SMMGP - Substance Misuse Management Good Practice

Substance Misuse Management Good Practice

Supporting good practice in drug and alcohol treatment

Conference Reports & Presentations:
RCGP 7th National Conference (May 2002)

Royal College of General Practitioners (RCGP)

Managing Drug Users in General Practice
"It's Not Just About Prescribing"

9-10 May 2002
Victoria Plaza Hotel, London
Conference organised by the RCGP Sex Drugs & HIV working Group

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1. Conference Briefing

[Note: This Conference Briefing was circulated as an insert in the SMMGP Network Newsletter No 2 - Jul 2002]

This year's conference was described by many delegates as the best one yet. There was a very positive and optimistic atmosphere born from the fact that it is increasingly recognised that primary care has become essential in the delivery of drug dependency treatment. Successive government and National Treatment Agency (NTA) publications have emphasised the importance of primary care. Latest national figures have shown that as many as 25% of GPs are now taking on the treatment of drug users. These figures together with the success of the Royal College of General Practitioners (RCGP) training programme for GPs with a Special Interest help explain why this year's conference felt so upbeat.

1.1 Policy Perspectives

Bob Ainsworth, the Minister of State from the Home Office talked supportively about the role of primary care and even spoke warmly of harm reduction (unusual for a government minister). Paul Hayes the Chief Executive of the NTA spoke of the history of primary care involvement; saying that in the 1950's it was too rare for specialists, in the 60's too difficult for generalists, now too common for specialists. He also expressed his high opinion of the role of the RCGP in supporting primary care in this area of work. Dr Clare Gerada presented the RCGP plans for developing GP expertise and influence in the drug treatment sector.

1.2 Rights of Drug Users

The conference has always strongly supported the rights of drug users and the importance of their involvement in the development of treatment services. Dr Chris Ford, Conference Chair, made the following statement in her summing up:

"Let's remember that we should not treat people who use drugs any differently than other patients. People who use drugs have the same rights to good health care as anyone else. The right time for treatment is when it is right for that person, whatever the reasons may be, and not when we feel they are ready or when we have a place available."

This quote sums up much of what was said at the conference, particularly by Bill Nelles from the Methadone Alliance, Dr Stefan Janikiewicz from the Wirral and Dr Richard Watson from Glasgow. Linked to this was the feeling that primary care is a treatment sector where the necessary flexibility and holistic attitude exists for this philosophy to be realised. It was therefore reassuring to hear the evidence base for the clinical effectiveness of primary care presented by Professor Michael Gossop from the National Addiction Centre.

There was an excellent presentation by consultant Hepatologist Dr Graham Foster. He presented evidence for new and exciting treatments for Hepatitis C. He made the point that IV drug users respond just as well to these treatments as any other group of people and should not be prevented from receiving them.

1.3 Other Topics

Other topics included the tricky subject of how to treat cocaine dependency, thoroughly covered by Dr John Dunn. Hywel Simms made sure that the families and carers perspective was not missed and eloquently advocated for better support for them and better treatment for their family members. Simon Morton presented the launch of the new look Network newsletter and guided delegates through Dr Fixit's Virtual Offices (www.smmgp.org.uk). Finally we were reminded of the political and social context, within which we are all working by 'masterchef' Ian Smith. His potent recipe entitled 'scum pudding - society gets the junkies it deserves' listed the very familiar ingredients used both at home and worldwide. This was a powerful exposé of the links between social deprivation, prohibition and drug use.

Evaluation was extremely positive and the workshops complimented the presentations very effectively. As usual a strong consensus statement was agreed at the end of the conference.

1.4 Consensus statement I

1.5 Consensus statement II

Finally some statistics: 320 people attended of whom over 50% were GPs, 15% other doctors and 25% other professionals and drug users.

Many thanks to all those who took part and helped make it such an enjoyable event. Next year's conference is at the Hilton hotel in Sheffield on the 15th and 16th of May, book early because it is always sold out. See you there.

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2. Conference Report

2.1 Background

This was the 7th National Conference organised by the RCGP Sex Drug and HIV Task Group.

This year 320 delegates packed themselves into a London hotel for 2 days to continue the debate about working with drug users in primary care. 320 delegates from general practice, primary health care professionals, shared care co-ordinators, shared care workers, commissioners, managers and drug users themselves came together to debate the theme - that caring for drug users is more than just prescribing.

