Review of the World Health Organisation Guidelines for the Psychosocially Assisted Pharmacological Treatment of Opioid Dependence.

Prepared by Catriona Matheson, University of Aberdeen

These guidelines were published by the WHO Management of Substance Abuse Team in Geneva in early 2011. The guidelines have been reviewed only to consider areas in line with, and diverging from, the UK Clinical Guidelines published in 2007 (referred to as the Orange Guidelines).

General

The WHO guidelines are well presented and give good background information and justification for the need to treat drug dependence pharmacologically and with psychosocial support. These guidelines have recommended these as a good background text for anyone new to the field who wants an overview. The guidelines are presented with two levels of recommendation: a minimum standard and a good practice level. The provision of evidence profiles is particularly helpful as the strength of evidence was not so explicitly presented in the Orange Guidelines. These WHO guidelines give a summary table of the evidence for each section as well as noting the strength of evidence next to recommendations.

In line with the Orange Guidelines:

  1. Maintenance prescribing with methadone or buprenorphine is recommended.
  2. Availability of community detoxification.
  3. Psychosocial support is also recommended.
  4. Supervision of treatment initially is recommended although no timescale is given.
  5. The duration of opiate agonist treatment is recommended to be open ended.

Areas of Difference from Orange Guidelines

There are not any actual areas of difference but the guidelines do cover areas not covered in the orange guidelines. In particular, there is a whole section on programme level guidelines which covers evaluation of treatment, staff training and naloxone provision. Similarly tuberculosis is addressed in the WHO guidelines but not the orange guidelines.

  1. Evaluation of treatment is recommended including a mechanism for monitoring the extent of diversion. (Unfortunately it does not suggest how.)
  2. Guidelines recommend both intermittent and ongoing evaluation of both the process and outcomes of treatment provided.
  3. Staff Training: Health authorities are recommended to ensure staff are appropriately trained. This goes a bit further than the orange guidelines which suggests doctors should be appropriately trained.
  4. Naloxone provision for overdose is recommended. In the text it notes there is evidence for users distribution but this is not encompassed in the wording.
  5. Tuberculosis should be treated. Importantly, those with active TB are highly contagious and should be kept separate from other patients prior to and in the first two weeks of treatment.