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Addiction, Treatment
Written by Mike Blank   

EDUCATING & TRAINING GPs IN THE MANAGEMENT & TREATMENT OF DRUG USERS

GPs are increasingly needed to cut down waiting lists. Mike Blank and Bill Nelles identify the training issues involved.

INTRODUCTION

There has been a long~standing reluctance'on the Part of general practitioners to become involved in the treatment of drug users. This reluctance was reinforced by the development of specialist clinics and drug services. However, in the 1990s the threat of AIDS and increasing pressure on specialist services has rneant a re-appraisal of the GP's role in the care of people who use drugs.

General practitioners can he crucial participants in the delivery of health care to drug users, and in the management and treatment of drug use. However, many GPs appear reluctant to see and treat drug users in their ordinary practice, preferring at best to refer to specialist clinics, or at worst, refusing to see drug users. Drug agencies complain of the difficulties in persuading GPs (with some honourable exceptions) to ,accept drug users on to their lists or to treat those who are already patients. Those GPs who do agree to see and treat drug users frequently set goals that are difficult for the drug user to achieve, as opposed to considering a range of flexible options. Even the ground-breaking textbook on the subject of GPs and drug users (Banks and Waller, 1988) finds difficulty in advocating longer-term prescribing as an option for GPs.

In Dyfed, a large county in West Wales served by two health districts, statutory specialist drug services are still in their infancy - consisting of three nonpre, scribing community agencies offering the usual range of interventions. There is, as yet, no consultant in addictions, andaccess to clinic facilities in othercounties is time-consuming, expensive and, because of the Welsh geography, difficult. Most local psychiatrists are not willing to see drug users for the treatment of their addiction problems.

Recognising the need for medical services to be available to drug users in Dyfed for provision of general health care and the treatment of addiction, and following the recommendations of the Advisory Council on the Misuse of Drugs( 1990; Department of Health ' 1991 ), it was decided to attract local general practi tioners and train them in the treatment and management of drug users. It was also recognised that a group of well-trained, motivated GPs practising over a wide geographical area would enhance the delivery of care to drug users in a county deficient in many basic drug services. The training would also help the GPs in their dealings with a group whom many felt to be 'difficult' patients.

Nowadays, there are few professionals working in the field of drug misuse who fail to recognise the potential role of the general practitioner in the treatment of drug users. The current Department of Health Guidelines (1991) estimate that every GP in the UK can expect to see several drug users as patients each year. There is every reason to assume that this is also the case in Dyfed.

PLANNING

The development of a course was first outlined in 199 1, and the suggestion was received with enthusiasm by management. This led to the establishment of a project team, consisting of the Unit General Manager of the East Dyfed Health Authority Mental Health Unit, the chairman of the County Substance Misuse Advisory Committee, the Primary Health Care Development Officer of the Family Health Services Authority, the Director of Public Health Medicine and the principal author.

It was felt to be of vital importance that very senior staff were involved in the planning of this project as they either had access to dec is ion- makers, or were themselves decision-makers. Their participation and seniority lentweightand substance to the development of the course and this in turn convinced others of the course's potential. At this point, the second author was contacted to act as a consultant, building on his experience as the developer of a similar, but less intensive, GP training programme for West Berkshire DHA (Duncan, 1990).

The team established the strategic objectives of the course.

1. The effective training of a minimum of 12 GPs (maximum 20) in the management of problem drug users.

2. That the participating GPs should come from a wide geographical area.

3. The promotion of closer working relationships between local drug services and GPs.


To meet these objectives, the course needed:

A firm funding base.
An assessment of demand.
A course programme which would gain local GP postgraduate training scheme approval.
To be residential and sited well away from Dyfed.
The offer of locum cover for those attending.
To be of sufficient length to allow time for attitude changes.

There were reasons for these principles. It was important to ensure that those attending the course were committed to attending all of it and would not leave from time to time to meet practice commitments. It was recognised that drug users were not particularly popular with most GPs, and to overcome this hurdle the course needed to be as attractive as possible.

This meant that there had to be a good mix of teaching methods, high quality external speakers, a high number of postgraduate points (GPs accrue points for attending accredited courses and are required to obtain a minimum of ten each year at which point they then qualify for extra income), and accommodation of sufficient quality both to maximise learning and to allowfor recreation. In essence an absolutely free course was planned, with GPs paying only for their social expenses.

The course content was planned in great detail. The internal logic of the 5-day course would take the participants through a sequence of steps. Initially participants would be given increased knowledge and helped to examine their attitudes towards drug users. Subsequent sessions would introduce participants to principles of harm reduction and treatment, followed by HIV and AIDS updates and models of rehabilitation. The final sessions would be devoted to developing action plans, building on the course content so that the participants could use their new-found skills and knowledge in their practice.

