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TitleUK Guidelines on Clinical Management
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Total Pages129
Table of Contents
	Members of the working group
	User and carer representatives
	Other contributors
	Who are the Clinical Guidelines for?
	What are the 2007 Clinical Guidelines?
	Why update the Clinical Guidelines?
	NICE and the 2007 Clinical Guidelines
	The status of the Clinical Guidelines
	Regulation and inspection
	The process for developing the 2007 Clinical Guidelines
	1.1	Key points
	1.2	Drug treatment is effective
	1.3	Drug misuse and drug treatment
	1.4 The impact of drug misuse on families and communities
	1.5	Models of drug treatment
	1.6	References
	2.1	Key points
	2.2	Principles of clinical governance
	2.3	Doctors’ training
	2.4	Non-medical prescribing
	2.5 Confidentiality, information sharing and child protection
	2.6	Involving patients
	2.7	Involving carers
	2.8	References
	3.1	Key points
	3.2 Assessment, planning care and treatment
	3.3	Delivery of treatment
	3.4	Drug testing
	3.5 General health assessment at presentation and in treatment
	3.6	References
	4.1	Key points
	4.2 Principles of psychosocial interventions
	4.3 Psychosocial interventions – evidence and models
	4.4 Psychosocial interventions and different drugs of misuse
	4.5 Competencies to deliver psychosocial interventions
	4.6	NICE guideline on psychosocial interventions
	4.7	References
	5.1	Key points
	5.2	Prescribing
	5.3	Induction onto methadone and buprenorphine treatment
	5.4	Supervised consumption
	5.5 Assessing and responding to progress and failure to benefit
	5.6	Opioid maintenance prescribing
	5.7	Opioid detoxification
	5.8	Naltrexone for relapse prevention
	5.9	Benzodiazepines
	5.10	Stimulants
	5.11	References
	6.1	Key points
	6.2	Blood-borne infections
	6.3	Preventing drug-related deaths
	6.4	Alcohol
	6.5	Tobacco
	6.6	References
	7.1	Key points
	7.2	Criminal justice
	7.3	Prisons
	7.4	Pregnancy and neonatal care
	7.5	Mental health
	7.6	Young people
	7.7 Older current and ex-drug misusers
	7.8 Pain management for drug misusers
	7.9	Hospital admission and discharge
	7.10	References
	A1 Doctors’ job titles and involvement in drug treatment
	A2 Cardiac assessment and monitoring for methadone prescribing
	A3	Writing prescriptions
	A4 Travelling abroad with controlled drugs
	A5	Interactions
	A6	Marketing authorisations
	A7	Drugs and driving
	A8	Injectable opioid treatment
	A9 Policy considerations for under-18s
	A10	Useful documents
	A11	Contacts
Document Text Contents
Page 1

UK guidelines on
clinical management

Drug misuse
and dependence

Drug Misuse prelim:Layout 1 05/10/2007 16:27 Page 1

Page 2

Produced by the Department of Health (England), the Scottish Government, Welsh Assembly
Government and Northern Ireland Executive.

Last updated September 2007 (NHS England Gateway reference: 8828).

The text of this document may be reproduced without formal permission or charge for personal or
in-house use.

If your require further copies of this book, contact DH Publications Orderline / Prolog, quoting reference

Email: [email protected]
Tel: 08701 555 455
Fax: 01623 724 524
Textphone: 08700 102 870 (8am to 6pm, Monday to Friday).

Copies are available in electronic form at and from the
National Treatment Agency for Substance Misuse at

Recommended citation
Department of Health (England) and the devolved administrations (2007). Drug Misuse and
Dependence: UK Guidelines on Clinical Management. London: Department of Health (England), the
Scottish Government, Welsh Assembly Government and Northern Ireland Executive

Page 64


Drug misuse and dependence: UK guidelines on clinical management

Page 65


6.1 Key points
� Reducing potential harm due to overdose,
blood-borne viruses and other infections should
be a part of all patient care.

� All drug misusers should be offered
vaccination against hepatitis B and against
hepatitis A where indicated.

� All drug misusers should be offered testing
and, if required, treatment for hepatitis C and
HIV infections.

� Retaining patients in high-quality treatment is
protective against overdose. This protection may
be enhanced by other interventions including
training drug misusers and their families and
carers in the risks of overdose, its prevention and
how to respond in an emergency.

� Drug misusers who are also misusing alcohol
should be offered alcohol treatments.

� Drug misusers who smoke tobacco should be
offered smoking cessation interventions.

6.2 Blood-borne infections

6.2.1 Introduction
Four viruses are currently of particular concern in
the context of drug misuse: hepatitis C, hepatitis
B, HIV, and to a lesser degree or more
sporadically, hepatitis A. Tetanus has also been a
concern for injecting drug users.

