Study in Lothian confirms findings

See editorial by Farrell and pp 581, 613

Editor—Ann Davies and Peter Huxley comment that little research is being done on general practitioners' attitudes and practice in the treatment of opiate misusers even though general practitioners are now seeing more drug misusers.1 According to the authors the last substantial report was by Glanz in 1985.2 We would like to draw attention to similar studies conducted in Lothian in 1988 and 1993.3 The 1993 study was a postal survey of the experience of, attitudes toward, and confidence in dealing with drug misusers among general practitioners in Lothian. Questionnaires were sent to all 517 general practitioners (response rate 75%). The study also compared changes in general practitioners' involvement with and confidence in dealing with drug misusers from 1988 to 1993; there was a significant increase in both areas. Davies and Huxley found that 80% of the general practitioners in Greater Manchester prescribed substitute drugs for opiate misusers; we found that 73% of the general practitioners in Lothian prescribed substitute drugs, while only 12% stated that they would not do so. Moreover, 67% of the general practitioners in Lothian had given advice on safer drug use and only 2% stated that they would not give such advice.

General practitioners in Lothian, like their colleagues in Greater Manchester, expressed the need for more training in dealing with drug misusers. For example, in Lothian they showed a lack of confidence in the management of drug related aggression and violence in the practice, a problem shared with general practitioners in other areas.4 Training can help build confidence. A positive similarity between the two studies is that general practitioners in both Greater Manchester and Lothian generally have an understanding approach toward drug misuse.

Local guidelines and support increase confidence

Editor—We were encouraged to read about the generally positive attitudes of general practitioners in Manchester to opiate misusers and their treatment in the study by Ann Davies and Peter Huxley.1 In Lothian more than four fifths of practices are now managing drug misusers, and our experience would support Davies and Huxley's emphasis on the importance of a specialist service and the need for training to encourage general practitioners to become involved in this work.

Davies and Huxley comment on how few general practitioners have read the government guidelines on treatment of drug misuse. We believe that, while government guidelines are essential to provide a framework for doctors working with drug misusers, locally developed guidelines that are supported by training are also needed.

Lothian has had a specialist drug service since 1988 and a drug facilitation team to support general practitioners who care for drug misusers since 1991.2 A handbook, Managing Drug Users in General Practice, which was developed locally, was distributed to every principal in general practice in Lothian in December 1995.3 These guidelines are reinforced by the facilitator team, which provides courses and on site training during visits to practices.2

A questionnaire survey of general practitioners in Lothian in October 1996 (which had a 72% response rate) showed that 82% of those who received the handbook had read at least part of it and that 99% of these had found it very or quite useful.4 The survey also found a significant increase in general practitioners' confidence in managing drug misusers; 34% indicated above average confidence in 1993 compared with 45% in 1996. There was also a decrease in those indicating a lack of confidence from 39% in 1993 to 17% in 1996.

In Lothian, local guidelines that are supported by training seem to have contributed to an increase in the confidence of general practitioners in caring for drug misusers.

Education may make general practitioners feel more confident

Editor—General practitioners in Ann Davies and Peter Huxley's survey said that they wished they had had more training in dealing with patients who misuse opiates.1 The need for such training has been highlighted before,2 3 but its provision may not attract many general practitioners to traditional educational events.4 We describe a successful partnership between a worker at a community drugs service and a general practice tutor.

In West Dorset, general practitioners felt poorly prepared to respond to the increasing demands made by patients who use illicit drugs. We offered local general practitioners an eight hour programme of training on working with drug misusers in general practice. The participants identified their learning needs, and the course presenters worked to meet these. Many of the participants initially had negative feelings about drug misusers; they admitted to feeling uncertain and lacking in confidence when working with these patients. The education was spread over at least one month, which allowed participants to integrate theory with their own practice and to test it. There was an emphasis on negotiating realistic treatment goals and advocacy of a model of shared care. General practitioners and drug service workers gained a clearer understanding of each other's roles and skills.

