Managing drug misuse in general practice

Guidelines on the clinical management of drug misuse were first issued by the Department of Health in 1991. The latest version, issued last month,1 has been long awaited and has already sparked controversy. The new guidelines focus more on the role of the generalist than on that of the specialist in drug misuse, so they are particularly relevant to general practitioners.

The differences between the new and the old guidelines reflect changes over the decade both in our knowledge of drug misuse and in service delivery. Firstly, the new guidelines emphasise the developing evidence base, particularly the strong evidence for the effectiveness of methadone maintenance treatment.2 Secondly, they recognise the importance of the structure of service delivery and the key role of shared care within this. The new guidelines place responsibilities not just on doctors but also on commissioning bodies to deliver a service and to support doctors. Thirdly, there is a new emphasis on the rights of drug misusing patients to access good quality services, and the responsibilities of all doctors to manage drug related problems. Running alongside this, however, is a strong emphasis on avoiding the “maverick” approach to replacement prescribing, on safety for patients and the public, and on the importance of local protocols to maintain standards.

So what do the new guidelines mean in practice? They spell out the rights of drug users to the same NHS entitlements as other patients and state that all doctors should be equipped to deal with drug related issues. This means that all general practitioners would be expected to offer basic harm minimisation advice, including offering vaccination against hepatitis B, as well as providing general medical services for drug misusers. This does not, however, mean that all general practitioners would be expected to prescribe replacement medication. Indeed, the guidelines make it very clear that doctors should not be pressured into accepting responsibilities beyond their level of skill, and a framework is provided for the involvement of doctors in the treatment of drug problems beyond the basic level which all doctors must attain. Doctors providing services more specialised than this basic level are divided into three groups: the generalist, specialised generalist, and specialist, and recommended levels of activities and training are set out for each group.

The underlying principles for treatment show once again the attempt to broaden the base of drug misuse treatment while building in safeguards against poor practice. A multidisciplinary approach is emphasised throughout, with medication as just one strand of treatment, and harm-minimisation approaches are recommended because of the evidence to support their effectiveness. Nevertheless, the guidelines make clear that when doctors prescribe methadone they are responsible for ensuring that the patient receives the correct dose and that the drugs are not diverted to other drug misuers or sold. This translates into recommendations that: new prescriptions should usually be dispensed for supervised consumption over the first three months; substitute drugs should be dispensed on a daily basis until stability is achieved; doses should not be given to take home when there is any doubt about instability or diversion; and prescribers should liase closely with pharmacists. The prescribing of tablets and injectable formulations is strongly discouraged, as is the prescribing of any preparations outside the licensed indications, except in exceptional circumstances or specialist settings.

Not all practitioners will endorse every recommendation in the guidelines. Some of the more specific recommendations, such as that regarding supervised consumption, are only very loosely evidence-based. The paragraph on diamorphine prescribing, which states that there is very little clinical indication for prescribed diamorphine, appears to fly in the face of some of the evidence available.3 The guidelines only hint at the possibility of accreditation being introduced, with no specifics. There is also a degree of political evasiveness. When the effectiveness of a relatively inexpensive treatment such as methadone maintenance in reducing mortality and morbidity is now so well established, 4 5 for how long can it be considered ethical for some general practitioners to refuse to prescribe it within a shared care framework?

Nevertheless, the new guidelines represent a serious attempt to bring the evidence base into practice and to standardise treatment for drug misuse. This is essential if drug misuse treatment is to be brought into the mainstream. The guidelines represent a consensus framework for good clinical practice,6 and clinicians can expect to be judged against this reference point. If we deviate from the guidelines we should defend such deviation because they provide protection for the public against practice which is deficient.