Drug Abuse

2 Guidelines for interventions in drug treatment – fact sheets (summary)

In the following the guidelines for the most relevant drug treatment interventions are
presented as short versions (fact sheets).
These versions are delivered also in German and French and will be disseminated to the
relevant national and European networks for drug treatment and also to the “best
practice” portal” of the EMCDDA.
Starting from the summary the detailed “Guidelines for drug treatment improvement”
are presented in chapter 6.

2.1 Brief intervention and brief therapies for illicit drug abuse

A Definition and objectives

1 Problem definition
Illicit drug abuse became a significant social and medical problem in the last decades. In
spite of numerous attempts to cut the consumption of drugs in Europe, the number of
drug abusers remains high as well as the number of urgent, chronic and disabling
medical conditions, related to drugs use. High prevalence of illicit drug use and drug
use disorders translates into high treatment demands which cannot be completely
satisfied by specialised addictions service institutions. This makes various primary care
institutions not specialised in addictions the first providers of medical help for those
individuals. Specific treatment settings in these institutions require implementation of
short-term, simple and cost-effective treatment models as brief interventions and
therapies.

2 Aims and objectives of Brief Interventions and Therapies
Brief interventions are short-term clinical practices comprising one ore few sessions and
aimed mostly to analyse the subject’s problem and motivate an individual to minimise
the harm from his substance abuse either directly during the intervention itself or
indirectly – by seeking additional substance abuse treatment.
Brief therapy is a process of systematic and focused assessment, client engagement, and
rapid implementation of actual change strategies. Brief therapies usually comprise more
sessions than brief interventions and also differ from brief interventions in that their
goal is to provide clients with tools to change basic attitudes and handle a variety of
underlying problems.

B Evidence base

1 Data availability
Currently there are numerous studies and meta-analytical reviews showing efficacy of
brief interventions and therapies for various categories of patients and types of
substance abuse, including poly-substance abuse. While reports regarding the
psychosocial interventions are mostly concentrated on cannabis and stimulants abuse,
literature on opiates abuse is dedicated prevalently to maintenance treatment.

2 Main findings
Research of efficacy of various psychotherapeutic techniques has shown mixed but
predominantly positive results for motivational enhancement therapy, high efficacy of
cognitive-behavioural therapy apart and in combination with MET, positive effects of
family and social therapies and appropriateness of implementation of pharmacological
interventions in certain cases.

C Recommendations

1 Motivational Enhancement Therapy
The evidence of effectiveness of motivational enhancement therapy is multiple and
diversified, mostly presented for cannabis and stimulants abuse and less – for opiates.
While certain studies report poor efficacy of MET, most of them show its high
effectiveness.
Motivational enhancement should include informational component and be based on the
following key points:
• Medical complications and related disorders, common for major types of substance
abuse affecting mental and physical functioning.
• Economic aspects of drug use – amounts spent for drugs and economic benefits of
abstinence.
• Social aspects of drug use – Social, family and vocational problems related to drug
use.
• Legal status of drug. Potential legal consequences of drug acquisition, use and
keeping as well as the legal outcomes of actions and emergency situations.
• Drug dependence and its acknowledgement by patient.

2 Cognitive-behavioural therapy
There are multiple evidences of high efficacy of cognitive-behavioural therapy for
substance abuse treatment. Most of the patients with substance abuse have certain
patterns of using the drugs. These may be certain situations, friends or companies or
certain life events. Consequently, there are some associative psychological “triggers”
that will obviously lead the patient into temptation to continue using the substance.
Analysis of these triggers, better understanding of psychological grounds of addiction
and development of coping skills based on it result in relatively higher abstinence rates
in the most of related studies.

3 Social and family therapy
Multiple studies of implementation of family- and/or social-based techniques have
shown their efficacy in coping of social deprivation and facilitating the treatment
process. Thus, it’s desirable that his or her family and friends were involved into the
treatment process.
The main goals and potential achievements of engaging the family and friends in the
treatment are:
• creating the psychologically comfortable circumstances for treatment;
• encouraging and inspiring the patient;
• preventing “occasional” relapses and
• increasing socialisation of the patient.

4 Pharmacological interventions
While pharmacological treatment is not a part of brief interventions, there may be
certain medical complications and related disorders, present or to be predicted. Thus,
the implementation of pharmacological interventions is obvious in some cases, both for
coping present medical problems and prevention of potential ones.
Pharmacological therapy may and must be used to improve general medical condition
of the patient as well.

5 Techniques to be chosen
All psychotherapeutic techniques described in the guidelines are effective. As the
clinical evidences show their complementary and cumulative effectiveness we
recommend their combined implementation.

6 Number of sessions and duration of treatment
While current evidences report effectiveness of single-session interventions, the
effectiveness of treatment is higher when multiple-session therapies are being used.

2.2 Enhancing motivation for change in drug treatment

A Definition & objectives

1 Problem definition
Motivational interviewing is a counselling style based on the following assumptions:
• Ambivalence about substance use (and change) is normal and constitutes an
important motivational obstacle in recovery.
• Ambivalence can be resolved by working with your client's intrinsic motivations and
values.
• The alliance between you and your client is a collaborative partnership to which you
each bring important expertise.
• An empathic, supportive, yet directive, counseling style provides conditions under
which change can occur. (Direct argument and aggressive confrontation may tend to
increase client defensiveness and reduce the likelihood of behavioral change.)
The Motivational Approach (MoAp) started off as a ‘transtheoretical’ model to deepen
understanding of the motivation for change among drug users and alcoholics.
The MoAp (and its clinical applications) covers the theme of the subject’s attitude,
his/her actions and reactions faced with the advantages and disadvantages of his/her
consumption.

2 Aims and objectives

The motivational approaches are based on the following assumptions about the nature
of motivation:
• Motivation is a key to change.
• Motivation is multidimensional.
• Motivation is dynamic and fluctuating.
• Motivation is influenced by social interactions.
• Motivation can be modified.
• Motivation is influenced by the clinician's style.
• The clinician's task is to elicit and enhance motivation.

B Evidence

1 General description of the current situation with regard to the available data
Motivational Interviewing is a well-known, scientifically tested method of counselling
clients developed by Miller and Rollnick and viewed as a useful intervention strategy in
the treatment of lifestyle problems and disease.
Although the demand for treatment of substance abuse continues to far exceed its
availability, changes in health care economics are placing greater pressure on providers
and their clients. Payers increasingly demand evidence that the services being provided
are not only effective, but cost-effective. Clinicians and programs are increasingly
challenged if they do not use research-supported, current methods. Public funding is
scarce, and third-party payers exert great pressure to provide treatment that is shorter,
less costly, and more effective.
In sum, clinicians are asked to do more with less

2 Short description of the main outcomes all studies
The incorporation of motivational approaches and interventions into treatment programs
may be a practical and efficacious response to many of these challenges. Recent
research (Brown and Miller, 1993; Kolden et al., 1997; McCaul and Svikis, 1991)
supports the integration of motivational interviewing modules into programs to reduce
attrition, to enhance client participation in treatment, and to increase the achievement
and maintenance of positive behavioral outcomes. Other studies have shown brief
interventions using motivational strategies and motivational interviewing to be more
effective than no treatment or being placed on a waiting list, and not inferior to some
types of more extensive care (Bien et al., 1993a, 1993b; Noonan and Moyers, 1997). A
review of the cost-effectiveness of treatments for alcohol use disorders concluded that
brief motivational counselling ranked among the most effective treatment modalities,
based on weighted evidence from rigorous clinical trials (Holder et al., 1991). Brief
motivational counselling was also the least costly--making it the most cost-effective
treatment modality of the 33 evaluated. Although cautioning that it was an
approximation that requires refinement, the same study found a negative correlation
between effectiveness and costs for the most traditional forms of treatment for alcohol
use disorders and highlighted a growing trend to favor effective outpatient care over less
effective or less studied--but far more expensive--inpatient, hospital-based, or
residential care (Holder et al., 1991).
As already noted, MI increases the effect of another treatment, but has not itself been
subjected to randomized study. Brief, motivation-enhancing treatment appears to have
the same effect as more extensive treatment. The studies, with the exception of Project
MATCH, have mainly recruited patients with a lower level of alcohol dependence.

