The most common use of a drug in treating a specific condition is called the:

This guideline is concerned with psychosocial treatment of the misuse of opioids, stimulants and cannabis. In the UK, it has been estimated that around 4 million people use illicit drugs each year, with cannabis by far the most commonly used, followed by cocaine and ecstasy (Roe & Man, 2006). Opioid misuse occurs on a smaller scale but is associated with much greater rates of harm than either cocaine or cannabis.

The term ‘opioids’ refers to a class of psychoactive substances derived from the poppy plant (including opium, morphine and codeine), as well as semi-synthetic forms (including heroin) and synthetic compounds (including methadone and buprenorphine) with similar properties (World Health Organization [WHO], 2006). Illicit use of opioids generally involves injecting, or inhaling the fumes produced by heating the drug. The term ‘opiate’ refers strictly to the subset of opioids that are naturally occurring or semi-synthetic, and therefore includes heroin and morphine but excludes methadone and buprenorphine.

Stimulants refer broadly to any substance that activates, enhances or increases neural activity (WHO, 2006). Illicit stimulants include cocaine, crack cocaine and amphetamines. Cocaine is one of the most commonly misused illicit stimulants in the UK (Roe & Man, 2006). It is extracted from the leaf of the coca plant and generally sniffed in powder form. Crack cocaine is usually smoked but sometimes injected. Amphetamines are a group of synthetic substances with different chemical structures but broadly similar stimulant properties to cocaine, and include dexamphetamine sulphate (a prescription drug licensed for the treatment of narcolepsy and attention-deficit hyperactivity disorder but which has misuse potential) and methamphetamine.

Cannabis is a generic term denoting the various preparations of the cannabis sativa plant, including cannabis leaves (the most common form, which is smoked), hashish resin and the rarely used cannabis oil. Tetrahydrocannabinol is the key constituent of cannabis that produces the psychoactive effect sought by most users, and the different forms of cannabis vary in their tetrahydrocannabinol content (WHO, 2006). Cannabis is the most commonly used illicit drug in the UK (Roe & Man, 2006).

Definitions

Drug misuse is defined as the use of a substance for a purpose not consistent with legal or medical guidelines (WHO, 2006). It has a negative impact on health or functioning and may take the form of drug dependence, or be part of a wider spectrum of problematic or harmful behaviour (DH, 2006b). In the UK, the Advisory Council on the Misuse of Drugs (ACMD) characterises problem drug use as a condition that may cause an individual to experience social, psychological, physical or legal problems related to intoxication and/or regular excessive consumption, and/or dependence (ACMD, 1998).

In this guideline, dependence is defined as a strong desire or sense of compulsion to take a substance, a difficulty in controlling its use, the presence of a physiological withdrawal state, tolerance of the use of the drug, neglect of alternative pleasures and interests and persistent use of the drug, despite harm to oneself and others (WHO, 2006). Dependence is diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) when three or more of the following criteria are present in a 12-month period: tolerance; withdrawal; increasing use over time; persistent or unsuccessful attempts to reduce use; preoccupation or excessive time spent on use or recovery from use; negative impact on social, occupational or recreational activity; and continued use despite evidence of its causing psychological or physical problems (American Psychiatric Association [APA], 1994).

The diagnosis of dependence is clearest with opioids. The WHO states that:

‘opioid dependence develops after a period of regular use of opioids, with the time required varying according to the quantity, frequency and route of administration, as well as factors of individual vulnerability and the context in which drug use occurs. Opioid dependence is not just a heavy use of the drug but a complex health connotation that has social, psychological and biological determinants and consequences, including changes in the brain. It is not a weakness of character or will.’ (WHO, 2006)

However, dependence, as characterised by the above definition, can also occur with stimulants and cannabis.

Repeated use of a drug can lead to the development of tolerance in which increased doses of the drug are required to produce the same effect. Tolerance develops to opioids, stimulants and cannabis. Cessation of use leads to reduced tolerance and this may present significant risks for individuals who return to drug doses at a level to which they had previously developed tolerance. This can result in accidental overdoses and, in the case of opioid misuse, could lead to respiratory depression and death.

Withdrawal syndromes have clearly been identified after cessation or reduction of opioid and stimulant use. DSM-IV criteria for a withdrawal disorder include the development of a substance-specific syndrome due to cessation or reduction in use; the syndrome causing clinically significant distress; and symptoms not due to a general medical condition or better explained by another mental disorder (APA, 1994). While withdrawal effects have been associated with cessation of heavy cannabis use, their clinical significance is uncertain at present (Budney et al., 2004).

Opioids, stimulants and cannabis also produce intoxication, that is, disturbances in psychophysiological functions and responses, including consciousness, cognition and behaviour, following administration (WHO, 2006). These are described in greater detail in Section 3.5.

People who misuse drugs may present with a range of health and social problems other than dependence, which may include (particularly with opioid users):

• physical health problems (for example, thrombosis, abscesses, overdose, hepatitis B and C, HIV, and respiratory and cardiac problems)

• mental health problems (for example, depression, anxiety, paranoia and suicidal thoughts)

• social difficulties (for example, relationship problems, financial difficulties, unemployment and homelessness)

• criminal justice problems.

Many people who misuse drugs use a range of substances concurrently and regularly (known as polydrug misuse). The use of opioids alongside cocaine or crack cocaine is common, with the National Drug Treatment Monitoring System (NDTMS), which collects, collates and analyses information from those involved in the drug treatment system, reporting an increase in the use of both drugs, from 18% of those presenting for drug treatment in 1998 to 24% in 2001 (NTA, 2005). Alcohol misuse is also common in all types of people who misuse drugs; data from the National Treatment Outcomes Research Study (NTORS) on drug misuse suggested that 22% of participants also drank alcohol frequently, 17% drank extremely heavily and 8% drank an excessive amount on a daily basis (Gossop et al., 2000a). People who misuse opioids in particular may often take a cocktail of substances, including alcohol, cannabis and prescribed drugs such as benzodiazepines, which can have especially dangerous effects in comparison with one of the drugs taken individually.

