SMMGP - Substance Misuse Management Good Practice

Substance Misuse Management Good Practice

Supporting good practice in drug and alcohol treatment

Conference Reports & Presentations:
RCGP 3rd National Conference (Apr 1998)

Royal College of General Practitioners (RCGP)

Managing Drug Users in General Practice
New NHS - Same Dilemmas: Caring for Drug Users in the New NHS

24 April 1998
Murrayfield Stadium Conference Centre, Edinburgh
HIV/AIDS Working Party of the RCGP

Conference Report by J-C Barjolin & Dr Chris Ford, June 1998

Conference Supported By

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Conference Supported By

Conference Organising Committee
Jean-Claude Barjolin
Dr Berry Beaumont
Dr Judy Bury
Dr Chris Ford
Dr Claire Gerada
Brian Whitehead

Conference Organisers - RCGP Courses London
Jennifer Goulding
Lisa Liu

Conference Organisers - Primary Care Facilitator Team, Edinburgh
Caroline Jaquet

Report Editors
Jean-Claude Barjolin
Dr Chris Ford

Rapporteur
Jean-Claude Barjolin

Educational Grants
Brent & Harrow Health Authority
Camden & Islington Health Authority HIV, Drugs & Alcohol Services
Lothian Health
East London and City Drugs Services (Tower Hamlets Healthcare NHS Trust)

Commercial Sponsors
Carfax Publishing
Boehringer Mannheim
Du Pont Pharmaceuticals Ltd
Lipha (Merk)
Turning Point
Reckett & Coleman

For comments or further information (including SMMGP Newsletter) please contact Dr Chris Ford at the Substance Misuse Management Project, Brent and Harrow Health Authority, The Harrovian Business Village, Bessborough Road, Harrow HA1 3EX. Tel: 0181 9661109

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1. Foreword - Dr Chris Ford

The management of drug users in General Practice has seen a number of significant changes over the past 3-5 years.

This has included the setting up of increasing number of GP shared care schemes, a shift towards primary care being more in the driving seat of service provision and the vast increase in the prescribing of methadone by General Practitioners. There is a move on a Government and national level to rationalise drug treatment after the generally good but extreme incongruities of 'the British System'.

Immediately following the 1998 conference, the Government 10 year strategy for drugs was launched 'Tackling Drugs Together. Building a Better Britain' (Ref 1) which reinforced this and stated unequivocally that "There is growing evidence that treatment works. (p.22)" and one of the key objectives is to "Increase participation of problem drug misusers, including prisoners, in drug treatment programmes which have a positive impact on health and crime. (p.22)"

This annual conference is playing a part in that change, bringing together GPs and other health professionals from across the UK to develop a shared understanding of the key issues currently facing the field and establishing a network for exploring and developing these.

The conference is an annual event under the umbrella the HIV/AIDS Working Party of the RCGP and we hope this momentum will take us into and well past the millennium.

- Dr Chris Ford

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2. Introduction & Background to the Conference

Edinburgh was this year host to the third national RCGP 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 moved out of London in order to reflect the national diversity of the work being undertaken. The focus had returned to Scotland, the source of much pioneering and dedicated work in substance misuse. The conference was full to capacity with over 130 delegates, the largest gathering to date. The venue located in Murrayfield Stadium seemed appropriate in terms of the growing momentum of this annual event.

2.1 Conference Background

The conference was first held in 1996 as a GP initiative as it was felt that the few GPs or schemes doing the work were experiencing common concerns, yet working largely in isolation.

The first conference looked at the 'why and how' of managing drug users in general practice. In fact it addressed the question 'if' general practice should be managing drug users at all. 1997 focused on 'embracing the diversity' of managing drug users in general practice; diversity in terms of the variety of roles and approaches within general practice and in terms of multi agency working and shared care. 1998 had a focus on a national structure of support, in order for primary care to influence this field of work within the new proposed and evolving primary care led NHS. The challenge might be how to maintain a focus around the management of drug users in general practice within the interesting if somewhat blurred vision of the future of primary care.

2.2 Aims of the conference

To bring together GPs and other health professionals working with drug users in general practice to examine, explore and debate current practice and concerns. The focus has deliberately been primary care as there has previously been little significant opportunity for primary care centred discussion.

2.3 Developing the conference 'initiative'

2.4 Organisation and support

Has been given by members of the Conference Committee, the Courses Unit of the RCGP, and the Substance Misuse Management Project at Brent and Harrow Health Authority. The 1998 conference was also supported by the Edinburgh Primary Care Facilitation Team

2.5 Future Activities

For further information on the SMMGP Newsletter or for comments on the report please contact Dr Chris Ford at the Substance Misuse Management Project, Brent and Harrow Health Authority, The Harrovian Business Village, Bessborough Road, Harrow HA1 3EX. Tel: 0181 9661109

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3. Summary - Key Points from 1998

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4. Consensus Statement 1998

As in the 1996 and 1997 conferences, delegates agreed a number of clear and strong consensus statements which arose from the discussion and pooling of experience on the day. Dr Judy Bury who chaired the afternoon session and closed the day urged that these be quoted, heard and used in higher circles.

  • 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) (Ref 3).
  • 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.

4.1 1997 Consensus Statement

Managing Drug Users in General Practice 'Embracing the Diversity'

It is clear that many GPs are involved to a high standard with the care of drug users throughout the UK.

Home Office Addicts Index

We call upon existing regional drug databases to be improved and to replace the lost function and for them to engage more with general practice.

4.2 1996 Consensus Statement

Managing Drug Users in General Practice 'Why? How?'

