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Summary
Introduction Treatment choice must be guided by detailed assessment and clear treatment goals. This section looks in broad terms at two of the principles underlying methadone prescribing:
It then outlines:
Motivation
and change
'Motivational interviewing' is the name given to the use of interventions, designed using this model, to help people achieve change in the component behaviours of their drug dependence and/or abstinence. Many clinicians use other psycho-social and counselling approaches to help clients resolve problems in all areas of their life while using the stages of change model to understand the processes the client is going through in terms of their drug use. Most people who achieve lasting change in any ingrained behaviour do not achieve it at their first attempt. This is equally true for opiate use; most people who become lastingly opiate free have been through a series of detoxifications and relapses which finally result in a lasting abstinence. It is possible to learn from each unsuccessful attempt, and to use the lessons learned to achieve better results in the future. The chances of success are higher if someone has been through the process of stopping and starting again than if they are stopping for the first time. For this reason it may be more helpful to view the process as progressing along an upward spiral rather than going round in circles. Precontemplation:
'Problem, what problem?' This perception can be reinforced by spending a lot of time with other drug users, thus rendering the problems they experience as 'normal' or by rationalising 'everybody takes something' or 'the people with a problem are the ones who are worse than me'. People in precontemplation often benefit from the opportunity to get their drug use in perspective, to understand which of their problems are drug-related and to understand the reasons why they are using drugs. If, to improve health or to achieve other goals, we wish to change the drug-using behaviour of a precontemplator, the initial aim is to enable them to weigh up the pros and cons of their drug use and to recognise problems and to attribute them accurately.
Contemplation:
'I'm not happy, but I'm not sure what to do' It is in this stage, as much as in relapse, that contemplators frustrate helpers with urgent requests for help that are then not followed through. People may ask for a detox one day, relapse only a few days into the programme and come back a week later demanding an in-patient detox, but then fail to attend the assessment interview. At this stage clients will benefit from help in understanding their predicament, coming to a stable decision about what they want, and identifying strategies to achieve it. Action:
'I'm making changes' People spend the least time in action: the strategies either fail and they go back to thinking about change or they move on to maintenance. At this stage they need support, encouragement and help to develop a sense of perspective: it can be an emotionally fragile time. Maintenance
of behaviour change The (ex)drug user may feel as if they have made it and fail to consider ways of holding on to the changes they have made - or look for danger signs. The helping services are often inclined to discharge the people in maintenance and go back to dealing with the more demanding contemplators. When in maintenance people may benefit from help in identifying things that may go wrong, access to help in dealing with problems before they get out of hand and peer support from other people who are maintaining the same changes. |
| Factors that would indicate that short-term detox may be a successful treatment option | Factors that would indicate that short-term detox may not be a successful intervention |
|---|---|
| Strong motivation to become drug-free | Little motivation to become drug-free |
| Strong social support network | Poor social support network |
| Short history of opiate use | Long history of continuous opiate use |
| Low daily opiate use | High daily opiate use |
| High degree of control in opiate use | Low degree of control in opiate use |
| No other drugs being used | Poly drug use e.g. opiates, alcohol, benzodiazepines, etc. |
| Client requesting this treatment option of their own free will | Pressure from others to undergo treatment despite reluctance and anxiety |
| Client has a clear vision of what they are aiming for and of the benefits of being drug-free | Client only wants to be 'off opiates' and has not considered how to stay off |
| Availability of in-patient detox facility | Early or late pregnancy |
| Detox is part of a care plan which includes residential rehabilitation | Unavailability of in-patient detox facility |
| Client is smoking rather than injecting opiates | Compulsory detox following breach of prescribing contract |
Long-term
detoxification
Long-term detox regimes are seldom the optimum treatment option, to read an additional piece on long-term detox written for this online edition of the book, please click here.
See also Section 9: Methadone detoxification.
