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National Collaborating Centre for Mental Health (UK). Drug Misuse: Opioid Detoxification. Leicester (UK): British Psychological Society; 2008. (NICE Clinical Guidelines, No. 52.)

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Drug Misuse: Opioid Detoxification.

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12-step group

A non-profit fellowship of people who meet regularly to help each other remain abstinent. The core of the 12-step programme is a series of 12 stages that include admitting to a drug problem, seeking help, self-appraisal, confidential self-disclosure, making amends (when possible) where harm has been done, achieving a spiritual awakening and supporting other people who misuse drugs who want to recover.


Abstinence-oriented treatments aim to reduce an individual’s level of drug use, with the ultimate goal of refraining from use altogether.


An agonist is a substance that mimics the actions of a neurotransmitter or hormone to produce a response when it binds to a specific receptor in the brain. Opioid drugs, for example heroin and methadone, are agonists that produce responses such as ‘liking’, analgesia and respiratory depression.

Alpha2 adrenergic agonist

An adrenergic agonist has an adrenaline-like action upon adrenergic receptors in the brain. Stimulation of the alpha adrenergic receptors leads to constriction of the bronchi and blood vessels, and dilation of the pupils of the eyes. Consequently, alpha2 adrenergic agonists are useful in improving opioid withdrawal symptoms associated with the noradrenaline system, including sweating, shivering, and runny nose and eyes. Clonidine and lofexidine are examples of adrenergic agonists used as adjunctive medication in opioid detoxification.


In contrast to the action of an agonist, an antagonist, such as naltrexone, binds to a specific receptor in the brain but does not activate it. Therefore, if an agonist, for example heroin or methadone, is present and activating the receptor, taking naltrexone will counteract the activation, resulting in withdrawal.


An analgesic opioid substitute used in maintenance-oriented treatment, buprenorphine has both agonist and antagonist properties.


Cannabis is a generic term denoting the various psychoactive preparations of the hemp plant, including marijuana leaves, hashish resin and oil (WHO, 2006). It is the most commonly used illicit drug in the UK.

Cognitive behavioural therapy

Cognitive behavioural therapy encompasses a range of behavioural and cognitive behavioural therapies, in part derived from the cognitive behavioural model of affective disorders, in which the patient works collaboratively with a therapist using a shared formulation to achieve specific treatment goals. Such goals may include recognising the impact of behavioural and/or thinking patterns on feeling states and encouraging alternative cognitive and/or behavioural coping skills to reduce the severity of target symptoms and problems. Therapies relevant to the field of drug misuse include standard cognitive behavioural therapy and relapse-prevention cognitive behavioural therapy.

Community reinforcement approach

In community reinforcement, emphasis is placed on environmental contingencies in aspects of life such as work, recreation, family involvement, and so on, to promote a lifestyle that is more rewarding than drug misuse (Roozen et al., 2004).

Confidence interval

The range within which the ‘true’ values (for example, size of effect of an intervention) are expected to lie with a given degree of certainty (for example, 95% or 99%). (Note: confidence intervals represent the probability of random errors, but not systematic errors or bias.)

Contingency management (CM)

Contingency management provides a system of incentives and disincentives designed to make continual drug use less attractive and abstinence more attractive (Griffith et al., 2000). The three main methods of providing incentives are voucher-based, whereby vouchers representing monetary values are provided upon receipt of biological samples (usually urine) that are negative for the tested drugs, prize-based (whereby participants receive prize-draw entries upon presentation of a negative biological sample) and privilege-based (whereby participants receive privileges such as take home methadone doses upon presentation of a negative biological sample).

Deep/heavy sedation

A high level of sedation, where the subject may not be easily aroused or purposefully respond to verbal commands and may only respond minimally to very significant stimuli (such as high levels of pain). He or she may experience partial or complete loss of protective reflexes, including the ability to independently and continuously maintain an open airway. The individual may therefore require assistance in maintaining an open airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.


Dependence is defined by the WHO as a strong desire or sense of compulsion to take a substance, a difficulty in controlling its use, the presence of a physiological withdrawal state, tolerance of the use of the drug, neglect of alternative pleasures and interests and persistent use of the drug, despite harm to oneself and others (WHO, 2006).


