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.
Which methods of implementing contingency management (including delivering and stopping incentives) and which settings (including legally mandated, community-based and residential) – compared with one another and with standard care – are associated with the longest periods of continued abstinence and reduced drug misuse, and with maintenance of abstinence/reduction of drug misuse at follow-up?
Although the efficacy of contingency management for drug misuse has been extensively investigated, there is a lack of large-scale and well-conducted implementation studies. The implementation of contingency management programmes in the UK would be aided by research assessing specific components of the programme.
For people who misuse drugs and who are participating in contingency management, which method of testing – urinalysis, sweat analysis or oral fluid analysis – is most sensitive, specific, cost effective and acceptable to service users?
There is a lack of data comparing the sensitivity and specificity, cost effectiveness and acceptability to service users of these methods of testing. Identifying drug use during treatment is an important aspect of contingency management; identifying which testing methods are the most effective is important for health and social care services intending to implement contingency management programmes.
For people who inject drugs, do needle and syringe exchange programmes with a greater psychosocial content reduce injection and sexual risk behaviours and rates of seroprevalence of blood-borne virus infection more than programmes with minimal psychosocial content? Examples of greater psychosocial content include distribution of syringes and needles by staff and/or provision of psychoeducation on reducing the risk of blood-borne viruses. Examples of minimal psychosocial content include machine dispensing of syringes and needles and provision of minimal or no information on reducing blood-borne virus risk.
There is extensive literature assessing whether needle and syringe exchange programmes reduce injection and sexual risk behaviours and HIV seroprevalence rates. However, there is very little research that seeks to distinguish the impact of the provision of sterile needles from that of the psychosocial interventions often offered within such programmes. Psychosocial contact and interventions require substantial resources; therefore it is important to assess whether these additional elements are clinically and cost effective.
Is residential treatment associated with higher rates of abstinence or reduction in drug misuse than community-based care?
There have been some studies comparing residential treatment with community-based treatment. However, these studies are often based on small sample sizes, lack methodological quality and have produced inconsistent results. Residential treatment requires significantly more resources than community-based treatment, so it is important to assess whether residential treatment is more effective.