Drug Addiction NICE Guidelines

DRAFT FOR CONSULTATION

Drug misuse: psychosocial management of
drug misuse

NICE guideline
Draft for consultation, January 2007

If you wish to comment on this version of the guideline, please be aware that
all the supporting information and evidence is contained in the full version.

Drug misuse: psychosocial NICE guideline DRAFT (January 2007) Page 1 of
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Contents
Introduction ......................................................................................................3
Person-centred care ........................................................................................4
Key priorities for implementation......................................................................5
1 Guidance ..................................................................................................7
1.1 General principles of care..................................................................7
1.2 Identification and recognition of drug misuse...................................10
1.3 Brief and low-intensity interventions ................................................10
1.4 Structured psychosocial interventions .............................................12
1.5 Residential, prison and inpatient care..............................................15
2 Notes on the scope of the guidance .......................................................17
3 Implementation in the NHS .....................................................................18
4 Research recommendations ...................................................................19
5 Other versions of this guideline...............................................................21
5.1 Full guideline ...................................................................................21
5.2 Quick reference guide......................................................................21
5.3 Understanding NICE guidance: information for patients and carers 21
6 Related NICE guidance ..........................................................................21
7 Updating the guideline ............................................................................22
Appendix A: The Guideline Development Group ...........................................23
Appendix B: The Guideline Review Panel .....................................................26
Appendix C: Contingency management – key elements in the delivery of a
programme ....................................................................................................27

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Introduction
This guideline makes recommendations for people who misuse opiates,
stimulants and cannabis in the healthcare and criminal justice systems. The
patterns of use vary for these drugs, with cannabis the most likely to be used
in the UK. This guideline will not deal with recreational drug use, although
opportunistic brief interventions for drug users not in formal drug treatment are
included. Cocaine is the next most commonly used drug in the UK, followed
by other stimulants such as amphetamine. Opiates, although presenting the
most significant health problem are, in comparison with cannabis and
stimulants, less frequently used. It should be noted that a large proportion of
people who misuse drugs are poly-drug users and do not limit their use to one
particular drug.

Opiate misuse is often characterised as a long-term, chronic relapsing
condition with periods of remission and relapse, so although abstinence may
be one of a range of long-term goals of treatment, it is not always achieved.
The patterns for cannabis and stimulant misuse vary considerably and are not
as well understood.

Pharmacological approaches are the primary treatment option for opiate
misuse, with psychosocial interventions providing an important element of the
overall treatment package. Pharmacological treatments for stimulant and
cannabis misuse are not well developed and therefore psychosocial
interventions represent the mainstay of effective treatment.

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Person-centred care
This guideline offers best-practice advice on the care of people who misuse
drugs.

Treatment and care should take into account service users’ needs and
preferences. People who misuse drugs should have the opportunity to make
informed decisions about their care and treatment, in partnership with their
healthcare professionals. If service users do not have the capacity to make
decisions, healthcare professionals should follow the Department of Health
guidelines – ‘Reference guide to consent for examination or treatment’ (2001)
(available from www.dh.gov.uk). From April 2007, healthcare professionals
will need to follow a code of practice accompanying the Mental Capacity Act
(summary available from www.dca.gov.uk/menincap/bill-summary.htm).

Good communication between healthcare professionals and service users is
essential. It should be supported by evidence-based written information
tailored to the service user’s needs. Treatment and care, and the information
service users are given about it, should be culturally appropriate. It should
also be accessible to people with additional needs, such as those with
physical, sensory or learning disabilities, and to people who do not speak or
read English.

Carers and relatives should have the opportunity to be involved in decisions
about the service user’s care and treatment, unless the service user
specifically excludes them.

Carers and relatives should also be given the information and support they
need.

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Key priorities for implementation
Provision of information and advice
• Healthcare professionals should, on initial contact with services and at
subsequent formal reviews, involve people who misuse drugs in decision-
making about their treatment and care. This should include options for
abstinence-oriented, maintenance-oriented and harm-reduction
interventions. [1.1.1.1]

Brief interventions
• For people in limited contact with services (for example, attendance at a
needle and syringe exchange) and if concerns about drug misuse are
identified by the service user or healthcare professional, opportunistic brief
interventions should be offered. These interventions should:
− be of a maximum duration of two sessions (normally ranging between 10
and 45 minutes)
− offer appropriate information and feedback in an empathic manner.
[1.3.1.1]

Self-help
• Healthcare professionals should routinely provide information about self-
help groups for people who misuse drugs. The most established of such
groups are those based on 12-step principles, for example, Narcotics
Anonymous and Cocaine Anonymous. [1.3.2.1]

Contingency management
• Drug misuse services should introduce contingency management
programmes to reduce illicit drug use and/or promote engagement in
services for people undergoing methadone maintenance treatment.
[1.4.1.1]

