Network No 14 (May 2006)
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Another packed issue coinciding with the 11th National Conference Management of Drug Users in Primary Care - indeed much of our content is in line with conference programme.
IN THIS ISSUE
HIV update - Huge improvements in HIV treatment and prognosis yet increasing levels of HIV and hepatitis co- infection in injecting drug users. A thorough update by Dr Gary Brook. Dr Fixit in the guise of Dr Ewen Stewart complements this with some practical advice on HIV and blood virus screening.
The GPwSI - is this odd hybrid heading out on a random evolutionary path? Jim Barnard takes a look for SMMGP.
Parenting and children of service users - Findings suggest that services are doing little to ensure that children are not being exposed to unacceptable levels of risk at home. In fact service users may not even be asked about their children, parenting needs or child related risk. Dr David Best and Victoria Manning highlight harm remaining hidden in this all too vulnerable child population. Anna Millington presents a parent's view on the difficulties and stigma that can be encountered when accessing services, and the need for parents to receive proactive friendship and support from staff.
SCAN, a network for addiction psychiatrists - With the rapid development of GP work in the field, Meredith Mora highlights the relevance of joined up working and consensus with addiction psychiatrists.
Addicted Doctors - Dr David McCartney tackles this sensitive topic and the difficulty in identifying, confronting and supporting colleagues. A dearth of dialogue, expertise or published literature is contrasted by estimates of 13,000 doctors with drug or alcohol problems in the UK. A thought provoking read.
First Contact: a new consultation model for GPs - With the time constraints of General Practice, Dr Morris Gallagher and Dr David Julien advocate getting the basics right and getting the patient wanting to come back. An excellent training and development model that promotes a positive and welcoming attitude as the key to good consulting behaviour.
Practice Based Commissioning - Dr Linda Harris Acting Director of the RCGP SMU calls for GP champions to work with new PCTs and their new found commissioning powers.
Usual courses and events listings.
Pain and pain management in people who are opiate dependent is a complex topic, sometimes leading to uncertainty or conflict between patient and practitioner. Hugh Campbell sheds light on this confounding yet fascinating topic revealing the evidence, myths and what is currently known about effective clinical practice. Ed.
My interest in this topic comes from clinical experience, and some of the theoretical material described in this article formed part of a dissertation submitted for the MSc in Addictive Behaviour at St George's Hospital, London in 2005.
Pain is a complex experience and is particularly clinically challenging in the context of substance use and dependence, and especially so in a Primary Care setting. 15% of those in treatment for opioid dependence under my care, give pain as a reason for first heroin use, and over 40% describe chronic pain at the present time. Interestingly, and unexpectedly, there is only a small overlap between these two populations. Not only can pain be challenging to treat but it can also be an obstacle to detoxification, and there is little doubt that untreated pain is a risk factor for relapse.
Pain has been defined as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. It is subjective and each individual learns the application of the word through experience related to injury in early life. It is a sensation in a part of the body, is always unpleasant, and therefore an emotional experience" (Ref 6). Pain may arise as a result of excitation of nociceptors (sensory receptors), or can occur in the absence of nociception.
Pain experience can be divided into physical, affective and functional components. There are several classifications of pain. These include acute and chronic (continuous pain of moderate severity or greater for more than 6 months) which can be sub divided into chronic non-malignant and cancer-related pain. The Pain Society classifies pain as:
- Persistent pain (continuous or intermittent pain for more than 3 months, and affects 10% of the general population)
- Intermittent severe pain (i.e. spontaneous episodes of recurrent severe pain)
- Breakthrough pain
- Incident pain (brought on by activity and relieved by rest)
Acute pain is predictable, has a direct association with tissue damage, is mediated by well-defined neuro- circuitry, is self-limiting, and responds well to unimodal treatments. It is useful and has a protective/warning function. Chronic pain, in contrast, is unpredictable, has a confusing relationship with tissue damage, and is often resistant to treatment. Its neuro-anatomico-pharmacological mechanisms are ill-understood. Chronic pain may respond to multimodal treatments but often tends to serve no apparent useful warning or protective function.
Pain can be affected by fears, age, gender, culture, and previous pain experience of either self or significant others, education/understanding, and history of substance use, including alcohol.
There are several different mechanisms of pain. These include nociception, neuropathic pain (peripheral or central, and possibly linked to for example systemic illness, neuritis/neuroma, and deafferentation pain e.g. after amputation), and sympathetically maintained pain (reflex sympathetic dystrophy).
Misunderstandings arise from the following relationships:
- Chronic pain and tissue damage
- Chronic pain and investigation findings
- Chronic pain and functional impairment and disability
Chronic pain may be unrelated to activation of nociceptors, but may be related to hyperalgesic states, autonomic nervous system dysfunction, myopathic states and a wide range of psychological factors. It may be an element of structural disease, psycho- physiological disorder (e.g. irritable bowel syndrome, tension headaches), or a range of psychiatric disorders including:
- Somatisation disorder
- Hypochondriacal states
- Elaboration of physical symptoms for psychological reasons
It is also commonly linked with chronic anxiety and chronic depression.
In the substance user the perception of pain may be sustained by alternating states of intoxication and withdrawal e.g. alcohol, opioids, sedatives and benzodiazepines, and also sleep disturbance. Another key fact of neuropharmacological importance is that the functional properties of opioids, notably tolerance/dependence and analgesia are mediated by different physiological mechanisms and this has fundamental importance for practical management of pain in the context of substance use.
Pain, particularly when it is chronic, therefore, is a multidimensional phenomenon and is often difficult to understand and manage using linear, reductionist thinking. More fruitful outcomes result from applying complexity thought and theory which has recently become a fashionable focus for discussion. A complex system with multiple interconnected components, with non-linear interaction may generate unpredictable, emergent behaviours of which the observer becomes a part i.e. the substance user with pain and the clinical carer are part of a complex, multidimensional adaptive system with a wide range of treatment possibilities.
Principles of the management of acute pain in the context of substance use
Patients with acute pain and substance use may present in several settings, but particularly frequently in hospital A/E departments and Primary Care. Careful assessment is of paramount importance, and depending on the time available may take account of the following:
- Information about the pain itself; onset, course, pattern, location, severity and quality, and the factors which provoke or relieve it.
- Awareness of the possibility of a referred pain pattern.
- Prior history of persistent pain.
- Documentation of prior pain treatments.
- Previous use of licit drugs for pain control, including OTC drugs and alcohol.
- Record of other symptoms including temporal features, location, quality and factors that provoke or relieve them, in particular their relation with the pain.
Reliance on autonomic signs e.g. changes in blood pressure and pulse may make interpretation confusing in the context of substance use. It cannot be stressed enough that an accurate clinical diagnosis of the cause of the pain needs to be made and should this not be possible, urgent referral for hospital investigation may be appropriate. A practical issue of importance is that details of prescribing of substitute agents and controlled drugs should be clearly communicated to the hospital team, and arrangements made to suspend community prescribing until discharge to eliminate the risk of double prescribing.
There are several key treatment principles for acute pain in substance users. It is wise to maintain the usual dose of opioid replacement as this serves to offset opiate withdrawal and confers only brief partial pain relief. Change of opioid dose should not be a first consideration. Be aware that non-pharmacological approaches may be useful and when prescribing use non-opioid and adjuvant analgesics, e.g. paracetamol, NSAIDs and tricycle anti-depressants in low dosage. Should these be ineffective, try increasing the opioid dosage with dose splitting (e.g. oral methadone 4-8 hrly). This has the effect of maintaining the dose of opioid to prevent withdrawal, at the same time substantially increasing the analgesic effect. Another approach may be to introduce a weak opioid in high dosage or another opioid e.g. Oramorph elixir or MST.
Severe acute pain may well require hospital investigation and treatment. It is of interest, though controversial, that PCA (patient controlled analgesia) including parenteral infusion of morphine has been used successfully post operatively and in sickle cell crisis with minimal risk of increasing opioid dependence and tampering of infusion equipment. Another agent in experimental use is remifentanil which, though a powerful and effective analgesic, also displaces methadone from receptors.
