Managing dependence on non-opiate drugs

Give some examples of Non-opiate substances that people may seek help with

• Alcohol

• Benzodiazepines

• Cocaine (crack/freebase or HCl)

• Cannabis

• Gabapentinoids

• Ketamine

• Amphetamine

• NPS e.g mephadrone, Spice………etc

What are the intended outcomes of treatment for non-opitae drugs

same as opiate

Reduce harm & reduce/stop (illicit) drug use, improve lives:

• Reduce BBV transmission, protect pubic.

• Improve physical health.

• Improve mental health.

• Improve social functioning e.g. relationships, families and meaningful activity.

• Reduce drug related crime, protect public.

Substitution therapy evidence base is largest and most strong for…

opiate dependence

Non pharmacological therapies form the mainstay of treatment for…

cocaine, cannabis, amphetamine and ketamine dependence

Short term pharmacological detoxification used for…

benzodiazepine and alcohol dependence.

Relapse prevention therapies (e.g. acamprosate, naltrexone, disulfiram) for alcohol dependence can be useful in…

highly motivated individuals. Naltrexone also used for relapse prevention from opioids.

What is Alcohol dependence?

• Psychological & physical dependence

• More common in older people. Male>female

• Risk of cognitive impairment long term plus poor nutrition; very harmful to physical health (e.g. gastric irritation/ulcer; liver function, fibrosis, clotting factors/bleeds, Wernicke’s encephalopathy etc etc)

• Associated with increased risk of violence (victim and perpetrator)

Describe the use of pharmacological detoxification in Alcohol dependence.

• For EtOH dependence commonly use chlordiazepoxide. Oxazepam if liver concerns.

• Planned, agreed short course reduction for alcohol (typically 7 days).

• UK Clinical Guidelines for Alcohol Treatment Alcohol use disorders: NICE guidance CG115 (Feb 2011)

• Alcohol - Assess risk of detox in community (e.g. seizures), sometimes done in hospital when risk is not acceptable for community detox e.g. no supportive person.

• Unplanned hospital admissions – people dependent on alcohol undergo detox regimens.

Describe the use of pharmacological detoxification in BZ dependence.

• Diazepam commonly used. Oxazepam if liver concerns.

• Currently most guidelines favour detoxification regimens, which can be adjusted to individual. Need more research into maintenance regimens.

• Maintenance risks with diazepam daily long term – but debate on extent and balance of risk e.g. increased all-cause mortality risk prescribed BZ with opioids; cognitive impairment risks, but are they overestimated and are the risks greater than no treatment? (see next).

• Unplanned hospital admissions – no clear guidance on how hospitals manage risks.

Combined exposure (prescribed + non-prescribed) associated with…

elevated drug death risk – especially for those not on OAT

OAT

opioid agonist therapy

What therapies should be used for Alcohol relapse prevention AFTER detoxification completed?

• Disulfiram- No longer routinely used.

• Acamprosate

• Naltrexone

Nalmafene rarely used.

Describe the mechanism and use of Disulfiram in Alcohol relapse prevention AFTER detoxification completed

blocks metabolism of alcohol > accumulation of acetaldehyde in blood stream. Disulfiram-alcohol reaction occurs within 10 minutes of ingestion of alcohol lasts several hours. Can be dangerous. No longer routinely used.

• It is characterised by intense flushing, dyspnoea, headache, palpitations, tachycardia, hypotension, nausea and vomiting

• Patients should carry a card warning of the danger of administration of alcohol.

• Careful with mouthwashes, cough mixtures, hand gel etc.

Describe the mechanism and use of Acamprosate in Alcohol relapse prevention AFTER detoxification completed

may stimulate GABAergic inhibitory neurotransmission & antagonise excitatory amino-acids e.g. glutamate, to reduce craving.

→ alter based on body weight over and under 60kg

Describe the mechanism and use of Naltrexone in Alcohol relapse prevention AFTER detoxification completed

a specific, high affinity, long acting competitive antagonist at opioid receptors, blocks on top opiate use, also benefit shown in alcohol. Nalmafene rarely used.

→ relapse intervention

What is Stimulant dependence e.g. Cocaine powder, crack cocaine and amphetamines?

• May be primary drug used or secondary/poly drug use.

• Strong psychological dependence.

• Binge patterns of use, with or without daily chronic use.

• Risks to CV system, mental health (eg. ADHD), physical risks from administration (nasal, IV, smoked etc).

