Treatment

The general principles of the treatment of drug dependence include the following:

• Motivating the person to change.
• Social and educational support, for example engagement with social services and voluntary sector support groups such as Narcotics Anonymous; Provision of advice on safe practices and harm reduction techniques.
• Withdrawal of the drug (detoxification), or if this cannot be achieved, continued prescribing of certain drugs, for example opioids, as part of a harm reduction programme (maintenance therapy). Detoxification can be carried out in inpatient, residential or outpatient settings.
• Other harm reduction measures, such as provision of sterile injection materials for intravenous abusers, counselling and screening for hepatitis and HIV, provision of hepatitis B vaccine to people who are not immune, advice on safe sex and reduction of overdose risk.
• Treatment of physical complications. These include accidental overdose, skin infections, abscesses, septicaemia, hepatitis and HIV infection, under nutrition and poor dental hygiene.
• Psychological measures that include simple counselling; group psychotherapy; “therapeutic communities” in which there is communal living with support staff, which allows for discussion of the effects of drug taking on the individual within the supportive environment of a group; cognitive behavioural therapy; relapse prevention where the person identifies individual or environmental triggers that result in drug taking and plans and rehearses methods of coping with these triggers, sometimes by deliberate exposure to the triggers or “cues” (cue exposure).
• Psychosocial interventions currently provided in drug treatment services include, drug advice and information, advice and support for social problems harm reduction, motivational interviewing and other motivational enhancement techniques, relapse prevention, mapping techniques and others, like skills based interventions and complementary or alternative therapies.
• Formal psychosocial interventions for drug misuse include: brief motivational interviewing, contingency management, behavioural couples therapy, family therapy, mutual aid (self help) approaches like Narcotics anonymous and cocaine anonymous, community reinforcement approach and social network behavioural therapy. Service users might benefit from psychosocial interventions to address common mental disorders e.g. cognitive behavioural therapy.
• Rehabilitation to help the person to leave the drug subculture and establish new social contacts. Dependent drug abusers who attain abstinence may require continuing specialist treatment provided in a residential setting. A range of short and longer-term residential rehabilitation programmes are available.

In the UK drug abusers are treated in a variety of settings. Most drug treatment clinics are NHS based, associated with either psychiatric hospitals or community psychiatric clinics (substance misuse services). Inpatient care is either provided in psychiatric or specialised drug units. Individual counselling, group therapy and therapeutic communities are provided by a number of different providers including NHS or non NHS providers like charitable organisations. Specially trained GPs may manage drug dependent patients, with the support of specialist services.

Certain drugs have specific treatment requirements and these are outlined below.

Amphetamines

The mainstays of treatment are psychosocial interventions. There is little evidence that any specific treatment improves outcome in the treatment of amphetamine abuse. The treatment of amphetamine dependence is difficult because craving can be intense. Abstinence is the usual goal. Benzodiazepines may reduce the distress associated with acute withdrawal and antidepressants may be needed for persistent depression. Intravenous users who refuse to engage in abstinence based programmes may receive maintenance treatment with oral amphetamines in a specialist treatment centre although there is no evidence to support this and it should not ordinarily be provided.

Anabolic steroids

Users of these substances are wrongly “put into the same basket” as illegal drug users. They are different in many ways, as they appear to -:

• Be well informed about their drug of choice
• Lead a healthy lifestyle and rigorous training regime
• Have low rates of illicit drug use
• Be well educated with high disposable incomes
• Not use for “pleasure” or to feel “good”. They use for a specific purpose, to achieve a goal.

Treatment should be focused on:

• Providing medical advice and physical and mental health monitoring, through regular health assessments.
• Providing injecting and other harm reduction advice.

Treatment involves withdrawal followed by psychological and psychosocial interventions. Few studies of treatments for anabolic steroid abuse have been conducted. Current knowledge is based largely on the experiences of a small number of physicians who have worked with patients who presented with these problems.

Barbiturates

Abrupt withdrawal is dangerous and may result in seizures or death due to cardiovascular collapse. If the person has been taking a therapeutic dose, slow outpatient withdrawal may be considered but if the dose taken is significantly higher than the therapeutic dose, inpatient withdrawal is necessary. Maintenance treatment may be considered for elderly people who have been taking barbiturates for a long time, in which case the barbiturate is substituted by a benzodiazepine, the dose of which is tapered off over time.

Benzodiazepines

Treatment consists of gradual withdrawal with supportive counselling. Shorter acting, high potency benzodiazepines may be replaced by longer acting drugs, like diazepam, before withdrawal is attempted. Anxiety management, including relaxation therapy may be helpful. Withdrawal takes place over several months, by lowering the dose by about 1/8 every fortnight, although this varies. If withdrawal symptoms are troublesome the dose can be maintained or even temporarily increased until they settle. Most people experience the most troublesome symptoms once the dose has been completely tapered off. Occasionally inpatient detoxification can be considered if community based detoxification is unsuccessful.

Cannabis

Cannabis could cause significant dependence requiring appropriate treatment interventions even though there may not be a prominent physical withdrawal syndrome. There is no medication that is suitable for treating cannabis misuse. The mainstay of treatment is psychosocial interventions especially brief motivational interviewing, in mild cases and if someone is heavily dependent then more structured treatment with key working might be necessary.