Drug dependence is associated with a high incidence of criminal activity, with associated costs to the criminal justice system in the UK estimated as reaching £1 billion per annum in 1996 (United Kingdom Anti-Drugs Coordinating Unit, 1998). For example, more than 17,000 offences were reported by an NTORS cohort of 753 participants in a 90-day period before entering treatment (Gossop et al., 2000b). Notably, most of the offences were committed by a small proportion of the cohort (10% of participants accounted for 76% of the crimes). Illicit drug use is also much more common among known offenders in the UK than among cohorts of comparable age drawn from the general population. In a sample of 1,435 arrestees drug-tested and interviewed by Bennett and colleagues (2001), 24% tested positive for opioids. The average weekly expenditure on drugs (heroin and crack/cocaine) was £290, and the main sources of illegal income were theft, burglary, robbery, handling stolen goods and fraud. The NTORS also found 61% of a drug misuse treatment sample reported committing crimes other than drug possession in the 3 months prior to starting treatment, with the most commonly reported offence being shoplifting.) In addition, there is a high prevalence of drug misuse among the incarcerated population: in a 1997 survey, between 41 and 54% of remand and sentenced prisoners were reported to be opioid, stimulant and/or cannabis dependent in the year prior to incarceration (Singleton et al., 1999).

The association between drug misuse and crime also applies in the younger population. For example, the Home Office 2004 Offending Crime and Justice Survey (The Information Centre, Lifestyle Statistics, 2006) found that young people who had used drugs in the past year were over twice as likely to have committed an offence compared with those who reported not having used drugs (52% versus 19%). In addition, young offenders who had taken a Class A drug in the past year were more likely to be frequent offenders than those who reported using other types of drugs. However, in contrast to figures for the general population, Class A drug users comprise a very small proportion (1% testing positive for heroin and 4% for cocaine) of arrestees aged below 18 years (Matrix Research and Consultancy & Institute for Criminal Policy Research, 2007).

Drug treatment can lead to significant reductions in offending levels (Gossop et al., 2003) and, as a consequence, the prison and the broader criminal justice system is an increasingly significant referral source and venue for providing drug treatment.

3.2. EPIDEMIOLOGY OF DRUG MISUSE

According to the national British Crime Survey 2005/6 (Roe & Man, 2006), 34.9% of 16–59 year olds had used one or more illicit drugs in their lifetime, 10.5% in the previous year and 6.3% in the previous month. These figures are much lower for opioid use, with 0.1% of the population having used opioids (including heroin and methadone) in the previous year. However, estimates based on data that also take into account other indicators such as current service usage provide an illicit drug-use figure of 9.35 per thousand of the population aged 15–64 years (360,811), of whom 3.2 per thousand (123,498) are injecting drug users (Chivite-Matthews et al., 2005). Analysis of the 2004/5 data from the NDTMS suggests that there were an estimated 160,450 people in contact with treatment services in England during that period, the majority for primary opioid misuse (NTA, 2005). Males comprise over 70% of new presentations, and the majority of those requiring treatment are opioid dependent (typically using illicit heroin). Similar figures have emerged from Frischer and colleagues (2001), who estimated 0.5% of the population of Britain (that is, 226,000 people) to be problem drug users. More recent estimates indicate that there are around 327,000 problem drug users (of opioids and/or crack cocaine) in the UK, with 280,000 of these opioid users (Hay et al., 2006).

The epidemiology of drug misuse among young people differs considerably from that of the general population. The 2003/4 NDTMS data found cannabis to be the primary problem drug for the majority of young people aged 11–17 years in contact with treatment services (around 60% overall, with a higher figure for males), whereas individuals with primary heroin use comprised a minority of this population.

Drug misuse is more common in certain vulnerable groups. For example, Ward and colleagues (2003) found that among care leavers aged between 14 and 24 years, drug misuse is much higher than in the general population, with three quarters of the sample having at some time misused a drug and over half having misused a drug in the previous month. Levels in the young homeless population are also much higher than the general population, with one survey finding that almost all (95%) of the sample had at some time misused drugs, many (76%) having used cocaine, heroin and/or amphetamine in the previous month.

3.3. AETIOLOGY AND MAINTENANCE OF DRUG MISUSE

Drug misuse is increasingly portrayed in the field as a medical disorder (known as the ‘disease model’ of drug misuse), in part due to advances in our understanding of the neurobiology underlying dependence (Volkow & Li, 2005). There is also no question that numerous socioeconomic and psychological factors all play an important part in the aetiology of drug misuse. These conceptualisations are not mutually exclusive; rather they are facets of the multifactorial aetiology of drug misuse.

The most robust evidence highlights peer drug use, availability of drugs and also elements of family interaction, including parental discipline and family cohesion, as significant risk factors for drug misuse (Frischer et al., 2005). In particular, traumatic family experiences such as childhood neglect, homelessness or abuse increase the likelihood that the individual will develop problems with drugs later on in life (Kumpfer & Bluth, 2004). Recent studies of twins, families and people who have been adopted suggest that vulnerability to drug misuse may also have a genetic component (Prescott et al., 2006), although it is unclear whether repeated use is primarily determined by genetic predisposition, or socioeconomic and psychological factors lead an individual to try and then later to use drugs compulsively. Risk factors for heavy, dependent drug use are much more significant when they occur together rather than individually.

