NTA

1

• Name
• Organisation

2
Status for health care providers

• MUST DO NICE TAs what medicines and
  treatments NHS has to fund
• SHOULD DO NICE CGs broader recommendations on
  treatment for NHS to review consider resources
  and implementation
• SHOULD DO Drug Misuse and Dependence UK
  evidence-based consensus guidelines on treatment.
  
• All used by NHS Watchdogs HealthCare Commission
  set criteria in line with guidance and manage
  performance
• GMC/Professional bodies

3
Drug Misuse and Dependence UK guidelines for
clinical management

• Last updated 1999
• Independent, UK-wide working group
• GPs, addiction psychiatrists, nurses, vol sector,
  pharmacists, users, carers GMC, NICE, prison
  service, home office, UK health policy NTA
• Timed to be able to incorporate NICE TAs and
  guidelines
• 1 year process
• Commissioned evidence-based reviews
• Consider, discuss, reach consensus
• Public consultation and redrafting
• Published September 2007

4
Who is this relevant to

• NOT JUST DOCTORS
• All providers of drug treatment (community,
  in-patient, residential rehabilitation, in
  custody)
• All Clinicians doctors, nurses, drug workers
  etc
• All who assess and care plan, provide
  psycho-social interventions, provide
  pharmacological interventions, provide health
  interventions
• Those who treat all types of drug misuse (opioid,
  stimulant, cannabis, poly drug and alcohol)
• Those who treat adults young people

5
90 rule

• Expect the vast majority of practice to fall
  within guidance
• Dependent on competence and clinical governance
• Where practice differs an individual clinician is
  reasonably expected to the rationale for the
  exception
• Allows for clinician decision-making within a
  framework
• If a whole service has a policy out of line with
  the Clinical Guidelines this should be challenged
  and changed, e.g. lack of access to supervised
  consumption in first 3 months of opioid
  prescription

6
What retained/strengthened?

• Clinicians must be competent, trained and
  supervised for the treatment they provide
• The range of drug treatment models and competency
  in primary care is recognised term shared care
  is dropped
• Assessment and care planned treatment
• Importance of proper induction onto medication
• Optimised maintenance dosing

7
What different?

• Importance of clinical governance
• Wider range of clinicians - associated
  competencies
• Improved evidence base
• Retention in treatment and optimising treatment
• Psychosocial plus prescribing
• Harm reduction as a thread throughout
• Health considerations
• Under 18s special considerations
• As substance misusers
• As children of drug-using parents

8
Chapter 1 Introduction

• A range of treatments have been found to be
  effective in reducing harm.
• Current levels of mortality and morbidity remain
  a concern.
• Substantial numbers could benefit from drug
  treatment.

9
Chapter 2 Clinical governance

• Clinicians must be appropriately competent,
  trained and supervised.
• Effective, safe and responsive services involve
  clinicians working together and with others.
• Clinical governance mechanisms affected by
  setting.
• Services should be consistent with national
  guidance and principles, and in line with the
  evidence base.
• Frameworks for those under 18 are different from
  adults.

10
Chapter 2 Clinical governance (2)

• Non-medical prescribing will change treatment and
  clinical governance.
• Audit and review cycles should be in place.
• Information governance policies and practice are
  critical.
• Patients must be involved in their own treatment
  and in planning, developing, designing and
  delivering local drug treatment services.
• Families and carers of drug misusers are an
  important resource in treating drug misusers and
  often in need of support for themselves.

11
Chapter 3 Essential elements

• Needs should be assessed across the four domains
  of drug and alcohol misuse, health, social
  functioning and criminal involvement.
• Risks to dependent children should be assessed.
• All drug misusers entering structured treatment
  should have a care or treatment plan which is
  regularly reviewed.
• Treatment involves a range of interventions.
• A named individual should manage and deliver the
  care plan.
• Drug testing can be useful in assessment and
  monitoring.

12
Chapter 4 Psychosocial components

• Treatment always involves a psychosocial
  component.
• Keyworking is a basic delivery mechanism for a
  range of key components.
• A good therapeutic alliance is crucial to
  treatment.
• Discrete formal psychosocial interventions
  addressing assessed need.

