A heterogeneous sample of 12 GPs from different general practices were interviewed (Table 1). The sample ranged in terms of sex, years of experience, location, size of the practice, and special interest in treating patients who misused drugs. All but one of the eight GPs with a special interest had completed at least one module of the Royal College of General Practitioners (RCGP) Certificate in the Management of Substance Misuse. Two global themes and six sub-themes emerged from the data (Figure 1).
Global theme 1: Acquiring information about drug misuse
The GP accounts illustrated that the complexity regarding the decision to ask patients about drug misuse preceded the decision about recording. As drug misuse is a legislative illegal action that can lead to adverse consequences, enquiring is complex and often challenging. The sub-themes that emerged from global theme 1 were the context and the process of acquiring information about drug misuse, and the influence of the interaction between GP and patient (Figure 1). Quotes from GP participants (P) are given below to illustrate the themes. (Descriptive information is included for each participant).
Sub-theme 1. Context of acquiring information
The first sub-theme was divided into the organisational and individual context, and the financial incentives of recording drug misuse.
a) Location of the general practice: practices located in areas where drug misuse was more prevalent were, unsurprisingly, more likely to be accessible and have registered patients who misused drugs:
‘We’ve traditionally been very keen, we’ve been very involved. Quite a lot of GPs, I think, are involved, particularly for maintenance, but also for reducing and stopping. So, I think we provide a very good place.’
(P6, male, >15 years’ experience, inner city, with a special interest in drug misuse [GPwSI])
The fact that patients who misuse drugs were regularly attending consultations in the practices seemed to desensitise the perception of drug use. In comparison, practices where drug misuse was less prevalent seemed to have fewer known registered patients misusing drugs:
‘I think possibly we don’t, just because we don’t see that many [who misuse drugs].’
(P10, female, 5–10 years’ experience, outer-city neighbourhood)
b) Size of the general practice: GPs from larger practices reported that patients did not always see the same GP at each visit, which added to the challenge of asking about drug misuse:
‘… because a lot of the time this isn’t their regular doctor.’
(P1, male, >15 years’ experience, inner city, GPwSI)
However, the data suggested that some of these larger practices in locations where drug misuse is more prevalent had the capacity to appoint a lead GP for drug misuse, so that patients could experience more continuity of care:
‘People who are specifically presenting with concerns [about drug misuse] will get channelled into me.’
(P4, female, 5–10 years’ experience, inner city, GPwSI)
Additionally, two of the inner-city large practices had an allocated weekly drug clinic, where patients could see the same GP and/or drug worker. This illustrates how the practice was working towards reaching the local enhanced service (LES) targets:
‘We’ve been running a specifically dedicated substance abuse clinic, which is run in liaison with [local drug clinic].’
(P7, female, >15 years’ experience, inner city, GPwSI)
c) Financial incentives for GP practices: treating drug misuse is not in the General Medical Services (GMS) contract. However, practices in certain areas where the need has been identified have a LES for treating drug misuse, and are therefore financially incentivised to provide drug misuse treatment:
‘Locally, the way our enhanced services have gone is that it isn’t just for our own practice, it’s actually for the whole of [named borough]. We all have to reach that target for the whole group to be paid.’
(P7, female, >15 years’ experience, inner city, GPwSI)
Consequently, recording of drug use was not only financially beneficial for all the practices in the area, but also facilitated continuity of care for the patient. Conversely, some GPs from practices without a LES expressed the opinion that the absence of Quality and Outcomes Framework (QOF) indicators for drug misuse influenced their decision to ask about and record drug misuse:
‘It will be great if [recording drug misuse] did [get financially incentivised], but it’s always been resisted because drug treatment isn’t part of the current GMS contract.’
(P9, male, 10–15 years’ experience, outer-city neighbourhood)
This suggests that enquiring about and recording drug misuse would increase if a national QOF existed for drug misuse.
d) Individual context: GP experience and training: the RCGP training modules for management of substance misuse were seen as a positive way to gain experience, build confidence, and help improve the services provided:
‘Well, I did it [RCGP modules] specifically to set up a shared care service … so, it was because we felt we weren’t looking after the patients well that we decided, as a practice, we needed to develop more of an expertise.’
(P7, female, >15 years’ experience, inner city, GPwSI)
In contrast, a GP trainee felt that she lacked confidence, but more experience would enable her to ask about drug misuse more frequently in the future:
‘I’m not as confident as I imagine I will be in 10 years’ time, when you’ve seen a lot more of this, and maybe as you get older you have more confidence to push an issue.’