A defining characteristic of drug dependence is that drug use begins as a voluntary action to seek a rewarding stimulus, but continued use results in loss of control over the use, despite its negative consequences (Dackis & O’Brien, 2005). The effects of many illicit drugs are mediated via various brain circuits, in particular the mesolimbic systems, which have evolved to respond to basic rewards (such as food and sex) to ensure survival. A diverse range of substances, including opioids, stimulants and cannabis, as well as alcohol and nicotine, all appear to produce euphoric effects via increasing levels of dopamine (a neurotransmitter) in the nucleus accumbens (Dackis & O’Brien, 2005). This has been well demonstrated in human brain-imaging studies (Volkow et al., 1999). Euphoria resulting from use then potentiates further use, particularly for those with a genetic vulnerability (see below). Chronic drug use may produce long-lasting changes in the reward circuits, including reductions in dopamine receptor levels (Volkow et al., 1999), and these contribute to the clinical course of drug dependence, including craving, tolerance and withdrawal (Lingford-Hughes & Nutt, 2003). In addition, other types of neurotransmitter systems (for example, opioids, glutamates and cannabinoids) are implicated in the misuse of specific drugs.

Although initiation into drug use does not lead inevitably to regular and problematic use for many people (Anthony et al., 1994), it is clear that when use begins, it often escalates to misuse and sometimes to dependence (tolerance, withdrawal symptoms and compulsive drug taking). Once dependence is established, particularly with opioids, there may be repeated cycles of cessation and relapse extending over decades (National Consensus Development Panel on Effective Medical Treatment of Opiate Addiction, 1998). Vulnerability to use is highest among young people, with most problem drug users initiating by the age of 20 (typically earlier for cannabis). Individuals dependent on drugs often become so in their early twenties and may remain intermittently dependent for many years.

With cannabis and cocaine, recreational use is more common and it is likely that there are different patterns of use, with those taking cocaine being divided between those who take the drug on an episodic basis and those who take it daily; in contrast, usually only a small number of people taking cannabis move to repeated (daily) increasingly heavy use, with many taking the drug intermittently. A general US population survey of 8,098 individuals (Anthony et al., 1994) found that among those who had used cocaine or cannabis in their lifetime, 16.7% and 9.1% subsequently became dependent on the respective drugs; for heroin, the figure was 23.9%. Such differences may relate to the different intensities of action different drugs produce within the neural reward sites (Stimmel & Kreek, 2000).

The neurobiological account of fundamental reward systems implicated in drug misuse may parallel the sociocultural–behavioural–cognitive model presented by Orford (2001). He conceptualised drug misuse as an ‘excessive appetite’, belonging to the same class of disorders as gambling, eating disorders and sex addiction. All involve activities that form strong attachment, and were once rewarding, but with excessive consumption result in compulsion and negative consequences. Orford argued that the emotional regulation of such appetitive behaviours in their respective social contexts (for example, the excitement associated with gambling or the anticipation of the next ‘fix’ of heroin), well characterised within the principles of operant conditioning, is a primary factor driving excessive use. Secondary factors such as internal conflict (knowing that the behaviour is harmful yet being unable to disengage from it) potentiate these emotions and thus excessive use, but an alternative result is that the individual alters behaviour in order to resolve such conflict. This crucially suggests that recovery is not impossible, but also that successful treatment attempts are likely to operate against a background of powerful natural processes (Orford, 2001).

3.4. THE COURSE OF DRUG MISUSE

Drug misuse is a relapsing and remitting condition often involving numerous treatment episodes over several years (Marsden et al., 2004). While the initiation of drug use does not lead inevitably to dependence over the long term (Anthony & Petronis, 1995), a number of factors can potentiate this developmental course. Earlier initiation of drug use increases the likelihood of daily use, which in turn results in a greater likelihood of dependence (Kandel et al., 1986).

Among people who misuse opioids, who form the predominant in-treatment population in the UK, most individuals develop dependence in their late teens or early twenties, several years after first using heroin, and continue using over the next 10–30 years. In a long-term outcome study (up to 33 years) of 581 male opioid users in the US, 30% had positive (or refused) urine tests for opioids, 14% were in prison and 49% were dead (Hser et al., 2001). Longitudinal data from the US also showed that the average time from first to last opioid use was 9.9 years, with 40% dependent for over 12 years (Joe et al., 1990). Although it is the case that problem drug users can cease drug use without any formal treatment (Biernacki, 1986), particularly for individuals with primary cocaine or cannabis misuse, for many it is treatment that alters the course of opioid dependence.

Most initiation of cocaine use occurs around the age of 20, with the risk of cocaine dependence occurring early and explosively after first use, and persisting for an average of 10 years (Anthony et al., 1994).

Cannabis use typically begins in early adolescence with heaviest use in the 15–24 age group (Harkin et al., 1997), which may in part be explained by strong peer influences (Frischer et al., 2005). Most use tends to decline steadily from the mid 20s to the early 30s (Bachman et al., 1997). Cannabis dependence persisting through adulthood is the most prevalent among those with sustained frequent use, as high as 40% among those who have used almost daily (Kandel & Davies, 1992).

Although drug misuse can affect all socioeconomic groups, deprivation and social exclusion are likely to make a significant contribution to the maintenance of drug misuse (ACMD, 1998). That said, an association has been found between income in adolescence and early adulthood and cannabis use (Makkai & McAllister, 1997), which may reflect the recreational nature of the majority of cannabis use.

Factors that influence the cessation of drug use in adulthood are similar to those associated with lack of drug use in adolescence. For example, transitions into social roles with greater conventionality, responsibility and/or contexts that are not favourable to using drugs (such as employment, mortgage, marriage and pregnancy; for example, Bachman et al., 1997) and good health are not associated with long-term use. Peer pressure is a major influence on experimental use and is also likely to affect a move towards regular use. The level of drug use is again a clear predictor of continued use.