If the substance user is prescribed maintenance buprenorphine (BPN), acute pain can be treated in one of the following ways:
- Split the daily dose to 6-8 hrly (the analgesic qualities of BPN show a disparity with tolerance/dependence, though less so than methadone).
- Discontinue BPN and introduce a full opioid agonist until the acute situation is over.
- Give high doses of a short acting opioid agonist in addition to BPN in an attempt to flood the mu receptors.
- Admit to hospital care, convert BPN to methadone, titrate the opioid requirement for analgesic effect and prevention of acute withdrawal, and then re-introduce BPN after the acute pain subsides.
Other points relating to acute pain
Acute pain is more likely to occur in patients who are opioid dependent than the general population as they experience more traumatic injuries and serious medical illness.
Under-treatment of acute and chronic pain in substance users is common and is based on 4 misconceptions (Ref 1):
- Maintenance opioid agonists provide adequate analgesia (this is not so as the duration of analgesic action, 4-8hr, is substantially shorter than that required for suppression of opioid withdrawal, 24-48hr).
- The use of opioids for analgesia may trigger relapse (the reverse is true, acute pain is a well-recognised potential trigger for relapse).
- The additive effects of opioid analgesics and maintenance opioids may increase the likelihood of respiratory and CNS depression (this is not true when pain is present).
- The pain complaint may simply be a manifestation of drug-seeking behaviour (experience teaches that this is rarely so).
There are 2 other phenomena which explain why patients derive little pain relief from maintenance opioids. Firstly, differential tolerance/cross-tolerance. This affects different opioid properties in different ways but with rapid tolerance to analgesic effect. Secondly, opioid-induced hyperalgesia (or antianalgesia). Chronic neuropharmacological changes in the locus coerulus/amygdala (and other NMDA and opioid receptor sites) result in an increase in pain sensitivity, especially to cold pressor and deep pain sensation. Though more important in the context of chronic pain, it may explain why much higher doses of opioid are required when treating acute pain in a patient on a long term opioid substitute agent.
Principles of treatment of chronic pain in the context of substance use
This occurs much more commonly than recognized with a prevalence of 30-50% in treated substance users. (compared with 10-15% of the general population) The assessment of chronic pain in the context of substance use is more complex and time consuming than for acute pain. Not only should it take account of the pain history described above, but also the following:
- Mental state assessment (because of the close correlation of chronic pain with chronic psychiatric morbidity), including pre-morbid psychiatric state.
- Psychological assessment, looking especially for chronic anxiety and depression, and also coping styles.
- Functional status, with special note of disparity between objective findings and functional ability.
- Relevant psycho-social factors.
- Past medical history (because of the co-relation of chronic pain with chronic illness).
- Other information including beliefs and attitudes to pain, to doctors and carers, and to possible referral.
Simple chronic pain strategies, e.g. treating initial pain early to minimize secondary immobility, encouraging early return to work or activity, so reducing the effect of chronic noxious neural change, are important. Also the early prescription of adequate effective analgesia reduces the risk of persistent pain.
In situations where chronic pain is becoming increasingly difficult to treat or where substance use is escalating or becoming difficult to manage with a substitute prescription, or both, consider early referral to either a Specialist Addiction Consultant (preferably one with an interest in pain), or a Pain Clinic, or possibly both.
While awaiting a specialist assessment, the following practical points may be helpful:
- Investigate the chronic pain appropriately, including routine blood tests to exclude serious medical causes.
- Encourage normal activity.
- If available use TENS, acupuncture or physiotherapy.
- Use effective pharmacotherapy for sufficient duration.
- Be aware of the pharmacodynamics of opioids. Opioid hyperalgesia may be more important than previously realised. In certain situations with careful consideration some patients benefit by reduction of opioid dose or even detoxification. This may reduce or abolish chronic pain, or give a clearer anatomical focus, with greater variability of pain intensity, and with improved therapeutic response to both pharmacological and non-pharmacological interven- tions.
- Consider the use of other pharmacological agents e.g. paracetamol, NSAIDs, tricyclic antidepressants (and SSRIs), anticonvulsants (carbamazepine, gabapentin, and pregabalin) or topical agents e.g. Capsacin cream.
Specialist interventions, e.g. regional anaesthesia, pain management therapy, CBT and psychotherapeutic approaches, may only be available through the hospital service.
Important messages about chronic pain include; pain cannot always be cured, pain does not always get worse, carry on life as usual but in 'smaller doses', and self management is very helpful.
Patients with chronic pain and substance use can be highly challenging, and it cannot be stressed enough that a multi- disciplinary approach, preferably in a community setting, is the most effective style of treatment. In addition, the following points are important: although there is anecdotal evidence for the successful use of opioids for chronic pain in those who are opiate naive, a history of addictive substance use is usually a relative contraindication to long term prescribing of opioids just for chronic pain. Also, increasing opioid dose to achieve pain control may be counterproductive because of hyperalgesia.
The treatment of cancer pain is similar with or without a history of substance use, whether in or out of treatment. Simple principles include; provide effective analgesia by any means necessary, including opioids. Non-opioids, NSAIDs and corticosteroids may substantially reduce the pain from metastatic disease. Other physical treatments including regional anaesthesia and neuroablation are highly effective. Identify and address non-pain distress, and be aware that opioids may be used by substance users with cancer to self medicate for emotions such as grief, fear, rage, anxiety, depression. Other non-drug approaches are often far more effective.
Acute and chronic pain in substance users are common complaints and often poorly treated. Under-treatment is common and is often based on misconceptions, which include assuming that the maintenance opioid will provide adequate analgesia, that there is an increased risk of respiratory depression with opioid analgesics and perhaps most commonly that the pain complaint is simply a manifestation of drug-seeking behaviour.
The use of a flexible, multi-dimensional adaptive approach, with due regard for the many pharmacological and non- pharmacological complexities, known and unknown, is the most effective way to relieve acute and chronic pain when substance use is a consideration. The combination of chronic pain (including cancer pain) and substance use, whether in active treatment or not, is best managed within a multi-disciplinary team with an appropriate care plan.
Correspondence to Dr H Campbell, Freedom Health Centre, 78 Lipson Road, Plymouth, Devon PL4 8RH. Tel No 01752 674494
There will be an RCGP special interest training day on Pain in Leeds on Wednesday, 27th September 2006. Cost for the day: Past and current certificate/graduates: £105. All other delegates: £135. To reserve a place contact Terri Myers: 020 7173 6091/6090 or firstname.lastname@example.org, RCGP Substance Misuse Unit, Frazer House, 32-38 Leman Street, E1 8EW
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There have been huge improvements in HIV and Hepatitis co-infection treatment along with a fall in infants infected during pregnancy. Yet HIV in injecting drug users is at its highest level for a decade and morbidity and mortality due to hepatitis co-infection is becoming more problematic as patients survive longer with HIV. Dr Gary Brook provides us with a thorough update on changing epidemiology and treatments. Ed.
In this article I will describe the changing epidemiology of HIV in the UK and issues that have recently affected the way I manage HIV. The latter includes new drugs, new ways of giving treatment, greater understanding of the long- term side effects of medication and the management of specific sub-groups such as those with hepatitis co-infection and pregnancy.
Figure 1: HIV Diagnoses, AIDS and Deaths, England and Wales 1994-2004
Link to material from the Health Protection Agency website showing
HIV in injecting drug users is at its highest levels for a decade; www.hpa.org.uk/hpa/news/articles/press_releases/2006/060316_hiv_idu.htm
Since 1995 there has been a huge improvement in the prognosis of HIV (fig. 1). Rates of diagnosis of new HIV cases has continued to rise and yet AIDS and death due to HIV have fallen (Ref 1). This dramatic change has been due to the routine use of triple antiretroviral therapy for patients with HIV. The situation has improved so much that currently the prognosis of someone with HIV is about the same as type-2 diabetes (Ref 2, 3). It could be argued that the prognosis may be better than diabetes for many patients as most of the illness in people with HIV is seen in the minority (about 30%) who present with a low CD4 count. The type of people seen with HIV has also changed in recent years. Since 1999 new positive patients have predominantly been heterosexual although other risk groups such as homosexual men continue to contribute to the pool of infected people. Whilst patients from sub-Saharan Africa make up a high proportion of new positives, there has been an increase in patients infected in, or with partners from, the Caribbean(Ref 1).
