Summary of main findings
The first important observation is that GPs in England and Wales are substantially involved in managing opiate misusers. Half of all GPs who responded had seen an opiate misuser in the preceding 4 weeks, and half of these GPs (25% of the total sample) had prescribed opiate-substitution therapies. Over two-thirds of patients were prescribed opiate substitutes. The extent of this involvement is markedly greater than in earlier years.
Some crude estimates can be made of the total number of opiate misusers receiving substitute-opiate drugs from GPs in England and Wales at any single point in time. If the findings from our random sample are assumed to be generalisable to the national GP population (approximately 30 000), then this points to a figure of approximately 62 000 opiate misusers being seen by GPs over this 4-week period in 2001. Alternatively, if we presume that our findings are not generalisable to the non-responder population in the survey, but instead assume that none of this non-responder sample attended or treated any opiate misusers, then this would give a lower (but still substantial) figure of approximately 41 000 opiate misusers being seen by GPs across England and Wales over this 4-week period in 2001. The true figure will lie somewhere between these estimates. We can also estimate the national extent of prescribing by GPs to opiate-dependent patients by extrapolating from the responses of these GPs: and thus it would indicate that somewhere in the order of 30 000 patients were receiving methadone (mostly oral syrup/linctus methadone), 2000 receiving dihydrocodeine, and 1000 receiving buprenorphine.
Comparison with existing literature
Compared to the 1985 study (that employed similar methodology), we have found evidence of a much higher level of activity — half (51%) having attended an opiate misuser within the last 4 weeks (compared to 19% in 1985), who had seen a mean of 4.1 opiate misusers during this time (compared to a mean of 2.0 in 1985), and of whom half (50%) had prescribed an opioid drug as part of the treatment response (compared to about a third (31%) in 1985). (The Glanz data from 1985 are not directly comparable for this last variable as Glanz did not specifically ask about the actual drugs prescribed and did not specify the time period to which the question applied.) Substantially more work is now being carried out by GPs with patients being seen by nearly three times as many GPs — a far cry from the mid-1980s when few GPs were involved and fewer still were willing to prescribe.
In the 1985 study, Glanz found that 35% of these patients were new to the doctor.19,20 The fall in the proportion of new patients seen by GPs in 2001 compared to 1985 (down from 35% to 15%) warrants further consideration. An explanation may be that an increase in the overall availability of treatment places since 1985 has reduced the need for opiate misusers to access primary care. It is also possible that while GPs are managing more patients, they may also be retaining them for longer, leaving no room for new patients. The smaller proportion of new patients in the 2001 study should prompt questions about whether there may now be a capacity problem developing with regard to patients trying to access treatment in primary care.
Strengths and limitations of this study
Study limitations need to be recognised. A sample size of 10% was chosen for this study, double that of the previous 1985 study,19,20 and a sampling and stratification process designed to eliminate bias due to multiple response from the same practice and to span single-handed through to large practices was used. However, caution should be exerted when extrapolating numbers of GPs and numbers of patients to the whole population. The response rate also needs to be considered, as studies of this nature have previously indicated that responders are more likely to be those who are interested or active in the field of study,35 and thus there is the risk of overestimate of the actual level of activity. Caution is also required in view of the reliance on self-report from GPs, which may result in bias due to error in recall or reporting. In an attempt to reduce any such bias or uncertainty, enquiry focused on activity in the previous 4 weeks, and GPs were encouraged to check recall through patient medical records. The issue of ‘social desirability’ in the responses is less likely to be a major issue as responses reported here are factual, and not attitudinal.
Implications for future policy and practice
The extent of GP activity is encouraging, but some areas of concern must also be recorded. We found widespread prescribing of methadone at low dose — certainly low in comparison to the international literature. The mean daily dose of methadone prescribed by GPs was 36.9 mg, with the modal value being 30 mg daily, and with nearly 50% of methadone prescriptions being for a daily dose of 30 mg or less. This is low dose (for opiate-dependence treatment) and is not in keeping with international evidence of greater benefit from higher-dose oral methadone maintenance.36-38 Various possible explanations for these low doses can be put forward: for some patients, the doses may originally have been higher but they may now be on a reducing path; the greater willingness of GPs to treat opiate misusers may have encouraged a larger number of opiate-dependent patients to seek treatment, perhaps with lighter dependence-problems. However, if these doses are meant to be methadone maintenance treatment, then they indicate a disturbingly widespread reliance on low-dose maintenance treatment, which has been found to be significantly less effective than high-dose maintenance.36 It is also possible that GPs are exercising increased caution about opioid prescribing following the growing concern about diversion of prescribed supplies of methadone and their contribution to overdose deaths among young people.39-42 However, even if such pressures may be understandable, the provision of suboptimal treatment is not defensible.
A second area of potential concern is the extensive provision of take-home supplies of methadone. Nearly half (42.9%) of all methadone prescriptions were being issued as a single dispensing of at least a week's supply, despite the existence of special regulations that permit GPs in the UK to instruct the dispensing pharmacist to supply the methadone in smaller installments (such as on a daily basis for a prescription covering a fortnight). In recent years, the Department of Health17,18 has guided that there should be more extensive supervision of methadone consumption (as already occurs in some cities such as Glasgow),5,43 or at least daily dispensing of each installment. Unless a more stable population is being managed by GPs (about which we have no data), the evidence from the current survey indicates that this guidance (about daily dispensing) has gone largely unheeded.
The UK government has strongly embraced the management of drug misusers in primary care with the development of shared care models,7-12,16 as a pragmatic solution to an ever-increasing demand for services. However, despite this move, demand continues to outstrip availability of services in many areas. Doubts and worries persist,14,15,30 and this study provides us with both encouraging and disappointing news. On the positive side, the majority of GPs were willing to be involved in providing care to drug misusers, with evidence of a considerable degree of further untapped willingness. But on the negative side, 36% still stated that caring for opiate misusers was not part of the work of their practice, and, of those who had not seen any opiate misusers in the previous 4 weeks, 22% were not willing to treat opiate misusers. It seems that two different conclusions can be reached. Firstly, that with appropriate support and funding, some of the remaining ‘dormant’ GPs might be stimulated into involvement. Secondly, despite more than a decade of active promotion of the vital contribution of the GP, there remains a substantial minority who remain opposed to such involvement. Enthusiasm for advancement on the positive front must be accompanied by serious attention to deficiencies in comprehensive coverage, if prompt access to appropriate health care at time of need is accepted as the proper objective.
The involvement of GPs in the management of opiate addiction (office-based practice) is being considered and implemented by several other countries, including Australia, France, Germany, and the US.22-29 We have charted the substantially increased contribution of GPs, and this is to be encouraged in the changing NHS.1-4 However, it will be crucial for this to be accompanied by specific attention to the training needs of these GPs34 and to the dissemination of guidance to promote the best (and avoid the worst) of clinical practice in the management of the opiate misuse.