Once an individual is dependent, drug use is generally a chronic condition, interspersed with periods of relapse and remission (Marsden et al., 2004). Repeated interaction with the criminal justice system, long-term unemployment and increasing social isolation serve to further entrench drug use.

3.5. THE PHARMACOLOGICAL EFFECTS OF DRUG MISUSE

Opioids

Opioids have many effects on the brain, mediated through specific receptors (μ, κ, or δ). The key opioid receptor subtype is μ, which mediates ‘euphoria’, as well as respiratory depression, and is the main target for opioids (Lingford-Hughes & Nutt, 2003), while the κ receptor is involved in mood regulation. Drugs such as heroin and methadone are agonists, which stimulate the receptor. Buprenorphine is a partial agonist; that is, it occupies the receptor in the same way but only partially activates it. In addition, it is an antagonist at the κ receptor and therefore is less likely to lower mood compared with μ agonists.

Soon after injection (or inhalation), heroin metabolises into morphine and binds to opioid receptors. This is subjectively experienced as a euphoric rush, normally accompanied by a warm flush, dry mouth, and sometimes nausea, vomiting and severe itching. As the rush wears off, drowsiness, and slowing of cardiac function and breathing (sometimes to the point of death in an overdose), persist for several hours (National Institute on Drug Abuse [NIDA], 2005a). The effects of methadone are similar but more drawn out and therefore less intense (lasting up to 24 hours when taken orally as prescribed); however, this may be circumvented by illicit users who inject the drug.

The most obvious consequence of long-term opioid use is the development of opioid dependence itself, and the associated harms. Repeated injection will also have medical consequences, such as scarring, infection of blood vessels, abscesses, and compromised functioning of the kidney, liver and lungs (with increased vulnerability to infections).

Stimulants

As central nervous system stimulants, cocaine and amphetamine affect a number of neurotransmitter systems in the brain but exert their effects primarily via dopamine, which mediates reward. Cocaine blocks the presynaptic reuptake of dopamine, such that it is not removed from the intracellular space and leads to extended firing of postsynaptic neurons, resulting in physiological arousal. Amphetamines also increase the availability of dopamine but are thought to do so by triggering a presynaptic leakage.

The acute subjective effects of cocaine are euphoria, increased energy, heightened alertness, sexual arousal, increased sociability and talkativeness. Physiologically there can be acute adverse effects on breathing, and the cardiovascular and central nervous systems: increased heart rate, blood pressure and body temperature, and pupil dilation. All these effects have near-immediate onset but also diminish quickly (after roughly 15–30 minutes if the drug is snorted and 5–10 minutes if smoked), as cocaine is metabolised rapidly by the body (NIDA, 2004). As acute effects wear off, users experience a rebound period (‘crash’), which may include restlessness, anxiety, agitation and insomnia. This can lead to the user bingeing on cocaine in an attempt to displace these negative effects. Chronic misuse of cocaine may lead to increased paranoia, inability to concentrate, sexual dysfunction and cognitive deficits.

For amphetamines, the acute effects are broadly similar except that they are long lasting (normally 4–8 hours), due to slower metabolism. Overdoses may lead to dangerously elevated body temperature, convulsions or even death. Chronic misuse may cause long-term damage to the brain’s ability to manufacture dopamine, possibly resulting in amphetamine psychosis.

Cannabis

Cannabis affects almost every body system, via cannabinoid receptors in the brain, which regulate a range of cognitive and motor functions (NIDA, 2005b). Within minutes of smoking cannabis, the heart rate increases and the bronchial passages relax. Often the individual experiences intoxication, mild euphoria and increased sociability. However, anxiety or paranoia may sometimes occur, particularly among first-time or psychologically vulnerable users (Johns, 2001). Distorted perceptions are common, for example colours may appear more intense and time may seem to slow down. The euphoria reaches a plateau lasting 2 hours or more, depending on the dose, after which the individual may feel sleepy or depressed.

Cannabis use also impairs memory, attention and motor coordination, with especially dangerous consequences on driving performance. Such effects may last for many hours after administration of the drug; the numerous metabolites of a single moderate dose of cannabis may require up to 4 weeks to be completely eliminated from the body (Maykut, 1985). The smoke from cannabis contains the same constituents as tobacco smoke; hence chronic cannabis smoking is associated with a range of respiratory tract disorders, including bronchitis, emphysema and cancers (Hashibe et al., 2005; Tashkin, 1990).

3.6. THE PUBLIC HEALTH IMPACT OF DRUG MISUSE

The harms associated with illicit heroin use include increased mortality from overdose and from other directly or indirectly associated harms such as increased risk of infection with blood-borne viruses (HIV, hepatitis B and hepatitis C); high levels of depression and anxiety disorders; social problems such as disrupted parenting, employment and accommodation; and increased participation in income-generating crime.

Mortality, particularly in heroin-dependent users, is high, with estimates of between 12 (Oppenheimer et al., 1994) and 22 times (Frischer et al., 1997) that of the general population. In England and Wales, there were 1,382 drug-related deaths in 2005 (National Programme on Substance Abuse Deaths, 2005). The majority (59%) were cases of accidental poisoning, although a sizeable proportion (16%) was a result of intentional self-poisoning. Opioids (alone or in combination with other drugs) accounted for some 70% of the deaths, and cocaine 13%. Many of the deaths appear to be due to multiple drug toxicity, especially the presence of central nervous system depressants (for example, alcohol and benzodiazepines), rather than simply an ‘overdose’ of an opioid. This is supported by research that shows those whose deaths were attributed to overdose have opioid levels no higher than those who survive, or than heroin users who die from other causes (Darke & Zador, 1996). Recent cohort studies have shown that mortality rates from methadone-related death are decreasing (Brugal et al., 2005).