C Recommendations

• MI is considered of great help for professionals of drug treatment. As motivation to
change is a predictor for adequate treatment, MI can be used for measuring
behaviour and aptitudes of patient toward treatment
• Mi is evidence based and its outcomes can be evaluated
• MI approach could be included in several treatment to increase their results
• MI should be used for high threshold treatment
• MI theoretical corpus should be known by the clinicians, even if not directly
involved in MI-based intervention
• MI should be intended as an early module of treatment to assess the readiness of
patient for residential and semi-residential treatment, psychosocial treatment
(residential or not) in prison milieu, psychosocial treatment in general

2.3 Interventions in blood-borne diseases

A Definition and objectives

1 Problem definition

Drug users and in particular injecting drug users (IDUs) are at risk of infections with
blood-borne diseases (BBD). These include especially Human Immunodeficiency Virus
(HIV) and hepatitis C (HCV), furthermore other hepatitis infections (HBV and HAV)
and tuberculosis, but other infections are rather common as well. In 2005, there were
around 3,500 new diagnoses of HIV in the European Union which were traced back to
injecting drug use (EMCDDA 2007a). The prevalence of HIV among IDUs differs
between the countries and may range from almost zero up to 40%, and the prevalence of
Hepatitis C (HCV) among IDUs ranges between 30% and 98% in the European Union
(EMCDDA 2007a).

HCV is a virus with potentially devastating hepatic complications, which will get
chronic in about 80% of the infected persons, while 20% will clear the virus (Wright
and Tompkins 2006). Young IDUs get infected with HCV still in the beginning of their
drug use career (EMCDDA 2007a).

Interventions in blood-borne diseases have been developed as an integral part of harm
reduction policy with the general aim to minimise harms and reduce risks related to
drug use. With respect to the prevention of blood-borne diseases main interventions are

• needle and syringe exchange services,
• drug consumption rooms,
• testing and vaccination and
• information and education.

2 Aims and objectives interventions in blood-borne diseases
In general, interventions in blood-borne diseases aim at reducing the transmission of
blood-borne infections in drug users. Priority aim of needle and syringe exchange
services is to reduce the sharing of equipment used in drug preparation and injection,
and consequently to reduce the transmission of HIV, hepatitis B and C, and other bloodborne
infections (Morissette, Cox et al. 2007; Ritter and Cameron 2006; Trimbos
instituut 2006). Main aim of testing and vaccination is provide access to testing for
hepatitis B and C and HIV, and for hepatitis immunisation in order to prevent bloodborne
diseases. Drug consumption rooms aim at reducing drug-related overdoses and
mortality, as well as to establish contact with difficult-to-reach clients and reduction of
public nuisance.

3 Client group served
• Needle exchange services provide easy access to all drug injectors.
• Pro-active testing for drug-related infectious diseases and vaccination is targeting at
all problem drug users that may practice sharing of injecting equipment or unsafe sex
(Trimbos instituut 2006).
• Specific target groups for testing, vaccination and related counselling are drug users
infected with HCV, new and young injectors, prisoners, drug addicted sex workers,
migrants etc.
• Target groups of drug consumption rooms are mainly high-risk drug users and
marginalized drug users.
• Information and education is targeted at drug users, their family, friends and the
wider community as well.

B Evidence base
Evidence of effectiveness for harm reduction measures in general is rather scarce,
compared to controlled medical research. Evidence base is methodological limited in
some points.

1 Evidence for needle and syringe exchange services
There is a strong evidence that the increased availability of needle and syringe provision
has contributed considerably to the control of HIV among drug injectors (Henderson,
Vlahov et al. 2003; Emmanuelli, Desenclos et al. 2005; Bravo, Royuela et al. 2007).
• The use of NSP is associated with clear benefits of decreased HIV risk behaviour
such as the decrease in sharing of injecting equipment.
• Needle exchange programmes seem to be less effective in preventing hepatitis C
infection.
• The slow decrease of HCV prevalence is attributed to the continued risk behaviour,
the infrequent use of NSP services, and the high risk profile of NSP clients (e.g. due
to cocaine injecting).
• There is some evidence that increased access to and utilisation of NSP services is
effective in reducing the drug use frequency, the transition from injecting to smoking,
and the enrolment and retention in drug treatment.

2 Evidence for testing and vaccination
• There is no clear evidence for the effectiveness of testing for blood-borne diseases
and counselling as single interventions. Current results suggest that testing for bloodborne
diseases might be effective in reducing HIV infections in terms of reduced risk
behaviour as a consequence of testing and related counselling.
• Testing and counselling may increase drug users enrolment in medical or drug
treatment (Trimbos instituut 2006; Samet, Walley et al. 2007).
• Vaccination against viral hepatitis B have been found to be strongly effective in
preventing hepatitis B infection after completing the primary course of 3
vaccinations.
• Vaccination against hepatitis B seems to have also a positive influence on the
hepatitis C serostatus.

3 Evidence for drug consumption rooms
• There is evidence that health status is stabilised and shows positive outcomes.
• (Re-) integration into drug help services does take place
• Consumption rooms do decrease public disturbances in the vicinity.
Research on information and education
• Information and education may help to reduce drug-related risks, mainly in
combination with other prevention strategies.

C Recommendations

1 Location
• In order to provide easy access to needle and syringe exchange services there should
be a comprehensive range of these services on local level, including rural areas.
• Outpatient drug services, drug treatment, health care centres, prisons, general
practitioners and further services are suitable locations for testing, counselling and
vaccination related to blood-borne diseases (Matic, Lazarus et al. 2008), as well as
for information and education.
• Since availability of rapid tests which reduce the time between testing and result, and
where testing and counselling is provided in settings convenient to clients voluntary
testing has increased markedly (WHO 2007).
• Targeted vaccination for injecting drug users seem to be most effective when done in
methadone maintenance programmes, at syringe exchange services or in other
community based settings that provide prevention of infectious diseases (Edlin,
Kresina et al. 2005).

2 Staffing and competencies
• Professional competencies in needle and syringe exchange as well as drug
consumption rooms include knowledge about injecting patterns and the provision of
harm reduction advice in terms of safer use.
• In specialised drug agencies or needle exchanges medical staff such as nurses should
be employed in order to treat minor infections or offer basis health checks.
• Health care professionals have to be offered necessary training in order to achieve an
understanding of the dynamics of drug use and drug addiction (Edlin, Kresina et al.
2005).
• Best practice is to ensure that suitable trained staff is available who have the
necessary skills and knowledge to advice clients about blood-borne viruses, testing
and vaccination, and further treatment.

3 Treatment environment
• Good practice is not to simply distribute sterile needles and syringes, but to combine
NSP with advice, risk counselling, primary healthcare for minor infections, overdose
prevention, and advice in housing, social welfare or legal issues. Drug users should
also be offered referrals to brief interventions and structured treatment.
• All services should provide information and advice about access to routine screening
for hepatitis B, C and HIV. Drug users who do not know they are infected cannot
take advantage of treatment, care and support, which can considerably improve their
health and quality of life.
• Testing for blood-borne diseases requires that professionals carefully prepare clients
for testing by providing information and advice on implications of testing for
hepatitis and HIV. Pre- and post-test counselling is an essential part of testing in
order to discuss with the client procedures of testing and further steps to be taken
after receiving the test result.
• Testing and related counselling should be voluntary and confidentiality.

4 Access
• In order to improve uptake of testing and vaccination services should ensure high and
easy access, and be designed as low-threshold, free of charge, and confidential
services.
• These open-access services have to be sensitive for different groups such as young
drug users, women, migrants etc. In general, all clients have to be ensured equal
access to testing for hepatitis and HIV, pre-and post-test counselling, hepatitis B
vaccination or other medical treatment for infectious diseases (National Treatment
Agency 2002).
• Needle exchange services and drug consumption rooms are to be made as accessible
as possible with no or low thresholds for eligibility. This kind of open-access service
includes drop-in service, no waiting list, minimal identification requirements and
informal relationships with staff.
• Vaccination for hepatitis B should be made available for all problem drug users.