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5. Presentations

5.1 Chairs Introduction to the Morning Session - Dr Claire Gerada

As morning Chair Dr Claire Gerada welcomed the third national conference to Edinburgh and acknowledged the significance and value of having moved the event out of London. Claire spoke briefly of the great changes once again facing primary care, and the changing NHS. She described entering partnerships as the name of the game in moving towards a primary care led NHS. Questions still remain on how the broader changes to primary care and the NHS are likely to impact on the development of drug and alcohol work responses. She suggested that GPs and Primary care need to be considering now how best to place themselves to emerge from the changes. Whilst the publication of the new Department of Health Clinical Guidelines had been delayed and were not available for the conference, Claire was able to 'speculate' somewhat as to the likely general framework of the document (see Section 7.1).

In line with other speakers on the day, Claire spoke of the positive impact general practice has had on the care of drug users to date, and the growing opportunity and need for it to be at the centre of political, strategic and operational developments in this field. One development reflecting this, was Claire's own recent appointment as 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 opportunity and acknowledgement for primary care in the management of substance misuse. Clare is an organiser and leading figure in the annual conference, a Lambeth GP who runs the Consultancy Liaison Addiction Service with over 150 users registered in her own practice, and a GP Commissioner for drug and alcohol services.

Claire welcomed and handed over to Mrs Nicola Munro, the Chair of the Scottish Advisory Committee on Drug Misuse, for the opening address to the conference.

5.2 Welcoming Address - Mrs Nicola Munro, Chair of the Scottish Advisory Committee on Drug Misuse (SACDM)

The welcoming address was given by Mrs Nicola Munro, Chair of the Scottish Advisory Committee on Drug Misuse. She highlighted the concentrated problems in Scotland in which parallels could be seen across the UK. This included the divisions and harm traditionally brought about within Scottish families through alcohol use, now carried over into drug use. She praised an increasing and changing strategic response to drug use in Scotland. GPs were identified 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 spoke of how high drug use in the 1980s combined with a high prevalence of HIV/AIDS led to sensible and pragmatic responses from medical and other quarters. The 1990s saw this backed up by more structural and strategic responses after the establishment of a ministerial task force and multi-agency advisory committee. The formal and statutory establishment of Drug Action Teams (DATs) around the UK was echoed by other fora working for greater co-ordination of service responses. This has been no easy task, but DATs efforts are beginning to pay off, as they start to get to grips with delivering results within a national and local strategic framework.

Scotland has recently seen the main political party leaders joined by other public figures in a high profile drug awareness campaign. This delivered a conflicting but interesting dialogue which has probably left the community more prepared to be open to the issues and more acknowledging of the expanding and changing patterns of drug use. Scotland has seen prevalence studies beginning to adapt measurement technology to use in less traditional areas of focus, such as rural and island areas. Mrs Munro drew attention to how with expanding and changing drug use, whilst deprived city estate areas still remain most at risk, rural areas are now demanding increasing levels of service provision. 1991-96 figures for Greater Glasgow showed a 1% risk of drug related emergency hospital admission for the top social class. For the bottom social, class the risk was 28%. In North East Scotland, problems and demands are manifesting, related to higher income heroin use.

Numerous aspects of changing drug use challenge the scope of services. We know of the increasing awareness of drug related accidents and we know that children and young people are reporting increasing drug use experimentation. Problems with teenagers with cluster risk behaviour including crime, social behavioural problems, and drug and alcohol use are now well documented. Mrs Munro took the opportunity to support and reinforce the need for effective drug and alcohol education in schools.

At the other end of the spectrum, older client groups with a long histories of complicated drug use, HIV, and mental illness are presenting in services, whilst care and treatment within some prisons is still lacking. She felt this may in part highlight the need to improve the effectiveness of programs which work towards abstinence goals; whilst we have lots of people entering programs, we have many fewer people coming out the end of programs able to cope with a drug free life. In response to a question regarding responsibility for care, Mrs Munro clarified her view that substitute prescribing as a treatment needs to continue in prison.

Mrs Munro stressed that we address what is behind current level of drug deaths in Scotland and the rest of the UK and look for ways to intervene. She highlighted the need for good information systems, particularly since the demise of the national addicts index. The central role of Community Pharmacists in the delivery of services was emphasised as was the importance of involvement of user groups in improving services. She urged delegates to reach out and increase support and involvement of both these groups. Mrs Munro spoke favourably of the opportunities offered by Scottish primary care trusts, together with the positive aspects of shared care in terms of improved opportunities for communication, more accessible services and expansion of skill base. She highlighted how, if prevalence surveys are to be believed, all GPs are probably seeing drug users, if not declared, and affirmed how few other areas of general practice are so challenging yet so valuable to the community.

5.3 Political Changes in Primary Care in England, Wales & Scotland and How they Affect Care of Drug Users - Dr Susanna Lawrence

Dr Susanna Lawrence is a GP working in a deprived area of Leeds, where she provides extended services for drug users. Her work also involves her as a non executive member of the Health Authority and is involved in the development of primary care groups. In terms of 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. Her caution was that general practice will have to be careful to maintain the focus and innovation around substance misuse as changes are implemented, if it is to ensure accessible and appropriate services within primary care.

Dr Lawrence viewed the framework of the New NHS as intending to put patients first and improve care. Whilst having some similarities with the internal market, she saw an improvement in that the new framework offers a greater focus on equity, communication and openness. The NHS service framework will aim to unify budgets and define new patterns and models of care with the intention of improving the consistency of care. 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 GMS and Hospital and Community Health Services (HCHS) budgets are pooled. Integration of secondary and primary care services has the potential to both help and hinder service delivery. Interventions will need to cover the broad spectrum of social and health, requiring effective training for all involved practitioners if understanding and approaches are to dovetail. A question from the floor highlighted this with an example of how a housing department, central in the welfare of drug and alcohol users lives, was working at loggerheads to local treatment service philosophy. In this example, clients with drug and alcohol problems were viewed as having self inflicted conditions, and a written policy deemed them unworthy of housing.

Dr Lawrence spoke of National Institute for Clinical Effectiveness (NICE) which show primary care to be already relatively ahead in terms of effectiveness in working with drug users. Work conducted by the new national guidelines committee and this conference network have begun to establish minimum national standards of good practice. It was acknowledged however, that good practice standards may differ considerably from what many GPs are actually doing in practice.

