The Department recognises the key role that effective pharmacotherapies, including substitute opiate prescribing and medications such as naltrexone to assist relapse prevention, may play in the management of opiate dependence. The Department published its evidence-based Clinical Guidelines, “Drug misuse and dependence—guidelines on clinical management”, in 1999, on the advice of an independent expert group and in conjunction with relevant professional bodies. The 1999 Clinical Guidelines address the use of methadone, buprenorphine (more recently with a marketing authorisation for use as Subutex) and naltrexone. The guidelines discuss the relative effectiveness of buprenorphine and methadone, but as naltrexone is licensed only for use to support relapse prevention, no direct comparison is feasible with the opiate substitute methadone and buprenorphine. The guidelines do support the use of all these drugs as potentially effective opiate misuse treatments when used appropriately. The Department’s clinical guidelines are due to be updated in 2006-07 and this will take into account planned guidance on the use of all these drugs due to be published in 2007 by the National Institute for Health and Clinical Excellence (NICE).
The Department of Health has asked NICE, within a package of work that they will be undertaking on drug treatment, to carry out a technology appraisal on oral methadone and sublingual buprenorphine as opiate substitute treatments. This appraisal will evaluate the clinical effectiveness and cost-effectiveness of these drugs as substitute opiates for the management of opiate misusers. The Department also asked at the same time for a similar technology appraisal for “naltrexone as a treatment for relapse prevention” for opiate misuse. This will include appraisal of its clinical effectiveness and cost-effectiveness. Both these technology appraisals are scheduled for publication in March 2007.
All three of these drugs are currently prescribed for management of opiate dependence. Given that the NHS are obliged to implement guidance produced by NICE, the outcome of their work on drug treatment will be an important support in enhancing the effectiveness of drug treatment and in particular substitute prescribing.