Essentially this conference has focussed on examining effective practice and reflecting upon local and national developments that impact upon primary care and practice. It retains a strong primary care focus - over 50% of delegates were GPs, 15 % other medical practitioners, and 35% other professionals and drug users.

The conference ran over 2 days; 13 key note speakers, 9 working groups, 10 rotating workshops, and dancing with the Beatles provided the platforms for delegates to come together to:

Recent Changes in the Management of Drug Users in Primary Care: Much has changed in the management of drug users in primary care in the last 7 years. There are increasing numbers of GPs and primary health care teams becoming involved in the care and treatment of drug users, There is an increasing body of evidence to support primary care interventions. Clinical Guidelines have been developed by the Department of Health to provide a framework for supporting effective clinical practice in managing drug dependence in primary care. There are models of good practice in shared care and partnership. There is an increasing role for primary care in defining and developing local commissioning. There are increasing mechanisms of support available to primary care to support their practice; In England: increasing Regional and National structures through the National Treatment Agency (NTA), Substance Misuse Management in General Practice (SMMGP) and local Shared Care Monitoring Groups (SCMG's); increasing numbers of SCMGs (95%) in Drug Action Teams (DATs) areas. Similar structures are developing in other parts of the UK but it was noted that the NTA & SMMGP currently only cover England.

RCGP Certificate: With the establishment of the RCGP Certificate in Managing Drug Dependence there has been increased recognition of this area of work. The course has just completed its first year with 400 GPs and 60 prison medical officers undertaking the course in England, and just started its first year in Wales. Additionally another 1.2 m has been provided to support the RCGP Certificate Course for another year. Scotland's training programme is developing slightly different lines. Increasing numbers of GPs are involved with caring for people who use drugs. The recent Audit Commission report showed an increase from 6-25%, with a further 25% being willing to care if they received the right support. How these doctors continue to develop their skills to become GPs with a special clinical interest or help develop services in their areas is the next significant discussion.

2.2 It's Not Just About Prescribing!

Round table discussion with the delegates drew varied consensus for the questions:

How can we provide this? - By working in partnership, establishing shared goals, developing commissioning arrangements which address the long term needs of users, and allocating appropriate levels of support training and finance to primary care.

The opportunities for improving individual and public health are evident: There is an increasing body of evidence that supports effective practice, there are new pharmacological interventions, treatment options, and growing evidence about what works. Primary care can make a real difference. Even small interventions, such as advising about safer drug use or Hepatitis B immunisation, can have a substantial effect on drug users health. The longer drug users are in treatment, the better the outcome. Patients tend to stay in Primary Care. Treatment exists that work, and deliver not only health benefits, but also improvements to lifestyle, reduction in criminal behaviour and an economic saving to society. Good primary heath care plus appropriate substitute prescribing do have an affect, and that methadone maintenance works with psychosocial support.

There is a need for working in partnership - with drug users, with other professionals and with commissioners and Primary Care Trusts (PCTs) to ensure improving networks of care and the development of total care packages; using the evidence base for what works and effective practice; supporting the professional development of practitioners in both specialist and generalist services; and Remembering the Rights of drug users, as drug users and as the users of primary care, and primary care based drugs services. Perhaps the most important partnership in all of this work is with the drug user themselves.

"It's not just about prescribing" - reinforced and reinforces the role and legitimacy of general practice in working with drug users.

(Conference Consensus Statement)

2.3 The Rights of Drug Users

"Let's remember that we should not treat people who use drugs any differently than other patients. People who use drugs have the same rights to good health care as anyone else. The right time for treatment is when it is right for that person, whatever the reasons may be, and not when we feel they are ready or when we have a place available".

Dr C Ford, Conference closing speech.

The presence and voice of users and user groups at this conference is important, and reflects the Task Groups' commitment to user involvement. The Task Group of the College has always considered it essential to include users views in the debate regarding the treatment, and care of drug users. Again this year the presence of users of primary care drug services, the Methadone Alliance, National Drug Users Development Agency, and the UK Harm Reduction Alliance ensured that users were seen and heard, articulating clearly, strongly, eloquently upon the needs of users, in society broadly but in treatment services specifically. It is increasingly recognised that users views have to be heard in the strategic debates and development of services. They must be central in the individual assessment and planning of their care.

