Guidance for the use of substitute prescribing in the treatment of opioid dependence in primary care
This guidance is to aid primary care clinicians and others in the use of substitute medication for opioid dependence when prescribing for maintenance or detoxification. The use of substitute medication can be an important element in the treatment of opioid dependent patients and can help support patients on their own road to recovery.
It includes methadone, buprenorphine and other medications for use with opioid dependence, including codeine, heroin and slow-release oral morphine. It should be read in conjunction with Drug misuse and dependence: UK guidelines on clinical management (2007) and Guidance on methadone and buprenorphine for the management of opioid dependence (National Institute of Health and Clinical Excellence, NICE); Drug misuse: opioid detoxification (NICE); Naltrexone for the management of opioid dependence (NICE); Drug misuse: psychosocial interventions (NICE); Community-based interventions to reduce substance misuse among disadvantaged children and vulnerable young people (NICE); Guidance for the pharmacological management of substance misuse among young people (DH/2009); and Guidance for the pharmacological management of substance misuse among young people in secure environments (DH/2009).
Treatment of patients with drug problems in primary care has increased markedly over the last few years,1 and with the increase in polydrug use (use of more than one drug with or without alcohol), treatment has become more complex. The spectrum of drugs being used by young people is also changing, and the number of young people presenting with heroin problems is falling. However, heroin still remains the most common drug problem presenting for treatment (NTA Annual Report 2008–9). Therefore, there is still a need for practical evidence-based guidance about prescribing specifically aimed at primary care.
The focus of this guidance is on prescribing and it does not attempt to cover the whole spectrum of treatment options for problematic drug users in primary care. It recognises that prescribing is an important but small part of the treatment of people who use drugs.
This guidance incorporates the documents Guidance for the use of buprenorphine for the treatment of opioid dependence in primary care (RCGP/2004) and Guidance for the use of methadone for the treatment of opioid dependence in primary care (RCGP/2005) and the majority of this guidance will be about prescribing these two drugs. The guidance documents are part of an RCGP series which includes the Guidance for working with cocaine and crack users in primary care (currently being updated and incorporated into a new stimulant guidance) and Guidance for the prevention, testing, treatment and management of hepatitis C in primary care.
These documents are available online at www.smmgp.org.uk and www.rcgp.org.uk.
Who is the guidance for?
This guidance is aimed at all clinicians involved in the care of patients who use drugs and/or alcohol. It has been developed specifically to support the prescribing of substitute medication in primary care.
It constitutes flexible guidance to help practice and should not be used as a rigid set of protocols. It is good practice to record in the patient notes the reasons for decisions taken in individual cases, especially and in particular if they depart from this guidance or the national clinical guidelines.
Evidence-based guidance
Treatment for opioid dependence can be effective in primary care and there is a substantial body of evidence to support this. This guidance draws on British and international research in the clinical use of substitute medication. The evidence base for the effectiveness of methadone and buprenorphine in the treatment of opioid dependency is extensive and continues to grow. There is more limited evidence for the effectiveness of other substitute medications, including dihydrocodeine and slow-release morphine sulphate. This guidance concentrates mainly on the prescribing of oral methadone and buprenorphine and covers practical aspects of management, drawing on the experience and recommendations of experts in the field.
The bulk of the guidance will concentrate on the areas of methadone and buprenorphine prescribing where the evidence base is most extensive.
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