44 CHAPTER 10
Drug misuse Dr Tom Waller,
SUMMARY 1. Assessment by history and examination should include: a history of all drugs taken during each day for the previous 7 days (including alcohol), length of drug use and route (including the sharing ofneedles or syringes), the possibility ofpregnancy iffemale, previous psychiatric history and treatment of drug misuse, social factors (including employment, family, friends, involvement in prostitution, legal problems), medical problems, including evidence of hepatitis, injection abscesses and other infections, suicide attempts, and weight loss. 2. Notification to the Chief Medical Officer of the Drug Branch of the Home Office is a legal obligation. 3. Investigations include: liver function tests (LFTs), hepatitis B surface antigen (HBsAg), hepatitis B surface antibody (HBsAb), hepatitis C antibody, full blood count (FBC), and urine for drug screening. Consider HIV testing if at risk but it is usually better arranged at a later stage. 4. Prescribing may be consideredfor a variety of drugs but objectives will differ according to drug type and individual. 5. In the case of opioid users, prescribing may be useful to stabilize their lives and to promote attendance for professional help. lt may reduce high risk behaviour for contracting and spreading HIV 6. If medication is given to opioid users, methadone mixture 1 mg/ml given once a day is the prescription of choice. Dispensing should be on a daily basis and the blue prescription form FPJO (MDA) allows the chemist to dispense daily for up to 14 days. A maximum ceiling of 100 mg methadone! day should not be exceeded. The initial dose will depend on the amount of opioid consumed in the previous week. The duration ranges from 2 weeks for a brief detoxification to 6 months or longer for those who are very damaged and unstable. The latter group are probably more appropriately managed by a drug dependency unit. 7. A written contract with the patient is often helpful and it is advisable to undertake regular urine checks to detect drug use. 8. Other sources of help should be mobilized, for example a community drug team, community psychiatric nurse, social
worker; and probation officer:
Introduction Drug users or their families usually only look for help when a problem arising from illicit drug use has occurred. This may be legal, social, medical or simply a problem of supply. These problems do not always imply significant dependence on a drug or an overriding wish to stop using drugs.
MB BS
However, even the most apparently unmotivated drug user has some degree of ambivalence, and motivation to cease drug use is always enhanced by good professional help and the restructuring of life patterns. Seemingly unmotivated patients should not be denied medical help and will require counselling with regard to safer injecting and safer sex even if no other treatment is given. They may sometimes be encouraged to change by appropriate interviewing techniques. For the dependent drug user seeking help a variety of treatment options are available. A decision as to the most appropriate can only be made by a thorough assessment of the patient from a full history and examination.
History Try to determine the following: 1. The length of regular drug use causing the current drug problem. 2. The number and extent of any drug-free periods and how they were achieved. 3. An explicit drug history of the number and quantity of drugs (including alcohol) taken each day for the past 7 days. 4. Age of starting drug use. Commonly there is sequential drug use, for example cannabis at 15 years, amphetamines at 17 years, opioids at 18 years. 5. A past or present drinking problem. 6. Route of drug use, whether patient ever injects and whether he/she has ever shared needles or syringes ('works'). Ask if ever tested for HIV. Counsel about safer injecting and safer sex (this should always be done at first interview as this may be the only time the person attends). An HIV test, if organized, is better arranged at a later stage. 7. If female, ask specifically if there is any possibility of pregnancy. The amenorrhoea of pregnancy may be concealed by amenorrhoea from opioid use. (If pregnant, sudden withdrawal from opioids is life-threatening to the fetus and immediate treatment with methadone mixture is indicated.) 8. Previous psychiatric history. 9. Inpatient admissions to a psychiatric ward. 10. Extent of previous contact with drug services or previous treatment by a general practitioner/other doctor. 11. Admissions to a rehabilitation house. 12. Whether employed.
45
13. Any outstanding court cases, any previous trouble with the police. 14. Any social problems resulting from drug use. Family disruption, whether involved in prostitution (male or female). What social support is there by way of family and friends? Are there any children? 15. A medical history, particularly: 0
hepatitis
*
convulsions injection abscesses overdoses (intentional and accidental) suicide attempts septicaemia pneumonia cervical smears breathlessness weight loss
.
chronic diarrhoea.
0 0 0
0 0 0 0
0
Examination Things
to
look for
particularly
are:
1. Injection track marks (fresh and old) and state of superficial veins. Examine in particular arms, legs, hands, feet, and inguinal regions. 2. Signs of HIV disease. Lymph nodes particularly at anterior border sternomastoid, posterior triangle and submandibular region; hairy leukoplakia of tongue. 3. Jaundice. 4. Pupil size and nystagmus. 5. Hepatosplenomegaly. 6. Heart murmur (congenital heart lesions predispose the drug injector to bacterial endocarditis). 7. Pulse rate. A persistent rate >100 in someone withdrawing from barbiturates or other CNS depressants indicates liability to fit and urgent treatment is required. 8. Respiratory tract infections and tuberculosis. 9. Temperature. The withdrawal process is commonly associated with a mild rise in temperature (37.5°C). Cocaine and amphetamines may cause a pyrexia of 38°C. If these have not been taken in the previous 24 hours a pyrexia of 38°C or more may indicate septicaemia which is potentially life-threatening and easily overlooked.
Legal obligations If a general practitioner believes or suspects that he or she is attending a person who is dependent on one or more of a list of 'notifiable' drugs then the doctor is required by law to notify the Chief Medical Officer, Drug Branch, Home Office, Queen Anne's Gate, London SWIH 9AT within 7 days. Notification should be made annually thereafter if the practitioner believes the patient is still taking drugs. Failure to notify may cause a doctor to be brought before a tribunal. The notifiable drugs are: *
cocaine
*
dextromoramide (Palfium)
diamorphine (heroin) dipipanone (Diconal) hydrocodone hydromorphone levorphanol (Dromoran) methadone (Physeptone) morphine (Duromorph, MST Continus, Cyclimorph, Nepenthe) opium (Opium Tincture, Papaveretum, Omnopon) . oxycodone pethidine (Pethilorfan, Pamergan) phenazocine (Narphen) piritramide. When notifying the Home Office, the following particulars should be given if available: * name * address * date of birth * sex * NHS number * name of notifiable drugs to which the person is addicted * date of doctor's attendance. (Although not legally required the Home Office also appreciates the names of any notifiable drugs the doctor prescribes and whether or not the person notified has been injecting.) A form, HS2A 1 (rev), provided for notification is obtainable from family health services authorities or from: DoH Printing and Stationery Unit, Primrose Hill, Clitheroe, Lancashire (telephone: 0200-22187). The information provided is purely for statistics and to help other doctors. It is compiled into what is known as the Addicts' Index. Information from this index is not available to the police, or embassies, and will not affect anyone attending court or applying for a visa. Further information should be sought, where possible, from previous doctors whom the drug user admits attending and from the Addicts' Index by ringing 071 273 2213. In most areas form HS2A l(rev) has now being supplanted by a new form which has three sheets, the top to be retained, the second to notify the Home Office, and the third to send to the local health region to help establish a regional database. These new forms are also available through family health services authorities. Treatment issues The doctor should consider: 1. Whether treatment for any associated medical condition is required 2. Whether prescribing should be undertaken 3. What is the best way of facilitating psychosocial change.
