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BMJ No 7108 Volume 315 Letters Saturday 6 September 1997 General practitioners' attitudes towards treatment of opiate misusersStudy in Lothian confirms findingsEditor,Ann Davies and Peter Huxley comment that little research is being done on general practitioners' attitudes and practice in the treatment of opiate misusers even though general practitioners are now seeing more drug misusers.(1) According to the authors the last substantial report was by Glanz in 1985.(2) We would like to draw attention to similar studies conducted in Lothian in 1988 and 1993.(3) The 1993 study was a postal survey of the experience of, attitudes toward, and confidence in dealing with drug misusers among general practitioners in Lothian. Questionnaires were sent to all 517 general practitioners (response rate 75%). The study also compared changes in general practitioners' involvement with and confidence in dealing with drug misusers from 1988 to 1993; there was a significant increase in both areas. Davies and Huxley found that 80% of the general practitioners in Greater Manchester prescribed substitute drugs for opiate misusers; we found that 73% of the general practitioners in Lothian prescribed substitute drugs, while only 12% stated that they would not do so. Moreover, 67% of the general practitioners in Lothian had given advice on safer drug use and only 2% stated that they would not give such advice. General practitioners in Lothian, like their colleagues in
Greater Manchester, expressed the need for more training in dealing
with drug misusers. For example, in Lothian they showed a lack of
confidence in the management of drug related aggression and violence in
the practice, a problem shared with general practitioners in other
areas.(4) Training can help build confidence. A positive
similarity between the two studies is that general practitioners in
both Greater Manchester and Lothian generally have an
understanding approach toward drug mi Edwin van Teijlingen
Department of Public Health, Mike Porter
Department of General Practice,
References
1 Davies A, Huxley P. Survey of general practitioners'
opinions on treatment of opiate users. BMJ
1997;314:1173-4. (19 April.)
2 Glanz A. Findings of a national survey of the role of general
practitioners in the treatment of opiate misuse: dealing with the
opiate misuser. BMJ 1986;293:486-8.
3 Bury J K, Ross A, van Teijlingen E, Porter A M D, Bath G. Lothian
general practitioners, HIV infection and drug misuse: epidemiology,
experience and confidence, 1988-1993. Health Bull
1996;54:258-69.
4 Hobbs F D. Violence in general practice: a survey of general
practitioners' views. BMJ 1991;302:329-32.
Davies and Huxley comment on how few general practitioners have read
the government guidelines on treatment of drug misuse. We believe that,
while government guidelines are essential to provide a framework for
doctors working with drug misusers, locally developed guidelines that
are supported by training are also needed.
Lothian has had a specialist drug service since 1988 and a drug
facilitation team to support general practitioners who care for drug
misusers since 1991.(2) A handbook, Managing Drug
Users in General Practice, which was developed locally, was
distributed to every principal in general practice in Lothian in
December 1995.(3) These guidelines are reinforced by the
facilitator team, which provides courses and on site training during
visits to practices.(2)
A questionnaire survey of general practitioners in Lothian in October
1996 (which had a 72% response rate) showed that 82% of those who
received the handbook had read at least part of it and that 99% of
these had found it very or quite useful.(4) The survey also
found a significant increase in general practitioners' confidence in
managing drug misusers; 34% indicated above average confidence in 1993
compared with 45% in 1996. There was also a decrease in those
indicating a lack of confidence from 39% in 1993 to 17% in 1996.
In Lothian, local guidelines that are supported by training seem to
have contributed to an increase in the confidence of general
practitioners in caring for drug misusers.
Judy Bury
Spittal Street Centre, Jim Sherval
Centre for HIV/AIDS and Drugs Studies, References
1 Davies A, Huxley P. Survey of general practitioners'
opinions on treatment of opiate users. BMJ
1997;314:1173-4. (19 April.)
2 Bury J K. Supporting GPs in Lothian to care for drug users.
Int J Drug Policy 1995;6:267-73.
3 Lothian Health Board. Managing drug users in general
practice. Edinburgh: LHB, 1995.
4 Van Teijlingen E, Ross A, Bury J, Porter M, Huby G.
Experience of Lothian GPs with drug users and people with HIV
infection, 1988-1993. Edinburgh: University of Edinburgh,
1994.
In West Dorset, general practitioners felt poorly prepared to respond
to the increasing demands made by patients who use illicit drugs. We
offered local general practitioners an eight hour programme of training
on working with drug misusers in general practice. The participants
identified their learning needs, and the course presenters worked to
meet these. Many of the participants initially had negative feelings
about drug misusers; they admitted to feeling uncertain and lacking in
confidence when working with these patients. The education was spread
over at least one month, which allowed participants to integrate theory
with their own practice and to test it. There was an emphasis on
negotiating realistic treatment goals and advocacy of a model of shared
care. General practitioners and drug service workers gained a clearer
understanding of each other's roles and skills.
