….. 28

Drug misuse in over 16s: opioid detoxi cation (CG52)

This guideline is the basis of QS23.

Overview

This guideline covers helping adults and young people over 16 who are dependent on opioids to stop using drugs. It aims to reduce illicit drug use and improve people’s physical and mental health, relationships and employment.

NICE has also produced guidelines on drug misuse in over 16s: psychosocial interventions.

Who is it for?

• Healthcare professionals

• Commissioners and providers

• People who work in specialist residential and community-based treatment settings

• People who work in prisons and criminal justice settings

• Adults and young people over 16 who misuse opioids and their families and carers

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Drug misuse in over 16s: opioid detoxi cation (CG52)

Introduction

This guideline makes recommendations for the treatment of people who are undergoing detoxi cation for opioid dependence arising from the misuse of illicit drugs. It is concerned with opioid detoxi cation in community, residential, inpatient and prison settings, and will refer to the misuse of other drugs such as benzodiazepines, alcohol and stimulants only in so far as they impact on opioid detoxi cation. The guideline does not address the particular problems of detoxi cation of pregnant women and the related management of symptoms in neonates whose mothers misused opioids during pregnancy.

Opioid detoxi cation 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. With opioids, this process may be carried out by using the same drug or another opioid in decreasing doses, and can be assisted by the prescription of adjunct medications to reduce withdrawal symptoms.

Opioid misuse is often characterised as a chronic condition with periods of remission and relapse. Although abstinence may be one of the long-term goals of treatment, it is not always achieved. However, detoxi cation is a key stage in achieving abstinence for people who are opioid dependent.

Pharmacological approaches are the primary treatment option for opioid detoxi cation, with psychosocial interventions providing an important adjunct.

In order to ensure that all people to whom this guidance applies obtain full bene t from the recommendations, it is important that effective keyworking systems are in place. Keyworking is an important element of care and helps to deliver high-quality outcomes for people who misuse drugs. Keyworkers have a central role in coordinating a care plan and building a therapeutic alliance with the service user. The bene ts of a number of the recommendations in this guideline will only be fully realised in the context of properly coordinated care.

This guideline should be read in conjunction with the Department of Health’s Drug misuse and dependence: UK guidelines on clinical management, also known as the ‘Orange Book’, which provides advice to healthcare professionals on the delivery and implementation of a broad range of interventions for drug misuse, including those interventions covered in the present guideline. For more information see Public Health England’s Alcohol and drug misuse prevention and treatment guidance.

Drug misuse in over 16s: opioid detoxi cation (CG52)

Key priorities for implementation Providing information, advice and support

Detoxi cation 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 detoxi cation 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 detoxi cation, 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 detoxi cation
Methadone or buprenorphine should be offered as the rst-line treatment in opioid detoxi cation. 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 detoxi cation should normally be started with the same medication

• the preference of the service user. Ultra-rapid detoxi cation
© NICE 2020. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and- conditions#notice-of-rights).

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Drug misuse in over 16s: opioid detoxi cation (CG52)

• Ultra-rapid detoxi cation 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 detoxi cation

Staff should routinely offer a community-based programme to all service users considering opioid detoxi cation. Exceptions to this may include service users who:

• have not bene ted from previous formal community-based detoxi cation

• need medical and/or nursing care because of signi cant comorbid physical or mental health problems

• require complex polydrug detoxi cation, for example concurrent detoxi cation from alcohol or benzodiazepines

• are experiencing signi cant social problems that will limit the bene t of community-based detoxi cation

Drug misuse in over 16s: opioid detoxi cation (CG52)

1 Guidance

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

1.1 General considerations

1.1.1 Providing information, advice and support

. 1.1.1.1 Detoxi cation should be a readily available treatment option for people who are opioid dependent and have expressed an informed choice to become abstinent.

. 1.1.1.2 In order to obtain informed consent, staff should give detailed information to service users about detoxi cation 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 detoxi cation, and the ensuing increased risk of overdose and death from illicit drug use that may be potentiated by the use of alcohol or benzodiazepines

1.1.1.3 Service users should be offered advice on aspects of lifestyle that require particular attention during opioid detoxi cation. These include:

• a balanced diet

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• adequate hydration

• sleep hygiene

• regular physical exercise.

1.1.1.4 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 detoxi cation should be considered

• maintain effective collaboration with other care providers.