Medical conditions Many important medical conditions may be overlooked in the drug user. Symptoms may be masked by drug use or be attributed to drug withdrawal. Some such conditions, for example head injury, appendicitis and septicaemia may be imminently life-threatening. Others such as HIV disease and chronic active hepatitis B and C may be symptomless but threaten life in the longer term. Chronic active hepatitis B is
46
now a potentially treatable condition and should be screened for by looking for persistently raised LFTs and a positive HBsAg for more than 6 months. Confirmation is by liver biopsy. The presence of antibodies to hepatitis C denotes chronic active hepatitis in the great majority of cases. After a prolonged asymptomatic latent period most cases progress to liver failure, cirrhosis, and hepatocellular carcinoma. This form of hepatitis can be found in 60-70% of some drugusing populations in the UK. The latent period appears to be about 20 years in those not taking illicit drugs but may be shorter in drug takers. Treatment is available but expensive.
Suggested investigations: * LFTs, HBsAg, HBsAb, antibodies to hepatitis C, FBC (consider HIV) * 50 ml urine (or as much as possible if less than this) for drug screening. A full blood count may show up anaemia due to inadequate nutrition or changes found in the later stages of HIV disease. If HIV testing is to be done at this juncture social support should be maximized. Fully informed consent must always be sought in conjunction with pre-test and post-test counselling. Prescribing Prescribing substitutes can be considered for a variety of drugs but the objectives will differ according to the drug type and the individual. Experience has shown that long-term prescribing to amphetamine users is generally not helpful, many developing psychotic features and behaviour changes. Most authorities do not prescribe to amphetamine users. If prescribing is undertaken, dexamphetamine can be given but for a suggested maximum period of 2 weeks. However, cessation of chronic amphetamine use of 15 years' duration or more may lead to a severe intractable depression, and such cases should be referred to a specialist for consideration for long-term substitute prescribing. Cocaine cannot be prescribed for the treatment of dependence unless a special licence has been issued by the Home Secretary. Tricyclic antidepressants have been used with modest success to reduce craving for cocaine. Most drug users who take benzodiazepines also take a number of other drugs including alcohol. The treatment of polydrug use is described later. It is rare to encounter high dose benzodiazepine use on its own but when this occurs it presents a very difficult problem. Like barbiturate users members of this group are generally chaotic, often appear drunk, suffer from memory loss and are difficult or impossible to counsel. Inpatient treatment is the best solution for those high dose barbiturate and benzodiazepine users, but in reality this is rarely available, although City Roads (telephone: 071 278 8671) may offer this facility if the patient is in crisis and lives in London. The general practitioner is therefore usually left with the responsibility for treatment and a slow benzodiazepine reduction as recommended for those on therapeutic doses of the drug which has been initiated under medical supervision is generally not practicable. Thus for high dose barbiturate and benzodiazepine users prescribe on the short term to prevent withdrawal fits
or delirium tremens. These are both complications of the 'general depressant withdrawal syndrome' found in those withdrawing from a number of drugs which depress the activity of the central nervous system. These drugs include barbiturates, benzodiazepines, alcohol, glutethimide, meprobamate, methaqualone and chlormethiazole. In theory this withdrawal syndrome could be countered by any one of these drugs. In practice it is best limited to one or two longacting drugs such as phenobarbitone or diazepam. Alcohol must be avoided during the withdrawal period. Using phenobarbitone to detoxify someone from high level barbiturate use, divide the stated amount of milligrams taken per day by 3 to work out total daily dose. Limit prescribing to 300 mg phenobarbitone/day, and reduce by a third every 2 days. For example: Tabs phenobarbitone 90 mg tds (2 days) 60 mg tds (2 days) 60 mg bd (2 days) 30 mg tds (2 days) (If using diazepam, 30 mg phenobarbitone is roughly equivalent to 15 mg diazepam.) Use diazepam to detoxify someone from high level benzodiazepine use. It is better to use a benzodiazepine to detoxify benzodiazepine users as up to 44% of these users may get a withdrawal reaction that is specific to benzodiazepines as opposed to other CNS depressant drugs (Tyrer et al., 1983). Most of the symptoms from this relate to heightened sensory perception, such as increased sensitivity to sound, light, touch, smell and taste, feelings of imbalance, gastrointestinal disorders, aches, pains, and muscle spasms. For some people these symptoms may be quite disabling and continue for a long period of time. However, as drug users taking high doses of benzodiazepines (eg 80 mg or more of diazepam) tend to be chaotic with impaired cognition they are difficult to treat on an outpatient basis, and withdrawal should initially be for a short period of time with the aim of preventing withdrawal fits and delirium tremens. Those taking less than 80 mg diazepam, or its equivalent, do not commonly seek help for their drug problem as problem drug use is unlikely to occur unless they are polydrug users. The initial withdrawal period should be slightly longer than that recommended for barbiturate users because late withdrawal fits can occur particularly in high dose diazepam users. This is because diazepam has an active metabolite, N-desmethyldiazepam, which has a half-life of over 100 hours. An initial detoxification period of 10-14 days is recommended but this may be extended if the drug taker complains of very severe symptoms which can be attributed to the specific benzodiazepine withdrawal syndrome. To calculate the initial dose, estimate the average total daily dose of benzodiazepine over the past 4 days, then convert to diazepam using the following rough equivalents: for diazepam 2.5 mg is equivalent to: * chlordiazepoxide 5 mg * nitrazepam 5 mg * lorazepam 0.5 mg * oxazepam 7.5 mg * temazepam 5 mg * triazolam 0.125 mg * lormetazepam 0.5 mg
47
The initial dose may have to be increased if excessive alcohol has been consumed in addition to benzodiazepines. Prescribing is best limited to a maximum of 120 mg diazepam/day. The patient must be told to avoid alcohol completely during the withdrawal period. An example of a detoxification regime might be: Tabs diazepam 30 mg qds (2 days) 20 mg qds (2 days) 20 mg tds (2 days) 15 mg tds (2 days) 10mgtds (2 days) 10 mg bd (2 days) 5 mg bd (2 days) The blue form FP1O (MDA) which allows daily dispensing by the pharmacist for up to 14 days cannot be used for either phenobarbitone or diazepam or dexamphetamine as, although these are controlled drugs, they are not controlled under Schedule 2 of the Misuse of Drugs Act 1971. Chlormethiazole users who are taking more than 4 grams/ day on a regular basis are at risk of developing a prolonged and severe psychosis on withdrawal and are best detoxified in hospital using reducing doses of chlormethiazole. Other CNS depressants are not effective in preventing this withdrawal psychosis.
