Recommendations

Guidance

1.1 General considerations
1.2 Identification and assessment of drug misuse
1.3 Brief interventions and self-help
1.4 Formal psychosocial interventions
1.5 Residential, prison and inpatient care

Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about 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.

The following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the guidance.

NICE has also produced information for the public explaining this guideline. We encourage NHS and third sector, including voluntary organisations, to use text from this information in their own materials about psychosocial interventions in drug misuse.

1.1 General considerations

1.1.1 Care of people who misuse drugs

1.1.1.1 To enable people who misuse drugs to make informed decisions about their treatment and care, staff should explain options for abstinence-oriented, maintenance-oriented and harm-reduction interventions at the person's initial contact with services and at subsequent formal reviews.

1.1.1.2 Staff should discuss with people who misuse drugs whether to involve their families and carers in their assessment and treatment plans. However, staff should ensure that the service user's right to confidentiality is respected.

1.1.1.3 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.

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

1.1.1.5 People who misuse drugs 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 (see NICE's guideline on supporting adult carers)
provide verbal and written information and advice on the impact of drug misuse on service users, families and carers.

1.1.2.2 Where the needs of families and carers of people who misuse drugs have been identified, staff should:

offer guided self-help, typically consisting of a single session with the provision of written material
provide information about, and facilitate contact with, support groups, such as self-help groups specifically focused on addressing families' and carers' needs.

1.1.2.3 Where the families of people who misuse drugs have not benefited, or are not likely to benefit, from guided self-help and/or support groups and continue to have significant problems, staff should consider offering individual family meetings. These should:

provide information and education about drug misuse
help to identify sources of stress related to drug misuse
explore and promote effective coping behaviours
normally consist of at least 5 weekly sessions.

1.2 Identification and assessment of drug misuse

1.2.1 Asking questions about drug misuse

1.2.1.1 Staff in mental health and criminal justice settings (in which drug misuse is known to be prevalent) should ask service users routinely about recent legal and illicit drug use. The questions should include whether they have used drugs and, if so:

of what type and method of administration
in what quantity
how frequently.

1.2.1.2 In settings such as primary care, general hospitals and emergency departments, staff should consider asking people about recent drug use if they present with symptoms that suggest the possibility of drug misuse, for example:

acute chest pain in a young person
acute psychosis
mood and sleep disorders.

1.2.2 Assessment

1.2.2.1 When making an assessment and developing and agreeing a care plan, staff should consider the service user's:

medical, psychological, social and occupational needs
history of drug use
experience of previous treatment, if any
goals in relation to his or her drug use
treatment preferences.

1.2.2.2 Staff who are responsible for the delivery and monitoring of the agreed care plan should:

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
maintain effective collaboration with other care providers.

1.2.2.3 Healthcare professionals should use biological testing (for example, of urine or oral fluid samples) as part of a comprehensive assessment of drug use, but they should not rely on it as the sole method of diagnosis and assessment.

1.3 Brief interventions and self-help

1.3.1 Brief interventions

Brief interventions can be used opportunistically in a variety of settings for people not in contact with drug services (for example, in mental health, general health and social care settings, and emergency departments) and for people in limited contact with drug services (such as at needle and syringe exchanges, and community pharmacies).

1.3.1.1 During routine contacts and opportunistically (for example, at needle and syringe exchanges), staff should provide information and advice to all people who misuse drugs about reducing exposure to blood-borne viruses. This should include advice on reducing sexual and injection risk behaviours. Staff should consider offering testing for blood-borne viruses.

1.3.1.2 Group-based psychoeducational interventions that give information about reducing exposure to blood-borne viruses and/or about reducing sexual and injection risk behaviours for people who misuse drugs should not be routinely provided.

1.3.1.3 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 2 sessions each lasting 10 to 45 minutes
explore ambivalence about drug use and possible treatment, with the aim of increasing motivation to change behaviour, and provide non-judgemental feedback.

1.3.1.4 Opportunistic brief interventions focused on motivation should be offered to people not in contact with drug services (for example, in primary or secondary care settings, occupational health or tertiary education) if concerns about drug misuse are identified by the person or staff member. These interventions should:

normally consist of 2 sessions each lasting 10 to 45 minutes
explore ambivalence about drug use and possible treatment, with the aim of increasing motivation to change behaviour, and provide non-judgemental feedback.

1.3.2 Self-help

1.3.2.1 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.

1.3.2.2 If a person who misuses drugs has expressed an interest in attending a 12‑step self-help group, staff should consider facilitating the person's initial contact with the group, for example by making the appointment, arranging transport, accompanying him or her to the first session and dealing with any concerns.