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• Contingency management aimed at reducing illicit drug use for people
undergoing methadone maintenance treatment or for people who primarily
misuse stimulants should adhere to the following principles.
− The scheme should provide incentives (usually privileges or vouchers)
contingent on each presentation of a drug-negative screen (for example,
free from cocaine or non-prescribed opiates).
− The frequency of screening should be set at three tests per week for the
first 3 weeks, two tests per week for the next 3 weeks and once weekly
thereafter until stability is achieved.
− If vouchers are used they should have monetary values in the region of
£5 which increase in value with each additional, continuous period of
abstinence.
− Urinalysis is the preferred method of testing but consideration may be
given to the use of oral fluids. [1.4.1.3]

Family-based interventions
• Family or couples-based interventions should be considered for people
who are in close contact with a partner, family member or carer and
continue to use illicit drugs when in opiate agonist maintenance treatment.
These interventions should:
− focus on the service user’s drug misuse
− consist of at least 12 weekly sessions
− be based on cognitive behavioural principles. [1.4.2.1]

Interventions to improve physical healthcare
• For all people at risk of physical health problems (including transmittable
diseases) resulting from their drug misuse, the use of modest material
incentives (for example, shopping vouchers, up to £10 in value) should be
considered to encourage specified harm-reduction objectives. Incentives
should be delivered on a one-off basis or over a limited duration, contingent
on compliance with or completion of each intervention, in particular:
− hepatitis B/C and HIV testing
− hepatitis B immunisation schedule
− TB test. [1.4.4.1]
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1 Guidance
The following guidance is based on the best available evidence. The full
guideline ([add hyperlink]) gives details of the methods and the evidence used
to develop the guidance (see section 5 for details).

1.1 General principles of care

1.1.1 General recommendations for the care of all people who
misuse drugs
1.1.1.1 Healthcare professionals should, on initial contact with services and
at subsequent formal reviews, involve people who misuse drugs in
decision-making about their treatment and care. This should
include options for abstinence-oriented, maintenance-oriented and
harm-reduction interventions.

1.1.1.2 Healthcare professionals should ensure, when assessing and
developing a care plan, that the following are considered:

• a full assessment of medical, psychological, social and
occupational needs
• the history of drug use
• the experience of previous treatment (if any)
• the clarification of the service user’s goals in relation to his or her
drug use
• the service user’s treatment preferences.

1.1.1.3 Healthcare professionals who are responsible for the delivery and
monitoring of an agreed care plan should ensure that:

• an appropriate therapeutic relationship is established and
sustained
• the service user is helped to identify situations or states in which
he or she is vulnerable to drug use and to consider alternative
coping strategies

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• full access to a wide range of appropriate healthcare services is
available to all service users
• maintaining engagement with services remains a major focus of
the care plan
• effective liaison and collaboration with other care providers is
maintained.

1.1.1.4 Healthcare professionals should provide during routine contacts
and opportunistically (for example at a needle and syringe
exchange) information and advice to all people who misuse drugs
about reducing their exposure to the transmission of blood-borne
viruses including the reduction of sexual and injection risk
behaviours, and if appropriate offer testing for such viruses.

1.1.1.5 Healthcare professionals should not routinely provide separate
group-based psychoeducational interventions for people who
misuse drugs designed specifically to provide information and
advice about reducing exposure to blood-borne viruses, including
the reduction of sexual and injection risk behaviours.

1.1.1.6 Healthcare professionals should be aware that service users are at
high risk of losing contact with services at points of transition
between services and should ensure that clear and agreed plans
are in place to ensure effective transfer through services. This
could be achieved through the use of agreed care plans, identified
professionals and appropriate assessment systems.

1.1.1.7 All interventions for people who misuse drugs should be delivered
by trained staff who are competent in delivering the intervention
and are in receipt of appropriate supervision.

1.1.2 General recommendations for the support of families and
carers
1.1.2.1 Healthcare professionals should explore with people who misuse
drugs whether to involve their families and carers in assessment

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and treatment plans, ensuring that the service user’s right to
confidentiality is respected.

1.1.2.2 When in contact with family members or carers of people who
misuse drugs, all healthcare professionals should:

• enquire about family and carer concerns in relation to the impact
of drug misuse on their lives and relationships
• provide verbal and written information and education on the
impact of drug misuse on service users, families and carers.

1.1.2.3 Healthcare professionals should make themselves accessible to
family members and carers if appropriate. The needs of family
members and carers should be taken into account, including:

• the welfare of dependent children, siblings and vulnerable adults
• a regular assessment of carers’ personal, social and mental
health needs.

1.1.2.4 Families and carers should be informed of, and if appropriate
offered, services to specifically address their needs. These may
include:

• the use of guided self-help
• support groups – for example, self-help groups solely for families
and carers, which are focused on addressing carers’ needs.

1.1.2.5 If families and carers have been offered but not benefited from
guided self-help and/or support groups and continue to have
significant family problems, consideration should be given to
providing formal psychosocial interventions. These should:

• provide information and education about drug misuse
• help identify sources of drug-misuse-related stress
• explore and promote effective coping behaviours
• normally consist of at least five weekly sessions.