5 Assessment
• Assessment is an important part of prevention related to testing for blood-borne
diseases as it will result in information which is essential for the care planning
process.
• In addition health checks and health information should be provided regularly to
clients. As well harm reduction messages on risk reduction and the transmission of
blood-borne infections (HIV, HBV, HCV) should be given ongoing. Drug users
should be given advice on how to prevent harmful behaviour.
• With regard to NSP services it is good practice to carry out a basic assessment of the
clients on their first visit. The initial assessment should cover information on the
drug use profile and injecting history, the health status, risk behaviour, and history of
referrals to treatment or other services.
• For testing and vaccination a broader risk assessments is required which includes
additional information on history of sharing injecting equipment, history of sexual
risk behaviour, history of imprisonment, alcohol use, previous testing for hepatitis
and HIV, and previous contact to health care for screening of blood-borne diseases.

6 Management
• It is of major importance important to implement a comprehensive approach by
providing sterile injecting equipment, and by offering condoms, harm reduction
advice, first aid and options for referrals to structured treatment (National Treatment
Agency 2002).
• Provider of dedicated needle exchange services should be able to recognise people
with physical or severe mental health problems, and to refer them to the most
appropriate treatment.
• In prison vaccination for hepatitis B and C, testing and counselling should have a
linkage to medical and drug treatment services.
• Drug users should be offered voluntary, confidential testing combined with clientcentred
pre- and post-test counselling. Counselling has to include an individualised
behavioural risk assessment.
• Main competences related to management include (Edlin, Kresina et al. 2005)
minimising barriers to participation in testing, vaccination and treatment by allowing
flexibility in adherence to appointment schedules and offering drop-in visits.
• In addition, clients have to be informed about appropriate treatments if needed and
on adverse effects of treatment. Access and adherence to antiretroviral therapy may
be improved if drug users are attending either a medication-based or a psychosocial
treatment programme (Altice, Springer et al. 2003; Kapadia, Vlahov et al. 2008).
both improved adherence to HIV treatment among drug users.

7 Pathways of care
• Integrated care pathways include that self-referrals and referrals from a variety of
services are accepted. Elements of care for drug users comprise a range of preventive
interventions covering assessment of risk behaviour, pre- and post-test counselling,
offers or referrals for testing for hepatitis and HIV and vaccination against hepatitis
A and B viruses.
• Care coordination requires that specialised services for drug users cooperate closely
with non-specialist services. Strong linkages with mental health services and the
provision psychiatric care are recommended as many IDUs suffer from co-morbid
psychiatric disorders.
• As needle exchange services and drug consumption rooms have been found to form a
gateway to further treatment clients have to be offered referral to a variety of
structured treatment programmes such as brief motivational interventions,
counselling, detoxification, substitution treatment with psychological care, and
rehabilitation.
• Clients requiring treatment for blood-borne infections or other health problems must
be referred to treatment where it is appropriate.
• If testing and vaccination are not provided on-site, local availability of HBV, HCV
and HIV testing should be mentioned and those clients who want to be tested should
be referred to other services such as GPs, health services or specialist AIDS services
etc.
• Clients with hepatitis C are at further risk of becoming infected with hepatitis B. For
this reason it is important to ensure that clients with hepatitis C who are not infected
with hepatitis B are offered HBV vaccination.
• Countries should increase access to antiviral treatment for drug injectors, and ensure
the same access and treatment standards regardless of gender, age, sexual orientation,
substance use, imprisonment or migratory status.
• Information and education should be available in all kind of setting for different
target groups.

8 Standards
• Standards include assuring quality and efficiency of the needle exchange service.
One approach to this task is to transform evaluation results into practice.
• For harm reduction services it is recommended to develop specific working standards
and methods – if not already existing – in order to ensure minimum quality
standards.
• Data should be collected in a standardised way by adopting the five key-indicators of
the EMCDDA to monitor harm reduction.
• For testing and management of infectious diseases a number of guidelines exist at
national (Canada, Scotland) and international level (WHO, UNAIDS). To address the
problem of undiagnosed HIV infection, WHO and UNAIDS issued a new guidance
on informed, voluntary HIV testing and counselling in the health facilities
(WHO/UNAIDS 2007).

9 Performance and outcome monitoring
• With respect to performance it is good practice to regard interventions to assess for,
prevent and manage blood-borne diseases as an integral part of treatment.
• Performance and outcome monitoring covers to collect routine information, monitor
and evaluate needle exchange services.
• Monitoring of performance includes to develop and implement adequate evaluation
protocols for the harm reduction services provided (Trimbos instituut 2006).

2.4 Maintenance treatment

A Definition and objectives

1 Problem definition
Treatment of drug dependence through prescription of a substitute drug (agonists and
antagonists) for which cross-dependence and cross-tolerance exists, with the goal to
reduce or eliminate the use of a particular substance, especially if it is illegal, or to
reduce harm from a particular method of administration, the attendant dangers for health
(e.g. from needle sharing), and the social consequences (Demand Reduction – A
Glossary of terms, UNDCP).

2 Aims and objectives
• Treatment of opioid dependence consists of pharmacological and psychosocial
interventions with the intention of reduction or cessation of opioid use and reduction
of harms associated with opioid use.
• The aims of agonist maintenance treatment include: reduction or cessation in illicit
opioids, reduction or cessation of injecting and other blood born virus risks,
reduction of overdose risk, reducing criminal activity and improving psychological
and physical health.
• Opioid agonist maintenance treatment is increasingly recognised to be the most
effective management strategy. Agonist maintenance treatment is indicated for all
patients who are opioid dependent and are able to give informed consent and for
whom specific contra-indications do not exist.
• In recent years, the value of psychosocial treatment has also been demonstrated,
particularly when used in combination with pharmacotherapy, be it in the context of
opioid agonist maintenance therapy, opioid withdrawal or relapse prevention.

B Evidence base
• Methadone maintenance treatment is known to reduce drug-craving as well as
morbidity associated with opioid dependence. Furthermore treatment outcome in
methadone maintenance seems to be improved with increased dosages and the
provision of adequate psychosocial support.
• Cochrane reviews found the efficacy of buprenorphine maintenance treatment to be
comparable to methadone maintenance with advantages in some treatment settings,
in alternate day dosing, better safety profile, and milder withdrawal syndrome.
• Slow-release morphine might prove as an alternative to methadone and
buprenorphine substitution treatment.
• A rather new development is the prescription of heroin to chronic, treatmentresistance,
heroin-dependent patients in some countries of Europe. Heroin-assisted
substitution treatment might be an effective option for chronically addicted patients
for whom other treatments have failed. However, it requires considerable resources
as patients usually inject three times per day under supervised conditions at treatment
centres, which need to have long operating hours as well as high demands on
personnel and security.
• Codeine (Dihydrocodeine = DHC) is an analgesic agent, which is available for
maintenance treatment in a few European countries. Due to a shorter bioavailability
compared to other opioid agonists, codeine treatment might require closer monitoring
as it has to be administered more than daily.
• The buprenorphine/naloxone combination compound contains buprenorphine, a
partial agonist at the μ-opioid receptor, as well as naloxone, an antagonist at the μ-
opioid receptor. While there is only a limited number of comparative studies
available, buprenorphine/naloxone seems to be equally effective as buprenorphine
alone, while buprenorphine/naloxone might be less likely to be misused
intravenously.

C Recommendations

1 Treatment environment
• Pharmacological treatment programmes and interventions should be integrated or
linked with other medical and social services and interventions to ensure possibility
of transition of patients to other treatment modalities as their treatment needs change.
• Men and women can be treated in the same facility, providing that culturally
appropriate and gender specific needs.

2 Choice of treatment and dosing
• Methadone should be considered the optimal treatment with buprenorphine reserved
for patients in whom methadone is not wanted, inappropriate or ineffective, of for
whom it is anticipated that buprenorphine will improve the quality of life in other
ways. Buprenorphine might be a safer option but there is not yet sufficient evidence
to advocate its value over methadone on this basis.
• Buprenorphine is effective for the treatment of opioid dependence and where
available should be offered as alternative to methadone for opioid dependent
patients. Reasons for use of buprenorphine include: previous response to
buprenorphine or lack of response to methadone; short duration of action of
methadone in the past; interaction between methadone and other medications taken;
specific adverse effects of methadone; treatment availability; and patient preference.
• Patients being treated with agonist maintenance pharmacotherapy, clinicians should
be encouraged to use adequate methadone doses, 60-120mg.
• Patients being treated with agonist pharmacotherapy, clinicians should be
encouraged to use buprenorphine doses in the range of 8-24 mg.
• To maximise recruitment into, and retention in agonist maintenance treatment
programmes, policies and regulations should allow flexible dosing structures,
without restriction on dose levels and the duration of treatment.
• Methadone and buprenorphine are not suitable for people with decompensate liver
disease (for example cirrhosis with jaundice and ascites) as they may precipitate
hepatic encephalopathy. They may also worsen acute asthma and other causes of
respiratory insufficiency.
• Other contra-indications listed by the manufacturers are: severe respiratory
depression, acute alcoholism, head injury, raised intracranial pressure, ulcerative
colitis, biliary colic, renal colic.