Participants on the initial courses have formed a local special
interest group that meets quarterly for peer support, discussion of
cases, and further learning. Evaluations of the course show that it
meets the needs of busy general practitioners who do not wish to become
experts but who feel poorly prepared for part of their everyday work.
About 40 (over 30%) local general practitioners have now taken part in
the training, and most continue to work with a number of patients with
drug related problems, often in partnership with our community drugs
agency.
Andrew Preston
West Dorset Community Alcohol and Drugs Advisory Service, Charles Campion-Smith
Postgraduate Centre, References
1 Davies A, Huxley P. Survey of general practitioners'
opinions on treatment of opiate users. BMJ
1997;314:1173-4. (19 April.)
2 Hindler C, King M, Nazareth I, Cohen J, Farmer R, Geralda C.
Characteristics of drug misusers and their perceptions of general
practitioner care. Br J Gen Pract l996;46:l49.
3 Martin E. Training in substance abuse is lacking for GPs.
BMJ 1996;312:186-7.
4 Stammers T. Managing drug abuse. Br J Gen Pract
1996;46:556.
We have recently completed a study of general practitioners' attitudes
and behaviour in providing primary care for single homeless people in
Birmingham. This group includes a large proportion of opiate misusers
and they are subject to negative stereotyping similar to that
experienced by other opiate misusers.(2) An analysis of
in-depth interviews with 25 general practitioners across the city
showed that general practitioners with positive views toward opiate
misusers were more likely to mention the benefit of local support
services. They emphasised this as an important coping mechanism both in
terms of the quality of service that they offered to clients and in
feeling supported in their work. In contrast, many of the general
practitioners who expressed negative views mentioned the lack of
support services or the excessive time involved in accessing them.
Our study explored doctors' attitudes in much greater depth than
Davies and Huxley's study, and the results suggest that the relation
between positive attitudes toward opiate misusers and greater contact
with support services is not a simple causal one. The origin of
positive or negative attitudes seems to be complex and rooted in the
accretion of influences from the lay and medical communities, including
influences operating before entry to medical school. Though we agree
that general practitioners should be offered better training in this
important aspect of primary care, our study suggests that the training
required will need to challenge deeply held attitudes in a manner that
is not too overt and will need to be quite intensive educationally. In
the longer term, the solution may lie rather more in the selection of
medical students and early formation of their attitudes.
Helen Lester
Department of General Practice, References
1 Davies A, Huxley P. Survey of general practitioners'
opinions on treatment of opiate users. BMJ
1997;314:1173-4. (19 April.)
2 Jones P. Drug abuse and homelessness. Br J Gen
Pract 1995;45:384.
During December 1996 and January 1997, I conducted a postal
survey of all 34 practices in the district served by the Mid Anglia
Community Health NHS Trust (a total of 131 general practice
principals). General practitioners were questioned about their contact
with opiate misusers and their willingness to prescribe substitute
drugs. They were asked to indicate on a five point Likert scale
(ranging from strongly agree to strongly disagree) if there were any
factors that might encourage them in this work. Altogether 84 (64%) of
the general practitioners contacted responded after a single mailing.
Forty four of those responding had seen a patient with problems related
to the misuse of opiates in the preceding four weeks. Only 29 doctors
were willing to prescribe substitute drugs for opiate misusers, whereas
59 had previously been prepared to prescribe them. This change in
stance followed the General Medical Services Committee's statement (of
which 73 of the general practitioners were aware; one non-respondent)
that such work falls outside core general medical
services.(2) Altogether 33 of the 55 of those who would not
prescribe substitute drugs stated that their position on prescribing
was influenced by practice policy.
Sixty seven of the respondents indicated that specific measures might
encourage them to maintain or adopt a more active role. These included
the provision of assessment and advice by a specialist agency within an
agreed timescale (44 in agreement; one non-respondent), local protocols
on the management of opiate misusers (35 in agreement; one
non-respondent), and training sessions for general practitioners and
other primary health care staff (25 in agreement). An
additional capitation fee, proposed by the commissioning authority, of
P15 every three months was rejected by 39 of the 67 respondents.
This study confirms a dramatic increase in the contact between general
practitioners and opiate misusers in rural East Anglia since the
national survey by Glanz.(3) It identifies a previously
unexamined factor-namely, that the refusal of some general
practitioners to prescribe substitute drugs might be the product of
practice policy rather than the general practitioner's personal
decision. None the less, this study provides confirmation that training
and support might encourage general practitioners to become more
involved in the shared care of opiate misusers.
Jane R Mason
West Suffolk Drug Advisory Service, References
1 Davies A, Huxley P. Survey of general practitioners'
opinions on treatment of opiate users. BMJ
1997;314:1173-4. (19 April.)
2 General Medical Services Committee. Annual report
1996. London: GMSC, 1996:20.
3 Glanz A, Taylor C. Findings of a national survey of the role of
general practitioners in the treatment of opiate misuse: extent of
contact with opiate misusers. BMJ
1986;293:427-30.
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