An enhanced service to treat substance misuse can bring social benefits as well as significant improvements in health outcomes, as Dr Susannah Harris explains
It is estimated that there are between 150 000 and 200 000 problematic drug users in the UK. So it is likely that most GPs have patients who misuse drugs on their list, although prevalence in urban areas is significantly higher than in rural areas.1
GPs in the UK, unlike their counterparts in other countries, have been treating drug users for decades. Until now, this has been done in a rather unstructured way.2 The new GMS contract provides GPs with a framework for providing treatment for substance misuse and, furthermore, offers relatively good remuneration levels.1
National guidelines on the treatment of drug misuse advise GPs to treat drug misusers in partnership with local drug treatment agencies – an arrangement known as shared care,3 and several excellent shared care schemes have evolved in the past few years.4 Around 38% of GP practices are now providing shared care treatment in the UK.5
Is drug misuse treatment effective?
There is good evidence that treatment of drug misuse improves a range of health outcomes. Perhaps most importantly, treatment of drug misuse has been shown to save lives. Studies show that street heroin users have a mortality rate of up to 17 times that expected.6 Most deaths are directly drug-related, for example overdose, blood-borne virus infection and bacterial infection, and some – violent deaths by suicide and assault – indirectly so.
This life-saving effect is only seen if patients are retained in treatment, however.7,8 In patients discharged early or randomised to placebo, death rates are almost as high as baseline rates.9,10
Drug misuse treatment also improves many other important outcomes. Evidence shows a significant reduction in risky injecting behaviour,11 and transmission of blood-borne viruses.12,13
There is a significant reduction in the use of illicit drugs, including cocaine,13 benzodiazepines and opiates. The rate of opiate use approximately halves with each year of treatment and is directly correlated to dose of substitution therapy.9,14,15 Unfortunately, alcohol use may rise.
Many outcome studies also show improvements in social functioning (Box 1, below).2 The costs of drug misuse include the use of health and social services as well as less quantifiable costs such as relationship breakdown and poor parenting.
|Box 1: Main areas of benefit in methadone treatment*|
Which treatment is best?
Methadone maintenance treatment is the most extensively studied and evaluated treatment. Research spanning 30 years and in very different cultures – the USA, Hong Kong, Sweden,Thailand 16,17 – shows consistently positive results. Meta-analysis has reliably demonstrated considerable reduction in harmful behaviour. 18
A Cochrane review concludes that higher methadone doses, of 60-100 mg per day, are more effective than lower doses in retaining patients and reducing use of heroin and cocaine during treatment.14
The recently published 5-year longitudinal prospective cohort study National Treatment Outcome Research Study (NTORS), the first of its kind in the UK, adds further weight to the body of evidence on methadone maintenance treatment and shows that the initial improvements are sustained over a 5-year period so long as treatment continues.19 In addition, it compares methadone reduction therapy with maintenance, and the poor outcomes associated with reduction programmes support the promotion of maintenance (as opposed to abstinence) philosophy.20
A Cochrane review found that while methadone reduction successfully ameliorated withdrawal symptoms, the majority of patients relapse to heroin use.21
Detoxification can even be dangerous, as newly detoxified patients are at greatly increased risk of overdose.22
NTORS also demonstrated a significant positive effect of retention in treatment, which confirms the findings of much research. Large studies from the USA demonstrated a clear relationship between length of time in treatment and improved outcomes. 11 Evidence also shows that discharge must be planned to maintain good outcomes – for unplanned discharges, the beneficial effects disappear as soon as treatment stops.
Buprenorphine treatment is relatively new and less research has been undertaken. In comparisons with methadone as maintenance therapy it has been found to be equally, but no more, effective.23-25 Studies used relatively low doses; it remains to be seen whether further improvements can be made with higher (>=16 mg) doses.
On the other hand, the role of buprenorphine in detoxification from opiates is established; systematic review has shown that withdrawal symptoms are significantly less severe in gradual buprenorphine withdrawal than with the standard non-opioid pharmacological aids to detoxification,26 and are the same or milder than in methadone withdrawal.27
Non-opioid detoxification therapies
The alpha-adrenergic agents clonidine and lofexidine have been used to aid withdrawal from opiates for a number of years, but systematic review does not support their use over that of opioid (methadone or buprenorphine) withdrawal.23 A Cochrane review found no significant difference between clonidine and lofexidine, but lofexidine is better suited to community-based treatment because of the lower incidence of hypotension.28
Naltrexone is a complete opioid antagonist which can be taken by the newly detoxified patient to prevent the reinforcing effects of subsequent opiate use. There is a suggestion that it is effective in reducing reincarceration rates, particularly in the wellmotivated. 29
Government guidance recommends hepatitis B immunisation for drug misusers,3,30,31 because they are at higher risk of hepatitis B infection. Past co-infection with hepatitis B can increase the risk of cirrhosis from hepatitis C infection,32 and coinfection with active hepatitis B and C increases the risk of progression to hepatocellular carcinoma.33
Hepatitis A immunisation is also recommended because outbreaks among drug users are common, and hepatitis A co-infection with either hepatitis B or C increases the risk of hepatic failure and death from liver disease.34
Psychological therapies without medication are ineffective, but there is reasonable evidence to show that some sort of supportive sociopsychological therapy enhances the effectiveness of methadone maintenance. 35 However, this effect is lost if counselling approaches are compulsory. 10 A high level of support for individuals maintained on methadone is not cost-effective, but a moderate level is better than a minimal level of support.36
Where should treatment take place?
Reducing drug misuse is one of the key priorities in the NHS Priorities and Planning Framework for 2003-6.37 There is now good trial evidence that drug misuse treatment is equally effective in general practice as in a specialist service in reducing illicit drug use and retaining patients in treatment. One study shows superior hepatitis B immunisation rates in patients treated in primary care.38-40
The Healthcare Commission clearly sees general practice as crucial in achieving these objectives. Last year (2003-4), the percentage of GP practices involved in shared care was one of the performance indicators used to calculate PCT star ratings.5
Setting up an enhanced service
PCTs or those commissioning services for drug action teams will need to negotiate with GP providers to set up enhanced services for drug misuse.
In addition to paying an annual retainer of £1000, the terms of the national enhanced service for treatment of drug misuse reward detoxification (set at £500 per patient per annum for 2003-4) more highly than maintenance treatment (£350 pppa for 2003-4), despite evidence that maintenance is more effective than detoxification. Many PCTs are therefore equalising rates of pay for the two types of treatment.
Notable requirements of the national enhanced service are to hold 6-monthly audits for hepatitis B screening and immunisation and for prescribing of substitute medication. Other requirements recommended by national guidance are:
- An accurate and up to date register of patients
- Regular planned review of patients by GP
- Offering advice on minimising harm
- Offering drug information and support to families and carers
- Liaison with other services and teamworking
- A safe and secure practice, suitable for providing drug services.
Local enhanced services
The lack of detail specified by the new GMS contract offers PCTs the opportunity to tailor local enhanced services contracts which set standards for other evidence-based interventions and find good quality process of care markers to be used in audit and as performance monitoring tools. Audit standards might include:
- Hepatitis immunisations
- Ratio of planned to unplanned discharges
- Offering blood-borne virus pre-test discussions with trained personnel
- Doses of substitution therapy used in maintenance treatment
- Markers of good preventative and general medical care, for example screening and immunisations and provision of contraceptive and sexual health services.
Many new local enhanced services will also include elements recommended by national guidance (see above).
A local enhanced service may also be an opportunity to increase access to primary care based treatments by offering an enhanced level of remuneration to practices that treat patients referred from other practices.
Clear protocols to avoid double prescribing, on immunisations and blood-borne virus screening, and for management of conditions that result directly from drug misuse will be needed. PCTs might like to consider offering higher levels of remuneration for GPs who have the skills and are willing to manage drug users with complex needs such as dual diagnosis and pregnancy.
PCTs may wish to tackle the problem of benzodiazepine misuse simultaneously, as monitoring and reviewing benzodiazepine prescribing is a target of the National Service Framework for Mental Health.41,42 They may consider offering additional rewards for successful reduction and detoxification in cases of established dependency.
Training standards should be incorporated into local enhanced services to maintain the skills and knowledge of participating GPs. For many, this will mean taking the RCGP Certificate in Drug Misuse Part 1, or demonstrating equivalent competencies.
Many established shared care schemes are being transferred to local enhanced services with little change in the numbers of GPs participating or the expectations placed on them. Yet demand for treatment is likely to increase significantly.
It is likely that new practices will be encouraged to set up enhanced schemes for drug misuse. Important factors to consider are the impact on practice time and set-up costs, including costs of IT, improved practice security and personal protection training for reception staff (Table 1, below).
|Table 1: Impact on practice time of setting up an enhanced service for drug misuse|
|Time||Activity||Time spent per 10-20 patients (estimated)|
Training, first year
Training, subsequent years
Clinical time, including correspondence
RCGP Part 1, one day face to face and 4 hours distance learning
6 hours per year
1-2 hours per week
1-2 hours per quarter
1-3 hours per year
Screening and immunisations
BBV pretest discussion
0.5-1 hour per week
0.5 hour per week
Correspondence (if treating
0.5 hour per week
Depends upon IT capability, likely to be
Funding a drug-dependency worker to assist in running the clinic is generally the responsibility of the commissioning organisation, although local arrangements may vary.
The National Treatment Agency, a special health authority for England tasked with improving drug treatment, is planning to issue a standardised set of Read codes in the near future. This will support clinical management and help to monitor clinical standards. However, monitoring of outcomes is far less well defined nationally, with many tools available and wide variation in use. This may be the subject of some local negotiation.
Drug misuse treatment in general practice is highly effective, evidence based and well supported. Addressing the often serious health needs of this relatively young group of patients and helping to reduce the enormous burden they place on our health, social service and criminal justice systems can be highly rewarding.
Further practical advice is available from:
Substance Misuse Management in General Practice c/o Bolton, Salford and Trafford Mental Health NHS Trust, Bury New Road, Prestwich, Manchester M25 3BL
The RCGP Drug Misuse Training Programme Suite 314, Frazer House, 32/38 Leman Street, London E1 8EW
The programme can give details of your local RCGP regional lead in drug misuse, who will be a highly experienced practitioner in primary care management of substance misuse
- Investing in General Practice: The New General Medical Services Contract. http://www.doh.gov.uk/ gmscontract/thecontract.htm
- Seivewright N. Community treatment of drug misuse: more than methadone. Cambridge: Cambridge University Press, 2000.
- Department of Health. Drug Misuse and Dependence Guidelines on Clinical Management. London:TSO, 1999.
- Gruer L, Wilson P, Scott R et al. General practitioner centred scheme for treatment of opiate dependent drug injectors in Glasgow. Br Med J 1997; 314: 1730-5.
- Healthcare Commission. 2004 Performance ratings http://ratings2004.healthcarecommission.org.uk/
- Hickman M, Carnwath Z, Madden P et al. Drug-related mortality and fatal overdose risk: pilot cohort study of heroin users recruited from specialist drug treatment sites in London. J Urban Health 2003; 80: 274-87.
- Caplehorn J, Dalton M, Haldar F, Petrenas A. Methadone maintenance and addicts’ risk of fatal heroin overdose. Subst Use Misuse 1996;31: 177-96.
- Darke S, Zador D. Fatal heroin ‘overdose’: review. Addiction 1996; 91: 1765-72.
- Gronbladh L, Ohlund LS, Gunne LM. Mortality in heroin addiction: impact of methadone treatment. Acta Psychiatr Scandin 1990; 82: 223-7.
- Kakko J, Svanborg KD, Kreek MJ, Hellig M. 1-year retention and social function after buprenorphineassisted relapse prevention treatment for heroin dependence in Sweden: a randomised, placebocontrolled trial. Lancet 2003; 361: 662-8.
- Ward J, Mattick RP, Hall W. Methadone Maintenance Treatment and Other Opioid Replacement Therapies. Reading: Harwood Academic Publishers, 1998.
- Des Jarlais DC, Hubbard R. Treatment for drug dependence.Proc Assoc Am Physicians 1999;111:126-30.
- Metzger DS, Woody GE, McLellan AT. Human immunodeficiency virus seroconversion among intravenous drug users in- and out-of-treatment: an 18- month prospective follow-up. J Acquir Immune Defic Syndr 1993; 6: 1049-56.
- Faggiano F, Vigna-Taglianti F, Versino E, Lemma P. Methadone maintenance at different dosages for opioid dependence (Cochrane Review).In:The Cochrane Library, Issue 3, 2004.
- Maxwell S, Shinderman M. Optimizing response to methadone maintenance treatment: use of higher-dose methadone. J Psychoactive Drugs 1999; 31: 95-102.
- Farrell M,Ward J, Mattick R et al.Methadone maintenance treatment in opiate dependence:a review.Br Med J 1994; 309: 997-1001.
- Bertschy G. Methadone maintenance treatment: an update. Eur Arch Psychiatry Clin Neurosci 1995; 245: 114-24.
- Marsch LA. The efficacy of methadone maintenance interventions in reducting illicit opiate use, HIV risk behavior and criminality: a meta-analysis. Addiction 1998; 93: 515-32.
- Gossop M, Marsden J, Stewart D (National Addiction Centre). NTORS after five years: (National Treatment Outcome Research Study). Changes in substance use, health and criminal behaviour in the five years after intake. London: DoH, 2001.
- Gossop M, Marsden J, Stewart D,Treacy S. Outcomes after methadone maintenance and methadone reduction treatment: two-year follow-up results from the National Treatment Outcome Research Study. Drug Alcohol Dependence 2001; 62: 255-64.
- Amato L, Davoli M, Ferri M,Ali R. Methadone at tapered doses for the management of opioid withdrawal (Cochrane Review) The Cochrane Library, Issue 3, 2004.
- Darke S, Hall W. Heroin overdose: research and evidencebased intervention. J Urban Health 2003; 80: 189-200.
- Mattick RP, Kimber J, Breen C, Davoli M. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence (Cochrane Review).The Cochrane Library, Issue 3, 2004.
- Barnett PG, Rodgers JH, Bloch DA. A meta-analysis comparing buprenorphine to methadone for treatment of opiate dependence. Addiction 2001; 96: 683-90.
- West SL, O’Neal KK, Graham CW. A meta-analysis comparing the effectiveness of buprenorphine and methadone. J Subst Abuse 2000; 12: 405-14.
- Gowing L, Ali R, White J. Buprenorphine for the management of opioid withdrawal (Cochrane Review). The Cochrane Library, Issue 3, 2004.
- Bickel WK,Amass L. Buprenorphine treatment of opioid dependence: a review. Experimental and Clinical Psychopharmacology 1995; 3: 477-89.
- Gowing L, Farrell M, Ali R, White J. Alpha2 adrenergic agonists for the management of opioid withdrawal (Cochrane Review).The Cochrane Library, Issue 3, 2004.
- Kirchmayer U, Davoli M, Verster A. Naltrexone maintenance treatment for opioid dependence (Cochrane Review).The Cochrane Library, Issue 3, 2004.
- Mantagni P,Kovats S, Hall A.Hepatitis B vaccination policy in drug treatment services. Br Med J 1995; 311: 1500 (letter).
- Department of Health.Hepatitis C Strategy for England. London: DoH, 2002.
- De Maria N, Colantoni A, Friedlander L et al.The impact of previous HBV infection on the course of chronic hepatitis C. Am J Gastroenterol 2000; 95: 3529-36.
- Benvegnu L, Alberti A. Patterns of hepatocellular carcinoma development in hepatitis B virus and hepatitis C virus related cirrhosis. Antiviral Res 2001;52: 199-207.
- Koff RS. Risks associated with hepatitis A and hepatitis B in patients with hepatitis C. J Clin Gastroenterol 2001; 33: 20-6.
- McLellan AT, Arndt IO, Metzger DS et al. The effects of psychosocial services in substance abuse treatment. JAMA 1993; 269: 1953-9.
- Kraft MK, Rothbard AB, Hadley TR et al. Are supplementary services provided during methadone maintenance really cost-effective? Am J Psychiatry 1997; 154: 1214-19.
- Healthcare Commission. Key targets for the star ratings 2004/05. http://www.chai.org.uk/assetRoot/04/00/ 19/07/04001907.pdf
- Lewis D, Bellis M. General practice or drug clinic for methadone maintenance? A controlled comparison of treatment outcomes. Int J Drug Policy 2001; 12: 81-9.
- Keen J, Oliver P, Mathers N. Methadone maintenance treatment can be provided in a primary care setting without increasing methadone-related mortality: the Sheffield experience 1997-2000. Br J Gen Pract 2002;52: 387-9.
- Gossop M, Marsden J, Stewart D et al. Methadone treatment practices and outcome for opiate addicts treated in drug clinics and in general practice: results from the National Treatment Outcome Research Study. Br J Gen Pract 1999; 49: 31-4.
- An update on benzodiazepines and nonbenzodiazepine hypnotics. MeReC briefing no 17, October 2001. http://www.npc.co.uk/MeReC_Briefings/briefing2001.htm
- Shaw E, Baker R. Audit protocol: benzodiazepine prescribing in primary care. J Clin Governance 2001; 9: 45-50.