Strang et al's message (BJGP June)1 that between 1985 and 2001 there has been an almost threefold increase in the number of GPs seeing opiate users is indeed good news.
Sadly, however, their report on the 2001 national survey of GPs in England and Wales makes no mention of the significant improvements made in the last 4 years, thus leaving the reader with a rather negative view of what we consider to be a quantum leap forward in the field of substance misuse.
That half of the GP responders in 2001 had seen an opiate misuser in the preceding 4 weeks and half of those had prescribed opiate substitution therapies, shows how mainstream this work had already become. But in contrast to the recent RCGP's 10th Managing Drug Users Conference celebrating the distance travelled in the last 10 years, the article warns of ‘rounds for concern about the quality of prescribing’. In particular, concern was expressed that the doses of methadone prescribed were sub-optimal (mean = 37 mg).
Although there is a long and robust evidence-base to favour optimal doses between 60–120 mg of methadone, guidance to GPs before the 1999 guidelines recommended GPs should only do detoxification (hence generally using lower doses). There is inevitably a lag phase of ‘catch-up’ and it would be interesting to see what the current situation is regarding methadone doses. The new national study currently being undertaken in England by the NTA is clearly needed and the results will be welcomed, but anecdotally, among 184 users at the Windmill practice in Nottingham, for example, methadone doses have generally increased since 2001.
Let me suggest three further reasons why the authors should not be overly pessimistic regarding both the dose and the instalments of methadone given. Firstly there are no details given of the work/family circumstances of the users in question. What, for example, if a significant proportion of users are trying their hardest to keep down a job or study?
Secondly, that there are more and more GPs seeing drug users, inevitably means that many will just be ‘dipping their toes in the water'. Do we expect GPs who are green to starting diabetics on insulin to be bold and get it right from the start? Indeed those who have just completed the first level certificate will have learned that the first 2 weeks of methadone treatment are the most dangerous with regard to lethal overdose.
And for those GPs experienced in substance misuse can we not trust them to use their clinical acumen to get it right for the individual user that they have developed a rapport with? Remember that since 2001, there is a growing body of GPs who have completed the RCGP certificate course. Four thousand e-modules have been completed, with 500 GPs finishing the part one certificate and 750 GPs in England alone having completed the (year-long) part two certificate. In keeping with both the June 2005 National Treatment Agency Plan 'Towards treatment effectiveness' and SMMGP's February 2005 Network we need to consider wider quality measures than just a methadone dose — for example, 'retention in treatment is fundamental to treatment effectiveness'.
In conclusion, while we applaud the intention of the authors to further mainstream this valuable work and to encourage better quality (there is always room for improvement), let's not shoot ourselves in the foot when both of these goals are already happening. Rather, let's send a message to our GP colleagues both here and abroad that this work is worthwhile to users, their families and the wider community, and that with the right support it's not only possible, but important and enjoyable work.
- © British Journal of General Practice, 2005.