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1.2 Identification and recognition of drug misuse

1.2.1 Routine clinical questions
1.2.1.1 Healthcare professionals in mental health and criminal justice
settings where drug misuse is known to be prevalent should
routinely ask service users questions about recent legal and illicit
drug use including whether they have used drugs and:

• of what type and method of administration
• in what quantity and
• how frequently.

1.2.1.2 In settings such as primary care, general hospitals and accident
and emergency departments, enquiry about recent drug use should
be considered in presentations in which drug misuse may be
implicated, for example in:

• acute chest pain in a young person
• acute psychosis
• mood and sleep disorders.

1.2.2 Biological tests
1.2.2.1 Healthcare professionals should use biological testing (for example,
urine or oral fluid samples) as part of a comprehensive assessment
of drug use, but they should not rely on it as the sole method of
diagnosis and assessment.

1.3 Brief and low-intensity interventions
Brief interventions of up to two sessions conducted opportunistically among
people who misuse drugs and are not in formal drug treatment can be used in
a variety of different settings for people not in contact with drug treatment
services (for example in mental health, general health and social care,
accident and emergency) and for people with minimal contact with drug
treatment services (needle and syringe exchanges, community pharmacies).

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1.3.1 Brief interventions
1.3.1.1 For people in limited contact with services (for example, attendance
at a needle and syringe exchange) and if concerns about drug
misuse are identified by the service user or healthcare professional,
opportunistic brief interventions should be offered. These
interventions should:

• be of a maximum duration of two sessions (normally ranging
between 10 and 45 minutes)
• offer appropriate information and feedback in an empathic
manner.

1.3.1.2 For people not in contact with drug misuse services and if concerns
about drug misuse are identified by the service user or healthcare
professional, opportunistic brief interventions should be offered.
These interventions should:

• be of a maximum duration of two sessions (normally ranging
between 10 and 45 minutes)
• offer appropriate information and feedback in an empathic
manner.

1.3.2 Self-help
1.3.2.1 Healthcare professionals should routinely provide information about
self-help groups for people who misuse drugs. The most
established of such groups are those based on 12-step principles,
for example, Narcotics Anonymous and Cocaine Anonymous.

1.3.2.2 If a person who misuses drugs has expressed an interest in
attending 12-step self-help groups, healthcare professionals should
consider facilitating the person’s initial contact with the groups.

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1.4 Structured psychosocial interventions

1.4.1 Contingency management
Contingency management provides a system of incentives to change
behaviour. The emphasis in contingency management is on offering
incentives for behaviours such as abstinence or reduction in illicit drug use,
and engagement or participation in health promoting interventions.

For example, incentives are provided when a service user submits a biological
sample (for example, urine or oral fluid) that is negative for the specified
drugs. For contingency management to be effective, healthcare professionals
need to discuss with the service user which incentives are to be used so that
they are perceived as genuinely reinforcing by those participating in the
programme. Incentives need to be provided consistently, and as immediately
as possible after submission of the sample. Limited increases in the value of
incentives with successive periods of abstinence also appears to be effective.

A variety of incentives have proved effective in contingency management
programmes including privileges (for example, take-home methadone doses),
vouchers (which can be exchanged for goods or services of the service user’s
choice) and monetary incentives.

For more information please see appendix C.

1.4.1.1 Drug misuse services should introduce contingency management
programmes to reduce illicit drug use and/or promote engagement
in services for people undergoing methadone maintenance
treatment.

1.4.1.2 Drug misuse services should introduce contingency management
programmes to reduce illicit drug use, promote abstinence and/or
promote engagement in services for people who primarily misuse
stimulants.

1.4.1.3 Contingency management aimed at reducing illicit drug use for
people undergoing methadone maintenance treatment or for
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people who primarily misuse stimulants should adhere to the
following principles.

• The scheme should provide incentives (usually privileges or
vouchers) contingent on each presentation of a drug-negative
screen (for example, free from cocaine or non-prescribed
opiates).
• The frequency of screening should be set at three tests per
week for the first 3 weeks, two tests per week for the next 3
weeks and once weekly thereafter until stability is achieved.
• If vouchers are used they should have monetary values in the
region of £5 and increase in value with each additional,
continuous period of abstinence.
• Urinalysis is the preferred method of testing but consideration
may be given to the use of oral fluids.

1.4.1.4 When delivering contingency management programmes,
healthcare professionals should ensure that:

• the target goal is agreed in collaboration with the service user
• the service user fully understands the relationship between the
desired behaviour change and the incentive schedule
• incentives are individualised, with choice available so that the
incentive is perceived as such by the service user (not just the
healthcare professional) and supports a healthy/drug-free
lifestyle.

1.4.2 Family-based interventions
1.4.2.1 Family or couples-based interventions should be considered for
people who are in close contact with a partner, family member or
carer and continue to use illicit drugs when in opiate agonist
maintenance treatment. These interventions should:

• focus on the service user’s drug misuse
• consist of at least 12 weekly sessions
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• be based on cognitive behavioural principles.