. 1.1.1.5 People who are opioid dependent and considering self-detoxi cation should be encouraged to seek detoxi cation in a structured treatment programme or, at a minimum, to maintain contact with a drug service.

. 1.1.1.6 Service users considering opioid detoxi cation 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.

. 1.1.1.7 Staff should discuss with people who present for detoxi cation whether to involve their families and carers in their assessment and treatment plans. However, staff should ensure that the service user’s right to con dentiality is respected.

. 1.1.1.8 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.

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. 1.1.1.9 All interventions for people who misuse drugs should be delivered by staff who are competent in delivering the intervention and who receive appropriate supervision.

. 1.1.1.10 People who are opioid dependent should be given the same care, respect and privacy as any other person.

1.1.2 Supporting families and carers

1.1.2.1 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 detoxi cation and the settings in which it may take place

• provide information about self-help and support groups for families and carers.
1.2 Assessment
1.2.1 Clinical assessment

1.2.1.1 People presenting for opioid detoxi cation 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 identi cation of the use of opioids and other substances; consideration may also be given to other near-patient testing methods such as oral uid 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)
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Drug misuse in over 16s: opioid detoxi cation (CG52)

• take a history of drug and alcohol misuse and any treatment, including previous attempts at detoxi cation, 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 nancial 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.

. 1.2.1.2 If opioid dependence or tolerance is uncertain, healthcare professionals should, in addition to near-patient testing, use con rmatory laboratory tests. This is particularly important when:

• a young person rst presents for opioid detoxi cation

• a near-patient test result is inconsistent with clinical assessment

• complex patterns of drug misuse are suspected.

. 1.2.1.3 Near-patient and con rmatory testing should be conducted by appropriately trained healthcare professionals in accordance with established standard operating and safety procedures.

1.2.2 Special considerations
1.2.2.1 Opioid detoxi cation 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
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Drug misuse in over 16s: opioid detoxi cation (CG52)

• 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.

. 1.2.2.2 For women who are opioid dependent during pregnancy, detoxi cation should only be undertaken with caution.

. 1.2.2.3 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.

1.2.3 People who misuse benzodiazepines or alcohol in addition to opioids

1.2.3.1 If a person presenting for opioid detoxi cation 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 detoxi cation should be offered. This should be carried out before starting opioid detoxi cation in a community or prison setting, but may be carried out concurrently with opioid detoxi cation in an inpatient setting or with stabilisation in a community setting.

1.2.3.2 If a person presenting for opioid detoxi cation is also benzodiazepine dependent, healthcare professionals should consider benzodiazepine detoxi cation. When deciding whether this should be carried out concurrently with, or separately from, opioid detoxi cation, healthcare professionals should take into account the person’s preference and the severity of dependence for both substances.

1.3 Pharmacological interventions in opioid detoxi cation

1.3.1 The choice of medication for detoxi cation
1.3.1.1 Methadone or buprenorphine should be offered as the rst-line treatment in

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opioid detoxi cation. 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 detoxi cation should normally be started with the same medication

• the preference of the service user.

. 1.3.1.2 Lofexidine may be considered for people:

• who have made an informed and clinically appropriate decision not to use methadone or buprenorphine for detoxi cation

• who have made an informed and clinically appropriate decision to detoxify within a short time period

• with mild or uncertain dependence (including young people).

. 1.3.1.3 Clonidine should not be used routinely in opioid detoxi cation.

. 1.3.1.4 Dihydrocodeine should not be used routinely in opioid detoxi cation.

1.3.2 Dosage and duration of detoxi cation

Opioid detoxi cation 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. Detoxi cation should not be confused with stabilisation or gradual dose reduction.

1.3.2.1 When determining the starting dose, duration and regimen (for example, linear or stepped) of opioid detoxi cation, 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)
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Drug misuse in over 16s: opioid detoxi cation (CG52)

• pharmacology of the chosen detoxi cation medication and any adjunctive medication

• setting in which detoxi cation is conducted.

1.3.2.2 The duration of opioid detoxi cation should normally be up to 4 weeks in an inpatient/residential setting and up to 12 weeks in a community setting.

