SMMGP - Substance Misuse Management Good Practice

Substance Misuse Management Good Practice

Supporting good practice in drug and alcohol treatment

Conference Reports & Presentations:
RCGP 4th National Conference (Apr 1999)

Royal College of General Practitioners (RCGP)

Managing Drug Users in General Practice
A Time of Change - Has Anything Changed?

23 April 1999
Royal Institute of British Architects, Portland Place, London
HIV/AIDS Working Party of the RCGP

Conference Report by J-C Barjolin & Dr Chris Ford

Conference Supported By

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Conference Supported By

Conference Organising Committee
Dr Berry Beaumont
Dr Judy Bury
Dr Chris Ford
Dr Claire Gerada
Brian Whitehead

Conference Organisers - RCGP Courses Unit, London
Jennifer Goulding
Lisa Liu

Report Editors
Dr Chris Ford
Jean-Claude Barjolin

Rapporteur
Lyn Summers

Educational Grants
Brent & Harrow Health Authority
Camden and Islington Health Authority
East London and the City Health Authority
Ealing, Hammersmith & Hounslow Health Authority
Kensington, Chelsea & Westminster Health Authority
Standing Conference on Drug Abuse (SCODA)

Commercial Sponsors
Reckitt & Colman
Britannia Pharmaceuticals
Merck

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1. Foreword

Welcome to the report of the 4th National Conference on Managing Drug Users in General Practice. This is an annual event run in collaboration with the RCGP and it's HIV/AIDS Working Party. It brings together GPs and other health professionals from across the UK to continue the debate of managing drug users in primary care.

Department of Health policy over the past few years has been to encourage the involvement of general practitioners in the care of drug users (Ref 1). Shared care is now an integral part of government drug policy (Ref 2). But there are many quarters that are saying GP's do not want to be involved, we are not very good at it and that perhaps we should leave it to specialists.

This negative view goes does not represent the complete picture of primary care involvement and ability. The conference is one example of GPs doing it, doing it well and wanting to improve. It is a coming together of GPs and others from primary care, of various levels of expertise to share, learn and gain support from their colleagues. We also know that more than 40% of methadone prescriptions dispensed by retail pharmacists in the UK are written by GPs (Ref 3).

So where does this disparagement originate? There seem to be three main sources of this negativity. Firstly some specialists, who write about GPs reluctance to care for problem drug users. They are often unwilling or unsure how to work effectively with primary care (Ref 4). Secondly we have GPs themselves, particularly the General Practitioners Committee (GPC), who claim that GP's are all unwilling to do this work. This view has been further polarised by responses to the recent clinical guidelines. The GPC seemed to interpret the guidelines as obligating GPs to work with drug users and responded by saying that no GP's are willing to do the work.

The final source of this misperception is the press, particularly the GP press. The GP press have even conducted surveys which have shown that a good percentage of GPs (18%) are already working with drug users and that a very healthy 47% would provide substitute drugs if requested to by an drug agency or as part of a shared care scheme. The results were then titled as 'GPs refuse to take on the care of drug users' (Ref 5)! This negative approach by the press was further highlighted in relation to the clinical guidelines and translated into headlines such as 'GPs blackmailed to treat addicts' and 'GPs lambaste proposals for drug misusers care' (Ref 6, Ref 7).

Within such a context perhaps we should congratulate ourselves on carrying on the work, attending conferences such as this and beginning the first steps to a national network of primary care workers working with drug users!

We need to be very clear what we can take on, what additional training we may need and what level of support we would hope to receive. Perhaps this conference and the resulting report will help to promote the more positive side of managing drug users in general practice.

The Conference Committee would like to thank the RCGP, especially the courses and conferences section for their help and support and all the sponsors who helped make this event possible.

- Dr Chris Ford & Jean-Claude Barjolin

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2. Introduction & Background to the Conference

London was this year's host to the fourth National RCGP Conference 'Managing Drug Users in General Practice'. New NHS - A time of change - has anything changed? The conference was again full to capacity with over 210 delegates with places, and many more people left waiting to attend.

2.1 Conference Background

The Conference was first held in 1996 as a GP initiative. It was felt that the few GP's or shared care schemes working with drug users were experiencing common concerns, yet working largely in isolation. Many seemed to have little or no support from specialist drug agencies.

The first conference looked at the 'why and how' of managing drug users in general practice. In fact it addressed the question as to whether 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 ha 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. 1999 needed to look at the changes in primary care and how they would affect substance misuse, the new Clinical Guidelines and the broadening and increasing drug problem.

2.2 Aims of the conference

To bring together GP's 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'

The new Department of Health Clinical Guidelines have had three members of the conference committee participating on the working group.

2.4 Organisation and support

Has been given by members of the Conference Committee, the Conference and Course Unit of the RCGP, and the Substance Misuse Management Project at Brent and Harrow Health Authority. The 1999 Conference was also supported by the Junction Project in Brent.

2.5 Future Activities

For further information or for comments on the report please contact Dr Chris Ford at the
Substance Misuse Management Project, Brent and Harrow Health Authority, Harrovian Business Village, Bessborough Road, Harrow HA1 3EX.
Tel: 0181 966 1109
or Jean-Claude Barjolin, GP Network
c/o SMAS, 46-48 Grosvenor Gardens, London SW1W 0EB

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3. Summary - Key Points from 1999

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4. Consensus Statement 1999

As in previous years, delegates agreed a clear consensus statement arising from discussion on the day.

  • This Conference welcomes the new Department of Health guidelines on clinical management of drug dependency as a step towards defining standards of good practice in the field.

  • It strongly endorses the recognition of the responsibility of all doctors to treat drug users. It also supports the emphasis placed on the evidence base for interventions, in particular the effectiveness of methadone treatment.

  • The Conference expresses reservations on some of the recommendation including the failure to fully recognise the effectiveness of treatments other than oral methadone.

  • We would encourage the development of local guidelines and protocols based on the national guidelines as a support to better care for drug users in primary care.

  • The Conference also welcomes the formation of the new Methadone Alliance, and wishes it well.

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5. Presentations

5.1 Chair's Introduction to the Morning Session - Dr Chris Ford

Dr Chris Ford welcomed everyone to the 4th National Conference which, she said, had grown from such small beginnings in 1996 to what it is today, a large and exciting forum, which hopes to assist in the support and training of GPs, and others working in primary care, in order to improve care for drug users.

5.2 Welcoming Address - Dr Paul Davis FRCGP, Vice Chairman of RCGP

On behalf of the RCGP Dr Paul Davis welcomed everyone to the 4th National Conference.

Dr Davis said that lack of knowledge around managing drug users in General Practice affects the majority of GP's. He said that he knew very little about dealing with drug users. On behalf of his colleagues, he stated that many feel less than well trained. He said that he hoped that today's conference will assist in an increase in knowledge and that people will leave feeling more informed and supported. He commented on the waiting list for the conference, which, he said, speaks volumes for people enthusiasm and commitment.