Decreasing
doses over more than one month
If methadone
treatment is justified, and short-term detox has been excluded, a minimum
definition of successful long-term detox would be:
| Factors that would indicate that long-term detox may be a successful treatment option | Factors that would indicate that long-term detox may not be a successful intervention |
|---|---|
| Client determination to become drug-free with a recognition that other factors (physical, social, psychological) need working on as a pre-condition to successful outcome of the detox | Client requests to become drug-free without recognition of the factors which may cause relapse |
| Failure of short-term detox: particularly if withdrawal symptoms precipitate relapse | Long-standing chaotic, drug-using lifestyle |
| Client request for long-term detox | Little motivation to become drug-free |
| Desire to address psychological issues during the detox period | No desire to address psychological issues that may contribute to relapse |
| Social support system in place or that can be rebuilt by the end of the detox | No prospect of a social support network developing during the detox |
| Need and desire to stop injecting behaviour in addition to detoxing | Desire to use injected drugs in a controlled way following detox |
| Support available from a specialist and/or counselling drug service | No support available from a specialist drug and/or counselling service |
Short-term maintenance
Stable
prescribing over 6 months or less
If methadone
treatment is justified, and short and long-term detox have been excluded
as options, a minimum definition of successful short-term maintenance
would be:
| Factors that would indicate that short-term maintenance may be a successful treatment option | Factors that would indicate that short-term maintenance may not be a successful intervention |
|---|---|
| Continued opiate use following past short and/or long-term detoxes | Long-term, chaotic drug-using history |
| Client request for short-term maintenance | Long-term injecting drug use |
| Opiate use following or during detox | Previous failure of detox following short-term maintenance |
| Prospect of social, physical and psychological factors improving given a period of drug-using stability | Client cannot envisage an end to their drug use |
| Client desire to work at creating pre-conditions to successful detox | Client feels dependent on injecting |
| Client has no dependence on injecting | Intravenous drug use which has, in the past, proved difficult to stop |
| Support available from a specialist drug service | No support available from a specialist drug service |
Long-term maintenance
Stable
doses over more than 6 months
If methadone
treatment is justified, and short and long-term detox and short-term maintenance
have been excluded as options, a minimum definition of successful long-term
maintenance would be:
| Factors that would indicate that long-term maintenance may be an appropriate intervention | Factors that would indicate that long-term maintenance may not be a appropriate intervention |
|---|---|
| Long-term history of drug use (particularly if injecting) | Short-term history of opiate use |
| Successful outcome of short-term maintenance but client still not ready to detox | Client has no desire to stabilise drug taking and poly drug use is continuing |
| Poor social support network | No previous histroy of methadone prescribing/detox |
| Client needs time to make considerable social or psychological changes in order to be able to successfully detox | Client is apparently able and willing to reduce methadone consumption |
| Support available from a specialist drug service | No support available from a specialist drug service |
Treatment setting
For more information on the services available see Section 1: The history of methadone prescribing - Services available in the UK today. This section looks at the areas to which each treatment setting is best and least suited in the context of making appropriate treatment choices.
Specialist
centre prescribing
Specialist
centres are usually most suited to managing:
They are usually less suited to helping:
GPs
prescribing alone
General
practitioners working without the support of a consultant with a special
interest in drugs or a community drug team are usually most suited to
managing people who:
They are less suited to prescribing for people who:
GPs
working with a community drug team
With specialist
support from clinicians who can have regular contact with the client over
and above their 5-10 minute weekly or fortnightly consultation, GPs can
take on and treat a much wider range of clients who have drug problems.
They are usually best suited for clients who:
They are usually less suited for people who:
Private
practice
Standards
in private practice probably vary more than in other types of service
for opiate users. Although all the questions below are legitimate questions
to ask of any service if you are referring to, or receiving a client from,
a private practice the following questions will help you ascertain the
type and quality of the service on offer:
In general, responsible, well-supported and informed private practitioners are best suited for prescribing to people who:
They are less suited to prescribing for people who:
Prescribing
injectable methadone
There are strong
arguments for and against the principle of prescribing injectable methadone
which are set out below.