HIV infection is a major problem for injecting drug users, with the number of new diagnoses of HIV in the UK holding at around a hundred for the last few years, with 5.6% of all UK diagnoses attributed to injecting drug use by the end of 2005 (Health Protection Agency et al., 2006). There are differences in geographical distribution of HIV in the UK, with rates higher in some centres such as London. Approximately 50% of injecting drug users have been infected with hepatitis C, but this rate, like the HIV prevalence rate, is lower than in many other countries (Health Protection Agency et al., 2006). Transmission of both hepatitis A and B continues even though there are effective vaccines. Needle and syringe sharing increased in the late 1990s, and since then has been stable with around one in three injecting drug users reporting this activity in the last month (Health Protection Agency et al., 2005).

Psychiatric comorbidity is common in drug misuse populations, with anxiety and depression generally common, and antisocial and other personality disorders in opioid-using populations (Regier et al., 1990, 1998). The national US Epidemiological Catchment Area study of the prevalence of mental health disorders reported a 47% lifetime prevalence rate of substance misuse (drugs and alcohol) among people with schizophrenia compared with 16% in the general population, and found that more than 60% of people with a diagnosis of bipolar I disorder had a lifetime diagnosis of substance misuse disorder. Around one in five of the people in the NTORS sample had previously received treatment for a psychiatric health problem other than substance misuse (Marsden et al., 2000). Drug misuse disorders complicated by other comorbid mental disorders have been recognised as having a poorer prognosis and being more difficult to treat than those without comorbid disorders; comorbid disorders are more likely to be chronic and disabling, and result in greater service utilisation.

Lost productivity and unemployment increase with the severity and duration of drug misuse, and personal relationships are placed under considerable strain by dependent drug use. Problems with accommodation are also common in such groups. For example, prior to intake in the NTORS, 7% of the study group were homeless and living on the street, 5% were living in squats and 8% were living in temporary hostel accommodation (Gossop et al., 1998).

Drug misuse may also have a negative impact on children and families (see Section 3.11). In the UK it is estimated that 2–3% of all children under the age of 16 years have parents with drug problems (ACMD, 2003). While use of opioids does not necessarily impact on parenting capacity, registration on UK child protection registers for neglect has been correlated strongly with parental heroin use, and parental problem drug use has been shown to be one of the commonest reasons for children being received into the care system (Barnard & McKeganey, 2004).

3.7. IDENTIFICATION AND ASSESSMENT OF DRUG MISUSE

So prevalent is drug use that all healthcare professionals, wherever they practice, should be able to identify and carry out a basic assessment of people who use drugs. Many people who misuse drugs do not present to drug treatment services, with perhaps 50% of people who misuse drugs not seeking treatment; however this represents a significant improvement on the position in the UK in the early 1990s, when perhaps only 20% of people who misused drugs sought treatment. Of those who do not seek treatment for their drug misuse, a proportion may nevertheless present to other medical services, the criminal justice system and social care agencies. Many will not be seeking help for their drug problems and many, for example some of those primarily misusing cocaine or cannabis, may not be aware of the potentially harmful effects of their drug use. It is probable that those who present to services for drug treatment have the greatest number of problems (Best et al., 2006b).

Routine screening for drug misuse is largely restricted in the UK to criminal justice settings, including police custody and prisons (Matrix Research and Consultancy & National Association for the Care and Rehabilitation of Offenders [NACRO], 2004); it is sparsely applied in health and social care settings. For example, a recent study of psychiatric inpatients in London found that only 1 in 50 people admitted to hospital had undergone screening for drug misuse (Barnaby et al., 2003). The NTA’s updated Models of Care service framework emphasises the importance of non-specialist (tier 1) services in the identification of drug misuse as a precursor to referral for treatment (NTA, 2006a). Opportunistic methods for the effective identification of drug misuse should therefore be considered in a variety of healthcare settings. These are described in Chapter 6.

For those identified and considering treatment, a good assessment is essential to continuing care. Assessment skills are important across all of those health and social care professionals who may come into contact with drug misuse. Assessment includes information about past and current drug use (amount, type, duration, periods of abstinence and effect of abstinence), history of injecting, risk of HIV and other blood-borne viruses, medical history, forensics and previous contact with treatment services. Assessment is a continuous process carried out at every contact with the individual and his or her healthcare professional, counsellor or social worker and can take place over many years. Urine testing for the absence or presence of drugs is an important part of assessment and monitoring. Formal rating scales may be helpful in assessing outcomes and in certain areas of monitoring, for example of withdrawal symptoms.

The aims of assessment are: to confirm drug use (history, examination and urinalysis); assess the degree of dependence; identify complications of drug misuse and assess risk behaviour; identify other medical, social and mental health problems; determine the expectations of treatment and the degree of motivation to change; assess the most appropriate level of expertise required; determine the need for substitute medication; and refer to/liaise appropriately with shared care, specialist or specialised generalist care, or other forms of psychosocial care where appropriate. In addition, immediate advice on harm reduction, including, if appropriate, access to sterile needles and syringes, as well as testing for hepatitis and HIV, and immunisation against hepatitis, should take place.

3.8. THE AIMS OF THE TREATMENT AND MANAGEMENT OF DRUG MISUSE

The clinical management of drug misuse may be categorised into three broad approaches: harm reduction, maintenance-oriented treatments and abstinence-oriented treatments. All treatments aim to prevent or reduce the harms resulting from use of drugs. Care planning and keyworking should form a core part of subsequent treatment and care.

