Resources for Secure Environments

Substance misuse

• Clinical Guidelines on Drug Misuse and Dependence Update 2017 Independent Expert Working Group (2017) Drug misuse and dependence: UK guidelines on clinical management. London: Department of Health: This is key guidance for clinicians treating people with drug problems in the UK and is frequently referred to as the ‘Orange book’. It was updated in 2017 and includes new guidelines about treating people in contact with the criminal justice system (community based and prison settings), new psychoactive substances and club drugs, misuse of prescription drugs and over-the-counter medicines and prevention of drug-related deaths, naloxone provision.

National Institute for Health and Care Excellence (NICE) Guidance

• NICE Quality standard (QS165) Drug misuse prevention (2018): The scope of this quality standard covers the prevention or delay of harmful use of drugs by assessing risk and signposting to appropriate services those children, young people and adults who are vulnerable to harmful use. There are four statements which refer to looked after children, care leavers, children in contact with youth offending services and adults. Although two statements apply directly to vulnerable individuals in community rather than settings, it is important to be aware of interventions and services that have the potential to change the trajectory of young lives and to be aware that looked after children and care leavers are over-represented in secure settings.
• NICE Quality standard (QS23) Drug use disorders in adults (2012): This quality standard covers assessment and treatment of drug use disorders in adults (aged 18 and over). It includes treating the misuse of opioids, cannabis, stimulants and other drugs.
• NICE Technology appraisal guidance (TA114) Methadone and buprenorphine for the management of opioid dependence (2007): This guidance for commissioners and providers considers the evidence for clinical and cost effectiveness of methadone and buprenorphine (oral formulations). It recommends a flexible case by case approach to deciding which drug to use and, where there is no difference in suitability, prescribing methadone as first choice. Other recommendations concern supervision of administration and embedding OST within a programme of supportive care.
• NICE (TA114) Methadone and buprenorphine for the management of opioid dependence - summary for patients and carers: This summarised guidance about the NICE TA on oral OST is written for patients and carers. If using the information for patients and residential staff, it is important to take in to account patient literacy levels and translation requirements, together with adjustments required for secure settings (e.g. supervised consumption only).
• NICE Technology appraisal guidance (TA115) Naltrexone for the management of opioid dependence (2007): This guidance covers the use of naltrexone under adequate supervision for detoxified, highly motivated people who were formerly opioid-dependent.
• NICE Clinical guideline (CG51) Drug misuse in over 16s: psychosocial interventions: This guideline covers treatment of problem drug use or dependence in adults and young people over 16 using psychosocial interventions, with the aim of reducing illicit drug use and improving people’s physical and mental health, relationships and employment
• NICE Clinical guideline (CG52) Drug misuse in over 16s: opioid detoxification: This guideline covers opioid detoxification in adults and young people over 16 in community, residential, inpatient and prison settings. It does not cover treatment of women who are pregnant.
• NICE Clinical guideline (CG120) Coexisting severe mental illness (psychosis) and substance misuse: assessment and management in healthcare settings (2011, 2016): This guideline covers assessment and management of people aged 14 years and over with coexisting severe mental illness (psychosis) and substance misuse. All adults and young people with psychosis and suspected drug use or with substance misuse and suspected psychosis should be referred to CAMHS or secondary care mental health.

 NHS England

• NHS England (2018) Advice on actions for suspected ingestion of nicotine e-cigarette vaping liquid:This brief information, prepared to support staff delivering care in health and justice settings, provides basic advice about e-cigarette and vaping products, signs and symptoms of nicotine toxicity and action to be taken when this suspected.

 Public Health England

• Public Health England: Five Nations Health and Justice Collaboration Statement on the presence of new psychoactive substances in custodial settings (2017): This statement contains information on the prevalence of NPS use in the community, feedback from people in prison, and recommendations for prisons that includes: clinical management plans; monitoring of drug use to inform health, security and operational policy; staff training and future research. 
• Public Health England. New Psychoactive Substances (NPS) in prisons: a toolkit for prison staff (2017): This toolkit provides information and advice to support custodial, healthcare and substance misuse staff working in prisons to manage NPS use from a clinical, psychosocial and regime perspective. A number of principles can also be applied in community settings.

The Home Office

• New Psychoactive Substances (NPS) resource pack (2015/16): This resource pack contains information about NPS and advice on intervention. It is designed to equip educators and practitioners working with young people to discuss NPS and prevent and challenge drug-taking behaviour.

Project NEPTUNE

• Project NEPTUNE (Novel Psychoactive Treatment UK Network) was set up in response to the emerging clinical challenge of harms related to club drugs and NPS. It has produced a comprehensive clinical guidance paper and other related resources (see linked documents). There are e-learning modules  which are open access but require registration.
• NEPTUNE Guidance on the Management of Acute and Chronic Harms of Club Drugs and Novel Psychoactive Substances (2015): This guidance is aimed at clinicians and other practitioners working across a range of settings. It is comprehensive and designed to help improve clinical practice in the management of NPS and club drug-related harms. 
• NEPTUNE. Harms of Synthetic Cannabinoid Receptor Agonists (SCRAs) and Their Management (2016): This guidance provides advice about harms and management of harms associated with acute toxicity and chronic use of *SCRAs (*a range of synthetic cannabinoids often referred to as ‘Spice’, popular in prisons and among homeless populations.)
• NEPTUNE. Club Drug Use Among Lesbian, Gay, Bisexual and Trans (LGBT) People (2016): This document is intended to guide improvements in service and treatment planning. It describes patterns and factors relating to club drug use among LGBT sub-populations and  discusses drug-related and other harms, including high-risk sexual behaviours.
• NEPTUNE. The misuse of synthetic opioids: harms and clinical management of fentanyl, fentanyl analogues and other novel synthetic opioids. Information for clinicians (2018): This document provides information on clinical management of the health-related harms associated with acute and chronic misuse of synthetic opioids. It is based on based available evidence.
• NEPTUNE. ATOMIC is a free, evidence-based, mobile-learning application aimed at clinicians and other practitioners who want to improve their knowledge of the acute and chronic clinical harms of non-medical prescription drug use.
  

