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

BMJ No 7108 Volume 315
Personal view Saturday 6 September 1997

Drug misuse: GPs' pivotal role

At a recent postgraduate meeting for psychiatrists I had to propose the
motion, "The management of drug addiction should not be within the remit of
the psychiatrist." After some reflection, I decided that there were three
reasons why this was so.

The first is that most people with drug problems are not mad. The second is
that psychiatrists have neither the knowledge, the skills, nor the
appropriate attitudes to manage drug misusers. And the third reason is that
general practitioners are far better at doing it.

In the spectrum of substance use, starting with experimentation, passing
through recreation, and then on to dependence, problems may appear at any
time. "It seems improbable, however, that gross mental illness is ever
likely to make more than a marginal contribution to the totality of drug
misuse." Says who? Drug Scenes, page 44, published by the Royal College of
Psychiatrists, that's who. Drug misusers with insight, the overwhelming
majority that is, will accept most opportunities for safer drug use and
alter their practices accordingly. Remember those incredible stories about
people stealing incinerator bins to reuse the contents? Once the penny
dropped that it made good sense, in the name of preventive medicine, to
provide clean equipment, drug injectors flocked to the needle exchanges.
This showed scant evidence of madness.

Psychiatrists who limit themselves to treating patients with a dependence
syndrome will fail to deal with several of the damaging consequences of
drug misuse. Not that many clamour for the chance of doing even that. Too
often drug clinics are tagged on to the other duties of those least able to
resist, and viewed as a chore rather than an opportunity. Surely that is a
rather wobbly base on which to construct a productive relationship between
doctor and patient. Doctors also need to listen to hearts and feel for
spleens, and sensibly interpret the findings. Drug related pathology
includes the soma as well as the psyche.

Can general practitioners do any better? I believe so. Many now play a
pivotal role in the management of drug misusers and, while not all are
natural born performers, their needs by now are well understood. Given
adequate resources, including the support of a specialist service, they can
take on this work, and even find professional satisfaction in the process.

Almost a quarter of practices in Glasgow now run drug misuse clinics, and
the number of patients receiving methadone has risen tenfold over the past
five years. As a consequence, 1997 should see a substantial decline in
three main indices of drug related harm to health: drug deaths, emergency
hospital admissions, and the prevalence of injecting drugs. There is no
longer any place for therapeutic nihilism in this business.

>From a purely medical perspective, I believe that we have recently been
living through a golden age of drug misuse. Soon, however, we may have to
confront a new therapeutic paradox. As medical interventions bring about a
fall in injecting related mortality and morbidity, it will no longer be so
easy to achieve so much for our patients by doing so little. New problems
will require new solutions. General practitioners are taking us into that
future and rightly so.

Perhaps it is more important that doctors looking after drug misusers
possess the correct attributes for the task, rather than a particular job
title. At present most psychiatrists lack these qualities and have no place
in the management of drug addiction.

Of course, I lost the debate. Now isn't that encouraging, but only if they
really mean it.

Robert Scott,
clinical director
Glasgow