Many speakers spoke strongly advocating for the human rights of drug users. Drug users have rights, indeed they have human rights, and Hymel Sims, Chief Executive of ADFAM spoke eloquently about the need to challenge the discrimination, prejudice and social exclusion experienced by drug users, and their families. The care and treatment of drug users cannot be separated from the wider policy agendas of social inclusion. The need to create social inclusion for drug users requires a commitment to a much broader social policy that includes housing, employment and education. Iain Smith's How to Make Scum Pudding reminded us of the effect of creating a social underclass, marginalized from main stream society, and the destructive impact of maintaining the war on drugs and drug users and their families.

2.4 National Strategy & Implications for Primary Care

"This UK conference welcomes the fact that this government is committed to the provision of care for people who use drugs in order to reduce harm caused to the individual and public health, as well as in order to reduce crime"

"We note that the government is committed to providing additional resources."

(Section of Conference Consensus Statement 1).

Bob Ainsworth Minister of State at the Home Office, and Paul Hayes, Chief Executive from the National Treatment Agency emphasised the important role primary care plays in the care of drug users. The Government's National Drug Strategy: Tackling Drugs to Build a Better Britain gives high priority to expanding and improving drug treatment services. The Government is committed to delivering on the National Strategy, and resourcing treatment approaches appropriately. Emphasis was placed on the need to provide effective treatment services rather than simply more ineffective services that were either inaccessible or unresponsive. The government spoke of their commitment to harm reduction, a commitment to maintaining strategies and interventions that are supported by evidence.

The Government cited the partnership between the Home Office and the Department of Health in working together to develop the NTA. The NTA has been set up to improve access and quality of treatment in England. It will be responsible for standards, reducing waiting times, and ensuring equity of access, aiming to improve quality and accessibility of care. This will provide DATs with new opportunities to improve the effectiveness of local services. The NTA aims to improve support to primary care by using new funding flexibilities to recognise increases in the workload of GPs who are supporting drug users and by ensuring that the funding regimes allows local agencies more flexibility to tailor services. The NTA aims to increase understanding of what treatment works by addressing research gaps and promoting the existing evidence base. It is currently developing the "Models of Care" document which will help to develop standards in drug treatment services.

The NTA cited the partnership between the NTA, Trafford Drug Treatment Services, and SMMGP Network, as an example of multi agency collaboration to support primary care developments in England, regionally and locally through DATs and Shared Care Monitoring Groups. The Conference also heard of the relaunch of the SMMGP newsletter, now named NETWORK and the Website as a information resource, with interactive surgeries and discussion forums and the use of SMMGP as a support to local SCMGs.

We are seeing the emergence of real partnership and support networks to support the development of primary care.

2.5 Opportunities for Primary Care

Claire Gerada Director of the RCGP Drug Training Unit spoke optimistically about the role of GPs and primary care in the management of drug users. She also spoke complimentarily of the role the RCGP had taken both in support for the Sex, Drugs and HIV Task Group but also the support of the EAG Certificate on the Management of Drug Dependency. The new GP contract provides an opportunity for GPs and primary care to influence and define it role in managing drug users. The National Plan calls for the development of new roles for GPs and practice nurses. The development of GPs with a Special Clinical Interest and the need for continued professional accreditation of practice and practitioner should lead to an increasingly competent and articulate voice being able to influence local service delivery and development. Networks of support should facilitate the voice of primary care, particularly through the DATS and SCMG. The work of the NTA in developing quality standards and consistency, delivered through the DAT, and through partnership with local SCMGs should ensure the delivery of local standards and improvements in capacity and quality.

2.6 What works? Evidence Based Treatment & Effective Practice: It's Not All Prescribing

The Conference was presented with a great deal of information about what works, effective practice and evidence based progress.

Professor Gossop from the National Addiction Centre, reported on outcomes from the 5 year National Treatment Outcome Research Study (NTORS), comparing community and specialist treatment outcomes with opiate users. The results demonstrate the feasibility of treating opiate users using methadone in primary health care settings, and show that treatment outcomes for these clients can be as satisfactory as those from specialist clinics. Gossop presented evidence of treatment outcomes among 452 clients admitted to 15 agencies providing community based methadone treatment services to opiate users in primary care and specialist clinic settings. The clients who received methadone substitute treatment from GPs and from clinics were very similar in their demographics and in the type and severity of drug using behaviours. Significant improvements at follow-up were found among both the GP and clinic treated group in terms of drug related problems, health and social functioning. Types and severity of problems, and levels and types of improvements at 6months were effectively the same among both groups.

