Comunidad Autonómica Andaluza

• stabilisation on substitution opioids (e.g. methadone)

• withdrawal from substitution opioids (e.g. methadone)

• withdrawal from opioids with non-opioid medications (e.g. lofexidine)

• maintenance on substitution opioids (e.g. methadone)

• stabilisation and withdrawal from sedatives (benzodiazepines and alcohol)

• relapse prevention prescribing (e.g. naltrexone, disulfiram)

• prescribing for stimulant users, including symptomatic prescribing

• maintenance prescription of substitution medication for opioids. Withdrawal from all classes of drugs may be achieved with no prescribing

intervention. Symptomatic interventions, which do not involve the use of substitute drugs, may be an effective treatment in some cases. Withdrawal may also be

achieved with substitution prescribing, for example, for benzodiazepines, alcohol and opiates. Reduction programmes are abstinence-oriented programmes in which an individual is given, in reducing doses, related drugs that provide effective chemical substitution to give relief from withdrawal.

For opiates, reduction programmes vary in duration from a few weeks to a few months until detoxification is achieved. However, not all drug misusers are able or willing to reduce or stop their drug taking. Longer-term, or maintenance, prescribing is therefore carried out and stable doses of methadone are thus prescribed to opiate misusers. It is part of a wider process of helping the drug misuser reduce the various forms of drug-related harm, including social, housing, legal and financial problems, until they are ready, able and willing to withdraw from the substitute (Department of Health et al. 1999). There are different models of longer-term or maintenance prescribing for opiate misusers, ranging from highly structured regimens to low- threshold programmes.

In reality, however, the distinction between rapid or gradual withdrawal and

maintenance programmes is not always clear-cut. Follow-up data from the National Treatment Outcome Research Study (NTORS) show that, whereas most service users receiving methadone maintenance received maintenance, only about a third of those allocated to reduction programmes received methadone reduction and many actually received a form of methadone maintenance. NTORS follow-up data show that service users on reduction programmes were more likely to receive low doses of methadone and were less likely to remain in treatment. Among users on

maintenance programmes, higher doses and retention in treatment were associated with reduction in heroin use. Among service users on reduction programmes, the more rapidly the methadone was reduced, the worse the outcome in heroin use. Reduction in heroin use among service users in both types of programmes was associated with improvements in other outcome areas. The more severely dependent service users showed better outcomes in maintenance programmes. Methadone reduction programmes were associated with poor outcomes, and many of those in reduction programmes did not receive reduction treatment as intended.

NTORs researchers believe that this calls into question the appropriateness of either the initial treatment planning process or the treatment delivery process, or both. A clearer distinction should be made between the two types of programmes and treatment goals should be made more explicit to service users and treatment staff. It is also suggested that a reappraisal of the goals and procedures of methadone reduction treatment is required (Gossop et al. 2001b) It also shows the importance of adequate dosage.

There may be a limited role for prescribing substitution amphetamines (Department of Health et al. 1999), although there is little evidence of its efficacy. Symptomatic prescribing may be of use, such as antidepressants for depressive episodes and anti-psychotic medication for psychotic symptoms (Ghodse 1995a).

2.5.1.3 Location

Community prescribing is carried out in specialist multidisciplinary teams or by general practitioners in shared care with specialist services. Specialist agencies are usually multidisciplinary and are resourced to offer specialist treatment and referral. There is now a diversity of team structures and labels used to name services that offer community prescribing, including community drug or substance misuse teams and drug dependency units. In this chapter we use the term substance misuse team (SMT) as a generic label to denote these multidisciplinary teams.

Recent Department of Health guidelines (Department of Health et al. 1999) have stressed the importance of a shared care approach between primary and secondary care in the management of drug misusers. GPs are encouraged to provide specialist treatment programmes, which may involve them prescribing substitutes. They are also encouraged not to prescribe in isolation but to liaise with other professionals who will help with factors contributing to drug misuse. A multidisciplinary approach to

2.5.1.4 Programme duration

Prescribing may be one part of a treatment programme, and such programmes may be of varying length. Detoxification programmes for benzodiazepines (Ghodse 1995a) and opiates (Task Force to Review Services for Drug Misusers 1996) are generally in the order of weeks to months.

This document does not support a finite duration for maintenance prescribing. On the contrary, the bulk of evidence shows that length of time spent in methadone

maintenance is a good predictor of outcome; the longer the time spent in methadone maintenance, the better the result in terms of reduction of illicit use and psychological adjustment. There is evidence that the duration of treatment is one of the most influential determinant factors in outcome of methadone maintenance; with adequate daily dose levels, longer retention is associated with better outcomes (Strain et al.

1993a, 1993b; Ball and Ross 1991). Similarly, studies show that retention in treatment is an important goal and is the result of successful methadone maintenance, and that premature termination of methadone maintenance is associated with a return to drug use (Gearing and Schiwitzer 1974; Ball 1991; Rosenbaum et al. 1988).

Although low-threshold methadone programmes are not new, there is in the UK increasing interest in such programmes. Low-threshold methadone programmes can vary quite significantly. At an international level, some programmes have been criticised because the criteria for entry are applied simply as a replacement for the more rigorous criteria of maintenance programmes. Others have more structured criteria (Perreault and Mercier 2001). The importance of better documenting and describing the ones that exist has been advocated (Perreault and Mercier 2001). Some programmes have been documented (Finch et al. 1995) and some evidence is available on the effectiveness and outcomes of some programmes. For example, a Dutch study suggests that low-threshold programmes reduce overdose mortality, with higher dosage being most protective (Vanameijden et al. 1999). A German study found that low-threshold programmes reached clients who are more advanced in their drug-taking career and less influenced by social pressure to enter treatment (Hoffman et al. 1997).