| Arguments used for prescribing injectable methadone | Arguments used against prescribing injectable methadone |
|---|---|
| It is an incentive for people who may not attend a service offering only oral methadone | It is difficult to determine who will benefit from prescribed injectables as there is no clear research or guidelines |
| It is an opportunity to work on a harm reduction basis with people who might not otherwise be in treatment | People may have stabilised well (and with less harm) on oral medication |
| It is a realistic prescribing response to people who cannot stop injecting | If decisions are made on prescribers’ preferences – in the absence of guidelines – it will be a constant source of conflict |
| It may attract users into treatment earlier in their career | Clinicians can feel more like legal dealers and could attract more people than they could cope with into services |
| Giving clients a menu of drug choices can be empowering | Giving clients more choice can reduce the therapeutic value of services and leave clinicians feeling de-skilled |
| It can provide a way of stopping using intravenous heroin | It can cultivate or perpetuate injecting behaviour |
| It is a useful addition to an oral methadone prescription if occasional injecting behaviour persists | It can be seen as doctors approving of, and colluding with, dangerous behaviour |
| It could be cost effective if it prevents people from catching HIV | It may be seen by politicians and the media as 'being soft' on drugs and provide the springboard for a backlash that could threaten all prescribing |
| Injectables on the illicit market would be even more dangerous than methadone mixture |
If, having considered the pros and cons of prescribing injectables, a service has decided to offer injectable methadone as a treatment option, the indications and contra-indications are set out below.
| Factors that would indicate that prescribing injectable methadone may be an appropriate intervention | Factors that would indicate that prescribing injectable methadone may not be an appropriate intervention |
|---|---|
| Client continuing to inject illicit opiate drugs despite 6 months or more on over 80mg oral methadone daily | Client has no experience of oral methadone treatment |
| Long history of injecting | Short history of injecting |
| Client only injecting opiates in addition to their methadone | Client injecting many drugs in addition to taking their oral methadone |
| Client has long-term contact with the drug service | Client is a new referral or temporary resident |
Diamorphine
prescribing
As with the
prescription of injectables there are strong arguments for and against
the principle of prescribing the user's drug of choice which are set out
below.
| Arguments used for prescribing diamorphine (heroin) | Arguments used against prescribing diamorphine (heroin) |
|---|---|
| Heroin, especially if smoked, is less likely to cause accidental overdose than methadone | As opiate users who are more chaotic are attracted into services there is more likelihood that the prescribed drugs will just increase the total drug consumption |
| It would attract many of the people who are most at risk of HIV and other drug-related harm into contact with drug services | The number of people who would request treatment with heroin could overwhelm services |
| This is a catch 22 situation: while ‘the establishment’ opposes heroin prescribing, research funding is not available to prove the improved efficacy its proponents expect | There is little research to demonstrate that it would be an effective intervention |
| It is for clinicians to inform policy makers of the most effective forms of health care: reduced crime and HIV spread are easy positive outcomes to ‘sell’ to opponents of prescribing | As with prescribing injectables, prescribing heroin could provide the basis for a reactionary backlash against all prescribing and services for drug users |
The prescribing of diamorphine in the treatment of dependence is restricted to those doctors who have a Home Office licence to do so. If, having considered the pros and cons of prescribing diamorphine, a service has decided to offer it as a treatment option, the indications and contra-indications are set out below.
| Arguments used for prescribing diamorphine (heroin) | Arguments used against prescribing diamorphine (heroin) |
|---|---|
| Factors that may indicate that prescribing diamorphine would be an appropriate intervention | Factors that may indicate that prescribing diamorphine may not be an appropriate intervention |
| Heroin has been the drug of choice over a long period of time | Client also injects drugs other than heroin on a regular basis |
| Client has a long history of injecting | Client has a short history of injecting |
| Client has continued to inject heroin regularly in addition to taking oral methadone | Client occasionally injects opiates in addition to taking oral methadone |
| Client has continued injecting despite receiving 80mg or more of methadone for more than 6 months | Client has continued injecting on a low dose of oral methadone |
| Client has long-term contact with the service | Client is new to the service or a temporary resident |
| Additional risk from injecting practice due to HIV-positive status | Client is reluctant to engage with the service and a diamorphine prescription is unlikely to improve this |
| Client is already on a diamorphine prescription |
