Care of Drug Users in General Practice

A Harm Reduction Approach, Second Edition

Berry Beaumont, Berry Beaumont

• Editorial: CRC Press
• Año: 2021
• ISBN:
  9780429533587
• Edición: 2
• Categoría: Medicine
• Categoría: Medical Theory, Practice & Reference

The National Primary Care Research and Development Centre series provides policy makers, commissioners, managers, primary care professionals and user organizations with up-to-date multi-disciplinary research on important issues that inform future decision making for primary care development. This book examines the key factors shaping the relationship between demand for, and use of, primary care. It provides a detailed picture with which to inform the planning of appropriate, acceptable and responsive primary care services. Patients' perceptions are important, not only because they are a barometer of the appropriateness and effectiveness of services, but because they are a unique source of knowledge about the way in which people use services when they do, for the reasons that they do. This book concisely presents empirical findings and summarizes key policy and conceptual issues.

CHAPTER 1
A GP’s role: past, present and future

Clare Gerada and Tom Waller

■ Introduction

National policy for the care of drug users in general practice has undergone considerable change in recent years and is continuing to evolve. In the space of 25 years the treatment of opiate dependency by primary care practitioners has moved from indifference, with few able or willing to get involved, to a position where primary care leads the way, with an estimated 50 000 drug users receiving treatment in a primary care setting in the year 2003.

As a result of medical or other problems related to drug misuse, GPs may come in contact with users of a wide variety of drugs, often at a relatively early stage in their drug-taking career. GPs who have developed skills to manage problems related to drug use are in a good position to facilitate change. Of paramount importance is a constructive doctor–patient relationship. General practitioners do not need to know every small detail of every drug of misuse. This book will demystify and give insights on how to manage users of different groups of drugs but drug problems are essentially people problems and the knowledge and skills that GPs have developed to help their patients with other problems will be of most help. Substitute prescribing, if it is needed, is an easily learnt technique and is usually best done on a shared-care basis with the local drug service, which will act as a source of expert advice and support. Treating drug users can be a heavy burden on time but with realistic expectations, reducing harm to both the individual and the local community through small, progressive goals makes it well worthwhile. Working in a general practice setting to help a patient minimise the harm from drug dependence, earning the deep-felt gratitude of the person concerned, their family and close friends can be a very rewarding experience.

■ Setting the scene: harm reduction

As drug taking becomes more common, so the likelihood increases that medical, social, psychological or legal problems will develop. The harm caused by these problems affects not only individual drug users but also their family and friends and the community within which they live, whether or not they are acquainted with the drug taker concerned.

It is now widely recognised that the harm associated with these problems can be reduced by appropriate professional input and that this is a much more constructive approach than treatments that aim at chemical abstinence alone. The way forward needs to be on a broad front, with appropriate co-ordinated professional input into the social, psychological, criminal and medical aspects of drug taking. This is best done as a partnership approach, not only for the treatment of individual drug users but also on a locality basis by local organisations and through the work of drug action teams. Some of the health harm to individual drug users can be reduced by GPs providing general medical services and further harm reduction can be achieved either by working together with or by referral to specialist drug services.

Nevertheless, many GPs have concerns over their roles when drug users attend surgery asking for help. What is the most appropriate help for them to provide and where do their responsibilities end under general medical services? These concerns are addressed throughout this book and are at first best viewed in the context of developments that have taken place in UK national policy.

■ Historical developments

In 1912, Britain signed the Hague Convention and in doing so gave an international commitment to control the supply of certain narcotic and other drugs. The first defined legislation on drugs of dependence in the UK, the Dangerous Drugs Act, followed in 1920. This Act allowed doctors to use narcotic drugs for bona fide medical treatment but unfortunately did not state whether this included the treatment of drug dependence. A Departmental Committee on Morphine and Heroin Addicts was set up to sort out this issue and was chaired by Sir Humphrey Rolleston, the then President of the Royal College of Physicians. The Departmental Committee’s deliberations were published in 1926 and became known as the Rolleston Report.¹ This was the first defined policy on the treatment of drug dependence in the UK. It was a flexible policy and was envied by physicians in many other countries, such as the USA, where a doctor’s clinical freedom to treat opiate addicts in the way he or she felt was most appropriate was curtailed by restrictive legislation. The Rolleston Report outlined the following two indications for the use of morphine or heroin in the treatment of drug dependence.

• If the person was being gradually withdrawn.
• If, after attempts at cure had failed, the patient could lead a normal and useful life when provided with a regular supply but ceased to do so when the supply was withdrawn.

