Dr Jez Thompson describes his practice's harm reduction/health promotion approach to the care of drug misusers, for which they were awarded Beacon status

Problem drug users are particularly likely to have health problems. They are at risk from the effects of the drugs themselves and from bloodborne viruses through the sharing of injecting equipment.

They also tend to have poor nutrition and suffer ill health associated with the socioeconomic consequences of drug misuse such as unemployment, poverty, poor living conditions, involvement in crime and incarceration. Studies have even shown high levels of dental problems in drug misusers.1

The pooled standardised mortality rate (SMR) for drug users in developed countries has recently been estimated from 12 studies to be 13.2.2 This is 13 times higher than would be expected for the general population after age and gender have been taken into account.

Problem drug users also visit their GPs more frequently than other patients3 and many have positive attitudes to asking GPs for help.4

Primary care teams are ideally suited to addressing the health needs of problem drug users, being the first point of contact with health services, often establishing long-term relationships with patients and their families, and having an extensive knowledge of the local community.

The Orange Book guidelines encourage GPs to provide care for both the general health needs of substance misusers and their drug-related problems, whether or not patients are ready to withdraw from drugs.5

In a previous issue of this journal, Dr Darvill has shown that with consistent and well thought out guidelines it is possible to manage the problems of drug misuse effectively and safely in primary care.6

Other work has shown that the levels of difficult behaviour from drug misusers seen in general practice (sometimes a GP's most significant worry) are low.7

St Martin's Practice is situated in the Chapeltown area of Leeds, an area known to have a high prevalence of drug misuse and high levels of social and economic deprivation. Like Dr Darvill's problem drug use service, our problem drug use service has developed over many years in response to local needs.

Last year we were awarded Beacon Status for our health promotion work, particularly with problem drug users. As well as providing treatment for drug misuse and encouraging cessation of illegal drug use and eventual drug-free living, we focus on a harm reduction and health promotion approach to care.

At all times we adopt forms of treatment to improve the physical, psychological and social wellbeing of people with problem drug use, and to help them function better in society.

Areas for target health promotion work

Problem drug users offer multiple opportunities for improving the health of the individual. In many cases this can have beneficial effects on the wider community, e.g. through a decrease in the prevalence of bloodborne infectious disease and the reduction in criminal activity that follows when drug misusers engage in treatment.8

The accessibility of primary care and the skill mix found there make it ideally suited to the provision of harm reduction and health promotion advice for problem drug users. Behaviour change in response to health advice is a feature of good relationships, an area where GPs can claim expertise.

At first contact, we aim to cover as many issues as possible, as this may be the only contact with the client (see Figure 1, below).

Figure 1: First contact (from St Martin's Practice Problem Drug Use Service Guidelines for Best Practice)
first contact guidelines

Drug misusers, like everyone else, respond best when doctors listen and avoid judgment. Harm reduction and health promotion work can be backed up with a variety of good quality leaflets available from local and national sources.

  • Provision of substitute prescription

The lives of many heroin users revolve around obtaining money for the next fix and the complex social rituals of injecting.

When clients receive a substitute prescription at the practice (usually for methadone) we see a rapid transformation. Risk behaviours, such as criminal activity and prostitution, reduce and may stop. Family relationships begin to improve and clients have a real opportunity to take stock, to stop injecting, and to work towards cessation of drug use.

  • Prevention of death through unintentional overdose

Drug overdose is the major cause of death among injecting drug users in developed countries. The mortality rate is increasing, and a worrying development is the possible increase in methadone-related deaths.9

This risk can be significantly reduced by the joint approach of careful prescribing along clear guidelines, and the provision of good advice regarding drug use.

At our practice, no prescription for methadone is given without a full assessment process (see Figure 2,below), which includes confirmation of opioid use by history (from other GPs or health agencies if necessary) and by urine toxicology.

Figure 2: Assessment of problem drug users (from St Martin's Practice Problem Drug Use Service Guidelines for Best Practice)
assessment guidelines

Starting doses are carefully worked out based on the history of current drug use, with a maximum initial dose of 40mg daily, and methadone mixture 1mg/1ml is prescribed. Doses are taken under the supervision of a local pharmacist. Increments in dose are limited to 10mg in any week, and our maximum prescribed dose is 80mg daily.