1.4.2.2 Behavioural couples therapy should be considered for people who
are in close contact with a partner, family member or carer and who
misuse cocaine, heroin and/or have completed opiate
detoxification. These interventions should:

• focus on the service user’s drug misuse
• be based on cognitive behavioural principles.

1.4.3 Cognitive behavioural therapy
1.4.3.1 Healthcare professionals should consider the use of individual
cognitive behavioural therapy for people who present with
problematic cannabis use. The cognitive behavioural therapy
should be focused on drug use and should:

• focus on the identification of situations or states in which the
service user is most vulnerable to drug use
• focus on skills training to help the service user to cope in such
situations or states.

1.4.3.2 Cognitive behavioural therapy should not be routinely provided for
people presenting for treatment of stimulant misuse or for people
receiving methadone maintenance treatment.

1.4.3.3 Cognitive behavioural therapy should be considered for the
treatment of comorbid disorders such as anxiety and depression (in
line with existing NICE guidance for the treatment of these
disorders) for people who misuse cannabis, stimulants and opiates.

1.4.4 Interventions to improve physical healthcare
1.4.4.1 For all people at risk of physical health problems (including
transmittable diseases) resulting from their drug misuse, the use of
modest material incentives (for example, shopping vouchers up to
33


£10 in value) should be considered to encourage specified harm-
reduction objectives. Incentives should be delivered on a one-off
basis or over a limited duration, contingent on compliance with or
completion of each intervention, in particular:

• hepatitis B/C and HIV testing
• hepatitis B immunisation schedule
• TB test.

1.4.5 Interventions to improve compliance with naltrexone
Naltrexone is an opiate antagonist that eliminates the positive experiences
associated with opiate use. Naltrexone may have some benefit in sustaining
abstinence among people who have completed opiate detoxification, and
psychosocial interventions can improve compliance with naltrexone.

1.4.5.1 For people on naltrexone maintenance treatment to prevent relapse
to opiate dependence, healthcare professionals should consider
the use of the following psychosocial interventions:

• for all service users – contingency management
• for people in contact with a partner, family member, or carer –
family or couples-based interventions.

These interventions should be based on the same principles as
those used for people on methadone maintenance treatment.

1.5 Residential, prison and inpatient care

1.5.1 Inpatient and residential settings
1.5.1.1 Psychosocial interventions in inpatient settings should consist of
the same range of interventions offered in community settings and
would normally include contingency management, family
interventions, cognitive behavioural interventions and
encouragement to participate in self-help programmes. Treatment
in inpatient settings should normally be reserved for those who
require a high level of medical and nursing support because of
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comorbid physical or severe psychiatric problems, and may be
associated with a detoxification programme.

1.5.1.2 Residential treatment may be considered for people who have
comorbid physical, psychiatric, or social (for example, housing
instability) problems and/or have not benefited from previous
community-based treatment. Treatment is often associated with a
detoxification programme and may be followed by a period of
community-based aftercare.

1.5.1.3 People who have relapsed to opiate use during or after treatment in
an inpatient or residential setting should be offered an urgent
assessment and considered for prompt access to alternative
community or inpatient support including maintenance treatment.

1.5.2 Criminal justice system
1.5.2.1 For people who misuse drugs, access to and choice of treatment
should be the same whether they participate in treatment
voluntarily or are legally required to do so.

1.5.3 Prison
1.5.3.1 For people in prison with drug misuse problems, treatment options
offered should be broadly equivalent to those available in the
community. Healthcare professionals should take into account
additional considerations specific to the prison setting, which
include:

• length of sentence or remand, and the possibility of unplanned
release
• risk of self-harm, death and post-release overdose.

1.5.3.2 People in prison with significant drug misuse problems should be
offered access, if appropriate, to a therapeutic community
developed for the specific purpose of treating drug misuse within
the prison environment.

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1.5.3.3 For people who have made an informed and appropriate decision
to receive drug treatment after release from prison, community-
based residential treatment should be arranged as part of an
overall care plan.

2 Notes on the scope of the guidance
NICE guidelines are developed in accordance with a scope that defines what
the guideline will and will not cover. The scope of this guideline is available
from www.nice.org.uk/page.aspx?o=275101.

This guideline is relevant to adults and young people who misuse opiates,
cannabis or stimulants (for example, cocaine or amphetamines) and will be of
relevance to the NHS and related organisations, including prison services and
inpatient and specialist residential and community-based treatment settings.
Although the guideline may comment on the interface with other services,
such as those provided by the voluntary sector, it will not provide specific
recommendations directed solely at non-NHS services, except insofar as they
are provided under contract to the NHS.

The guideline does not specifically address:

• people with dual diagnoses
• people who misuse alcohol, prescription drugs or solvents
• diagnosis or primary prevention
• pregnancy
• people younger than 16 years.