Recent data from the Health Protection Agency also show a rise in HIV prevalence in injecting drug users from the National Unlinked Anonymous Seroprevalence Study (Ref 4). Currently the prevalence of HIV in patients taking part in this study is 1.6% which is the highest since 1992 and largely due to a sharp rise in IDUs outside of London. Most worrying is the steep rise in HIV in new IDUs from 0.25% in 2002 to 1.3% in 2005. The rate of HIV diagnosed in IDUs taking the test in England and Wales has risen from 131 people in 2004 to 182 in 2005.
There has been a great improvement in the convenience and side effects of treatment recently. Many drugs can be used once a day (e.g. abacavir, tenofovir, 3TC, FTC, ddI, efavirenz, nevirapine, atazanavir) and there are also new fixed drug combination tablets such as Kivexa (abacavir/3TC) and Truvada (tenofovir/FTC) (Ref 5). Therefore, an effective first line treatment would often be two tablets once a day. Short term-side effects are quite mild in most patients but we are increasingly becoming aware of potential long-term problems. Stavudine is associated with lipoatrophy of the arms, legs and face, which can be very disfiguring, and there is increasing evidence that AZT/combivir may also cause this problem (Ref 6, 7). It is also becoming clear that people with HIV have an increased risk of coronary heart disease which is often related to treatment with some of the protease inhibitors (Ref 8). This risk relates to increases in blood lipids and therefore routine patient assessment in the HIV clinic includes coronary risk prediction and management of raised lipids with lipid lowering agents if necessary. Currently the safest drugs in this respect seem to be abacavir, tenofovir, 3TC, FTC, nevirapine, efavirenz and atazanavir (Ref 5). None the less, the risk of heart attack is minor compared with the benefits of being on antiretrovirals.
As patients survive longer with their HIV, they are much less at risk of AIDS. Therefore morbidity and mortality due to hepatitis co-infection has become a relatively significant problem and now accounts for about 15% of deaths in HIV+ patients. This is especially the case as patients with co-infection are ten times more at risk of death than patients infected with HIV or hepatitis alone (Ref 9, 10). It is fortuitous that several drugs are effective against both HIV and hepatitis B (HBV) and includes tenofovir, 3TC and FTC. It has now become standard of care that all patients with active HBV infection who are HIV+ should receive either tenofovir or tenofovir plus 3TC or FTC (Ref 11). 3TC and FTC should not be used alone or in combination as HBV resistance develops rapidly, with around 50% resistance after one year. Tenofovir alone or in combination with 3TC or FTC is much more likely to lead to a sustained long-term response with little risk of resistance. A small proportion of patient will be 'cured' with loss of HBeAg but the major aim of treatment is suppression of viral replication and concurrent reduction in liver damage and inflammation. If patients have a high CD4 count, the choices include starting anti-retroviral therapy earlier than otherwise their HIV disease would dictate including tenofovir/3TC/FTC in the regimen or to use drugs that have no significant HIV activity. These include pegylated interferon, low dose adefovir and newer drugs such as entecavir (Ref 11).
Hepatitis C (HCV) co-infection has become eminently treatable nowadays (Ref 12). In general, treatment with pegylated interferon and ribavirin is about 20% less successful than in HCV mono-infection. However, if patients can be given maximal treatment doses for up to a year then sustained virological responses of 20-40% are seen with genotypes 1 and 4 and 60-70% for genotypes 2/3. Because of the reduced response for types1/4 a liver biopsy is usually performed pre- treatment so that those with minimal fibrosis may opt not to be treated. For types 2/3 we often do not do a liver biopsy except to exclude cirrhosis if that is suspected. There is still a reluctance to treat injecting drug users, but some units will now offer treatment if patients are stable on methadone and have not injected for six months.
For the last decade there has been a steady fall in infants infected in pregnancy in the UK (Ref 1). The reasons are two-fold. Firstly, HIV testing in pregnancy has become normalised such that most antenatal clinics test over 90% of pregnant women. Secondly, treatment in pregnancy has improved to such an extent that the risk of the baby being infected is less than 1% (Ref 13). Most babies who are infected become so if the mother is undiagnosed or takes sub- optimal therapy. Standard therapy up until recently has included anti-retrovirals for the mother from 28 weeks pregnancy or before, planned caesarean section and exclusive bottle feeding. However, the role of caesarean section is being questioned if the mother is on triple therapy and has an undetectable viral load. In such circumstances, a vaginal delivery is often attempted, providing labour lasts no longer than 4 hours, which is quite feasible in women who have previously had a normal birth (Ref 13).
HIV care continues to improve and most patients can now expect to survive many decades with a very good quality of life.
1. Health Protection Agency. Mapping the issues. HIV and other Sexually Transmitted Infections in the United Kindom, 2005. Accessed March 2006. http://www.hpa.org.uk/hpa/publications/hiv_sti_2005/pdf/MtI_FC_report.pdf
2. Roper NA, Bilous RW, Kelly WF et al. Cause- specific mortality in a population with diabetes: South Tees Diabetes Mortality Study. Diabetes Care 2002;25:43-8
3. Mocroft A, Brettle R, Kirk O et al. Changes in the cause of death among HIV positive subjects across Europe: results from the EuroSIDA study. AIDS 2002;16:1663-71
4. Health Protection Agency. HIV in injecting drug users reaches highest levels for a decade. Accessed March 2006. www.hpa.org.uk/hpa/news/articles/press_releases/2006/060316_hiv_idu.htm
5. B Gazzard, J Anderson, A Babiker et al. British HIV Association (BHIVA) guidelines for the treatment of HIV-infected adults with antiretroviral therapy (2005). HIV Medicine 2005;6 (Suppl 2):1-61
6. Martin A, Smith DE, Carr A, et al. Mitochondrial Toxicity Study Group. Reversibility of lipoatrophy in HIV-infected patients 2 years after switching from a thymidine analogue to abacavir: the MITOX Extension Study. AIDS. 2004;18:1029-36
7. Carr A, Samaras K, Thorisdottir A, Kaufmann GR, Chisholm DJ, Cooper DA. Diagnosis, prediction, and natural course of HIV-1 protease-inhibitor- associated lipodystrophy, hyperlipidaemia, and diabetes mellitus: a cohort study. Lancet 1999;353:2093-2099
8. Periard D, Telenti A, Sudre P, et al. Atherogenic dyslipidemia in HIV-infected individuals treated with protease inhibitors: the Swiss HIV Cohort Study. Circulation 1999;100:700-705.
9. Rosenthal E, Poirèe M, Pradier C et al. Mortality due to hepatitis C-related liver disease in HIV-infected patients in France (Mortavic 2001 study). AIDS 2003;17:1803-9
10. Thio C, Seaberg EC, Skolasky R et al. HIV-1, hepatitis B virus, and risk of liver-related mortality in the Multicenter Cohort Study (MACS). Lancet 2002;360:1921-6
11. Brook MG, Gilson R, Wilkins EL. BHIVA Guidelines on HIV and chronic hepatitis: coinfection with HIV and chronic hepatitis B virus infection (2005). HIV Medicine 2005;6 (Suppl 2):84-95
12. Nelson MR, Matthews G, Brook MG, Main J. BHIVA Guidelines on HIV and chronic hepatitis: coinfection with HIV and chronic hepatitis C virus infection (2005). HIV Medicine 2005;6 (Suppl 2):96-106
13. Hawkins D, Blott M, Clayden P et al. Guidelines for the management of HIV infection in pregnant women and the prevention of mother-to-child transmission of HIV. HIV Medicine 2005;6 (Suppl 2):107-48
The GPwSI is a somewhat odd hybrid that leaves many scratching their heads. Whilst the concept of a specialising GP has proved useful in the evolution of the primary care led NHS and in GP revival, its role and future seem unclear. With the success of the enhanced services contract and the development of the Addiction Specialist (primary care), is the GPwSI heading out on a random evolutionary path? Jim Barnard takes a look for SMMGP. Ed.
