SMMGP - Substance Misuse Management Good Practice

Substance Misuse Management Good Practice

Supporting good practice in drug and alcohol treatment

Post-its from Practice:
Reducing the prescribing tool box unnecessary (Sep 2009)

I recognised the face of the man standing at reception but I couldn't put a name to it. Charlie reminded me that he had been a patient of mine 16 years ago but had then moved out of London and had left the list. He had with him a letter addressed to me from the local hepatology department so I invited him into my room to discuss it.

The story was that he had moved back into north London about ten years ago. He had originally come to me from a private doctor on a script for 16 methadone tablets, I had continued prescribing the same and he had remained on it during his various moves. For the past decade, he had been very settled on the same treatment with a GP who had recently retired. Most of this GPs patient had been placed with other practices and those remaining, mainly more complex patients, were assured continuity of treatment by the local specialist service.

When Charlie attended for his original assessment with the specialist service, naturally his first question was could he get his tablets; the answer was "no" hence he left. He was undergoing hepatitis C treatment at the time which was going well, so the hepatitis nurse wrote to me asking if I would prescribe for him. Our only restriction for treatment is that people need to live in the practice area and unfortunately Charlie lives over ten miles away.

I knew the retiring GP and had heard from her that she had been reassured that her patients would be placed and that stable prescriptions would be continued after an assessment. I immediately explained to Charlie that I thought there had been a misunderstanding and I would talk to the specialist service manager. She was very helpful and quickly arranged a full assessment by the service's lead clinician.

Charlie had been on the same script for over 18 years and for a large majority of that time, he had not injected. His GP also had confirmation that he was unable to tolerate methadone mixture, that he had always worked to support his family, and was doing well with his HCV treatment. Given these facts I felt confident that all would be sorted.

Perhaps I was being more naive than usual but I was genuinely shocked when Charlie handed in a letter which said that the doctor had refused his request stating 1) it was Trust policy not to prescribe tablets at all 2) the Clinical Guidelines state you must not prescribe them and 3) he was at risk of injecting them - and would he like injectables?!

The clinical guidelines 2007 in fact state: "Methadone tablets are not licensed for the treatment of drug dependence and should not normally be prescribed due to the increased potential for diversion."

Like his old GP, I believed Charlie when he said that he had never injected or sold his tablets and that they allowed him to live a normal life by taking them along with his statins, and currently his ribavirin, first thing in the morning.

Some may think I am a bad doctor because I do prescribe tablets if appropriate to the individual and I feel we are wasting a sometimes useful tool from the toolbox. But perhaps even more importantly, I believe that drug treatment of any kind, whether its harm reduction, staying on maintenance or becoming drug free, cannot be effective unless we first treat people who have drug problems as individuals with individual needs.

- Dr Chris Ford