Select Committee on Home Affairs Appendices to the Minutes of Evidence


Memorandum submitted by the Royal College of General Practitioners


  Existing drugs policy aims at increasing the numbers of drug users in treatment and increasing the numbers of general practitioners involved in their care.


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.

    —  Lack of skills.

    —  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).


  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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