APPENDIX 11
Memorandum submitted by the Royal College
of General Practitioners
DOES EXISTING DRUG POLICY WORK?
Existing drugs policy aims at increasing the
numbers of drug users in treatment and increasing the numbers
of general practitioners involved in their care.
1. GENERAL PRACTITIONERS
AND THE
CARE OF
DRUG USERS
2. Background
Historically there has been a drive by policy
makers to involve General Practitioners in the care of drug users,
this drive given impetus during the 1980's AIDs epidemic.
3. Reasons put forward favouring general practice
involvement are:
— Often first point of contact for
patients and their families.
— General practitioners make up the
majority of doctors in the UK.
— General practitioners able to provide
care that bridges physical, social psychological.
— Drug users prefer treatment by their
family doctors, seeing it as more "normalising; less stigmatising
and more easily accessible.
— Escalating waiting lists and absence
of specialist care in some areas.
— Increasing move towards primary care
led NHS and diversification of primary care.
4. With few notable exceptions general practitioners
have been slow to respond to this policy drive. Estimates in the
1980s of general practice involvement have varied but were around
5 per cent to 10 per cent of general practitioners were actively
involved in the care of drug users. Of these doctors that were
involved they tended to have large numbers of patients—with
some estimates showing that 5 per cent of general practitioners
looked after 50 per cent of all the drug using patients receiving
treatment in a primary care setting. This wide variance left these
doctors at risk from exploitation, burnout and of falling into
bad practice. Surveys also identify geographical variations.
5. Barriers to GP involvement
— Difficulty in establishing rapport
and fears of being taken advantage of and deceit.
— Negative attitudes to drug users.
— Disgust at injecting practices.
— Concern about legal status and potential
litigation.
— Fear of contracting HIV from needle
stick injuries.
— Fear of censure from colleagues for
substitute prescribing.
— Possible effect on other practice
patients.
— Disillusionment at patient's relapses.
— Costs of substitute prescribing.
— Work load involved in seeing drug
users—estimated at around 20 times age matched patient.
6. In order to improve this level of general
practice involvement Government Drug Policy has needed to address
with the profession three fundamental principals:
7. Role Legitimacy (GPs must feel they have
a role to play not just that "something has to be done")
7.1 This is perhaps the most important of
these three principals, without general practitioners feeling
they have a role to play in the care of these patients no amount
of additional resources, structures, training etc will produce
change. There is little doubt that general practitioners have
a legitimate role to play in the treatment of drug users, nevertheless
for many this means the provision of general medical services
only (for example treatment of acute episodes of illness). Arguments
amongst the profession over the years have been focused on what
is considered to be "general medical care" and whether
this includes provision of substitute medication. Without general
practitioners becoming involved in the total care of these patients
the Government's strategy to increase the numbers of drug users
in treatment cannot be met.
7.2 Perhaps the turning point for the profession
came in 2000, when the RCGP together with the General Practitioners
Committee (subcommittee of BMA) produced a joint statement: see
Annex. This statement emphasised that general practitioners should
get involved in the general care of drug users, though adding
that where GPs developed a special expertise in the management
of drugs misuse, they must be trained and supported in this work.
8. Role Support (share care, good specialist
services, clinical guidelines)
8.1 Government policy, in relation to primary
care/drug misuse treatment has centred on the provision of shared
care. This can be considered as joint participation in the care
of drug users that goes beyond the simple exchange of letters.
There are many models of shared care: most centre on liaison nurses
providing general practitioners with a range of support depending
on the needs of the GP, the complexity of the patient, access
to other services etc. Shared care should be about reducing the
burden of care on continuing care by specialist services which
in turn also would encourage general practitioners to cope with
less severe and complex illness.
8.2 Clinical guidelines provide general
practitioners with the framework for safe, evidence-based treatment.
Whilst some general practitioners feel these guidelines are too
prescriptive (for example recommending daily supervised ingestion)
many value them as a means of reducing the risks to themselves
and to their patients.
9. Role Adequacy
9.1 The average amount of time provided
for training in substance misuse at undergraduate level is around
one to two hours this figure being a reduction from previous surveys.
With few notable exceptions, no medical school deals with substance
misuse as part of the core curriculum. However, there are centres
of excellence in this respect with a handful of medical schools
devoting a much longer amount of training time to this subject.
However, most doctors will have had no training in substance misuse
either at undergraduate or postgraduate level. Lack of training
inevitably leads to fear and prejudices which in turn fosters
negative responses towards this patient group. Lack of training
also means that general practitioners are ill prepared to understand
the place of drugs in our society and particularly amongst young
people. Messages from general practitioners must be informed and
relevant.
10. Government led initiatives to support
drug strategy have been put in place over the last two to three
years to improve the quality and quantity of general practice
involvement and to address the three principals discussed above.
These initiatives are:
— development of National Clinical
Guidelines for Treatment of Drug Misuse (1999);
— funding for the establishment of
a National Primary Care Network (1999);
— funding for the establishment of
Shared Care Monitoring Groups within each Health Authority (2000);
— funding of a Royal College of General
Practitioners National Drugs Training Programme aimed at Primary
Care Practitioners with Special Interest in Drug Misuse (2000);
— funding National Training Programme
aimed at Generalist Practitioners (2000); and
— funding of Drug Prevention initiatives
aimed at improving the links between primary care and primary
care aged school children (1999).
