My own approach to substance abuse has been to target crime prevention. This reduces the cost to society and also seems to be high on the Government's agenda at present.
A typical drug abuser presents with multiple health problems, e.g. significant weight loss, dehydration, and acute constipation of up to 2 weeks' duration. I find that craving for sweet foods is common in heroin users. Their sleep pattern is inverted and poor. Some also feel anxious and agitated, and many have low self-esteem and little confidence.
I have stopped prescribing methadone, except in very rare cases. This is because methadone is also a respiratory depressant and I find that many patients continue to take heroin in addition to methadone.
I currently prescribe lofexidine, starting with a dose of 0.2mg twice a day and increasing to 2.4mg (12 tabs) daily if required. In addition, diazepam or temazepam, given in limited amounts, controls symptoms if the patient is motivated.
When the patient has provided three opiate-negative specimens of urine I put him/her on naltrexone 50mg at night for 3 months. The results have been encouraging, and one day I hope to audit my findings.
Another reason for dealing with drug abusers in primary care is that the waiting list in the hospital sector is about 13 weeks on average. Many consultants who deal with substance abuse have no private appointments available.
These patients need help now not in 13 weeks. During those 13 weeks they may develop target organ damage and may also commit crimes.
There is also evidence that early intervention in the management of heroin abuse results in a better cure rate.
Dr Kausar Jafri, GP, Stoke-on-Trent
Dr Jez Thompson replies:
I was pleased to read Dr Jafri's response to my article, and to see many areas of common ground.
In particular I share his commitment to engaging and working with problem drug users in primary care, and to tackling psychological and social aspects of care as well as purely medical issues. We also agree on the need for great care when prescribing methadone, and for prompt intervention when a patient asks for help.
In addition, I fully subscribe to his awareness that promoting health in drug misusers not only leads to a better quality of life for the patient, but will also improve the health and wellbeing of the wider community in a number of ways, one being a reduction in levels of crime.
He describes a personal approach with his patients, comprising immediate managed withdrawal from street heroin using lofexidine, and benzodiazepines to help reduce withdrawal symptoms, followed by naltrexone as an opioid antagonist to block the euphoriant effects of further street heroin and help to discourage relapse.
This is certainly one option when faced with a heroin user, and for a number of clients it is undoubtedly a good approach.
It is worth mentioning here the cautions for the use of lofexidine. These include starting on a small dose and increasing in steps while monitoring for bradycardia and hypotension, and the need to take great care to avoid any chance of precipitating severe opioid withdrawal when prescribing naltrexone in a patient who may still be using heroin illicitly. The manufacturer's data sheet, for example, advises the use of a small parenteral test dose of naltrexone under observation before prescription.
Many areas are developing guidelines for safe opioid detoxification, often on a 'shared care' basis with local specialists.
In addition, at St Martin's Practice we avoid giving prescriptions for benzodiazepines, particularly diazepam and temazepam, as these drugs have a significant potential for misuse, and a high street value if sold.
Our experience at St Martin's Practice has been a little different with the majority of patients who have a clear opioid addiction, and we have not found immediate detoxification successful.
Instead, we use the evidence-supported approach of an initial methadone prescription, under strict guidelines and close control, to give the patient an opportunity to progress towards detoxification.
This approach has resulted in significant improvements in risk behaviours (such as injecting and criminal activity), illicit drug use (with the aim of cessation), social wellbeing, general lifestyle, development of support structures, improved family relationships, and breaking with previous habits and behaviour patterns.
Regular contact with the patient provides an opportunity for ongoing health promotion work, relationship building, supervision and observation until he/she is ready for detoxification, using one of several different options.
The particular area of concern for us with the 'quick fix' of instant detoxification is the low long-term success rate. We have found that most of our clients relapse relatively quickly unless there is sufficient preparation, and sufficient time to deal with underlying social and emotional needs before detoxification.
When Dr Jafri audits his results I would be most interested to see his longer term (perhaps after 3 or 6 months) relapse rates to find out whether his expeience is different from ours.
Dr Jez Thompson, GP, Leeds
In February 2001, I compiled and produced a clinical audit technical training programme for all members of the primary healthcare teams within West Sussex and Surrey. It was supported by the Mid Sussex PCT.
Approval and accreditation was granted by the Open College Network panel, Brighton University, in 2001, and the programme is accredited for 5 years.
The programme comprises four units:
- Foundations for audit (credit value 1)
- Clinical audit design (credit value 2)
- Concept of clinical governance (credit value 1)
- Closing the audit loop (credit value 2)
Thus candidates gain 6 credits at level 3 on completion of the programme.
The candidates will have acquired skills and experience in:
- Evidence-based healthcare
- Reading and critique of research papers
- Ethical issues and audit
- Design of questionnaires
- Quality assurance models
- Clinical audit project design
- Components of clinical governance
- Management of change
- Design of templates, using Read codes.
Attached to all units are assessment documents. These are contained within the student's course workbook, e.g. essay (200-400 words) on 'What is best practice for your target population?'. Use of the Iskikawa problem-solving diagram and the matrix model for risk management, and completion of the course workbook, enable students to put theory into practice and the lead tutor to assess students' knowledge base.
Students need to produce a full clinical audit report focusing on an aspect of the NSF for CHD to gain a pass mark. Additional optional workshops support the programme.
Students have no course fees, thanks to an educational grant awarded by both Pfizer and Aventis. Mid Sussex PCT funds the students' NSF for CHD audit activity within their individual practices.
Anyone interested in attending the programme or setting up such a scheme should contact Julia Bennett at Dr Shearn & Dr Warburton's Practice, The Health Centre, Windmill Ave, Hassocks, West Sussex BN6 8LY (tel: 01273 843563).
Julia Bennett, nurse practitioner, Hassocks, West Sussex
See also 'Intensive approach to CHD management proves effective' in this issue.