1.3.3 Ultra-rapid, rapid and accelerated detoxi cation

The terms ultra-rapid and rapid detoxi cation refer to methods that shorten the duration of detoxi cation and thereby also the duration of withdrawal symptoms. In both ultra-rapid and rapid detoxi cation, withdrawal is precipitated at the start of detoxi cation by the use of high doses of opioid antagonists (such as naltrexone or naloxone). The essential distinctions between ultra-rapid and rapid detoxi cation are the duration of the detoxi cation itself and the level of sedation. Ultra- rapid detoxi cation takes place over a 24-hour period, typically under general anaesthesia or heavy sedation. Rapid detoxi cation may take 1–5 days, with a moderate level of sedation. Accelerated detoxi cation, which typically does not involve the use of heavy or moderate sedation, refers to the use of limited doses of an opioid antagonist after the start of detoxi cation to shorten the process without precipitating full withdrawal. All of these methods may help to establish the person on a maintenance dose of naltrexone for preventing relapse.

The levels of sedation used in ultra-rapid and rapid detoxi cation are brie y de ned below (see section 6.5.2 in the full guideline for further details).

General anaesthesia: the person is unconscious and unresponsive, even in the face of signi cant stimuli. The ability to maintain ventilatory function independently is often impaired, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug- induced depression of neuromuscular function.

Heavy/deep sedation: the person is clearly sedated, may not be easily aroused or able to respond purposefully to verbal commands, and may only respond minimally to very signi cant stimuli. The person may experience partial or complete loss of protective re exes, including the ability to maintain an open airway independently and continuously.

Moderate sedation: the person appears obviously sedated but, importantly, can maintain an open airway independently and respond purposefully to stimuli such as verbal questioning.

The risk to the person will be proportionate to the risk inherent in the use of different levels of sedation. In addition, the relatively high use of adjunctive medication associated with ultra-rapid

Drug misuse in over 16s: opioid detoxi cation (CG52)

and rapid detoxi cation exposes the person to risks associated with the use of the medications themselves and their potential interactions.

. 1.3.3.1 Ultra-rapid and rapid detoxi cation 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.

. 1.3.3.2 Ultra-rapid detoxi cation 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.

. 1.3.3.3 Rapid detoxi cation should only be considered for people who speci cally request it, clearly understand the associated risks and are able to manage the adjunctive medication. In these circumstances, healthcare professionals should ensure during detoxi cation 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.

. 1.3.3.4 Accelerated detoxi cation, using opioid antagonists at lower doses to shorten detoxi cation, 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.

1.3.4 Adjunctive medications

1.3.4.1 When prescribing adjunctive medications during opioid detoxi cation, 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.
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1.3.5 Monitoring of detoxi cation medication

1.3.5.1 Healthcare professionals should be aware that medications used in opioid detoxi cation 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.

1.4 Opioid detoxi cation in community, residential, inpatient and prison settings

1.4.1 The choice of setting

1.4.1.1 Staff should routinely offer a community-based programme to all service users considering opioid detoxi cation. Exceptions to this may include service users who:

• have not bene ted from previous formal community-based detoxi cation

• need medical and/or nursing care because of signi cant comorbid physical or mental health problems

• require complex polydrug detoxi cation, for example concurrent detoxi cation from alcohol or benzodiazepines

• are experiencing signi cant social problems that will limit the bene t of community- based detoxi cation.

. 1.4.1.2 Residential detoxi cation should normally only be considered for people who have signi cant comorbid physical or mental health problems, or who require concurrent detoxi cation from opioids and benzodiazepines or sequential detoxi cation from opioids and alcohol.

. 1.4.1.3 Residential detoxi cation 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 bene t signi cantly from a residential rehabilitation programme during and after detoxi cation.

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1.4.1.4 Inpatient, rather than residential, detoxi cation should normally only be considered for people who need a high level of medical and/or nursing support because of signi cant and severe comorbid physical or mental health problems, or who need concurrent detoxi cation from alcohol or other drugs that requires a high level of medical and nursing expertise.

1.4.2 Continued treatment and support after detoxi cation

1.4.2.1 Following successful opioid detoxi cation, 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.

1.4.3 Delivering detoxi cation

. 1.4.3.1 Community detoxi cation 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 (see section 1.5).

. 1.4.3.2 Inpatient and residential detoxi cation 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 signi cant comorbid physical or mental health problems.