3 Diagnosis and assessment
• The diagnosis of opioid dependence and other medical conditions should be made by
trained health care personnel. If the diagnosis leads to agonist maintenance treatment
it should be done by a trained physician. Social conditions should be determined by
social workers or staff trained in social conditions.
• Patient history and self reported drug use are generally reliable, but for making a
diagnosis of drug dependence but these should be correlated with other methods of
assessment including and history from family and friends, the clinical examination
and relevant investigations.
• A detailed individual assessment of treatment needs includes: past treatment
experiences; medical and psychiatric history; living conditions; legal issues;
occupational situation; and social and cultural factors, that may influence drug use.
• Patients should have proof of identity before commencing treatment with controlled
medicines. The patient must be able to give informed consent before treatment.
• Voluntary testing should be offered as part of an individual assessment, accompanied
by pre- and post- test counselling.
• All patients who have not been exposed to hepatitis B should be vaccinated against
it, with consideration given to accelerated vaccination schedule to improve
completion rates.
• Voluntary pregnancy testing should be offered as part of an individual assessment.

4 Management
• In some cases, a simple and short-term intervention such as assistance with opioid
withdrawal will result in an immediate and lasting improvement.
• However, in many others, treatment will have to be regarded as a long-term, or even
a life-time process, with the occasional relapse. The aim of treatment services in such
instances is not only to reduce or cease opioid use, but also to improve their health or
social functioning gradually, to encourage them to try again, or to avoid some of the
more serious consequences of drug use.

2.5 Psychosocial interventions

A Definition and objectives

1 Problem definition
Psychosocial treatment is an expanding intervention for the treatment of drug
dependence. There is not a single method, but a set of different forms of psychosocial
interventions offered to people. There are a vast number of psychosocial methods
available for drug dependence, even if the methods on one hand might look very
different; they have some common aspects:
• Focus on the misuse
• The treatment is structured around the patient/treatment
• Sufficient amount of time for treatment
• Focus on both the misuse and the psychological factors (Fridell 2007)
The psychosocial methods can be divided into supportive methods, re-educative
methods and re-constructive or psychodynamic oriented methods (Berglund et al. 2001
p. 12).

2 Aims and objectives

The idea of psychosocial treatment is that the therapist and the client should cooperate.
Cooperation is to avoid direct confrontation and instead base the interaction on trust and
understanding. A very important part of the treatment is that the patient should be active
and learn about his or her specific situation through self-exploration and data gathering.
This data is a ground for discussion in the sessions with the therapist. The role of the
therapist is to share knowledge about different factors that may be important reasons for
drug- or alcohol misuse. The aim is that the client should learn about those reasons and
be able to understand why he or she has problems and what to do about it. An important
part of the therapy is that problematic drug users become more aware of the negative
consequences of the dependence and instead develop a larger self-control, become
calmer and more active when it comes to choices of life. Different forms of therapy
includes role play and concrete practices when it comes to different social areas and
skills, such as not being late to appointments, buying food and contact with the social
governments.
Inpatient drug and alcohol misuses treatment programmes are designed for drug and
alcohol misuse disorders. The aim is to support the addict to get free from his/her drug
use and to create a social context.
The residential treatment takes place in many various settings and includes both longterm
and short-term placements in residential treatment facilities, prisons and other
criminal justice facilities, involuntary institutions and halfway houses.

B Evidence base
• A great deal of the material in this overview comes from the meta analysis the
Swedish council of technology assessment in health care (SBU 2001; Berglund et al.
2001) which was an initiative to establish an evidence-based practice platform.
• An important finding is that psychosocial treatment per se has effects on drug
dependence, but no individual form of psychosocial treatment is superior to another
(see e.g. Socialstyrelsen 2007; Shulte et al. 2006; Berglund 2003).

C Recommendations

1 Counselling
Counselling can effectively be used in different settings and combinations in reducing
drug use and enhance treatment retention.
Structured counselling can lead to moderation of cannabis and cocaine use.

2 Cognitive behavioural therapy
• CBT can be provided in many different settings e.g. privately founded care, through
and within the primary care system, inpatient/residential care, etc.
• Treatment for drug misuse should always involve a psychosocial component.
• Homework compliance can be used in a CBT to improve outcomes.
• Psychosocial treatment has effects on drug dependence, but no individual form of
psychosocial treatment is superior to another. Family therapy dynamic forms of
therapy and CBT are more effective when it comes to continued participation in
treatment.

3 Community reinforcement approach
• The community reinforcement approach can be carried out in inpatient programmes
and in combination with vouchers, but also in outpatient treatment contexts.
• Community Reinforcement Approach (CRA) in combination with vouchers as
positive reinforcers can reduce cocaine use.

4 Group therapy
• It is important that the individuals in the group take ownership of the problem.
• If all members in the group are in a similar situation it might be easier to discuss the
problems and get social support.
• Group therapy is particularly effective when it comes to treating depression.

5 Motivational interviewing
• Care givers must try to understand the logical reactions, based on previous
experiences, that the patient makes, and from there point out the difference in the
experienced situation and how the patient would like it to be.
• Methods of Motivational Interviewing (MI) have shown effectiveness particularly for
those with initial low motivation and less severe dependency.
• Motivational Interviewing (MI) can be used to effectively enhance motivation,
retention rate, and reduction of use.
• Motivational Interviewing can help even as a single-session intervention.

6 Relapse prevention therapy
• Highly structured relapse prevention seems to be more effective than less structured
interventions, with regard to cocaine users with co-morbid depression.
• People who have relapsed should be offered an urgent assessment. Immediate access
to treatment should be considered.

7 Contingency management
• The staff needs to be trained in “appropriate near-patient testing methods and in the
delivery of contingency management”.
• Vouchers and prizes as reinforcers can be used on the short-term to reduce cocaine
use.
• The magnitude and immediacy of reinforcement may be critical to the efficacy of
vouchers.
• Contingency management in conjunction with pharmacotherapy may increase
treatment retention and compliance for opiate dependence.

8 The 12 step programme
• The 12 step programme can be used in both residential and outpatient care.
• The 12 step programme can be used as a control condition for other treatment
interventions.

9 Case management
Generalist case management might be appropriate for enhancing treatment participation
and retention. It can be combined with other interventions or with more intensive or
specialised models of case management.
Intensive case management is most effective for extremely problematic substance
abusers. It is also effective for treatment of chronic public inebriates and dual diagnosed
individuals.
A strong perspective on case management might help to enhance treatment participation
and retention among persons with little or no motivations for change.

10 Inpatient and residential treatment
• The same interventions as is available in community settings should be available in
residential and inpatient settings.
• All the different psychosocial treatments should be carried out by professional staff.
• Short-term and other less intense programmes are better adapted for less problematic
clients.

2.6 Detoxification

A Definition and objectives

1 Problem definition
Detoxification denotes a set of interventions aimed at managing acute intoxication and
withdrawal, so that the effects of drugs are eliminated from dependent users in a safe
and effective manner. Detoxification is often used as a first step in the patient's drug
treatment career, and has the primary aim of providing symptomatic relief from
withdrawal while physical dependence on drugs is eliminated. A range of settings have
been used for detoxification, including specialist in-patient drug dependence units,
psychiatric hospital wards, residential rehabilitation programmes, community-based
settings and prisons. Different settings may suit different users in different
circumstances or suit the same user at different stages of their career. It should also be
considered that detoxification is often not successful, particularly at the first attempt.
Opioids, cocaine and benzodiazepines are the main problem drugs addressed by
detoxification programmes. The European Monitoring Centre for Drugs and Drug
Addiction (EMCDDA) has estimated an average prevalence of problem opioid use of
between four and five cases per 1,000 of the population aged 15-64 in Europe and
Norway. The EMCDDA further estimates that this rate suggests that 1.5 million people
experience problem opioid use in Europe. Similar estimates for cocaine are not
available for Europe as a whole but available for only three countries, Italy, Spain and
the United Kingdom. Here the estimates from these countries are between three and six
problem users of cocaine users per 1,000 adults aged 15-64.
Benzodiazepines are infrequently the primary drug reported by those coming for
treatment but are widely used by problem drug users. For example, around 25% of
treatment clients recorded by the UK Drug Treatment Outcomes Research Study
(DTORS) reported benzodiazepine use (Home Office 2007).