11. CONCLUSION
12. General practice has moved a great deal
over the last 30 years in its response to the care of drug users,
and more so in the last two years than at any other time. There
can be few general practitioners who believe that given adequate
support, training, funding and access to specialist services that
they do not have a role to play. However, treatment provision
is still patchy across the country and many general practitioners
still are reluctant to get involved in the provision of care of
these patients, beyond perhaps general medical services.
13. Many of the gains have been obtained
through carefully persuading doctors to adhere to the National
Clinical Guidelines and to practice safe medicine. The Clinical
Guidelines recommend that doctors work within their levels of
expertise and according to evidence based practice. With regards
to prescribing this must mean the provision of safe, effective
treatments that are delivered in means that reduce diversion on
to the illicit market. To date this has meant the provision of
methadone linctus. In recent years an alternative to methadone
has become available, that of buprenorphine. This latter drug
will undoubtedly have a role to play in the future though the
basic safeguards of reducing the risk to the patient, the doctor
and the public remains, whatever is prescribed.
14. Heroin prescribing
15. The committee is particularly interested
in this area. It is the belief of the Royal College of General
Practitioners that there would be no added value from general
practitioners prescribing heroin to their patients.
16. Heroin, though no doubt having a place
in the armoury of treatment, has no place in the armoury of but
an exceptional few general practitioners. Heroin has a low therapeutic
index (that is the difference between safe and toxic dose), and
in a naïve user or a user that has lost their tolerance it
is rapidly fatal in overdose. Heroin has a short duration of action
and has to be injected at least three times per day to avoid withdrawal.
Heroin will have a high street value and in order to reduce diversion
must therefore be given on a daily basis and preferably under
supervision. Urine testing cannot distinguish whether prescribed
heroin is being "topped up" by street bought sources.
Heroin is an expensive drug to prescribe and these costs will
be increased when dispensed daily and preferably under supervision.
A year's treatment with methadone (taking into account all costs)
is around £2,000. The equivalent for heroin is around £10,000-£15,000.
These costs, whilst not the sole reason for not recommending it
as a widespread treatment, must of course be taken into account
in today's overall NHS priorities. It is unlikely that once a
patient is placed on prescribed heroin that they will ever come
off, hence all costs must be considered for life and the treatment
one of last resort. Heroin assisted substitution programmes; such
as the Swiss programme have a high rate of treatment retention,
though similar to that of methadone maintenance programmes.[1]
Prescriptions of heroin must therefore be compared to the well
researched, safer, cheaper and easier to administer alternatives
such as methadone[2]
and buprenorphine. Heroin prescribing can be considered within
the overall spectrum of available treatment for opiate addiction
but should not be considered as anything other than a specialist
intervention where high levels of security with tight supervision
of consumption is available. These arguments also apply to the
provision of other injectable substitutes such as methadone ampoules.
17. Training: The RCGP welcomes its opportunity
to improve the training of general practitioners in the care of
drug users. However, more investment is required if the gains
are to be sustained and generalised across primary care. Training
requires resources, both to release doctors from their surgeries
but also to ensure that an infrastructure of mentors/trainers
and supervisors are maintained to support general practitioners
in this work.
18. Resources
There is no doubt that treating drug users is
time-consuming and often difficult for all members of the primary
health care team. Drug use also most commonly occurs in deprived
areas of the country where high prevalence of all chronic diseases
and social determinants of ill health are present. These areas
also tend to have smaller numbers of doctor and other health professionals.
Funding must be adequate to ensure that health professionals have
the time to see and treat these patients alongside competing demands
and that the prescribing budget adequately compensates for the
additional drug costs inherent in providing substitute medication.
19. The RCGP would conclude that one aspect
of the Governments Drug Policy is working, in as much as the numbers
of general practitioners willing and able to deliver safe and
effective care is increasing, as is the quality of care they provide.
However, there is still a long way to go and it is the belief
of the RCGP that only by having a commitment to training over
a long period; to continuing staff support including access to
specialist care and to improving access to rehabilitation and
residential treatments for drug users, will the Drug Policy continue
to make gains.
January 2002
1 It is important to note that all the Swiss subjects
failed to respond to oral methadone treatment programmes and had
to attend to inject heroin three times daily under supervision
in treatment centres. Back
2
There have been many well-researched studies of methadone maintenance
treatment. The proportion that continue to inject varies across
studies from 10-60 per cent. The most successful programmes retained
patients in treatment longer, prescribed higher doses of methadone,
did not enforce detoxification after a period of maintenance,
provided better counselling and medical services achieved a good
level of clinic attendance by patients, had a close long term
relationship with patients and low staff turnover. These studies
all involved secondary care, but a good primary care practitioner
can achieve all of these good outcome characteristics. Good outcome
equates to substantially reduced illicit drug use, injecting and
crime whilst improving physical and mental health and social functioning. Back
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