Opioid detoxification This is an easily learnt technique and could be offered by most general practitioners. Opioid users are often well motivated to change and do not have those features of other drug use that make treatment so difficult: the impaired cognition and chaos of the high dose barbiturate/benzodiazepine user, or the psychotic and behavioural difficulties of those who use high doses of CNS stimulants. Treatment does not always necessitate the prescribing of chemical substitutes and indeed the avoidance of such prescribing is not likely to be medically disastrous unless the patient is pregnant. However, it is difficult and often impossible to facilitate the psychosocial changes necessary for recovery without such a prescription, for it is this that ensures regular attendance for professional help. It is this rather than the relief of physical withdrawal which is the main advantage of prescribing. For some, too, it helps stabilize their lives so they can avoid future conflict with the law or loss of job. Those that are refused treatment usually continue their illicit drug use, at least for a time, and often continue to risk contracting and spreading HIV. Oral methadone mixture (1 mg/ml) given once a day is the prescription of choice. It is long-acting and very unpleasant to inject. The rate of detoxification is best tailored to the individual rather than the rigid enforcement of a favourite detoxification regime to all comers. Those who have been using regularly for a short time (for example a year) and who appear to be relatively stable might be appropriately detoxified over 2 weeks, for example 20 mg methadone (3 days), 15 mg methadone (3 days), 10 mg methadone (3 days), 5 mg methadone (3 days). Those who have a longer history of drug use (for example less than 7 years) might be appropriately detoxified over a longer period perhaps 3-6 months, while those who have a long history of drug use and/or who appear to be very chaotic or damaged might best be maintained at a steady level over a 3- or 6-month
Table 1 Guide to rough methadone equivalent to prescribe for users of other opioids Rough methadone equivalent
Drug
1 g at £80-90
80 mg 40-60 mg 30-40 mg Pharmaceutical heroin 10 mg tablet (taken orally) 6 mg 10 mg freeze dried ampoule 10 mg 30 mg freeze dried ampoule 30 mg 5 mg 10 mg ampoule Morphine 5 mg Diconal (dipipanone) 10 mg tablet 3 mg 30 mg tablet Dihydrocodeine 5-10 mg 5 mg tablet Dextromoramide 2.5 mg, Pethidine 25 mg, 50 mg tablet 5 mg (taken orally) 8 mg 50 mg ampoule 2.5 mg 0.2 mg tablet Buprenorphine 4 mg 0.3 mg ampoule 4 mg Pentazocine 50 mg capsule 2 mg 25 mg tablet 100 ml 10 mg Codeine linctus (300 mg codeine phosphate) 15 mg, 30 mg, 60 mg 0.5, 1.2 mg Codeine phosphate tablets 6 mg 100 ml (200 mg codeine Actified Co. phosphate) 100 ml 8 mg Gee's linctus (16 mg anhydrous morphine)
Street heroin
'/2 g at £40-45 1/4 g (2x£20 bags)
Note: If tablets are ground up and injected they will avoid partial metabolism in the first pass through the liver and their methadone equivalent will be greater.
period or sometimes longer prior to detoxification to enable stabilization, self-assessment and change to take place. Dispensing should always be on a daily basis and the blue prescription form FP1O (MDA) allows the chemist to dispense controlled drugs daily for up to 14 days from one prescription. A maximum ceiling of 100 mg methadone/day should never be exceeded. The initial dose given will depend on the amount of opioids consumed over the previous week. A rough guide as to how much methadone to prescribe for users of other opioid drugs is given in Table 1. If unsure what dose to start on, discuss with the local drug dependency unit/community drug team. Prescribing can be initiated before results or urinalysis are known. Further urine screening may be done at intervals to ensure that the patient is not continuing to use illicit drugs. Some agencies feel that patients who have taken opioids for 10 years or more are unlikely to respond to a relatively short course of methadone and should probably be referred to a drug dependency unit. Methadone maintenance prescribing has been shown in other countries to be of value in helping to reduce the spread of HIV, but this form of treatment is best handled by the local specialist drug services, rather than in general practice. contract with the patient can be useful although many doctors prefer to work without one. If the surgery has not devised its own brief contract between a patient accepted for detoxification and the practice, the patient can be enA
48 couraged to attend the local community drug team who will supply such a contract as well as provide counselling and support.
Writing a prescription on form FP10 (MDA) The law demands that prescriptions for methadone mixture are completely handwritten by the doctor, that the dose is stated, and that the total amount is in both words and figures. When prescribing is down to small amounts the volume can be increased by adding methadone base (methadone mixture without any methadone). This makes it easier for the patient to swallow particularly at very small doses such as 2 mg. Chemists seem to prefer it if the amount to be dispensed each day is given with the date. Do not forget that most chemists are closed on Sundays and Bank Holidays. For example, a prescription might be written as follows: Name Address Methadone mixture 1 mg/ml 10 ml daily 10 ml Thursday (date) 10 ml Friday (date) 10 mlx2 Saturday (date) 10 ml Monday (date) 10 ml Tuesday (date) then 5 ml daily 5 ml Wednesday (date) Total 65 ml (sixty-five millilitres) (signature) Forms FPI0(MDA) are available from family health services authorities. Polydrug users have the poorest post-treatment outcome and the worst record of behaviour problems during treatment than any other group of drug users. For this reason they are sometimes best treated by specialists. However, general practitioners supported by a community drug team (CDT), or a street agency, can often be very successful in treating this difficult group of patients. The aim should be to stabilize the individual on a single drug, preferably methadone, while attention is directed at improving other areas of the drug taker's life such as family relationships, employment, and psychological problems before they are ready for detoxification. Both amphetamine (Cohen et al., 1982) and alcohol (Blum et al., 1980) use has been shown significantly to increase human plasma-endorphin levels and there is clinical evidence that the desire to take these drugs is reduced and often abolished by opiates. Possibly all dependent drug use is through a common endorphin pathway (Blum et al., 1980). If CNS depressant drugs have been taken, detoxification from these may be needed first, if withdrawal convulsions are to be avoided. Paradoxically polydrug users taking benzodiazepines are often less chaotic than those taking benzodiazepines alone, and a slow detoxification of benzodiazepines is often more achievable while there is joint prescribing of methadone. Once stabilization on a maintenance dose of methadone has occurred and adequate psychosocial change has taken place, the individual can be detoxified by reducing doses of methadone, perhaps over a 3-month period.