There have been recent increases in the levels of
blood-borne viruses among drug misusers
(particularly those who inject). This increase is
more marked in certain groups, including those
injecting crack cocaine with heroin, and
homeless drug users. Blood-borne virus
incidence has also increased among new
(predominantly younger) injectors and there has
been a rise in the rate of sharing of injecting

Overall, approximately one in two injecting drug
users in the UK have been infected with hepatitis
C but there are marked regional variations. The
overall prevalence of hepatitis C infection among
injecting drug users has probably increased in
recent years and levels of hepatitis C
transmission remain elevated (HPA, 2006).

Risks can be reduced by providing an optimised
range of drug services, including access to:

� needle exchange services

� adequate doses of opiate substitution

� structured psychosocial interventions.

6.2.2 Prevention and testing
In addition to the virus-specific
recommendations, there are some general
measures that clinicians working with drug
misusers should take.

� Injecting equipment and education to reduce
equipment sharing should be made available to
all injecting drug users.

� Opiate-dependent patients, whether injecting
or not, should be encouraged to access relevant
advice and information or counselling which
includes strategies for avoiding exposure to
blood-borne virus infection and contamination.

� All patients, and especially those engaged in
sex work, should be made aware of the risk of
infection from sexual contact.

� Sexual partners and household contacts
should be supported and tested where

� All injecting drug users and their partners
should be offered testing for hepatitis C and
hepatitis B infection even if they regard
themselves as unlikely to have acquired these
infections. Patients should be made aware that a
test in general practice may have to be disclosed
if they give permission for a medical report for
financial purposes, and that confidential test
facilities are available, usually in sexual health
(GUM) clinics.

� Testing may have to be repeated when the
risk of exposure continues.

6.2.3 Responding to
exposure to infection

Prevention of avoidable exposure to infection is
of prime importance. When exposure to
infection does occur, it is vital to respond
urgently and for appropriate protocols to be in
place for dealing with incidents. The risk of
transmission of infection, from an infected
individual as a result of an injury caused by a
used needle or other sharp object contaminated
by blood or body fluids, is affected by a number
of factors.


Chapter 6: Health considerations

Page 128


Amfetamine (including dexamfetamine) is used
in line with 2004 MHRA changes to bring the
British Approved Name (BAN) of medicinal
products in line with the recommended
International Nonproprietary Name (rINN). The
convention is extended to methylamfetamine
where it is used to describe a medicinal product,
although this is not specifically named in the
BAN or rINN lists. It is not used to describe non-
medicinal products (illicit drugs) – in these cases
the established “ph” spellings (amphetamine(s),
dexamphetamine, methamphetamine) are used.

Carer is used only to describe a partner, child,
relative, friend or neighbour who, without
payment, provides help and support for a drug-
misusing patient. Paid, professional carers
provided under a care plan are not included.

Clinician is used throughout the 2007 Clinical
Guidelines to refer to the range of professionals
working in treatment settings with drug
misusers. In the past, the Clinical Guidelines
were targeted principally at doctors and, while
doctors are still the primary audience, clinicians
increasingly covers other professions, including
nurses, pharmacists, psychologists and drug

Dependence vs. addiction. Dependence is the
preferred term in these 2007 Clinical Guidelines.
The term ‘addiction’ has generally been avoided
except in relation to addiction psychiatry.

Drug is used to describe a psychoactive
substance (other than alcohol) used illicitly or
illegally, except in the term ‘controlled drug’
where it refers to a substance defined by and
controlled under the Misuse of Drugs Act.

Drug misuse is the generally preferred term in
the 2007 Clinical Guidelines for illicit or illegal
drug use which is causing sufficient harm to
require treatment. Someone who engages in
drug misuse is called a ‘drug misuser’. However,
some generally accepted compound terms, such
as ‘injecting drug user’ (or IDU), have been kept.
‘Problem drug user’ (or PDU) is also retained
where it has the specific definition of a heroin or
crack cocaine misuser.

Medicine is used to describe a substance made
up into a suitable formulation for use in
treatment, except where the term ‘controlled
drug’ is used to describe a substance defined by
and controlled under the Misuse of Drugs Act.

The term ‘drug’ may also be used when
describing the properties of a chemical used as a
medicine, or when used in a widely accepted
compound term such as ‘non-steroidal anti-
inflammatory drug’ or Z-drug.

Opiate vs. opioid. Opioid is used in line with
the WHO definition to refer to the whole group
of natural, semi-synthetic and synthetic
compounds that act on opioid receptors. Opiate
is used for substances derived from the poppy
plant and for the semi-synthetic drug
diamorphine (heroin). Although drug misusers
may use a range of opioids, most will have
developed problems while using heroin
therefore, in line with common usage, we refer
to opiate misusers.

Substance is used to describe the wider range
of drugs, volatile substances and alcohol often
misused by young people.

These conventions may not be maintained
where the text is quoted from elsewhere.


Drug misuse and dependence: UK guidelines on clinical management

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