5.3 The Government 10 Year Strategy for Tackling Drugs Together and How it Relates to Primary Care - Mike Trace, Deputy UK Anti-Drugs Co-ordinator

Mike Trace opened by saying that he was grateful for the opportunity to speak. The Department of Health had advised that the general rule was 'be nice to doctors' - we have tried to do what they say and, pharmacists - we love you too!' The role of GPs and pharmacists in furthering the national drug strategy has become increasingly important and is now written into the new policy of the national drugs strategy.

Mike explained that his job was to support Keith Halliwell, UK Anti-Drugs Co-ordinator in advising ministers about all aspects of drug policy. This was a very broad remit. The Labour administration wanted a new drug strategy around all aspects of drug policy.

The Government's '10 Year Strategy' had very clear objectives and transparent targets. The first report was due out in May 1999 (Ref 8).

The focus was on providing effective and accessible treatment. Treatment is a sound investment both for the person entering treatment, the people around them and the rest of society. The benefits of treatment are cost effective, such as reducing crime and health problems, which provides a saving to the treasury. Politicians and the treasury need to hear that treatment was cost effective. Treatment of drug users is also relevant to the Government's social inclusion policy, which the cabinet are genuinely committed to.

With the implementation of more treatment the plan is to keep a broad treatment approach and support what is effective.

The next phase of implementing the national strategy has many challenges. Challenges of substitute prescribing need to tackle problems: overdose, diversion onto to the illicit market and supply and demand, so there is free and easy access to prescribing services, with no waiting lists. The long term objective was for there to be immediate access to detoxification and prescribing services, but there also needs to be an improvement in measures to ensure that medication given is taken by that client. Leakage is not thought to be causing major problems, but is relevant to good practice.

Greater focus on the windows of opportunity for people to achieve stability and make progress, which does not necessarily have to be through abstinence. This is very much a human issue down to the judgement of the person and professionals involved. Large numbers of people achieve stability through long term prescribing and/or abstinence, which helps with their employment, relationships and health. Stability of users is therefore the focus and GPs prescribing substitute medication should also include on-going work around the stability of the patient as part of their role.

With this approach to treatment, there was a real dilemma of numbers of people entering treatment versus the quality of the treatment they received. Supply and demand and the aim to have no waiting lists fuel this dilemma. This is a strategic challenge for every health authority to shape services that walk the line between numbers in treatment and the quality of the treatment they receive.

Ensuring that there is appropriate surveillance for the right people will go some way to resolving this. Some drug users need services with close supervision and support and others need very little surveillance. Daily pick-up of medication and urine testing do have a place and are an important element of substitute prescribing for those needing close supervision. Higher cost, higher intensity services must be directed to those who need them. When people enter treatment they should start at high intensity and move to lower intensity as they achieve stabilisation.

Organise your services locally so that needs are met appropriately. We need to challenge health authorities to conduct assessments to ensure needs are met.

Central government has allocated extra money to health authorities for this purpose: 12 million this year; 18 million next year and 22 million the year after. The guidance to health authorities this year assumes that the key was greater GP involvement and therefore money should be spent providing support and training for GPs.

Government also aims to enable the dissemination of creative approaches to treatment. In the next 3 years - Central Government aim to look at services which work, as there is a wide disparity of outputs for unit cost and waiting lists. Do not doubt the political backing to see this system work well and the Government will back it up.

Questions and Comments

  1. What is the Government doing about supply of drugs going onto the market?
    Easier to get hold of drugs on the street - there is a need to concentrate on what can be done creatively to stop this happening.
    Enforcement authority good at arresting people and seizing drugs but this makes little difference.
    Most areas of the world are finding it very hard to stifle the availability or stem the flow of illegal drugs - there is no quick fix!
  2. Every pound spent on treating a problem save three pounds - this means that there are savings to the Criminal Justice Systems but Health Authorities are being asked to fund the treatment - is this fair!
    Agreed with this analysis.

5.4 Drug Strategy for Primary Care - Dr Claire Gerada

Dr Clare Gerada opened by saying that it was a great pleasure to be here - and that seeing so many new faces was very satisfying. However, "as we only represent 10% of colleagues - there is a long way to go". Clare stated that drug users are regularly and consistently denied treatment - in fact, only infertile couples are treated as badly.

She said that sometimes there are problems in surgeries with drug using clients, and that they are sometimes difficult patients to manage, but no more than anybody with a long term illness.

There is evidence that methadone maintenance works and should be easily available from primary care.

Training is needed but it is the responsibility of the doctor to get that training then those patients who are drug users and who are registered with GP's can be supported. SCODA has been commissioned to produce a training package/manual/CD ROM for GP's. Clare commented that she felt very strongly that it was the GPs duty to get trained - she said that she hoped that once the new drug strategy mechanisms are put in place, both locally and nationally, issues that have stopped GP's dealing with drug users in the past will be addressed. She went on to say that managing drug users is not an optional extra, it should be as mainstream as managing any other patient.

Questions and Comments

  1. Nobody seems to mention that training should be part of the national GP curriculum.

  2. Drug users don't feel that they have any part in policy - Chris Ford has taught me a lot about involving users and we should be hearing the view of drug users.

  3. One GP stated that she didn't have much of a problem with the drug users she treats, but she would like to see training and safety not only for GP's but also for surgery staff and pharmacists - staff members and other patients can be treated badly.
    Clare suggested organising the practice to reduce risk - she felt that the difficulties of managing drug users is slightly overplayed - she said she has a list of 13,000 patients and only three have been discharged from the list.

  4. Developing shared care in Leeds - it is crucial for every member of the primary health care team to be involved in training - there was a need to press for the HA to provide funds for this essential training.

5.5 DoH Clinical Guidelines - Why these Guidelines are Important - Dr Jenny Keen

The new Department of Health Clinical Guidelines for Drug Misuse and Dependence (Ref 1), published in April this year, replaced the old 1991 Guidelines and have been endorsed by all four health departments in the United Kingdom. They were produced by a multi-disciplinary committee in an attempt to be evidenced based, relying on the work of the Task Force 1996 (Ref 2) and are fully referenced. They were published by the Department of Health within the framework of their good practice booklet on Clinical Guidelines (Ref 9) and they are firmly based in government policy. They have seven main chapters, which will be discussed briefly in this report, and 18 practical and useful annexes.

Overview

So how do the new guidelines differ from the 1991 version? The old Guidelines were very much in the style of traditional clinical guidelines in that they emphasised an individual approach regarding specific clinical management issues. They gave no overview of service provision and no specific view of shared care, and they made a number of assumptions about the availability of services, which were not always borne out in practice. The new guidelines on the other hand are part vision statements, part policy statement and part textbook. They do include the specific "clinical" guidelines, but they place a major emphasis on the mechanics of service provision and shared care. They also rely heavily on the evidenced base regarding methadone maintenance treatment, which is now available. These changes reflect the changes in the field of drug misuse treatment this decade.

Context of Change

The guidelines are a product of their time and as such they reflect their context In particular they reflect service developments and changes in the pattern of drug misuse treatments. They also take account of the Task Force report in 1996 (Ref 2) and the 10-year plan 1998 (Ref 8), both of which emphasise the role of primary care in the treatment of drug misuse. However, they also demonstrate an awareness of the dangers of methadone and in this respect they echo the ground swell of opinion against "maverick" treatment which has aroused much media interest and derives from the low public tolerance of methadone related deaths compared with heroin deaths.

