SMMGP - Substance Misuse Management Good Practice

Substance Misuse Management Good Practice

Supporting good practice in drug and alcohol treatment

Special Bulletin (July 2000)

Support for Clinicians Following GP Arrests
Information for GPs Who Work With Drug Users

Comment and advice drawing on the Drug Misuse and Dependence - Guidelines on Clinical Management 1999 ('Clinical Guidelines'), intended for GPs and those supporting the development of shared care arrangements and the management of drug users in primary care.

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Concern is now widespread for the need for protection and support for clinicians involved in the care of drug users following GP arrests in connection with patient overdose. Concern follows in the wake of the Shipman episode - with a shifting media and police focus on GP responsibility for deaths in relation to substitute prescribing. Unfortunately situations may occur, as in any area of medicine, where there is evidence of unhelpful and very occasional 'abusive' prescribing and clinical practice. Appropriate and stepped responses are needed. However, a 'witch hunt' climate, with GPs having to look over their shoulder for fear of suspension or arrest, is unlikely to encourage widespread uptake of the work.

Reassurance and support for GPs - What primary care does not need is fear of knee jerk police involvement in what may often, and certainly initially, be a clinical governance issue (quality monitoring, review, support, training, extending to stepped disciplinary measures). GPs need to be reassured by local Directors of Public Health, DATs and Shared Care Monitoring Forums, that they are valued and supported around their involvement in caring for drug users. This reassurance should include: local guidance fitting in with the national 'Clinical Guidelines'; assurance that support, training and formalised shared care structures are being put in place; and assurance of an understanding climate of partnership working with the police around treatment and clinical issues.

Police partnership in treatment - Enforced partnership working and the criminal justice interventions now mean that police are closer to local treatment issues than previously. We have a situation of an increasingly politicised agenda of drugs, and a post Shipman media and police scrutiny of certain clinical activities. However, for the police, Home Office and treatment agencies to establish useful partnership working (and have some of the criminal justice agenda met through treatment), it is important that any fear of inappropriate and hasty police interventions is quelled.

Patient and clinician responsibility - A GP has a duty to take due care and attention and follow clinical guidelines. This will include advising the patient as to the contra-indications of a medication. Without responding to specific instances that have been recently highlighted by the media, there is evidence that many deaths associated with prescribing are partly or wholly attributable to other drug or alcohol use additional to substitute prescribing. We want to ensure the best possible clinical practice for all patients groups, but drug use is a risky business, with a high client-group morbidity. Clinicians have a duty to do their best and be responsible, as do patients. There needs to be understanding and acknowledgement however, that when working with this client group, even with the most responsible clinical practice in place, that deaths may still occur.

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Chief Medical Officer
Drug Misuse & Primary Care Update May 2000

"The Drug Misuse Clinical Guidelines, published in April 1999, stressed the importance of the provision of safe treatment in the care of drug misusers. They were targeted at GPs and emphasized the importance of good assessment, urine testing before prescribing, shared care, supervised ingestion (where available) and training."

"Shared care means GPs working in the context of a local network of services, supported by specialist service provision. Medical practitioners should not prescribe in isolation and health authorities must ensure appropriate services are in place to support GPs."

"The Government attach importance and welcome the recent announcement from the General Practitioners Committee and Royal College of General Practitioners [see below] emphasizing and supporting the important role that GPs have in providing care for drug misusers and also their emphasis on shared care."

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Royal College of General Practitioners/General Practitioner Committee Policy Statement on Care of Substance Abusers

"The RCGP and GPC believe that General Practitioners should offer appropriate care to all patients on their lists. Where patients have problems with substance abuse, appropriate care will include aspects of primary care normally provided by the practice primary health care team, shared care with other care services and referral to other appropriate services."

"Certain GPs may develop particular expertise in the care of substance abusers, and the number and location of these doctors should, ideally, be sufficient to prevent substantial workload falling onto only a few GPs. In supporting the development of this expertise, the Health Departments must ensure the provision of appropriate training in this field; facilitate professional support; resource the adequate provision of support services including specialist services and offer appropriate additional remuneration for this work."

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Effectiveness of Methadone

Recent concerns should not undermine the fact that there is substantial evidence for the effectiveness of methadone maintenance, more so than many other common types of treatment. To obtain maximum effectiveness, correct dosing is paramount. This is acknowledged by the 'Clinical Guidelines':

"The use of methadone maintenance now has a strong evidence base, 5, 6 Methadone Maintenance is one of the most researched of the available treatment modalities and an overall assessment of its effectiveness can be made with more confidence than for other treatments. If practitioners are properly trained, methadone maintenance can be effectively delivered in a wide range of settings, including primary care."
(Clinical Guidelines p53)

"Taken over two decades, the randomised studies of methadone maintenance demonstrate consistent, positive results over vastly different cultural contexts... The one-year follow up of the National Treatment Outcome Research Study, which is monitoring the progress of 1075 clients recruited into either residential or community treatment services over five years, also supports these findings."
(Clinical Guidelines p53)

Dosing (also see below for starting dose and risk of overdose/dosing)
"After careful dose induction... (See commencement dose in 'Clinical Guidelines' p45-6) and dose stabilisation, there is a consistent finding of greater benefit from maintaining individuals on a daily dose between 60mg and 120mg. In some instances, due to a patient's high tolerance, higher doses may be required but this is exceptional..."
(Clinical Guidelines p54)

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Development of Local Support

Clinicians need reassurance and development of better local support. This should include: