Drug and alcohol treatment in primary care

Treatment of drug misuse in primary care was extremely rare even ten years ago. However now the roles played by General Practitioners (GPs) and other primary care professionals have become widespread and varied.

Latest figures show that up to 40% of practices now treat opiate dependency and it has become a ‘mainstream’ activity. It is an enhanced service in the GP contract, there are comprehensive training packages available from the RCGP and increasingly GPs are developing a special interest in this field and in some cases have become specialists. It is in fact the third largest field for the formal appointment of GPwSI’s by Primary Care Trusts. Pharmacists are also crucial to effective community treatment and comprehensive training is also available for these through the CPPE and the RCGP.

The role of primary care has traditionally been a venue for community prescribing of drugs such as methadone and buprenorphine and this continues to be the case. Substitute maintenance treatment is now a well-established treatment modality across a variety of treatment settings and supported by both research evidence and clinical Practice.1,2,4 There is an increasing body of evidence that the primary care setting is an effective means of delivering treatment for opioid dependence.5,6,7,8 However it is also the best venue for delivering essential health interventions for drug misusers who often suffer from a number of related health complaints. Screening of blood borne viruses such as Hepatitis C and vaccination of Hepatitis A and B are particular services that can be offered in General Practice.3

Other services that can be offered in primary care include community detoxification, referral to specialist outpatient or inpatient services or structured day care, counselling, social support, liaison with social services, housing and employment services. In many cases much of this work will be carried out by a drug worker (usually a nurse or social worker) attached to the practice, usually employed by a specialist agency, the PCT, or increasingly the practice itself.

The participation of all practice staff is vital to deliver a full primary care service to this patient group. Training is increasingly available for primary care professionals such as practice nurses, health visitors and midwives. Also, training is often available for reception staff who play a vital role as the public face of the practice.

The Pharmacist is crucial to the community prescribing process as they often see the patient every day, if they are receiving daily supervised consumption, (recommended for at least the first 3 months of treatment) and are in a unique position in terms of monitoring a patient’s progress and picking up on any problems they may be having. Increasing numbers of pharmacists are developing a special interest and many of the large chains are now embracing this area of work. Pharmacy staff training is now starting to be developed.

In the past this area of work was seen as problematic and unrewarding by General Practitioners and Pharmacists but now that training, remuneration, support and robust national guidance (from the department of health and the RCGP) these professions are increasingly finding this a rewarding area of work which reap significant, tangible benefits for their patients. A well-managed system means that there is always something that can be offered to a patient who attends requesting treatment, which serves to minimise some of the potentially argumentative situations an unmanaged system, is liable to produce

esponsible for developing treatment systems in primary care locally and will usually have someone responsible for managing the local system. Many areas now have robust local guidelines and protocols with well-developed enhanced service contracts for GPs. These are increasingly now being developed for pharmacists involved in supervising medication consumption.

The situation with alcohol treatment is somewhat different. To a great extent this is something that has always been dealt with by General Practitioners, but the field has not had the same amount of funding as the drug misuse field. It is an enhanced service in the new GP contact and many health areas have not had the funds to commission against this so services are still often ad hoc and disorganised. The new alcohol strategy may do something to improve the situation and there may be small amounts of new money going into the fielding the near future. However there will still be the same issues of training, support, remuneration and clinical governance to address.

short article. For more information on the many innovative services now available in primary care it is worth a visit to www.smmgp.org.uk which houses a vast amount of relevant information and has interactive discussion forums where leading GPs answer any questions you have around this field.

By Jim Barnard, Primary Care Advisor, Substance Misuse Management in General Practice

Other good sources of information include: www.nta.nhs.uk, www.drugscope.org.uk

References

• Guidance for the use of Methadone in primary care. RCGP 2005
• Guidance for the use of buprenorphine for the treatment of opioid dependence in primary care. RCGP, 2004.
• Guidance for hepatitis A and B vaccination of drug users in primary care and criteria for audit. RCGP 2004.
• Ward J, Hall W, Mattick R. Role of maintenance treatment in opioid dependence. Lancet 1999; 353: 221-226.
• Keen J, Oliver P, Rowse G, et al. Does methadone maintenance treatment based on the new national guidelines work in a primary care setting? Br J Gen Pract 2003; 53: 461-467.
• Keen J, Oliver P, Mathers N. Methadone maintenance treatment can be provided in a primary care setting without increasing methadone related mortality: the Sheffield experience 1997-2000. Br J Gen Pract 2002; 52 (478): 387-9.
• Hutchinson S, Taylor A, Gruer L, et al. One year follow-up of opiate injectors treated with oral methadone in a GP centred programme. Addiction 2000; 95: (7) 1055-68.
• Gossop M, Marsden J, Stewart D, et al. Methadone treatment practices and outcomes for opiate addicts treated in drug clinics and in general practice: results from the capital’s National Treatment Outcome Research Study. Br J Gen Pract 1999; 49: 31-4