The guidelines also reflect the current emphasis on medical legal issues and the necessity for practice to be defensible. The tension evident in this context runs right through the guidelines: the right to treatment versus safe prescribing, and clinical freedom versus agreed protocols. Overall approach taken by the New Guidelines.

The following four principles underlie the main thrust of the guidelines:

  1. The use of evidence based interventions is recommended especially methadone maintenance.
  2. There is a responsibility of the doctors at all levels to address drug-related problems and prevention of harm.
  3. The specifics of service provision are important for service delivery.
  4. There is a central role for shared care in delivering services. However the dualistic nature of the context within which we operate is reflected once again in the ambivalence of the guidelines towards shared care: primary care doctors are to treat drug misusers, but doctors are warned to keep within a broadly agreed protocol.

Chapter I - Key Points

This chapter is all about the rights and responsibilities of doctors and patients. The main general points are as follows:

My concerns with this classification are as follows:

  1. It fails to emphasise the responsibility of doctors who are not involved directly in the treatment of drug users at any level, but who encounter them in their clinical practice.
  2. The classification attempts to define what activities should be carried out at these different levels of involvement, without addressing the thorny issue of accreditation, which is hinted at in the guidelines but not explicitly addressed.

Chapter II Treatment - Key Points

This chapter attempts to define the structure of treatment delivery and how it should be monitored.

  1. Local shared care guidelines should be developed (primary care groups to be involved in this).
  2. Local level Shared Care Monitoring Groups should be set up, relating to drug action teams and involving the Director of Public Health and representation from all relevant agencies. These Shared Care Monitoring Groups would approve local agreement and protocols as well as reviewing training needs, clarifying performance indicators and monitoring the delivery and effectiveness of shared care.
  3. Underlying principles for treatment:

    Multi-disciplinary approach

    Importance of the structure of service provision- the health authority has the responsibility to provide services and support GPs, and explicit local shared care arrangements should be made.

    Patients requiring specialist services should still get their general medical services from a GP.

    Treatment should be based on harm minimisation because there is an evidence base for this (Ref 10).

    Once again these principles broaden out the responsibility for drug misuse treatment but an emphasis is still placed on reducing diversion of prescribed drugs and the building in of safeguards.

  4. Chapter III Assessment - Key Points

    Once again this chapter seeks to broaden the responsibility for drug misuse treatment whilst building in suitable safeguards. It states that all members of the multi-disciplinary team should have assessment skills, but that only in exceptional circumstances should substitute medication be prescribed without specialist/generalist or specialist advice. However in those exceptional circumstances, there is a responsibility to treat. There is an emphasis on adequate assessment (history, examination, and urinalysis etc) which must be made before prescribing substitute medication. However the role of urinalysis, whilst frequently mentioned, is never really clarified and whilst it is recorded as an adjunct to history and examination in confirming drug use, it is in no way suggested that the results of urinalysis should be used in order to determine whether or not the patient is allowed to remain in treatment.

    Chapter IV Responsibilities of Prescriber - Key Points

    This chapter is a key statement of principles within the guidelines: it states the rights of patients to be treated but also stresses the responsibilities of doctors to provide treatment safely.

    • All doctors must care for general health and drug related problems, but prescribing should only be done as part of a multi-disciplinary intervention, and specialist help should be sought especially when using new drugs.

    The chapter outlines a number of safeguards for prescribers and patients which are in fact very specific:

    • All new prescriptions to be taken initially under daily-supervised consumption for a minimum of three months (subject to social factors).
    • Substitute drugs to be dispensed on a daily basis but less often when stable.
    • The clinician has a responsibility to ensure that the patient receives the correct dose and that diversion is avoided.
    • The doctor should liaise with the pharmacist about specific patients and regimes.
    • No more than one week's drugs should be dispensed together.
    • Prescribing of injectable formulations (by specialists or after specialist assessment) has "a very limited place".
    • Tablets should not be prescribed.

    Chapter V Dependence and Withdrawal, VI Dose Reduction, and VII Preventing Relapse - Key Points

    Chapter V and the next two chapters are about textbook aspects of treatment but once again safeguards and evidence based prescribing are emphasised. Major points are as follows:

    • Safe dispensing and supervised consumption are emphasised throughout.
    • Doctors should adhere to licensed medications where possible (NB Dihydrocodeine not licensed and not recommended).
    • Non-prescription routes from addiction should be sought.
    • Benzodiazepines have no evidence base for maintenance treatment. They are recommended and licensed only for management of withdrawal.
    • Stimulants should be prescribed in specialist settings only and are not licensed.

    Methadone maintenance treatment is widely evaluated (and should occupy a key position (Task Force 1996)(Ref 2).

    But once again the tension between clinical freedom and safety is evident.

    • Information on recognition and management toxicity should be given to patients and carers.

    No injectable preparations are licensed for use in drug dependence but these are probably useful for some patients and should where possible be used on a daily dispensing regime - supervised where necessary.

    • Diamorphine prescribing: "very little clinical indication".

    This last recommendation does in fact fly in the face of the evidence base, which suggests that diamorphine prescribing under the right circumstances may be extremely useful (Ref 11).

    • It is the responsibility of the prescriber to ensure that patients receive the correct dose and to avoid diversion. This places a very strong responsibility on prescribers which is not normally in place with regard to other prescriptions.

    Take-home doses are not appropriate where:

    1. There is an unstable or increasing pattern of drug misuse (this is not clearly defined).
    2. Where there is unstable psychiatric illness.
    3. Where there is concern regarding diversion of prescribed drugs (this is also very poorly defined).

    • Important role for community pharmacist includes supervising consumption and taking part in shared care, with safeguards regarding confidentiality.

    Strengths of the New Guidelines

    Individual clinicians will inevitably not find themselves in agreement with every one of the guidelines. It is in the nature of national protocols that they are not perfect and need to be adapted for local use. Nevertheless these guidelines have a number of strengths. First they represent an attempt to recognise and formalise changes that have already taken place in the treatment of drug misusers, and to put this in a framework. They attempt to derive an evidence-based practice from the often unrecognised and increasingly diverse evidence base.

    They emphasise a multi-disciplinary rather than a rigidly medical approach and they take a robust attitude to the responsibility of all doctors and the rights of all patients within the health service. There is also a new and important recognition that good practice cannot exist without good structures for service provision and that administrators as well as doctors hold a responsibility for this. Within these structures the guidelines are prepared to confront the realities of shared care and local differences in provision whilst maintaining an emphasis and the avoidance of diversion of prescribed drugs and the final responsibility of the prescriber.

    On a very different note, the annexes are wide ranging and cover a number of practical problem areas in great detail, including equivalent doses of drugs, drugs and driving, drugs and pregnancy and other complex issues.

