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Addiction, Treatment
Written by Judy Greenwood   
Wednesday, 29 March 1995 00:00

SHARED CARE WITH GENERAL PRACTITIONERS FOR EDINBURGH'S DRUG USERS

Dr Judy Greenwood, Community Drug Problem Service, Edinburgh, Scotland

This is a version of a paper presented at the Vlth Intemational Conference on the Reduction of Drug Related Harrn in Florence, March 1995.

As a result of the high rate of infection among Edinburgh's drug users and the lack of clinical drug service in 1988, the Community Drug Problem Service (CDPS) was established using a model of shared care between local general practitioners (GPs) and the new specialist drug3 service. GPs were encouraged to prescribe methadone and offer physical health care to their drug-using patients and the CDPS would offer advice and support for the GP about medication levels etc. and regular counselling and urinalysis for the drug user. The paper examines how GPs were persuaded to work with drug users, not usually their favourite patients . Seventy per cent of the GPs in the area (population 750 000) now prescribe for over 1200 drug users whereas the CDPS prescribes centrally for 150 of the more difficult patients. Injecting rates among drug users in the area have fallen from 87% in 1988 to less than 20%. Few new HIV seroconversions have occurred from injecting drug use, although HIV rates have continued to rise from homosexual and heterosexual spread.

INTRODUCTION

In 1986, Edinburgh woke up and realised that it had an HIV epidemic among its injecting drug users, thanks to the work of Dr Roy Robertson, a general practitioner in Muirhouse. He estimated that up to 50% of his drug users were infected. By 1987, an experimental Government Needle Exchange Scheme had been established by Dr George Bath and Dr Judy Greenwood (the author) agreed to provide medical cover. She had previously been a general practitioner and was then working as a community psychiatrist. At that time, there were no clinical drug treatment services in Edinburgh, although a few HIV-positive drug users were being offered methadone at the Infectious Disease Hospital by Dr Ray Brettle.

In 1988, Dr Judy Greenwood metamorphosed into a drug consultant and established the Community Drug Problem Service based on her recognition of the need for drug services other than the existing needle exchange.

ESTABLISHMENT OF THE COMMUNITY DRUG PROBLEM SERVICE

The service began with a staff of four, but to date has increased to a staff of 24. It serves a population of 750 000 covering the Lothian region and at the time of establishment it was estimated that there were 3000 - 4000 intravenous drug misusers. It has a current budget of over £500 000 and a drug budget which has increased to over £100 000 despite general practitioner prescribing. It shares the care of Lothian's drug users with 530 GPs working from 133 practices.

Referrals are made by the GP to the hospital. A community psychiatric nurse (CPN) arranges a local assessment of the patient, followed by a management meeting to discuss appropriate treatment which is then communicated to the GP by letter. Once the GP has agreed to continue treatment, the patient may be put through the CDPS Methadone Clinic for 3 days, with methadone administered on site followed by 3 weeks central prescribing before the GP is asked to take over the now stabilised drug user to undertake prescribing and physical health care, with the CDPS key worker ( usually a CPN ) continuing to offer counselling to the drug user often in his or her own home and support to the GP.

Initially, there was much medical ambivalence about the model of shared care, much of which stemmed from the GPs' emotional and attitudinal situation. GPs often feel untrained, confused, alienated, disgusted, anxious, de skilled, disillusioned, angry, overwhelmed, concerned or indifferent to drug-using patients and such emotions can interfere with their professional skills.

How we persuaded GPs to prescribe

An explanatory letter about the CDPS was sent to every GP requesting their help to kerb the HIV epidemic among Edinburgh's drug users and assuming that they would prescribe methadone as they do with any other medication recommended by a hospital specialist. After each patient referral, the GP would receive a full explanatory letter about the patient advising on the proposed management and its rationale, and encouraging the GP to take part in the treatment programme. Stabilising the patient or methadone at the CDPS before handing them back to the GP undoubtedly helped in this process. The service quickly became sectorised to cut down the number of GPs each nurse and doctor would work with and we ensured infiltration of many medical training events in order to expose GPs to the rationale of our harm-reduction approach. We would visit local surgeries, local congregations of GPs and arrange specific drug-training events. A group of local GPs and specialists was soon set up and began producing a local information sheet every 2 months, sent free of charge to each GP in Lothian concerning the care of HlV-positive patients and drug users and this has been well received.

From this group, the post of Primary Care Facilitator was established and Dr Judy Bury is now a full time facilitator who visits practices individually and arranges training events on the subject of HIV and drug treatment. She continues to produce the local information sheet. The Local Prescribing Advisor and General Practitioner Sub committee have also been regularly contacted by the staff of the CDPS with whom we have a good working relationship. The Government produced several relevant publications from the Advisory Council on the Misuse of Drugs, ÀIDS and Drugs Update, the Department of Health produced prescribing guidelines and the Scottish Task Force also produced an excellent document, all of which recommended that GPs become more involved in working with drug users.