This guideline should be read in conjunction with ‘Drug misuse and
dependence: guidelines on clinical management’, which provides advice to
healthcare professionals on the delivery and implementation of a broad range
of interventions for dug misuse including those interventions covered in this
guideline. Further information is available from www.nta.nhs.uk

How this guideline was developed

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NICE commissioned the National Collaborating Centre for Mental Health to
develop this guideline. The Centre established a Guideline Development
Group (see appendix A), which reviewed the evidence and developed the
recommendations. An independent Guideline Review Panel oversaw the
development of the guideline (see appendix B).

There is more information in the booklet: ‘The guideline development process:
an overview for stakeholders, the public and the NHS’ (second edition,
published April 2006), which is available from
www.nice.org.uk/guidelinesprocess or by telephoning 0870 1555 455 (quote
reference N1113).

3 Implementation
The Healthcare Commission assesses the performance of NHS organisations
in meeting core and developmental standards set by the Department of Health
in ‘Standards for better health’, issued in July 2004. Implementation of clinical
guidelines forms part of the developmental standard D2. Core standard C5
says that national agreed guidance should be taken into account when NHS
organisations are planning and delivering care.

NICE has developed tools to help organisations implement this guidance
(listed below). These are available on our website (www.nice.org.uk/CGXXX).
[NICE to amend list as needed at time of publication]

• Slides highlighting key messages for local discussion.
• Costing tools:
− costing report to estimate the national savings and costs associated with
implementation
− costing template to estimate the local costs and savings involved.
• Implementation advice on how to put the guidance into practice and
national initiatives which support this locally.
• Audit criteria to monitor local practice.

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4 Research recommendations
The Guideline Development Group has made the following recommendations
for research, based on its review of evidence, to improve NICE guidance and
patient care in the future.

4.1 Implementation of contingency management
For people who misuse drugs, what methods of implementing contingency
management (including delivering and ceasing incentives) and in what
settings (including legally mandated, community-based and residential),
compared with one another and standard care, are associated with longer
periods of continued abstinence, reduced drug use and maintenance of
abstinence/reduction of drug use at follow-up?

Why this is important
Although the efficacy of contingency management for drug misuse has been
extensively investigated, there is a lack of large-scale and well-conducted
implementation studies. The implementation of contingency management
programmes in the UK would be aided by research assessing specific
components of the programme.

4.2 Testing within contingency management
programmes
For people who misuse drugs and are receiving contingency management,
are urinalysis, sweat and oral fluid analyses alone and in comparison with one
another sensitive, specific, cost-effective and acceptable to service users?

There is a lack of data comparing sensitivity and specificity, cost-effectiveness
and acceptability to service users of these methods of identification of drug
use. Identifying drug use during treatment is an important aspect of
contingency management; therefore assessing which method(s) are more
effective on the above outcomes is an important issue for health and social
care settings intending to implement contingency management programmes.

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4.3 Psychosocial interventions within needle and syringe
exchange programmes
For people who use injected drugs, do needle and syringe exchange
programmes with greater psychosocial content (including staff distribution of
syringes and needles and/or provision of psychoeducation on reducing blood-
borne virus risk) compared with those with minimal psychosocial content
(including machine dispensing of syringes and needles and minimal or no
information on reducing blood-borne virus risk) reduce injection and sexual
risk behaviours and seroprevalence blood-borne virus rates associated with
drug use?

There is extensive literature assessing whether needle and syringe exchange
programmes reduce injection and sexual risk behaviour and HIV
seroprevalence rates. However, there is very little research that seeks to
distinguish the impact of the provision of sterile needles from the psychosocial
interventions often offered in such programmes. Psychosocial contact and
interventions in needle and syringe exchange programmes require a great
deal of resources, therefore it is important to assess whether these additional
psychosocial elements are clinically and cost-effective.

4.4 Residential treatment
For people who misuse drugs, is residential treatment associated with better
outcomes than community-based care, as measured by higher rates of
abstinence or reduction in drug use?

There have been some studies comparing residential treatment with
community-based treatment. However, these studies are often based on small
sample sizes, lack methodological quality and have produced inconsistent
results. Residential treatment requires significantly more resources than
community-based treatment, so it is important to assess whether residential
treatment is more effective.

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5 Other versions of this guideline

5.1 Full guideline
The full guideline, ‘Drug misuse: psychosocial management of drug misuse’,
contains details of the methods and evidence used to develop the guideline. It
is published by the National Collaborating Centre for Mental Health, and is
available from [NCC website details to be added], our website
(www.nice.org.uk/CGXXXfullguideline) and the National Library for Health
(www.nlh.nhs.uk). [Note: these details will apply to the published full
guideline.]

5.2 Quick reference guide
A quick reference guide for healthcare professionals is also available from
www.nice.org/CGXXXquickrefguide

For printed copies, phone the NHS Response Line on 0870 1555 455 (quote
reference number NXXXX). [Note: these details will apply when the
guideline is published.]

5.3 Understanding NICE guidance: information for
patients and carers
Information for people who misuse drugs and their carers (‘Understanding
NICE guidance’) is available from www.nice.org.uk/CGXXXpublicinfo

For printed copies, phone the NHS Response Line on 0870 1555 455 (quote
reference number N1XXX). [Note: these details will apply when the
guideline is published.]