    Weakness of the New Guidelines

    The new Guidelines were written by a committee and, at times, it shows. Whilst it apparent that there is a real attempt to be prescriptive, they nevertheless back off at the last minute in some areas. Whilst this allows room for clinical judgement and prevents the guidelines from being too prescriptive it nevertheless can result in weakness as in the failure to spell out the expected role of the non-prescribing GP with no interest in drug misuse in spite of the fact that failure to provide medical care on the part of some GPs can be one of the worst problems facing the drug user. There is also a lack of evidence base for some of the more specific recommendations, including the need for supervised consumption and the role of take-home doses, and the role of diamorphine prescribing is not properly evaluated in the light of available evidence.

    Why are the Guidelines important?

    In spite of any reservations about the new guidelines, they are nonetheless a reflection and also a definition of the framework from which we operate. Once again they reflect the tensions between the right to treatment and the necessity to be safe. There is no escaping the drive towards standardisation of practice and the definition of protocols, and this is important for two sets of reasons:

    1. Good practice considerations

      • The guidelines constitute a "national template" for local guideline development.
      • They represent a serious attempt to bring the evidence base into practice.
      • They attempt to standardise practice.
      • They attempt to spell out the responsibilities of different groups of doctors.
      • They reflect a shift away from old style referral patterns and primary/secondary care divides.
      • They attempt to bring more doctors into the field and to ensure fewer variations within the field - the guidelines represent an essential stage that has to be reached before this can happen.
      • They help to bring drug misuse treatment into the mainstream, which is where it needs to be - but it may mean that those of us already in the field may have to reconsider our practice.

    2. Legal Considerations

      The guidelines have no defined legal position but:

      • They represent a consensus view of good clinical practice.
      • They represent a consensus view of good clinical practice and doctors operating in this field can expect to be judged against this reference point. This can of course be our protection, as clinical practice falling within the recommendations of the guidelines can be defended in these terms, but even more importantly the guidelines offer protection for the public against practice which is deficient.
      • The government 10-year strategy, "Tackling Drugs to Build a Better Britain" (Ref 8) states that clinical services and in particular prescription of substitute medication should be in line with the forthcoming clinical guidelines. This means that we need to be able to defend why we deviate from the guidelines if we do.

    Questions and Comments

    1. Who was involved in writing the guidelines?
      A working party of many different professionals, mainly doctors. There were four GP's involved but no 'Generalist' which perhaps was a mistake.

    2. The division between specialist generalist and generalist needs to be considered. It may not always be positive.

    3. Major concern - first three months treatment needs daily observed consumption - only rare cases where this would not happen. Pharmacists cannot provide this service :- no space, no training around when not to give out medication, etc - therefore not possible.

    4. Not realistic to provide supervised consumption throughout the country - it will need to be developed.

    5. It is also not right that all patients should have supervised consumption but we have to accept that.

    6. 20% target 1/5th do not want to get involved. You are trying to sell a losing commodity, how are you going to do this?
      Guidelines works well with this - they provide a framework for new GP's although there may be a problem with existing GP's set in their ways.

    7. One in five GPs are interested so concentrate on them, but they are probably specialist generalists.

    8. Stimulants are mentioned negatively and are badly needed.
      There is negativity around stimulants and the suspicion is to frighten people off - there is a need to agree that the Guidelines fall short on areas such as this.

    5.6 A User's View of Government Drug Policies - Gary Sutton

    1: "What have service users to teach us"

    'If you are immovably of the opinion that drug users have nothing to teach clinicians then I will be speaking for about 15 minutes so you can go and get a nice cup of tea!'

    Traditionally this area has been a bit of a battlefield with distrust and suspicion from both sides of the consultation table.

    There is an old adage that a user goes into a doctor, multiplies his or her needs by three and produces a list of mitigating circumstances why they are a special case. The doctor responds by dividing the sum by four and explains the various pseudo legal reasons why this or that request is impossible before signing the prescription and ending the appointment.

    The reason for this charade has been that one of the major problems with treatment has always been that for any patient the single most important diagnostic factor was your postcode. However, it is no great accident that patients over the years have drifted away from local Drug Dependency Centres towards more sympathetic GP's or private practitioners who have operated independently of the so called "specialists" at the major clinics. The clinical guidelines seek to end this clinical freedom. The consultant psychiatrist is very much back on the agenda.

    The reality is that for most users, for most of their careers the main therapeutic choice has been which black market dealer to use. All too frequently clinicians see drug users as a homogenous entity. What I find so depressing about the new guidelines is the reliance on "off the peg" prescribing as opposed to identifying areas of choice and variation in clients. "One size fits all" will lead to an increased uniformity of choice.

    The development of the polydrug user reliant on methadone, benzo's and strong lager is a direct consequence of low dose methadone prescribing.

    Methadone equivalence chart:

    Between 1984 and 1999 there seems to have been an approximate 200%
    increase in the amount of methadone equivalent to diamorphine.

    1984 30mg diamorphine ampoule = 25mg methadone
    1991 30mg diamorphine ampoule = 50mg methadone
    1999 30mg diamorphine ampoule = 60mg methadone

    Every user knows methadone is much stronger than heroin, although how the equation can have altered in the last 15 years is a total mystery. It is not the point to say the postscript says half-lives may alter the equation.

    A London clinic was recently involved in a heroin trial which had a much higher drop-out rate than it should have had due to insufficient dose levels. In fact, the conclusions probably owed more to a concurrent Swiss trial than they did to the actual results obtained in Chelsea and Westminster.

    Out of date information about paraphernalia cleaning was allowed to remain in the public domain, in the guidelines for 5 years, without an amendment being added. This was two and a half years after a user forum had been assured that an amendment was unnecessary because the matter would be dealt with by the new Guidelines.

    We can only guess at the consequent infection rates among IDU's due to this inaction and it was a national scandal.

    The ministers launch rhetoric about improving services and making sure drug misusers get the best possible care suddenly looks a bit sick to me.

    The medical mode of drug use is problematic in that it medicalises all aspects of our lives. We as drug dependants, have to proiritise getting our drugs.

    Government policy impacts profoundly on our lives. We are not involved in policy developments and the forces of the law are turned on us.

    2: "Don't they realise how dangerous all this [advocating drug use as a human rights issue] is?"
    (This quote was eavesdropped after a recent presentation on drugs and human rights).

    Advocating for the right to take drugs or work in the drug field upsets the victim stereotype. It disturbs the personal dynamic in the consulting room in counselling sessions and in the employment market. It also reclaims harm reduction back from a group of health professionals who have rewritten history to make risk minimisation their own intellectual property.

    For some years we have struggled as ex-users to become more accepted in the field. A few years ago I might have been standing here arguing against the proposition "what can ex-users teach us?". Perhaps there is something that ex-users need to throw away when they cease to use that is unquantifiably or perhaps they fear criticism of over identification with clients from other staff.

    I believe the time for users to stop accepting the victim role and state that nobody can effectively advocate for us in the current climate except ourselves. Would Forest, (the pro-smoking group), allow an ex-smoker to advocate for smokers rights?

    The difficulty we have as ex-users in the field is nicely and inadvertently expressed by an executive from a well known rehab. "I like to ensure balanced staffing among counsellors i.e. less than 50% ex-users". Obviously some balances are more even that others.

    The war on drugs is a war on me.

