Newsletter No 10 (June 1998)
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'New NHS - Same Dilemmas: Caring for drug users in the New NHS'
RCGP HIV/AIDS Working Party
Edinburgh was this year's host to the third national conference 'Managing Drug Users in General Practice - New NHS - Same Dilemmas: Caring for Drug Users in the New NHS'. It seemed fitting that the conference had moved out of London, to reflect the national diversity of the work being undertaken, and that the focus returned to Scotland, the source of much pioneering and dedicated work in substance misuse.
As in previous years a number of clear and strong consensus statements arose from the discussion and pooling of experience on the day.
- As general practitioners and members of the Primary Health Care Team we continue to be committed to caring for drug users.
- We are preparing to meet the challenge of adapting to new models of working in the 'New NHS' - given appropriate support and resources.
- We believe that the management of problem drug use in primary care should be included as an indicator in the Health Improvement Programme (HIP).
- Collaboration with a range of services including specialist drug services, the voluntary sector and pharmacists remains essential to the provision of good care.
- We support the proposal to establish a new primary care network to improve the provision and effectiveness of care for drug users in the general practice setting.
The opening address was given by Mrs Nicola Munro, Chair of the Scottish Advisory Committee on Drug Misuse. She highlighted an increasing and changing strategic response to drug use in Scotland where she identified GPs as having a valued and increasing contribution through substitute prescribing, an intervention which stabilises peoples lives and reduces their need to turn to crime to fund their habit. She highlighted the concentrated problems in Scotland in which parallels could be seen across the UK; of a tradition of division within Scottish families brought about through alcohol use now carried over into drugs use. She spoke of the value of sensible pragmatic responses from medical and other quarters backed up by more structural and strategic responses. Mrs Munro drew attention to how, with changing patterns of drug use, deprived city estate areas still remain most at risk, but other areas and groups such as rural and higher income are demanding increasing levels of service provision. She highlighted how all GPs are probably seeing drug users, even if not declared, and affirmed how few other areas of general practice are so challenging yet so valuable to the community.
Dr Susanna Lawrence, a GP from Leeds, discussed the political changes in primary care in England, Wales and Scotland. She suggested that the new government papers have good and bad news for drug users, and that general practice will have to be careful to maintain the focus and innovation around substance misuse as changes are implemented, to ensure accessible and appropriate services within primary care. She stressed how important it was to ensure that the Government's plans for the NHS (set out in the white paper, "The New NHS, Modern, Dependable") addressed the needs of substance users. There is likely to be a 'wait to see' if Primary Care Groups allow the formation of natural communities or not, if designated GPs for drug use evolve, how secondary care and primary care integrate, and whether or how General Medical Services and Hospital and Community Health Services budgets are pooled. The need to get drugs and alcohol into the Health Improvement Programme HIP, was given priority in the talk, and formally supported in one of the consensus statements from the day (see over). The impact of general practice to date and the growing opportunity for it to be at the centre of political, strategic and operational developments in this field was very evident throughout the day.
One development reflecting this, was the recent appointment of Dr Claire Gerada, who Chaired the morning session, to the post of Senior Medical Officer for Drugs and Alcohol within the Health Promotion Division of the Department of Health. As the first 'jobbing' GP appointed the Department, this represents both a significant acknowledgement and an opportunity for primary care in the management of substance misuse. With Clare as an organiser and leading figure in the annual conference, a Lambeth GP who runs the Consultancy Liaison Addiction Service, managing many drug users in her own practice, and a GP Commissioner for drug and alcohol services, it seems that the cause is in good hands.
Another exciting announcement, an idea grown out of last year's conference and supported in this year's consensus statement, was the progress of a national network for supporting primary care in managing drug use. Dr Berry Beaumont, a lead in establishing the network, described its aims being to establish a stronger national profile and support structure, both operationally and politically, for GPs undertaking the work of caring for drug users. It would bring together existing expertise and research and facilitate new research into effective care in the general practice setting. In addition the network would promote training and the development of adequately resourced shared care schemes across the county. It would disseminate good practice guidance and encourage the representation of GPs in local and national fora concerned with problem drug use. The network would be based at, and work in conjunction with, the Centre for Research on Drugs and Health Behaviour in London, maintain linkage to the national conference, and establish formal links to the RCGP and other national bodies. Very positive support has been given from the DoH, although funding is yet to be secured.