Although the green papers make mention of illegal drugs, she suggested that their focus on mortality indicators (whether people stay alive rather than if people come off or make other changes) is too simple. 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" (Ref 4)) addressed the needs of substance users. She also prioritised the need to get drugs and alcohol into the Health Improvement Programme (HIP) (Ref 5), which received formal support in one of the consensus statements from the day (see Section 4). Significant differences with Scotland such as the inclusion of mental health in Scotland and the English primary care commissioning role were mentioned.

How primary care conducts and responds to genuine community consultation is an area Dr Lawrence identified as requiring urgent improvement. Public involvement needs to be more than just public meetings, which she viewed as probably the worst method for effective consultation. However, accurately reflecting community needs and wishes can present difficulties. Communities may be telling us they want drug users 'out' at all costs, a clear conflict with the GPs responsibility to deliver good interventions for the whole community, including drug users.

A similar difficulty may exist in addressing the culture of difference within the GP community. Numerous fears exist amongst GPs around drug and alcohol client groups. These arise from the responsibility of delivering care as well as the potential ability of these groups to be high consumers of local budgets. Extending the point to budgets, deprivation and high need, Dr Lawrence made the point that financial equity is not same as health equality. There are dramatic differences in areas, between densely and less densely populated areas even within cities, making health needs assessments and equality of planned responses difficult. Responses are probably best determined on local primary care group and city wide areas, but the divulging of budgets is likely to be difficult and complex. Possibilities in terms of increasing the effectiveness of care delivery included the use of designated specialist GPs, skill mix and greater use of other members of the PHCT as in fact the push of the White Paper suggests. GPs may not always be the best people for doing all of the work.

5.4 Progress Towards a National Network of GP Support - Dr Berry Beaumont

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 GP from Islington has become a lead in establishing the network after volunteering at last year's conference. She described how official policy over the last twenty years, particularly in a number of recent policy documents from the Department of Health (Ref 6, Ref 7, Ref 8), has been encouraging and increasing the role of GPs who have become major providers of care for drug users in Britain. However, support for GPs in this work has been patchy, uncoordinated, poorly researched and poorly resourced. The consensus statements from the 1997 national conference on managing drug users in general practice said 'There is a lack of and a need for primary care based research on effective interventions and models of care', and 'Although there has been an increase in support provided by specialist services, there is an urgent need to provide a national framework of GP support with secure funding' (Ref 9).

Dr Beaumont highlighted how we still do not know the numbers of GPs or patients involved in the management of drug users in general practice, and how we have a patchy picture of the varied schemes and progress of shared care across the UK. Even the core/GMS debate hangs in the air to some extent with the GMSC being somewhat unsure on their position. Dr Beaumont reminded us how the forum from this conference, the growing momentum of three national conferences, has organised itself and moved the national agenda forward. This is represented by a regular dissemination of the SMMGP Newsletter, a book "Care of Drug Users in General Practice - a harm minimisation approach" for GPs by GPs, conference committee representation on the new clinical guidelines committee at the DoH, and now the benefit of Dr Clare Gerada being appointed at the DoH. The time seems ripe to support this with a national network, to provide a framework of training, research and support as identified in last year's conference consensus statement.

Berry described how she had initially canvassed many GPs and London Academic departments, and she took the opportunity to thank the many who had written and offered help. She eventually opted for the support of the Centre for Research on Drugs and Health Behaviour (CRDHB) and drew up the proposal in conjunction with Professor Gerry Stimson and Nicky Metrebian from the Centre together with GP and other colleagues. The first outline proposal names the network as PRISM, but the search continues for a clinching name not already used by other organisations. CRDHB was chosen because of its history of community focused research of drug use, its strong links with primary care, and its academic independence from some of the larger established specialist drug centres.

Berry describe the aims of the network 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 CRDHB in London, maintain an affiliation to the national conference network, and establish formal links with the RCGP and other national bodies.

Objectives of the network:

The activities in the first year programme of work would include:

An implementation group of GPs are working with CRDHB to obtain funding. Once established, the network would be managed by a steering committee of GPs and others caring for drug users in the general practice setting. There will be elected officers to oversee day to day work together with a full time co-ordinator and administrator. The steering committee will be able to be periodically extended or changed. Dr Beaumont extended an invitation to individuals to join, help or feedback ideas. The likely funding start date would be April 1999. With the initial future funding yet to be decided, the on-going funding arrangement is still undecided, but the possibility exists of it becoming a membership organisation, with a self financing capacity after its initial funding period. Very positive support has been given from the DoH to date, although funding is yet to be secured. Dr Clare Gerada, speaking with her DoH hat on, supported the initiative and praised the very good proposal format which she felt likely to get funding during the next funding round.

A suggestion was made from the floor, that the network liaises with the Society of Occupational Physicians as it is presently difficult to get clients and GPs to come forward in occupational scenarios. A question from the floor asked how we address the need for the RCGP and the RCPsy. to work together towards supporting both specialist and GP competence. Berry said the RCGP has reviewed the proposal, and it is hoped there will be ongoing RCGP involvement together with joint working with other colleges and bodies. However, as not all GPs look to the RCGP for leadership, the network would take a broader approach for developing support and competencies amongst GPs. A joint conference between the RCGP, the RCPsy. and RCN may be another step forward.

5.5 Morning Session Discussion - Shifting Resources for an Integrated Primary and Secondary Care Service

Discussion from the morning sessions focused on resourcing and supporting GPs in relation to shared or shifting workload from secondary care. The point was made that national policy is not always a direct concern of 'on the ground' GPs, but that the time and resource issue is, and that this has not been addressed. The concern is a direct one, that if GPs are expected to expand services, a corresponding input of resources is required. Various approaches for addressing this were discussed. Health Authorities are able to provide limited funding originating from Tackling Drugs Together (Ref 10) which is managed through local Drug Action Teams. This may be able to address minimum training requirement or go towards some recognition of GP payment. A little known but undoubtedly more significant possibility is in HSG (96) 31(Ref 11) which allows Health Authorities to vire money from secondary care into primary care where primary care can demonstrate competence to deliver services.

The question was raised as to how often Health Authorities actually release money to primary care from secondary services at present. It was suggested that the new Guidelines will give more clout to this possibility. Recommendations were made for more lobbying of Health Authorities to recognise resourcing needs and shifting workload and for the use of statistical arguments such as audited workload. This is an area that the new GP network can engage in, as both national and local advocates for GPs. Clare Gerada also offered her support from the Department of Health in addressing any problems around Health Authority resourcing between primary and secondary care.

An example was cited by Dr Chris Ford of shifting resources and workload at Brent and Harrow Health Authority. Here the process resulted in a re-tendering of specialist drug and alcohol services. The re-tendering allowed some resources to be shifted to primary care, and for contractual specifications for specialist services to be re-focused into supporting a primary care model of service delivery. In the given example, the problem highlighted the difficulty large established and well resourced specialist services can have in voluntarily changing their historical role, and willingly releasing or transferring clients who could be in primary care. The dilemma for services wishing to work with primary care, is that this can be counteracted by a fear of reducing client base and service role and relinquishing resources and power. The suggestion was made that tinkering with services may be unlikely to bring about the real structural or resourcing adjustments necessary for an integrated primary and secondary care model. More affirmative strategic and commissioning action, whilst having its disadvantages, may be a more effective means.

The discussion also highlighted that at present, funding is often only available for methadone treatment. We need to move away from this approach which supports a limited notion of what is possible in terms of working with drug users.

5.6 What are Drug Users Rights? - Tam Miller

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 issue of drug user rights and user involvement. This was a stark reminder for the largely GP audience of how it can be to sit on the 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. Tam made the point that an employed person may come to the surgery with flu symptoms and receive appropriate care, whereas a prescribed person with the same symptoms may well be dismissed as simply withdrawing. Many stable users on scripts may attend for a variety of other non scripting health concerns which may not be recognised. The script may be irrelevant to their reason for consultation, and feeling unwell may not be related to their drug use. Many scripted drug users lead stable lives, have families and mortgages, may work, yet often find themselves stereotyped by GPs.

The behaviour of a minority of users during 'chaotic' periods of their lives can influence the reputation and treatment of others. An incident was reported of two scripted users talking at a surgery, where one was questioned by the GP about the reason he was talking to 'that junkie'. Complaint, by patients regarding GP behaviour is difficult in any circumstance, but particularly when a script is at stake. GPs do hold considerable power, which often engenders a reluctance for honest dialogue from the client, out of fear of losing the script. This point was backed up by a GP in the audience who stated that 'we get more respect back from patients than we give'. Situations were described of GPs appearing to be overtly displaying or wielding power for power sake, such as being inconsistent or petty in deciding when to strike patients off, or whether or not to issue a script. Many users may consequently choose not to discuss with the GP, aspects of their drug use, such as using on top. An amnesty by the Drug Problem Service in Edinburgh for users to say they are using extra on top and not lose their script was welcomed as a positive development by users.

Tam spoke of the merits of starting up a drug users group. This may provide an opportunity for stable users to get on with something productive in their lives which contributes something to society. Involvement may include meeting and working with local GPs, the local drug squad, local authorities, or the media, towards breaking down stereotypes and having a user voice heard.

A point was made from the floor, that it may be difficult for some users to talk in groups, and that not all users wish to spend time with other drug users once their lives are stabilising. Groups were explained as being usually mixed in terms of drug free and drug using members, where the group looks to support where each individual is at.

Users Groups have a large network in Scotland, probably more effective than any GP network for working with drug users. GPs and other authorities could learn from this model and be more open for meeting and working with User Groups on an equal basis. A key message was the value user involvement has in informing GPs, service management and commissioning and planning groups such as the Drug Reference Group or Drug Action Team in the design and response of services.

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. Several views were expressed on urine screening, with Tam Miller describing it as a disgrace, defeating any notion of trust. It was suggested that urines also offer the client the right to safe care, a demonstration that the practitioner does care. In this context, screening should be used as a supportive tool for developing trust both initially and randomly, where the client is free to openly discuss any use on top or other issue. The sticking point seemed to be one of attitude or approach and how the urine screening is presented and used.

One question was why patients are not more willing to come off methadone, which a GP from the audience described as 'horrendous'. Tam made the point that users have to fight hard to get and maintain a script, and that once secured it stabilises and makes their lives more comfortable. Methadone was described as a drug that sometimes receives unfair press, being blamed for deaths which in fact often result from alcohol mix and other causes. Tam suggested that most users would agree that supervised consumption has had some success in lowering the death rate, and that it may have an application with the user who consumes as many drugs as possible from any available source.

5.7 Chair's Introduction to the afternoon session - Dr Judy Bury

The afternoon was Chaired by Dr Judy Bury, well known for her work with primary care in Edinburgh who affirmed both the value and challenge of hosting the conference outside London. She welcomed the many who had come from all over the UK, and was pleased to see the event not so London dominated. She supported the new national network proposal and requested support and involvement in the network, together with suggestions for a different name than PRISM (currently used by other organisations).

Dr Bury praised the organisers in Edinburgh, at the RCGP in London and the members of the conference organising committee for the enormous amount of work in both setting the conference up and running it on the day. She also thanked the many sponsors, both Health Service and commercial, for supporting the cause financially.