    I believe that we have to look at "Tackling Drugs to Build a Better Britain", the new 10 year anti-drug strategy to understand the rationale for the guidelines.

    FOUR KEY AIMS:

    1. Young People - To Help Young People Resist Drug Misuse in Order to Achieve Their Full Potential in Society.
    2. Communities - To Protect our Communities from Drug-Related Anti-Social and Criminal Behaviour
    3. Treatment - To Enable People with Drug Problems to Overcome them and Live Healthy and Crime-free Lives.
    4. Availability - To Stifle the Availability of Illegal Drugs on our Streets.

    This is not a primer to facilitate GP involvement with drug users. This is a document that entirely redefines the perimeters of clinical responsibility.

    The link between drugs and crime, which is a prohibition issue, is being used to make doctors an instrument of control.

    3: "If you're so smart what are you doing here"
    (Clinic doctor to drug user)

    Imagine an employed drug user, not accessing services, and using street drugs, faced with the following conundrum:

    "Do I buy my drugs every day and multiply my chances of arrest or do I buy my drugs every week and multiply my chances of a conviction for supplying?"

    There is a real danger with any society where the lawmakers lose touch with a large proportion of the people they purport to represent.

    Since ecstasy drug use has become normal behaviour among a large section of the under 25's. With the current anti-drug hysteria, I often wonder if it is really that smart to present for treatment even if the problem becomes acute.

    It is a strange type of client confidentiality where police regularly inspect prescriptions at pharmacists and where we get campaigns asking members of the public to inform on drug offenders.

    The rewards of presenting to a treatment agency are not that enticing. On site consumption forces users to wait until the chemist is empty to preserve confidentiality. On many occasions users are asked to sign contracts which in legal terms with no equity of opportunity between both parties are meaningless.

    Urine tests are taken without a chain of custody, sealed patient samples and in denial of basic human dignity. Samples are often demanded on the spot as in produce one before we go to lunch or you get no prescription. Punishments for dirty urines are still commonplace. Treatment offers stimulant dependants less than it did 30 years ago.

    It also seems that private prescribing has been scapegoated to justify increase control and raise the discussion of licensing of all doctors to be able to prescribe any controlled drug other than oral methadone.

    Approx. no. heroin users on substitute prescriptions in London = 10,000
    No. of heroin users in capital not in treatment (H.O./W.H.O. estimate of multiplier = 4) = 40,000
    Average daily dose heroin per user = 0.25g (ISDD and author estimate)
    Therefore total amount of heroin consumed daily in London = 10,000g

    Number of patients in private sector receiving methadone in London = 1,000
    Average dose privately prescribed methadone daily (author estimate) = 130mg
    Therefore daily total of privately prescribed methadone in London = 130g

    If EVERY patient receiving a private methadone prescription diverted ALL their methadone to heroin users not in treatment this would account for 130/10000 = 1.3% of opiates available "on the street".

    Rather than commission the same old studies from the 2 usual sources why isn't money put in to evaluating some of the real benefits from drug of choice prescribing:

    1. Does smokable heroin work?
    2. Does high dose drug of choice reduce total demand by killing the local black market?
    3. How viable is cocaine prescribing if it can be proven to reduce street crime?

    The field does not need overt politically driven agenda. It can produce massive social good by addressing individual patient issues.

    In comparison with other medical disciplines, the drug treatment field has yielded so few genuine innovations in the last 30 years.

    Gary's talk was followed by a lively discussion on some of the points raised. There was concern that the Guidelines meant no support for abstinence based models and that leakage of methadone was a problem that we needed to address. We needed to learn more from the Swiss Heroin Trails, especially around doses. We needed to discover why the Chelsea and Westminster Heroin and Methadone Injectable Trail was so punitive and how they got the doses so wrong (Swiss average dose of Heroin = 580mgs, C & W 180mgs maximum).

    5.7 Chair's Introduction to the Afternoon Session - Dr Susannah Lawrence

    Susannah stated that a conference consensus statement was being developed. She said that the general feeling would be to respond to the new Clinical Guidelines.

    5.8 Progress Towards a National Network of GP Support - Dr Berry Beaumont/Don Lavoie

    The background to the Network was explained. The National Network was now funded. Section 64 funding has been obtained from the DoH for two years from 1/4/99. Funding was through the Substance Misuse Advisory Service (SMAS). There were limitations to the funding, i.e. it was only in England; it was less than hoped for; funding was for two not three years and it may be difficult getting a worker to set up in such a short space of time

    An Advisory Group would need to be set up to secure on-going funding.

    An executive/working group would need to help to implement a work programme, revamp the newsletter, help with publicity and the next conference, and update and extend the database.

    SMAS was a small service set up approx. 18months ago as an offshoot from HAZ 2000 - advising both Health Authority and Local Authority commissioners on setting up Shared and Primary Care schemes.

    One worker will be employed by SMAS with a national remit, to see what was happening and what was needed in different parts of the country.

    5.9 Pharmacists - A Vital Cog in the Care for Drug Users - Kay Roberts

    Extent of drug misuse in UK and Scotland notifications to the Home Office rose by 17% in 1996. Pharmacists had a vital role to play in providing services to drug users.

    • Misuse of over the counter medicines needs monitoring - Early warning system in Glasgow, which stopped misuse of sleeping capsules.
    • A project to start to see whether methadone patients are being denied over the counter medication.
    • The sale of ascorbic acid is controlled by law and pharmacists need to be aware of the risks of moving outside the law, even if the law is not helpful to harm reduction.
    • Need to develop leaflets and stickers about the safety of methadone.
    • Sticker being developed for needle exchange packs in order to encourage safe disposal.
    • Supervised consumption has cost implications.

    Following the presentation a discussion began on the pros and cons of supervised consumption both from a personal and public health point of view. This needed more time and will form one of the items of next years conference.

    5.10 Working with Crack Cocaine Users - What is Possible? - Aidan Gray

    Very few services or workers are able to deal with crack cocaine users.

    • Explaining to the client what is happening to them helps gain their trust and enables them to deal with the problems.

    Effects of Crack Cocaine Use on Adrenaline and Dopamine Levels

    The adrenaline and dopamine chemicals in the brain are age-old systems. Adrenaline is the chemical responsible for the 'fight or flight' response and dopamine is a 'feel good' chemical system.

    ADRENALIN

    INITIAL USE
    Release of adrenaline
    Increased heart rate
    Breathing (faster and shorter)
    Increased sweating
    Butterflies in stomach
    Shaking (particularly hands)
    Pupils dilate
    Heightened state of sexual arousal

    PROLONGED USE
    High adrenaline levels in the body
    Decreased need to sleep
    Decreased need to eat
    Paranoia
    Need to use toilet before smoking
    Visual and auditory hallucinations
    Very sensitive skin
    Weight loss
    Increased senses (hearing)
    Lessened state of sexual arousal

    DOPAMINE

    INITIAL USE
    Release of dopamine
    The buzz
    Orgasmic feeling
    Feeling of wellbeing
    Heightened feeling of confidence
    Increased sense of self esteem

    PROLONGED USE
    Severe lack of dopamine
    The crash (bad come down)
    Headaches (irritability)
    Lethargy (no interest in life)
    Hallucinations
    Mood swings
    Severe depression
    Thought distortion (suicidal thoughts)

    What goes up must come down...