1.4 Formal psychosocial interventions

A range of psychosocial interventions are effective in the treatment of drug misuse; these include contingency management and behavioural couples therapy for drug-specific problems and a range of evidence-based psychological interventions, such as cognitive behavioural therapy, for common comorbid mental health problems.

1.4.1 Contingency management

Contingency management is a set of techniques that focus on changing specified 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 specified 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 financial incentives.

For more information on contingency management, see appendix C.

1.4.1.1 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.

1.4.1.2 Drug services should introduce contingency management programmes, as part of the phased implementation programme led by the NTA, to reduce illicit drug use, promote abstinence and/or promote engagement with services for people who primarily misuse stimulants.

1.4.1.3 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 and drug-free lifestyle.

1.4.1.4 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).
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 3 tests per week for the first 3 weeks, 2 tests per week for the next 3 weeks, and 1 per week thereafter until stability is achieved.
Urinalysis should be the preferred method of testing but oral fluid tests may be considered as an alternative.

1.4.2 Contingency management to improve physical healthcare

1.4.2.1 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 or C and HIV testing
hepatitis B immunisation
tuberculosis testing.

1.4.3 Implementing contingency management

The implementation of contingency management presents a significant challenge for current drug services, in particular with regard to staff training and service delivery systems. The following recommendations address these 2 issues (for further details please refer to appendix C).

1.4.3.1 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.

1.4.3.2 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.

1.4.4 Behavioural couples therapy

1.4.4.1 Behavioural couples therapy should be considered for people who are in close contact with a non-drug-misusing partner and who present for treatment of stimulant or opioid misuse (including those who continue to use illicit drugs while receiving opioid maintenance treatment or after completing opioid detoxification). The intervention should:

focus on the service user's drug misuse
consist of at least 12 weekly sessions.

1.4.5 Interventions to improve concordance with naltrexone treatment

Naltrexone is an opioid antagonist that eliminates the positive experiences associated with opioid use. It may provide some benefit in sustaining abstinence among people who have completed opioid detoxification. Psychosocial interventions can improve concordance with naltrexone treatment.

1.4.5.1 For people receiving naltrexone maintenance treatment to help prevent relapse to opioid dependence, staff should consider offering:

contingency management to all service users (based on the principles described in recommendations 1.4.1.3 and 1.4.1.4)
behavioural couples therapy or behavioural family interventions to service users in close contact with a non-drug-misusing family member, carer or partner (based on the principles described in recommendation 1.4.3.1 for behavioural couples therapy).

1.4.6 Cognitive behavioural therapy and psychodynamic therapy

1.4.6.1 Cognitive behavioural therapy and psychodynamic therapy focused on the treatment of drug misuse should not be offered routinely to people presenting for treatment of cannabis or stimulant misuse or those receiving opioid maintenance treatment.

1.4.6.2 Evidence-based psychological treatments (in particular, cognitive behavioural therapy) should be considered for the treatment of comorbid depression and anxiety disorders in line with existing NICE guidance (see NICE's guidelines on depression in adults and generalised anxiety disorders and panic disorder in adults: management) for people who misuse cannabis or stimulants, and for those who have achieved abstinence or are stabilised on opioid maintenance treatment.

1.5 Residential, prison and inpatient care

1.5.1 Inpatient and residential settings

1.5.1.1 The same range of psychosocial interventions should be available in inpatient and residential settings as in community settings. These should normally include contingency management, behavioural couples therapy and cognitive behavioural therapy. Services should encourage and facilitate participation in self-help groups.

1.5.1.2 Residential treatment may be considered for people who are seeking abstinence and who have significant comorbid physical, mental health or social (for example, housing) problems. The person should have completed a residential or inpatient detoxification programme and have not benefited from previous community-based psychosocial treatment.

1.5.1.3 People who have relapsed to opioid use during or after treatment in an inpatient or residential setting should be offered an urgent assessment. Offering prompt access to alternative community, residential or inpatient support, including maintenance treatment, should be considered.

1.5.2 Criminal justice system

1.5.2.1 For people who misuse drugs, access to and choice of treatment should be the same whether they participate in treatment voluntarily or are legally required to do so.

1.5.2.2 For people in prison who have drug misuse problems, treatment options should be comparable to those available in the community. Healthcare professionals should take into account additional considerations specific to the prison setting, which include:

the length of sentence or remand period, and the possibility of unplanned release
risks of self-harm, death or post-release overdose.

1.5.2.3 People in prison who have significant drug misuse problems may be considered for a therapeutic community developed for the specific purpose of treating drug misuse within the prison environment.

1.5.2.4 For people who have made an informed decision to remain abstinent after release from prison, residential treatment should be considered as part of an overall care plan.