(P11, female, GP trainee, inner city)
GPs who worked in both general practice and drug treatment clinics found experience from the latter made them more aware of the signs of drug misuse, and therefore more confident about asking:
‘[Working in the drug clinic] helps me suspect things earlier and address them, I think, because a lot of people are nervous to ask.’
(P5, male, 10–15 years’ experience, inner city, GPwSI)
This suggests that combining experience from working across both general practice and drug treatment clinics contributes to improved awareness of people who misuse drugs, and will therefore influence whether GPs ask about and record drug misuse in the electronic health records.
e) GPs’ role in managing drug misuse: most of the GPs perceived that their role for managing individuals who misuse drugs was important:
‘I think that GPs definitely have a role. I think one of the first things is actually uncovering that there’s a problem.’
(P11, female, GP trainee, inner city)
Their role seems to encompass identifying the problem and working together with other health professionals and services in order to manage and support individuals who misuse drugs.
Sub-theme 2. Interaction between GP and patient
The second sub-theme was divided into building a relationship and shifting agendas.
a) Building a relationship: GPs perceived that continuity of care was important to help establish a respectful relationship, as well as trying to remain non-judgemental:
‘We do actually encourage a bit of continuity, so they’d stick with one person, because then you build up a rapport and you’re more likely to have an idea of what is actually going on at home, and with their drug abuse.’
(P8, female, >15 years’ experience, inner city, GPwSI)
It seemed as though this particular GP was trying to gain a deeper understanding of the patient’s situation outside of the general practice. Furthermore, GPs discussed the need to balance clinically appropriate actions and maintaining the relationship:
‘If I don’t give them what they want, some of them will try to just test another doctor out, and whether or not they will be prepared to modify the prescription.’
(P1, male, >15 years’ experience, inner city, GPwSI)
The decision about recording raised a dilemma, with concern that recording may adversely affect patient disclosure:
‘If they felt that to come and talk to you about something and that would require it being recorded would stop them coming to see you, then that would be detrimental to their care.’
(P3, female, >15 years’ experience, outer-city neighbourhood, GPwSI)
At times, GPs need to strike a balance between clinically appropriate actions and the established relationship, although GPs felt that, as occurs with the disclosure of alcohol use, people may minimise the extent of drug use in the accounts they presented to GPs:
‘I think, generally, if people are willing to talk about it, then I’ve noticed people will talk it down, and say something like “Oh, well, I just sort of, you know, occasionally might use.”’
(P5, male, 10–15 years’ experience, inner city, GPwSI)
Scepticism seems to creep in when patients disclose their drug misuse.
b) Patient’s choice: some of the GPs discussed not recording misuse of drugs in the patient record following patient requests:
‘… but if someone asked me specifically not to, then I wouldn’t.’
(P4, female, 5–10 years’ experience, inner city, GPwSI)
GPs appeared to respect patients’ autonomy and choice. Others, however, discussed circumstances in which they would urge recording, even when requests were made by patients to the contrary:
‘I do think I would have the discussion with the person and make a judgement, and if it was really important I’d try to persuade them that it actually is important to put on their medical notes.’
(P7, female, >15 years’ experience, inner city, GPwSI)
GPs’ actions depended on the circumstances, and GPs seemed more uncompromising about recording drug misuse if a woman was pregnant, or if there was someone else involved (for example, a child) and/or other agencies needed to be brought in:
‘There are some situations where I would record, regardless of the use — if it was relevant to the consultation, or if there were children involved, or the person was pregnant.’
(P4, female, 5–10 years’ experience, inner city, GPwSI)
The consequence of GPs asking about drug misuse during pregnancy may have adverse implications for mother and child. Additionally, potential bias exists as GPs did not mention asking fathers about drug misuse.
c) Shifting agendas: there was the potential for a patient’s original agenda and formulation of their problem to be superseded by a conversation about drug misuse:
‘Also, social problems, work problems, I might ask them about [drug misuse] if they present with these [symptoms].’
(P2, male, >15 years’ experience, inner city, GPwSI)
However, the consultation may be sent in a different direction, with a risk of communication breakdown as the patient’s agenda is not properly met. Patients presenting with common signs, symptoms, and comorbidities seemed to trigger awareness of drug misuse, and prompt the GP to ask about it:
‘They generally come along with emotional difficulties — symptoms of depression and anxiety — and have just been unhappy with the way they are, really.’
