Source: British Medical Journal
Contact: bmj@bmj.com

BMJ No 7108 Volume 315
Editorial Saturday 6 September 1997

Drug misusers: whose business is it?

Shared care can work well, but drug misusers still need specialist services

All indicators of illicit drug dependence have continued to climb over the
past two decades, showing no sign of reversal. The one success has been the
containment of HIV: through the provision of community services and the
promotion of needle exchanges Britain has maintained one of the lowest HIV
seroprevalence rates among injecting drug users globally.(1) The increasing
tide of drug misuse has, however, continued to place additional burdens on
public services, from the criminal justice system to health and social
services.(2) How medical services should respond to drug dependence and its
associated harms, and in particular which doctors should be responsible, is
currently the subject of debate.

In his personal view in this issue (p 613) Scott argues that psychiatrists
have neither the skills or the attitudes appropriate to looking after drug
misusers and that general practitioners are far better at it(3) Primary
care services are often the first port of call for users and their families
and neighbours and, after a slow start, are now responding to the challenge
of treating this disenfranchised group, as evidenced by this week's
correspondence columns (p 601).(4) General practitioners are concerned
about the increased workload and in some areas have obtained specific
funding. Nevertheless, even in the best developed practices the
multiplicity of problems presented by drug using patients means that a
similar multiplicity of skills must be deployed, including skills held by
those outside primary care.

The new challenge is to develop closer integration between all providers of
services, identify effective interventions, and then ensure that these
interventions are delivered.(2) Such interventions may include methadone
maintenance, behaviourally based therapies including motivational
interviewing and relapse prevention, detoxification, targeted health
promotion, and, when appropriate, residential rehabilitation. The new BMA
report on drug misuse is a significant contribution to this broad based
approach to services for drug misusers.(5)

Encouraging primary care to take responsibility for drug misusers has been
policy since the early 1980s.(6) Models of shared care developed in alcohol
treatment have been applied to drug misuse services. Shared care involves
joint participation of specialists and generalists (generally psychiatrists
and general practitioners but also community pharmacists(2)) in planned
delivery of care, supported by information exchange beyond routine
discharge and referral letters. In many settings better communication and
greater mutual awareness are at the heart of improved services. Such
arrangements make explicit which clinician is responsible for different
aspects of management. In most cases the general practitioner maintains the
central coordinating role for the patient's long term health care. As the
correspondents point out, good shared care requires training and support
for general practitioners,(4) but it can work only in the context of a well
developed specialist service.

Specialist services are needed for patients with chaotic patterns of drug
use, multiple dependencies, and serious physical or mental health problems,
or other complex problems. The task force to review services for drug
misusers reported that community drug services had expanded in response to
the growth of drug problems and dependence but that many had problems with
overall management, with poor delivery of hepatitis B vaccination and other
aspects of health care.(2) The growing number of very young drug users
presenting to services and the need for services tailored for amphetamine
and cocaine users means that the staff of community agencies will require a
combination of behavioural science training and basic health skills
training. Specialist services have a critical role to play in providing
such training and applying different models of consultancy and liaison as
new patterns of drug use emerge. The future involves figuring out how to
integrate the intake of new users into services, to match them to
appropriate interventions, to plan long term management, and to integrate
health and social care for rehabilitation.

The national treatment outcome study showed that a quarter of those
entering drug services had suicidal thoughts, a quarter had been admitted
to general medical wards, and a tenth to psychiatric wards.(7) Other
studies suggest that over half of drug dependent individuals in the
community have mental health problems, and rates of mental health problems
are significantly higher among those entering treatment services.(8)
Separate reports indicate that 6070% of injectors are hepatitis C
positive. With these levels of serious ill health associated with drug
dependence it makes as much sense to argue against psychiatric involvement
with drug users as to argue that hepatologists, gastroenterologists,
genitourinary physicians, and prison medical officers have no role because
they deal with only a particular dimension of the problem. Clearly, general
practitioners retain their traditional role as providers of primary care to
drug misusers, but simplification of the problems of, or responses to, drug
misusers does no justice to their needs.

Michael Farrell
Senior lecturer and consultant psychiatrist

National Addiction Centre,
Maudsley Hospital and Institute of Psychiatry,
London SE5 8AF

(m.farrell@iop.bpmf.ac.uk)

References

1 Stimson G. AIDS and injecting drug use in the United Kingdom, 19871993:
the policy response and the prevention of the epidemic. Soc Sci Med
1995;41:699716.

2 Department of Health. The task force to review services for drug
misusers. London: Department of Health, 1995.

3 Scott R. Drug misuse: GPs' pivotal role. BMJ 1997;315:6134.

4 Van Teijlingen E, Porter M; Bury J, Sherval J; Preston A, CampionSmith
C; Lester H, Bradley C; Mason J R [letters]. General practitioners'
attitudes towards treatment of opiate misusers. BMJ 1997;315:6012.

5 British Medical Association. Misuse of drugs. Amsterdam: Harwood Academic
Publishers, 1997.

6 Glanz A. The fall and rise of the general practitioner. In: Strang J,
Gossop M, eds. Heroin addiction and British drug policy. Oxford: Oxford
University Press, 1995:15166.

7 Gossop M, Marsden J, Edwards C, Wilson A, Segar G, Stewart D, et al. The
October report. The national treatment outcome study. Report prepared for
the Department of Health. London: National Addiction Centre, 1995.

8 Hall W, Farrell M. Comorbidity of mental disorders with substance misuse.
Br J Psychiatry 1997;171:45