Psychosocial help Psychosocial help is best obtained by: 1. Ensuring a network ofprofessional helpfor the drug user This may include social worker, probation officer, youth worker, health visitor, community psychiatric nurse, community drug team, or street agency. The last two are invaluable local sources of help and will usually see the patient for a long counselling session each week as part of a contract made with him or her. 2. Encouraging attendance at local self-help groups particularly Narcotics Anonymous (NA), tel: 071 351-6794/6066). This does not suit everybody and should not be insisted upon.
3. Ensuring help for the family and involving them in the process of treatment has been shown to help the drug taker recover. The self-help group Families Anonymous (tel: 071 731-8060) and the support organization ADFAM, 99/101 Old Brompton Road, London, SW7 3LE (tel: 071 5814163) are particularly useful. In addition:
4. Legal advice and information can be obtained from Release, 169 Commercial Street, London, El 6BW (tel: 071
603-8654). 5. Further advice about services may be obtained from SCODA (Standing Conference on Drug Abuse), 1 Hatton Place, London, ECIN 8ND (tel: 071 430-2341).
6. For someone living in the London area in severe crisis which cannot be handled in a community setting, City Roads (Crisis Intervention) Ltd may offer admission and detoxification (tel: 071 278 8671). It is best to give patients this telephone number and ask them to come back to you if they are unsuccessful. 7. Drug users who are very damaged by prolonged drug use may best be treated by admission to one of the rehabilitation centres. Details of all current UK rehabilitation projects are given in a national directory entitled Drug Problems: Where to Get Help available through SCODA price £3.95. With one exception (ROMA) these all require the client to be drugfree on entry. The usual period of rehabilitation is 12-15 months. There are basically four types: (a) Concept houses which have a rigid hierarchical framework and lay considerable emphasis on confrontation, for example Phoenix House. (b) Christian houses with a caring atmosphere usually based on the family unit and often giving gentle counselling, for example Coke Hole Trust. (c) Community-based houses which aim to get drug users back into a normal community, for example Cranstoun. (d) Minnesota method houses often have joint drug and alcohol projects, are mainly in the private sector and give great emphasis to AA and NA. Thus there is a wide variety of rehabilitation available. Agencies who are working with drug users all the time develop expertise in placing someone appropriately and rehabilitation placements are usually best made through them.
49
Referral Those most suitable for treatment in a general practice setting include drug users with: * a short history * good support systems * family contacts * stable employment * single drug use * high motivation. Those most suitable for treatment by a specialist or drugdependency unit include: * the chronic chaotic multidrug user * those requiring treatment by injectable drugs * those requiring maintenance prescribing for more than 6 months * pregnant drug users.
Monitoring recovery Researchers determine recovery from drug use by looking at a number of social and economic variables as well as whether or not drug-taking has ceased. Such factors might include employment and financial status, whether there are continuing problems with the police, whether the drug taker is able to hold together a close personal relationship, and so on. It is helpful to use these as goals to monitor recovery. Monitoring psychological change is more difficult. One of the most important things a drug user must do is to leave all his or her drug-using friends and form a new circle of friends who do not use. Peer group pressure is a major factor in both relapse and recovery. Tackling psychological problems may be aided by a warm sympathetic approach and utilizing counselling skills gained from other surgery contacts. Some doctors find it helpful to ask the drug taker to write a life history. Recovery is generally slow and goes on long after a prescription for chemical substitutes has stopped. The general practitioner who has continuing care is therefore well placed to give professional help. Lapses must be expected from time to time but some may be prevented by opportunistic intervention. Lapses may occur as conditioned responses to various emotional (Marlatt and Gordon, 1985) or environmental (Wikler, 1980) cues. They may be preceded by a period of conscious deliberation, but with intervention they may be prevented from becoming prolonged relapses (Marlatt and Gordon, 1985). Some doctors have unrealistic expectations as to the effect of a prescription, expecting major changes in all areas the moment a prescribed drug is given as a substitute. Others view it purely as a substance problem and become angry or disillusioned if a slip occurs. Lapses and relapses may sometimes be prevented by the use of a contract and by regular monitoring of the urine for illicit drugs. A contract between the general practitioner and the drug taker will often be arranged by a local community drug team. It will generally contain an agreement not to use any non-prescribed drug, to attend appointments regularly, provide urine for analysis, not to use any verbal or physical threats or attempt to renegotiate a prescription. Many doctors, particularly when they first start treating drug users, find it helpful to have a contract, but it is not necessarily bad practice not to have one.
Public health implications It is important that all drug takers do have access to treatment not only for their own benefit and that of their families but also for the more important reason that the spread of AIDS into the general population will be mainly via index cases who are injecting drug users. All doctors therefore have a public health responsibility to ensure that treatment is available for their patients who are using drugs, and that efforts are made to lower the risk of behaviour likely to encourage the spread of HIV.
Audit points Audit can be applied for all those patients who have attended their general practitioner over a 12-month period asking for help with an illicit drug problem: 1. Proportion notified to the Home Office 2. Proportion who have received counselling for both injecting and sexual habits 3. Proportion tested for LFTs and hepatitis B and C 4. Proportion of those susceptible to hepatitis B infection who have been immunized 5. Proportion of opiate users who have received a prescription for a substitute opioid drug for at least 2 weeks 6. Frequency of urine testing as a percentage of consultations for all those receiving a prescription for a substitute drug. (Note: HIV testing and counselling for the HIV test have deliberately been excluded from this audit.) References Blum K, Briggs A H, Elston S F A et al. (1980) A common denominator theory of alcohol and opiate dependence. Review of similarities and differences. In Alcohol Tolerance and Dependence. Ed. Rigter H and Crabbe Jr J C. Amsterdam, Elsevier/ North Holland Biomedical Press. pp 371-91. Cohen M R, Pickner D, Dubois M et al. (1982) Clinical and experimental studies of stress and the endogenous opioid system. In Opioids in Mental Illness. Ed. Vereby K. Annals of the New York Academy of Sciences 398, 424-32. Marlatt G A and Gordon J R (1985) Relapse prevention. In Maintenance Strategies in the Treatment of Addictive Behaviours. New York, Guilford Press. Tyrer P, Owen R and Dawlings S (1983) Gradual withdrawal of benzodizepines after long term therapy. Lancet 1, 1402-6. Wikler A (1980) Opioid Dependence and Treatment. New York, Plenum.
Further reading Banks A and Waller T A N (1988) Drug Misuse: A Practical Handbook for GPs. London, Blackwell Scientific. Institute for the Study of Drug Dependence (1991) Drug Misuse and Dependence. Guidelines on Clinical Management. London, HMSO.
Further information ISDD (Institute for the Study of Drug Dependence) I Hatton Place London EC IN 8ND Tel: 071 430 1991.
