UK Government Injectable Opiates Prescribing Guidelines

Link here to the NTA (national treatment agency) UK injectable opiate prescribing guidelines

I've quoted below the most important parts... There is a lot of interesting information in the PDF so I would suggest reading through if you have an interest in the subject

This is taken from the PDF. The main message from the NTA is that the following eight principles should be adhered to when considering prescribing injectable opiates:

This link is the guidelines issued to my local NHS specialist addiction unit, it's specific to east London but the guidelines are probably applicable to most drug services nationwide.

        Principles guiding injectable maintenance prescribing

This guidance recommends that injectable maintenance prescribing should only be undertaken in line
with eight principles.

1. Drug treatment comprises a range of treatment modalities which should be woven together to
form integrated packages of care for individual patients.

2. Substitute prescribing alone does not constitute drug treatment. Substitute prescribing requires
assessment and planned care, usually with other interventions such as psycho-social
interventions. It should be seen as one element or pathway within wider packages of planned
and integrated drug treatment.

3. Within the substitute prescribing modality, a range of prescribing options are required for
heroin misusers requiring opioid maintenance. Some options may carry more inherent risks
than others (e.g. injectable versus oral options). Patients who do not respond to oral
maintenance drug treatment should be offered other options in a series of steps. This would
normally include:
• oral methadone and buprenorphine maintenance, specifically optimised higher dose
oral methadone or buprenorphine maintenance treatment, then
• injectable methadone or injectable heroin maintenance treatment (perhaps in
combination with oral preparations).

4. Injectable maintenance options should be offered in a local area that can offer optimised oral
methadone maintenance treatment including adequate doses, supervised consumption and
psycho-social interventions. This is essential to ensure oral drug treatment options have been
fully explored prior to a trial of injectable maintenance treatment and to ensure smooth
transition back to oral treatment if required.

5. Injectable and oral substitute prescribing must be supported by locally commissioned and
provided mechanisms for supervised consumption. Injectable drugs may present more risk
of overdose than oral preparations and have a greater value on illicit markets and hence may
require greater levels of supervision.

6. Injectable maintenance treatment is likely to be long-term treatment with long-term resource
implications. Clinicians should consider the move from oral to a trial of injectable preparations
carefully, including long-term implications for the patient and drug treatment systems and
involvement of services.

7. Specialist levels of clinical competence are required to prescribe injectable substitute drugs.
Heroin prescribing also requires a Home Office licence.
8. The skills of the clinician should be matched with good local systems of clinical governance,
supervised consumption and access to a range of other drug treatment modalities.



         Clinical eligibility

The expert group reached some consensus on eligibility criteria, precautions and outcome measures.
However, guidance on issues such as dose or the prescribing of combinations of oral and injectable
preparations will require further work.
The agreed criteria are set out in full and relate to factors such as:
• age and drug usage
• willingness to comply with conditions such as supervision and monitoring, engagement
in a range of care options, avoidance of some risky behaviours and of diverting prescriptions
into illicit markets
• persistence of poor outcomes within an optimised oral programme.


         Recommendations

The key recommendations are that:
• optimised oral methadone maintenance should be the maintenance treatment for
the majority of heroin users
• injectable heroin and methadone treatments should be considered only for the minority of
patients who are genuinely unresponsive to an optimised oral maintenance treatment approach
• injectable heroin and injectable methadone treatments based on this guidance should
be seen as a new drug treatment modality requiring the development of new integrated
care pathways.


         Key messages

The document has four key messages:
1. The prescribing of injectable substitute opioid drugs may be beneficial for a minority of heroin
misusers. The document makes preliminary recommendations on eligibility criteria.
2. Future maintenance prescribing of injectable heroin or methadone should only be undertaken
if it is in line with eight principles identified by the expert groups. This is essentially a new
standard of injectable drug treatment to that previously provided in England. Applying these
principles in practice, sets a high standard for delivery of this treatment intervention, in
recognition of the risks involved.
3. Services should be improving for patients already in receipt of injectable maintenance
prescriptions for heroin or methadone. Where patients are stable, maintaining this stability
is paramount.
4. Priority should be given to improving the effectiveness of oral maintenance treatment (on
methadone or buprenorphine) for the majority of patients in all drug action team areas in England.


         Clinical evidence

The following statements were agreed as consensus on ‘clinical evidence’ by the expert group based
upon many years’ experience of prescribing heroin and other injectable drugs.
Statements from the expert advisory group

1. We consider that the prescribing of injectable substitute opioid drugs, including heroin and
methadone ampoules, may be of benefit for a minority of heroin misusers. In principle this
should be part of a range of potentially available drug treatment options, provided it is set
in the context of a comprehensive drug treatment package.

