Checked: 18-08-2017 by
vicky.ryan Next Review: 23-08-2019
Substance misuse NS MOM
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Efforts are made to ensure the accuracy and agreement of these guidelines. However, we cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties
management of detoxification and withdrawal syndromes of dependencies and use of illicit substances, including opioids, benzodiazepines, and stimulants, specifically:
maintenance of substitute therapies for the above substances
prevention of complications
psychosocial components of treatment
management in primary and secondary care
management in adults and young people over age 16 years with special considerations for:
people with a co-morbid, psychiatric illness
other conditions to consider are:
depression − see 'Depression NS MOM care map
schizophrenia − see 'Schizophrenia NS MOM' care map
bipolar affective disorder
smoking cessation − see 'Smoking cessation NS MOM' care map
Out of scope:
alcohol withdrawal and detoxification, and treatment for dependency − see Alcohol Misuse-suspected NS MOM care map
nicotine dependence − see 'Smoking cessation NS MOM' care map
related management of symptoms in neonates whose mothers misused opioids during pregnancy
the use of a substance for a purpose not consistent with legal or medical guidelines 
the substance has a negative effect on health or functioning and may take the form of drug dependence 
dependence is defined as :
a strong desire to take a substance, or difficulty in controlling its use
the presence of a physiological withdrawal state
tolerance of the use of the drug
neglect of alternative pleasures
persistent use of the drug despite harm to self and others
crack cocaine 
new psychoactive drugs 
opioids include :
sedatives, such as:
benzodiazepines, eg :
zopiclone and zolpidem 
pregabalin and gabapentin 
Incidence and prevalence:
the UK has among the highest rates of recorded illegal drug misuse in the western world, particularly heroin and crack cocaine 
substance misuse is more prevalent in areas characterised by social deprivation 
majority of adult substance misusers in treatment in the UK report opiates as their main problem drug  − but most people who use drugs are now poly drug users combining opiates with at least one or all of cocaine, alcohol, and benzodiazepines 
drug profiles are changing with younger users using alcohol, cannabis, cocaine, and ecstasy (ACCE) 
two out of three substance misusers in treatment age 17 years or younger report cannabis as their main problem drug 
Morbidity and mortality:
substance misusers may have a range of health and social care problems which may or may not be associated with drug misuse 
substance misusers and injecting drug users are at particular risk of contracting and spreading hepatitis B, C, HIV, and other infections by sharing injecting equipment 
heroin addicts have been shown to have a mortality risk nearly 12 times more than the general population 
drug-related mortality due to loss of tolerance following release from prison is a particular concern 
the UK is a low prevalence country for hepatitis B − 97% of its cases are imported , but out of the remainder of cases, 34% are associated with injecting drugs 
over 90% of hepatitis C infections in the UK are transmitted by injecting drug use 
injecting drugs accounted for 5.6% of HIV diagnoses in the UK in 2006 
over 1500 drug-related overdose deaths were recorded in England in 2005 − the vast majority of these deaths were from heroin misuse associated with alcohol, benzodiazepines, and other depressants 
The care map has been restructured to aid substance misuse diagnosis and management. Content has been updated for red flags, initial assessment, and management as well as prescribing issues, opioid detoxification and opioid maintenance guidance.
 Clinical Knowledge Summaries (CKS). Opioid dependence. March 2014. Newcastle upon Tyne: CKS; 2014.
 National Institute for Health and Care Excellence (NICE). Needle and syringe programmes. NICE public health guidance 52. Manchester: NICE; 2014.
 Recovery Orientated Drug Treatment Expert Group (RODT). Medications in recovery: best practice in reviewing treatment: supplementary advice from the Recovery Orientated Drug Treatment Expert Group. London: PHE; 2013.
 Health Protection Agency (HPA). Shooting up: infections among people who inject drugs in the UK 2012: an update: November 2013. London: HPA; 2013.
 National Institute for Health and Clinical Excellence (NICE). Methadone and buprenorphine for the management of opioid dependence. NICE technology appraisal guidance 114. London: NICE; 2007.
 Mattick RP, Breen C, Kimber J et al. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev 2014; 2: CD002207.
 Lingford-Hughes AR, Welch S, Peters L et al. BAP updated guidelines: evidence-based guidelines for the pharmacological management of substance abuse, harmful use, addiction and comorbidity: recommendations from BAP. J Psychopharmacol 2012; 26: 899-952.
 Clinical Knowledge Summaries (CKS). Benzodiazepine and z-drug withdrawal. July 2013. Newcastle upon Tyne: CKS; 2013.
 British National Formulary (BNF). BNF July 2014. London: BMJ Group and RPS Publishing; 2014.
 World Health Organization (WHO). Guidelines for the identification and management of substance use and substance use disorders in pregnancy. Geneva: WHO; 2014.
 World Health Organization (WHO). Guidance on prevention of viral hepatitis B and C among people who inject drugs. Geneva: WHO; 2012.
 British Pain Society (BPS). The British Pain Society's Opioids for persistent pain: good practice: a consensus statement prepared on behalf of the British Pain Society, the Faculty of Pain Medicine of the Royal College of Anaesthetists, the Royal College of General Practitioners and the Faculty of Addictions of the Royal College of Psychiatrists. London: BPS; 2010.
 National Treatment Agency for Substance Misuse (NTA). Medications in recovery: re-orientating drug dependence treatment. London: NTA; 2012.
Expert opinion has been added to this care map in line with:
 Practice-informed recommendations, including contributors representing the Royal College of General Practitioners (RCGP); 2014.