"Although the formalised concept of the GPwSI is a relatively new development, GPs specialising in a particular area of medicine or care have existed as long as general practice itself. Indeed, a 2002 article by Professor David Colin-Thome, National Clinical Director of Primary Care, estimated that 16% of GPs had a clinical special interest in addition to their general practice work." (Ref 1)
This quote outlines the general GPwSI concept clearly. This article concentrates on the 'formalised concept' mentioned above. This probably started with HSG/96/31 which allowed for the delivery of secondary care services in primary care. The concept has gained considerable momentum over the last decade in particular in the field of substance misuse. No other field has as many GPs trained to this level, with over 800 GPs having completed the RCGP Part 2 Certificate, the training baseline towards becoming a GPwSI (N.B not a qualification), it is also the third most common field for GPs to be formally appointed to this role by PCOs (Ref 1).
There are wide and varied ways GPs are contracted to provide this role. They are usually employed by PCTs but can be contracted by others such as providers (statutory and non-statutory), DATs, police, and probation. Broadly the roles split into two types clinical and developmental.
The concept of the GPwSI has also become less clear since the nGMS contract as it predated it as a concept and was not covered in any detail within the contract. Some of the clinical roles which might have been covered within the role can now be delivered within enhanced services and at the other end of the spectrum the strategic, leadership and supervision elements to the role are often delivered by the emerging 'Addiction Specialists (primary care)'. This article will look at the various utilisations of GPwSI and analyse their position within the treatment system.
The joint paper between the RCPsych and the RCGP on the roles and responsibilities of doctors (Ref 2) defines a GPwSI in substance misuse thus:
GPs with special clinical interest in addiction have received specific higher-level training in the management of substance misusers in primary care, usually the Royal College of General Practitioners' Certificate in the management of drug misuse in primary care, Part 2. Such practitioners can deliver a fuller range of drug treatment services. In some cases these GPs also conduct one or more clinical sessions outside of their own GP practice or provide care on behalf of other primary care practitioners. As a result of additional higher-level training and CPD, GPs with special clinical interest delivering locally enhanced or nationally enhanced services are able to work more autonomously and take responsibility for more complex cases in substance misuse.
Thus the paper very much defines a GPwSI as a clinical role, and later on nearly all of the development roles (apart from designing enhanced service contracts) are assigned to Addiction Psychiatrists or Addiction Specialists (primary care). This is reinforced by the fact that the DH has published specific guidance for PCTs appointing GPwSI in clinical roles in substance misuse, although they have published generic guidance on appointing GPwSI in developmental roles. However there is still a debate about whether a clinical or developmental role is the most appropriate for a GPwSI.
GPwSIs in a clinical role
Most commonly this is to provide an intermediate service, dealing with patients either who are deemed too complex for GPs delivering enhanced services but not requiring a specialist service, or whose own GP is not under an enhanced service contract. Typically such GPs treat large numbers of patients in bespoke clinics and often this is the GPs full-time employment or is delivered outside their own practice premises.
- Can greatly increase treatment capacity locally.
- Treatment delivered with a primary care ethos by an experienced and qualified clinician.
- Opportunity for constructive communication with GP colleagues and development of wider GP involvement through 'championing'.
- Economies of scale, through resources being centred around this service.
- Service can end up being in competition with existing specialist service, with very few patients being deemed too complex to be dealt with, leading to very little if any cross referral.
- The wider GP community can feel that there is no longer a need for them to get involved in treatment. The advantages of being treated by ones own practice are lost.
- The service becomes very similar to a community drug team and primary care needs may still not be fully met.
- Sometimes GPs in these roles are better described as Addiction Specialists (primary care).
Another common use of GPwSI is to deliver clinical sessions within a specialist service. In reality this is usually fulfilling the position that used to be known as a clinical assistant and the clinician will usually be working under the direct supervision of a specialist. Whilst this is obviously a useful role it is really that of a drug service doctor, who happens also to be a GP, and probably does not require the same level of training and experience as other GPwSI roles.
GPwSI are also often used to deliver criminal justice interventions as part of the Drug Interventions Programme, within prisons or other local initiatives. The level of clinical knowledge and experience required in such schemes varies enormously from the clinical assistant role described above, to having total clinical responsibility for very innovative and sometimes controversial schemes. Again, whilst sometimes requiring significant levels of expertise this is sometimes more a 'drug doctor' role rather than a GP role.
These many roles have probably developed because General Practitioners now form the pool of the most available, adequately trained and flexible doctor resources for local areas to draw on when developing new services. Are these doctors GPs in these roles though?
GPwSIs in a developmental role.
PCTs in particular often employ GPs to lead their local 'shared care' development. This role may include:
- Being the PCT lead for this field.
- Attending, possibly chairing, the shared care monitoring group.
- Executive responsibility for developing shared care model and clinical protocols and guidance.
- Responsibility to communicate effectively with local GP community.
- Responsibility to ensure and deliver local GP training.
- Clinical governance responsibility.
- Clinical advice and mentoring to GPs delivering enhanced services.
- Responsibility to ensure appropriate CPD opportunities for enhanced service practitioners.
These posts have often been instrumental in the rapid and successful development of primary care based treatment in a locality. They are in some cases combined with one of the clinical roles outlined above. Possible difficulties for this role can occur when:
- The GP in this role is not sufficiently experienced and competent to lead, or does not command the respect of GP colleagues locally.
- There is a negative outlook towards the role among local stakeholders.
- Too much weight is given to the clinical side of the role (if there is one) as opposed to the developmental so that wider primary care development is not taken forward.
- Insufficient supervision arrangements. These should be for both elements of the role and may come from different sources. Clinical supervisors need to be GPwSI level or above. It should be regular, minuted and with targets.
- Lack of appropriate appraisal provision from expert and sufficiently experienced appraisers.
Whilst using clinical expertise available among the GP community is hugely beneficial in substance misuse field, the use of the term GPwSI has become problematic. Specific GPwSI clinical services are often in reality specialist services. Some GPwSIs can deliver significant services under the banner of enhanced services in their own practices and thus usually fall outside the definition used here. Other GPwSIs are possibly better defined as drug service doctors. In a streamlined system perhaps most patients would be treated under an enhanced service contract (which can allow for the treatment of other practices' patients) and the rest treated in a specialist service clinically led by an Addiction Psychiatrist or Addiction Specialist (primary care), making the formal clinical role of the GPwSI redundant. Is the GPwSI concept going to be absorbed into enhanced service GPs at one end and Addiction Specialists (primary care) at the other? Conversely can the maintenance of the concept sustain a crucial stepping stone from one to the other?
However, a developmental role although seemingly clearer, may also be problematic to define. For instance, at what point does someone strategically leading a local shared care scheme become an Addiction Specialist as the roles and responsibilities paper suggest they should. It is certainly an important role for areas trying to initiate or further develop a local shared care scheme.
Perhaps the definition is best left for the profession to define, rather than commissioners. Some regional deaneries are now accrediting GPwSIs and perhaps this is the way forward so that it is about the services you provide rather than about who your employer is or in what setting?
We would welcome readers perspectives on this, please feel free to submit your views.
2. The Roles and Responsibilities of Doctors in the Provision of Services to Drug and Alcohol Misusers' Council Report 1, Royal College of Psychiatrists and Royal College of General Practitioners, 2005 www.rcpsych.ac.uk/publications/cr/council/cr131.pdf
Findings suggest that services are doing little to support parents or to ensure that children are not being exposed to unacceptable levels of risk at home. In fact service users may not even be asked about their children, parenting needs or child related risk. With no Government research planned in this area, David Best and Victoria Manning highlight that harm in this all too vulnerable child population is likely to remain hidden. Ed.
Prevalence and risk profiles
In 2003, the Advisory Council on the Misuse of Drugs (ACMD) published the findings of an inquiry assessing the needs of children of problem drug users. The report estimated that there are between 250,000 and 350,000 children of problem drug users in the UK - almost the same number as the estimates of problem drug users.
That is not to say all of these children are experiencing harm, and the report acknowledges that many drug users, particularly those who are stable and in treatment, may be perfectly competent and loving parents. However, this is a population that is rendered vulnerable as a result of a number of factors:
- The parents preoccupation with drugs may mean both neglect of the child's needs and the diversion of money to drugs that should be spent on basics for the child
- Using or dealing in the vicinity or presence of the child, exposing the child to direct and indirect risks related to substance use
- Stigma and the fear of family separation and disruption, including the involvement of social services
- Increased risk of disease from vertical transmission of blood- borne viruses
- Reduced parental monitoring increasing the risks of accident and the vulnerability of the child to early experimentation with substance use and other high-risk behaviours.
