Drug Matrix cell C1: Management/supervision: Reducing harm

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Society for the Study of Addiction web site

Society for the Study of Addiction

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Skills Consortium web site. Opens new window

Alcohol Treatment Matrix

Effectiveness Bank Alcohol Treatment Matrix

Includes brief interventions

Drug Treatment Matrix

Effectiveness Bank Drug Treatment Matrix

Includes harm reduction

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Seminal and key studies on the role of management and supervision in reducing harm associated with illegal drug use.

S Seminal studiesK Key studiesR ReviewsG Guidancemore Search for more studies

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S Forced discharge and drop-out mean more post-methadone deaths (1999). Cites US study (1998) which found that in the first year after leaving a methadone programme the death rate was eight times higher than among patients who remained in treatment; all nine deaths were of patients who had dropped out or been discharged for breaking programme rules, and two-thirds were overdoses. For related discussions click here and here and scroll down to highlighted headings.

K Slow ‘cascade’ of anti-overdose training from staff to other staff and patients (2011). Drug service staff in England trained in overdose recovery using naloxone then trained other staff and patients, but why on average did each clinician train just one drug user every 11 months? From same study report on resulting use of naloxone (2008) and a follow-up (2009) of some of the trainees which revealed reluctance to carry around naloxone kits, partly due to having completed treatment intended to divorce them from drug use and by extension, drug using associates. For discussion click here and scroll down to highlighted heading.

K Prematurely discharging heroin users from treatment risks lives (2007). Reports on a large Italian study which demonstrated the protection against overdose deaths afforded by being in treatment, and the danger of leaving with reduced tolerance to opiate drugs but still vulnerable to relapse. For managers, highlights the dilemma of balancing retention with throughput, and enforcing expectations and rules with keeping ‘problem’ patients safe(r). For discussion click here and scroll down to highlighted heading.

K Supervised consumption cuts methadone deaths (2010). From the mid 1990s British addiction treatment clinics started to require patients to take their methadone under medical supervision, preventing diversion to the illicit market and thousands of overdose deaths.

K Dilemma posed by continued illegal drug use during methadone treatment (2013). In Norway even patients in the top quarter for continuing drug use while on methadone benefited from a near four-fold reduction in the number of courses of hospital treatment needed for drug-related physical complaints. These episodes rebounded when patients were forced to or chose to leave. Similar findings have come from Sweden (2009), where during an enforced gap in treatment for breaking programme rules (usually by continuing to use illegal drugs), hospital admissions rose only to fall again when the same addicts were allowed to return. For related discussions click here and here and scroll down to highlighted headings.

K Vancouver’s needle exchange: lessons of failure (2012). The city which hosted North America’s most prolific exchange nevertheless saw HIV and hepatitis C sweeping through its drugs quarter. Prime among the reasons are believed to have been restrictions imposed and self-imposed on the service, including limited opening hours and one-for-one exchange. Related review below. For discussion click here and scroll down to highlighted heading.

R Don’t restrict supply of injecting equipment (2013). Extensive UK review updated in 2013 which underpinned NICE guidance below. The reviewers found consistent evidence that more liberal supply of injecting equipment was associated with less risky injecting practices. For related discussion click here and scroll down to highlighted heading.

R Challenge of reconciling community concerns with needle exchange priorities (2003 and 2004). Four-part series from Drug and Alcohol Findings highlights the challenge of freely distributing the “flood” of injecting equipment needed to curtail hepatitis C and managing local wariness about needle exchange fuelled particularly by discarded syringes. Part 2 includes the instructive case study of Vancouver, subject of key study above. For discussion click here and scroll down to highlighted heading.

G NICE says abundance is the objective for injecting equipment provision ([UK] National Institute for Health and Care Excellence, 2014). UK’s health technology regulator says exchange service managers should aim for every injector to have more sterile injecting equipment than they need for every injection. Also available NICE-endorsed checklist (2015) to audit compliance with the guidance. For discussion click here and scroll down to highlighted heading.

G Scottish guidance on running and commissioning needle exchanges (Scottish Government, 2010). Includes needs assessment, locations, opening hours, staff training, injecting equipment provision policies, and integration with other services. Calls on services to redress the large shortfall in supplying enough needles/syringes for each injection.

G WHO guide to starting and managing needle and syringe programmes (World Health Organization [etc], 2007). Rare in this sector to have what is effectively a management manual, a sign of the importance WHO attaches to making needle exchanges as effective as possible to combat HIV. Also issued by a UN agency is a similar guide (United Nations Office on Drugs and Crime, 2014) for prisons and other closed settings. For discussion click here and scroll down to highlighted heading.

G UN guide on planning, coordinating and managing comprehensive HIV and hepatitis C programmes for injectors (United Nations Office on Drugs and Crime, 2017). Includes guidance on needle exchange, substitute prescribing, treatment of infection, naloxone distribution, education, and addressing risk of sexual transmission.

G How UK treatment services can help reduce drug-related deaths (Collective Voice and NHS Substance Misuse Provider Alliance, 2017). Recommendations and practice examples developed (with the support of Public Health England) by bodies representing drug and alcohol services in England.

G Scottish Drugs Forum naloxone web site. Offers resources, advice, guidance, information and news on programmes featuring the drug naloxone which reverses opiate overdose. Being reconstructed at time of writing.

G EU advice on preventing overdose through naloxone programmes (European Monitoring Centre for Drugs and Drug Addiction [EMCDDA ], 2016). Background information on naloxone and in chapter 5 advice on setting up take-home naloxone training and distribution programmes.

G Balancing recovery ambition with safety and harm reduction ([UK] National Treatment Agency for Substance Misuse, 2012). Clinical consensus developed for UK government on how drug-based treatment for heroin addiction can be made more recovery-oriented without losing harm reduction benefits. See also supplement (2013) on reviewing patients to see if treatment should be changed or ended. For discussion click here and scroll down to highlighted heading.

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