5.8 Beyond Methadone - Dr Tom Gilhooly

Dr Tom Gilhooly presented on 'Beyond Methadone', highlighting the frequent reluctance by practitioners to look at alternatives to methadone. Methadone has been established as the "Gold Standard" in opiate substitution over the past 30 years and is now the most widely used drug in the UK for the treatment of drug misusers. Despite this exalted position in the treatment of addiction, it still attracts a good deal of controversy and is widely criticised for its toxicity and involvement in drug overdose deaths. Whilst a great advocate of methadone, he felt it was unreasonable that a condition as complex as opiate addiction is being mainly dealt with through the use of one drug and often one approach, namely methadone maintenance. Dr Gilhooly did not downplay the value of maintenance or methadone, but advocated that GPs need to be on the leading edge of trying different approaches, and targeting care at the early stages, for different types of patients, or at different stages in an individual's treatment.

Dr Gilhooly described the involvement of GPs in the treatment of drug users in past decade as probably the single most significant factor in the changes in availability of treatment. He described how he and colleagues together with the Health Board support and finance, had aimed to have 100 local GPs managing 2,000 users. This has now been realised. Methadone is still a core treatment for GPs, but he regarded it as both healthy and timely that new treatments emerge to challenge the supremacy of methadone. His review looked at some of these contenders and the pros and cons of these treatments.

A variety of drugs were reviewed favourably in terms of possible targeted application in general practice. These included LAAM, diamorphine, buprenorphine, and benzodiazepines.

Levo-alpha-acetylmethadol (LAAM) has become available for prescribing in the UK this year (1998). As a cogener of methadone, LAAM is an oral preparation and has advantages in terms of its long duration of action allowing alternate day, or two to three day dosing. It is not safer in overdose but is cost effective. Concerns about toxicity and the need for careful patient selection created licence difficulty for its trial in Glasgow. Many patients in the American trials have been happy with LAAM and prefer it to methadone. There seems to be no difficulty moving from methadone to LAAM that we know of.

Heroin has been used for a number of years in the UK but is no longer widely prescribed here for a variety of reasons. Up until the mid '60's it was the most frequently prescribed drug for drug users in treatment. The move towards specialist services providing care, increasing numbers of drug users, and frustration with the maintenance approach, created a shift towards oral methadone on a reducing basis during the '70's.

Diamorphine can be considered the drug of choice for most opiate dependant patients and can be used via injectable and inhaled routes. Disadvantages include a short half life, difficulties in monitoring it, and the current expense of delivering it as a treatment. The results of the Swiss heroin trials have been very encouraging and may lead us to reassess our policies here. With diamorphine, the best Swiss study shows 69% client retention at 18 months. This was all the more impressive as many were methadone 'failure patients', including those who had failed with injectable methadone. Dr Gilhooly sees heroin as a tremendously useful drug, with great potential as a 'move on drug' for those who have failed with methadone. In response to questions from the floor, he advocated intra-muscular use of heroin rather than intravenous for users who have no veins (painful but safer), and the need for heroin to be injected on the clinic premises.

Dr Gilhooly questioned the political, public, and practitioner concern of using heroin, when in fact it is a very useful and safe drug that is commonly used in hospital medicine. Legitimate limitations include that it is expensive to deliver, has a short half life and is difficult to monitor. He felt that these can be more than compensated for by the social and health benefits of its use as a treatment for drug users. Political pressure from the US to inhibit trials or change of policy together with present pharmaceutical production and pricing policies are major factors in limiting its use. The promising Australian study has been downsized partly due to US pressure.

Buprenorphine, a partial opiate agonist/antagonist is becoming more popular as a substitution treatment, especially in France in the absence of methadone where the use of high dose preparations is being tried. French GPs are not able to prescribe methadone without specialist support which led to a search for alternatives. These high dose preparations are not yet available in the UK. Buprenorphine has long duration of action and a good safety profile. In the form of Temgesic (low dose), it is easily injectable with serious health consequences, and has been the subject of some controversy. This potential to be abused, led to it being banned by the Glasgow LMC in 1990 with mixed results. Dr Gilhooly feels the decision was a bad one, as users have simply moved on to other drugs especially heroin, which may have greater risk. He sees buprenorphine as a relatively safe drug, safer than methadone, with the long duration of action being a big advantage, particularly to working people. When combined with naloxone, studies show that users go into withdrawal if they inject this combination, but have the opiate effect if it is taken sublingually - a real designer drug combination. He sees it as a potential star contender for use in primary care settings.

When questioned on the subject of benzodiazepines, Dr Gilhooly said he would prescribe for clients during withdrawal as many seem to derive benefit, or for maintenance for regular street users as it offers many of the advantages of other prescribed substitutes.

Drugs he perceived as having more drawbacks or limited application were primarily dihydrocodeine and naloxone but include others such as hydromorphone implants, GA/naloxone, acuphase, lofexidine, clonedine, and buspirone.

Dihydrocodeine has been used for opiate substitution and has a chequered history with some strong advocates but little documented evidence of efficacy. He felt there was little positive to say about it as a maintenance drug It has a short half life, a street value (often there is a fear of giving adequate dosage because of street value), and is difficult to monitor. There is little published evidence of its efficacy and it has been banned in the Glasgow Drug Clinic Scheme. It was stated from the floor that the first useful study on the use of dihydrocodeine which shows some promising results was being published in the Drug and Alcohol Review [Macleod, Whittaker & Roberston. Observational study looking at 100 people on dihydrocodeine and 100 people on methadone. There were no significant differences in outcomes over five years].

Patients have had little positive to say on naloxone and it tends to have poor compliance. However, whilst not having broad application it needs to considered for selected patients. In the US it has been claimed to be successful with alcohol users following detox. It is useful in alcohol dependence and may have uses with dual dependency. Some work has been done in the UK for post rapid detox from opiates. Careful patient selection is important.