The response of specialist treatment providers
As drug services have expanded since the advent of the National Treatment Agency (NTA) in 2001, there has been an enormous increase in the range and breadth of provision, including major advances in joint working and addressing the needs of vulnerable users.
Yet, in the surveys commissioned by ACMD, the monitoring of family activity by drug services was poor. Only just over half of the specialist addiction services that responded to the survey (53%) provided services for drug using parents and only 52% provided services for pregnant drug users. Under one-third of specialist addiction services (31%) actually offered any provision to the children themselves. However, perhaps more surprisingly and more worryingly, only 68% of specialist services even recorded the number of dependent children their clients had (see table 1 below). The National Drug Treatment Monitoring System (NDTMS) does not require drug agencies to record this information as part of the national monitoring programme.
Table 1: Frequency of information collected by specialist drug agencies (n=418)
Thus, even when the number of children were recorded some services did not ask about age, gender or living arrangements while only one third of services attempted to assess the child's needs or the parenting needs.
Is this a changing picture and is it the same elsewhere?
The survey reported above was carried out in 2002 before the Hidden Harm report was launched and it is hoped that the ACMD work may have been the catalyst for change. ACMD have commissioned the same research team from the National Addiction Centre to repeat the survey in Spring 2006 and the questionnaires are ready to be sent to the same services to assess change.
However, the UK situation appears to reflect an international picture in which data collection is incredibly poor with no standard monitoring of the number of children involved nor assessment of the risks involved. Across the European Union, there are no epidemiological assessments of the extent or patterning of risks to children of drug using parents, in spite of research activity in this area in a number of countries and the presence of some specialist provision in this area in many countries. Indeed, there is a European network, ENCARE, dedicated to addressing this issue (its focus is alcohol rather than illicit drugs). The site highlights some of the innovative projects across Europe that provide community-based interventions for working with parents, with children and with communities to address the needs of vulnerable populations. Unfortunately, these projects tend to be localised, often reliant on the commitment of individuals and are generally poorly evaluated, if at all.
There is currently work underway, commissioned by the Australian National Commission on Drugs (ANCD) that is attempting to develop a method for measuring the profile of risks to children of drug using parents, how this risk is likely to shift over time and what risk and protective factors there are to mediate or moderate these risks. However, in the UK the Government has no plans for specific research in this area, meaning that much of this harm is likely to remain hidden, embedded in a population who, even when they access treatment, may not be asked about their children, far less what they need to assist their parenting endeavours or to ensure that the child is not being exposed to an unacceptable level of risk at home.
With unsettling findings suggesting that many services may not even be asking about children or parenting needs (see Asking No Questions About Hidden Harm), Anna Millington presents a parent's view on the difficulties and stigma that can be encountered when accessing services. She praises the welcoming hand of pro-active friendship and support offered by her parent friendly GP. Ed.
Being a parent and accessing services can often be an emotive topic, hard to broach without people feeling under attack. This can often be an area, where misguided perceptions are at the fore.
There is nothing to fear
One of the first issues with a parent who accesses services is fear, fear at admitting to another and sometimes to yourself what situations you have gotten both you and your child involved in. Fear of the reality of social services in many places, where the availability of resources or personal based opinions, outweigh what could be achieved, or what may be best for the child.
"Fear that systems are such, that what is sometimes on offer, is not a warm welcoming hand of pro-active friendship and support, but a judgemental, punitive, reactive stance."
Parent who uses drugs VS a drug user (with a child in tow)
Accessing treatment can often mean this shift in how people are viewed. We often translate how that person is with professionals, how they look, what they take, with how they parent. When there is an opportunity to view how people parent, by their children being present, often it's 'frowned' upon. But in reality, with no money or appropriate childcare links, parents are left with no other practical options.
Emotional blackmail is a motivational tool
Emotional blackmail is very often un-intentional... it is often meant with the best intentions. This is somewhere, where I fear from my experiences (and those of many other parents nationally), that professionals sometimes step out of their remit. Hoping to motivate the parent, they touch on emotive topics and make statements such as "think of your child... put your child before the drugs... Your child needs you". These are important issues to address in therapy, but often having made these comments outside of a positive and supported therapeutic session, professionals create a void they cannot fill. They raise guilt levels but have no expertise to help alleviate them. Guilt and shame can make parents feel so depressed, they alleviate it themselves, using the only coping mechanism they know.
Loving your child and being able to stop using drugs are linked
It can be assumed that being a parent automatically means that a user has more ability to tackle their addiction. Adding this additional pressure can often have devastating consequences. Most users do well when we help lift additional pressures, not increase them.
However, within that is a way forward... being a parent 'can' be an added incentive. Sometimes it all comes down to approach and speech. A parent attempting to access treatment, is attempting to break the cycle, attempting to take responsibility.
We call this child protection?
When we work with a parent who uses drugs we often forget the impact that attending appointments, picking up medication daily, inappropriate images, and urine testing can have on the child, on the family relationship. We forget how the child must view someone watching their parent pass urine. We forget that being a parent means at times, being late for appointments. We forget that the child is exposed to stigma through chemist staff. We forget that they are often not blessed with the luxury of having lazy days during holiday periods because their parent is tied to picking up their medication on a daily basis - also meaning they are denied day long trips or are forced to go out in horrendous weather conditions.
We can often not think, that children are being exposed to hard hitting and often misleading images. For my child this was the 'hep c' posters depicting dirty needles and spoons, which can lead them to believe that all drugs are consumed via injection, or can lead them to assume that the dirty images, relate to their parents being somehow dirty, and thus ultimately, they can feel dirty by association.
We forget the impact of reductions on the family. That it can be a difficult task to reduce medication when dealing with the stresses of parenting. That medication may need to be reduced and increased because of this.
Last but not least, I would like to mention the 'risk' criteria. What does 'at risk' actually mean, and how can we know whether a child truly is 'at risk', based upon seeing the parent alone, or knowing their drug history? I urge people to ask if they would apply the same doctrine of referral to social services for a parent who accesses treatment for smoking (which can actually often relate to physical damage for the child).
It can take minimal change and effort to address some of these issues... i.e., walking around the surgery/agency and trying to view the experience from a child or parent perspective. Thinking through the often forgotten implications and hidden harm that reduction (especially blind), daily pick ups, rigid appointment structures, etc. can bring.
"Having a good GP, who understood and accepted the issues surrounding accessing treatment and being a parent made the difference between my gaining an extremely successful outcome, and the dismal failures of my previous attempts."
With the rapid development of GP work in the field, the need to conduct joined up working with addiction psychiatrists and the network that supports them is increasingly relevant. Meredith Mora outlines the work of SCAN and the important opportunities for joint working and consensus building across the field. Ed.
SCAN has been in existence for 2 and a half years now, a baby compared to the mature network, SMMGP. We have learned much in our first couple of years of operation, not least that facilitating a network is exciting - and hard work! SCAN stands for the Specialist Clinical Addiction Network. It is a network for addiction psychiatrists - namely consultants, specialist registrars and associate specialists working in the addiction field. More recently, the network has expanded to offer affiliate membership to staff grade psychiatrists in addiction. Our project brief is set by the Department of Health (DH), which funds the project, and is supported by the National Treatment Agency and the Royal College of Psychiatrists. The SCAN project arose out of a need identified by DH for addiction psychiatrists to have the kind of support and networking SMMGP has provided to primary care for many years. Like SMMGP, SCAN seeks to build support and promote networking to improve practice and enhance provision.
The SCAN network looks a little different though, because it is dealing with a much smaller group of doctors who have chosen to specialise in addiction. We therefore cater for a more homogeneous group who have addiction treatment, policy, and in some cases, research and training, as their primary remit. We also aim to promote recruitment into the field by supporting specialist registrars working in addiction.
