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University of Birmingham, Queen Elizabeth Psychiatric Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2QZ
University of Birmingham
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Abstract |
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 Top Abstract IntroductionMethodResultsDiscussionReferences |
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In order to assess the current provision for patients who misuse opiates in primary care, the discrepancy between this, and government expectations and the resources required to bridge this gap, a purpose-designed questionnaire based on the Department of Health guidelines was distributed to all general practitioners (GPs) in Solihull and Warwickshire (n=379). Data were analysed with the Chi-squared, Fisher’s exact, Mann-Whitney U and Kruskal-Wallis tests, using the computer software SPSS version 10.
RESULTS
Replies were received from 205 GPs, representing 77.2% of the practices. Only 12 GPs (6%) provided all four key services studied and 71 (34%) provided none of these services. One hundred and six GPs (51.7%) had read the guidelines. Of these, 51 (49%) were not willing to change their practice. Forty-one (39.4%) were prepared to change their practice, but only with additional resources. The main resources identified as necessary were shared care and training.
CLINICAL IMPLICATIONS
There is a huge gap between current provision and government expectations, which may be unrealistic. If this gap is to be bridged, then resources should be targeted to shared care and training for GPs.
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Introduction |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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This initiative raises many questions. What is the current level of service provided by GPs? Have they received any training on aspects of drug misuse and what is their level of knowledge? How confident are they in managing patients who misuse opiates? Are they aware of the guidelines? Are they willing to change? What resources are required to achieve these expectations? At present, there is little information available to answer these questions. We carried out a large questionnaire study among GPs designed to explore these issues. Here, we report the level of current provisions, the discrepancy between this and the Department of Health expectations and resources required to bridge this gap.
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Method |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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The questionnaire was distributed to all GPs in Solihull and Warwickshire (n=379). Data were analysed with the Chi-squared, Fisher’s exact, Mann-Whitney U and Kruskal-Wallis tests, using the computer software SPSS version 10.
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Results |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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Services currently provided
The number of the studied services provided by GPs is shown in
Table 1. The mean number of
services provided was 1.45 (SD=1.31). The number of GPs providing each
individual service is shown in Table
2. These services include:
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Methadone prescribing
GPs were significantly more likely to prescribe methadone if they had more
opiate misusers on their personal list (Spearman’s correlation
coefficient=0.227, P=0.003), were more confident in managing opiate
addicts (
2=13.681, df=1, 2-sided P<0.001,
Fisher’s exact test <0.001), had a positive attitude to the
prescribing of methadone (2=13.755, df=1, 2-sided
P<0.001, Fisher’s exact test <0.001), had received
training in the past 12 months (2=5.038, df=1, 2-sided
P=0.025, Fisher’s exact test=0.044), were also offering
hepatitis B vaccine to opiate addicts (Spearman’s correlation
coefficient=0.338, P<0.001) or treating secondary infections in
addicts (Spearman’s correlation coefficient=0.290, P<0.001).
The likelihood of GPs prescribing methadone was not influenced by training in
addiction as a medical student.
Hepatitis B vaccination
GPs were significantly more likely to offer hepatitis B vaccination if they
had more patients dependent on opiates on their list (Spearman’s
correlation coefficient=0.197, P=0.011) or were more confident in
managing opiate addicts (2=15.616, df=1, 2-sided
P<0.001, Fisher’s exact Test <0.001). Attitudes to
methadone prescribing, or training, either as a medical student or in the past
12 months, did not influence whether or not hepatitis B vaccination was
offered.
Harm reduction
GPs were significantly more likely to offer harm reduction if they had more
opiate users on their list (Spearman’s correlation coefficient=0.153,
P=0.048) or if they were more confident in managing opiate addicts
(2=7.980, df=1, 2-sided P=0.005, Fisher’s exact
test=0.008). Attitudes to methadone prescribing or training, either as a
medical student or in the past 12 months, did not influence whether or not
harm reduction was offered.
Treatment of secondary infections
GPs were more likely to treat secondary infections if they had more
patients using opiates on their list (Spearman’s correlation
coefficient=0.468, P<0.001) or if they were more confident in
managing opiate addicts (2=8.632, df=1, 2-sided
P=0.003, Fisher’s exact test=0.004). Attitudes to methadone
prescribing or training, either as a medical student or in the past 12 months,
did not influence whether or not treatment of secondary infections was
offered.
Referral to secondary care
Sixty-seven per cent of GPs would refer even non-dependent users of opiates
to secondary care and 90.9% would refer all of those who are dependent on
opiates. The remaining 9.1% of GPs would refer only those patients who misuse
opiates with a chaotic lifestyle, forensic history, or comorbid mental or
physical disorders.
Willingness to change
One hundred and six (51.7%) GPs had read the guidelines. Of these, only 12
(11.5%) planned to change their practice within existing resources, 41 (39.4%)
were prepared to change their practice, but only with additional resources,
and 51 (49%) were not willing to change their practice, even with additional
resources. Willingness to change was significantly associated with having more
patients who misuse opiates on their list (Spearman’s correlation
coefficient=0.241, P=0.026), as was already providing more services
(Spearman’s correlation coefficient=0.234, P=0.017). Training,
either as a student or in the past 12 months, did not influence whether or not
the GP would read the guidelines or be prepared to follow them.
Resources required to improve services
The mean ranks for the shared care scheme, additional training and
additional funding were 1.87, 1.98 and 2.15, respectively. The GPs considered
shared care and additional training to be equally important, and additional
funding as being least important. The mean rank for additional funding was
significantly different to that for either training or shared care
(Mann–Whitney U=10282, Wilcoxon W=22372, Z=–2.252,
P=0.024 and Mann–Whitney U=9520.5, Wilcoxon W=21610.5,
Z=–3.237, P=0.001, respectively).
GPs who already prescribed methadone (Spearman’s correlation coefficient=0.178, P=0.027), were confident in managing opiate addicts (Spearman’s correlation coefficient=–0.188, P=0.021) or had the greatest amount of training in the past 12 months (Spearman’s correlation coefficient=–0.876, P=0.002) were less likely to want training. Those who prescribed methadone were more likely to want a shared care scheme (Spearman’s correlation coefficient=–0.168, P=0.037).
What GPs want from shared care
The mean ranks for training, advice and supervision were 1.799, 2.087 and
2.107, respectively. Training was considered to be significantly more
important than either advice or supervision (Mann-Whitney U=17779.5, Wilcoxon
W=38689.5, Z=–2.68, P=0.007 and Mann-Whitney U=17605.5,
Wilcoxon W=38515.5, Z=–2.834, P=0.005, respectively).
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Discussion |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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The likelihood of services being provided was significantly correlated with the number of patients who misuse opiates on the GP’s personal list. This might be because these service users tend to register with GPs who are known to cater for them. Furthermore, it could also be that GPs who are not particularly interested in treating patients who misuse opiates may well under-diagnose them. It is not surprising to find that confidence in managing such patients was significantly associated with service provision. It was remarkable, however, that training as a medical student had no impact on the likelihood of providing these services. This might be because such training was insufficient. Glass (1989) found that undergraduate training in substance misuse in British medical schools was inadequate. Training in the past 12 months only had a positive impact on the provision of methadone prescribing. It had no impact on the provision of the other services studied or on the overall number of services provided.
It was interesting to note that there was a large variation in the provision of each of the services. Treatment of infections and hepatitis B vaccination were the most commonly provided services. Less than a third of GPs prescribed methadone and less than a quarter offered harm reduction advice. This is to be expected, as GPs are confident in treating infections and with providing vaccinations, whereas the prescribing of methadone and provision of harm reduction advice are more specialised interventions. It is therefore important to look at ways to increase GPs’ confidence in these interventions.
Department of Health guidelines recommend that only complicated cases of opiate dependence should be referred to secondary care. Such cases include those patients with comorbid physical or mental disorders, a serious forensic history, polydrug use or a history of frequent relapses. However, almost 90% of our respondents referred all patients dependent on opiates, and this referral pattern might indicate an unwillingness to work with those who misuse opiates. Many GPs do not consider primary care to be an appropriate setting for working with such individuals (Deehan et al, 1997).
There is a huge gulf between the government expectations and current practice with regard to the management of those who use opiates in primary care. It is important that this gap be narrowed if care is to be improved. This will be a difficult task, as only a small proportion of GPs have even read the guidelines and of these, only half are willing to change their practice. It may well be that the government expectations are unrealistic. If one wishes to increase the involvement of GPs in this area, then scarce resources should be targeted towards shared care and training.
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Acknowledgments |
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References |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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DEPARTMENT OF HEALTH (1999) Drug Misuse and Dependence: Guidelines on Clinical Management. London: Stationery Office.
GLASS, I. B. (1989) Undergraduate training in substance abuse in the United Kingdom. British Journal of Addiction, 84, 197-202.[CrossRef][Medline]
STATIONERY OFFICE (1998) Tackling Drugs to Build a Better Britain: the Government’s Ten-year Strategy for Tackling Drug Misuse. London: Stationery Office.
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| British Journal of Psychiatry | Advances in Psychiatric Treatment | All RCPsych Journals |