2 Aims and objectives
The aim of detoxification is to eliminate or reduce the severity of withdrawal symptoms
in a safe and effective manner when the physically dependent user stops taking drugs
(WHO 2006). Detoxification programmes should include the following elements:
• An assessment of the psychological, psychiatric, social and physical status of patients
using defined assessment schedules.
• An assessment of the degree of misuse and/or dependence on relevant classes of
drugs, notably opioids, stimulants, alcohol and benzodiazepines.
• To define a programme of care and to develop a care plan to carry out a risk
assessment.
• To prescribe medication safely and effectively to achieve withdrawal from
psychoactive drugs.
• To identify risk behaviours and offer appropriate counselling to minimise harm.
• To assess the longer-term treatment needs of patients and provide an appropriate
discharge care plan.
• To assess and refer patients to other treatments as appropriate.
• To monitor and evaluate the efficacy and effectiveness of prescribing interventions.
• To provide referral to other services as appropriate (NTA).

B Evidence base - managing opioid detoxification

1 Methadone
The most extensively tested medication for opioid detoxification is the long-acting
opioid agonist methadone. Detoxification with tapered doses of methadone shows fewer
withdrawal symptoms and fewer drop-outs than placebo. Methadone has been found to
have a better adverse-event profile, particularly in relation to hypotension, compared to
clonidine and better detoxification completion rates when compared to lofexidine.
Extant studies do not indicate a difference between buprenorphine and methadone for
detoxification completion rates but there is no data available to compare abstinence
outcomes.

2 Buprenorphine
Available studies suggest that the efficacy of buprenorphine with regard to treatment
retention, illicit drug use and suppression of withdrawal symptoms compares to that of
methadone, although detoxification with buprenorphine can be conducted more quickly
than with methadone. There are also no significant differences in completion of
withdrawal.

3 Dihydrocodeine
Limited evidence suggests that dihydrocodeine is less likely to lead to abstinence and
treatment completion than buprenorphine in detoxification.

4 Clonidine and lofexedine
A recent major review found there was no evidence that clonidine is more effective than
lofexedine for managing opioid withdrawal and, because of its greater side effect
profile, suggested that clonidine is not used in routine practice. Lofexedine has
comparable clinical efficacy to clonidine but has a slight advantage of fewer side
effects, and in particular less postural hypotension.

5 Buprenorphine and naloxone
It has been demonstrated that rapid detoxification with buprenorphine-naloxone is safe
and well-tolerated by patients with positive outcomes for treatment retention,
detoxification completion and abstinence rates in treatment.

6 Other medications for symptomatic treatment
Opiate detoxification when properly conducted usually can be conducted without
significant patient discomfort. However patients receiving adequate detoxification doses
may still complain of withdrawal symptoms such as diarrhoea or insomnia and which
can be treated with adjunctive medications. However, there is no systematic evidence
that any of the medications work to improve outcomes.

7 Psychosocial interventions in combination with detoxification
The majority of the studies examining psychosocial interventions combined with
detoxification have featured contingency management techniques during community
detoxification. Contingency management in these studies usually begun after
stabilisation and continued through the detoxification process until treatment was
completed. Patients receiving contingency management were more likely to be abstinent
at the end of treatment and to complete treatment than those patients who did not
receive it. This outcome was found with both short-term and longer term detoxification
programmes.

8 Managing benzodiazepine withdrawal
The limited evidence available supports a stepped care approach to benzodiazepine
detoxification. Those with low dose benzodiazepine dependence normally do not
require special treatment. During early abstinence these patients should be given support
and reassurance that the withdrawal effects will soon reduce or disappear. If minimal
intervention fails then supervised gradual withdrawal can be initiated. The treatment
aim for benzodiazepine detoxification should be to prescribe a reducing regimen for a
limited period. Adjunctive therapies such as structured psychosocial interventions,
counselling, support groups and relaxation may be helpful to alter negative cognitions
related to medication cessation, provide patient education and provide cognitive and
behavioural techniques for anxiety reduction and sleep enhancement during withdrawal.

9 Managing stimulant detoxification
Antidepressant drugs such as fluoxetine have been used to manage the depressive
episodes associated with stimulant withdrawal. There is no evidence that
antidepressants have any effect on the withdrawal effects of stimulants regardless of the
type of antidepressant used.

C Recommendations
Due to the limited evidence base for cocaine and benzodiazepine detoxification, the
following recommendations largely concern detoxification from opioids.

1 Access to care
Detoxification should be a readily available option for people who are dependent and
have expressed an informed and appropriate choice to become abstinent. Information
should be made available on criteria for access to detoxification programme. The
material should describe who the service is intended for and what are the expected
waiting times for entry.

2 Programme duration
Most opioid detoxification treatments with methadone use a linear reduction schedule
with regular equal dose decrements from an individually tailored starting dose to zero.
Treatment programmes typically last 10-28 days. While research suggests that longer
periods in treatment with a critical period of 28 days may predict better outcomes, there
is little evidence to support more protracted detoxification schedules which may lead to
residual symptoms continuing after treatment has finished.

3 Setting
Inpatient opioid detoxification should provide 24-hour supervision, observation and
support for patients who are intoxicated or experiencing withdrawal.
Community-based programmes should be offered to those considering detoxification
except for those:
• Have not benefited from earlier community-based detoxification.
• Need medical and/or nursing care because of significant co-morbid physical or
mental health problems.
• Require complex polydrug detoxification.
• Are experiencing significant social problems that limit to the benefits of community
detoxification (NICE 2007).
In patient care should normally only be considered for people who need a high level of
medical and/or nursing support for significant and severe co-morbid physical or mental
health problems or need concurrent detoxification from alcohol and other drugs which
need a high level of medical and nursing expertise (NICE 2007).
Residential detoxification should normally only be considered for those who have
significant co-morbid physical or mental health problems or need sequential
detoxification from alcohol and opioids or concurrent detoxification from opioids and
benzodiazepines. It may also be considered for those who have less severe levels of
dependence e.g. those who have only recently started their drug use, or would benefit
from the residential setting during and after detoxification.

4 Assessment
Those presenting for opioid detoxification should be assessed to establish the presence
and severity of opioid dependence, as well as misuse of and/or dependence on other
substances including alcohol, benzodiazepines and stimulants.
Assessment should include:
• Urinalysis to aid confirmation of the use of opioids and other drug use/ dependence.
• A clinical assessment of the signs of withdrawal if present.
• The taking of a history of drug and alcohol use and previous treatment episodes.
• A review of current and previous physical and mental health problems.
• Risk assessment for self-harm, loss of opioid tolerance and the misuse of drugs or
alcohol as a response to opioid withdrawal symptoms.
• An assessment of present social and personal circumstances.
• A consideration of the impact of drug misuse on family members and any
dependents.
• Development of strategies to avoid risk of relapse.

5 Staffing Competencies
Community detoxification should be co-ordinated by competent primary or specialist
practitioners. Residential and in-patient detoxification programmes should be staffed by
multidisciplinary teams with an emphasis on medical and nursing staff.

2.7 Treatment in Criminal Justice System

A Definition and objectives

At any day more than half a million people are imprisoned in 27 EU countries. The
prevalence of drug dependence in individual countries varies from 10 to 48 % among
male prisoners and 30 to 60 % in female prisoners. Therefore, questions of their health
have to be considered of crucial importance from public health perspective.
The aim of this guideline is identification and depiction of the evidence-based best
practices in drug treatment in prisons. It is focusing on illicit drug users and especially
on problematic drug users who are subjects to prevention, treatment and harm reduction
programmes offered in the framework of the Criminal Justice System. The term
“prison” is used for all places of detention no matter if the person is in police detention,
pre-trial/remand prison, or prison for sentenced inmates.