Detoxification is the process by which an individual is withdrawn from the effects of a psychoactive substance. As a clinical procedure, the withdrawal process should be supervised and carried out in a safe and effective manner, such that withdrawal symptoms are minimised. Typically, the individual is clinically intoxicated or already in withdrawal at the outset of detoxification. Detoxification may involve the administration of medication, the dose of which is calculated to relieve withdrawal symptoms without inducing intoxication, and is gradually tapered off as the individual recovers.

Drug misuse/problem drug use

Drug misuse is the use of a substance for a purpose not consistent with legal or medical guidelines (WHO, 2006). The ACMD defines problem drug use as a condition that may cause an individual to experience social, psychological, physical or legal problems related to intoxication and/or regular excessive consumption, and/or dependence; any injection drug use also constitutes misuse (ACMD, 1998).

False negative

A test result that fails to detect an effect, condition or drug when it is in fact present.

False positive

A test result that incorrectly shows an effect, condition or drug to be present when it is not.

Family intervention

A psychological intervention derived from a model of the interactional processes in families. Interventions are aimed to help participants understand the effects of their interactions on each other as factors in the development and/or maintenance of drug misuse. Additionally, the aim is to change the nature of the interactions so that they may develop relationships that are more supportive and have less conflict (NICE, 2004).

General anaesthesia

Under general anaesthesia, an individual is unconscious and unresponsive, even in the face of significant stimuli. The ability to independently maintain ventilatory function is often impaired and assistance is frequently required in maintaining an open airway. Cardiovascular function may be impaired.

Harm reduction

Measures aiming to prevent or reduce negative health or other consequences associated with drug misuse, whether to the drug-using individual or to society. Attempts are not necessarily made to reduce the drug use itself.

Incremental cost-effectiveness ratio

The difference in the mean costs in the population of interest divided by the differences in the main outcomes in the population of interest.

Individual drug counselling

The assessment of an individual’s needs, provision of information and referral to services to meet these needs (including psychosocial interventions, methadone and residential rehabilitation). No attempt is made to engage in any specific formal psychological intervention. Sessions are normally weekly and last 15–20 minutes (Rawson et al., 1983). This to some extent resembles keyworking as used in the UK drug treatment field.

Interpersonal therapy (IPT)

A discrete, time-limited, structured psychological intervention that focuses on interpersonal issues and where therapist and service user: a) work collaboratively to identify the effects of key problematic areas related to interpersonal conflicts, role transitions, grief and loss, and social skills, and their effects on current drug misuse, feelings states and/or problems; and b) seek to reduce drug misuse problems by learning to cope with or resolve interpersonal problem areas (Weissman et al., 2000).

Legally coerced (drug) treatment

This requires that the person who misuses drugs enter into treatment as an alternative or adjunct to criminal sanctions (Wild et al., 2002). Such treatment can either be legally ordered by the court or through diversion away from the judicial process, usually following arrest and charge for drug-related and other offences.


An alpha2 adrenergic agonist currently licensed and used widely in the UK to ameliorate a cluster of opioid withdrawal symptoms (those associated with the noradrenaline system, including sweating, shivering, and runny nose and eyes).


In the UK context this refers primarily to the pharmacological maintenance of people who are opioid dependent; that is, prescription of opioid substitutes (methadone or buprenorphine). This aims to reduce illicit drug use and its consequent harms.


The use of statistical techniques to integrate the results of several independent studies.


A chemical product derived from breakdown (metabolism) of another chemical.


A synthetic, psychoactive opioid substitute used in maintenance-oriented treatment, particularly heroin dependence. Methadone has agonist properties.

Minimal/light sedation

This involves the administration of medication in order to deal with anxiety, insomnia or agitation. The defining characteristic of this type of sedation is that the individual still appears relatively awake and is able to communicate clearly at all times. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected.

Moderate sedation

This occurs where the individual appears obviously sedated but, importantly, is able to independently maintain an open airway and respond to stimuli purposefully (such as verbal questioning).


A short-acting antagonist that blocks the effects of opioid drugs on receptors in the brain, naloxone is used to detect the presence of opioid effects (in what is known as a naloxone challenge test) and also in emergency situations to reverse opioid overdose.


An antagonist that blocks the effects of opioid drugs on receptors in the brain, naltrexone is used in maintenance treatment to prevent detoxified service users from relapsing to opioid use.