Drug misuse Dr Tom Waller,
SUMMARY 1. Assessment by history and examination should include: a history of all drugs taken during each day for the previous 7 days (including alcohol), length of drug use and route (including the sharing ofneedles or syringes), the possibility ofpregnancy iffemale, previous psychiatric history and treatment of drug misuse, social factors (including employment, family, friends, involvement in prostitution, legal problems), medical problems, including evidence of hepatitis, injection abscesses and other infections, suicide attempts, and weight loss. 2. Notification to the Chief Medical Officer of the Drug Branch of the Home Office is a legal obligation. 3. Investigations include: liver function tests (LFTs), hepatitis B surface antigen (HBsAg), hepatitis B surface antibody (HBsAb), hepatitis C antibody, full blood count (FBC), and urine for drug screening. Consider HIV testing if at risk but it is usually better arranged at a later stage. 4. Prescribing may be consideredfor a variety of drugs but objectives will differ according to drug type and individual. 5. In the case of opioid users, prescribing may be useful to stabilize their lives and to promote attendance for professional help. lt may reduce high risk behaviour for contracting and spreading HIV 6. If medication is given to opioid users, methadone mixture 1 mg/ml given once a day is the prescription of choice. Dispensing should be on a daily basis and the blue prescription form FPJO (MDA) allows the chemist to dispense daily for up to 14 days. A maximum ceiling of 100 mg methadone! day should not be exceeded. The initial dose will depend on the amount of opioid consumed in the previous week. The duration ranges from 2 weeks for a brief detoxification to 6 months or longer for those who are very damaged and unstable. The latter group are probably more appropriately managed by a drug dependency unit. 7. A written contract with the patient is often helpful and it is advisable to undertake regular urine checks to detect drug use. 8. Other sources of help should be mobilized, for example a community drug team, community psychiatric nurse, social
worker; and probation officer:
Introduction Drug users or their families usually only look for help when a problem arising from illicit drug use has occurred. This may be legal, social, medical or simply a problem of supply. These problems do not always imply significant dependence on a drug or an overriding wish to stop using drugs.
MB BS
However, even the most apparently unmotivated drug user has some degree of ambivalence, and motivation to cease drug use is always enhanced by good professional help and the restructuring of life patterns. Seemingly unmotivated patients should not be denied medical help and will require counselling with regard to safer injecting and safer sex even if no other treatment is given. They may sometimes be encouraged to change by appropriate interviewing techniques. For the dependent drug user seeking help a variety of treatment options are available. A decision as to the most appropriate can only be made by a thorough assessment of the patient from a full history and examination.
History Try to determine the following: 1. The length of regular drug use causing the current drug problem. 2. The number and extent of any drug-free periods and how they were achieved. 3. An explicit drug history of the number and quantity of drugs (including alcohol) taken each day for the past 7 days. 4. Age of starting drug use. Commonly there is sequential drug use, for example cannabis at 15 years, amphetamines at 17 years, opioids at 18 years. 5. A past or present drinking problem. 6. Route of drug use, whether patient ever injects and whether he/she has ever shared needles or syringes ('works'). Ask if ever tested for HIV. Counsel about safer injecting and safer sex (this should always be done at first interview as this may be the only time the person attends). An HIV test, if organized, is better arranged at a later stage. 7. If female, ask specifically if there is any possibility of pregnancy. The amenorrhoea of pregnancy may be concealed by amenorrhoea from opioid use. (If pregnant, sudden withdrawal from opioids is life-threatening to the fetus and immediate treatment with methadone mixture is indicated.) 8. Previous psychiatric history. 9. Inpatient admissions to a psychiatric ward. 10. Extent of previous contact with drug services or previous treatment by a general practitioner/other doctor. 11. Admissions to a rehabilitation house. 12. Whether employed.
45
13. Any outstanding court cases, any previous trouble with the police. 14. Any social problems resulting from drug use. Family disruption, whether involved in prostitution (male or female). What social support is there by way of family and friends? Are there any children? 15. A medical history, particularly: 0
hepatitis
*
convulsions injection abscesses overdoses (intentional and accidental) suicide attempts septicaemia pneumonia cervical smears breathlessness weight loss
.
chronic diarrhoea.
0 0 0
0 0 0 0
0
Examination Things
to
look for
particularly
are:
1. Injection track marks (fresh and old) and state of superficial veins. Examine in particular arms, legs, hands, feet, and inguinal regions. 2. Signs of HIV disease. Lymph nodes particularly at anterior border sternomastoid, posterior triangle and submandibular region; hairy leukoplakia of tongue. 3. Jaundice. 4. Pupil size and nystagmus. 5. Hepatosplenomegaly. 6. Heart murmur (congenital heart lesions predispose the drug injector to bacterial endocarditis). 7. Pulse rate. A persistent rate >100 in someone withdrawing from barbiturates or other CNS depressants indicates liability to fit and urgent treatment is required. 8. Respiratory tract infections and tuberculosis. 9. Temperature. The withdrawal process is commonly associated with a mild rise in temperature (37.5°C). Cocaine and amphetamines may cause a pyrexia of 38°C. If these have not been taken in the previous 24 hours a pyrexia of 38°C or more may indicate septicaemia which is potentially life-threatening and easily overlooked.
Legal obligations If a general practitioner believes or suspects that he or she is attending a person who is dependent on one or more of a list of 'notifiable' drugs then the doctor is required by law to notify the Chief Medical Officer, Drug Branch, Home Office, Queen Anne's Gate, London SWIH 9AT within 7 days. Notification should be made annually thereafter if the practitioner believes the patient is still taking drugs. Failure to notify may cause a doctor to be brought before a tribunal. The notifiable drugs are: *
cocaine
*
dextromoramide (Palfium)
diamorphine (heroin) dipipanone (Diconal) hydrocodone hydromorphone levorphanol (Dromoran) methadone (Physeptone) morphine (Duromorph, MST Continus, Cyclimorph, Nepenthe) opium (Opium Tincture, Papaveretum, Omnopon) . oxycodone pethidine (Pethilorfan, Pamergan) phenazocine (Narphen) piritramide. When notifying the Home Office, the following particulars should be given if available: * name * address * date of birth * sex * NHS number * name of notifiable drugs to which the person is addicted * date of doctor's attendance. (Although not legally required the Home Office also appreciates the names of any notifiable drugs the doctor prescribes and whether or not the person notified has been injecting.) A form, HS2A 1 (rev), provided for notification is obtainable from family health services authorities or from: DoH Printing and Stationery Unit, Primrose Hill, Clitheroe, Lancashire (telephone: 0200-22187). The information provided is purely for statistics and to help other doctors. It is compiled into what is known as the Addicts' Index. Information from this index is not available to the police, or embassies, and will not affect anyone attending court or applying for a visa. Further information should be sought, where possible, from previous doctors whom the drug user admits attending and from the Addicts' Index by ringing 071 273 2213. In most areas form HS2A l(rev) has now being supplanted by a new form which has three sheets, the top to be retained, the second to notify the Home Office, and the third to send to the local health region to help establish a regional database. These new forms are also available through family health services authorities. Treatment issues The doctor should consider: 1. Whether treatment for any associated medical condition is required 2. Whether prescribing should be undertaken 3. What is the best way of facilitating psychosocial change.