    Adrenaline High -----> Treatment Lower

    Treatment Raise <----- Dopamine Low

    There are many health problems associated with crack and cocaine use and these vary from person to person. There is no way to take it that is guaranteed to be safe. Death through heart failure can happen no matter how much or little crack or cocaine is taken.

    Heart Problems

    It is advised that if clients already suffer from heart problems that they do not use crack, cocaine or any stimulant drug for that matter. High blood pressure, irregular heart contractions, chest pains and poorly oxygenated blood (greyness of the skin) are all symptoms of crack or cocaine abuse on the cardiovascular system. This is basically what happens: when people take crack or cocaine their blood vessels shrink (due to the release of serotonin), this means that less oxygen can be carried by the blood vessels. Doctors believe that this in turn causes arteries to shrink and cut off the blood supply to the heart. This is how the heart muscle can get damaged and once the heart is damaged it cannot repair itself. In mild cases heart pains will be felt. In severe cases it can be fatal.

    Brain Damage

    Damage to the brain through smoking crack or cocaine is mainly caused by what is generally known as a stroke. The most probable cause for this is increased blood pressure due to increased heart rate and blood vessels shrinking, which in turn reduce the blood supply to the brain. Strokes cause loss of feeling or movement to various parts of the body (arms, legs, face) and may also effect speech.

    Respiratory Problems

    The main problems caused by crack or cocaine on the lungs is referred to as 'crack lung' and is due to a build up of fluids in the lungs. This produces symptoms very similar to asthma such as shortness of breath, wheezing, chest pains and coughing. Use of crack and cocaine will also damage the respiratory membranes and users may find that your nose bleeds a lot or that you cough up blood. If clients are piping or spliffing they will be more susceptible to respiratory infections such as flu and bronchitis. Their immune system will be low so it becomes harder to fight these infections. It is thought that the impurities in crack or cocaine is not the main cause for lung problems but cocaine itself and can happen even if the drug is injected.

    Tuberculosis

    There have been recent reports from the USA which have highlighted the increased risk of catching TB when smoking crack/cocaine (particularly when it is done in a crack house, if they are homeless and if they are HIV positive). Symptoms of TB can be confused with general problems of crack/cocaine use, but if a client has 3 or more of the symptoms as follows, then there is a small possibility that they may have TB: a cough that will not go away with antibiotics; dramatic loss of weight without dieting; loss of appetite; severe night sweats; spitting blood when coughing The only way to be sure you do or don't have TB is by having a chest x-ray. At present there is little information on this subject with regard to crack/cocaine use in the UK. When TB was epidemic in this country during the beginning part of this century, it was people who had poor diets, low immune system, were cigarette smokers, lived in poor unventilated conditions rendering them more susceptible to this disease. There is a correlation between those conditions and todays crack smoking environment.

    Depression

    As mentioned in a previous section dopamine deficiency and life problems combine together to create the feeling of depression. This can be so strong sometimes that users may have suicidal thoughts and may even act upon these. It is suggested that many crack users commit suicide although no research has yet been undertaken. Remember that dopamine levels (part of the cause of depression) should return to normal within 6-12 weeks of stopping use, so the feeling is not permanent. Some doctors will prescribe short-term doses of anti-depressants to help users over this period. Counselling and support groups are also advised.

    Liver Damage

    If taking crack or cocaine, there will most likely be damage to the liver. The liver is a tough organ and can take a lot of abuse and repair itself from this damage. However there have been some cases where people have died due to the toxic effects of crack and cocaine on the liver. This can be made worse by the use of alcohol during use.

    Pregnancy

    The use of crack or cocaine when you are pregnant may lead to spontaneous abortion and increases the likelihood that users will deliver their baby prematurely. Babies are more likely to be born underweight which may be due to poor diet and restricted blood supply to the foetus. Some babies have been reported to show disturbed behaviour for the first month or so after birth , but there is no evidence to suggest that there is any lasting damage or so called 'crack babies'. Again the bottom line is that there is no safe amount to use. If you are breastfeeding a child and using, the crack or cocaine will pass into your child through the milk, so it is safer to bottle-feed if users continue to use after the birth of their child.

    Immune System

    When people use crack or cocaine they damage suppressor T-cells. These white cells help protect us from all sorts of infections, if they are damaged their immune system is impaired. This is especially important if they are HIV positive. Prolonged crack or cocaine use leads to vitamin, mineral and amino acid deficiency. This also impairs the immune system and makes users more susceptible to infections and disease. Eating a healthy diet and the use of multi vitamins/minerals will aid the immune system but it can recover fully unless they stop using.

    Weight Loss

    Many people experience weight loss when using crack or cocaine. This is more likely to occur if they are using on a daily basis rather than bingeing. For some people it can be very serious, even life threatening. Crack and cocaine suppress the appetite, so users may not eat for long periods of time. It also slows down the absorption of food in the stomach. Again eating a healthy diet is very important to help build themselves back up, especially if they continue to use.

    Skin Problems

    Users may feel that their skin is tender or very sensitive. Increased sweating and sometimes lack of personal hygiene whilst using can lead to spots and skin infections. Couple this together with the lack of oxygenated blood and an impaired immune system it may be likely that users may suffer from skin complaints in some form or another. Other skin conditions may be caused by high stress and anxiety levels.

    Psychiatric Problems

    Crack and cocaine can sometimes cause a drug-induced psychosis. This usually happens when they have been using large amounts and have been experiencing high levels of stress in their lives. If they have been diagnosed as a schizophrenic then crack and cocaine can either make it worse or appear to make it better. If you know they have a schizoaffective disorder then you will need to encourage them to see a psychiatric doctor to help them stabilise the condition if they have lapsed in taking their medication.

    Other Problems

    Crack and cocaine use can also cause dehydration , headaches, kidney damage, physical and mental fatigue, stress, anxiety, muscle pains and insomnia. It will also increase the amount of attacks that users have in conditions like Epilepsy and Sickle Cell. If they are injecting then they increase the risk of Septicaemia, abscesses, Thrombosis, HIV and Hepatitis C. they are also increasing the risk of sexually transmitted infections such as HIV, Hep C and herpes if they practice unsafe sex.

    • Create a friendly environment to see or work with users in.
    • Know your subject.
    • Provide specific things/services for crack users.
    • Burn relaxing oils to help create a relaxing environment.
    • See people quickly.
    • Be prepared to have flexible boundaries.
    • Use complementary therapies: auricular acupuncture, herbal teas and aromatherapy are all useful.
    • Refer to services that you know work well with this client group.
    • Be prepared for your clients to progress quickly in recovery.
    • Try not to make your approach too therapeutic.
    • Help clients access adequate health care provision.
    • Service should be able to work with cultural differences.
    • Talk to clients before you get the forms out.
    • Try to keep things simple
    • And finally... remember to be comfortable with your clients so that they can be comfortable with you.