Although emphasis was placed on group work which would help participants to develop assessment and intervention skills, the project team also recognised the need for high-quality external speakers. In particular speakers had to carry a stamp of intellectual authority, to be informative and entertaining. It was also considered vital that two of the speakers were practising GPs who were themselves experienced in the treatment and care of drug users.

The course facilitators decided that they should be resident at the venue for three reasons: first it was felt that on-site facilitators should be available if practical difficulties arose in the delivery of the course or with accommodation; secondly they wanted the opportunity to develop stronger links with the participants; lastly, they correctly anticipated that many opportunities for informal learning would take place during free time.

The planning phase was completed with the assessment of the likely demand for the course. This was done by letter to individual practices throughout the county asking for expressions of interest. A number of individual approaches were also made to GPs who were known to drug agency staff or who were thought to be sympathetic to drug users.

Twenty GPs confirmed their interest in attending a course. During demand assessment the opportunity was taken to ask potential participants about their experiences of drug users and the subjects they would like to see in the course.

Key issues for GPs were the following:

Management in the surgery (i.e. dealing with difficult or potentially difficult behaviour).

Fear of being manipulated or deceived.

Concern that should they start seeing drug users their practices would be inundated to the overall detriment of the practice.

Frustration with the high level of relapse among drug users and the inability of users to stay drug free despite repeated attempts at detoxification.

These concerns strongly influenced the content of the course and the choice of speakers.

The detail and care with which the course was structured subsequently paid an enormous dividend. The importance of meticulous planning must be emphasised. Time spent planning is an investment in success.


FUNDING AND COSTS

In estimating the funding requirements of the course theprojectteam assumed 20 participants plus 2 fac41itators resident for 5 days/4 nights.

Original cost estimates were broken down thus:

Hotel/Conference accommodation £7500 (UK Sterling)
Locum cover per GP £20 000 ( £1000 per GP)
External speakers £5000
Books/Materials £1000
Miscellaneous £500
Estimated total £34 000

In fact the team over,estimated the costs, primarily because the locum cover proved less expensive than anticipated, and because, despite the offer of fees, speakers frequently gave their services free or at very reasonable rates. The final total for the course was under 20 000, which paid for 15 participants and 3 resident facilitators. The costs were met from a central funding allocation underspend which the principal funder (the Welsh Office) gave permission to use for funding the course. Expenditure on the course was considered a worthwhile capital investment for the future.


IMPLEMENTATION

The course lasted for 5 days at an excellent and wellequipped hotel. Fourteen GPs attended plus the Medical Adviser to the Dyfed Family Health Service Authority (FHSA) - 15 participants in all. Conference facilities included a main lecture room and syndicate room with access to some public areas. This allowed for small group work. All the speakers attended as arranged.

During the first sessions the participants were asked to identify key issues which they wanted addressed. These included the following:

Management in the surgery - in particular concerns about verbal and physical aggression towards reception and medical staff.

Fear of deception, manipulation.

Drug users as time-consuming patients.

Ethics of prescribing/harm reduction.

Transient patients.

Fear of attracting drug users to the practice - the 'junkie' practice syndrome.

Assessment - in particular the gauging of the quantities of prescription drugs equivalent to the street drugs being consumed.

Conflict between practice partners over seeing drug users.

The need to develop practice protocols for the treatment of drug users.

Payment for seeing users.

Many of these concerns reflected those outlined by Greenwood (I 992a) in her work with GPs in Lothian. They seem to indicate that GPs' fears of drug users are universal.

In the event, the course ran smoothly and the participants formed a close-knit group. No participant objected to the group-work - indeed, there were demands towards the end of the course for more group work. This was a surprise to the facilitators who had anticipated some difficulty in training doctors who were, they thought, more comfortable with didactic forms of teaching. As the course proceeded, all the GPs demonstrated increasing knowledge, confidence and skills, and a better understanding of the work of drug services.

In their turn, the facilitators, none of whom was a doctor, felt that they had gained a greater insight into the pressures on GPs and a better understanding of the problems currently besettin general practices in the UK. It may also be of interest to note that many of the speakers felt intimidated at the prospect of teaching. Informal discussions revealed specific reasons for this fear. Many of the speakers had previously had hierarchical relationships with doctors. They were all patientsof theirownGPs, and insome caseshad worked as nurses. Most commonly, drug workers had come into contact with GPs from whom they were seek ing something - most usually a prescription for a patient. This often resulted in difficult exchanges.