Dr Gilhooly spoke of other drug treatments such as hydromorphone implant, and buspirone nasal spray. He spoke of the use of tranquillisers in rapid detox such as acuphase and GA/naloxone combination as expensive and yielding poor results. He commented though that he had heard one client suggest that paying £3000 helps significantly toward positive outcomes. He considers lofexidine and clonidine not useful in general practice settings, although possibly having uses in in-patient care. He viewed clonidine as at least a cheaper drug than lofexidine. This was not totally supported from the floor, as it was felt that both drugs may have their place for short term users wanting a quick community detox without methadone. [Lofexidine is being used in London in a 10 day in-patient detox with 92% of users completing treatment. However, relapse seems high when used in the community. Editor]

In response to a question on crack use, he said that they did not yet have the experience of treating heavy crack use in Glasgow and is unsure what approaches might work best. Sedatives may be useful for in patient and buprenorphine may have applications.

In conclusion Dr Gilhooly said that we need to try different treatments for different types of patient, that care needs to be targeted and that more focus is needed on rehabilitation. Beyond all these treatments are the almost uncharted waters of treating the problems that underlie the drug problem. He reminded us that effective prescribing is only the first step to recovery for patients.

5.9 What Research is There and is it Useful to Primary Care? Dr John Macleod

Dr John Macleod reviewed the research available and its use to primary care. He argued that primary care is currently the mainstay of the service response to problem drug use in the UK.

The scenario he described was one of rising drug use, rising costs, finite resources, and scepticism about the effectiveness of interventions aimed at helping problem drug users. This, together with proposals to divert drug users from the criminal justice system, will increase the burden on services, particularly primary care. How will GPs and other members of the primary health care team respond to this challenge? Many are already reluctant to engage with drug users for a variety of reasons. He argued that these challenges create a duty to patients to use research effectively.

With the move towards evidence based practice, it could be argued that the addictions field is arguably one of the most 'evidence free' areas of medicine. A small number of trials have suggested that in older opiate injectors, motivated to change but unable to sustain abstinence, methadone mixture is more effective than nothing at reducing peoples use of other drugs and keeping them in contact with services. So is there something particular about methadone or would other drugs work as well? Can we generalise from these trials (some over 20 years ago conducted only on methadone, none in the UK) to our patients who may be young, poly-drug users, not necessarily motivated to change, not necessarily injection users? In an age of finite resources could we achieve what we currently achieve more cost effectively? Evidence that might help us answer these questions is thin on the ground and most of it comes from non-experimental observational studies.

Dr Macleod described 'research' supporting practice which ranges from grade A randomised control trial to grade D science free or experience debates, the latter consisting of pragmatic arguments where we are not sure if what we are achieving is more harm or more good. Dr Macleod suggested however, 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.

A question from the floor asked what is the relationship between research and practice in terms of encouraging involvement of more GPs and raising standards. Dr Macleod responded that because we sincerely believe working with drug users is 'right' (that a GP should do it, and that it achieves positive outcomes), when confronted with a colleague who is sceptical and reluctant to engage with drug users, we tend to be economical with the truth about the size of our evidence base. This means that we can oversimplify and overstate what treatment consists of and what it can achieve.

As to the broader question of how research relates to practice, Dr Macleod suggested that we are still in the new territory stage of feeling our way. He elaborated that it is only recently that medicine as a whole has made any ideological commitment to being scientific (i.e. to practice based on research evidence) as opposed to scientistic (donning the mantle of science to enhance professional credibility and status).

What was also highlighted in this discussion, is that it may be a contradiction between what research suggests is good practice and what is appropriate or acceptable within the public sentiment.

Statements were made about complacency around Hepatitis C and the urgent need for more research and information. Concern was expressed regarding the loss of the National Addicts Index on the possibility for data collection. Clarification was given that in spite of the cost of the service, the system proved ineffective with only very patchy notification. Concern was expressed around the fact that there are no clear plans to replace or improve the index, although some local development work is being conducted on improving regional database reporting and in developing other possible options and technology for the purpose. Dr Macleod suggested that rather than lamenting the passing of a system for keeping tabs on addicts, we need to look at newer surveillance systems that can be used in a health rather than a public order context.

Dr Macleod argued that most questions in the addictions field remain unanswered. We require more good quality evidence as the basis for effective practice. 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. Problems resulting from prescribed methadone diversion is not just media hype and it is unclear with the absence of research how much the benefits of prescribing are mitigated by these. Supervised consumption may have a place but it is expensive, probably not humane and certainly not a 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 the above.

'Does our practice need to be evidence based or can we trust our common sense? If we want some reassurance that what we do actually achieves something positive, a good starting point would be a thorough appraisal of the existing evidence, published and unpublished. Earlier this year a " Drugs and Alcohol " Critical Review Group of the Cochrane Collaboration was registered in Rome. Their remit will be the co-ordination and collation of systematic reviews in this area. If we establish exactly "where we are now" hopefully what should also become apparent is "where do we go from here".'

'In the meantime we will continue as medicine traditionally has, doing what seems humane and sensible in the light of the limited evidence that is available and guided by our personal experience and beliefs. This is not criticism of that approach, just a suggestion that it is a starting point, not a destination.'

[Conference abstract extract, Dr J Macleod]

5.10 Chairs Closing Comment

Dr Judy Bury closed what had been a packed and exciting day by commenting on the evolving mood of the 3 conferences to date. She concluded that the focus is no longer on whether or not general practice should do the work, but on a positive commitment to doing it better.

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6. Workshops

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, the role of the voluntary sector in running specialist services, and 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, training verses competence, extending the team to pharmacists, and working with the homeless and working outside of the inner city. Treatment options included lofexedine use and community detox, residential rehabilitation, talking therapies, and benzodiazepine prescribing.

