2635Prelims 7/4/04 1:27 pm Page i Care of Drug Users in General Practice A harm reduction approach Second Edition Edited by Berry Beaumont General Practitioner Foreword by David Haslam Chairman of Council Royal College of General Practitioners Boca Raton London New York CRC Press is an imprint of the Taylor & Francis Group, an informa business First edition 1997 First published 2004 by Radcliffe Publishing Published 2021 by CRC Press Taylor & Francis Group 6000 Broken Sound Parkway NW, Suite 300 Boca Raton, FL 33487-2742 © 2004 Berry Beaumont CRC Press is an imprint of Taylor & Francis Group, an Informa business No claim to original U.S. Government works ISBN-13: 978-1-85775-624-1 (pbk) This book contains information obtained from authentic and highly regarded sources. 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Typeset by Action Publishing Technology Ltd, Gloucester 2635Prelims 7/4/04 1:27 pm Page iii Contents Foreword v List of contributors vii Acknowledgements xi 1 A GP’s role: past, present and future 1 Clare Gerada and Tom Waller 2 Assessment of the drug user 11 Chris Ford and Brian Whitehead 3 General healthcare of drug users 21 Katie Kemp 4 Counselling drug users 35 Brian Whitehead 5 Polydrug use: cocktails and combinations, including benzodiazepines, alcohol and cannabis 43 Chris Ford and Tom Carnwath 6 Care of opiate users: maintenance treatment 57 Jenny Keen and Judy Bury 7 Care of opiate users: detoxification 73 Gordon Morse 8 Stimulants: cocaine, amphetamines and party drugs 81 Tom Carnwath 9 Safer injecting, safer use, safer sex: a harm reduction approach 93 Clare Gerada 10 Drug users with special needs: 99 Drug use and homelessness 99 Nat Wright Women who use drugs 105 Sue Tyhurst Caring for the pregnant drug user 108 Mary Hepburn Parents who misuse drugs 111 Jane Powell Black and minority ethnic (BME) drug use 114 Dima Abdulrahim Young people and drugs 117 Tom Aldridge 2635Prelims 7/4/04 1:27 pm Page iv iv Contents 11 What do drug users need from the general practitioner? 121 Alan Joyce 12 Families and carers 129 Vivienne Evans 13 Practical aspects of managing drug users 137 Judy Bury 14 The primary care team and shared care 147 Jim Barnard, Jean-Claude Barjolin and Christina McArthur 15 Working with other agencies 157 Kate Davies and Jim Barnard 16 Drugs and the law 167 Greg Poulter 17 Training, continuing professional development and appraisal 177 Linda Harris Index 183 2635Prelims 7/4/04 1:27 pm Page v Foreword Drug abuse is a nightmare feature of the 21st century. From tabloid headlines to crime statistics, this is a problem that makes most of us feel a sense of genuine despair. Pessimism and hopelessness are often rife. Good news is all too rare. But there is one area of hugely positive news relating to illegal drug abuse. The recent quite remarkable upsurge in interest by general practitioners and other members of the primary healthcare team in learning about how to tackle this problem is a huge counter to the prevailing pessimism. In the last few years over a thousand clinicians have been through the RCGP’s Certificate in the Management of Drug Misuse training course and many more have expressed an interest in becoming involved. At a time of apparently low national morale in general practice, of a dreadful workforce crisis and countless and increasing demands on the team’s time, it is even more remarkable that so many doctors, nurses and pharmacists have chosen to develop expertise in this vital area of care. For primary care to become involved is completely appropriate. Few condi­ tions exemplify more clearly the need for a generalist holistic approach to a problem. It has been estimated that some 50 000 drug users received treatment in a primary care setting in the year 2003 and, as Clare Gerada and Tom Waller write in their overview in this remarkable book, as a result of medical or other problems related to drug misuse, GPs may come in contact with users of a wide variety of drugs, often at a relatively early stage in their drug-taking career. Whilst the natural inclination to shrug and say that this problem is too great for GPs to deal with is completely understandable, nevertheless general practi­ tioners who have developed skills to manage problems related to drug use are in a unique position to facilitate change. Drug abusers may be the unhealthiest members of the population, with physical and mental health factors compound­ ing their drug problems. Whether the problems are depression, infection, diet, hygiene, childhood abuse, unemployment or any one of the other ills that flesh is heir to, the person who abuses illegal drugs is likely to have more health- related problems than almost anyone else. However, despite this obvious need there is a huge risk that this particular group of our population will suffer from the inevitable consequences of the inverse care law. This states that ‘the availability of good medical care tends to vary inversely with the need for it in the population served’.1 Or, as the Bible puts it: ‘Unto every one that hath shall be given, and he shall have abundance; but from him that hath not shall be taken away even that which he hath’. Could there be a more cogent and convincing reason for high-quality GPs and high- quality primary care teams to get involved? With most medical conditions, clinicians feel nervous and uneasy until their knowledge and skill base is adequate. Caring for road traffic accidents or emer­ gencies in childbirth make most of us nervous, because we lack experience and 2635Prelims 7/4/04 1:27 pm Page vi vi Foreword exposure. But drug abuse is becoming such a major part of our society that involvement of practices is becoming more and more pressing. The fact that this excellent book has reached its second edition is a measure of the interest that GPs and primary care teams are now showing in this topic and the speed with which knowledge and drug abuse, are changing. I commend it unreservedly. David Haslam Chairman of Council Royal College of General Practitioners April 2004 ■ Reference 1 Hart JT (1971) The inverse care law. Lancet. i: 405–12. 2635Prelims 7/4/04 1:27 pm Page vii List of contributors Dima Abdulrahim Specialist Adviser National Treatment Agency Hannibal House Elephant and Castle London SE1 6TE Tom Aldridge Young Person’s Manager National Treatment Agency Hannibal House Elephant and Castle London SE1 6TE Jean-Claude Barjolin Primary Care Development Adviser SMMGP (Substance Misuse Management in General Practice) c/o Trafford Substance Misuse Services 1–3 Ashton Lane Sale Manchester M33 6WT Jim Barnard Primary Care Adviser SMMGP (Substance Misuse Management in General Practice) c/o Trafford Substance Misuse Services 1–3 Ashton Lane Sale Manchester M33 6WT Dr Berry Beaumont Non-executive Director National Treatment Agency General Practitioner The Surgery 2 Mitchison Road London N1 3NG Dr Judy Bury Primary Care Facilitator (HIV/Drugs) Lothian Primary Care Trust Spittal Street Centre 22–24 Spittal Street Edinburgh EH3 9DU 2635Prelims 7/4/04 1:27 pm Page viii viii List of contributors Dr Tom Carnwath Consultant Psychiatrist County Durham Substance Misuse Service Pierremont Unit Hollyhurst Road Darlington DL3 6HX Kate Davies Co-ordinator, Nottinghamshire County Drug and Alcohol Team 5a Beech House Ramsom Wood Business Park Southwell Road West Rainworth Mansfield NG21 0ER Vivienne Evans Chief Executive, Adfam Waterbridge House 32–34 Loman Street London SE1 0EH Dr Chris Ford General Practitioner Chair RCGP Sex, Drugs and HIV Task Group GP Adviser, SMMGP (Substance Misuse Management in General Practice) Lonsdale Medical Centre 24 Lonsdale Road London NW6 6RR Dr Clare Gerada Project Director RCGP National Drug Misuse Training Programme Frazer House 32–38 Leman Street London E1 8EW Dr Linda Harris Clinical Director, Primary Care Substance Misuse Wakefield Integrated Substance Misuse Services Grosvenor House Union Street Wakefield WF1 3AE Dr Mary Hepburn Senior Lecturer in Women’s Reproductive Health Consultant Obstetrician and Gynaecologist University of Glasgow Princess Royal Maternity Hospital Alexandra Parade Glasgow G31 2ER 2635Prelims 7/4/04 1:27 pm Page ix List of contributors ix Alan Joyce Senior Advocate, The Methadone Alliance c/o The Alliance PO Box 32168 London N4 1XP Dr Jenny Keen Clinical Director, Primary Care Clinic for Drug Dependence, Sheffield Clinical Research Fellow, Institute of General Practice and Primary Care, University of Sheffield Guernsey House 84 Guernsey Road Sheffield S2 4HG Dr Katie Kemp Specialist in Primary Care Camden and Islington Substance Misuse Services Primary Care Unit St James’s House 109 Hampstead Road London NW1 2LS Christina McArthur Primary Care Adviser SMMGP (Substance Misuse Management in General Practice) c/o Trafford Substance Misuse Services 1–3 Ashton Lane Sale Manchester M33 6WT Dr Gordon Morse Medical Consultant to Clouds House RCGP Regional Lead, South West England Riversdale High Street Fovant Salisbury Wiltshire SP3 5JL Greg Poulter Director, DETRU 11 Doverfield Road Guildford GU4 7YF Jane Powell Children’s Guardian Senior Development Officer, National Children’s Bureau PO Box 44605 London N16 6XD