Many of the speakers therefore felt threatened at the prospect of teaching GPs and anticipated a difficult session. Suffice it to say that the GPs were not at all threateningand indeed were quite concerned thatthey were perceived in this fashion. Equally the speakers weredelighted to discover that their fears were groundless.

EVALUATION

Methodology: the course was formally evaluated by the use of 'before and after' questionnaires (Table 1 ). Eleven of the questions were identical but the 'after' questionnaire asked six supplementary questions. The questionnaires were administered anonymously and measured changes in attitudes and knowledge through the use of rating scales ( 1 = disagree strongly, 10 = agree strongly). Participants were also given the opportunity to give verbal feedback and recommendations on future course content, personal action plans etc. One participant was unable to attend for the final day and did not complete an 'after' evaluation. One questionnaire was missing. It is acknowledged that this form of evaluation is crude. However, the formal evaluation combined with the verbal feedback gives clear indications as to the success of the course.


TABLE 1: Participant questionnaire

Questions (1 =disagree strongly) (10=agree strongly) Before (n=14) After (n=13)
1. Drug users should be detoxified as Vickly as possible in all cases. 5.1 1.6
2. HIV is a greater threat to individuahnd public health than continued drug use 8.7 8.2
3. GPs have a part to play in preventing the spread of HIV 8.3 9.0
4. Drug use is a major problem in my practice area. 5.0 7.1
5. Drug users bring their problems on themselves. 3.7 4.4
6. Once addicted, people will remain addicted to drugs or alcohol for the rest of their lives. 10Y 4N 2Y 11N
7. If 1 start treating drug users my practice will become a magnet for allthe junkies in the neighbourhood. 5.6 4.0
8. Drug users are devious, manipulative and not to be trusted 7.5 6.3
9. 1 feel that 1 don't have the skills and knowledge to cope with drug users. 8.0 2.6
10. Drug addiction is an illness. 6.6 5.5
11. Stabilising people on a long-term therapeutic dose of a substitute drug such asmethadone does little good and means that 1 am just a'licensed'drug dealer. 4.3 1.9
12. 1 have found the course useful.
13Y
13. 1 feel more confident about seeing drug users in my practice.
8.9
14. 1 will see drug users in my practice in future in conjunction withDyfed's drug services.
13Y
15. 1 have a greater understanding of the theory and practice of teating drug users.
8.8
16. 1 would like to participate in a follow-up day in a few months time.
12Y
17. 1 would like to see the appointment of a specialist support worker to assistGPs in managing drug users and developing services for them.

Questions 1-11 were administered at the beginning of the course and at the end. Questions 12-17 were administered at the end of the course. The scores represent the average scores. Y - yes; N - no.

The results of the questionnaires and the feedback from participants confirmed that a significant learning process had taken place. Many of the concerns regarding the managementand treatment of drug users had been addressed and some negative attitudes had been markedly moderated. The CiPs also reported that they felt more skilled and knowledgeable and now had a framework within which to treat users. Of particular interest are the changes which took place in response to questions 1, 4, 6 and 11, By the end of the course the participants felt that immediate detoxification as outlined in question 1 should not he the first option in all cases. In question 4 it is interesting to note that more of the GPs thought that drug use was a problem for their practice. It is possible that during the course they began to identify patients for whom drug misuse was a diagnosis that they had previously not considered or it may be that the course sensitised them to problem drug use in general. The depressing opinion expressed at the beginning of the course in response to question 6 that drug addiction is a life sentence changed completely with most of the participants reversing their opinion.

Finally the response to question 11 showed that the fear of being a'licensed'dealer had also been markedly moderated. Thus the responses to these and othe'rquestions demonstrated that the course had indeed achieved its objectives.

In the final session, issues arising from the course were addressed, and proposals for future action were identified. Specifically, it was felt that:

Training and education would be enhanced by the provision of a GP Support Worker.

There was a need for further courses both as a follow-up for the original attenders and for other GPs in Dyfed.

Some form of payment should be considered for GPs who treated drug users. Whether this should be by way of Health Promotion Clinic Payments, or in some other fashion, needed to be explored. However, there was a general acceptance that drug users could and should be seen in normal surgery time if possible.

GPs treating drug users should be required to attend a course and should be 'approved' or accredited. They should also be able to demonstrate close cooperation with local drug agencies.

A Special Interest Group should be developed.

GPs treating drug users should actively consider providing injecting equipment on an exchange basis to their drug,using patients. Condoms should be provided where possible.

All drug-using patients should be screened for hepatitis and inoculated as a matter of routine.