13
Chapter 4 Psychosocial components (2)

• Discrete formal psychosocial interventions to
  treat drug misuse related problems or common
  mental disorders.
• Psychosocial interventions alongside
  pharmacological or alone, depending on need and
  goals.
• Psychosocial interventions are the mainstay for
  cocaine and other stimulants, and for cannabis
  and hallucinogens.
• Self-help and mutual aid approaches are
  effective.
• Strong evidence base for contingency management
  (CM) and family/couple interventions.

14
Chapter 5 Pharmacological interventions

• Methadone or buprenorphine at optimal dose range
  effective for maintenance.
• Dose induction should aim to achieve an effective
  dose while exercising caution.
• Supervised consumption should be available for
  all for a length of time appropriate to needs and
  risks.
• Patients must be made aware of the risks of their
  medication and of the importance of protecting
  children.
• Clinicians should optimise treatment for patients
  who are not benefiting, by providing additional
  and more intensive interventions.

15
Chapter 5 Pharmacological interventions (2)

• Opioid detoxification should be offered to
  patients ready for abstinence.
• Methadone, buprenorphine and lofexidine are all
  effective.
• Opioid detoxification should be part of a
  package.
• Benzodiazepines prescribed for benzodiazepine
  dependence should be at the lowest dose and
  reduced as soon as possible.
• No effective pharmacological treatments for
  stimulant withdrawal - psychosocial interventions
  are the mainstay.
• Injectable opioid treatment may be suitable for a
  small minority.

16
Chapter 6 Health considerations

• Reduce harm due to overdose, blood-borne viruses
  and other infections.
• All should be offered hepatitis B vaccination,
  and hepatitis A where indicated.
• All should be offered testing and treatment for
  hepatitis C and HIV.
• Retaining patients in treatment is protective
  against overdose. Enhance protection by overdose
  training.
• Drug misusers misusing alcohol should be offered
  alcohol treatments.
• Drug misusers who smoke should be offered smoking
  cessation.

17
Chapter 7 Situations and populations

• Consistent quality of treatment regardless of how
  patients enter.
• Seamless care assured by appropriate
  communication and transfer of information.
• Liaison or multi-disciplinary team appropriate in
  many clinical situations.
• With pregnant women, balance between reducing the
  amount prescribed and the risk of the patient
  returning to illicit use.

18
Chapter 7 Situations and populations (2)

• Common mental health problems typical - may need
  to treat in drug misuse services. Severe mental
  health problems need care with mental health
  services.
• Young people need different interventions and
  therefore competencies.
• Older drug misusers have increasing drug-related
  and non-drug related health needs.
• Drug misusers in pain need interventions similar
  to non-drug users.
• Drug misusers in hospital need medical treatment
  and improved engagement with drug treatment.

19
Conclusion

• Increasing evidence-base for effective treatment
• More people involved, wider range of
  evidence-based treatments, clearer competencies,
  etc.
• Challenge is to build on improvements within
  clinical governance framework

20
What needs to be done?

• Three things to consider
• REVIEW - what needs to change?
• ACTION PLAN - how might it be changed?
• IMPLEMENTATION - what can help it to change?
• Clinical implementation vs. system
  implementation
• for NHS, third sector, and commissioners

21
Process

• Identify the clinical governance lead(s) Review
  treatment system using local and national data
  against the guidelines
• Identify key areas of change required, define the
  new treatment system, and commission accordingly
  (not vice versa)
• Look at existing mechanisms to support change
  (e.g. MHT/PCT clinical governance)
• Set timetable for change
• Identify resources and support for change
• Performance management through treatment planning
  and other means (e.g. HCC)

22
Crack user care planned treatment involving key
working

• Care planning including interventions such as
  mapping
• Co-ordination of care and review
• Drug related advice and information
• Interventions to reduce harm, eg. reduce
  injecting overdose
• Motivational interventions
• Interventions to prevent relapse
• Help to address social issues, e.g. housing

23
Crack user key working plus formal psychosocial
Discrete psychosocial for drug misuse
Psychosocial for depression

• If key working alone does not tackle drug misuse,
  provide
• discrete packages of psycho-social interventions
  for
• Drug misuse eg family/couples intervention
• Anxiety or depression eg programme of CBT

24
Heroin user Key working plus methadone
maintenance
25
Heroin and crack user not responding to key
work and pharmacology
Discrete psychosocial for drug misuse
Psychosocial for depression

• Regular key working plus
• Opioid maintenance prescribing plus
• formal psychosocial intervention to treat crack
  use
• Formal psychosocial intervention to treat
  depression