1.4.4 Detoxi cation in prison settings

1.4.4.1 People in prison should have the same treatment options for opioid detoxi cation as people in the community. Healthcare professionals should take into account additional considerations speci c to the prison setting, including:

• practical dif culties in assessing dependence and the associated risk of opioid toxicity early in treatment

Drug misuse in over 16s: opioid detoxi cation (CG52)

• length of sentence or remand period, and the possibility of unplanned release

• risks of self-harm, death or post-release overdose.

1.5 Speci c psychosocial interventions

The focus in this section is on the use of contingency management (the only psychosocial intervention with clear evidence for effectiveness as an adjunct to detoxi cation) to promote effective detoxi cation. Other psychosocial interventions are considered in a separate NICE guideline on drug misuse in over 16s: psychosocial interventions.

Contingency management is a set of techniques that focus on changing speci ed behaviours. In drug misuse, it involves offering incentives for positive behaviours such as abstinence or a reduction in illicit drug use, and participation in health-promoting interventions. For example, an incentive is offered when a service user submits a biological sample that is negative for the speci ed drug(s). The emphasis on reinforcing positive behaviours is consistent with current knowledge about the underlying neuropsychology of many people who misuse drugs and is more likely to be effective than penalising negative behaviours. There is good evidence that contingency management increases the likelihood of positive behaviours and is cost effective.

For contingency management to be effective, staff need to discuss with the service user what incentives are to be used so that these are perceived as reinforcing by those participating in the programme. Incentives need to be provided consistently and as soon as possible after the positive behaviour (such as submission of a drug-negative sample). Limited increases in the value of the incentive with successive periods of abstinence also appear to be effective.

A variety of incentives have proved effective in contingency management programmes, including vouchers (which can be exchanged for goods or services of the service user’s choice), privileges (for example, take-home methadone doses) and modest nancial incentives.

For more information on contingency management, see the appendix.
1.5.1 Contingency management to support opioid detoxi cation

. 1.5.1.1 Contingency management aimed at reducing illicit drug use should be considered both during detoxi cation and for up to 3–6 months after completion of detoxi cation.

. 1.5.1.2 Contingency management during and after detoxi cation should be based on

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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 rst 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 uid tests may be considered as an alternative.

1.5.1.3 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.
1.5.2 Implementing contingency management
The implementation of contingency management presents a signi cant challenge for current drug services, in particular with regard to staff training and service delivery systems. The following recommendations address these two issues (for further details please refer to the appendix).

. 1.5.2.1 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.

. 1.5.2.2 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

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delivery systems are carefully evaluated. The outcome of this evaluation should be used to inform the full-scale implementation of contingency management.

Drug misuse in over 16s: opioid detoxi cation (CG52)

2 Research recommendations

The Guideline Development Group has made the following recommendations for research, based on its review of evidence, to improve NICE guidance and care of service users in the future.

2.1 Adjunctive medication during detoxi cation

If a person needs adjunctive medication during detoxi cation, in addition to their opioid agonist reducing regimen or in addition to an adjunctive alpha-2 adrenergic agonist (for example, lofexidine), what medications are associated with greater safety and fewer withdrawal symptoms?

Why this is important

A large variety of adjunctive medications are used for the management of withdrawal symptoms during detoxi cation, particularly when alpha-2 adrenergic agonists are used. Research is needed to guide decisions on how best to manage withdrawal symptoms with minimal risk of harm to the service user.

2.2 Comparing inpatient or residential and community detoxi cation

Is inpatient or residential detoxi cation associated with greater probability of abstinence, better rates of completion of treatment, lower levels of relapse and increased cost effectiveness than community detoxi cation?

Why this is important

There have been some studies comparing inpatient or residential detoxi cation with community detoxi cation. However, these studies are often based on small sample sizes, have considerable methodological problems and have produced inconsistent results. Inpatient or residential detoxi cation requires signi cantly more resources than community detoxi cation, so it is important to assess whether treatment in such settings is more clinically and cost effective. If so, it is also important to understand if there are particular subgroups that are more likely to bene t from treatment in these settings.