The support we provide to addiction psychiatrists takes several forms including: a website, much of which is open access www.scan.uk.net; a quarterly newsletter, SCANbites, with articles from the membership as well as stakeholders - which is freely available to download from our website; support of regional specialist networks and help to set up new ones where needed; an annual conference for SCAN members and co-organisation of a conference for specialist registrars in addiction; ongoing mapping of the wider network to identify and highlight areas where provision is limited; informal support and information involving the matching of specialists with queries to colleagues with particular experience; and opportunities for consultation on policy and guidance.
In addition, SCAN has recently been working on building consensus through a series of projects which aim to produce guidance to the field. Current consensus projects include models of inpatient treatment, and a document intended to help CJIT workers identify and appropriately refer addicted people with psychiatric co-morbidity. Recent linkage work includes promoting links with other organisations, such as regional NTA teams through the Royal College of Psychiatrists' regional representatives, and meetings with SMMGP and the Royal College of General Practitioners' Substance Misuse Unit to discuss joint working. Future developments include developing our clinical advisory and support role with the relevant stakeholders. We look forward to collaborating on joint projects!
Quarterly newsletter, SCANbites, is freely available to download from our website www.scan.uk.net
Dr David McCartney tackles the sensitive area of addicted doctors and the difficulty in identifying, confronting and supporting colleagues. There is a dearth of dialogue, expertise or published literature in the UK on this topic, something Dame Janet Smith remarked upon in the Shipman Enquiry report. Yet with estimates of as many of 13,000 doctors having drug or alcohol problems in the UK, it makes for a thought provoking read. Ed.
Controversy surrounds the issue of addiction in the medical profession. The concept produces uncomfortable feelings in many of us and can lead to a reluctance to tackle the issue. Although the practice of medicine does not seem to make us any more vulnerable to addiction as a group, neither does it offer protection. Nevertheless there may be a belief that it does. In America, this is referred to as the MD-eity syndrome (Ref 1).
Stigma and fear contrive to keep the problem occult. Many addicted doctors fear loss of status, job and perhaps GMC registration. The alcohol or drug addicted doctor often feels huge professional shame; he or she 'should have known better'. This is in spite of our increased understanding of genetic, neurophysiological and psychosocial influences on the development of the addictive process. We aspire not to judge patients with addictions, but it seems we do less well with colleagues.
Some authorities refer to the 'conspiracy of silence' to explain the lack of an open forum,2 and although the American Medical Association acknowledged the problem of substance dependent physicians in 1973 and the British Medical Association addressed it in 1984, there is little understanding or debate on the topic (Ref 5).
The size of the problem
Numerous studies indicate that the prevalence of substance and alcohol dependence in doctors is similar to that in the general population (Ref 6, 7), though the nature of the substance used may be different (more prescription drugs) and we often have access to our drug of choice in the workplace (Ref 8). The Sick Doctors' Trust suggests as many as 13,000 doctors in the UK could have drug or alcohol problems (Ref 9). Sir Graham Catto, President of the GMC, indicates that around 600-700 doctors are under GMC supervision for health reasons (mostly drug or alcohol) at any one time out of a total of 220,000 registered practitioners (Ref 10). Many more will be managed at a local level and a greater number will not have been identified as yet.
Identifying the problem
Denial as a feature of addiction is no less prevalent in the medical profession than in our patients. Denial affects the addicted doctor, their family AND often their colleagues, who will, either consciously or subconsciously, overlook some obvious warning signs. While relationships, health, social and community life may become seriously impaired or even lost, addicted doctors will continue to turn up at work with their performance relatively undisturbed. Nevertheless, there are warning signs, listed below.
- Accidents or injuries
- Marital discord/repeated family crises
- Deterioration in personal appearance
- Pin-point or dilated pupils
- Tremor, slurred speech, flushed face
- Stale alcohol on breath
- Significant weight loss or gain with hostility when identified
- Chewing gum or sucking mints
- Legal problems
- Recurrent health problems and recurrent sick days
- Frequently late for work and appointments
- Surgeries/clinics running over
- Emotional outbursts/mood swings or loss of control
- Changed personality and isolating
- Excessive talking or quietness
- Drugs going missing at work
- Deteriorating hand writing
- Paperwork always out of control
What to do
It may be desperately hard to confront a colleague when you are suspicious about an alcohol or drug problem. Nevertheless because of patient and doctor safety, it is important to develop a plan of action. Denial can be malignant in character, and a team approach, involving occupational health, is important. Admission to a residential treatment setting may be advisable. The GMC have recently acknowledged on their website that in the majority of cases, they are happy for addiction problems to be managed locally. The Sick Doctors' Trust can advise on interventions and treatment as well as support for the affected doctor. There is a network of self-help organisations for addicted doctors (British Doctors and Dentists' Groups) throughout the UK who meet regularly. There is a wealth of data to show that doctors who enter treatment for addictions do much better than the non-medical population, with more than 80% achieving long term recovery (Ref 11). Many recovering doctors maintain their recovery through attendance at Alcoholics Anonymous, or Narcotics or Cocaine Anonymous meetings.
In the US, every State has a Physicians' Health Programme which provides a comprehensive approach to managing the issue. Although Strang et al and separately, Williams, called for a dedicated service for the UK in 1998 (Ref 12, 13), such a service is yet to be developed. The Shipman enquiry called for research into the problem of addicted doctors and a change in the way they are managed.
There is something of the 'elephant in the living room' about our approach to the problem of addicted doctors in the UK. We know that it is there, but nobody is talking about it. If we want to show as much compassion and care for our colleagues as we do for our patients, this needs to change.
Tom is a 35 year old GP whose drinking had escalated gradually since his days as a student. Over a period of time he became less reliable, had marital problems and was frequently off sick, particularly on a Monday. He took time off to 'sort himself out', but began drinking earlier in the day and although resistant, when faced with his wife leaving him, accepted he was alcohol dependent. His GP referred him to a consultant who detoxed him and allowed him back to work. He began abusing opiates shortly after this and within a year was opiate dependent, initially using patient return medication and supplies from his own bag. His personal life was chaotic and he was unreliable once more. When he was caught writing fraudulent prescriptions and reported to the GMC, he went into residential treatment, felt he learned about addiction 'for the first time' and was allowed to return to the workplace under GMC supervision a year or so later. Three years later he is clean, sober and reliable and helps maintain his sobriety through AA.
1. Angres D et al (1998), Healing the Healer, the Addicted Physician. Madison, CT, Psychosocial Press
2. Blondell RD, Impaired Physicians. Primary Care 1993;20:209-219
3. Regier DA et al, The sick physician. Impairment by psychiatric disorders, including alcoholism and drug dependence JAMA 1973;223:684-7
4. The misuse of alcohol and other drugs by doctors. London, British Medical Association 1988
5. Gossop M et al, Health Care Professionals Referred for Treatment of Alcohol and Drug Problems, Alcohol and Alcoholism Vol. 36, No. 2, pp. 160-164, 2001
6. Bennett & O'Donavan, Substance misuse by doctors, nurses and other healthcare workers Current Opinion in Psychiatry 2001;14(3)195-199
7. Storr et al, Similarities of substance abuse between medical and nursing specialties. Substance Use and Misuse 2000;35(10):1443-1469
8. Hughes et al, Physician substance use by medical specialty. Journal of Addictive Diseases 1999;18(2)23- 37
11. Ganley OH et al, Outcome study of substance impaired physicians and physician assistants under contract with North Carolina Physicians Health Program for the period 1995-2000 Journal of Addictive Diseases 2005;24(1):1-12
12. Strang et al, Missed problems and missed opportunities for addicted doctors. BMJ 1998;316:405-406
13. Williams et al, (1998) Improving the health of the NHS workforce Nuffield Trust, London
With the time constraints of General Practice, Morris Gallagher and David Julien advocate getting the basics right and getting the patient wanting to come back. An excellent training and development model that promotes a positive and welcoming attitude as the key to good consulting behaviour. Ed.
"I must create a system, or be enslaved by another man's."
A 'new consultation model' for GPs working with substance misusers sounds pretentious. But it is human nature to re- shape the old to create something fresh and of the moment. We describe how we developed a 'new consultation model' to help GPs to manage substance misusers in the consulting room.