6.1 Morning Session Workshops

Each workshop was asked to report back a few key points from the session. These are listed below:

6.1.1 Shifting care or shifting costs. Setting up a shared care scheme - Jean-Claude Barjolin

6.1.2 Training verses competence - Dr Susanna Lawrence

6.1.3 Regional Drug Misuse Database and other alternatives to the Addicts Index - Peter Knight and Arun Sondhi

6.1.4 Specialist services - statutory or voluntary? The role of the voluntary sector. Why you need us - Sebastian Saville

6.1.5 Secondary Care and shifting resources - Paul Carvajal

6.1.6 Widening the team. Working with pharmacists - Jane Pettifer

6.1.7 Giving Drug Users a voice. Setting up a local drug users self help organisation - Scottish Drug Action Group

6.1.8 Working outside the inner cities - Andy Rome

6.2 Afternoon Session Workshops

Each workshop was asked to report back a few key points from the session. These are listed below:

6.2.1 Community detoxification and the use of lofexidine - Dr Richard Solomons

6.2.2 Pros and cons of heroin prescribing - Dr Roger Smith

6.2.3 Talking therapies - Brian Whitehead

6.2.4 Benzodiazepines - Dr Tom Gilhooly

6.2.5 Working with the homeless drug users - Dr Nat Wright

6.2.6 GPs are not enough - supporting the PHCT - Caroline Jaquet

6.2.7 Getting going on research - Nicky Metrebian<

6.2.8 When to suggest residential rehabilitation - Dr Gordon Morse

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7. Developments

7.1 National Clinical Guidelines

The Department of Health Guidelines on Clinical Management of Drug Misuse and Dependence

During 1997 and early 1998 a working party chaired by John Strang, with Judy Bury, Dr Chris Ford and Dr Clare Gerada as members, has been meeting to rewrite and update the above guidelines. These guidelines were last updated in 1991. There have been so many changes in the 'drug problem', the type of drugs used and treatments since the previous edition, that the guidelines originally planned to be completed in late 1997, have been delayed several times.

Numerous questions have been raised during the production of the new guidelines. What is to be recommended for primary care? Is it time to broaden out treatment approaches from methadone as the dominant response for opiate dependent drug users? What other dependent drug users should general practice be treating and with what? Should the prescribing of injectable methadone be limited to specialists? Is there a place for heroin prescribing? How do we avoid spillage of methadone on to the black market and limit methadone deaths? How should shared care operate and who should take the lead?

Dr Clare Gerada was able to speculate on the content of the new guidelines during her opening address as chair. It seemed likely that the guidelines may suggest:

This supports and extends the 1993 GMC statement:

'It is unethical for a doctor to withhold treatment from any patient on the basis of a moral judgement that the patient's activities or lifestyle might have contributed to the condition for which treatment was being sought. Unethical behaviour of this kind may raise the question of serious profession misconduct.'

The guidelines are to advocate a harm minimisation approach, making advice on safer drug use available to all patients seeking help. This is not sanctioning drug misuse, only limiting the harm caused by that use.

Care could be provided by doctors under 3 divisions:

  1. Generalist - all doctors with contact with drug users.
  2. Extended Generalist - medical practitioners involved in the treatment of drug misuse, although this is not their only area of work. They must demonstrate competence and may often work within a shared care set up.
  3. Specialists - drug misuse is their principle clinical activity, working in a multidisciplinary team and undertaking regular training.

Dose assessment facilities may become required, with recommendations that if facilities are not available, that funding need be provided. Supervised consumption may become required for newly scripted patients at Community Pharmacy outlets, with recommendations for resourcing this facility if required. Funding is likely to be found centrally. Some recommendations are to be made on limiting leakage and deaths associated with prescribed medication, together with the need to show competence before allowing continuation of prescribing drugs other than oral liquid methadone. The guidelines are intended to encourage practitioners to treat and prescribe safely, and could be possibly used in GMC investigations.

The new guidelines were intended to be out by 'the summer', but the most recent information suggests the autumn.

7.2 SCODA Training Package

The Standing Conference on Drug Abuse (SCODA) has been charged by the Department of Health with the creation of a training package for GPs and other primary health care staff. This is being done in tandem with the clinical guidelines working party. A questionnaire was given to all delegates at the conference to ask what type of training (lectures, CD-ROM, leaflets, interactive small group training etc.) and educational content the delegates would prefer. The data from this survey has been used to inform the advisory group consisting of representatives from some of the relevant primary care organisations and the voluntary sector.

At present the advert to initiate a tendering process for consultants or organisations to produce the training package is being written. It is hoped to pilot the paper based training package towards the middle of next year and the electronic media later in 1999.

7.3 SMMGP - Substance Misuse Management in General Practice Newsletter

The SMMGP newsletter is now entering its third year and has just produced its 10th edition which is a brief report of this conference. The mailing list has now over 250 recipients. All lead articles have been written by people on the mailing list about topics that affect primary care from a primary care perspective. Most of the contributors have volunteered (some with a little encouragement from the editorial board!). We did hope to restrict it to two sides of A4 but it has recently doubled in size due to the wealth of information that is being produced.

7.4 'Care of Drug Users in General Practice - A Harm Minimisation Approach'

Judy Bury highlighted the 'Care of Drug Users in General Practice - a harm minimisation approach'. published by the Radcliffe Medical Press in August 1997. The text is edited by Dr Berry Beaumont and has contribution by many organisers and delegates of the conference. It has its roots in this conference, and reflects a 'for GPs by GPs' approach.

7.5 North West London Combined GP Support Scheme

There is currently an initiative in at least three North West London Health Authorities which have existing shared care schemes, and several Health Authorities that would like to develop schemes, to examine the possibility of a standardised substance misuse support scheme for GPs. This is currently in the initial discussion and proposal stage, but the areas being explored are: a centrally co-ordinated training scheme; a common clinical auditing procedure monitored and reported by the North Thames Drugs Database; the development of common good practice guidelines; standardised GP payments and cross boundary care; and reviews of specialist and primary care service structure, strategy and resourcing. The intention of the scheme would be to begin to implement a common approach and protocol where possible whilst still retaining flexibility to respond to differing needs and different service arrangements in different boroughs.

7.6 Primary Care Led Drug Services

There are an increasing number of primary care led specialist drug services which present a variety of approaches for supporting primary care and which deliver a range of innovative services to drug users. The largest is in the Wirral, the most formalised in Glasgow, and the most recent in Brent. These and many other services are addressing a re-balance of power and resources between primary and secondary services within a context of integration rather than distinct specialisms. They also challenge the notion that specialist drug services need to be psychiatry led, which has been the dominant model over the last thirty years.