6 Related NICE guidance
Anxiety: management of anxiety (panic disorder, with or without agoraphobia,
and generalised anxiety disorder) in adults in primary, secondary and
community care. NICE clinical guideline 22 (2004). Available from
www.nice.org/CG022

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Depression: management of depression in primary and secondary care. NICE
clinical guideline 23 (2004). Available from www.nice.org/CG023

Self-harm: the short-term physical and psychological management and
secondary prevention of self-harm in primary and secondary care. NICE
clinical guideline 16 (2004). Available from www.nice.org/CG016

Schizophrenia: core interventions in the treatment and management of
schizophrenia in primary and secondary care. NICE clinical guideline 1
(2002). Available from www.nice.org/CG001

NICE is developing the following guidance (details available from
www.nice.org.uk):

• Drug misuse: opiate detoxification drug misusers in the community, hospital
and prison. NICE clinical guideline. (Publication expected July 2007.)
• Methadone and buprenorphine for the management of opioid dependence.
NICE technology appraisal guidance. (Publication expected January 2007.)
• Naltrexone for the management of opioid dependence. NICE technology
appraisal guidance. (Publication expected January 2007.)
• Substance misuse interventions: an assessment of community-based
interventions to reduce substance misuse among the most vulnerable and
disadvantaged young people. NICE public health intervention guidance.
(Publication expected March 2007.)

7 Updating the guideline
NICE clinical guidelines are updated as needed so that recommendations
take into account important new information. We check for new evidence 2
and 4 years after publication, to decide whether all or part of the guideline
should be updated. If important new evidence is published at other times, we
may decide to do a more rapid update of some recommendations.

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Appendix A: The Guideline Development Group
Professor John Strang (Chair, Guideline Development Group)
Professor of Psychiatry of Addictions; Director – National Addiction Centre,
Institute of Psychiatry; Honorary Consultant Psychiatrist, South London and
Maudsley NHS Trust

Mr Stephen Pilling (Facilitator, Guideline Development Group)
Joint Director, The National Collaborating Centre for Mental Health; Director,
Centre for Outcomes, Research and Effectiveness, University College
London; Consultant Clinical Psychologist, Camden and Islington Mental
Health and Social Care Trust

Dr Eliot Ross Albert
Service-user representative

Ms Janet Brotchie
Clinical Psychology Advisor, Quality Team, National Treatment Agency for
Substance Misuse; Lead Psychologist, Central and North West London
Mental Health NHS Trust Substance Misuse Service

Dr Alex Copello
Clinical Director, Substance Misuse Services and Addictions Research and
Development Programme Director, Birmingham and Solihull Mental Health
NHS Trust; Senior Lecturer in Clinical Psychology, University of Birmingham

Professor Colin Drummond
Professor of Addiction Psychiatry, St George’s Hospital Medical School,
University of London; Honorary Consultant Psychiatrist, South West London
and St George’s NHS Trust

Mr Mark Gilman
North West Regional Manager, National Treatment Agency for Substance
Misuse

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Ms Sarah Hopkins
Project Manager, The National Collaborating Centre for Mental Health (2006–
2007)

Dr Christopher Jones
Health Economist, The National Collaborating Centre for Mental Health (until
2006)

Ms Rebecca King
Project Manager, The National Collaborating Centre for Mental Health (2005–
2006)

Mr Tim Leighton
Head of Professional Education, Training and Research, Clouds; Director of
Studies, University of Bath Foundation Degree and BSc (Hons) Degree in
Addictions Counselling

Mr Ryan Li
Research Assistant, The National Collaborating Centre for Mental Health

Dr Ifigeneia Mavranezouli
Senior Health Economist, The National Collaborating Centre for Mental Health

Mr Peter McDermott
Service-user representative

Dr Nicholas Meader
Systematic Reviewer, The National Collaborating Centre for Mental Health

Ms Poonam Sood
Research Assistant, The National Collaborating Centre for Mental Health

Ms Sarah Stockton
Information Scientist, The National Collaborating Centre for Mental Health

Mr Andy Stopher
Borough Services Assistant Director (Camden), Substance Misuse Services

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Dr Clare Taylor
Editor, The National Collaborating Centre for Mental Health

Mr Ian Wardle
Chief Executive, Lifeline Project, Manchester

Mrs Tina Williams
Carer representative

Dr Nat Wright
Clinical Director for Substance Misuse, HMP Leeds, Leeds Primary Care
Trust

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Appendix B: The Guideline Review Panel
The Guideline Review Panel is an independent panel that oversees the
development of the guideline and takes responsibility for monitoring
adherence to NICE guideline development processes. In particular, the panel
ensures that stakeholder comments have been adequately considered and
responded to. The Panel includes members from the following perspectives:
primary care, secondary care, lay, public health and industry.

