The council ward in which my practice is situated is one of the 30 most deprived in the UK. One local road is known as 'Scag Alley' and has a higher number of drug addicts per capita than areas of nearby Brighton. I personally have 0.5% of my list registered as addicts; the real total is probably even higher.
It is a treatment area in which I have had no formal training, but inevitably I come into contact with a lot of drug problems. Professor Strang's article summarising the recently issued Orange Book guidelines Drug Misuse and Dependence – Guidelines on Clinical Management has been very useful in filling in several gaps in my knowledge, as well as raising issues I had not thought of before.
Professor Strang summarises the guidelines well, highlighting the need for regular training, knowledge of prescribing issues, development of dependence, and drug treatment for those doctors – the majority – classified as generalists.
The guidelines themselves contain a very full discussion of most of the issues surrounding drug misuse, and I found them a very good educational document.
Unfortunately, the guidelines have been assembled by those with a personal interest in treating drug abuse – all specialised generalists. There is not one true generalist on the panel.
If there had been, perhaps the problems of prescribing for this group might have included the fact that GPs are often threatened and verbally abused when refusing to prescribe despite enjoiners to contact the local drug team. This has happened to me – often by patients whom I have referred previously.
I find this quite frightening, especially as it tends to occur at the end of surgery when I am the only doctor on site with only one receptionist to call for help. I can't say that I'm excited at the prospect of increasing the frequency of these encounters by becoming more expert in the field.
The document has, however, shown me that the whole area is much more complicated than I first thought, and that I could do with an away day on drug abuse to bring me up to date.
I am concerned that the thrust of this guideline is to increase the proportion of drug abuse dealt with in general practice. My personal feeling is that there simply isn't the slack in the system to take on this responsibility as well as everything else.
However, I think there is no doubt that we are failing drug addicts: not in the provision of primary care, but certainly in giving them a full service for their addiction problems. I have to admit that I feel a little guilty about this.
In summary, that is where these guidelines, although excellent in their way, may come unstuck. They seem to assume that GPs at the coal face are keen to specialise in yet another health promotion area on top of asthma, diabetes and ischaemic heart disease.
I have no doubt that these problems could be overcome by training if enough GPs can be found who wish to do the work.
Professor Strang is right when he says that the success of these guidelines at national level will depend on proper support from health purchasers, specialists and GPs; let us hope it's forthcoming.
- See also Updated guidance on drug misusers focuses on primary care by Professor John Strang.