National Collaborating Centre for Mental Health

One of seven centres established by the National Institute for Health and Clinical Excellence (NICE) to develop guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS in England and Wales. Established in 2001, the NCCMH is responsible for developing mental health guidelines, and is a partnership between the Royal College of Psychiatrists and the British Psychological Society.

National Institute for Health and Clinical Excellence

An independent organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health. It provides guidance on three areas of health: clinical practice, public health and health technologies.

National Treatment Agency for Substance Misuse

The NTA is a special health authority, which was established by the government in 2001. It is tasked with increasing the availability, capacity and effectiveness of treatment for drug misuse in England and embraces user involvement as a core component of its strategy.

Near-patient testing

This refers to the process of obtaining a biological sample from a service user and using a drug-testing kit to immediately detect the presence of any of a variety of substances (for example, opioids, amphetamines, cocaine metabolite, benzodiazepines, methadone and cannabis) on site. This process eliminates the need for external laboratory support and provides rapid results.

Needle and syringe exchange

A service aiming to reduce transmission of blood-borne viruses through the promotion of safer drug injection behaviour, primarily via the distribution of sterile needles, but often also by offering education and other psychosocial interventions.


A chemical messenger (for example, dopamine or noradrenaline) used by nerve cells to transmit nerve impulses from one nerve cell (neuron) to another, or between neurons and other tissues, such as muscles or glands.

Noradrenaline system

A neuronal system that is responsible for the synthesis, storage and release of the neurotransmitter noradrenaline, which exists in both the central and peripheral nervous systems. It is the primary neurotransmitter released by the sympathetic nervous system, which mediates the ‘fight or flight’ reaction, preparing the body for action by affecting cardiovascular function, gastrointestinal motility and secretion, bronchiole dilation, glucose metabolism, and so on.

Odds ratio

A measure of the relative benefit of the experimental treatment that can be obtained by dividing the experimental odds by the control odds.


A class of psychoactive substances derived from the poppy plant, including opium, morphine and codeine, as well as their semi-synthetic counterparts, including heroin (WHO, 2004). In this guideline, the term ‘opioid’ is used more broadly to incorporate synthetic compounds (including methadone) with similar properties, also commonly known as opioids.

Psychosocial intervention

Any formal, structured psychological or social intervention with assessment, clearly defined treatment plans and treatment goals, and regular reviews (NTA, 2006), as opposed to advice and information, drop-in support or informal keyworking.

Quality adjusted life years

A form of utility measure calculated by estimating the total life years gained from a treatment and weighting each year with a quality-of-life score in that year.

Randomised controlled trial

An experiment in which investigators randomly allocate eligible people into groups to receive or not to receive one or more interventions that are being compared. The results are assessed by comparing outcomes in the different groups. Through randomisation, the groups should be similar in all aspects, apart from the treatment they receive during the study.

Rapid/ultra-rapid detoxification

Approaches for detoxifying those dependent upon opioids whereby opioid antagonists, such as naloxone, naltrexone or nalmefene, are used under general anaesthesia or deep sedation. The aim is to flood the brain with an opioid antagonist to remove all agonists while the sedation (for rapid detoxification) or anaesthesia (ultra-rapid detoxification) minimises discomfort. The individual is then maintained on naltrexone.

Relapse-prevention cognitive behavioural therapy

This differs from standard cognitive behavioural therapy in the emphasis on training drug users to develop skills to identify situations or states where they are most vulnerable to drug use, to avoid high-risk situations, and to use a range of cognitive and behavioural strategies to cope effectively with these situations (Carroll & Onken, 2005).

Relative risk

The ratio of risk in the intervention group to the risk in the control group. The risk (proportion, probability or rate) is the ratio of people with an event in a group to the total in the group. An RR of 1 indicates no difference between comparison groups. For undesirable outcomes, an RR that is less than 1 indicates that the intervention was effective in reducing the risk of that outcome.

Residential rehabilitation programme

Residential rehabilitation centres provide accommodation in a drug-free environment and a range of structured interventions to address drug misuse, including, but not limited to, abstinence-oriented interventions (NTA, 2006). Services vary and are based on a number of different treatment philosophies.