[NICE to add]

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Appendix C: Contingency management – key
elements in the delivery of a programme
Contingency management has been used to reinforce a variety of behaviours
including abstinence from drugs (Higgins et al. 1993), reduction in drug use
(Elk et al. 1995), promoting engagement with psychosocial interventions
(Petry et al. 2006) and ensuring compliance with physical health interventions
(Malotte et al. 1998). Although the principles of contingency management are
relatively straightforward, implementing such a programme in practice
requires careful organisation. The different types of incentives that can be
used and key implementation issues will be discussed below. All the
interventions have a strong base in psychological theory (Domjan et al. 2003).

Reinforcement schedules
There are four main methods for delivering incentives that have been applied
to drug treatment: clinic privileges, vouchers, monetary incentives and award
draws.

Clinic privileges
Trials assessing privileges within treatment have focused on contingency
management for people undergoing MMT. Privileges used for reinforcement
include take-home methadone doses (Stitzer et al. 1992). Privileges are
commonly provided in drug treatment in the UK but tend not to be used
consistently. Their use more formally within a contingency management
programme may have a significant impact on particular target behaviour.
Other examples of privileges that may be used include access to a rapid
dosing line, reserved parking space for a specific duration or a special food
item in a clinic cafeteria (Petry et al. 2002).

Voucher reinforcement
Service users receive ‘vouchers’ of various monetary values for each
biological sample (usually urine) that is negative for the tested drugs. Each
voucher usually escalates in value as the number of uninterrupted negative
samples increases. For example the first negative sample earns £1.50, the
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next £3, the third £5 etc. If a positive sample is submitted no voucher is given
and the next voucher earned for a negative sample is reset to £1.50.

One advantage of the voucher system is that it allows for individual
preferences, with service users able to spend their vouchers on a variety of
items. In some programmes, a staff member purchases the items chosen by
the service user and they can veto certain requests that may not support a
healthy drug-free lifestyle; other trials have used on-site stores where the
items can be purchased directly. Voucher systems seem to have a high level
of acceptability among service users, with fewer than 5% refusing to
participate in these trials (Petry 2000).

Monetary incentives
There have been a few studies, mainly on offering incentives for compliance
with physical health interventions (Malotte et al. 1998; Malotte et al. 1999;
Seal et al. 2003), that have assessed the use of monetary incentives. It
appears that low value (for example, £1.50/$3) incentives are as effective as
higher value (for example, £10/$20) incentives.

Awards
This is more formally referred to as the ‘variable magnitude of reinforcement
procedure’ (Prendergast et al. 2006). Participants receive the opportunity to
participate in draws, often from a number of slips of paper kept in a bowl, for
providing a negative biological specimen. Often the number of draws
increases with the submission of continuous negative samples (Petry 2005b).
Provision of a specimen indicating recent drug use results in the withholding
of draws and the number of draws earned for a negative sample is reset to
one.

The awards available typically range from £1 (for example, in the form of a
food voucher) through £20 (for example, a choice of a discman, watch, phone
credits) to £100 (for example, a TV, stereo, MP3 player). Service users are
given a choice of prizes within a particular category to ensure they receive
something they perceive as reinforcing. The chance of winning is inversely
related to prize costs. For example, there may be a 1 in 2 probability of
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winning a £1 prize, and 1 in 250 probability of winning a £100 prize (Petry
2000).

The evidence suggests that all the above reinforcement systems can be
effective, with some evidence to suggest a slight but not significant advantage
for monetary incentives over the other methods. However, in the NHS it may
prove easier to implement contingency management through the use of
privileges and vouchers, because of their potentially greater acceptability to
services.

Key issues in implementing a contingency management
programme
Kellogg and coworkers (2005) summarised five key aspects of implementing
contingency management.

• Incentives should be given frequently.
• It should be very easy to earn incentives at the start.
• Incentives need to include material goods and services that are of use and
value to service users.
• The connection between incentives and behaviour should be clear.
• The emphasis should be on incentive-oriented rather than punishment-
oriented approaches.

Frequency and ease of earning incentives at the start
The first two issues discussed by Kellogg and coworkers (2005) are closely
linked. In order to strengthen the connection between the incentive and the
behaviour it is important that the incentives are provided frequently. However,
for incentives to be earned frequently the target behaviour must not be too
difficult, particularly at the start of the programme. Abstinence from drugs can
be a difficult target for many people who misuse drugs, so some trials use
‘successive approximation’ – a system in which service users receive
reinforcement for approximations of abstinence. For example, Elk and
coworkers (1995) reinforced reductions in benzoylecognine metabolites to
encourage initial attempts at abstinence.

33


Providing early access to incentives is an important aspect of establishing
contingency management programmes. A common method is ‘priming’ –
service users are provided with reinforcement for the first time they attend the
clinic. For example, Higgins (1993) provided service user with their choice of a
restaurant voucher or cinema tickets for their first session. Similarly, Petry and
Martin (2002) offered participation in a draw on the first day of treatment. The
aim of priming is for service users to experience the reinforcements available
in attending treatment and to encourage them to continue with the
intervention.