Participants on the initial courses have formed a local special interest group that meets quarterly for peer support, discussion of cases, and further learning. Evaluations of the course show that it meets the needs of busy general practitioners who do not wish to become experts but who feel poorly prepared for part of their everyday work. About 40 (over 30%) local general practitioners have now taken part in the training, and most continue to work with a number of patients with drug related problems, often in partnership with our community drugs agency.

Better attitudes can be formed by better training

Editor—Ann Davies and Peter Huxley's survey of general practitioners' opinions on treating opiate misusers provides an insight into an increasingly common part of primary care practice.1 The authors comment that they are unable to assess whether the relationship between positive attitudes and greater contact with support services is causal. They also suggest that additional training is needed if general practitioners are to become confident about their ability to treat opiate misusers.

We have recently completed a study of general practitioners' attitudes and behaviour in providing primary care for single homeless people in Birmingham. This group includes a large proportion of opiate misusers and they are subject to negative stereotyping similar to that experienced by other opiate misusers.2 An analysis of in-depth interviews with 25 general practitioners across the city showed that general practitioners with positive views toward opiate misusers were more likely to mention the benefit of local support services. They emphasised this as an important coping mechanism both in terms of the quality of service that they offered to clients and in feeling supported in their work. In contrast, many of the general practitioners who expressed negative views mentioned the lack of support services or the excessive time involved in accessing them.

Our study explored doctors' attitudes in much greater depth than Davies and Huxley's study, and the results suggest that the relation between positive attitudes toward opiate misusers and greater contact with support services is not a simple causal one. The origin of positive or negative attitudes seems to be complex and rooted in the accretion of influences from the lay and medical communities, including influences operating before entry to medical school. Though we agree that general practitioners should be offered better training in this important aspect of primary care, our study suggests that the training required will need to challenge deeply held attitudes in a manner that is not too overt and will need to be quite intensive educationally. In the longer term, the solution may lie rather more in the selection of medical students and early formation of their attitudes.

Attitudes may be influenced by practice policy

Editor—Ann Davies and Peter Huxley surveyed general practitioners' opinions about the treatment of opiate misusers in three districts in Greater Manchester.1 I write to report the findings of a questionnaire study which I recently carried out in rural East Anglia.

During December 1996 and January 1997, I conducted a postal survey of all 34 practices in the district served by the Mid Anglia Community Health NHS Trust (a total of 131 general practice principals). General practitioners were questioned about their contact with opiate misusers and their willingness to prescribe substitute drugs. They were asked to indicate on a five point Likert scale (ranging from strongly agree to strongly disagree) if there were any factors that might encourage them in this work. Altogether 84 (64%) of the general practitioners contacted responded after a single mailing. Forty four of those responding had seen a patient with problems related to the misuse of opiates in the preceding four weeks. Only 29 doctors were willing to prescribe substitute drugs for opiate misusers, whereas 59 had previously been prepared to prescribe them. This change in stance followed the General Medical Services Committee's statement (of which 73 of the general practitioners were aware; one non-respondent) that such work falls outside core general medical services.2 Altogether 33 of the 55 of those who would not prescribe substitute drugs stated that their position on prescribing was influenced by practice policy.

Sixty seven of the respondents indicated that specific measures might encourage them to maintain or adopt a more active role. These included the provision of assessment and advice by a specialist agency within an agreed timescale (44 in agreement; one non-respondent), local protocols on the management of opiate misusers (35 in agreement; one non-respondent), and training sessions for general practitioners and other primary health care staff (25 in agreement). An additional capitation fee, proposed by the commissioning authority, of £15 every three months was rejected by 39 of the 67 respondents.

This study confirms a dramatic increase in the contact between general practitioners and opiate misusers in rural East Anglia since the national survey by Glanz.3 It identifies a previously unexamined factor—namely, that the refusal of some general practitioners to prescribe substitute drugs might be the product of practice policy rather than the general practitioner's personal decision. None the less, this study provides confirmation that training and support might encourage general practitioners to become more involved in the shared care of opiate misusers.