B Evidence base

To sum up outcomes of studies presented in the guideline, it can be said that majority of
services which are offered in a community can be used after necessary modifications in
prison settings, including drug-free treatment, treatment of infectious diseases,
methadone maintenance programmes (MMP) and harm reduction measures. A number
of studies confirmed that both MMT and harm reduction strategies do not produce any
serious unintended side-effects that have been feared of or anticipated by prison
administration. Nevertheless, specificity of prison environment has to be taken into
consideration, prisoners’ needs should be respected and their social capital utilised in
treatment process. Assuring continuity of care after release is of outmost significance.

C Recommendations

1 Testing for infectious diseases
Testing for infectious diseases and vaccination is a very important tool to promote and
secure health in prison. Vaccination for Hepatitis B and A is highly recommended for
prisoners.

2 Drug testing
Even though drug testing may play important role in implementing prison drug policy,
mandatory drug testing should be carefully applied as it is rather expensive and can be
counterproductive, due to an increasing tensions between prisoners and staff.

3 Treatment of infectious diseases
Prison authorities should ensure that prisoners receive care, support and treatment
equivalent to that available for people living within the community, including Anti-
Retroviral Therapy (ART). Treating HIV-infected prisoners with ART will not only
have an effect on the individual’s health but also an impact on public health outside the
prison. It has been shown that treatment for HCV is also feasible and successful in
prison.

4 Abstinence oriented programmes
Abstinence-oriented programmes should be offered for all who are likely to accept
drug-free approach. However, it is important for prison systems to develop particular
strategies for prison drug treatment (e.g. drug-free wings) rather than simply just
reflecting those strategies that exist in the community. Generally there is a growing
consensus that drug treatment programmes in prison can be effective if they are based
on the needs and resources of prisoners and are of sufficient length and quality.

5 Detoxification
There is no sufficient literature on this issue to formulate recommendations.
In general, detoxification with adequate medication is rarely available in prisons
throughout Europe.

6 Substitution treatment
Substitution treatment in prisons is highly recommended. It can reduce sharing injection
equipment, results in decreasing opiate use, diminishing drug-related violence in prisons
as well as crime following release. In several studies negative side-effects often feared
by prison staff, such as a black market for methadone, were reported not to have
occurred. A sufficiently high dosage (more than 60 mg) also seems to be important for
an increase in the retention rate. Offenders participating in substitution treatment in
prisons are more likely to continue treatment after release and their prison readmission
rates are clearly lower.

7 Needle exchange
Prison needle exchange programmes (PNEP) should be offered for those who do not
accept drug-free treatment or substitution treatment. A number of reviews gathered
evidence for the effectiveness of PNEP, so a further discussion on the implementation is
needed. Evidence indicates that the implementation of such measures is possible and
feasible with no security problems and no problems in an increase of injecting drug use
or drug use in general.

8 Provision of bleach
There is no evidence of effectiveness of decontamination with bleach in the community
and therefore it seems rather unlikely to be effective in prison. Disinfection as a means
of HIV prevention is of varying efficiency, and is regarded only as a secondary strategy
to syringe exchange programmes.

9 Provision of condoms
Condoms are likely to be the most effective method for preventing sexually transmitted
infections. No serious negative effects of condom provision in prisons have been found,
and the provision of condoms seems feasible in a wide range of prison settings.

10 Case management
Available data do not show compelling evidence of its effectiveness. Nevertheless,
some positive effects are noted including reduced drug use and relapse rates, increased
treatment participation and retention and less violation of judicial conditions.

11 Clients’ needs
Programmes offered in prison should be based on the needs and individual resources of
clients and their goals, whether this be maintenance or abstinence, and provide adequate
support in this regard. The needs of women must be treated specifically.

12 Continuity of care
Sustainability of successful drug treatment in prison requires a continuum of care that
takes a drug-using inmate from the correctional environment to the re-integrative
processes of community-based treatment. Facilitation of personal links between a
prisoner and potential after release treatment is highly recommended.

13 Staff competences
Prisoners have the right to receive state of the art medical care. To secure this right staff
should get professional training including not only medical or therapeutic issues, but
also attitudes towards drug using prisoners.

2.8 Treatment of substance abuse clients with co-occurring disorders

A Definition and objectives

1 Problem definition
• Co-occurring disorders (COD) refer to occurrence of both substance use (abuse or
dependence) and mental disorder.
• A diagnosis of co-occurring disorders is confirmed when at least one disorder of each
type has established independently of the other.

2 Aims and objectives
• The co-occurrence of a severe mental illness and a substance use disorder is highly
prevalent; about half of the patients in psychiatric and substance abuse treatment
suffer from both disorders.
• Clients with COD represent a major public health problem which predicts poor
treatment outcome related to medication compliance, physical co-morbidities, poor
health, social dysfunction, and poor quality of life.
• Clients with co-occurring disorders also have poorer outcomes such as higher rates
of relapse, hospitalisation, depression, and suicide risk.
• The rates of mental disorders increase as the number of substance use disorders
increases and complicating further treatment.

B Evidence base
• Current research indicates that at least three types of interventions are probably
effective for drug abusing clients with dual diagnosis: group counselling,
contingency management, and long-term residential treatment.
• Group counselling effects are consistent across several types of groups, suggesting a
non-specific effect based on common elements such as cognitive-behavioural
intervention, education, skills building, and peer support.
• Contingency management interventions tend to be narrowly focused on substance
use, but results appear to show an improvement of other factors such as housing and
employment. Improvements achieved by contingency management are probably not
related to motivation and other cognitive factors, which may be an advantage for
clients with COD.
• Long-term residential substance abuse treatment is effective in reducing drug use and
crime.
• Other interventions have shown minor effects on substance use outcomes but often
lead to improvements in other areas. For example intensive case management is
effective to engaging and retaining clients with COD in outpatient treatment.
Assertive community treatment is a promising approach to treat mental disorders as
it reduces re-hospitalisation and improves the quality of life.

C Recommendations

1 Guidelines for core elements of interventions
The following principles reflect the evidence and experience of models how best to
provide COD treatment in substance abuse treatment agencies:
• Providing access: A “no wrong door” policy should be implemented at the initial
contact with the service system to the full range of clients with COD.
• Completing screening and full assessment: The aims of assessment are to obtain a
comprehensive picture of needs and problems through an ongoing process. Screening
is a formal process of testing to determine whether a client does or does not warrant
further attention at the current time in regard to a particular disorder and, in this
context, the possibility of a co-occurring substance use or mental disorder. A basic
assessment consists of gathering information that will provide evidence of COD and
mental and substance use disorder diagnoses; assess problem areas, disabilities, and
strengths; assess readiness for change; and gather data to guide decisions regarding
the necessary level of care.
• Adopting a multi-problem, tailored and phased approached viewpoint: As people
with COD generally have an array of mental health, medical, substance abuse,
family, and social problems treatment services should be able to integrate care to
meet the multidimensional problems. Clients are progressing empirically though
identified phases or stages including engagement, stabilisation, treatment, and
aftercare or continuing care. The use of these phases enables to develop and use
effective, stage-appropriate treatment protocols. As co-occurring disorders arise in a
context of personal and social problems, approaches that address specific life
problems early in treatment are important. Services for clients with more serious
mental disorders should be tailored to individual needs and functioning.
• Providing an appropriate level of care – matching to treatment: A framework should
be established for fostering consultation, collaboration, and integration among drug
abuse and mental health treatment systems and providers to deliver appropriate care
to every client with COD (related to the combination and severity of problems).
• Ensuring continuity of care: As recovery for COD is a long-term process the
recovery perspective generates as principles: A treatment plan should be developed
that provides continuity of care over time. It is important to reinforce long-term
participation in these continuous care settings.

