Special Bulletin (November 2000)
Licensing Can Seriously Damage Your Health
(And the UK National Strategy)
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A recent Home Office consultation document (Ref1) has proposed that the current law on licensing doctors involved in the treatment of addiction should be extended far beyond its current limits of heroin, cocaine and dipipanone to include:
- A licence requirement for prescribing any controlled drug in Schedule 2 or 3 with the exception of methadone liquid or mixture on an NHS prescription.
- A licence requirement for prescribing any controlled drug in Schedule 2 in injectable form.
This new licensing proposal was recommended "in order to reinforce the clinical standards set out in the Clinical Guidelines (Ref2) and to tackle the problems caused by inappropriate prescribing, especially overdose death and leakage of prescribed drugs on to the illegal market."
In itself licensing is not sufficient to counter inappropriate prescribing, and it may have the opposite effect to that intended. For instance the potential important contribution of methadone alternatives, such as buprenorphine, or LAAM, will be stifled. It ends the flexible and coveted British System of prescribing, so envied by those countries we now seek to emulate. Furthermore drug companies will not see it as a profitable exercise to invest in research for new and better drugs to treat addiction if only a few licensed doctors can prescribe them.
Inappropriate prescribing would be far less now if teaching about substance misuse was a core part of undergraduate and postgraduate medical education for GP registrars, as was recommended in 1990 by the ACMD in a report (Ref3), which was accepted by ministers but not acted upon. Instead, since then education in medical schools on drug misuse has substantially reduced (Ref4) and this is not being rectified.
Although the licensing proposals have profound implications for doctors, there has been no widespread debate within the medical profession. Of the 36 bodies who were officially consulted few had any representation from GPs who were actively engaged in treating drug misusers. Those that did have such representation do not support it. The Royal College of GPs and the two GPs on the ACMD reject the proposal. Furthermore, at the last annual RCGP conference on the Management of Drug Users in General Practice, there was shock at the failure to consult the doctors who will be mainly affected. This was the first time that most of these GPs had heard about the proposal, and the end consensus statement abhorred this lack of consultation.
The proposed licensing changes may increase anxiety and reluctance among the doctors contemplating whether to start treating drug users, and they will place additional hurdles for practices already doing this. A practice may have only one licensed GP, and when that doctor is absent his or her colleagues will be barred from providing cover. If any urgent change to the prescription is required, conflict and distress amongst patients and staff at the practice will be likely when a replacement prescription has to be refused. It will only take one or two such instances for an average practice to decide to pull out of the treatment process. This will discourage participation in shared care schemes, which are a pillar of current government strategy, and make targets in this area more difficult to achieve.
Encouraging GPs to become involved has been a slow process, but there are great benefits of involving even a relatively small percentage of the UK's 36,000 GPs. Licensing will deter such involvement. Many GPs not wishing to be seen as the local licensed expert will decline to be involved. They will view it as official recognition that non-specialist doctors should stay away from this area of medical practice. Because of the size of the workforce, the costs are large of even a small percentage of GPs pulling out.
- Specialist drug services, which are already stretched beyond capacity, will become overwhelmed with drug users seeking help they cannot obtain from their GP or elsewhere.
- Waiting lists for treatment will grow progressively longer.
- More drug-related deaths, counteracting recent recommendations (Ref5) to help reduce fatalities.
- A rise in blood borne virus infection rates. We already have a national disaster from the hepatitis C epidemic. This will worsen.
- A deterioration in the health problems of drug users, their families, and local communities.
- More crime on the streets perpetrated by those unable to access treatment.
An alternative has been suggested, which would provide access to high quality, evidence-based interventions, and be flexible enough to meet the needs of the range of potential users of services. It includes incentives if protocols are followed, and a robust system of clinical governance. Are policy makers flexible enough to accept a better solution?
1) Home Office consultation document (2000) Changes to the Misuse of Drugs Legislation Licensing of Controlled Drugs Prescribed in the Treatment of Addiction. (see Home Office web site for more details).
2) Dept of Health, Scottish and Welsh Offices, Dept of Health & Social Services Northern Ireland (1999) Drug Misuse and Dependence - Guidelines on Clinical Management. London: The Stationery Office.
3) Report by the Advisory Council on the Misuse of Drugs (1990) Problem Drug Use: A Review of Training. London: HMSO.
4) Crome, I.B. (1999) The Trouble with Training: substance misuse education in British medical schools revisited. What are the issues? Drugs: education, prevention, and policy, Vol 6, No 1, p.111-123.
5) Report by the Advisory Council on the Misuse of Drugs (2000) Reducing Drug Related Deaths. London: The Stationery Office.
Material from this article is published by Druglink in its November/December 2000 edition. This article has been circulated by Substance Misuse Management in General Practice (SMMGP) at the request of the authors. SMMGP would like to thank Druglink for their permission to reproduce this material.