In 1995, our practice faced a crisis because of a 15-fold increase in the number of heroin users seeking help. We took the lead in developing guidelines for their management, which were adopted across the locality (11 practices, covering around 80 000 patients).
The guidelines have been taken up by several other local PCGs, with minor alterations. Their success has been due to timeliness and to widespread local ownership – vital to guideline implementation.
Our practice is situated in the middle of a large housing estate in the south of Bristol. The estate is characterised by excess morbidity and premature mortality, and their social determinants of poverty, unemployment and lack of amenities. The tower blocks are slowly being redeveloped.
In 1991, a Wills cigarette factory, the major employer in the area, was closed. There were riots in 1992 following repeated failure to attract funding to the area in 'City Challenge' bids.
A sense of isolation from the rest of Bristol and a lack of prospects marked the future for a generation of young people.
At this time there were a few heroin users in the area, mostly in their late 20s or older, who were managed largely by the specialist drug team.
In the mid-1990s, the price of street heroin fell and availability increased. There was an explosion in its use by younger people: in our practice the number of known heroin users shot from half a dozen, out of a list of 7500, to 150, 2% of the practice population. The specialist service did not have the resources to cope with this increase.
GPs in the area were faced with a dilemma. Up to this point they had not needed to provide any treatment for heroin users. Now there was nowhere else for users and their families to turn.
There was no consistent response from the practices across the area. Some prescribed methadone or other opiates and/or benzodiazepines in brief reduction courses. Others declined to provide treatment themselves on the grounds that this was beyond general medical services, and continued to refer to a specialist service, which rapidly became swamped.
The inconsistency of provision was a problem in itself. The heroin users and their families were not sure how their GP would respond to a request for help.
This led to some confrontational consultations and outbreaks of violence in surgeries as patients vented their frustration or tried to force GPs to prescribe.
The heroin users who did receive methadone did not always consume it under supervised conditions. This meant that methadone became freely available on the local black market. At times the price of black-market methadone was lower than that of heroin.
Worst of all, the diversion of methadone to people who were not regularly taking opiates led to at least two deaths in Bristol.
We had to question whether the guiding principle of primum non nocere (first, do no harm) was being fulfilled.
At this stage, our practice was prescribing methadone, on blue, 14-day maximum prescriptions, with the patient collecting it daily from the pharmacy. It became clear that even this was open to abuse.
We learnt that users were selling their blue prescriptions outside the health centre. Drug dealers were sending non-heroin users or users who had no intention of addressing the problem to surgeries to obtain drugs, which were then sold on. Inconsistent, uncontrolled prescribing and dispensing (although intended to help) was potentially fuelling the problem.
Staff in surgeries felt threatened and disempowered. My heart used to sink when I saw that the next patient waiting was male and aged between 16 and 25 years. I knew that setting limits on the number of users we treated at any one time was essential to the functioning of the practice, yet this was likely to lead to confrontation.
Development of the guidelines
Fortunately, at the same time, local practices were involved in a locality commissioning group. Through this, we arranged meetings to develop guidelines for the management of heroin users throughout the locality.
We had willing help from local pharmacists, who also felt overwhelmed. Local drug agencies, both NHS and voluntary, and patient groups were similarly enthusiastic contributors.
We negotiated with the health authority for financial support for GPs who were willing to treat heroin users according to published guidelines.
Contributions and comments from all the practices involved produced a strong feeling of local ownership. The guidelines were relevant to everyone working in primary care at the time. All could see the advantage of introducing consistency across the area.
We divided the guidelines into:
- absolute criteria, which would be adhered to by everyone all the time
- desirable criteria, of which we would aim to achieve 80%
- good ideas suggested by practices.
We adopted this format from the local accreditation guidelines for training practices.
The resultant Hartcliffe methadone guidelines are shown in Figures 1 & 2 (below).
|Figure 1: Hartcliffe Methadone Guidelines – Drs Stubbs, main, Main, Darvill and Williams. Part 1|
|Figure 2: Hartcliffe Methadone Guidelines – Drs Stubbs, Main, Main, Darvill and Williams. Parts 2 & 3|
Over the past 5 years the guidelines have been, and continue to be, modified in the light of what works, what is practical, national good practice guidance and evidence from studies.