Medical conditions Many important medical conditions may be overlooked in the drug user. Symptoms may be masked by drug use or be attributed to drug withdrawal. Some such conditions, for example head injury, appendicitis and septicaemia may be imminently life-threatening. Others such as HIV disease and chronic active hepatitis B and C may be symptomless but threaten life in the longer term. Chronic active hepatitis B is
46
now a potentially treatable condition and should be screened for by looking for persistently raised LFTs and a positive HBsAg for more than 6 months. Confirmation is by liver biopsy. The presence of antibodies to hepatitis C denotes chronic active hepatitis in the great majority of cases. After a prolonged asymptomatic latent period most cases progress to liver failure, cirrhosis, and hepatocellular carcinoma. This form of hepatitis can be found in 60-70% of some drugusing populations in the UK. The latent period appears to be about 20 years in those not taking illicit drugs but may be shorter in drug takers. Treatment is available but expensive.
Suggested investigations: * LFTs, HBsAg, HBsAb, antibodies to hepatitis C, FBC (consider HIV) * 50 ml urine (or as much as possible if less than this) for drug screening. A full blood count may show up anaemia due to inadequate nutrition or changes found in the later stages of HIV disease. If HIV testing is to be done at this juncture social support should be maximized. Fully informed consent must always be sought in conjunction with pre-test and post-test counselling. Prescribing Prescribing substitutes can be considered for a variety of drugs but the objectives will differ according to the drug type and the individual. Experience has shown that long-term prescribing to amphetamine users is generally not helpful, many developing psychotic features and behaviour changes. Most authorities do not prescribe to amphetamine users. If prescribing is undertaken, dexamphetamine can be given but for a suggested maximum period of 2 weeks. However, cessation of chronic amphetamine use of 15 years' duration or more may lead to a severe intractable depression, and such cases should be referred to a specialist for consideration for long-term substitute prescribing. Cocaine cannot be prescribed for the treatment of dependence unless a special licence has been issued by the Home Secretary. Tricyclic antidepressants have been used with modest success to reduce craving for cocaine. Most drug users who take benzodiazepines also take a number of other drugs including alcohol. The treatment of polydrug use is described later. It is rare to encounter high dose benzodiazepine use on its own but when this occurs it presents a very difficult problem. Like barbiturate users members of this group are generally chaotic, often appear drunk, suffer from memory loss and are difficult or impossible to counsel. Inpatient treatment is the best solution for those high dose barbiturate and benzodiazepine users, but in reality this is rarely available, although City Roads (telephone: 071 278 8671) may offer this facility if the patient is in crisis and lives in London. The general practitioner is therefore usually left with the responsibility for treatment and a slow benzodiazepine reduction as recommended for those on therapeutic doses of the drug which has been initiated under medical supervision is generally not practicable. Thus for high dose barbiturate and benzodiazepine users prescribe on the short term to prevent withdrawal fits
or delirium tremens. These are both complications of the 'general depressant withdrawal syndrome' found in those withdrawing from a number of drugs which depress the activity of the central nervous system. These drugs include barbiturates, benzodiazepines, alcohol, glutethimide, meprobamate, methaqualone and chlormethiazole. In theory this withdrawal syndrome could be countered by any one of these drugs. In practice it is best limited to one or two longacting drugs such as phenobarbitone or diazepam. Alcohol must be avoided during the withdrawal period. Using phenobarbitone to detoxify someone from high level barbiturate use, divide the stated amount of milligrams taken per day by 3 to work out total daily dose. Limit prescribing to 300 mg phenobarbitone/day, and reduce by a third every 2 days. For example: Tabs phenobarbitone 90 mg tds (2 days) 60 mg tds (2 days) 60 mg bd (2 days) 30 mg tds (2 days) (If using diazepam, 30 mg phenobarbitone is roughly equivalent to 15 mg diazepam.) Use diazepam to detoxify someone from high level benzodiazepine use. It is better to use a benzodiazepine to detoxify benzodiazepine users as up to 44% of these users may get a withdrawal reaction that is specific to benzodiazepines as opposed to other CNS depressant drugs (Tyrer et al., 1983). Most of the symptoms from this relate to heightened sensory perception, such as increased sensitivity to sound, light, touch, smell and taste, feelings of imbalance, gastrointestinal disorders, aches, pains, and muscle spasms. For some people these symptoms may be quite disabling and continue for a long period of time. However, as drug users taking high doses of benzodiazepines (eg 80 mg or more of diazepam) tend to be chaotic with impaired cognition they are difficult to treat on an outpatient basis, and withdrawal should initially be for a short period of time with the aim of preventing withdrawal fits and delirium tremens. Those taking less than 80 mg diazepam, or its equivalent, do not commonly seek help for their drug problem as problem drug use is unlikely to occur unless they are polydrug users. The initial withdrawal period should be slightly longer than that recommended for barbiturate users because late withdrawal fits can occur particularly in high dose diazepam users. This is because diazepam has an active metabolite, N-desmethyldiazepam, which has a half-life of over 100 hours. An initial detoxification period of 10-14 days is recommended but this may be extended if the drug taker complains of very severe symptoms which can be attributed to the specific benzodiazepine withdrawal syndrome. To calculate the initial dose, estimate the average total daily dose of benzodiazepine over the past 4 days, then convert to diazepam using the following rough equivalents: for diazepam 2.5 mg is equivalent to: * chlordiazepoxide 5 mg * nitrazepam 5 mg * lorazepam 0.5 mg * oxazepam 7.5 mg * temazepam 5 mg * triazolam 0.125 mg * lormetazepam 0.5 mg
47
The initial dose may have to be increased if excessive alcohol has been consumed in addition to benzodiazepines. Prescribing is best limited to a maximum of 120 mg diazepam/day. The patient must be told to avoid alcohol completely during the withdrawal period. An example of a detoxification regime might be: Tabs diazepam 30 mg qds (2 days) 20 mg qds (2 days) 20 mg tds (2 days) 15 mg tds (2 days) 10mgtds (2 days) 10 mg bd (2 days) 5 mg bd (2 days) The blue form FP1O (MDA) which allows daily dispensing by the pharmacist for up to 14 days cannot be used for either phenobarbitone or diazepam or dexamphetamine as, although these are controlled drugs, they are not controlled under Schedule 2 of the Misuse of Drugs Act 1971. Chlormethiazole users who are taking more than 4 grams/ day on a regular basis are at risk of developing a prolonged and severe psychosis on withdrawal and are best detoxified in hospital using reducing doses of chlormethiazole. Other CNS depressants are not effective in preventing this withdrawal psychosis.