    Questions and Comments

    1. What is the difference between crack cocaine and cocaine?
      Cocaine 40% of the drug released - Crack smoked approx. 80% released and it gets into your system more quickly.

    2. The role of anti-depressants was also discussed. It was felt that they can cause more problems and clients can become more manic. Many crack users will also be opiate users so if in doubt do not prescribe anti-depressants. Fluoxetine has been tried with little or no success. Very low dose thioradazine (and benzodiazepines) have been used for helping in-patient clients after a crack binge. It was felt that they should be used sparingly if at all.
      It was felt that there was no detox as such as it is a psychological problem. Would suggest alternative therapies - anything that relaxes. Calming people down/feeding them up and sleeping.

    5.11 Closing Remarks and Evaluation - Dr Susannah Lawrence

    The Government seemed committed to include and not exclude drug users. There needed to be drug user input into policies and guidelines.

    We needed to recognise that voluntary sector agencies are important and we need to respect the contributions that we all make to this area of work. We needed to respect each other as GP's, encourage our colleagues who are not here and face the exclusion of this client group and work against it. Work with your local primary care group to ensure that addiction services are on the agenda, they get into the mainstream and they stay there.

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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 The way forward - primary care and/or psychiatry led services? - Sebastian Saville & Robyn Doran/Chaired by Iain Ryrie

    • To hold positive expectation that professionals can change
      - Respect each other and compromise
    • Major stakeholders need to agree local priorities/strategies
      - contextual difficulties
      - 'stable' 'chaotic'
      Need to let GPs define and feedback.
    • Equality across service provision in specialist services or primary care.
      Access may be better in primary health care.

    6.1.2 Harm reduction - a different way with dual diagnosis - Paul Russell

    • Extent - difficult to estimate.
    • Some studies:
      40% acute psychiatric admissions related to substance issues.
      50% drug service clients had mental health issues.
    • There are problems dealing with this group regarding specialist services accepting that there are mental health problems when there are substance misuse problems.
    • Solutions:
      Change negative attitudes
      Improve liaison between services
      Explore and evaluate creative ideas

    6.1.3 Setting up a shared care programme - Dr Claire Gerada

    • Identify interested doctors and nurses.
    • Adopt national guidelines and apply to local area.
    • Establish a shared care monitoring group.

    6.1.4 Prescribing injectable methadone - the real harm reduction? - Dr Berry Beaumont & Nicky Metribian

    • Clients need education about injecting, especially intramuscularly.
    • Formulate an IV preparation.
    • Client assessment is crucial.
    • Injectable methadone prescribing does have a place in general practice. It shouldn't be driven out of general practice if there is no evidence when the guidelines are supposedly evidence based.

    6.1.5 Can doctors do drug prevention? - Brian Whitehead

    • Prevention is possible - investment for gain.
    • Evidence based & multi-disciplinary approach.
    • There must be involvement of the community including the community of drug users.

    6.1.6 The new DoH guidelines on "drug misuse & dependence" - Dr Judy Bury

    • Suggest writing to DoH either with complaints or for clarification.
    • Supervised consumption for 3 months...
      - was a compromise
      - needs money, training and support for pharmacists
    • Use guidelines to help produce local guidelines (With the PCG's and/ lead on clinical governance).
    • Conclusion: we like some of it.

    6.1.7 Using alternative therapies in the treatment of drug use - John Tindall

    • Ear acupuncture: misconception re: health and safety of needles.
    • Misconception that there is no research when there is.

    6.1.8 A training package for primary care - Fiona Hackland & Ken Platt

    • Recommendation of 3 days in 6 months on one subject is impossible. Training needs to be more targeted. Not possible for busy GPs.
    • Need to fill in gaps in clinical guidelines e.g. stimulant users, dirty urines.
    • Must be multidisciplinary working for all involved in primary care.

    6.1.9 The Methadone Alliance - Why we need drug users views on prescribed drugs? - Bill Nelles

    • Guidelines
      - licensing (very concerned there is a sub-agenda)
      - information
      - consultation
    • GP/clinician involvement
    • Media response/hysteria - need someone to speak to press to counterbalance

    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 Chasing the dragon - how to manage heroin smokers - Sebastian Saville & Sue Willimott-Ruiz

    • Moving users from IV to smoking is acceptable harm reduction supported by GP's.
    • Promote as harm reduction.
    • Need for flexible treatment options.
    • Equal rights to treatment.

    6.2.2 Managing alcohol problems in people who use drugs - Dr J. Ranade & Denise Isherwood

    • Large, often unrecognised problem.
    • Assessment/building rapport in GP setting can take time; build up a picture over time; value of template.
    • Treatment important to tackle alcohol first - alcohol detox whilst stable or increase methadone use.

    6.2.3 What is the place of benzodiazepine prescribing? - Dr Chris Ford

    • Problems:
      - Lack of evidence.
      - No evidence maintenance reduces harm.
      - Long term cognitive harm.
    • What & how to use
      - Use only diazepam
      - Maintenance vs reduction - reducing more
    • Any advantages with maintenance?
      - As an aid to controlling alcohol use; mental health.

    6.2.4 Alternatives to methadone for opiate detox - Dr Katherine Orton

    The group considered the different ways and advantages and disadvantages for lofexidene, buprenorphine and other drugs.

    6.2.5 Trying alternatives to substitute prescribing - Auricular acupuncture and other techniques to reduce cravings - Rachel Peckham & Gail Percival/Maria Longo

    • Group participants were keen to think of alternative to drugs.
    • Complementary therapies can be helpful especially for cravings.
    • Need to learn more about techniques.

    6.2.6 Using significant others in treatment - Brian Whitehead

    • Expectations - need careful assessment.
    • Confidentiality.
    • Services for significant others.

    6.2.7 Hepatitis C - the sleeping giant - Dr Tom Waller

    • Large and increasing problem in past and present injecting drug users.
    • No national strategy for such important problem.
    • Don't underestimate the problem.

    6.2.8 Steroid users - Do GP's have a role? - Kim Clarke

    • Awareness and information available to health care professionals re: steroid use.
    • Training around effective interventions.
    • Health promotion information for users and potential users in GP. surgeries.

    6.2.9 The sexual nature of drug use - Rima Chowdury & Pauline McKenzie

    • Drugs have positive and negative effects on sexual enjoyment.
    • Don't ignore sexual behaviour as part of harm reduction.
    • Recognise source of problem.
    • Recognise what can be done in primary care.
    • Listen to the patient and what they want.

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    7. Developments

    7.1 GP Network

    Jean-Claude Barjolin started in post as the Primary Care Development Advisor at the Substance Misuse Advisory Service (SMAS) in August 1999. SMAS is a Department of Health-funded project of HAS 2000 (Health Advisory Service) to assist health and social care commissioners in England to develop their commissioning practice.

    A key role of the post-holder will be to work in an advisory capacity with primary care, secondary care and commissioners. This will be with the aim of developing service delivery and commissioning practices that better support and encourage GPs and other primary care workers to work with drug users. He will also take on the task of managing the SMMGP newsletter with a view to expanding its readership.