Discuss and commence the following initial interventions as soon as possible with the substance-misusing patient [1,2]:
treatment of any acute illness [1,2]
information, advice about, and immunisation against hepatitis A and B [1,2]
pre-test discussion and testing for [1,2]:
cervical cancer screening [1,2]
sexual health, contraception, and safer sex advice [1,2]
diet and nutrition advice [1,2]
smoking status 
long-term conditions 
assessment of dental health 
if injecting [1,2]:
treatment of direct complications of injecting
safer injecting advice
advice on local needle and equipment provision
alcohol advice, brief interventions, and other treatments for those also misusing alcohol [1,2]
Special considerations in pregnant women:
refer all women to an obstetrician and/or a midwife specialising in drug misuse (depending on local expertise) and to the local drug dependency service 
services are advised to fast-track pregnant women into drug treatment to allow for the earliest engagement possible 
engagement with and close monitoring in antenatal care and drug treatment are integral to achieving stability 
there are several health problems during pregnancy that need to be discussed, including :
risks of anaemia
alcohol and nicotine consumption
oral hygiene and dental health
complications from chronic infection related to injection practice
antenatal and postnatal mental health problems
advice should be given regarding potential complications of pregnancy associated with drug use, eg :
low birth weight
neonatal abstinence syndrome
Drug-related deaths are most common in opioid misusers and may be caused by :
accidental overdose − often combined with alcohol and benzodiazepines
physical problems, including complications of drugs and alcohol use such as liver disease
Drug-related deaths are especially common in the first weeks following release from prison or other situations where tolerance is lost, such as post-detoxification, amongst those with a previous history of injecting drug use and polydrug dependency .
Clinicians can help to reduce the likelihood of drug-related deaths by:
identifying and assessing patients at high risk of drug-related death 
providing education and training to patients and their families on the risks of overdose and how to respond effectively 
advising of the dangers of combining drugs, especially alcohol and benzodiazepines 
educating patients that the use of methadone, outside of its medical purpose, is extremely dangerous 
educating new patients starting on methadone and buprenorphine on the risks of loss of tolerance 
using supervised consumption, especially in the early stages of methadone and buprenorphine treatment 
adjusting dispensing frequency according to risks 
requiring that patients moving on to take-home methadone and buprenorphine provide details of satisfactory home storage arrangements and recording these in the patient's notes, especially when children are in the home 
conducting or arranging for mental health assessments in patients who present a suicide risk 
making use of local specialist support and referral in complex cases, such as cases of poly-pharmacy requiring specialist review 
contributing to effective care pathways between prisoners and the community 
take home naloxone :
used in emergency situations to reverse opioid overdose 
evidence for the effectiveness of take-home naloxone in preventing overdose related deaths is largely anecdotal at present 
is established practice in some parts of the country 
All services working with substance misusers should have an emergency protocol in place that covers the management of drug overdoses .
Include the following examination in the early assessment :
assessment of injection sites in all limbs, if injecting
measurement of height and weight
urine testing for common conditions such as diabetes mellitus and infection
blood pressure (BP) measurement
general impression of respiratory, cardiovascular, and other systems, paying attention to symptoms offered and complaints given  − subacute bacterial endocarditis is not uncommon and requires urgent admission if suspected [4,7]
can be used to confirm drug use as part of a comprehensive assessment 
includes urinalysis or saliva testing 
point of care testing should be used if available 
the patient should consent to these tests first 
Further examinations and tests that may be required depending on history, risks, and symptoms include:
peak flow to test for crack damage 
chest X-ray and pulmonary function tests [1,2], to test for:
chronic obstructive pulmonary disease (COPD) 
tuberculosis (TB) [1,2]
examination of gastrointestinal (GI) system, including the liver [1,2]
pregnancy testing [1,2]
testing for HIV antibodies, hepatitis B, and C infection [1,2]:
if hepatits C positive, consider performing a polymerase chain reaction (PCR) test 
consider vaccination for hepatitis B, if indicated by the history 
other blood tests to assess liver function, thyroid function, and renal function [1,2]
full blood count (FBC) to assess for anaemia and infection 
All of the above examinations and tests may need to be repeated if appropriate  − eg if patient continues to inject drugs, review hepatitis C status every 6 months .
NB: These examinations should preferably be performed in primary care providing the GP or health professional has the appropriate expertise and equipment .
Before initiating any investigations or treatment in patients with co-existing psychosis :
ensure informed consent is achieved by providing appropriate information on psychosis and substance misuse
apply the principles underpinning the Mental Capacity Act (2005)
assess mental capacity using the test set out in the Mental Capacity Act (2005)
We provide a service for young people in North Somerset who would like support, information or advice about drugs and alcohol.
The SAS work directly with young people who are using drugs, alcohol or tobacco and want support to stop their use.
We can meet with young people wherever they feel most comfortable. Whether at home, in the community, at school/college or in our offices, the service we provide is friendly, accessible, and accommodating.
Our work also includes visiting schools, colleges and youth centres to provide education and information to groups of young people about drugs, alcohol and tobacco.
We are able to provide support and training to parents, carers and professionals. All our workers are "No Worries" advisors.
A young person can refer themselves by contacting us directly or, with the individual's permission, a referral can be made by a parent, carer or professional.
There is no waiting list and there is no charge for the service.
Addaction provides an integrated drug and alcohol service in North Somerset.
Over the counter medicines
aged 18 and over
resident or registered with GP in North Somerset
deems their substance use to be problematic, there is no requirement to meet diagnostic definitions of dependence in order to access the service
-Access times into Addaction are the same for everyone, regardless of the referral routes. If an individual walks into the service they will be assessed immediately (or as near as practicable), if a referral is sent via mail (post, email, fax etc) the individual will be written to within a week and requested to attend at their earliest convenience.
- Specific appointments will be booked where individuals require treatment on an outreach basis.
- High risk factors such as pregnancy, risk of physical harm (to themselves or others), or leaving prison, may result in an individual receiving an expedited service.