2. We consider the prescribing of heroin and other injectable opiate maintenance treatment is
not a first-line treatment for dependent heroin users. Injectable opioid maintenance treatment
(including injectable heroin maintenance) is an exceptional treatment that should only be
considered for patients who have not responded to optimised conventional oral
maintenance treatment.

3. We consider that there may be greater inherent risks with injectable opioid treatment, when
compared with the better-studied oral methadone maintenance (and other treatments, such
as sublingual buprenorphine maintenance that has less risk of overdose). These include
greater risks of overdose, continued injecting harms and greater risks of diversion and abuse
of medication. Formal consideration of the risks and benefits of injectable opioid treatment
should be undertaken with all potential patients, particularly those who may be at highest risk.

4. We consider that these risks and dangers (to the individual patient and to society at large)
can be greatly reduced by adherence to practices and procedures which increase
compliance with treatment, and which reduce prescribing to inappropriate patients, erratic
use and diversion to the illicit market.

5. We consider the assessment of potentially suitable patients, and the subsequent initiation of
injectable opioid maintenance treatment, to be a task that requires considerable experience
and expertise in the addictions field, and which should consequently be undertaken by a
competent specialist doctor* working in an appropriately supported treatment setting.

6. We consider that the wider safe provision of injectable opioid maintenance treatment
requires substantial identifiable resources and facilities (as recently established in Switzerland
and the Netherlands). These are required in order to make possible the wider provision of
injectable maintenance treatment options and thereby achieve these greater potential benefits
to the patient and society whilst minimising adverse consequences.


           Cost and cost-effectiveness of injectable substitute prescribing

Injectable substitute drug treatment is a relatively expensive drug treatment option. Calculating cost
and cost-effectiveness of different types of drug treatment is complex and attempts to do so are
compounded by a lack of agreement on appropriate methodology. The NTA is engaged in further
work to provide more accurate and consistent unit costings of drug treatment modalities and options.
Strang et al (2003) estimated that injectable methadone represented 20 per cent of the methadone
prescription drug costs in 2001 for four per cent of treatments. Indeed injectable methadone and heroin
treatment has been estimated to cost between 5 to 15 times as much as oral methadone treatment,
depending on the content of treatment packages and arrangements to supervise consumption.
Surveys of clinicians indicate that the cost of injectable heroin in particular is a prohibitive factor. In
addition, it is recognised that the substitute prescribing of injectable heroin and methadone in the UK
appears to be a long-term treatment which may limit long-term cost-effectiveness.
The NTA will explore issues of cost in greater depth. However, cost factors indicate that commissioners
need to be able to ensure that the provision of injectable maintenance drug treatment does not
undermine the overall quality of care for all patients. Where adequate access to optimised oral drug
treatment options are not available to the majority of patients, it may be particularly difficult to
demonstrate this.
The potentially “high cost and low volume” nature of injectable maintenance drug treatment indicates
that it should be targeted at patients with high levels of need. These patients are, in any case, likely
to incur high levels of costs to health and social care systems.


          Inclusion criteria for injectable opioid maintenance

Clients should meet all of the following inclusion criteria in order to be eligible for injectable
opioid maintenance:
• The client should have a protracted history (> 3 years) of heroin dependence and regular
daily injecting.
• The client should be aged 18 or over.
• The client should be able to provide informed consent. This includes no active medical
or psychiatric condition impairing the patient’s capacity to provide informed consent
• The client should be willing to comply with the conditions of injectable opiate
treatment2, including:
• a treatment plan
• regular supervision and monitoring
• avoidance of persistent injecting in high risk areas (e.g. neck or groin veins)
• continuation of injectable treatment being conditional upon positive healthy response
to treatment (which includes other treatment elements in a package of planned,
co-ordinated care)
• diversion of the prescribed injectable drugs and “double scripting” being grounds
for discontinuation of injectable treatment.
• The client should first have received optimised oral maintenance treatment - an adequate
period (normally at least six months and for some this could be significantly longer) of
optimised conventional substitution maintenance treatment and associated package of care.
• There should be a persistence of poor treatment outcomes despite a current optimised oral
maintenance treatment episode. Indicators of poor outcomes may include:
• continued frequent (daily or almost daily) injecting of illicit heroin or other opioids
• patients at continuing high risk of the transmission of HIV, HBV or HCV to
themselves or others
• continuing injecting-related health problems (e.g. abscesses, cellulitis,
systemic infections), poor general health, poor psychosocial functioning and
drug-related criminality.
If the inclusion criteria are met injectable opioid maintenance treatment may then legitimately
be considered by the clinician, in consultation with the patient, key carers and the relevant
multidisciplinary team.
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