The systematic application of a test or enquiry to identify individuals at high risk of developing a specific disorder who may benefit from further investigation or preventative action (Peckham & Dezateux, 1998). Routine screening for drug misuse in the UK is largely restricted to criminal justice settings, including police custody and prisons (Matrix Research and Consultancy & NACRO, 2004).

Self-help group

A group of people who misuse drugs meet regularly to provide help and support for one another. The group is typically community-based, peer-led and non-professional.


A term used to assess screening tools, sensitivity refers to the proportion of people with disease who test positive for that disease.

Short-term psychodynamic intervention

A psychological intervention, derived from a psychodynamic/psychoanalytic model in which: a) therapist and service user explore and gain insight into conflicts and how these are represented in current situations and relationships, including the therapy relationship; b) service users are given an opportunity to explore feelings and conscious and unconscious conflicts originating in the past, with the technical focus on interpreting and working through conflicts; c) therapy is non-directive and service users are not taught specific skills such as thought monitoring, re-evaluation or problem solving. Treatment typically consists of 16–30 sessions (Leichsenring et al., 2004).

Social network interventions

Professionals seek to promote change by helping the person who misuses drugs to engage with a close network of family members or friends who provide positive social support for attempting or maintaining abstinence (Copello et al., 2005).


A term used to assess screening tools, specificity refers to the proportion of people without disease who test negative for that disease.

Standard cognitive behavioural therapy

A discrete, time-limited, structured psychological intervention, derived from a cognitive model of drug misuse (Beck et al., 1993). There is an emphasis on identifying and modifying irrational thoughts, managing negative mood and intervening after a lapse to prevent a full-blown relapse (Maude-Griffin et al., 1998).

Standard deviation (SD)

A statistical measure of variability in a population of individuals or in a set of data. While the average measures the expected middle position of a group of numbers, the standard deviation is a way of expressing how different the numbers are from the average. The standard deviation is (approximately) the amount by which the average person’s score differs from the average of all scores.

Standardised mean difference

In a meta-analysis, a way of combining the results of studies that may have measured the same outcome in different ways, using different scales. Statistically, it is calculated by dividing the weighted average effect size by the pooled standard deviation. The SMD is expressed as a standard value with no units.


Broadly any substances that activate, enhance or increase neural activity (WHO, 2006). Illicit stimulants include cocaine, crack cocaine and methamphetamine. Cocaine is one of the most commonly misused stimulants in the UK; crack cocaine refers to the cocaine alkaloid that has been purified from the other components of cocaine powder, and methamphetamine is one of a group of synthetic substances (amphetamines) with broadly similar properties to cocaine.

Systematic review

Research that summarises the evidence on a clearly formulated question according to a predefined protocol using systematic and explicit methods to identify, select and appraise relevant studies, and to extract, collate and report their findings. It may or may not use statistical meta-analysis.


A synthetic opioid, tramadol is a weak agonist which may also have partial antagonist properties. More commonly used in the context of pain relief, it is neither licensed nor routinely used in the UK for the treatment of opioid dependence.

Weighted mean difference

A method of meta-analysis used to combine measures on continuous scales, where the mean, standard deviation and sample size in each group are known. The weight given to each study (for example, how much influence each study has on the overall results of the meta-analysis) is determined by the precision of its estimate of effect and, in the statistical software used by the NCCMH, is equal to the inverse of the variance. This method assumes that all of the trials have measured the outcome on the same scale.

Withdrawal symptoms

Withdrawal symptoms ensue when a person who has become tolerant to the effects of a drug stops taking it. Such symptoms typically emerge within 6–12 hours for short-acting opioids such as heroin and about 24–36 hours after the last dose of methadone or buprenorphine, depending on the dose. Withdrawal can also ensue when an opioid antagonist, such as naloxone or naltrexone is taken; this is called precipitated or abrupt withdrawal. Opioid withdrawal symptoms can include pupil dilation, diarrhoea, low mood, irritability, anxiety, insomnia, muscular and abdominal pains, restlessness and ‘craving’. In addition, tachycardia, sweating, runny nose, hair standing on end and shivering are generally experienced.

Copyright © 2008, The British Psychological Society & The Royal College of Psychiatrists.

All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Enquiries in this regard should be directed to the British Psychological Society.

Bookshelf ID: NBK50644


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