Harm reduction aims to prevent or reduce negative health or other consequences associated with drug misuse, whether to the drug-using individual or, more widely, to society. With such approaches, it is not essential for there to be a reduction in the drug use itself (although, of course, this may be one of the methods of reducing harm). For instance, needle and syringe exchange services aim to reduce transmission of blood-borne viruses through the promotion of safer drug injecting behaviour.

Maintenance-oriented treatments in the UK context primarily refer to the pharmacological maintenance of people who are opioid dependent, through the prescription of opioid substitutes (methadone or buprenorphine). This therapy aims to reduce or end their illicit drug use and the consequential harms.

Abstinence-oriented treatments aim to reduce an individual’s level of drug use, with the ultimate goal of abstinence. The NTORS found that approximately one third of those entering treatment services were abstinent 5 years later (Gossop et al., 2003). However, these treatments may be associated with an increased risk of death from overdose in the event of relapse after a period of abstinence, during which time drug tolerance is lost (Verger et al., 2003). Consequently, it is particularly important for abstinence-oriented treatment to include education on post-detoxification vulnerability to relapse (Gossop et al., 1989) and to overdose, and for wider psychosocial rehabilitation support to be provided.

Care planning should consider the following when any treatment or management plan is developed:

• type and pattern of use

• comorbid mental and physical health problems

• setting

• age and gender

• service user’s aspirations and expectations.

The general principles of treatment are that no single treatment is appropriate for all individuals, treatments should be readily available and begin when the service user presents, and there should be the capacity to address multiple needs. It is also accepted that treatments will change over time. It appears that treatment does not need to be voluntary to be successful – comparisons of voluntary and legally coerced drug treatment have been reviewed recently elsewhere (NCCMH, 2008). For most people in long-term treatment, that is those with opioid dependence, substitute medications, such as methadone and buprenorphine, are important elements of care. However, services also need to address coexisting problems, such as mental health and physical health problems, alongside the drug misuse.

Keyworking forms the core part of treatment for most service users with long-term drug misuse problems (NTA, 2006a). Typically, this involves the following:

• conducting an assessment of need (and a risk assessment)

• establishing and sustaining a therapeutic relationship

• clarification of the service user’s goals in relation to his/her drug use

• discussion, implementation, evaluation and revision of a treatment plan to address the client’s goals and needs

• liaison and collaboration with other care providers

• integration of a range of interventions based on a biopsychosocial model of drug use (for example, prescribing, addressing needs such as housing and improving personal relationships)

• use of one or more techniques derived from one or more therapeutic models to engage and retain the service user in treatment and to support the treatment plan (for example, use of drug diaries and motivational skills) in the absence of delivering a complete course of formal psychological therapy.

3.9. CURRENT CARE AND TREATMENT IN THE NHS

The British response to drug problems dates back to the report of the Rolleston Committee of 1926. The committee accepted dependence as a disease and established a medical approach to drug problems in Britain rather than the predominantly punitive one pursued in other countries such as the US. Rolleston gave doctors a large degree of clinical freedom in their response to people who were dependent, including the use of maintenance treatment. To this day, maintenance is considered an essential aspect of drug treatment.

A large increase in the number of people with heroin dependence in Britain in the mid-1960s prompted the establishment of a network of drug dependence clinics set in psychiatric hospitals and run directly by the NHS. The second epidemic of heroin use in the early 1980s led to a further reshaping of the British treatment response. A multidisciplinary approach was encouraged through the establishment of community drug teams and attempts to increase general practitioner (GP) involvement in drug treatment, with the first in a series of clinical guidelines setting out the responsibilities of the prescribing doctor (DH, 1999). The guidelines also sought to encourage shared care of the person who misuses drugs by different professional groups. While the drug dependence clinics remained the cornerstone of this reshaped approach, the vast majority of treatment prescriptions, namely oral methadone, were now dispensed by community pharmacists and consumed at home. This was further supported by the 2004 General Medical Services contract provision for enhanced maintenance prescribing services (British Medical Association, 2004).

The emergence of HIV/autoimmune deficiency syndrome (AIDS) in the 1980s led to the introduction of needle and syringe exchange schemes as an addition to the treatment services available. These schemes provided needles and syringes to the dependent and non-dependent injector. Harm reduction also became an important aspect of treatment responses to drug misuse. Another refocusing of drug treatment came in the 1990s, with increased concern over the link between criminal activity and drug misuse. Criminal justice settings were seen as an important conduit for getting people who misuse drugs into treatment and a number of interventions such as Drug Treatment and Testing Orders (DTTOs) were established. In 2003, the Home Office, with the DH and the NTA as its key partners, introduced the Drug Interventions Programme (DIP), which seeks to bring treatment and criminal justice services together in responding to drug misuse (Witton et al., 2004).

Current practice

Much of the current treatment of drug misuse in services directly provided or purchased by the NHS focuses on the treatment of opioid misuse. In large part, this is reactive to the drug problems with which service users present, who may themselves be informed by awareness of relevant treatments as well as their own perceptions of whether their drug use is problematic. Few services are focused solely on the treatment of cocaine and cannabis misuse; often these problems are only addressed when the primary presenting problem is opioid misuse. In particular, the provision of treatment is almost non-existent for adults who primarily misuse cannabis, although young people are more likely to receive such treatment. The main treatments for opioid misuse are opioid substitution therapies (methadone and buprenorphine), with stabilisation of the drug user being the treatment aim, leading to improved physical health, well-being, social stabilisation and reduced criminality and costs to society. There is also provision of harm-reduction interventions, for example needle and syringe exchange facilities, alongside formal drug treatment, aiming to minimise the health risks resulting from illicit drug use to the individuals themselves as well as to wider society.

