General Practice

# General practitioner centred scheme for treatment of opiate dependent drug injectors in Glasgow

BMJ 1997; 314 (Published 14 June 1997) Cite this as: BMJ 1997;314:1730
1. Laurence Gruer, consultant in public health medicinea,
2. Philip Wilson, research fellowb,
3. Robert Scott, clinical directorc,
4. Lawrence Elliott, director of health services researchd,
5. Jayne Macleod, research officera,
6. Kenneth Harden, secretary, local medical committeee,
7. Ewing Forrester, medical prescribing adviserf,
8. Stewart Hinshelwood, director of practitioner servicesg,
9. Howard McNulty, chief administrative pharmaceutical officerg,
10. Paul Silk, principal officer (community care services)h
1. a HIV and Addictions Resource Centre, Ruchill Hospital, Glasgow G20 9NB
2. b University of Glasgow Department of General Practice, Woodside Health Centre, Glasgow G20 7LR
3. c Glasgow Drug Problem Service, Ruchill Hospital, Glasgow G20 9NB
4. d School of Nursing and Midwifery, Dundee University, Ninewells Hospital, Dundee DD1 9SY
5. e Glasgow G4 9JT
6. f Prescribing Adviser's Department, Glasgow Royal Infirmary, Glasgow G4 0SF
7. g Greater Glasgow Health Board, Glasgow G1 1ET
8. h Social Work Department, Glasgow City Council, Glasgow G2 4PF
1. Correspondence to: Dr Gruer
• Accepted 25 April 1997

## Introduction

Injecting opiate drugs is now common in the United Kingdom, particularly in deprived urban areas.1 The judicious use of oral methadone may enable many opiate dependent drug injectors to reduce or cease injecting, with consequent improvements in health and social stability.2 Key elements of effective methadone treatment include ensuring oral ingestion of an appropriate daily dose and addressing patients' other health and social problems.3

Successive reports to government have emphasised the key role of general practitioners in treating drug injectors.4 5 6 However, few have received training in managing such patients, and consequently many experience difficulty in treating them.7 8 Coping strategies range from refusing to register any drug injectors to prescribing various substitute drugs for unsupervised use, with the consequent dangers of overdose or diversion of the drugs to the black market.9 Although some practices provide effective care 10 11 little has been published on how this can be achieved across a larger population.12

In most countries methadone must be given under supervision at specialist addiction centres.2 Although this has the advantage of ensuring a consistent approach within each clinic population, specialist services may be inaccessible to many and may lack the capacity to meet need when the prevalence of drug injecting is high. Unusually, in the United Kingdom both hospital doctors and general practitioners are allowed to prescribe methadone for dispensing by community pharmacists, thus enabling the treatment of injectors to be decentralised. However, a recently published survey of community pharmacies in England and Wales found that methadone is frequently dispensed in large amounts for unsupervised use.13 The opportunities for abuse or diversion are clear. In a recent survey of drug related deaths in Manchester a large proportion seemed to be associated with methadone.14

Greenwood reported that many general practitioners in Edinburgh have been encouraged to participate in a shared care scheme with a specialist service.15 We describe innovative arrangements enabling general practitioners and pharmacists in Glasgow to play a central part in managing opiate dependent drug injectors.

#### Summary points

Judicious use of methadone can improve the health and social wellbeing of opiate dependent drug injectors

A coordinated scheme in Glasgow has enabled many more general practitioners to treat drug injectors effectively–in the first two years of the scheme methadone prescribing increased by 173

The additional clinical work may justify special payments to general practitioners

A specialist medical referral service to which only general practitioners can refer patients and additional support from nurses or drug workers from community based agencies are essential adjuncts

Community pharmacists have a key role in supervising the self administration of methadone by patients in pharmacies–to date, 60% have participated in Glasgow

## Establishing the scheme

In 1991 there were about 8500 drug injectors in the area covered by the Greater Glasgow Health Board (population 915 000).16 Although this number may now have fallen, the characteristics of drug injectors have remained the same. Most are aged between 20 and 35 and live in areas of socioeconomic deprivation; around two thirds of them are men. Over 80% inject heroin at least daily, and they often use other drugs, some of which are injected and some taken by mouth. The most popular are temazepam, dihydrocodeine, diazepam, buprenorphine, and amphetamine.17 Around 1% of drug injectors die annually from overdose.18 Although only 1% have HIV infection, at least 70% have hepatitis C, and there are numerous other serious health and social consequences.19

Our unpublished survey of general practitioners carried out in 1992 showed that three quarters of the 221 practices in the area had patients who were known to be injecting drugs. Many respondents described difficulties in managing drug injectors, for whom they often prescribed psychoactive drugs, most commonly dihydrocodeine, temazepam, diazepam, and buprenorphine. Only a handful of respondents prescribed methadone at that time. Respondents also often asked for access to a specialist medical service, more information on existing services, and opportunities for training. Several psychiatrists in the area accepted referrals of drug injectors, although their main focus was the treatment of alcohol misuse. As psychiatric services were poorly resourced and inconsistent in approach, they could not provide the support that general practitioners sought.

