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G .Evidence for effectiveness of harm-reduction services and improved uptake of treatment and support services (Recovery Model) |
Summary There is highly processed and review-level evidence of the effectiveness of harm reduction services such as IEP, THN, ORT and provision of foil, to prevent or reduce the significant harms associated with problem drug use, including bloodborne viruses and drug-related deaths. Harm reduction services have immediate public health benefits and are widely acknowledged to contribute to engaging and promoting recovery programmes. Rationale Injecting equipment provision (IEP)
The main aim of needle and syringe programmes is to reduce the transmission of blood-borne viruses and other infections caused by sharing injecting equipment, such as HIV, hepatitis B and C. In turn, this will reduce the prevalence of blood- borne viruses and bacterial infections, so benefiting wider society. Many needle and syringe programmes also aim to reduce the other harms caused by drug use and include:
NICE public health guidance PH52 (2014), which updates and replaces NICE public health guideline 18 (published on February 2009 and available from: ww.nice.org.uk/guidance/ph18) has 10 recommendations:
The guidance outlines a number of factors and issues it took into account when developing the recommendations and updating the guidance:
PHAC considered a summary of the findings from the health economic modelling undertaken for the original guidance. This showed that providing people who inject opioid drugs with sterile injecting equipment is estimated to be cost-effective from an NHS/personal social services (PSS) perspective (that is, excluding the costs of crime). It is similarly cost-effective from a societal perspective. If the indirect 'gateway' effects of needle and syringe programmes – of increasing the proportion of people who inject drugs who take up opioid substitution therapy, or take part in other drug treatment – are included, a fall in the number who inject drugs is likely. This would, in turn, lead to a reduction in crime. If that is the case, modelling shows that these programmes are likely to be cost-effective in the longer term. However, the figures in relation to the size of the 'gateway effect' are subject to considerable uncertainty, as are figures relating to any effect that an increase in needle and syringe programmes will have on the number of people injecting drugs. [1]
Take-home naloxone (THN) Naloxone is an opioid antagonist, which temporarily reverses the effects of heroin and other opioids, it has no intoxication effects and no abuse potential. Naloxone is recommended as an intervention to prevent overdose by the World Health Organization as an essential medicine and is already used by the emergency services. In their review of UK and international evidence on the effectiveness of naloxone provision the ACMD (2012) recommends that naloxone should be made more widely available to tackle the high numbers of fatal opioid overdoses in the UK. The report highlights the educational and public health benefits, in that the provision of naloxone will widen awareness of the risks opioid overdose, and emphasises the importance of basic life support training as part of the package of interventions to prevent opioid overdose. The ACMD (2012) report on the consideration of naloxone notes that risks and concerns regarding the provision of naloxone programmes potentially increasing drug using risk(s) are not supported by evidence. The report cites literature (see Gaston et al 2009) that participants in naloxone programmes have been found to have an ‘increase in self efficacy and more insight in relation to personal safety and health’. [2] Opioid replacement therapy (ORT) In their commissioned independent expert review of the place of ORT for the Chief Medical Officer for Scotland [3], the Drug Strategy Delivery Commission (DSDC) (2013) cite consistent conclusions from systematic reviews that ORT is effective treatment for opioid dependency and is associated with improved retention in treatment, reduced illicit heroin use and reduced risk of harm related to injecting and transmission of BBVs. Less consensus from the systematic reviews is noted in relation to positive effects on criminal activity and mortality. Factors identified with positive outcomes are treatment dose and quality of therapeutic relationships. The DSDC authors conclude that despite the limitations noted in the quality of research the benefits to physical health and reduction in BBVs is strongly supported by the evidence. The final report of the independent review makes 12 recommendations, including the following:
The provision of foil The following was provided as rationale:
(Reference to the ACMD’s previous recommendations on drug paraphernalia are also included in the report – namely to amend the misuse of drugs legislation to permit the supply of swabs, bowls, spoons, stericups, citric acid and water for injecting (May 2001) and filters (May 2003) – these recommendations were accepted by government and changes made by secondary legislation -Regulation 6A of the 2001 Regulations.) On 5 September 2014 a statutory instrument was announced as a change to the Misuse of Drugs Regulations 2001 to authorize, subject to strict conditions, the lawful supply, or offer to supply, of foil by persons employed or engaged in the lawful provision of drug treatment services. [5] “The legislation only refers to a ‘treatment plan’ but the clear ambition of the drug strategy and of the Home Secretary in allowing for the provision of foil is that this will be treatment aimed at recovery from dependence, not only the reduction of harm. A treatment plan is not a requirement at the stage when steps are being taken to engage a patient in treatment. Although not covered in the legislation, the expectation is that in the vast majority of cases foil will be provided at the early stages to engage a patient into treatment, or at a time when a patient has been assessed and commenced treatment but has yet to stop taking drugs. However, it is also recognized that there may be exceptional circumstances when provision of foil may be necessary later in a patient’s treatment at a time when they are at risk of a relapse to help them avoid returning to injecting.” NICE Clinical Guidelines for Drugs Misuse: Psychosocial Interventions' (CG51) key priority for implementation [6]:
There is review-level evidence of the effectiveness of screening and brief interventions for secondary prevention of drug use in multiple settings. Results from one study found brief interventions in a clinical setting can reduce cocaine and heroin use (even without meaningful contact with the treatment system). There is evidence from single studies that motivational interviewing is effective in students to reduce cannabis, alcohol and tobacco use and to reduce consumption among regular amphetamine users. Limited evidence of effectiveness of the impact of GP and primary-care-based brief interventions to reduce excessive benzodiazepine use and other illicit drugs. Evidence of effectiveness of brief interventions with adolescent school-aged children is less conclusive, with limited studies finding mixed results in reducing drug use. [7]
Scottish policy and practice note The Sexual Health and Blood Borne Virus Framework (2011–2015) [8] combines areas of work surrounding sexual health, HIV, hepatitis C and hepatitis B. It is a multi-agency, cross-agenda approach based on five high-level outcomes: Outcome 1: Fewer newly acquired blood borne virus and sexually transmitted infections
Guidelines for services providing injecting equipment: Best practice recommendations for commissioners and injecting equipment provision (IEP) services in Scotland (2010) [9]
A National Take Home Naloxone Programme [10] has been centrally funded by the Scottish Government investment in the programme provides
Further information can be found here: www.sdf.org.uk/index.php/drug-related-deaths/take-home-naloxone-thn-overdose-intervention-training/ or www.naloxone.org.uk
It specifically focuses on the blood-borne virus (BBV) (HIV, hepatitis C and hepatitis B) elements of the national framework, reflecting sexual health issues only as they relate to BBVs. Available online at:
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