2 Guidelines for interventions and programme elements
Both substance use and mental disorder interventions are targeted to the management or
resolution of acute symptoms, ongoing treatment, relapse prevention, or rehabilitation
of a disability associated with one or more disorders, whether that disorder is mental or
associated with substance use.
• Maintaining therapeutic alliance: Guidelines for addressing therapeutic alliance
should be part of all interventions.
• Motivational Interviewing: Several well-developed and successful strategies for
motivational enhancement from the substance abuse field should being adapted for
COD.
• Contingency Management (reinforcement approaches): Approaches with
reinforcement as Contingency Management (CM) maintain that the form or
frequency of behaviour can be altered through the introduction of a planned and
organised system of positive and negative consequences.
• Cognitive-behavioural Therapy (CBT): Cognitive-behavioural Therapy (CBT) uses
the client’s cognitive distortions as the basis for prescribing activities to promote
change.
• Relapse Prevention (RP): Relapse Prevention (RP) has proven to be a particularly
useful substance abuse treatment strategy and it appears adaptable to clients with
COD.
• Ensure proper medication: The use of proper medication is an essential programme
element, helping clients to stabilise and control their symptoms, thereby increasing
their receptivity to other treatment.
• Outpatient programmes with key elements of Assertive Community Treatment
(ACT) or Community Reinforcement Approach (CRA): Outpatient treatment
programmes serve the greatest number of clients and should use the best available
treatment models to reach the greatest possible number of persons with COD.
Assertive Community Treatment (ACT) and Community reinforcement Approach
(CRA) employ extensive outreach activities, active and continuing engagement with
clients, and a high intensity of services. These approaches should be introduced in
Europe.
• Intensive Case Management (ICM): The goals of ICM are to engage individuals in a
trusting relationship, assist in meeting their basic needs (e.g. housing), and help them
access and use brokered services in the community. The fundamental element of
ICM is a low caseload per case manager, which translates into more intensive and
consistent services for each client.
• Modifications in residential settings: The principles and methods of residential
models (see special guideline to psychosocial interventions) have to be adapted to the
circumstances of the client, making the following alterations: increased flexibility,
more individualised treatment, and reduced intensity. A number of continuing care
(aftercare) options should be made available for clients with COD who are leaving
treatment.
• Aid for self help approach: These approaches apply a broad spectrum of personal
responsibility and peer support principles, often employing 12-Step methods that
provide a planned regimen of change.
• Promotion of coordination and continuity of care: Continuity of care refers to
coordination of care as clients move across different service systems and is
characterised by consistency among primary treatment activities and ancillary
services, seamless transitions across levels of care, and coordination of present with
past treatment episodes.
• Implementation of integrated interventions: Integrated interventions are specific
treatment strategies or therapeutic techniques in which interventions for both
disorders are combined in a single session or interaction, or in a series of interactions
or multiple sessions. Integrated interventions can include a wide range of techniques.

2.9 Treatment for stimulant use disorders

A Definition and objectives

1 Problem definition
Stimulant users include users of powder cocaine, crack cocaine and amphetamines. At
present there is not a complete treatment package that has been demonstrated to achieve
abstinence and prevent relapse for stimulant users. Consequently treatment for stimulant
users should include an initial phase of seeking the cessation of stimulant use, a second
phase involving relapse prevention and a third phase that seeks to maintain abstinence
through the learning of new skills to achieve this. However stimulant users, like other
problem drug users, may experience a range of medical problems or emergencies,
psychiatric problems or crises or various social, legal or employment problems which
may need the involvement of a range of services beyond drug treatment services.
Estimates of the extent of problem cocaine use in Europe are available for only three
countries, Italy, Spain and the United Kingdom. Here the estimates from these countries
are between three and six problem users of cocaine users per 1,000 adults aged 15-64.
Using its Treatment Demand Indicator data the EMCDDA has recorded cocaine as a
secondary problem drug for around 15% of all outpatient clients. Most countries in
Europe report a low proportion of cocaine users among all clients in drug treatment,
although the Netherlands and Spain have reported high proportions of 35% and 42%
respectively in 2004.

2 Aims and objectives
Treatment for stimulant users aims to achieve cessation of stimulant use, prevent relapse
and maintain abstinence through the learning of new skills to achieve this. Programmes
to treat stimulant misuse should include the following:
• An assessment of the psychological, psychiatric, social and physical status of patients
using defined assessment schedules.
• An assessment of the degree of misuse and/or dependence on relevant classes of
drugs, notably opioids, stimulants, alcohol and benzodiazepines.
• To define a programme of care and to develop a care plan to carry out a risk
assessment.
• To prescribe medication safely and effectively to achieve withdrawal from
psychoactive drugs.
• To identify risk behaviours and offer appropriate counselling to minimise harm.
• To assess the longer-term treatment needs of patients and provide an appropriate
discharge care plan.
• To assess and refer patients to other treatments as appropriate.
• To monitor and evaluate the efficacy and effectiveness of prescribing interventions.
• To provide referral to other services as appropriate.

B Evidence base

1 The available data
Patients with a cocaine or other stimulant use problem generally do not require
treatment in an inpatient setting as withdrawal syndromes are not severe or medically
complex. The limited evidence available suggests that most patients can be effectively
treated in intensive outpatient programmes. Studies have demonstrated that patients
offered rapid entry to treatment are more likely to attend initial appointments.

2 Prescribing for stimulant dependence
Antidepressants (notably desipramine and fluoxetine), dopamine agonists (notably
amantamide, bromocriptine and pergolide, and anticonvulsants (notably carbamazepine
and phenytoin) and mood stabilisers (notably lithium) have been trialled for the
treatment of cocaine dependence and there is no evidence to support their effectiveness.
Other medications, including modafinil, are currently being trialled.

3 Maintenance therapy
There is no evidence to support the use of stimulant maintenance therapy for stimulant
users. Studies have shown that providing methadone or buprenorphine maintenance
therapies for those with opiate dependence problems but also use cocaine, can lead to
reductions in cocaine use, an effect enhanced when used in combination with
contingency management techniques or disulfiram.

4 Psychosocial Interventions

5 Contingency management
Research evidence has found that contingency management is acceptable to patients,
contributes to patient retention and is effective in achieving initial abstinence.

6 Psychotherapeutic interventions including Cognitive-Behavioural Therapy
The results of studies of cognitive-behavioural therapies (CBT) with cocaine
dependence are inconsistent. Whilst one study found better long-term outcomes for
CBT than clinical management, other studies found no long- or short-term positive
effects for CBT. A recent RCT on brief cognitive behavioural interventions for
amphetamine users found that the number of treatment sessions had a significant effect
on the level of depression, and also abstinence rates were better in those attending at
least twice or more (Baker et al. 2005).

7 Relapse prevention and skills training
Several studies have failed to demonstrate greater efficacy of skills training or relapse
prevention over control approaches. Those patients with CST in addition to their
treatment programme experienced shorter and less severe relapses.

8 Motivational interviewing
Studies have shown that motivational interviewing may help patients with lower initial
motivation or ambivalence about treatment.

C Recommendations
There is a limited evidence base to guide treatment practice.

1 Access to care
Treatment should be a readily available option for people who have a stimulant problem
and have expressed an informed and appropriate choice to seek help. Information
should be made available on criteria for access to the treatment programme. The
material should describe who the service is intended for and what are the expected
waiting times for entry. Services should respond quickly and positively to initial
telephone enquiries and schedule appointments with minimal delay.

2 Programme Duration
The limited data available and clinical experience suggest that treatment programmes of
12-24 weeks in duration are commonly used for treating stimulant misusers. Studies
have found that the benefits of treatment among those in residential therapeutic
communities were concentrated among those who had stayed for at least three months.

3 Setting
The majority of stimulant users are likely to be seen in an out-patient setting, while
crisis management services may be needed for some users with an acute crisis. Patients
with multiple needs are more likely to benefit from intensive residential rehabilitation
which can be provided on a day-care basis.

4 Assessment
Those presenting for problematic stimulant use should be assessed to establish the
presence and severity of stimulant use, as well as misuse of and/or dependence on other
substances including alcohol. Assessment should be brief and focussed to avoid
becoming a barrier to treatment for stimulant users who want quick access to treatment.
Assessment should include:
• Urinalysis to aid confirmation of the use of stimulants and other drug use.
• The taking of a history of drug and alcohol use and previous treatment episodes.
• A review of current and previous physical and mental health problems.
• Risk assessment for self-harm.
• An assessment of present social and personal circumstances.
• A consideration of the impact of drug misuse on family members and any
dependents.
• Offer screening for hepatitis, HIV and sexually transmitted infections.
• Development of strategies to avoid risk of relapse.

6 Staffing Competencies
Staff involved in treating stimulant users should include nursing and medical staff,
social workers and care managers, psychologists and counsellors. Staff should be
trained in crisis management, specific counselling techniques and trained in mental
health issues.