Tam Miller, a development worker at the Castle Project in Edinburgh and founding member of Chemical Reaction users group gave a frank presentation on the question of drug user rights. This was a stark reminder for the largely GP audience of how it can be to sit on other side of the consultation table, where a patient can be perceived merely as a 'drug user' and not a regular patient or member of the community with legitimate health or personal concerns. The talk prompted an eager and useful question and answer session that resembled something akin to 'All a GP has ever wanted to ask a drug user but...'. Many topics were touched on including trust and the supportive or punitive role of urine screening; the script, GP control of the patient and what can often be an unequal balance of respect; how methadone can sometimes receive unfair blame for deaths that often result from alcohol mix and other causes. A key message was the value user involvement has in informing GPs, service management and commissioning and planning groups in the design and response of services.
Morning and afternoon workshops covered a broad range of topics some more political in nature such as giving drug users a voice, shifting care and resources from secondary care to primary care, the role of the voluntary sector in running specialist services, and the pros and cons of heroin prescribing. More operational topics included alternatives to the addicts index, 'getting going on research', setting up a shared care scheme, supporting the whole PHCT, the differences between training and competence, extending the team to pharmacists, working with homeless drug users and working outside the inner city. Treatment options included the use of lofexidine and community detox, residential rehabilitation, talking therapies, benzodiazepines, and the limitations of medicine.
Dr Tom Gilhooly then presented 'Beyond Methadone', highlighting the frequent reluctance to look at alternatives to methadone. He felt this results in a ludicrous scenario of something as complex as opiate addiction being mainly dealt with through the use of one drug and often one approach, namely methadone maintenance. Dr Gilhooly did not underestimate the value of maintenance or methadone, but advocated that GPs need to be on the leading edge of trying different approaches, targeting care for different types of patients or at different stages in an individual's treatment. He reviewed a variety of drugs favourably in terms of possible targeted application in general practice. These included LAAM, diamorphine, high dose buprenorphine (not yet available in the UK), and benzodiazepines. Other drugs he perceived as having more drawbacks or limited application included dihydrocodeine, lofexidine, clonedine, naloxone (and implants). He spoke favourably of treating the problems that underlie the drug problem, of some non prescribing interventions such as Biographical Therapy, stating that substitute prescribing was only the first step in allowing change.
Dr John Macleod reviewed the research available and its use to primary care. He argued that rising drug use, rising costs and finite resources, and scepticism about the effectiveness of interventions aimed at helping problem drug users, create a duty for providers to use research effectively. Research ranges from grade A randomised control trial to grade D science free or experience debates which consist of pragmatic arguments where we are not sure if what we are achieving is more harm or more good. Dr Macleod suggested that the evidence does indicate that doing something is probably better than doing nothing, that methadone maintenance does work for older heroin injectors, that the provision of other strong opiates (e.g. buprenorphine, diamorphine) probably also works, and that generally the bigger dose (at a safe and correct level for the individual) the better the outcome.
Many questions remain unanswered and require effective evidence based research. Research at the moment does not tell us what to do with people whose drug problem extends beyond opiate dependence, or what treatments offer best 'value for money'. Whilst we know that long term opiate users benefit from methadone, this may not include the majority of drug users presenting in general practice. Prescribed methadone diversion is not just media hype and it is unclear with the absence of research how much the benefits of prescribing are outweighed by diversion. Supervised consumption may well have a place but it is expensive, and may not be a humane or total solution. Whilst commitment to harm reduction is a worthy aim, questions remain around how we can help people to be drug free sooner. It would seem that systematic reviews of all data on community based treatments, improved information and monitoring systems, and imaginative high quality primary research is much needed to address many of the above.
The afternoon was Chaired by Dr Judy Bury, well known for her work in Edinburgh, who affirmed both the value and challenge of hosting the conference outside of London. Dr Bury closed what had been a packed and exciting day struck by the evolving mood of the three conferences to date. She drew attention to how the focus is no longer whether or not general practice should be doing the work, but a positive commitment on how to do it better. (A full report of the conference will be sent out to all delagates in the next 4-6 weeks. A copy can be requested from below if you didn't attend).
Are you interested in research, research in general practice and primary care examining the care and management of drug users?
If so then please register your interest with Dr Berry Beaumont, who is developing a network of those who are interested to develop this area further. Please send your name address and contact number to: Dr B Beaumont, 23 Jackson Road, London N7 6ES. Tel:
Are you happy with the format of the conference?
We are, but it would be great to know if anyone has ideas. One suggestion on the evaluation forms was to invite papers/abstracts from people working in primary care - what do people think? Would this be a good way to support and encourage primary care research? Would this be a better way of hearing what we are all up to? Don't be shy - write to us at the address below!
This Newsletter was originally created by:
- Chris Ford
- Brian Whitehead
- Jean-Claude Barjolin