Only a minority entering treatment initially chooses abstinence and enforced abstinence appears ineffective. However, approximately one third entering treatment services generally are abstinent 5 years later (at least for a period of time) (Gossop et al., 1998).

Despite the increase in treatment research, current UK practice is not underpinned by a strong evidence base and there is wide variation in the implementation of psychosocial treatment across services. Two factors may contribute to this situation. First, practice tends to be influenced more by the background and training of those delivering treatment within services than by what research has shown to be effective. Second, there is a lack of studies from the UK, with most evidence coming from the US. These studies are reviewed in Chapter 8.

The most common types of psychosocial interventions available in NHS programmes specifically targeting drug-use behaviours might be based on one of a number of models, including cognitive-behavioural (for example, motivational interviewing and relapse prevention), humanistic and 12-step approaches (Wanigaratne et al. 2005). Often this is unfocused, and therapist and client may not have a clear understanding of the therapeutic goals or therapeutic method. In addition, there exist formal psychological therapies delivered within adult mental health settings, aiming to address drug users’ coexisting mental health problems (NTA, 2006a).

In addition to formal, structured treatment, there is a long tradition in North America and Europe of community-based, peer-led self-help groups for people with substance misuse problems. The most well-established of these deliver the principles of 12-steps, which has its origins in Alcoholics Anonymous (AA). Two such organisations especially relevant to people who misuse drugs are Narcotics Anonymous (NA) and Cocaine Anonymous (CA). The 12-step fellowships of AA and NA largely predate the existing drug treatment field as a medical specialism. AA was founded in the US in 1935 and in the UK in 1947. NA was founded in the US in 1953, and the first UK meeting was held in 1980 (White, 1998).

Brief interventions, typically empathic in nature and lasting up to two sessions, have a variety of potential advantages in the treatment of drug misuse, including ease of delivery and retention of drug users. These interventions can be conducted in a variety of settings, opportunistically to people not in formal drug treatment and as an adjunct to formal, structured drug treatment (Ashton, 2005). Although brief interventions are considered to be an important component of psychosocial treatment in open-access drug services (for example, NTA, 2002 for example, NTA, 2006a), provision of such interventions varies widely throughout England and Wales.

As previously mentioned, the mainstay of current UK drug treatment lies in the pharmacological maintenance of dependent opioid users. Very little is currently known or practiced in relation to managing the misuse of cocaine, amphetamines or cannabis. Recent research on brief interventions provides for potential development in this area, and is covered more extensively in Chapter 7.

Needle and syringe exchange programmes, which provide injecting drug users with clean injecting paraphernalia, have proven effective at helping to reduce the risk of HIV/AIDS (Wodak & Cooney, 2006). Some of these initiatives include opportunities for psychosocial support alongside needle exchanges. Needle and syringe exchange programmes have been established in all drug action team regions in England, with the overwhelming majority providing specialist services alongside pharmacy provision (Abdulrahim et al., 2006), although the level of provision appears to be variable across regions and on average appears to be insufficient to provide injecting drug users with a clean needle/syringe for every instance of injection. Specialist services provide a wider range of harm-reduction interventions (for example, on-site blood-borne virus testing) than pharmacies, but it does not appear that service users in all specialist services receive comprehensive harm-reduction support.

Residential rehabilitation programmes and therapeutic communities for the treatment of drug problems are well established in the UK. These programmes often have abstinence as their goal. They respond to the complex problems related to the drug misuse of their residents by offering respite and highly structured and intensive programmes of support and care as they seek to make fundamental changes to the lifestyles of the residents, and treatment in some programmes is lengthy, lasting 6–12 months (NTA, 2006b).

Most drug treatment is initiated as a result of drug users themselves seeking treatment. However, there has recently been a rapid expansion in forms of legally coerced treatment, whereby the person who misuses drugs is coerced into treatment as an alternative or adjunct to criminal sanctions (Wild et al., 2002). Such treatment may be legally ordered by the court or through referral away from the judicial process, usually following arrest and charge for drug-related and other offences. Despite recent policy shifts of referral away from the courts, however, many people who misuse drugs still serve prison sentences. A recent estimate suggests that around 39,000 prisoners with a serious drug problem are in custody at any one time (All-Parliamentary Group on Prison Health, 2006). Within the prison setting, drug misuse treatment is increasingly being offered following a number of recent developments, including the phased transfer of responsibilities for commissioning healthcare in publicly funded prisons from the Home Office to the NHS (DH, 2006a). While the mainstay of treatment in prison has traditionally been one of detoxification upon admission, there has been a recent policy shift allowing increased access to opioid maintenance therapy and psychosocial interventions.

3.10. SERVICE USER ORGANISATIONS

As outlined in Chapter 5, organisations for people who misuse drugs, such as the 12-step fellowship of NA, were formed in the US before the drug treatment field had fully defined itself as a medical specialism. Many rehabilitation centres in the US based themselves on the ‘concept houses’ that developed out of AA. Since this time, a wider range of service-user organisations has developed, encompassing harm reduction and maintenance-oriented goals as well as abstinence.

In the 1980s and 1990s, as harm reduction moved up the agenda due to the advent of HIV and AIDS, organisations such as Drug Dependents Anonymous (DDA) and Mainliners were established. Although the profile of such organisations is now in decline, there has been growth in collaborations amongst clinicians, researchers and service users, most notably in the UK Harm Reduction Alliance. In the late 1990s, there was a move towards forming national drug organisations: the National Drug Users Development Agency (NDUDA) and the Methadone Alliance (later called the Alliance).

