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This study repeated a Scotland-wide survey of one-in-four GPs from 2000, to compare findings with 2008. A 60% response was achieved (of 1065). Almost 44% of GPs were treating drug misusers (62% in 2000). Enhanced services were provided by less than half of practices. Seven per cent of responders were only comfortable prescribing below the recommended minimum dose of 60 mg methadone, (33% in 2000). Over 70% offered blood-borne virus screening and 71% were aware of patients using psychostimulants. Recent changes, particularly the new GP contract may have decreased GP involvement in treating drug misusers.
In 2000, a nationwide survey of GPs in Scotland explored factors influencing treatment decisions, attitudes to, and involvement with drug misusers.1 Since then there have been changes in both general practice and drug misuse management, including: greater integration between health and social services in Scotland; new national guidelines for drug misuse;2 a new GP contract with the NHS, which includes enhanced services for drug misusers; increased availability of drug misuse training; introduction of alternative treatments (for example, buprenorphine); higher prevalence of blood-borne viruses particularly hepatitis C among injecting users;3 and changes in the nature of illicit drug use (for example, psychostimulant use).
In Scotland, the number of methadone users is increasing,4 with a current estimate of 22 000 people prescribed methadone.5 There are over 400 drug-related deaths annually.6 The main drug used is heroin, but polydrug use is common. Cocaine and crack cocaine are used increasingly in the opiate-using population.7
There has been a long debate among drug treatment service providers about the relative roles of primary care and specialist services. Since 2000, a specialised GP role has emerged across the UK, recognised in the GP contract, and managing both simple and more complex cases. Specialist service contracts specify the provision of ‘enhanced’ services (which can be ‘national’, ‘local’, or ‘directed’) beyond the provision of general medical care for management of the patient’s drug problem.
While evidence-based guidelines for the treatment of drug misuse provide clear guidance on preferred treatment strategies, the authors’ previous survey showed that only a minority of GPs use guidelines, and practice often did not match recommendations.1 National guidelines have been updated but there is no evidence about whether GPs follow these.
These changes may have influenced GP management of drug misusers. This paper reports the findings from a survey of Scottish GPs to ascertain current practice in drug misuse, and how this has altered since 2000.
Previous research found GP involvement in the management of drug misusers was considerable. Primary care provision of services is considered a complementary part of drug treatment services and, given the scale of the problem, an essential part in maximising capacity and increasing access to care. This survey presents current involvement and how it has changed in 8 years.
The data collection instrument was based on the 2000 questionnaire.1 Where possible, questions remained unchanged but some modifications were made to account for the aforementioned changes that may influence practice. Data collected included: demographics; caseload of drug misusers; services provided; use of guidelines; extent of specific training; and attitudes to drug dependency treatment. The questionnaire was pre-piloted among nine drug-misuse clinicians, incorporating minor changes made following feedback, then piloted by mail to a further 50 Scottish GPs.
A random sample of one in four Scottish GPs (n = 1065) was obtained from the Information Services Division (ISD Scotland).
The main questionnaire, covering letter, and reply-paid envelope was mailed in May 2008. A reminder and further copy were mailed to non-responders, after 3 weeks. By June the response rate was just 43%, so a short, two-page version (the‘short questionnaire’) was developed including only key questions on level of involvement from the‘main questionnaire’. A second reminder accompanied by the short questionnaire was mailed to non-responders in late June.
Data were entered into an SPSS database (SPSS 16.0 for Windows). Where appropriate, 2008 and 2000 findings are compared using the χ2, Mann–Whitney, and independent t tests.
The main questionnaire was completed by 447 GPs, and the short questionnaire by a further 173 GPs. Thirty-seven GPs were excluded from the baseline (returned unopened, retired, no longer at the practice, or on extended leave). The overall response was 60.3% (620/1028). These 620 responders represented 415 practices in Scotland, which corresponds to 76.3% of the 544 practices included in the survey, and almost 40% of all Scottish GP practices (n = 1050). There were no statistically significant differences in key characteristics between responders to the main or short questionnaire (n = 620), and non-responders. Similarly, no significant differences were detected between responders (n = 447) and non-responders to the main questionnaire.