All patients, whether receiving a prescription or not, are advised of the dangers of drug overdose, and the dangers of polydrug use. All patients receiving prescriptions for methadone and in particular buprenorphine are warned of potentially dangerous drug interactions, which include benzodiazepines and alcohol.

Supervised consumption has reduced the risk to children of accidental ingestion of methadone in the home, but all clients with children must take care with Sunday doses dispensed on Saturday.

  • Hepatitis B immunisation

Despite the significant adverse effects of hepatitis B infection, its transmission through sharing of needles, unprotected intercourse and the risks to health personnel through contact with body fluids, the uptake of immunisation among injecting drug users remains disappointingly low.10

Some drug misusers engage poorly and sporadically with health services, and any contact opens a window of opportunity. This has led us to adopt a rapid immunisation policy for at-risk groups using Engerix B, with the first dose given at the time of firstÄcontact (unless there is a very clear history of recent immunisation), and subsequent doses given at short intervals (see Table 1).11

Table 1: Engerix B rapid immunisation schedule

First contact (day 0) 1st dose
Day 7 2nd dose
Day 21 3rd dose
12 months Booster dose
14 months Check serology

One or two previous doses of vaccine or a suspected history of previous hepatitis B infection is not a contraindication to immunisation.

  • Hepatitis C management

Hepatitis C infection is associated with significant morbidity and mortality. All service users, with a history of injecting drug use or not, receive full and regular advice about safer injecting and are encouraged to cease injecting.

We recommend annual testing for all clients with a history of recent injecting. Clients with a positive test result receive further advice about other routes of transmission, including razor and toothbrush sharing, sexual (low risk) and vertical, and about the need to minimise alcohol use to prevent liver damage.

Hepatitis C positive clients are fully investigated with blood tests, including polymerase chain reaction, to assess viral load, and referred for hepatology assessment when necessary. They are invited to our hepatitis C self-help group for information and mutual support.

The prevalence of hepatitis C infection in our clients has fallen as our health promotion work has developed.12

HIV testing

The prevalence of HIV infection in injecting drug users in British cities is relatively low.13 HIV testing and pre- and post-test counselling are beyond the remit of most general practices, and the practical consequences of having HIV test results in general practice records worry many doctors.

However, early intervention with antiviral drugs and other treatments may improve the prognosis for HIV-positive patients, and we advise referral of injecting users to other agencies for confidential testing.

  • Nutrition

Many drug users have poor levels of self-care together with an unhealthy diet, and spare money is often used to buy drugs. Concurrent alcohol use may compound dietary deficiency.

Progress towards regaining health includes receiving general advice on healthy eating. Together with hepatitis B and C management this is an important area for involvement of the practice nurse in the care of drug misusers.

Drug users with symptomatic HIV or hepatitis C infection may become malnourished, and may need specific nutritional advice and the provision of supplement foods on prescription.

  • Dentition

Drug-using clients suffer dental problems as part of general self-neglect.1 Clients can be referred to a local general dental practitioner who takes new NHS patients, and the prescription of sugar-free methadone should be considered.

  • Safer injecting

Injecting drug use brings the risks of local infection, distant embolisation, transmissible viruses and, rarely, infective endocarditis.

All clients receive advice about safer injecting, including avoidance of needle sharing and referral to the local needle exchange scheme, and avoidance of sharing the paraphernalia used to prepare injections (the 'works'), which can also transmit viruses.

Although clients are encouraged at all times to cease injecting as part of a treatment programme, we are aware that many will continue injecting, at least for the short term. Clients are advised on issues of hygiene, technique and safer sites for injection.

  • Safer sex

We have been able to obtain a supply of free condoms to give to clients. All clients are given advice on safer sex; women or men who sell sex are at particular risk. Many inner-city areas have a specific organisation working with women in the sex industry to reduce risk and promote good health. GPs can refer clients to these services.

  • Cervical smear testing

The uptake of cervical smear testing by drug-using women is low.14 Women who sell sex may be at particular risk of developing cervical disease. As a group, problem drug users should be targeted with encouragement to take up the offer of cervical smear testing.