Initially, we found little published evidence relating to primary care. Most of the research referred to specialist treatment services. It was reassuring to find that the Orange Book,1 published in 1999, contained most of the elements of our guidelines.
The benefits to patients and practices have been numerous:
- Most important has been consistent management throughout the locality. Patients and their families know that help is available and that there is no advantage to shopping around practices.
- All heroin users enter into a contract with their practice and pharmacist before starting treatment. This sets limits and details rights and responsibilities.
- Local pharmacists supervise 98% of methadone consumption. After drinking the methadone the patient is asked to speak or to drink a glass of water to ensure that the methadone is not retained in the mouth and later bottled for resale (so-called 'spit methadone').
- Unsupervised consumption is permitted when the patient is on a low dose (<15mg per day) and finding it hard to attend the pharmacy because of hours of work. Nowadays, however, the advent of late-night pharmacies in the city's supermarkets means that it is almost always possible for heroin users to attend for supervised consumption if necessary.
- All those taking methadone see a liaison worker who has specialist counselling skills. The non-attendance rate for this service has been reduced to almost zero by linking attendance to the continued prescription of methadone. We start each 14-day prescription 2 days after the patient has seen the liaison worker, to allow time for generating the script and delivering it to the pharmacy.
- We do not allow patients to handle methadone prescriptions. Patients choose which pharmacy they wish to use and then either the pharmacist collects the prescriptions or we post them. GPs check with the pharmacist before sending a new patient to the pharmacy.
- We negotiated with the Home Office for handwriting exemptions for controlled drug prescriptions. This means that we can save time by using a stamp to write the bulk of the prescription. The exemption is available to doctors who issue at least 10 controlled drug prescriptions to heroin users each week.
- We do not prescribe methadone at the first meeting with a patient requesting help. This allows time for proper assessment, ensures that the results of a urine drug screen are available (to identify non-heroin users) and, most importantly, acts as a 'cooling-off' period. It has become local knowledge that a drug user cannot decide to obtain some drugs from the doctor on the spur of the moment, but only as part of a planned treatment programme.
- Many practices maintain a waiting list, which sets a limit on the number of heroin users undergoing treatment with the practice at any one time. It is important to maintain a balance between the cooling-off period and striking while the iron is hot in those who request help. Our aim is to have a maximum wait time of 3 weeks.
- We have a hepatitis B immunisation programme and offer screening for HIV and hepatitis C, with advice on safe injecting practice.
- We use a 'yellow-card' system for abuses of the contract, leading to a 3-month suspension from the treatment programme. Violence in a surgery or pharmacy would lead to a 'red-card' ban from the programme and involvement of the police. This has not been a significant problem since implementation of the guidelines.
The guidelines will remain the subject of constant review by those who use them. The overwhelming need for consistency has meant that, in general, GPs have been very flexible in adopting alterations in practice.
We have audited our performance against our absolute criteria. The following areas are currently being developed:
- Feedback from pharmacists to practices about non-attendance to drink methadone on two or more days per week. The patient may well be using heroin on top and this can be challenged.
- Transfer of care guidelines for patients who are receiving treatment in prison, in hospital or in other areas, and then register in our locality.
- Improving the uptake of hepatitis B immunisation. In our practice, many drug users say that they would like immunisation but do not visit the nurse to receive it.
- Greater acceptance of the need of some users for very long- term prescription of methadone (maintenance). There is good evidence for the value of this in terms of reduction of heroin use, reduction in crime and improved health.2
For an information pack, contact: Dr Dougal Darvill, Hartcliffe Health Centre, Hareclive Road, Bristol BS13 0JP (Tel: 0117 964 0412; Fax: 0117 964 9628).
- Department of Health. Drug Misuse and Dependence – Guidelines on Clinical Management. London: The Stationery Office, 1999.
- National Treatment Outcome Research Study (NTORS) ( London: Department of Health, ongoing.
NHS Beacon Awards
Beacon status is awarded to practices, trusts and other healthcare organisations within the NHS that have demonstrated good practice. The NHS Beacon programme aims to spread best practice across the health service. For further information visit the website: www.nhs.uk/beacons