1 Guidance

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 (see section 5 for details).

1.1 General considerations

1.1.1 Providing information, advice and support

1.1.1.1 Detoxification 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 detoxification 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 detoxification, 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).

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

  • a balanced diet

  • 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 detoxification should be considered

  • maintain effective collaboration with other care providers.

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

1.1.1.6 Service users considering opioid detoxification 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 detoxification 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.

1.1.1.8 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.

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 detoxification 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 detoxification 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 identification of the use of opioids and other substances; consideration may also be given to other near-patient testing methods such as oral fluid 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)

  • take a history of drug and alcohol misuse and any treatment, including previous attempts at detoxification, 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 financial 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 confirmatory laboratory tests. This is particularly important when:

  • a young person first presents for opioid detoxification

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

  • complex patterns of drug misuse are suspected.

1.2.1.3 Near-patient and confirmatory 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 detoxification 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

  • 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, detoxification 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 (see section 6).

1.2.3 People who misuse benzodiazepines or alcohol in addition to opioids

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

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

1.3 Pharmacological interventions in opioid detoxification

1.3.1 The choice of medication for detoxification

1.3.1.1 Methadone or buprenorphine should be offered as the first-line treatment in opioid detoxification. 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 detoxification 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 detoxification

  • 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 detoxification.

1.3.1.4 Dihydrocodeine should not be used routinely in opioid detoxification.

1.3.2 Dosage and duration of detoxification

Opioid detoxification 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. Detoxification 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 detoxification, 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)

  • pharmacology of the chosen detoxification medication and any adjunctive medication

  • setting in which detoxification is conducted.

1.3.2.2 The duration of opioid detoxification 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 detoxification

The terms ultra-rapid and rapid detoxification refer to methods that shorten the duration of detoxification and thereby also the duration of withdrawal symptoms. In both ultra-rapid and rapid detoxification, withdrawal is precipitated at the start of detoxification by the use of high doses of opioid antagonists (such as naltrexone or naloxone). The essential distinctions between ultra-rapid and rapid detoxification are the duration of the detoxification itself and the level of sedation. Ultra-rapid detoxification takes place over a 24-hour period, typically under general anaesthesia or heavy sedation. Rapid detoxification may take 1–5 days, with a moderate level of sedation. Accelerated detoxification, 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 detoxification 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 detoxification are briefly defined 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 significant 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 significant stimuli. The person may experience partial or complete loss of protective reflexes, 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 and rapid detoxification 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 detoxification 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 detoxification 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 detoxification should only be considered for people who specifically request it, clearly understand the associated risks and are able to manage the adjunctive medication. In these circumstances, healthcare professionals should ensure during detoxification 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 detoxification, using opioid antagonists at lower doses to shorten detoxification, 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 detoxification, 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.

1.3.5 Monitoring of detoxification medication

1.3.5.1 Healthcare professionals should be aware that medications used in opioid detoxification 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 detoxification 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 detoxification. Exceptions to this may include service users who:

  • have not benefited from previous formal community-based detoxification

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

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

  • are experiencing significant social problems that will limit the benefit of community-based detoxification.

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

1.4.1.3 Residential detoxification 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 benefit significantly from a residential rehabilitation programme during and after detoxification.

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

1.4.2 Continued treatment and support after detoxification

1.4.2.1 Following successful opioid detoxification, 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 detoxification

1.4.3.1 Community detoxification 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 detoxification 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 significant comorbid physical or mental health problems.

1.4.4 Detoxification in prison settings

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

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

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

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

1.5 Specific 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 detoxification) to promote effective detoxification. Other psychosocial interventions are considered in a separate NICE clinical guideline on psychosocial interventions for drug misuse (see section 6 below).

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.

1.5.1 Contingency management to support opioid detoxification

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

1.5.1.2 Contingency management during and after detoxification 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 three tests per week for the first 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 fluid 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 significant 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 appendix C).

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

  • National Institute for Health and Care Excellence (NICE)