MANAGING DRUG MISUSE IN GENERAL PRACTICE

New Department Of Health Guidelines Provide A Benchmark For Good
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.

Jenny Keen, Primary care specialist in drug dependence. Institute of
General Practice and Primary Care, University of Sheffield, Sheffield
S5 7AU (j.keen@shef.ac.uk)

References

1. Department of Health. Drug misuse and dependence: guidelines on
clinical management. London: Stationery Office , 1999.

2. Department of Health. Task force to review services for drug
misusers: report of an independent review of drug treatment services in
England. London: Department of Health , 1996.

3. Farrell M, Hall W. The Swiss heroin trials: testing alternative
approaches. BMJ 1998; 316: 639[Full Text].

4. Farrell M, Ward J, Mattick R, Hall W, Stimson G, des Jarlais D,
et al. Methadone maintenance treatment in opiate dependence: a review.
BMJ 1994; 309: 997-1001[Medline].

5. Ward J, Hall W, Mattick R. Role of maintenance treatment in
opioid dependence. Lancet 1999; 353: 221-226[Medline].

6. Tackling drugs to build a better Britain: the government's ten-year
strategy for tackling drugs misuse. London: Stationery Office , 1998.