DISCUSSION

This course grew from the need to develop services for drug users in a large mixed rural/urban county where the provision of specialist services is sparse. It was also an attempt to implement recommendations regarding GP training contained within various ACMD reports and to meet the needs of GPs encountering drug users in their normal everyday practice. It was clear that, in common with Greenwood's findings in her'shared care'work (1992h), GPs were -amenable to training in the treatment of drug users. They were willing to see their roles expand from providers of 'curative'l medicine, to embrace harm-reduction practices, thus reducing the potential harm of drug use.

Interestingly, many of the GPs discovered that the harm-reduction model of intervention was very similar to interventions offered to patients presenting with chronic, relapsing conditions such as asthma or arthritis, where the aim of treatment is to reduce discomfort and improve the patient's quality of life. These were -also acknowledged as laudable aims in the management of drug users. The OPs found that viewing problem drug use in such a manner allowed them to assimilate and understand the management of drug users in the light of their previous experience and training.

The facilitators also found that their understanding of the demands placed on GPs improved markedly and the opportunity to spend time with GPs away from the demands of normal work was extremely valuable. The course was very intensive forthe facilitators, who found that they were discussing'drugs'work from breakfast to midnight every day. The formal and informal discussions stimulated an prodigious exchange of skills and knowledge.


CONCLUSION

The facilitators drew the following conclusions from the course:

A significant proportion of GPs practising in any one district can be trained in the management of drug users provided that the training offered is attractive. Once trained, GPs can provide a vital component of the primary care and treatment facilities available to drug users. GPs are willing and able to work with non-prescribing specialist drug services. A residential course of this type is an ideal environment in which to offer such training. The provision of a GP support worker is a reasonable expectation.

This course offers a model for the training of GPs throughoutWales and theUK. It is a very cost-effective investment in the primary care sector which pays dividends in terms of widening the choice of services available to drug users and in the improvement of general health care available to drug users.

Whether this type of GP training is successful in the long term, only time and follow-up studies will demonstrate. However, the facilitators feel that this course is a paradigm for the training of GPs in the management of drug dependency. It is particularly suited to those drug services that wish to involve GPs in the care of drug users and which operate in rural locations or overburdened city clinics.

This course was a valuable beginning in the provision of GP training, the development 4 good working practices between specialist services and GPs, and the widening of choice for drug users.

This has not been an exercise in moving the burden of care from the specialist to the primary care service. Rather, it enhances the opportunities for drug users to seek treatment close to home. Indeed, it may well be that the workload of specialist services increases following such a course as more drug users are seen in GPs' surgeries. However, the pattern of service delivery is shifting towards a concept of 'shared care', with drug services providing specialist support for the GP and his or her drugusing patients. The real payoff will come with an increase in drug users receiving treatment where before there was none available. That, in turn, must reduce the risk of HIV spreading even further into the drug-using community.

ACKNOWLEDGEMENTS

Many people helped in the development and delivery of the Dyfed GP course - too many to name individually. However, the authors would like to express their gratitude in particular to: David Elias Schofield, Coordinator, Pembrokeshire Drug Services; Dr Jeremy Queenborough, Chris Jones, Dewi Williams of East Dyfed HA; Gill Patterson, Dyfed FHSA, Dick Pates of the Cardiff Community Drug Team; all the staff of the Dyfed Substance Misuse Services, in particular Delma McAlpine, the external speakers and the GPs themselves. The course was funded entirely by the Welsh Office and the assistance of PHFl is gratefully acknowledged.

Michael Blank, Manager of the Substance Misuse Services, Llanelli Drugs Project, Dyfed, Wales.

William Nelles, Health Promotion Department, Sutton Coldfield, W. Midlands.


REFERENCES

Banks, A. and Waller, TA.N. (1988) Drug Misuse A Practical Handbook for GPs, pp.247 - 250. Oxford: Blackwell.

Advisory Council on the Misuse of Drugs (1989) AIDS and Drug Misuse part 2, pp. 31-32. London: HMSO.

Advisory Council on the Misuse of Drugs (1990) Problem Drug Use, A Review of Training, p.27. London: HMSO

Department of Health, Scottish Home and Health Department, Welsh Office (1991). Drug Misuse and Dependence - Guidelines on Clinical Management, p.25. London: HMSO

Duncan, A. (1990) The quiet revolution. International journal on Drug Policy, 1, 23-26.

Greenwood, J. (1992a) Unpopular patients, GPs attitudes to drug users. Druglink, 7 (4), 8-9.

Greenwood, J. (1992b) Persuading GPs to prescribe. British Journal of Addiction, 87,562-5 75.