The proportion of responders currently treating drug misusers was 43.7% (n = 270), a statistically significant decrease compared to 2000 (62.3%, P<0.001). The majority (77.2%, n = 206) saw fewer than five drug misusers per week for their dependency, similar to 2000 (74.5%, P = 0.65). Reasons given for not treating drug misusers was‘practice policy’(59.3%, n = 137), more than doubling from 28.2% in 2000 (P<0.001). Other reasons were ‘personal choice’ and ‘no demand’.
Almost 45% of responders to the main questionnaire (n = 178) said an enhanced service was provided by their practice. However, only 27% (n = 146) personally provided this.
Between 2000 and 2008 there was a decrease in the proportion of GPs personally providing the specified treatment options (Table 1). In 2000, 33.6% of GPs indicated the maximum daily dose of methadone they were ‘comfortable’ prescribing was less than the recommended daily dose in guidelines (60 mg).2 This proportion fell to 6.8% in 2008 (Table 2). A greater proportion of GPs in 2008 than in 2000 felt ‘comfortable’ prescribing methadone above 120 mg, at which level further monitoring is required.
One-third of responders to the main questionnaire had referred to at least one of the listed guidelines when treating drug misusers (37.1%, n = 166), compared to 22% in 2000. The‘Orange guide’(35.0%, n = 156) was most commonly used.2
There was no significant change in the proportion of responders with specific training in drug dependency: 38.7% (n = 237) in 2008 compared to 33.5% in 2000 (P = 0.07). Those personally providing an enhanced service were more likely to have received training (P<0.001). Almost 34% (n = 145) said that they would like further training, a decrease from 46.6% in 2000 (P<0.001). Preferred training included refresher courses, guidelines, withdrawal, reduction and detoxification, and methadone alternatives.
Most responders (70.5%, n = 431) were aware of some patients using psychostimulants, although this varied by area (P = 0.009). Most believed these patients were recreational (62.1%, n = 260) or polydrug users (61.1%, n = 256). A further 20.5% (n= 86) considered some patients to be primary psychostimulant users.
This repeat survey found that GP involvement in the management of drug misusers has decreased for all treatment options since 2000. Only 27% of responders personally provided an enhanced service, and less than half of practices. A positive finding was the smaller proportion of responders prescribing below the recommended minimum daily dose (60 mg), indicating that GPs appear more comfortable prescribing at the recommended effective levels. Training levels have not changed significantly but, reassuringly, training is considerably higher in those who provide enhanced services. Over 70% of responders reported awareness of psychostimulant misuse.
The study strengths were the national representativeness of the sample, the two-phased approach to get a minimum dataset from the maximum number of people, and the reuse of an existing questionnaire to compare changes in practice and attitude. A limitation was that two separate cohorts were compared rather than conducting a longitudinal survey of the same GPs. However, since this represents the population of current practising GPs it may actually be a more valid comparison.
Data on prescription sources revealed that the proportion of methadone prescriptions from GP practices has decreased. Against a background of increasing methadone users,4 this indicates a considerably higher rate of methadone prescribing by specialist services since 2000.
One influence on reduced GP involvement may be the new GP contract which encourages GPs to specialise. Those without enhanced service contracts may be more likely to refer drug misuse patients to specialist services. The increase in the proportion citing‘practice policy’as the reason for not treating drug misusers supports this theory. In future, comparison of treatment outcomes between the two models of care should inform contract design. Psychostimulant use and management need further research and development, including training, as also noted by a working party,7 and a local GP survey.8
In conclusion, it seems likely that the GP contract, is at least partly responsible for the decreased involvement of GPs in treating drug misusers, despite increasing numbers of drug misusers in treatment. However the GP workforce engaged in service provision generally trained in this area.
The authors would like to thank all the GPs who took the time to complete and return a questionnaire.
This study was funded by the Chief Scientist Office of the Scottish Government (CZG/2/320).
The authors have stated that there are none.
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