Material goods and services
The use of material goods and services as incentives in contingency
management programmes has been extensively examined in trials and
implementation studies. A key point to emphasise in providing such incentives
is that the items provided should be perceived as genuinely reinforcing by the
service user participating in the programme. For example, vouchers or clinic
privileges should all be chosen in conjunction with the service user.

Connection between incentive and behaviour
Incentives are likely to be more effective if their distribution is directly
connected to specific and observable behaviours and if the service user
receives them immediately after they exhibited the behaviour (for example,
attending a therapy session). The greater the delay in receiving the
reinforcement, the weaker its effect is likely to be.

Incentive-oriented rather than punishment-oriented
One major advantage to contingency management is its emphasis on
providing incentives for positive target behaviours, whereas some aspects of
current practice can focus on a more negative approach such as the loss of
privileges and discharge from services. Almost all trials showing the efficacy
of contingency management have been incentive-oriented (for example,
Higgins et al. 1993; Stitzer et al. 1992). Furthermore, adding a punitive aspect
(reduction in methadone dose when testing positive for illicit drug use) to a
contingency management incentive-oriented treatment has not been found to

33


be effective (for example, Iguchi et al. 1988). This suggests a shift away from
punishment-oriented to incentive-oriented treatment may be beneficial in
changing drug users’ behaviour.

Maintenance of behaviour after reinforcement
A final important issue not mentioned by Kellogg and coworkers (2005) is how
to maintain the target behaviour once the reinforcement schedule has been
completed. Firstly, it would be good clinical practice not to terminate a
contingency management programme until the service user is stabilised.
Secondly, a number of studies have reduced the frequency and value of
incentives towards the end of treatment in order to lessen the impact after the
primary contingency management programme has been completed. For
example, Higgins (1993, 1994) after 12 weeks of voucher reinforcement with
escalating incentives provided $1 lottery tickets for each negative urine
sample over a further 12 weeks. Petry (2004, 2005b) gradually reduced the
number of prize draws available from three times a week in the first 3 weeks,
to twice a week in the next 3 weeks, to finally once a week for 6 weeks.

References
Domjan M (2003) The principles of learning and behavior. Belmont, California:
Thomson/Wadsworth, 2006.

Elk R, Schmitz J, Spiga R, Rhoades H, et al, (1995) Behavioral treatment of
cocaine-dependent pregnant women and TB-exposed patients. Addictive
Behaviour 20: 533–42.

Higgins ST, Budney AJ, Bickel WK, et al. (1993). Achieving cocaine
abstinence with a behavioral approach. American Journal of Psychiatry 150:
763–9.

Higgins ST, Budney AJ, Bickel WK et al. (1994) Incentives improve outcome
in outpatient behavioral treatment of cocaine dependence. Archives of
General Psychiatry 51: 568–576.

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Iguchi M, Stitzer ML, Bigelow GE, et al. (1988). Contingency management in
methadone maintenance: Effects of reinforcing and aversive consequences
on illicit polydrug use. Drug and Alcohol Dependence 22: 1–7.

Kellogg SH, Burns M, Coleman P, et al (2005) Something of value: The
introduction of contingency management interventions into the New York City
Health and Hospital Addiction Treatment Service. Journal of Substance Abuse
Treatment 28: 57–65.

Malotte CK, Rhodes F, Mais KE (1998) Tuberculosis screening and
compliance with return for skin test reading among active drug users.
American Journal of Public Health 88: 792–6.

Malotte CK, Hollingshead JR, Rhodes F (1999) Monetary versus nonmonetary
incentives for TB skin test reading among drug users. American Journal of
Preventive Medicine 16: 182–8.

Petry NM (2000) A comprehensive guide to the application of contingency
management procedures in clinical settings. Drug and Alcohol Dependence
58: 9–25.

Petry NM, Martin B (2002) Low-Cost Contingency Management for Treating
Cocaine- and Opioid-Abusing Methadone Patients. Journal of Consulting and
Clinical Psychology 70: 398:405.

Petry NM, Simcic F (2002) Recent advances in the dissemination of
contingency management techniques: clinical and research perspectives.
Journal of Substance Abuse Treatment 23: 81–6.

Petry NM, Alessi S, Marx J et al (2005) Vouchers Versus Prizes: Contingency
Management Treatment of Substance Abusers in Community Settings.
Journal of Consulting and Clinical Psychology 73: 1005–14.

Petry NM, Alessi SM, Carroll KM et al (2006) Contingency management
treatments: Reinforcing abstinence versus adherence with goal related
activities. Journal of Consulting and Clinical Psychology 74: 592–601.

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Prendergast M, Podus D, Finney J et al (2006) Contingency management for
treatment of substance use disorders: a meta-analysis. Addiction 101: 1546–
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Seal KH, Kral AH, Lorvick J et al. (2003) A randomized controlled trial of
monetary incentives vs. outreach to enhance adherence to the hepatitis B
vaccine series among injection drug users. Drug and Alcohol Dependence 71:
127–31.

Stitzer ML, Iguchi MY, Felch LJ (1992) Contingent take-home incentive:
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