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8. Editor's Remarks - Going Forward

8.1 Enhancing the Role of Primary Care

The evolving mood of the conference seems to reflect a number of possible dynamics which could be summarised as:

  1. Acknowledgement of a growing foundation of experience, knowledge, competence and commitment within the conference network.
  2. A pragmatic vision of a way forward, and the creation of possibilities from the conference network for improving and advancing this work in the UK.
  3. A backdrop of significant changes at national/policy level which offer further opportunity for enhancing the care of drug users in general practice.

A number of useful messages and recommendations have emerged from the 1998 conference. There seemed to be a focus and a 'consensus' within the core themes re-emerging throughout the many presentations, workshops and the discussion during the day. These are best highlighted in the summary and the consensus statement, but a number of points are worth re-iteration.

The role of the GP in maintaining the health of drug users is of undeniable and significant value. Few other areas of general practice may be so valuable to the community, and is it seems like we have moved past the threshold of whether general practice should be doing the work, into how it should be doing it, and the support needed for it to be most effective. There is much to be gained in the GP being supported in this work through more coherent efforts both nationally and locally. Not least is the need for GPs to be supported in trying different treatment approaches, and for practice to be supported by evidence and research. Whilst many GPs sincerely believe working with drug users is 'right', that it achieves positive outcomes, it is only very recently that medicine as a whole has begun to demand more scientific rigour in generally raising the standard of treatment. An opportunity exists for primary care to be leading the way in an approach to care, evidence based medicine and service delivery. There is a positive commitment from general practice for improving the quality of treatment and access to services. What seems inspiring is that this commitment has taken the initiative for broader change, seeming for it to be possible to improve not only what is available to users in primary care, but also in the range of substance misuse services working in collaboration with primary care.

Although the power of the conference comes from the belief that general practice can undertake this work successfully, there are still vast areas of the country and a significant proportion of GPs who are still unsure, frightened and opposed to being involved in this work. The conference and network must attempt to reach these other areas. Where change has happened there has tended to be a scheme to support GPs. The most successful schemes have been GP initiated and often GP led.

8.2 User Involvement

There has been an interest since the first conference in representing the perspective of drug users, with this being reflected in a lead presentation. This is not tokenism but a sincere commitment to the belief that users need to be involved in the process of change. Many of us have been more positively challenged by our patients than any other party. This is now supported by the Government 10 year strategy (Ref 11) and in Scotland, by the formal mechanism for user input to Scottish drug policy.

8.3 The Development of Primary Care and Specialist Services

In order for primary care to effectively take on more involvement and responsibility, secondary care too must change. The practice of specialist services and primary care working with poor communication or in mutual isolation needs to be challenged. Primary care does need the support of specialist services, in fact we need them all the more, but they must be accessible and responsive. They must begin to operate like specialist services in other disciplines, in supporting patients who cannot be managed in the community. At the same time primary care needs to normalise the treatment of drug users on a more widespread basis. Specialist services would best focus primarily at initiating treatments which achieve patient stability, together with offering periodical interventions in patient treatment when that stability is lost due to a change in life events, changing drug use etc.

The diabetic is well managed for most of the time in the community, but if the sugars become erratic or if they need to move on to injectable drugs they are again stabilised by the specialist services. When the patient and the specialists are happy with their management, they are again transferred back to care in the community. Why has it taken so long for specialist drug services and primary care to be able to mirror this model.

For this model to work well in the drug field we must learn more about each other and grow to a greater understanding. This co-operative working may well work best in a shared care framework, but this too must be accessible and responsive and not become bogged down with bureaucracy.

Perhaps as well as continuing to get strong through these annual conferences, the network and the newsletter, we need to think more about joint working. Examples of this as suggested at this year's conference, may be joint working parties involving the RCPsy and RCGP, and a joint conference with all parties involved in drugs work. We now need to make these a reality.

Editors

Dr Chris Ford
Jean-Claude Barjolin

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9. References

1. Tackling Drugs to Build a Better Britain. The Governments Ten Year Strategy for Tackling Drugs Misuse presented to Parliament by the president of the Council by Command of Her Majesty. April 1998.

2. Health Service Circular 1998/065 'The New NHS Modern and Dependable. Establishing Primary Care Groups'. NHS Executive.

3. Health Improvement Programme (HIP) will be the local strategy for improving health and healthcare. Criteria for HIP are laid out in the Green Paper "Our Healthier Nation" and the Health Service Circular 1998/065 'The New NHS Modern and Dependable. Establishing Primary Care Groups'. NHS Executive.

White Paper on HIP:

Green Paper on HIP:

4. Health Service Circular 1998/065 'The New NHS Modern and Dependable. Establishing Primary Care Groups'. NHS Executive.

5. Health Improvement Programme (see Ref 3).

6. Department of Health Circular. El (95) 114 Reviewing Shared Care Arrangements for Drug Misusers. NHS Executive.

7. The Task Force to Review Services for Drug Misusers. Report of an Independent Review of Drug Treatment Services in England. Department of Health (1996).

8. Tackling Drugs to Build a Better Britain. The Governments Ten Year Strategy for Tackling Drugs Misuse presented to Parliament by the president of the Council by Command of Her Majesty. April 1998.

9. Barjolin J (1997) Conference Report: Managing Drug Users in General Practice. 'Embracing the Diversity'. Royal College of General Practitioners. October 1997.

10. Tackling Drugs Together: A Strategy for England 1995 -1998. May 1995. HMSO. London.

11. Health Service Guideline (96) 31 'A National Framework for the Provision of Secondary Care Within General Practice'. NHS Executive.

12. Tackling Drugs to Build a Better Britain. The Government's Ten Year Strategy for Tackling Drugs Misuse. Presented to Parliament by the President of the Council by command of Her Majesty. April 1998.