    The advisory post is a start, with initial funding until March 2001, but it will be important to ensure on-going funding and possibly the development of a comprehensive primary care support project. A well-resourced project could offer more services for supporting and building a larger primary care network. It could also begin to address specific issues such as research.

    7.2 SMMGP Newsletter

    The newsletter continues to be successful and currently distributed to over 250 readers. It will now be produced through SMAS in a slightly revamped format and work will be undertaken to expand its readership and network base.

    Contributions in the form of discussion-articles, view points, questions or concerns or news items are extremely welcome:

    Jean-Claude Barjolin
    Primary Care Development Advisor
    Substance Misuse Advisory Service
    46-48 Grosvenor Gardens
    London SWIW OEB.
    Tel: 0171 8819254
    Fax: 0171 8819260
    E-mail: (address to J-C Barjolin) smasuk@compuserve.com

    7.3 SMMGP - SCODA Training Package

    Nearing completion. A paper package has been piloted and appropriate changes made. It is in press and will soon be sent out to Health Authorities. A CD-ROM version is also under development. It is intended to be more succinct, more widely available and more directed at self-learning than the paper package.

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    8. Editor's Remarks - Going Forward

    The much awaited and expectation-laden guidelines are a welcome step forward (Ref 1). They emphasise a right to treatment for users, a legitimate role for primary care, support for shared care and a strong validation of methadone maintenance. However, the guidelines present certain ambiguities, mixed agendas and flaws borne out of compromise.

    Responses to the guidelines have consequently tended to polarise a discussion around the GPs role in treating drug users. On the one hand they suggest that it is every doctor's duty to provide health care for drug users through GMS. On the other hand they suggest that no doctor should manage drug users without extensive training and controls. Shared care working is rightly encouraged, but not all areas have agencies in place to support primary care. Not all specialist services yet feel adequately able or inclined to take on this role. Some services may be more rigid and less accessible for drug users than the willing elements of primary care. These type of concerns have tended to provoke some GPs not usually active in medical politics, to strike out against the guidelines, the GPs involved on the working party and drug users themselves.

    The guidelines have also brought into question valid approaches to managing drug users in general practice, such as dihydrocodeine and injectable preparations. The possible treatment options in general practice appear to be narrowing to methadone mixture. This is partly due to a political decision and partly to an increasing reliance on an evidence base approach. Evidence base should be generally welcomed as contributing to better practice. However, an over-reliance on this approach is hampering due to the narrow range of evidence that currently exists. Fear of stepping outside of the current evidence base can lead to an inability to respond to individual needs, and can act as a disincentive for practitioners to develop good alternative clinical practice.

    The government 10-year strategy for all its merit, appears to run all the risks of a narrowing focus and an oversimplification of responses to drug use (Ref 10). We need to be wary of treatment being inappropriately over-run by a 'command and control' central government policy. This is highlighted in the political murmuring about all doctors needing licensing for all controlled drugs except methadone mixture. Similarly, supervised consumption is another area of concern. It may well prove to be one effective option in reducing diversion. But we need to beware of knee-jerk 'mandatory' responses to implementation. This may not actually be necessary or therapeutically beneficial for many clients. There is still insufficient evidence in the need for supervision. Support and resource issues need to also be considered for pharmacists.

    In general practice we have tended to see patients/drug users as individuals needing individual packages of care. With the guidelines, the drug strategy, tighter clinical governance, emphasis on mechanisms of control and the restrictions on the NHS, practitioners will need to consider how to respond to increasing public health, community safety and criminal justice agendas. On one level, it has been positively argued that central policy is simply attempting to open many more referral routes into treatment.

    This raises questions of capacity of services, equity of access and resources that will need addressing. On another level there is an issue of treatment becoming a prime agent of social control. The criminal justice and community safety agenda seems to be increasingly used to influence treatment aims and legitimise treatment per se. It is impossible and undesirable to separate social and treatment issues. However, a failure to question elements of central guidance may be likely to considerably constrain the scope of individualised health care, locally relevant service approaches and individual clinical judgement.

    A time of change - has anything changed? It certainly has, but how much and where it will end will become clearer over the next year. The guidelines could be viewed as not a fixed end point but a reflection of changing paradigms, and an invitation and a starting point for a new round of development. They have certainly given the area a higher profile, and dramatically expanded the debate. Much will rest on how we choose to respond to what are still arguably 'guidelines', and the questions raised by this new framework of compromise.

    - Dr Chris Ford & Jean-Claude Barjolin

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    9. References

    1. Drug Misuse and Dependence - Guidelines on Clinical Management. London: HMSO, 1999, Department of Health.

    2. The Task Force to Review Services for Drug Misusers: Report of an Independent Review of Drug Treatment Services in England. London: 1996, Department of Health.

    3. Strang J, Sheridan J, Barber N. Prescribing Injectable and Oral Methadone to Opiate Addicts: Results from the 1995 National Postal Survey of Community Pharmacists in England and Wales. BMJ: 1996, 313:270-274.

    4. Deehan A, Taylor G, Strang J. The General Practitioner, the Drug Misuser and the Alcohol Misuser: Major Differences in General Practitioner Activity, Therapeutic Commitment and Shared Care Proposals. BTGP: 1997, 47:705-709.

    5. Pine K & Ryan C. GP's Refuse to Take on the Care of Drug Users. Pulse: 1999, June 5 p27.

    6. Editorial 'GP's blackmailed to treat addicts'. Medical Monitor: 1999, May 26.

    7. Hartley J. GP's lambast proposals for drug misusers care. GP:1999, May 28 p14.

    8. Tackling Drugs to Build a Better Britain - The Government's Ten-Year Strategy for Tackling Drugs Misuse. London: HMSO, 1998.

    9. Clinical Guidelines: Using Clinical Guidelines to Improve Patient Care Within The NHS. London: Department of Health.

    10. Farrell M, Ward J, Mattick R, Hall W, Stimson G, des Jarlais D, et al. Methadone Maintenance Treatment in Opiate Dependence: A Review. BMJ: 1994, 309: 997-1001.

    11. Farrell M, Hall W. The Swiss Heroin Trials: Testing Alternative Approaches. BMJ: 1998, 316: 639.

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    10. Appendix 1

    10.1 1998 Consensus Statement

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

    • 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.

    10.2 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.

    • There is a lack of and a need for primary care-based research on effective interventions and models of care.
    • 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.
    • There is much more to the care of drug users than prescribing methadone. Other effective interventions need to be developed.

    Home Office Addicts Index

    • As representatives of general practice, we regret the loss of the Addicts Index. We deplore the lack of consultation before the decision was taken. We recognise that the decision has been made, but we are concerned that we have lost the possibility of checking if our patients are being prescribed for elsewhere, both for our own and our patient's welfare.

    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.

    10.3 1996 Consensus Statement

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

    • All GPs should offer General Medical Services (GMS) to drug users.
    • All GPs should be willing to assess drug misuse problems and refer patients as appropriate.
    • Where GPs take on an extended role in the care of drug users this should be resourced in recognition of the extra workload involved.

    There is an urgent need for training about drug misuse to be included in 'core medical training' at an undergraduate level. There is also a need for continuing medical education in this area for all GP registrars, GPs and hospital doctors.