• An in press systematic review  has found no treatment effective across all outcomes studied for cocaine dependence but some limited benefit from combinations of medications.

What is Cannabis dependence?

• Cannabis Use Disorder in susceptible individuals can have psychological dependence issues and linked with psychosis, depression and other psychiatric problems.

• May be underlying ‘self-medication’ e.g. ADHD.

• Links with psychosis esp teenage use and use of skunk (high THC)

• THC vs Spice vapes – especially younger people.

• Risks from smoking tobacco if it is mixed with as well as substance itself.

• Behaviour change interventions: CBT + motivational approaches + contingency management has strongest evidence. Treatment >12 weeks with continued follow up.

What is Prescribed medication dependence?

• Happens with a range of medications e.g. opioids inc codeine, tramadol; gabapentinoids…

• May be augmented by poor prescription monitoring e.g. early repeats.

• May be obtained legitimately or on streets (inc. online).

• May be trying to manage own mental health issues.

• May be associated with poly drug use e.g. heroin, crack. e.g. BZ use to ‘come down’/sleep/reduce withdrawals.

• Dependence on OTCs e.g. co-codamol.

• Withdrawal regimens using the substance dependent on or for opioids can use OAT. Needs psychological support.

What is Adjunct prescribing?

• Complications e.g. insomnia–need to remove the cause in an ideal world.

• Short term BZ or Z drugs used – restrict to max 14 days. Melatonin?

• Antidepressants.

• Be alert to co-existing mental health problems, psychiatry referral if needed. Community Mental Health Team. Challenges!!

• Adjunct in opioid detox e.g. loperamine, hyoscine, short term BZ / Z drug.

→ Remove symptoms and side effects experienced part detox

→ weeks / couple of weeks duration

For drugs with no physical withdrawal syndrome and no replacement therapy psychosocial support is the…

mainstay offered, alongside referral for mental health issues if required

Treatment for drug misuse should always involve a…

psychosocial component to help support an individual’s recovery

What current guidance is available for Managing dependence on non-opiate drugs?

1. UK Clinical guidelines (2017)

• Oral methadone and buprenorphine: recommendations (Dec 2024), DHSC.

2. British Association for Psychopharmacology guidance (2026)

3. RCGP Guidance for the use of substitute prescribing in primary care (2011)

4. NICE offer a range e.g.

• Drug misuse - methadone and buprenorphine TA114 (2007)

• Drug misuse: opioid detoxification  GC52 (2007)

• Drug misuse: psychosocial interventions  GC51 (2007)

The term ‘psychosocial intervention’ is used to refer to…

a broad range of processes aimed at psychological and social change

Interventions aimed at psychological change range from…

less structured forms of support and motivational interviewing techniques, to more highly structured psychological techniques and therapy delivered by specialists e.g. CBT.

Interventions aimed at social change include…

assistance with basic needs such as food, clothing and accommodation; supporting engagement with healthcare services, social activities and employment; and supporting the development of positive friendship, family and community relationships and networks.

Better outcomes can be achieved by using suitable interventions, including those that emphasise…

personal-goal-directed work; use rewarding activities; build self-efficacy and coping skills, and help to develop more positive non-drug-using social networks.

Discrete formal interventions can be targeted at specific needs such as…

§addressing depression or anxiety linked to drug use.

Self-help and mutual aid approaches, including…

12-Step (e.g. Narcotics Anonymous) and SMART Recovery groups, have been found to be highly effective for some individuals in supporting recovery, and patients seeking post-treatment support can be signposted to them.

There is a strong evidence base for…

contingency management and family and couples interventions.

The relationships that the individual has with those involved in care provision have been shown to be highly important in determining the

outcome of treatment

What can pharmacy teams do to support?

• Taking a non-judgemental approach will avoid stigma, so prevent disengagement from care due to negative experiences (community & hospital teams!)

• Offer brief interventions to people who may benefit from them (e.g. ABI commissioned services) or informally.

• Offer other appropriate services e.g. MUR, stop smoking, health checks – do not make assumptions based on drug use.

• Small things can make a difference – a friendly welcome, small talk.

• When appropriate, can discuss goals with individuals and offer positive praise.

• Encourage engagement with structured psychosocial support; know what is available locally and ‘myth-bust’ when opportunity presents.

• Signpost to support services e.g. know local SMART recovery meetings.

• Know your community and what is available e.g. local food banks, Citizen’s Advice etc.

• Discuss with people at the end of a detox if they have psychosocial support and encourage them to engage in relapse prevention after they stop medication.