Genesis of the model
It began three years ago in our general practice of 11,000 patients. We were seeing lots of drug users. They were unhappy with the local service which prescribed low doses of methadone and had a punitive approach to 'using on top' and 'dirty urines'. We were also unhappy with the local shared care scheme. Only 15 per cent of 81 GPs in South Tyneside were involved in 'shared care.' The shared care monitoring group had disbanded. Only 250 of an estimated 400 substance misusers were in treatment.
We decided to develop expertise in managing drug users. The DAT funded us to 'pilot' how we could provide shared care in the surgery. After a year they also funded two Substance Misuse Practitioners (SMPs) to work with us. The aim was to develop a way of working that could be 'rolled out' to other practices. As a small practice based team, which included our pharmacist, we made many mistakes but learnt first hand the advantages and pitfalls of working together. We also had time to research what local GPs wanted.
In the spring of 2004 we visited seven general practices (25 GPs and three managers) with a total patient population of 55,000. Most were involved in a limited way with managing substance misusers. Three key themes emerged from this 'listening exercise'; the need for better 'basic' training and support for prescribers and non prescribers, pragmatic solutions to assessing drug users and clear referral pathways (Box 1 below).
We wanted to recruit more GPs into shared care. But it would have been inappropriate to pitch our training at the level of prescribing substitute drugs or Part 1 of the RCGP Certificate in substance misuse management. GPs, practice nurses and receptionists primarily wanted 'basic' training about how to manage that 'first contact' with a substance misuser in the surgery or at the reception counter.
The consultation model
The most important requirements of our model, and associated 'First Contact' training, were that it should increase the numbers of GPs willing to engage with substance misusers, that it should promote a primary care approach to the consultation, that is should make the patient want to come back and that it should reflect our experience and research about what GPs wanted - be time efficient and focus on harm minimisation interventions (Box 2 below).
Basic 'First Contact' training
The format of the 'First Contact' GP training is a one and a half hour workshop with GPs and practice nurses. All of the training is practice based. It covers participants learning needs and the problems and benefits of managing substance misusers in general practice. The First Contact consultation model is described and participants practice using our approach with three increasingly difficult scenarios, using role play or group discussion. The referral pathway is presented and opportunities for further training are discussed. Finally the learning needs of the group are reviewed. Each participant receives a copy of our manual of the model, referral pathways and reference information on prescribing and psychosocial interventions.
We present the 'First Contact' consultation model as only the first step in a process that includes referral, full assessment, and engagement with other professionals and agencies. The emphasis is on making a good 'first contact' with the patient which makes it more likely that they will come back. We don't set limits on what they could do in the consultation - some practitioners want to do more. But we set a baseline for what they should do.
In parallel with the GP and nurse training we provide education and training to reception and administrative staff. This one hour session covers attitudes to substance misusers and how to manage that first contact at the reception counter. So far 50 receptionists have received training.
Is it working?
The new GP led service and shared care scheme (in collaboration with the local mental health trust) was launched five months ago. So far a fifth of GPs have had basic First Contact training. Half of GPs have also been visited by members of the shared care team for a 10-30 minute 'taster' session where we talk about the new shared care scheme and the training that we offer. Already two GPs have completed Part 1 of the RCGP certificate; we anticipate holding our own course in June.
Things are on the up. More GPs have enrolled for First Contact consultation training. We have identified key GPs and practices that are likely to share the care of substance misusers. The shared care monitoring group has been resurrected and the PCT is now involved with substance misuse. We are developing integrated working with the local specialist service; we are devising common referral pathways, prescribing protocols and assessment documents. We are also working with service users on a patient information leaflet and a series of harm minimisation workshops for practice teams.
First Contact consultation training is our first step to prepare GPs to share the care of substance misusers. For us it is a 'new approach' that meets what GPs and their teams want. It is a local solution to a local problem. The last comment should go to a GP who recently completed the basic First Contact training.
"It was thorough with just the right amount of information. The most helpful thing was not to feel pressurised to cover everything, especially social and psychological issues, or to prescribe. It has increased my confidence: I now know what is worthwhile to do and what can be left."
Box 1: What GPs want from shared care - key themes
Training and support
Some GPs felt "totally unqualified" to manage substance misusers. This related to a lack of training about assessment and prescribing. GPs and their practice teams, especially receptionists, wanted advice and 'basic' training about how to manage 'difficult' consultations with substance misusers. (GP comments are in italics.)
"We need training for staff and doctors, specifically around what are the local services, who to contact for advice, legal requirements, notification, conflict management and safe practice."
Prescribers felt unsupported. They also wanted a named person attached to the surgery to help them -not a 'distant figure.'
"I feel uncomfortable about signing a piece of paper (a prescription) without knowing the patient or having adequate training.
I have no objections to take people back (into shared care). But there needs to be a structured consultation where it is clear what I need to do.
The local service is not responsive... there's no back up for problems. That's OK for me... but not for the inexperienced GP"
'Real solutions' that 'fit' general practice
GPs wanted practical help and advice about how to structure initial and subsequent consultations with substance misusers. It had to be sensitive to the context of general practice where GPs have limited consultation time.
"Solutions (to managing substance misusers) need to be realistic to general practice. Assessment can't take 30 minutes - time and workload are an issue.
You cannot do everything the first time, but what should you do and in what order?"
Clear referral pathways
"I need to have a plan before they walk out of the door, to be able to make a phone call to get an appointment for them."
Box 2: The '10 minute' consultation model
Engage with the patient
This is about having a positive and welcoming attitude; affirming the patients desire to do something about their drug use and listening and responding positively. This is good general practice consulting behaviour. It is the start of a relationship.
Take a brief history
This includes drug use and behaviour, physical and psychological health and social issues. The priority is to identify 'high risk' behaviour. They also need to garner enough information to make a referral to the GP shared care scheme or a specialist service
Giving basic harm minimisation advice and overdose education
This is based on the history. The focus is on keeping the patient safe. Local research has identified that sharing drug using paraphernalia is a common 'high risk' behaviour1 . Our advice focuses on not sharing and obtaining sterile drug using equipment. The training manual contains 'pull out' leaflets to give to the patient about minimising harm and reducing the risk of overdosing.
Refer to the right agency
The history provides enough information to decide who to refer to and how quickly. If the GP wishes to take the patient back, after they have been assessed and stabilised on substitute medication, they refer to the GPwSI led service. If they do not want to take the patient back or they have complex problems such as dual diagnosis or child protection issues then they refer to the specialist service. Both services work together. We have a common referral pathway which is available in a computer template (on the EMIS system).
Get the patient to come back
We encourage the GP to get the patient to make another appointment to review the patient's progress and so that they will benefit from ongoing primary health care.
1. Stuart Honor. Problem Drug use in South Tyneside. HPR, 2004.
Dr Linda Harris, Acting Director of the RCGP SMU calls for GP champions to work closely with new PCTs to ensure their patients get the most from their new found commissioning powers.
Practice based commissioning is being hailed as the "best vehicle for ensuring clinical leadership from primary care professionals in redesigning services" (Ref Practice based commissioning: early wins and top tips. DH 2006). GPs are at various states of readiness to embrace their new found responsibilities as part of "shifting the balance" of power back toward primary care.
Many localities have been able to harness local enhanced services (LES) as a means of developing shared care and there is evidence of improvements in treatment effectiveness as measured by waiting and retention times and average methadone doses. Much of this is down to primary care service development, however, much more needs to be done to improve those areas yet to develop good shared care and to ensure improvements thus far are sustained especially as PCTs tackle the problems of financial deficits.
With the launch of practice based commissioning there is now a mechanism for PCTs to work in partnership with GPs to commission local substance misuse services that are "in touch" with the needs of their patients.
Sensing the speed at which changes are being introduced throughout local NHS Trusts many GPs with an interest in substance misuse are already seeking information as to how to take things forward, and understand the opportunities (and threats) practice based commissioning may offer local services.
In line with the objectives of both the SMU and SMMGP we want to hear from any GPs who are already using PbC as the vehicle to achieve improvements in their local shared care or community treatment services. This will be fed into a more detailed joint SMMGP/SMU Briefing on Practice Based Commissioning which we aim to publish later in the year.