In 1992 a small group of general practitioners in Glasgow who were prescribing methadone to their patients began meeting informally. Several had started separate clinics for drug injectors under a national health promotion scheme.11 Although they found this approach helpful, it was time consuming and required a degree of clinical commitment that they thought went beyond the range of services contractually agreed between general practitioners and health authorities. They argued that such an approach would not be adopted by other practices unless the additional work was rewarded.

## Discussion

To our knowledge, this is the first published report of arrangements enabling general practitioners across a large area to contract to provide coordinated evidence based treatment for opiate dependent drug injectors. The central element of treatment is the prescription of an appropriate daily oral dose of methadone. The scheme offers a framework within which general practitioners and their staff, community pharmacists, and drug counsellors can cooperate to ensure that methadone is used safely and patients are given the opportunity to improve their physical, emotional, and social wellbeing.

The scheme is based on an approach that had already proved workable.11 The principle was established that its requirements went beyond the scope of general medical services and that participating general practitioners should therefore receive additional payment. Engaging general practitioners in a formal contract has been crucial in ensuring a high degree of compliance with the conditions of the scheme.

### Specialist advice, guidelines, and training

Three factors have been important in building a greater sense of confidence among general practitioners, most of whom had had no previous training in the management of drug injectors. Firstly, a medically led specialist service, the Glasgow Drug Problem Service, to which all general practitioners in the city can refer drug injecting patients, was established. Restricting referrals to general practitioners alone has ensured that the continuing responsibility of the general practitioner for the ongoing shared care of the patient is clear from the outset. Because the clinics of the Glasgow Drug Problem Service are held in local health centres most patients can be assessed and treated close to where they live. Furthermore, direct discussion with the referring general practitioner is facilitated and primary care staff can see that such clinics can be run smoothly alongside services for other patients.

Secondly, the scheme provides general practitioners with detailed guidance on the clinical management of patients and the use of methadone, as well as advice on problems such as coexisting benzodiazepine dependence.

Thirdly, a quarterly series of evening seminars has been established. General practitioners participating in the scheme are required to attend at least two annually, but the seminars are also open to all other general practitioners. This enables general practitioners to increase their knowledge and meet colleagues with similar patients. We see ongoing training as an essential element of the scheme.25

### Supervising and supporting patients

The two other key partners in the scheme are community pharmacists and drug counsellors. Nearly two thirds of the community pharmacists in Glasgow have recognised the importance of ensuring that the correct daily dose of methadone is taken by patients. As a result, not only are almost all prescriptions for methadone from doctors in the scheme now dispensed daily but, in over 91% of cases, supervised self administration of methadone by the pharmacist is arranged. This is in sharp contrast to the results of a recent survey of community pharmacies in England and Wales, which found that daily dispensing of methadone occurred in only a third of cases and that supervised self administration was rare.13 We believe that supervised self administration in pharmacies greatly reduces the opportunity for misuse and diversion to the black market while enabling patients to obtain their methadone close to where they live. This arrangement also ensures that there is daily contact between the patient and a trained health professional and conveys a powerful message that patients being properly treated for drug addiction can receive their drug treatment in the community pharmacy. There have been very few complaints from either patients or other customers.

The scheme places great importance on providing additional counselling and support. Whereas methadone may successfully reduce injecting and chaotic drug use, unless help is offered in dealing with coexisting psychological, social, and legal problems the patient may feel unable to cope. Counsellors are able to address these complex and time consuming issues in joint clinics, leaving doctors free to concentrate on clinical management. Many doctors in the scheme have commented on how much this relieves the pressure and sense of isolation they previously felt when treating drug injecting patients alone.

### Unresolved problems

Survival analysis showed that 60% of patients in the scheme would continue to take methadone for at least a year. The reasons for stopping are many, including relapse to chaotic drug use and exclusion due to unacceptable behaviour on the one hand and the successful achievement of abstinence on the other. Studies are in progress to assess the outcome of treating patients within the scheme. Factors affecting outcome may include the dose of methadone prescribed and whether a maintenance or reducing regimen is used.26 Both factors vary considerably between practices.

Many problems remain, only some of which may be within the power of the health service to address. Many drug injectors in the city either are not registered with a general practitioner or are unable to find one who is prepared to prescribe methadone. We are thus trying to encourage more general practitioners to join the scheme, particularly those who already prescribe methadone. In some parts of the city community pharmacists are working to full capacity and counselling services are likewise overstretched. Major problems are frequently encountered when patients are imprisoned and methadone is discontinued.27 During the past two years heroin smoking, previously rare in Glasgow, has become much more common; the grounds for prescribing methadone for non-injectors are less certain and currently under debate. The management of coexisting benzodiazepine dependence remains troublesome. Despite these continuing challenges, the scheme has been enthusiastically adopted by a growing number of general practitioners in Glasgow. They see it as a huge improvement on the previously chaotic state that continues to exist in many other parts of the United Kingdom.

We thank Paula Barton and Julie Ann Cullen for processing the clinic data, and Heather Telford for preparing the manuscript. Billy Smythe and Martin Frischer advised on and helped with data processing and analysis. Kay Roberts provided useful comments on the paper. We thank our many colleagues in general practice, the Glasgow Drug Problem Service, community pharmacies, and the community drug projects for their continuing support.

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