Twelve-step treatments have traditionally taken account of service-user experience and indeed such experience forms the bedrock of these programmes. Recently, harm reduction and maintenance-oriented services have started to formally involve service users and take account of their experience. In addition, the NTA was established as a special health authority to increase the availability of drug treatment in the UK and improve its quality. From the outset, the NTA embraced user involvement as a central component of its strategy.

Service-user involvement in service provision has expanded considerably (see Chapter 5). User groups are now widespread in the UK and are firmly established in the drug treatment field. It should be noted, however, that most organisations are unlikely to reflect the views of people under the age of 18, of whom many will have very different needs and experiences from adults.

3.11. DRUG MISUSE AND THE FAMILY

In the literature, drug misuse is seen as both a ‘problem of the family’ and a ‘problem for the family’ (Bancroft et al., 2002). The evidence that points to traumatic family experiences, such as childhood neglect, homelessness, abuse, loss and bereavement, increasing the likelihood that a person will go on to have drug problems (Kumpfer & Bluth, 2004) can be seen as a problem of the family.

As 60–80% of people who misuse drugs live or are in regular contact with their family (Stanton & Heath, 2005), and approximately 2–3% of all children under the age of 16 years have parents with a drug problem (ACMD, 2003), drug misuse can also be said to be a problem for the family. The impact may be psychological (for example, depression and anxiety), physical (raised blood pressure and ulcers) (Velleman et al., 1993), social (feelings of isolation and work, family and social difficulties [Hudson et al., 2002]) and financial (see Chapter 5).

As a consequence, it is important to address the needs of carers and other family members. In Chapter 5 there is a summary of carers’ needs, which may also include coping with stigmatisation and feeling excluded from the treatment plans of their friend or relative, and access to services. Chapter 8 contains a review of psychological interventions for carers.

Appropriate involvement of family members and carers in the assessment and treatment process may also support the family member/carer and facilitate a more successful outcome for the user. There is evidence that families (including parents, children and siblings) have a role to play in effective treatments; see Chapter 8 for the evidence for behavioural couples therapy in cocaine and opioid dependence and family- or couples-based interventions for people who continue to use illicit drugs while having methadone and naltrexone maintenance treatment.

3.12. ECONOMIC IMPACT OF DRUG MISUSE

Drug misuse is a growing public health concern that carries a substantial economic burden. It is associated with high healthcare and social costs, mainly as a result of transmission of infectious disease, crime and violence (Petry et al., 2004). It has been estimated that problematic drug use accounts for annual social costs in England and Wales of approximately £11,961 million, or £35,455 per user, per year (Godfrey et al., 2002). Chronic health problems comprise a significant element of the health and social care costs of drug misuse. It has been estimated that the prevalence of HIV among new injecting drug users in London reaches 4.2% (Judd et al., 2005). Godfrey and colleagues (2002) estimated the median number of HIV-positive injectors in England and Wales in 2002 to comprise 931 asymptomatic individuals, 1,756 symptomatic and 1,007 with AIDS. The same authors estimated the median per person annual cost of combination therapy at £13,381 for asymptomatic, £14,222 for symptomatic and £24,314 for people with AIDS. These estimates yielded median annual costs to the NHS for the treatment for HIV infected drug users of £12.5 million, £25 million and £24 million, respectively, totalling over £60 million.

In 1999, the reported prevalence of hepatitis B in injecting drug users was estimated at 25% among those attending agencies in London and 17% outside London, with a combined estimate for England and Wales of 21% (Godfrey et al., 2002). Based on these estimates, the same study calculated that the number of injecting drug users who were infected with hepatitis B in 2002 was roughly 54,000. An annual cost of £143 per year assumes a lifetime cost of £4,300 to treat people with hepatitis over their average life expectancy of 30 additional years (Godfrey et al., 2002). The annual NHS treatment cost of hepatitis B for injecting drug users was therefore calculated at approximately £7.8 million (Godfrey et al., 2002). Similar estimates for hepatitis C (based on a median 2002 estimate of 81,782 injecting drug users with the virus) yielded an annual NHS treatment cost of £11.7 million (Godfrey et al., 2002). Beyond the healthcare costs incurred directly by the users, the NHS costs relating to treatment of neonates affected by their mothers’ drug misuse were calculated at £4.3 million per year (Godfrey et al., 2002), with the annual cost of social services in caring for these children amounting to £63 million.

Including primary care, emergency departments, inpatient care, community mental health, and inpatient mental healthcare, problem drug users are estimated to cost the health service between £283 million and £509 million per year (Godfrey et al., 2002). This estimate was in addition to psychosocial interventions, which at present cost £1,000 per user, per year (Godfrey et al., 2002). Furthermore, drug misuse increases substantially crime-ralated costs. Godfrey and colleagues (2002) estimated that the criminal justice system and crime victim costs were £2,366 million and £10,556 million respectively, based on the medium estimates of the number of problematic drug users. Criminal justice costs include costs associated with drug arrests for acquisitive crimes, stays in police custody, appearances in court, and stays in prison; crime victim costs refer to material or physical damage, crime victims’ loss and expenditures taken in anticipation of crime.

The above estimates did not consider the impact of current drug use on future healthcare demands, the lost output of the victim or perpetrator of crime, nor the intangible effects on the community at large, such as security expenditure, property depreciation or increased reliance on private transportation. It is therefore evident that drug misuse places a considerable economic burden to the health service and the society as a whole.

3.13. CLINICAL PRACTICE RECOMMENDATIONS

People who misuse drugs should be given the same care, respect and privacy as any other person.

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.

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.

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.

Which type of drug is used for the treatment of a condition?

What are the 4 types of medicine?

What are medicinal drugs used for?

What are examples of medicinal drugs?