(P2, male, >15 years’ experience, inner city, GPwSI)
Sub-theme 3. Process of acquiring information
The last sub-theme here incorporates whether, who, how, and when GPs ask about drug misuse.
a) Do GPs ask about drug misuse? GPs do not always ask about drug misuse. However, when the topic arises, it is usually during a consultation about a different problem. This relates to the earlier theme about shifting agendas:
‘It’s more, kind of, mostly an incidental thing that will come up as part of questioning during a consultation.’
(P4, female, 5–10 years’ experience, inner city, GPwSI)
Mainly, GPs who did not have a special interest in substance misuse expressed the view that time was a barrier for enquiring about drug misuse:
‘But I don’t routinely ask. I mean, to be honest, we just don’t have time.’
(P11, female, GP trainee, inner city)
In contrast to GPs with a lot of experience, GPs with less experience seemed more hesitant and less confident when asking about drug misuse. Some GPs reported not asking about drug misuse as they may not have time within the consultation to help with the other emerging complex issues:
‘Otherwise, a lot of people [GPs] are just thinking they’re going to open a can of worms, and it’s going to make a consultation twice as long.’
(P7, female, >15 years’ experience, inner city, GPwSI)
However, some GPs perceived that patients seemed relieved when asked, as they could then get the appropriate help:
‘I think often people are relieved [to be asked], and actually quite pleased to feel like there is some help.’
(P8, female, >15 years’ experience, inner city, GPwSI)
GPs are in a good position to query about drug misuse, although barriers such as time, experience, and the complexity of the issue seem to have an impact on the number of patients that GPs ask, and therefore record information in electronic health records.
b) Who do GPs ask? Stereotypical versus atypical: GPs recounted that they did not have time to ask every patient about drug misuse, and therefore experience has taught them to direct their queries to individuals presenting with certain characteristics. These included those with mental health issues, young professionals, students, and homeless people:
‘And anybody who comes in with depression or mental health issues we’d ask, regardless of age, in the same way as you’d ask about alcohol.’
(P7, female, >15 years’ experience, inner city, GPwSI)
It appeared that certain types of people were triggers for GPs asking about drug misuse. There was, however, an awareness that certain types of people, particularly those in a more privileged position in society, may not be asked:
‘I think some of the party drugs male patients are not presenting, not being honest about it, and maybe that’s because they’re in, sort of, more professional roles, such as solicitors and barristers, than our typical drug misuser in the past.’
(P7, female, >15 years’ experience, inner city, GPwSI)
A key difference emerged between GPs who saw and GPs who did not see patients regularly who misused drugs. The former viewed that there was a risk of individuals being missed if the GP only focused on asking particular groups of patients.
c) How do GPs approach asking about drug misuse? GPs have developed different styles of questioning in order to ask about drug misuse. Accounts included both direct and indirect approaches:
‘I don’t ask people directly whether they are taking or misusing substances. I ask them permission to ask it first, and so they have a “get out” clause.’
(P9, male, 10–15 years’ experience, outer-city neighbourhood)
‘I think you have to ask your question to the point, because otherwise you might not get the answer, and people might not understand your questions either.’
(P3, female, >15 years’ experience, outer-city neighbourhood, GPwSI)
Experience and reflection seemed to have shaped different questioning styles that fulfilled the purpose of acquiring information about drug misuse.
d) When were the critical time points for asking? There were distinctive and significant time points when opportunities for asking about drug misuse naturally fitted, such as new patient registration:
‘This is our new patient health questionnaire, and on it, it has a section: “Do you misuse any of the following drugs or substances?” Alcohol is slightly easier than substance misuse, and, you know, in a questionnaire, I probably don’t get the whole details of alcohol, and less of drugs.’
(P6, male, >15 years’ experience, inner city, GPwSI)
It seems that, although the patient questionnaire may be an opportunity for the GP to indirectly ask about drug misuse, there was some scepticism about the validity of the results. Although registration of a new patient may be a critical time for asking about drug misuse, it may not be the right time for an individual to disclose and therefore affects recording of drug misuse in electronic health records.
A GP trainee without a special interest in drug misuse described how she does not routinely ask about drug misuse on its own, but found it easier to ask about drug misuse together with sexual health issues:
‘The other time when I would have asked [about drug misuse] — people who’d come in for the morning after pill.’