Cocaine

There is little evidence that any specific treatment improves outcome in the treatment of cocaine abuse. Acute intoxication may require treatment with benzodiazepines and anti-psychotic medication. Treatment of dependence is difficult because of the intense craving associated with abstinence. Withdrawal followed by cognitive behavioural therapy (CBT), relapse prevention and cue exposure are the preferred lines of treatment. Moderate users may be treated successfully with psychological and social support on an outpatient basis but heavy and chaotic users may require inpatient treatment. Antidepressants like Fluoxetine can be effective in managing major depressive episodes associated with stimulant use. There is no evidence that antidepressants have any effect on withdrawal symptoms from stimulants.

Ecstasy

People should be educated about the potential consequences of abuse and how to avoid overheating by drinking sufficient fluids and taking breaks when dancing.

Gamma hydroxybutyric acid (GHB)

There is a very limited evidence base for effective treatment. Current evidence is only based on some case reports, but there are no large scale trials. Treatment generally involves withdrawal, which might need to be carried out in an inpatient unit with close medical supervision, followed by psychological and psychosocial interventions.

Heroin and other opioids

There is clear evidence that coerced detoxification against a patient’s express will, is likely to lead to relapse and increased risks of harm such as overdoses and blood borne virus infections. In some cases, withdrawal from all opiates is probably the preferred option, but if this is not possible, then maintenance treatment would be more suitable. This is usually with Methadone liquid or Buprenorphine (Subutex) dispensed usually on daily basis and provided as part of a package of care that includes psychosocial interventions, harm reduction interventions and regular key worker and medical appointments. This decreases the use of illicit opioids, associated criminal activity, the harm resulting from self injecting and suicide risk.

Naltrexone is an opiate antagonist, which can be used to help prevent relapse in a small number of highly motivated detoxified opiate dependent people. While a few patients can achieve abstinence rapidly, most require the support of prescribed medications for longer than just a few months. Opioid maintenance treatment is increasingly recognised, as an effective management strategy and oral Methadone remains the most commonly used medicine, however there is an increasing body of work on the effectiveness of Buprenorphine.

Withdrawal can be carried out on either an inpatient or outpatient basis. Drugs used for withdrawal symptoms include clonidine, lofexidine, metoclopramide for nausea and vomiting, loperamide for diarrhoea and anti-inflammatory medication for muscular pains. Naltrexone is also used in “rapid opioid detoxification” in conjunction with heavy sedation and sometimes general anaesthetic although the safety and efficacy of this procedure are not established, and to treat people who have overdosed on opiates.

There are programmes in place, which supply fresh injection needles (Needle Exchange) with a view to reducing the risk of hepatitis and HIV.

Ketamine

There is little evidence that any specific treatment improves outcome in the treatment of ketamine abuse. Treatment is similar to that for amphetamine and cocaine abuse.

Khat

Treatment involves withdrawal followed by psychological and psychosocial interventions.

At present the consequences of khat use are not well recognised by health care professionals. There are no specific pharmacological agents available to treat a case of khat dependence. Addiction services have some experience in treating individuals with dependency on stimulants and would therefore be able to use such a model as a basis for treatment of khat dependence. However, evidence suggests that khat chewers are extremely unlikely to use other drugs or alcohol, and therefore are different from the majority of individuals seeking treatment in addiction services.

Khat use is rarely perceived as a problem and not seen as a drug. Because of this khat users are unlikely to attend for treatment services at current treatment facilities. A more useful method to engage the community would be a “one-stop shop” that could combine services that the community are likely to use (such as housing, employment and benefit advice) with khat using information. Workers would require specific training to be aware of culturally sensitive issues and to deliver health advice and harm reduction strategies. This could be done by encouraging primary and secondary care to provide outreach at such facilities or be involved in training people from the local community.

Lysergic acid diethylamide (LSD)

Panic reactions associated with a “bad trip” can be treated by “talking down the patient” or with oral benzodiazepines. Hallucinogen persisting perceptive disorder is treated by education and supportive psychotherapy to help the person cope with persisting symptoms. Medication can be used but is not usually very effective. Prolonged psychotic episodes are treated by supportive psychotherapy and anti-psychotic medication. Alternative treatments that can be tried are Electro-convulsive therapy (ECT), lithium and anticonvulsants.

Nitrites (Poppers)

Users of these substances are very unlikely to present to treatment services asking for help. Also they are unlikely to perceive these substances to be addictive. Treatment involves the use of education, counselling and harm reduction measures.

Phencyclidine

Treatment of intoxication depends upon the symptoms. Anti-psychotic medication or benzodiazepines may be given. Phencyclidine psychosis can be treated with benzodiazepines, anti-psychotics and other medication.

Psilocybe mushrooms

Users do not usually regard themselves as having a problem and almost never present to drug services for help with cutting down or stopping. There are no specific treatments available.

Solvents

For the majority of users dependence does not occur and advice and support usually suffices. However, a significant number who often have poor social circumstances and also abuse alcohol and other substances, may become dependent. Treatment of these people is difficult and requires a full range of psychological and social treatments. There is no specific pharmacological treatment available.

Prevention

Prevention measures include restricting availability, reducing social deprivation, identification and treatment of family problems and providing information on the dangers of drug abuse.

Amended June 2008