GPs would be advised of the harm-reduction advantages of offering substitute oral prescribing for drug users which included making contact, reducing injecting, reducing adulterated intake, reducing crime and increasing the dignity of lifestyle, and the possibility of treatment leading to abstinence.

Practical issues regarding practice policies would be discussed with individual health centres encouraging the involvement of all staff in training, aiming for friendliness and firmness for drugs users, offering realistic appointments to one named doctor only, with local practice agreements or contracts outlining sanctions for delayed appointments, changing scripts and encouraging staff to share problems with each other in a consistent and supportive fashion.

Recommended prescribing policies would include no prescription at the first appointment, urine analysis and insistence of a drug diary signed by the drug users for medicolegal protection, assurance that health education about sexual and intravenous spread of HIV is given, making realistic objectives with the drug user before prescribing and encouraging continued help if the patient was in police custody.

CLINICAL AUDIT

CDPS referrals have risen to almost 4000 between 1988 and 1994. Sixty three per cent of these have attended for assessment. By 1993, 1200 drug users were receiving prescriptions from their GPs and 70% of practices were reported prescribing to drug users according to a survey. Prescribing by GPs was not evenly distributed throughout the city, with general practices in deprived areas often working with between 20 and 50 drug users on their list, whereas practices in more middle class areas would have one or two drug users at the most.

Fifty per cent were on a stable dosage of methadone and 50% were on reducing doses, and 66% were also receiving benzodiazepine prescriptions, reflecting the high rate of benzodiazepine dependence in Scotland. There have been recent seizures of large quantities of temazepam and diazepam from illicit wholesale pharmacy deals and benzodiazepines represent a major threat to Scottish drug users.

CHANGE IN DRUG USE

At the time of first assessment, striking changes in the pattern of Lothian's drug use have been observed. In 1988, 97% had injected at some time, and 87% had injected in the past month. By 1993, less than 45% had injected at some time, and 15% had inject ed in the past month. These figures are confirmed in the Scottish Office Drug Misuse Database Bulletin from 1991 to 1994 which also shows significant reductions to less than 20% in injecting rate among Lothian's newly identified drug users. Sally Haw's survey comparing street drug users in Edinburgh with street drug users in Glasgow also showed a remark able contrast between the rate of injecting drug use in Edinburgh and that in Glasgow. HIV rates among tested drug users new to the service also fell from 21 % in 1988 to 8% in 1993. Past and recent condom use did not, however, show any significant difference in the same timespan.

Once in treatment, clinical observation confirmed a continued reduction in injecting and research data on three samples taken at 6 months,12 months and 24 months (n = 74, 76,57) showed further significant reductions in the rates of injecting throughout the course of treatment. Clinical observations and independent research evidence also confirmed a marked reduction in the amount of acquisitive crime occurring in the month before interview, falling from around 60% involved in crime in the month before assessment to an average of 30% after treatment. Coincidentally, a dramatic fall in Lothian's crime figures was also reported by the press as the crime rate fell by 8%, decreasing for the first time since 1988!

CHANGES IN GP BEHAVIOUR

A survey by Dr Bury showed that, in 1988,36% were prepared to prescribe substitute drugs for drug users, 17% would do so if asked and 47% would not. By 1993,73% would prescribe for drug users,15% would if asked and only 12 % would not prescribe.

A survey of GP attitudes to the CDPS conducted by the psychologist, Andy Peters, in 1993, showed that 69% felt positive or very positive about the CDPS and 11 % felt negative or very negative. Seventy four per cent were currently prescribing for drug users and 88% had referred patients to the CDPS. They particularly appreciated the specialist back-up, the good communication and the ethos of the service of the CDPS.

DISCUSSION

The advantages of sharing the care with GPs include the logistics of being able to work with more drug users, normalising drug users and treating them like anybody else, GP training so that fewer referrals need to be made as GPs become more experienced, the cost benefits of using generic workers, being able to share anxieties about patients with GPs who have often known the client since childhood, and the advantage of good physical health care from the GP.

Disadvantages include the expenditure of energy involved in persuading the GPs to prescribe, the variations in quality control by using 530 GPs, the extra hassle of shared decisions, the increased likelihood of street leakage from drugs being dispensed from many pharmacies and not taken on site, the dispensing cost of not using a central dispensing agency, and the likelihood of double prescribing by drug users being able to use more than one GP.

QUESTIONS STILL TO BE ANSWERED

1. Has the CDPS prescribing played a key role in reducing injecting in Lothian?
2. Will GPs continue to share the care for another 8 years?
3. Can the CDPS risk prescribing for some (we now do prescribe for 150 of the most difficult patients) but will this encourage GPs to stop prescribing?
4. Will the predictability of methadone lead to eventual abstinence or the use of alternative more exciting drugs?
5. Are we flooding the streets of Lothian with pharmaceutical drugs?
6. Is it appropriate to treat never injectors and benzodiazepine users with the same substitute prescribing policies as used for intravenous drug users?

Dr Judy Greenwood,
Community Drug Problem Service, Royal Edinburgh Hospital, Morningside, Edinburgh EH1 0.