Substance Misuse - my Tips

This page has my advice on what actually to do  - something that the DoH guidelines are rather short on.

They are my own views, and other GPs may not necessarily agree with them.

"I want a prescription, and I want it now"

A patient registers with you, states that he takes heroin/valium/dihydrocodeine; he wants a prescription for methadone/diazepam/dhc now or he says he'll do a burglary to raise money for his next fix. If you don't give the prescription it'll be your fault...

No. Before you prescribe there needs to be:

• a medical assessment (by a GP) at a time of your choosing;
• an assessment by the drugs agency;
• a recommendation by the drugs agency on whether and what to prescribe;
• a clear treatment plan and contract.

Make it clear to the patient that if he commits a crime, it is his responsibility and his alone.

"I take Valium (or dihydrocodeine or codeine linctus...) and need a prescription for that"

As I state on the prescribing page, methadone is the only prescription where you can ensure controlled, supervised, daily consumption, with the least chance of misuse.

Benzos (and dhc, codeine linctus etc) have a significant street value:

• if you prescribe a week's worth of benzos, you can't control what will happen to them;
• my experience is that a significant proportion will be sold;
• my advice is never to prescribe benzos (or dhc or codeine linctus etc) to addicts.

Not all GPs agree with this, however.

The first week of prescribing

GPs aren't obliged to treat addictions. If you and your practice do, then the the drugs team should give you advice on the starting dose of methadone.

Patients have died from starting doses that are too high, and their doctors have been taken to the GMC because of it. So, we start low and titrate up. For instance:

• the drugs team may suggest starting a patient on 35ml methadone daily;
• give a single prescription ("to be consumed on the premises")
• review the next day; is the patient "clucking" (showing signs of withdrawal)?
  • if so, increase to, say, 40ml
• review daily and, if needed, increase the dose until there are no symptoms of withdrawal and he doesn't need "on-top" heroin use.

Warn the patient that while they are on daily consumption:

• they can't go away on holiday;
• if they work or find a job, they will still need to visit the pharmacy daily.

The first month of prescribing

See the patient weekly:

• give support and encouragement;
• be prepared to increase the dose if needed - if the patient is getting withdrawal symptoms, they will use heroin on-top, and you want to avoid that;
• as soon as the patient says he is "clean", start weekly urine testing;
• check that they are seeing the drugs counsellor regularly.

Advice on urine testing.

Tell the patient in advance:

• that he will be testing weekly then randomly;
• they will need to provide the sample while they are in the surgery:
  • they can't bring it with them;
  • they will need to arrive ready to pass urine - if they say they can't provide a sample, that will count as a positive test.
• that they can only take (and you can only prescribe) paracetamol or NSAIDs as painkillers while on methadone:
  • the urine testing will show positive if the patient has taken co-proxamol, for instance, as the test can't distinguish between it and heroin;
• a positive result, for whatever cause, is unacceptable and will result from the patient being withdrawn from the treatment programme
• (however, many clinicians will allow one or two positive results before stopping treatment).

Beware - when they give you their sample, some patients will tell you that they have used heroin on-top that week, in the hope that their honesty will stop you counting it as a positive result. Don't be bamboozled.

The lab should give results for a variety of drugs of abuse:

• discuss cannabis use with the patient; if the test shows they have used it, will you count it as a positive result and consider stopping prescribing?
• expect the test to be positive for opioid (methadone is an opioid) and negative for opiates (eg heroin, dihydrocodeine).

When you're away

Make sure that your plan and prescribing system is clear in the notes, so that if you are off sick or on hols someone else know what to do. For instance, state:

• whether daily pickup & consumption on the premises;
• when next urine test planned;
• if recent positive urine test, what action should be taken if next one is positive also;
• discussions between you & drugs worker.

Maintenance

When the patient is stable on methadone and has had at least two negative tests in a row, you may wish to see the patient less frequently:

• every two weeks
• or every month, with the drugs worker seeing them and giving them their prescription in between seeing you.

Continue urine tests, every month and then randomly.

Don't relax the "daily consumption on the premises" rule until they have been stable for a few months and have had consistently negative urine screening.

Reduction

At some stage, with the agreement of the patient, reduce the daily methadone dose:

• consider letting the patient dictate the pace - they are the ones that will need to handle the withdrawal symptoms;
• a 5ml daily reduction every month is typical, though may be too quick for some.

Continue

• regular review, and
• random urine testing.

If the contract has been broken - when to stop prescribing

Your contract with the patient should explain under which circumstances you will stop prescribing. Examples are:

• a second positive urine test;
• persistent late attendances or DNAs;
• failure to engage (e.g. seeing the drugs worker but not working with him/her);
• any abusive behaviour to staff.

Following abusive behaviour you may feel it appropriate to stop prescribing immediately.

Otherwise, a reduction to zero over 3-4 weeks may be suitable - discuss it with the drugs worker if needed.

If stopping prescribing, many practices have a rule that they won't consider re-starting methadone for a certain time, e.g. 6 months.

Is it worth it?

Yes.

Untreated, heroin addiction has a high fatality rate.

If you and your practice have a consistently-applied drugs prescribing policy, the word will soon get around on the streets and many of the addicts that you see will be serious about withdrawing.

It's really satisfying to see the change in addicted patients:

• when they first present they often look ill and are having a miserable time as a result of their heroin addiction;
• a couple of months later their appearance can be transformed - looking well and keeping a job down.

Stopping heroin is very, very difficult. Many won't complete the course or will relapse. Even if they are only stable for a couple of months, you will have helped

• reduce a patient's risk from
  • injecting,
  • illegal behaviour;
• increase the chance of a future successful withdrawal.

On to:       Health and safety; managing challenging behaviour

Back to:    Substance misuse home page

Written by:    Michael Harris

Last update: 07 May 2007

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