Opioid detoxification This is an easily learnt technique and could be offered by most general practitioners. Opioid users are often well motivated to change and do not have those features of other drug use that make treatment so difficult: the impaired cognition and chaos of the high dose barbiturate/benzodiazepine user, or the psychotic and behavioural difficulties of those who use high doses of CNS stimulants. Treatment does not always necessitate the prescribing of chemical substitutes and indeed the avoidance of such prescribing is not likely to be medically disastrous unless the patient is pregnant. However, it is difficult and often impossible to facilitate the psychosocial changes necessary for recovery without such a prescription, for it is this that ensures regular attendance for professional help. It is this rather than the relief of physical withdrawal which is the main advantage of prescribing. For some, too, it helps stabilize their lives so they can avoid future conflict with the law or loss of job. Those that are refused treatment usually continue their illicit drug use, at least for a time, and often continue to risk contracting and spreading HIV. Oral methadone mixture (1 mg/ml) given once a day is the prescription of choice. It is long-acting and very unpleasant to inject. The rate of detoxification is best tailored to the individual rather than the rigid enforcement of a favourite detoxification regime to all comers. Those who have been using regularly for a short time (for example a year) and who appear to be relatively stable might be appropriately detoxified over 2 weeks, for example 20 mg methadone (3 days), 15 mg methadone (3 days), 10 mg methadone (3 days), 5 mg methadone (3 days). Those who have a longer history of drug use (for example less than 7 years) might be appropriately detoxified over a longer period perhaps 3-6 months, while those who have a long history of drug use and/or who appear to be very chaotic or damaged might best be maintained at a steady level over a 3- or 6-month
Table 1 Guide to rough methadone equivalent to prescribe for users of other opioids Rough methadone equivalent
Drug
1 g at £80-90
80 mg 40-60 mg 30-40 mg Pharmaceutical heroin 10 mg tablet (taken orally) 6 mg 10 mg freeze dried ampoule 10 mg 30 mg freeze dried ampoule 30 mg 5 mg 10 mg ampoule Morphine 5 mg Diconal (dipipanone) 10 mg tablet 3 mg 30 mg tablet Dihydrocodeine 5-10 mg 5 mg tablet Dextromoramide 2.5 mg, Pethidine 25 mg, 50 mg tablet 5 mg (taken orally) 8 mg 50 mg ampoule 2.5 mg 0.2 mg tablet Buprenorphine 4 mg 0.3 mg ampoule 4 mg Pentazocine 50 mg capsule 2 mg 25 mg tablet 100 ml 10 mg Codeine linctus (300 mg codeine phosphate) 15 mg, 30 mg, 60 mg 0.5, 1.2 mg Codeine phosphate tablets 6 mg 100 ml (200 mg codeine Actified Co. phosphate) 100 ml 8 mg Gee's linctus (16 mg anhydrous morphine)
Street heroin
'/2 g at £40-45 1/4 g (2x£20 bags)
Note: If tablets are ground up and injected they will avoid partial metabolism in the first pass through the liver and their methadone equivalent will be greater.
period or sometimes longer prior to detoxification to enable stabilization, self-assessment and change to take place. Dispensing should always be on a daily basis and the blue prescription form FP1O (MDA) allows the chemist to dispense controlled drugs daily for up to 14 days from one prescription. A maximum ceiling of 100 mg methadone/day should never be exceeded. The initial dose given will depend on the amount of opioids consumed over the previous week. A rough guide as to how much methadone to prescribe for users of other opioid drugs is given in Table 1. If unsure what dose to start on, discuss with the local drug dependency unit/community drug team. Prescribing can be initiated before results or urinalysis are known. Further urine screening may be done at intervals to ensure that the patient is not continuing to use illicit drugs. Some agencies feel that patients who have taken opioids for 10 years or more are unlikely to respond to a relatively short course of methadone and should probably be referred to a drug dependency unit. Methadone maintenance prescribing has been shown in other countries to be of value in helping to reduce the spread of HIV, but this form of treatment is best handled by the local specialist drug services, rather than in general practice. contract with the patient can be useful although many doctors prefer to work without one. If the surgery has not devised its own brief contract between a patient accepted for detoxification and the practice, the patient can be enA
48 couraged to attend the local community drug team who will supply such a contract as well as provide counselling and support.
Writing a prescription on form FP10 (MDA) The law demands that prescriptions for methadone mixture are completely handwritten by the doctor, that the dose is stated, and that the total amount is in both words and figures. When prescribing is down to small amounts the volume can be increased by adding methadone base (methadone mixture without any methadone). This makes it easier for the patient to swallow particularly at very small doses such as 2 mg. Chemists seem to prefer it if the amount to be dispensed each day is given with the date. Do not forget that most chemists are closed on Sundays and Bank Holidays. For example, a prescription might be written as follows: Name Address Methadone mixture 1 mg/ml 10 ml daily 10 ml Thursday (date) 10 ml Friday (date) 10 mlx2 Saturday (date) 10 ml Monday (date) 10 ml Tuesday (date) then 5 ml daily 5 ml Wednesday (date) Total 65 ml (sixty-five millilitres) (signature) Forms FPI0(MDA) are available from family health services authorities. Polydrug users have the poorest post-treatment outcome and the worst record of behaviour problems during treatment than any other group of drug users. For this reason they are sometimes best treated by specialists. However, general practitioners supported by a community drug team (CDT), or a street agency, can often be very successful in treating this difficult group of patients. The aim should be to stabilize the individual on a single drug, preferably methadone, while attention is directed at improving other areas of the drug taker's life such as family relationships, employment, and psychological problems before they are ready for detoxification. Both amphetamine (Cohen et al., 1982) and alcohol (Blum et al., 1980) use has been shown significantly to increase human plasma-endorphin levels and there is clinical evidence that the desire to take these drugs is reduced and often abolished by opiates. Possibly all dependent drug use is through a common endorphin pathway (Blum et al., 1980). If CNS depressant drugs have been taken, detoxification from these may be needed first, if withdrawal convulsions are to be avoided. Paradoxically polydrug users taking benzodiazepines are often less chaotic than those taking benzodiazepines alone, and a slow detoxification of benzodiazepines is often more achievable while there is joint prescribing of methadone. Once stabilization on a maintenance dose of methadone has occurred and adequate psychosocial change has taken place, the individual can be detoxified by reducing doses of methadone, perhaps over a 3-month period.