2.10 Pregnancy and parenting in drug treatment

A Definition and objectives
• Substance abuse in pregnancy leads to consequences for the pregnant women, the
foetus and neonate in two ways: direct consequences due to substance use or abuse
as well as indirect outcomes resulting from the influence of living environment.
• Abstinence of opioids during pregnancy is difficult to maintain, but it presents the
ideal goal. Opioid maintenance therapy is the recommended treatment approach
during pregnancy and there appear to be few developmental or other effects on these
children in the long term.
• Poly-substance dependence and misuse of either licit or illicit substances lead to the
manifestation of a neonatal abstinence syndrome (NAS). The incidence of NAS in
neonates of opioid-dependent women is between 70% and 95%. NAS is
characterised by a variety of symptoms of variable intensity: sneezing, yawning,
hyperactive Moro reflex, sleeping after feeding, tremor, increased muscle tone,
myoclonic jerks, high pitched crying, excoriation, mottling, generalised seizure,
convulsions, fever, sweating, nasal stuffiness, tachypnea, retractions, nasal flaring,
poor feeding, excessive sucking, vomiting, diarrhoea, failure to thrive, excessive
irritability and, in very rare cases, convulsions.

B Evidence base
• Methadone in the context of comprehensive care is associated with more prenatal
care, increased foetal growth and less neonatal morbidity and mortality than
continued opioid abuse.
• Although methadone is clearly beneficial, it has been estimated that 60–87% of the
infants born to methadone-maintained mothers need treatment for NAS.
• Buprenorphine, approved in Europe since 1999 for the treatment of non-pregnant
opioid-dependent adults, may reduce the incidence and/or severity of NAS.
Buprenorphine demonstrates safety for mother and child, and shows effectiveness in
the treatment of opioid-dependence during pregnancy, although limited controlled
data are published so far.
• NAS may start any time during the first postnatal 24 hours up to 10 days, depending
on the medication administered during pregnancy or substance abused. The
withdrawal syndrome of heroin in the neonate sets in during the first 24 hours. With
methadone, the symptoms don not develop until after 48 hours. An even later onset
of withdrawal symptoms can be observed if the neonate was exposed to
buprenorphine, benzodiazepines or barbiturates in utero.
• It is not easy to determine which substances are the most beneficial in the treatment
of NAS, as there are currently no double-blind controlled studies available. The
effectiveness and safety of opiate treatment in neonates has been dealt with in a
recent Cochrane Review, which concludes that opiates represent the preferred initial
therapy for NAS, particularly for infants of mothers taking opioids during pregnancy.

C Recommendations

1 Maintenance therapy during pregnancy
• Methadone maintenance therapy is the gold standard pharmacotherapy. There is a
growing body of evidence regarding the use of buprenorphine while it was shown
effective in recent studies.
• Methadone is the gold standard treatment during pregnancy because there is more
evidence on the safety of methadone than buprenorphine in pregnancy. If women are
being well treated with buprenorphine then the risks of transferring to an alternative
treatment should be weighed against the certainty of methadone effects.
• Women who are in treatment should be encouraged to remain in treatment during
pregnancy.

2 Management of NAS
• Clinicians should use opioids or barbiturates for the management of NAS. Untreated
NAS can cause considerable distress to infants and in rare cases seizures. Cochrane
reviews indicate that opioids and barbiturates are more effective than placebo or
benzodiazepines. Of the two, opioids are probably more effective than barbiturates.

3 Access to treatment
• Every maternity unit should ensure that it provides a service that is accessible to and
non-judgemental of pregnant problem drug users and able to offer high quality care
aimed at minimising the impact of the mother’s drug use on the pregnancy and the
baby.
• Every maternity unit should have effective links with primary health care, social
work children and family teams and addiction services that can enable it to contribute
to safeguarding the longer-term interests of the baby.

4 Breastfeeding
• For women on methadone and buprenorphine, breast feeding is safe and should not
be precluded. Breastfeeding is not recommended if the mother is infected with HIV
or Hepatitis C virus. If an opioid-maintained mother wants to breastfeed her child,
this should be encouraged: it can be helpful for mother-child bonding, and it might
decrease NAS symptoms.

5 Blood borne viruses
• Pregnant female drug users should be routinely tested, with their informed consent,
for HIV, hepatitis B and hepatitis C, and appropriate clinical management provided
including hepatitis B immunisation for all babies of drug injectors. Transmission of
these viruses from an infected mother to her baby can occur during pregnancy or
birth or through breastfeeding.
• Elective Caesarean section appears substantially to reduce the rate of transmission.

2.11 Systemic aspects of drug treatment

A Definition and objectives
Across Europe enormous resources are committed for drug treatment. Their share in
overall drug policy expenditures vary form about 50% in Ireland to around 90% in
Portugal, Hungary and France. However, distribution of these funds among different
treatment modalities does not seem to be related to any pragmatic evidence-based
standards. E.g. in UK and Luxembourg about 90% of all treatment expenditures goes
for out-patients interventions while in France residential services consume 60% and in
Poland over 80% of all drug treatment funds. This huge variation cannot only be
attributed to different epidemiological situation. It is more likely that contrasting
financial priorities reflects vested interests, petrified power structures and treatment
traditions of individual countries.
Therefore an urgent need exists to elaborate special recommendations for drug
treatment to become a system of inter-related interventions that offer the optimal
balance between individual treatment needs and individual outcomes. In addition to
individual level perspective, a public health outcomes should be achieved including
satisfactory access to treatment, high coverage rates, optimal cost/benefit rates of
different treatment modalities, low relapse rates as well as diminished morbidity and
mortality associated with drug use.
In addition, social indicators should be considered such as welfare expenditures and
crime rates.

B Evidence
There are very few studies available on systemic aspects of treatment. Research focus is
more on characterizing treatment populations, individual treatment approaches,
problems associated with drug use at the individual level, and even to a lesser extent on
individual assessment and case co-ordination. Nevertheless, there are some studies
available focusing on systemic aspects of the one hand as well as guidelines provided
by international organizations as well national guidelines that may serve as a
background for a set recommendations.

C Recommendations

1 Evidence based treatment policy
Drug treatment policy should be formulated and adopted by relevant authorities at the
national, regional and local levels. Treatment policy should be integrated within general
drug policy on the one hand, and with general treatment policy, on the other. Instead of
promoting dominant treatment approaches, drug treatment policy should encourage
development of drug treatment system(s) at the national and local levels composed of
coordinated network of open-access and structured services. Treatment policy should be
based on evidence of effectiveness and cost-effectiveness rather than on existing
traditions and convictions.

2 Comprehensive needs assessment
Needs assessment at the national and local level should precede decisions aiming at
expanding or ameliorating existing treatment system. Needs assessment should be
methodologically sound but politically – participatory including commitment from local
authorities as well participation of current and potential clients. Comprehensive
assessment includes not only epidemiological data but also expectations of potential
users of a treatment system as well as available treatment resources with focus on
human resources, their competence, attitudes and commitments.

3 Implementation of a differentiated treatment system
Treatment system should offer a range of services and be tailored to a range of specific
needs of heterogeneous target groups. System must offer services which are accessible,
of different intensity, requiring varying client’s commitment. Clients’ needs are very
likely to go beyond health needs and to include social, legal and economic dimensions.
Therefore, treatment system should spread across different sectors: health, social
welfare, criminal justice, employment et cetera.

4 Care oordination
Coordination between different elements of the system including inter-sectoral
coordination is crucial. It will take into account systemic coordination i.e. appropriate
distribution of tasks and resources as well as individual case coordination. To this end,
effective communication structures should be established to secure efficient referrals
and continuity of care.

5 Evaluation and research
Research on drug treatment as a system should be among top priorities among EU
research programmes as well as national and regional research funding schemes. Drug
treatment system studies do not need to be expensive. Simple approaches work and
bring useful information on treatment demand, needs assessment, adequacy of
treatment, feasibility, effectiveness and even cost-effectiveness. New approaches need
to be invented to study continuity of treatment, level of system integration and
population impact of treatment.

6 Tailoring to specific needs
Population impact of drug treatment system should be continuously studied. This
includes proportion of population in-need that receives treatment (coverage rates),
morbidity and mortality due to drug-specific causes such as HIV, hepatitis, overdose,
social marginalisation (e.g. homelessness, unemployment), crime rates

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