The European Monitoring Centre for Drugs and Drug Addiction

• Guidance for the use and reduction of misuse of benzodiazepines and other hypnotics and anxiolytics in general practice (PDF): This evidence-based guidance was written to support primary care clinicians prescribing and managing withdrawal and dependence on benzodiazepines and ‘Z’ drugs. It also considers misuse and the different effects sought from benzodiazepines. It has not been endorsed by other bodies and does not replace advice in the ‘Orange book’ however it provides helpful primary-care focused guidance.

Regional Medicines Optimisation Committee (RMOC)

• Position Statement. Oral Vitamin B supplementation in alcoholism (Nov 2019) (PDF): The RMOC has issued a position statement on oral Vitamin B supplementation in chronic alcoholism (parenteral supplementation is not covered). Vitamin B complex preparations are no longer recommended for prevention of Wernicke’s Encephalopathy in alcoholism however they may be prescribed on a short-term basis (10 days) for patients at risk of refeeding syndrome (see NICE CG32 Box 1 below). Vitamin B complex (as Vitamin B compound strong) may also be prescribed in rare cases e.g. medically diagnosed deficiency or chronic malabsorption.

Oral thiamine should continue to be prescribed (see NICE CG100) 200-300mg daily in divided doses for the prevention of Wernicke’s Encephalopathy to harmful or dependent drinkers who are malnourished (or at risk or malnourishment), have decompensated liver disease, acute withdrawal, before and during planned medically assisted alcohol withdrawal. Following successful alcohol withdrawal, thiamine should be continued for 6 weeks, providing patients have regained an adequate nutritional status.

• RMOC Buprenorphine Long Acting Injection Guidance (April 2021): The RMOC has produced guidance on the use of long-acting Buprenorphine injection opioid substitution treatment in community settings and secure environments (e.g. prisons, immigration removal centres, children and young people secure estates) in England. The guidance is aimed at substance misuse service providers, commissioners, community pharmacies and acute NHS Trusts in England. It includes topics such as practical considerations in different care settings, starting treatment and transferring care. It provides recommendations, clinical scenarios and a Buvidal® cost calculator to provide guidance to organisations/commissioners on the potential financial impact of Buvidal® implementation for a local population.

NICE Guidelines for Assessment, diagnosis and management of Physical and Mental Health in prisons

• NICE Clinical guideline (CG100) Alcohol-use disorders: diagnosis and management of physical complications (2010, 2017): This guideline provides recommendations on managing acute alcohol withdrawal and treating alcohol-related conditions in adults and young people (aged 10 years and older) with physical health problems that are completely or partly caused by an alcohol-use disorder.
• NICE (CG115) Alcohol-use disorders: diagnosis, assessment and management of harmful drinking (high-risk drinking) and alcohol dependence (2011): This guideline covers identification, assessment and management of alcohol-use disorders (harmful drinking and alcohol dependence) in adults and young people aged 10–17 years. Through improved assessments and goal setting for reduced consumption, it aims to reduce physical and mental health problems caused by alcohol.

NICE CG32: Box 1 - Criteria for determining people at high risk of developing refeeding problems 

Patient has one or more of the following: BMI less than 16 kg/m2 unintentional weight loss greater than 15% within the last 3–6 months little or no nutritional intake for more than 10 days low levels of potassium, phosphate or magnesium prior to feeding.

Or patient has two or more of the following: BMI less than 18.5 kg/m2 unintentional weight loss greater than 10% within the last three to six months little or no nutritional intake for more than 5 days a history of alcohol abuse or drugs including insulin, chemotherapy, antacids or diuretics.

Prescriber

• Parsons G. (2018) Guide to the management of gabapentinoid misuse: This article covers licensed and unlicensed indications of pregabalin and gabapentin, their pharmacology, misuse and management of patients who are discontinuing them.

Courses

• Drugs: Management of Drug Misuse (Level 1): This is an online course which provides introductory learning on evidence-based treatment of substance misuse in primary care, including the role of opiate substitution therapies (OST). It is a useful starting point for staff working in secure environments.

Addiction Professionals: Registration body and network (formerly known as SMMGP and FDAP)

The SMMGP (Substance Misuse Management in General Practice) – FDAP (Federation of Drug and Alcohol Practitioners partnership has changed its name to Addiction Professionals. It is a network for people from a wide range of professional backgrounds including GPs, psychiatrists, counsellors, key workers, pharmacists, psychologists, social workers, nurses and mentors, who work in the field of addictions treatment, including alcohol, other drugs and behavioural addictions. The organisation offers training and support for members and provides quality assurance through registration and professional accreditation. It runs ongoing professional development courses and provides free resources, which include a range of webinars and published guidance, pertinent to managing substance misuse in prison.

Webinars (published by SMMGP)

• Buprenorphine prescribing in criminal justice settings - the real picture
• How to deliver effective opioid substitution treatment in prisons