(P11, female, GP trainee, inner city)
Consultations regarding other sensitive, but perhaps slightly less stigmatised, issues may present an opportune time for asking about drug misuse. Pregnancy was also seen as a timely opportunity, when other lifestyle decisions (for example, drinking and smoking) are discussed:
‘The other area would be in pregnancy — so, for example, if I’m concerned that either someone might be smoking or could potentially be using drugs.’
(P4, female, 5–10 years’ experience, inner city, GPwSI)
Global theme 2: Recording of drug misuse
Once GPs have acquired information on drug misuse, they need to make a decision on whether or not to record in the EPR (Figure 1).
Sub-themes 4 and 5. When and who do GPs record?
GPs’ opinions differed with regards to when and for which patients to record drug misuse in the EPR. Some GPs did not feel that it was necessary to ask patients for their permission to record, and described how recording was an administrative issue, and did not appear to engage with the potential sensitivity:
‘If somebody comes in about a drug issue, they would see me writing during the consultation. So, I guess that’s implied consent.’
(P8, female, >15 years’ experience, inner city, GPwSI)
Other GPs expressed the view that the patient should be made aware of recording:
‘I think that’s something we’d have to discuss with the patient, because the problem is that once it’s on their record, it’s on their record forever.’
(P3, female, >15 years’ experience, outer-city neighbourhood, GPwSI)
In contrast to this argument, a female GP from an inner-city practice with a special interest in drug use perceived that it was important to record for insurance purposes:
‘And, even if you don’t do it, I would be liable if, say, it’s an insurance report. It’s still, if you know the information, then it would make their insurance thing null and void.’
(P8, female, >15 years’ experience, inner city, GPwSI)
These differences in opinion suggest that GPs may struggle between the role of providing care and that of a gatekeeper.
The issue of not recording could be explicitly raised in an attempt to gain an accurate picture of use:
‘I’ve asked somebody about their drug misuse, and said to them that I’m not looking to record this, I think it’d just be useful to know ‘cos it’s potentially relevant to their stress or insomnia.’
(P5, male, 10–15 years’ experience, inner city, GPwSI)
In contrast, other GPs stated the need to record drug misuse in the interests of providing continuity of care across different clinicians:
‘So, I usually say to them: “Look, if you’re seeing somebody and they don’t know something about you that’s going to influence how they treat you, then it’s in your interest to have it on the record.”’
(P7, female, >15 years’ experience, inner city, GPwSI)
It seemed that the decision to record was a balancing act with regards to patient care and the existing GP–patient relationship.
All of the GPs were unanimous about recording in detail if a child was affected by parental drug misuse, as they viewed it as their duty and responsibility to record any adverse situations affecting a child:
‘Usually, when I’m doing a consultation with someone who is pregnant, or if I was doing a consultation where I thought that it would be a social work [sic] concern, I’d be more structured and detailed, I think, than just my usual rambling free text.’
(P4, female, 5–10 years’ experience, inner city, GPwSI)
Recording may, however, not be via a Read code, but rather in the referral letter to the midwifery service:
‘I can think of one woman recently who was a cannabis user, but she wasn’t using any opiates. So, I put that in her letter [referral] but I did not use a Read code.’
(P4, female, 5–10 years’ experience, inner city, GPwSI)
Sub-theme 6. How do GPs record information about drug misuse?
GPs described how time consuming finding specific Read codes can be, and that free text was often easier and quicker:
‘So, yes, I think that’s very true of EMIS, that it probably needs to be cleaned, but I guess there’s often one [Read code] to find.’
(P11, female, GP trainee, inner city)
GPs both with and without a special interest in drug misuse described how they usually use Read codes for the primary problem that the patient had consulted about, rather than drug misuse:
‘In general practice, it would just be what you thought the main problem was.’
(P9, male, 10–15 years’ experience, outer-city neighbourhood)
Once a woman is discharged from the midwifery service, GPs receive a detailed discharge letter that is usually scanned, but not always Read coded:
‘I would certainly record if I got that [drug misuse in the discharge letter] letter back. I would open up the mum’s and kid’s records, and pick a Read code, and put it in.’
(P11, female, GP trainee, inner city)
Finally, some general practices have developed templates or protocols to use specific Read codes to record drug misuse:
‘So, the only way you’re going to get people to use similar Read codes is to make them use a template.’
(P4, female, 5–10 years’ experience, inner city, GPwSI)
The template offers more opportunity for auditing the information regarding drug misuse in their general practice, as the same Read codes would be used. Practices with more registered patients misusing drugs seemed more likely to have developed a template or protocol.