In advance of this and for those seeking a quick summary guide, Dr Linda Harris has produced a presentation on PbC detailing policy context, emerging governance arrangements and how to make the most of partnerships with local PCTs ot take Pbc forward in your local area. (See PbC presentation)
Dr Harris and SMMGP are keen to receive information on any emerging models of PbC to inform the briefing document and disseminate as part of sharing good practice. Please contact LHarris@rcgp.org.uk or email@example.com.
Chiara was just registered with me, after coming to live with her boyfriend in London. She tells me she was receiving 90mg of methadone daily from an Italian drug service, which I have been able to confirm and am happy to continue. On her second presentation she requests a HIV test as she is worried as one of her using friends has just been diagnosed in Italy. She speaks excellent English but has little understanding of HIV and other viruses that she may be at risk of such as hepatitis B and C.
What are the key points I should cover before doing the HIV test and what other blood viruses should I screen for?
It is important to establish - what is Chiara's risk? A careful history about injecting and sharing of any injecting equipment (including filters, water and spoons), and when it last happened, is vital. Hepatitis C has a very high prevalence in injecting drug users across the world and many do not realise that it can be transmitted through sharing paraphernalia other than needles and syringes. She may have been at sexual risk of HIV and Hep B and a sexual history should be taken.
You should explain the nature of the initial tests. The HIV test is an antibody test that shows whether the person is infected but not how long for or the state of their immune system. The Hepatitis C test is also an antibody test but an additional test, the polymerase chain reaction (PCR) or viral load, is required to determine whether there is evidence of active infection. Many labs will automatically carry out the PCR test if the antibody test is positive - find out what happens locally. Hepatitis B tests will show ongoing infection or whether immunisation is required. In all cases positive tests will need to be followed with further investigation in the practice or by specialist referral.
Chiara should also understand the 'window period' when tests may be falsely negative and whether she will require repeat testing at a later stage because of this.
- HIV - 3 months
- Hep B and C - up to 6 months
Latest advice suggests that a positive antibody test for Hepatitis C with a negative PCR should be repeated after at least 6 months to confirm that there is no evidence of active infection.
A brief explanation of the long natural history of HIV and Hep C infection is useful and emphasise the availability of treatment for these viruses. HIV can be controlled with life-long combination therapy. Hepatitis C cure rates with inteferon/ribavirin treatment for 6-12 months are between 40-80% depending on the genotype of the virus.
Use testing as an opportunity to give advice on prevention - safer sex, safer injecting and advise that there are interventions for HIV and Hep B to prevent infection of the unborn child.
Concerns about life assurance have deterred people from testing in primary care. Negative tests for BBV should have no impact on the ability to obtain assurance. Positive tests, wherever they are carried out, will make it more difficult to obtain life policies. As Chiara has a history of drug use most companies would insist on BBV testing when applying for any such policy.
Ask about how she will cope with waiting for a result and if she got a positive test? Is this the right time to take a test or are there other issues which should be dealt with first? For example depression. What support does she have?
Use leaflets to reinforce your discussion. It may be better to give her a chance to think about the testing and get her back to see the doctor or nurse for the blood test.
Do not wait for blood tests or serology results before initiating Hepatitis B immunisation - give it today and follow the super-accelerated schedule (O, 7 and 21 days) unless subsequent serology shows she is immune.
When you take the blood test make an appointment to give her the result, explain it will never be given out over the telephone, and suggest she brings a friend with her when she comes.
Daren is aged 26 years and has been a patient of mine for two years. He has been stable on 110mls of methadone mixture for over one year. He tells me he takes occasional heroin and crack but these have never been picked up on in his urines. He decided he wanted to go back to college and he began a bricklayer's course 4 months ago. He was enjoying it and doing well until he slipped 2 weeks ago while carrying a load of bricks and injured his back. He is in severe pain and NSAIDs (oral and topical) and anti-spasmodic have not helped.
I am reluctant to increase his methadone, although that is what he has requested. Would this be worth trying and are there any other alternatives that I could use?
This question raises some very important and complex issues. The management of acute pain in patients on substitute opiate medication is frequently suboptimal in part because of the understandable anxieties and misconceptions of the prescribing doctor.
Darren is clearly managing very well and needs good medical treatment to ensure that he does not feel the need to self- medicate his pain and return to more regular heroin use. Fear of inadequate treatment of his pain may be contributing to it and it is important to reassure him on this.
History and examination will have ascertained that this is likely to be a short-lived condition with no worrying neurological signs. Physical treatment including physiotherapy, acupuncture and the use of a TENS machine may be offered in addition to any change in medication.
However, experience tells me that Darren is likely to need opiate based analgesic to manage his pain. The experience of pain is wider than simply the level of pain felt, but includes fear, anxiety and the loss of the feeling well-being all of which are very well-treated with opiates.
Methadone is of course a very good analgesic. The problems for Darren are that he will have developed tolerance to the analgesic effects of methadone and some cross-tolerance to the analgesic effects of other opiates. In addition he may have increased pain sensitivity due to opiate-induced hyperalgesia.
You ask if you should increase the methadone. I agree this is a reasonable first step. However, the analgesic effect of methadone is not as long lasting as its effect as a substitute opioid, most patients requiring a dose every 6-8 hours to maintain analgesic effects. I would therefore initially ask Darren to divide his methadone into a 3x a day dose and slowly increase the dose if required.
Another approach would be to leave the methadone dose alone and add an alternative opiate to provide analgesia. Morphine sulphate is an appropriate choice. This has the advantage of clearly distinguishing between pain and addiction treatment and making it easier to return to the status quo once the pain has subsided. The relative insensitivity to the analgesic effects of opiates due to tolerance will mean that the doses of morphine will be relatively high and may need to be given more frequently than usual. There is no clearly defined starting dose of slow release morphine in this situation and I would start on 10-20mgs bd and give morphine liquid 10mgs in 5 mls for break through pain. I would review very frequently until pain is adequately relieved, increasing the slow release morphine as required.
As the prescribing GP you may be concerned that additional morphine will cause respiratory depression. Tolerance to respiratory depression develops rapidly on methadone and risk of respiratory depression appears to be theoretical rather than clinically significant in this situation (Ref 1). There is likewise no evidence that the use of opioid analgesics to treat acute pain is associated with relapse to heroin use (Ref 1) Darren should of course be appropriately counselled and reviewed and any additional opiates stopped once the pain is resolved.
1. Daniel P Alford et al. Acute Pain Management for Patients Receiving Maintenance Methadone or Buprenorphine Therapy Ann. Intern. Med. 2006;114:127-135.
RCGP Certificate in the Management of Drug Misuse
Part 1 National Events
York - 17th May 06
Swindon - 13th September 06
London - 8th November 06
Part 1 Local Events
Northampton 9th May 06
Manchester 11th May 06
Birmingham 24th May 06
Haringey, London 16th June 06
To book onto one of these events or for more information please contact Tom Inkelaar, firstname.lastname@example.org, tel 0207 173 6093, or visit www.rcgp.org.uk/substancemisus.
RCGP - Update on Methadone Prescribing
19th July 06 - Derby
RCGP Special Interest Training Day on PainManagement & Opiate Dependence
27th September 06 - Leeds
Past and current certificate/graduates: £105.
All other delegates:£135.
To reserve a place contact Terri Myers, tel 020 7173 6091/6090 or email@example.com
RCGP Substance Misuse Unit, Frazer House, 32-38 Leman Street, E1 8EW
SMMGP and NTA
Taunton - 7th June 06
One day conference
Developing Effective Treatment within Substance Misuse Shared/Primary Care in the South West Region
For GPs, shared care workers, commissioners, managers, pharmacists and service users. Speakers include Clare Gerada.
Cost: £40 - booking form/further info. Mark Birtwistle, tel 0161 772 3546, e-mail Mark.Birtwistle@bstmht.nhs.uk.
NTA - Delivering the Treatment Effectiveness Strategy
A series of three events to inform practitioners about how to take thetreatment effectiveness strategy from inception to implementation.
24 May 2006, East Midland Conference Centre
Nottingham7 June 2006, Winter Gardens, Blackpool
28 June 2006, Mermaid Conference Centre, London
Booking form can be obtained from http://www.nta.nhs.uk/events/main.htm.
Network Production Group
Dr Chris Ford
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Network ISSN 1476-6302.