Drug misuse in over 16s: opioid detoxi cation (CG52)

Appendix: Contingency management – key

elements in the delivery of a programme

The introduction of contingency management into drug misuse services in the NHS presents a considerable challenge. This is primarily because contingency management has not been widely used in the NHS; hence staff are not trained in the technique and a major training programme will be required to implement it. Another challenge is address the concerns of staff, service users and the wider public about contingency management, in particular concerns that:

• the intervention may ‘reward’ illicit drug use

• the effects will not be maintained in the long term

• the system is open to abuse as people may ‘cheat’ their drug tests

• incentive-based systems will not work outside the healthcare system (that of the United States) in which they were developed.
The aim of this appendix, rstly, is to provide a brief introduction to contingency management for those not familiar with this intervention. Secondly, it will address the issues outlined above by setting out a possible strategy for implementation in the NHS, drawing on an evidence base from the United States, Europe and Australia.
Introduction to contingency management
Contingency management refers to a set of techniques that focus on the reinforcement of certain speci ed behaviours. These may include abstinence from drugs (for example, cocaine), reduction in drug misuse (for example, illicit drug use by people receiving methadone maintenance treatment), and promoting adherence to interventions that can improve physical health outcomes (for example, attending for hepatitis C tests) (Petry 2006). To date, over 25 trials of contingency management have been conducted, involving over 5000 participants, which constitute the largest single body of evidence for the effectiveness of psychosocial interventions in drug misuse. In the formal studies of contingency management, incentives have included vouchers (exchangeable for goods such as food), cash rewards (of low monetary value), prizes (including cash and goods) and clinic privileges (such as non-supervised consumption). All the incentives have been shown to be effective, although it was the view of the guideline development group that vouchers and clinic privileges would generally be more easily implemented in the NHS.
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The following principles underlie the effective delivery of contingency management (Petry 2006).

• Robust, routine testing for drug misuse should be carried out.

• Targets should be agreed in collaboration with the service user.

• Incentives should be provided in a timely and consistent manner.

• The relationship between the treatment goal and the incentive schedule should be understood by the service user

• Incentives should be perceived by the service user to be reinforcing and to support a healthy/ drug-free lifestyle.
Implementing contingency management in the NHS
Although contingency management has not yet been implemented in the NHS (but see McQuaid et al. 2007 for a report of a pilot study), there have been a number of major studies looking at its uptake in the United States, Europe and Australia. Crucially, these studies give an account of its implementation in services where initially there was considerable resistance on the part of both staff and people who misuse drugs. They report positive shifts in staff attitudes as the understanding of contingency management increased and its bene cial impact on the lives of people who misuse drugs became apparent (McGovern et al. 2004; Kellogg et al. 2005; Kirby et al.2006; Ritter and Cameron 2007).
Studies have also looked at the organisational development required to support successful implementation. Kellogg et al. (2005) identi ed, in addition to the principles outlined above, four key aspects of the uptake of contingency management in the public healthcare system in New York:

• endorsement of the programme by senior managers and clinicians, and their engagement with the concerns of direct care staff

• provision of a comprehensive education and training programme that provided clear direction for staff, many of whom were unfamiliar with the basic principles of contingency management

• recognition by staff that contingency management is an intervention aimed at changing speci c key behaviours, and does not simply reward people for general good behaviour

• a shift in the focus of the service to one that is incentive-orientated, where contingency management plays a central role in promoting a positive relationship between staff and service users.[1]
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In a series of interviews and discussions with staff and service users, Kellogg et al. (2005) found that contingency management increased the motivation of service users to undergo treatment, facilitated therapeutic progress, increased staff optimism about treatment outcomes and their morale, and promoted the development of more positive relationships both between service users and staff and among staff members. As a result, there was a shift from viewing contingency management as an intervention that would be dif cult to integrate with other interventions to it becoming the main focus of interventions with service users. Other studies (for example, Higgins et al. 2000) also provide important advice on how the effects of interventions can be maintained once incentives are discontinued.

In the NHS, several other factors will need to be considered when developing an implementation programme. These may include:

• the integration, where appropriate, of contingency management with the keyworking responsibilities of staff

• the identi cation of those groups of people who misuse drugs who are most likely to bene t from contingency management (for example, it might be expected that about 30% of people receiving methadone maintenance treatment will be considered for contingency management)

• the development of near-patient testing

• the impact on service-user government bene ts. The implementation process
Where possible, implementation in the NHS should draw on the experience so far (albeit limited) of contingency management in the NHS and on the experience of agencies such as the National Treatment Agency for Substance Misuse (NTA) in the implementation of service developments in drug misuse. The NTA, with its lead role in drug misuse, is best placed to lead an implementation programme, as it has both the national and regional infrastructure and the experience (for example, through its work on the International Treatment Effectiveness Project). Any implementation programme should include the following elements:

• the establishment of a series of demonstration sites

• dissemination of the ndings, including those emerging from demonstration sites, to inform the eld
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• an agreement with local commissioners where change of contracts or service level agreements are required

• a review of service readiness to implement contingency management and the involvement of senior management, clinicians and key workers in any required service developments

• training programmes for staff to enable them to deliver contingency management

• working with service users to raise awareness about contingency management and involve them in local service design

• evaluation of the implementation programme.
The provision of training to deliver contingency management may include a requirement for service managers, supervisors and front-line staff to acknowledge the need for institutional change and staff ‘buy in’. Training could be designed to provide a foundation covering the theory, practice and research ndings of contingency management, including the factors associated with its successful implementation (Kellogg et al. 2005). A major focus of the training programme will be on identifying and developing staff competencies to deliver contingency management in a manner that emphasises the positive, reinforcing aspects of the intervention.
The structure of any evaluation of contingency management could follow that of the implementation programme and may examine the following issues using quantitative and qualitative methods:

• service design (the feasibility of establishing contingency management in services, structures associated with effective uptake and barriers to uptake)

• the most effective training models associated with sustained uptake

• the experiences of staff and service users. Conclusion
This appendix sets out the background and process by which contingency management may be implemented in drug misuse services in the NHS. Successful implementation of contingency management will have considerable bene ts for people who misuse drugs, their families and wider society.
References
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Higgins ST, Badger GJ, Budney, AJ (2000) Initial abstinence and success in achieving longer term cocaine abstinence. Experimental and Clinical Psychopharmacology 8: 377–86.

Kellogg SH, Burns M, Coleman P, et al. (2005) Something of value: the introduction of contingency management interventions into the New York City Health and Hospital Addiction Treatment Service. Journal of Substance Abuse Treatment 28: 57–65.

Kirby KC, Benishek LA, Dugosh KL, et al.(2006) Substance abuse treatment providers’ beliefs and objections regarding contingency management: implications for dissemination. Drug and Alcohol Dependence 85:19–27.

McGovern MP, Fox TS, Xie H, et al. (2004) A survey of clinical practices and readiness to adopt evidence-based practices: dissemination research in an addiction treatment system. Journal of Substance Abuse Treatment 26:305–12.

McQuaid F, Bowden-Jones O, Weaver T (2007) Contingency management for substance misuse. British Journal of Psychiatry 190: 272.

Messina N, Farabee D, Rawson R (2003) Treatment responsivity of cocaine-dependent patients with antisocial personality disorder to cognitive-behavioral and contingency management interventions. Journal of Consulting and Clinical Psychology 71: 320–9.

Petry N (2006) Contingency management treatments. British Journal of Psychiatry 189: 97–8.

Ritter A, Cameron J (2007) Australian clinician attitudes towards contingency management: comparing down under with America. Drug and Alcohol Dependence 87: 312–5.

[1] The emphasis on incentives is consistent with current knowledge about the underlying neuropsychology of many people who misuse drugs; speci cally that people with antisocial personality disorder (ASPD) (who account for a signi cant proportion of long-term drug users) are much more likely to respond to positive than to punitive approaches. Messina et al. (2003) found that people with ASPD who received contingency management were more likely to abstain from cocaine use than both participants without ASPD receiving contingency management or cognitive behavioural therapy and participants with ASPD receiving cognitive behavioural therapy.

Drug misuse in over 16s: opioid detoxi cation (CG52)

Finding more information and resources
You can see everything NICE says on drug misuse in over 16s: opioid detoxi cation in our

interactive owchart on drug misuse management in over 16s.
To nd out what NICE has said on topics related to this guideline, see our web page on drug misuse.

For full details of the evidence and the guideline committee’s discussions, see the full version. You can also nd information about how the guideline was developed, including details of the committee.

NICE has produced tools and resources to help you put this guideline into practice. For general help and advice on putting NICE guidelines into practice, see resources to help you put guidance into practice.

Drug misuse in over 16s: opioid detoxi cation (CG52)

Update information Minor changes since publication

March 2019: Some links to reference materials were updated. ISBN: 978-1-4731-3384-6

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