Thus the principle of maintenance treatment was born and this became known as ‘the British system’. The number of opiate addicts in the UK at that time was relatively small. Before the 1950s there were so few heroin addicts in Britain that nearly all of them were known personally to the Home Office Drugs Branch Inspectorate, which periodically checked pharmacy records. There were several exaggerated press reports about the danger to the British public of Chinese opium dens in London’s docklands but in reality almost all opiate dependence in the UK was probably due to prolonged prescribing of morphine by doctors. From 1926 until the late 1950s, the number of people who were being helped to lead normal and useful lives through the British system (usually on an injectable diamorphine prescription) was stable, varying between 400 and 600. These people were mainly middle class and middle aged or elderly.

■ The Brain Committee reports

Around 1960, reports began to emerge of a new group of opiate drug takers. These were young people, mainly in their late teens and 20s, who were misusing and advocating the use of prescribed drugs for ‘kicks’. An Interdepartmental Committee on Drug Addiction chaired by Sir Russell Brain was set up to look into this matter and reported in 1961 that the drug situation in Britain gave little cause for concern.² However, media coverage continued and the committee was asked to reconvene. In 1965, the second Brain Committee reported very differently that a new, young, unstable, non-therapeutic group of drug takers had emerged and that although some illicitly produced drugs were sold on the street, much of the problem was caused through overprescribing of therapeutic drugs by unscrupulous, uninformed or vulnerable doctors open to blackmail. The second Brain Committee³ recommended that where possible, prescribing should be taken out of the hands of GPs and instead carried out by specialist psychiatrists, who would work from special centres to be known as drug dependence units (DDUs).

The DDUs were set up between1968 and 1970 in densely populated inner-city areas, mainly in London. They were few in number and almost exclusively confined to England. Only one specialist centre for drug users was established in Wales and none at all in Scotland and Northern Ireland. Since not all areas of the country could be covered by the new specialist psychiatrists, general psychiatrists and GPs, although discouraged, were not completely prevented from treating drug users.

By the late 1970s the number of drug users, far from falling, had shown a rapid rise. There were several reasons for this.

• Cheap and plentiful supplies of illicitly produced heroin from abundant harvests in Pakistan and the Far East.
• The appeal of high-gain, low-risk operations enticed criminal gangs (who had previously avoided this area of activity) to start drug trafficking.
• The widespread introduction of the new habit of smoking heroin (‘chasing the dragon’) as opposed to injecting or sniffing it.

The rapid increase in numbers of opiate users seeking help caused the specialist services to become overwhelmed. The British system of maintenance prescribing was questioned and by the early 1980s, the specialist clinics almost all moved over to rigid detoxification regimes of a maximum duration of 3–6 months.

Almost four decades since the introduction of DDUs, the relentless increase in illicit drug use has continued, particularly among young people, in spite of many efforts to contain it. Every year the situation has worsened, in the UK and throughout the world, and the prevalence of drug use has shown a consistent inexorable increase, year on year. During this time many changes have taken place in the UK treatment services.

■ The impact of HIV

The fear of an AIDS epidemic in the late 1980s brought about a change in policy in relation to the treatment of drug users. A working party of the Advisory Committee on the Misuse of Drugs (ACMD) was set up in 1987 to report on the issues in relation to HIV and AIDS and to make recommendations. The first of three reports on acquired immune deficiency syndrome (AIDS) and drug misuse was published in 1988.⁴ It was highly influential and led to a major change in the way that drug services worked with patients. The report stated a fundamental principle that it was more important to both the individual and the public health to limit the spread of HIV within the drug-using population than to overcome the drug problem itself. Harm reduction was to take precedence over abstinence and although abstinence was not forgotten, there was a hierarchy of other goals that were more important to achieve. An example of this hierarchy for individual drug users might be:

1. the cessation of sharing injecting equipment
2. the cessation of injecting
3. reduction of drug use
4. abstinence.

It was now seen as vital to be proactive rather than reactive, so that services could reach as many drug users as possible, including those who did not wish to stop using drugs, to help them reduce the risk of contracting and spreading HIV disease both through shared injecting practices and sexually. It was recommended that outreach services and facilities for the promotion of needle exchange were introduced. General practitioners were seen as a key resource because of their widespread accessibility and because they would be one of the first ports of call when drug problems began to develop. They were thus in a good position to reduce the spread of HIV at an early stage, both by giving harm reduction advice and by prescribing oral opiate substitute drugs, such as methadone mixture, to opiate injectors.

One of the recommendations was to give more back-up resources to GPs by the provision of community drug teams (CDTs) in every health district who would work with GPs on a shared-care basis. The CDTs would perform a counselling and non-prescribing function and the GP would look after the medical side of the treatment package. The teams would be a source of expert advice for GPs, if required, and would work closely with GPs on individual cases. This package of measures is now recognised as having been highly successful in helping to limit the epidemic of HIV in drug users and reducing its spread into the general heterosexual population.⁵ There is, however, no room for complacency as a much larger epidemic...