  • Contraception

Often, female drug misusers are amenorrhoeic, and many do not use contraception in the belief that they won't get pregnant. As a client's general health improves on a treatment programme, ovulation may occur before regular periods start again, and contraceptive advice is paramount in avoiding unplanned pregnancy at a potentially vulnerable time.

  • Mental health

Many drug users have coexisting mental health problems. Some of these may stem from drug use itself, while others, such as depressive illness and psychological trauma arising from childhood difficulties, may lead or contribute to problem drug use.

Practitioners involved in the management of problem drug users should be alert to psychological and psychiatric factors; appropriate management of the underlying problems will contribute to success in dealing with a drug problem.

  • Family health

The GP's role in the community opens unique and valuable avenues for helping the families of problem drug users, while at all times maintaining confidentiality. Parents and partners may experience severe stress and have been called 'secondary sufferers' in problem drug use.

Primary care teams play a crucial role in the support of drug misusers who are parents, and in maintaining the health and wellbeing of their children.

  • Pregnancy

The management of a pregnant drug misuser is highly specialised. We recommend early referral to an antenatal unit experienced in the management of problem drug use.

The benefits

Problem drug use and its health implications can be managed effectively and safely in primary care. Harm reduction and health promotion for drug misusers is part of the role of every GP and primary care team.

Through the formation of good working relationships with patients, the giving of personal advice and specific interventions and the provision of well-written leaflets, health staff can significantly improve the health of drug misusers, their families and the wider community.

For an information pack, contact Angela Walker, Practice Manager, St Martin's Practice, 319 Chapeltown Road, Leeds LS7 3JT (tel: 0113 2621013, fax: 0113 2374747, e-mail: angela.walker@gp-b86100.nhs.uk)

References

  1. Szymanzak E, Waszkiel D, Dymkowska W. The condition of teeth and the need for teeth treatment in drug addicts. Czas stomatol 1990; 43(3):134-9.
  2. English DR, Holman CDJ, Milne E. The Quantification of Drug-caused Morbidity and Mortality in Australia. 1995 edn. Canberra: Commonwealth Department of Human Services and Health, 1995.
  3. Telfer E, Clulow C. Heroin users: what they think of their general practitioners. Br J Addiction 1990; 85: 137-40.
  4. Hindler C, Nazareth I, King M. Drug users' views of general practitioners. Br Med J 1995; 310: 302.
  5. Department of Health. Drug Misuse and Dependence – Guidelines on Clinical Management. London: The Stationery Office, 1999.
  6. Darvill D. Practice-based guidelines enable GPs to manage heroin users effectively. Guidelines in Practice 2001; 4(4): 55-62.
  7. Thompson JC. Difficult behaviour in drug-misusing and non-drug-misusing patients in general practice – a comparison. Br J Gen Pract 2001: 51; 391-3.
  8. Gossop M, Marsden J, Stewart D. NTORS (National Treatment Outcome Research Study) at One Year: changes in substance use, health and criminal behaviours one year after intake. London: Department of Health, 1998.
  9. Neeleman J, Farrell M. Fatal methadone and heroin overdoses: time trends in England and Wales. J Epidemiol Community Health 1997; 51 (4): 435-7.
  10. Lamagni, TL, Davison, KL, Hope, VD et al. Poor hepatitis B vaccine coverage in injecting drug users: England, 1995 and 1996. Communicable Disease and Public Health 1999; 2: 174-7.
  11. Tiffen L. St Martins Practice Addictions Service Annual Report 1999/2000. 2000.
  12. Bock HL, Loscher T, Scheiermann N. Accelerated schedule for hepatitis B immunization. J Travel Med 1995; 2(4): 213-17.
  13. Department of Health. Prevalence of HIV in the United Kingdom. Annual report of the unlinked anonymous prevalence monitoring programme. London: DoH, 1998.
  14. Morrison CL, Ruben SM, Beeching NJ. Female sexual health problems in a drug dependency unit. Int J STD AIDS 1995; 6(3): 201-3.

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

 

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Guidelines in Practice, July 2001, Volume 4(7)
© 2001 MGP Ltd
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