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Medeconomics: Specialist Services - How to ... treat substancemisusers

Treating and caring for addicted patients should not be confined to specialist GPs, says Jennifer Taylor.

Treating substance misusers is slowly but surely becoming a mainstream activity in general practice. This is a good reason for all GPs - and not just GPSIs - to be aware of the issues and learn more about managing such patients.

Basic training

Going on an appropriate course will enable you to find out which illnesses can be associated with substance misuse. This in turn will help you recognise when patients are trying to conceal misuse problems. Courses can also help guide GPs on how to manage awkward patients and diffuse difficult situations, such as pressure to prescribe.

The RCGP's Certificate in the Management of Drug Misuse Part 1 is for GPs working with misusers at a generalist level. It is also relevant if you are seeing misusers as part of a local shared care scheme or if you are intending to provide treatment to misusers as part of a local or national enhanced service.

Further details are available from the RCGP's substance misuse unit.

Specialist training

Part 2 of the RCGP's Certificate in the Management of Drug Misuse is aimed at GPs who want to become GPSIs. Applicants should have gained the Part 1 certificate or undergone equivalent training, or be able to show that they already have the generalist skills appropriate to caring for misusers.

The model of care for substance misuse has moved away from abstinence towards the safer use of substances. Nottingham GPSI in substance misuse and RCGP sex, drugs and HIV task group lead, Dr Stephen Willott says the work is very client-focused.

Less harmful behaviour

Even if patients do not want to - or are unable to - quit, GPs can suggest less harmful behaviour. For example, injecting heroin increases the risk of hepatitis C, HIV and abscesses. GPs can suggest patients try smoking the drug, rather than injecting.

This might shock some GPs, but looking after addicts calls for pragmatism say experts: some will stay addicted.

Dr Willott says a large proportion of patients can be looked after in primary care and are more likely to continue with treatment than in secondary care services. If GPs feel they are out of their depth, or if a misuser has complex problems that are not appropriate within a standard primary care setting, they can be referred to a specialist GP.

'Some of these patients are chaotic and damaged people,' he says. 'I would not propose that doctors who are new to this should take on the chaotic patients.'


The DoH has clinical guidelines to help GPs manage and care for addicts 'Drug Misuse and Dependence - Guidelines on Clinical Management'. The guidelines divide treatment into assessment, management of withdrawal and dependence, and preventing relapse, but they do not have the force of law behind them except in relation to prescribing of controlled drugs.

GPs need to ensure that they prescribe to addicts in line with regulations on controlled drugs.

The RCGP has a number of guidelines, including 'Guidance for Working With Cocaine and Crack Users in Primary Care', which can be downloaded from its website.


The Substance Misuse Management in General Practice website provides a forum for discussing issues related to substance misuse management.

It also has a resource library and details of courses and events.


- RCGP Certificate in the Management of Drug Misuse Parts 1 and 2. www.rcgp.org.uk

- 'Guidance for Working With Cocaine and Crack Users in Primary Care' and other RCGP guidelines for treating misuse. www.rcgp.org.uk

- 'Drug Misuse and Dependence - Guidelines on Clinical Management'. www.dh.gov.uk

- Substance Misuse Management in General Practice. www.smmgp.co.uk


'Addicts are just people'

Essex GPSI in substance misuse Dr Roger Gardiner works four days a week at the Victoria Surgery in Southend-on-Sea. The surgery specialises in patients with alcohol and drug addiction, and was set up two years ago by Southend-on-Sea PCT. The surgery also has a team of specialist nurses.

Dr Gardiner says patients are treated for both medical and substance misuse problems. Ideally, once the substance misuse problems are stabilised, these patients would move on to a shared care scheme. They would be seen at a standard GP practice, but be monitored regularly by a specialist nurse. If problems recur, the patient would go back to the Victoria Surgery.

Local GPs receive £5,000 to take up to 10 patients who have attended Victoria Surgery.

'Despite this, there is a lack of GP interest locally, ' Dr Gardiner says. 'Practices are afraid addicts will disrupt surgery sessions.'

The result is that, with 400 patients, the Victoria Surgery's list is closed to new patients. Dr Gardiner feels that attitudes might change if GPs were more aware of the financial rewards and accepted that substance misusers 'are normal people'.

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