Psychosocial help Psychosocial help is best obtained by: 1. Ensuring a network ofprofessional helpfor the drug user This may include social worker, probation officer, youth worker, health visitor, community psychiatric nurse, community drug team, or street agency. The last two are invaluable local sources of help and will usually see the patient for a long counselling session each week as part of a contract made with him or her. 2. Encouraging attendance at local self-help groups particularly Narcotics Anonymous (NA), tel: 071 351-6794/6066). This does not suit everybody and should not be insisted upon.
3. Ensuring help for the family and involving them in the process of treatment has been shown to help the drug taker recover. The self-help group Families Anonymous (tel: 071 731-8060) and the support organization ADFAM, 99/101 Old Brompton Road, London, SW7 3LE (tel: 071 5814163) are particularly useful. In addition:
4. Legal advice and information can be obtained from Release, 169 Commercial Street, London, El 6BW (tel: 071
603-8654). 5. Further advice about services may be obtained from SCODA (Standing Conference on Drug Abuse), 1 Hatton Place, London, ECIN 8ND (tel: 071 430-2341).
6. For someone living in the London area in severe crisis which cannot be handled in a community setting, City Roads (Crisis Intervention) Ltd may offer admission and detoxification (tel: 071 278 8671). It is best to give patients this telephone number and ask them to come back to you if they are unsuccessful. 7. Drug users who are very damaged by prolonged drug use may best be treated by admission to one of the rehabilitation centres. Details of all current UK rehabilitation projects are given in a national directory entitled Drug Problems: Where to Get Help available through SCODA price £3.95. With one exception (ROMA) these all require the client to be drugfree on entry. The usual period of rehabilitation is 12-15 months. There are basically four types: (a) Concept houses which have a rigid hierarchical framework and lay considerable emphasis on confrontation, for example Phoenix House. (b) Christian houses with a caring atmosphere usually based on the family unit and often giving gentle counselling, for example Coke Hole Trust. (c) Community-based houses which aim to get drug users back into a normal community, for example Cranstoun. (d) Minnesota method houses often have joint drug and alcohol projects, are mainly in the private sector and give great emphasis to AA and NA. Thus there is a wide variety of rehabilitation available. Agencies who are working with drug users all the time develop expertise in placing someone appropriately and rehabilitation placements are usually best made through them.
49
Referral Those most suitable for treatment in a general practice setting include drug users with: * a short history * good support systems * family contacts * stable employment * single drug use * high motivation. Those most suitable for treatment by a specialist or drugdependency unit include: * the chronic chaotic multidrug user * those requiring treatment by injectable drugs * those requiring maintenance prescribing for more than 6 months * pregnant drug users.
Monitoring recovery Researchers determine recovery from drug use by looking at a number of social and economic variables as well as whether or not drug-taking has ceased. Such factors might include employment and financial status, whether there are continuing problems with the police, whether the drug taker is able to hold together a close personal relationship, and so on. It is helpful to use these as goals to monitor recovery. Monitoring psychological change is more difficult. One of the most important things a drug user must do is to leave all his or her drug-using friends and form a new circle of friends who do not use. Peer group pressure is a major factor in both relapse and recovery. Tackling psychological problems may be aided by a warm sympathetic approach and utilizing counselling skills gained from other surgery contacts. Some doctors find it helpful to ask the drug taker to write a life history. Recovery is generally slow and goes on long after a prescription for chemical substitutes has stopped. The general practitioner who has continuing care is therefore well placed to give professional help. Lapses must be expected from time to time but some may be prevented by opportunistic intervention. Lapses may occur as conditioned responses to various emotional (Marlatt and Gordon, 1985) or environmental (Wikler, 1980) cues. They may be preceded by a period of conscious deliberation, but with intervention they may be prevented from becoming prolonged relapses (Marlatt and Gordon, 1985). Some doctors have unrealistic expectations as to the effect of a prescription, expecting major changes in all areas the moment a prescribed drug is given as a substitute. Others view it purely as a substance problem and become angry or disillusioned if a slip occurs. Lapses and relapses may sometimes be prevented by the use of a contract and by regular monitoring of the urine for illicit drugs. A contract between the general practitioner and the drug taker will often be arranged by a local community drug team. It will generally contain an agreement not to use any non-prescribed drug, to attend appointments regularly, provide urine for analysis, not to use any verbal or physical threats or attempt to renegotiate a prescription. Many doctors, particularly when they first start treating drug users, find it helpful to have a contract, but it is not necessarily bad practice not to have one.
Public health implications It is important that all drug takers do have access to treatment not only for their own benefit and that of their families but also for the more important reason that the spread of AIDS into the general population will be mainly via index cases who are injecting drug users. All doctors therefore have a public health responsibility to ensure that treatment is available for their patients who are using drugs, and that efforts are made to lower the risk of behaviour likely to encourage the spread of HIV.
Audit points Audit can be applied for all those patients who have attended their general practitioner over a 12-month period asking for help with an illicit drug problem: 1. Proportion notified to the Home Office 2. Proportion who have received counselling for both injecting and sexual habits 3. Proportion tested for LFTs and hepatitis B and C 4. Proportion of those susceptible to hepatitis B infection who have been immunized 5. Proportion of opiate users who have received a prescription for a substitute opioid drug for at least 2 weeks 6. Frequency of urine testing as a percentage of consultations for all those receiving a prescription for a substitute drug. (Note: HIV testing and counselling for the HIV test have deliberately been excluded from this audit.) References Blum K, Briggs A H, Elston S F A et al. (1980) A common denominator theory of alcohol and opiate dependence. Review of similarities and differences. In Alcohol Tolerance and Dependence. Ed. Rigter H and Crabbe Jr J C. Amsterdam, Elsevier/ North Holland Biomedical Press. pp 371-91. Cohen M R, Pickner D, Dubois M et al. (1982) Clinical and experimental studies of stress and the endogenous opioid system. In Opioids in Mental Illness. Ed. Vereby K. Annals of the New York Academy of Sciences 398, 424-32. Marlatt G A and Gordon J R (1985) Relapse prevention. In Maintenance Strategies in the Treatment of Addictive Behaviours. New York, Guilford Press. Tyrer P, Owen R and Dawlings S (1983) Gradual withdrawal of benzodizepines after long term therapy. Lancet 1, 1402-6. Wikler A (1980) Opioid Dependence and Treatment. New York, Plenum.
Further reading Banks A and Waller T A N (1988) Drug Misuse: A Practical Handbook for GPs. London, Blackwell Scientific. Institute for the Study of Drug Dependence (1991) Drug Misuse and Dependence. Guidelines on Clinical Management. London, HMSO.
Further information ISDD (Institute for the Study of Drug Dependence) I Hatton Place London EC IN 8ND Tel: 071 430 1991.