The study emphasised the need for a thorough assessment of clients, and the need to able to match that assessment with an appropriate intervention. A poor assessment and under-dosing, and ill-matching to treatment choice leads to lower retention and poorer outcomes.

A clear distinction needs to be made between methadone maintenance and methadone reduction. Methadone reduction treatment processes were associated with poor outcomes, and many patients who were allocated methadone reduction did not receive drug treatment as intended.

For maintenance patients higher doses and retention in treatment were both associated with reduction in illicit heroin use. The more severely dependent patients showed better outcomes in methadone maintenance.

Richard Watson spoke reflectively of his experience of a patient consistently poorly assessed and under-dosed, and underprovided for, who only improved after a more comprehensive assessment, appropriate treatment and care package was provided in primary care. He expounded on the value of methadone maintenance.

Opiate use can be effectively managed in primary care, by appropriate substitute treatment and appropriate psychological interventions and support, based on the tested principles of on-going and progressive assessment and diagnosis, and the appropriate matching of pharmacological and psychological interventions, based upon the severity, complexity and chronicity of the problem.

Dr John Dunne, Consultant Psychiatrist from the Royal Free Hospital, reported less favourable on treatment outcomes with crack/cocaine users. However both he and Grantley Haynes reinforced the role of GPs in supporting and caring for cocaine users. There is currently no substitute prescribing available for cocaine. Dunne presented a range of clinical trials, and suggested that greatest possible promise lay in disulfiram, with psychosocial interventions. He talked of the potential for a cocaine vaccine, although it raises important ethical questions.

John Dunne reported that psychosocial interventions are effective but that no one treatment is more effective than the other. Psychosocial interventions require training but are eminently usable in primary care.

Grantley Haynes in one of the workshops was able to go into more depth on the interventions, including auricular acupuncture and psychological support t that can be helpful to cocaine users.

2.7 Hepatitis C: Significant Improvements

There have been significant changes in the treatment of Hepatitis C. infection: Dr Graham Foster spoke of recent improvements in the management of Hep. C. He advocated strongly for the right of drug users to access treatment, and diagnostic services. He spoke of the need of GPs and PHCTs to advocate for their patients right to treatment and care. Knowledge in the disease course and treatment of Hep C has improved dramatically. Drug users should be seen and treated on the basis of clinical need. GPs should lobby and advocate on their behalf. NICE guidelines should be challenged that exclude drug users right to detection and treatment. He very rightly said we should undertake evidence-based practice NOT opinion-based practice!

2.8 Conference Themes

Working in Partnership and developing support and commissioning networks were important themes. Workshops in the conference facilitated a range of experienced GPs, GPs with a special interest (GPwSIs), generalists, shared care coordinators, shared care workers, other members of primary health care teams, specialist drug services providers to identify the needs of drug users, treatment providers, commissioners, and primary care in managing drug users. Common themes emerged from these groups.

2.9 Concensus Statement

As part of the conference, a consensus statement was produced. The conference has a history of producing a consensus statement that reflects upon the major themes occurring within the conference. Parts of the Statement have been integrated into the body of the conference report at appropriate points. But overall the Conference concluded:-

Consensus statement 1

Consensus Statement II

2.10 Closing Summary From the Conference

There is increasing evidence that treatment for people who use drugs, in primary care is as effective as that provided in specialist settings and that primary care can provide the whole range of health care required, but that we do not have to do it alone. We need to work in partnership with our patients, the local shared care schemes and use the help that is offered regionally and nationally. We must remember to use the evidence and not make up our own (opinion-based evidence). Good examples of misusing the evidence are setting a low maximum dose of methadone; not providing more than a prescription and punishing opiate positive urines by educing doses.

People who use drugs need more than a prescription: integrated accessible and flexible services; non-judgemental, patient-orientated services and a total package of care. Primary care can provide this with appropriate resources and links to other services and be provided by appropriately skilled practitioners confident and competent to assess, treat and care.