Managing Drug Abusers in Primary Care

The management of opioid dependence requires medical, social, and psychological treatment. Management is most effective when delivered by the coordinated efforts of a multidisciplinary team. Primary care has a major role in many aspects of care, including initial assessment, support and treatment. The Department of Health has produced guidelines for the clinical management of drug misuse. The guidelines are available on the Substance Misuse Management in General Practice website.¹

• It is estimated that in 2002/03 there were around 140,900 problem drug misusers in treatment at drug treatment agencies and general practitioners in England, compared to around 128,200 in 2001/02 (an increase of 10%).¹
• In England, during the six month period ending 31 March 2001, about 33,200 users were reported as presenting to drug misuse agencies. 50% of those users presenting were in their twenties and about 13% were aged under 20, as in previous periods. The ratio of males to females was 3:13.¹
• Heroin was still the most frequently reported main drug of use, accounting for 67%. The next most frequently reported main drugs of misuse were cannabis (9%), methadone (8%), cocaine (7%) and amphetamines (3%).¹

• Aims of assessment
  • To treat any emergency or acute problem
  • Confirm patient is taking drugs (history, examination and urine analysis)
  • Assess degree of dependence
  • Identify complications of drug misuse and assess risk behaviour
  • Identify other medical, social and mental health problems
  • Give advice on minimising harm, including, access to sterile needles and syringes, testing for hepatitis, HIV and immunisation against hepatitis B
  • Determine the patient's expectations of treatment and the degree of motivation to change
  • Refer and liaise appropriately with local substance misuse services
  • Determine the need for substitute medication
  • Notify the patient to the local Regional Drug Misuse Database using the appropriate local reporting form. Contact numbers are also given in the BNF.²
• History should include:
  • Reason for presentation
  • Past and current (last 4 weeks) drug use
  • History of injecting and risk of HIV and hepatitis
  • Medical and psychiatric history
  • Past and present contact with the criminal justice system
  • Assessment of social and family situation
  • Past contact with treatment services
  • Drug and alcohol misuse in partner, spouse and other family members
  • Impact of drug misuse on other aspects of the patient's life

Informed consent is required.

• Haemoglobin, creatinine, liver function tests
• Hepatitis B, Hepatitis C, HIV antibody
• Urine analysis should be obtained at the outset of prescribing and randomly throughout treatment. Opioids can be detected in the urine for up to 2-4 days (up to 7-9 days for methadone). False positive and negative results can occur.³ Ask the patient to produce a specimen on the premises. Though supervision of urine collection lessens the likelihood of introducing a substituted or contaminated sample, it is often impracticable.

It is no longer necessary to notify the Home Office. However doctors are expected to report on a standard form available from their local Drug Misuse Database when a patient first presents with a drug problem or one re-presents after a gap of six months.

Non-drug

• A multidisciplinary approach with local shared care guidelines is essential. Shared care should deliver a flexible service, adapted to the needs of the individual.
• Ensure that all physical and mental health as well as social problems are properly evaluated and addressed.
• Health education on access to sterile needles and prevention of infection, particularly HIV, hepatitis
• Keep good, clear records of prescribing
• Before prescribing substitute drugs the doctor should establish:
  • The drug/s is/are being taken on a regular basis and there is convincing evidence of current dependence.
  • The patient is motivated to change at least some aspects of their drug use. What changes the patient wishes to make in the way he or she uses drugs.
  • The patient appears likely to co-operate and demonstrate adequate compliance with the prescribing regime.
  • What lifestyle changes the patient wants to make.
  • How a prescription might help the patient to achieve these changes.
• It is good practice for all new prescriptions to be taken initially under daily supervision (doctor, nurse or community pharmacist) for a minimum of three months, and after this time if felt appropriate.

Drug management

• Drug treatment for drug dependence must be given as part of a support programme to help the person manage their drug dependence.
• Dose reduction regimes should be shaped by a realistic appraisal of jointly agreed treatment goals and outcomes between the patient, the doctor and other members involved in the patient's care.
• Maintenance prescribing: while some patients can achieve abstinence rapidly, others require the support of the prescribed drugs for longer than just a few months. Longer-term prescribing should be reviewed at regular intervals (at least 3-monthly) and should be part of a broader programme of social and psychological support. It should not be a treatment of first choice in a patient presenting for the first time, where other options have not initially been explored and tried.
• Preventing relapse:
  • Withdrawal and detoxification regimens have a high failure rate unless linked to long-term rehabilitation.
  • Non-pharmacological approaches, e.g. behavioural techniques, rehabilitation and therapeutic communities, self-help groups, such as Narcotics Anonymous (NA).
  • Community Care Assessment can be accessed through local Social Service Departments. Such services have some funding to purchase residential or day programmes for individuals, after appropriate assessment.

Opioid dependence

There are separate articles that cover cocaine addiction and amphetamine abuse.

• Methadone and buprenorphine are recommended as treatment options for people who are opioid dependent. Unless there are any particular individual reasons to prescribe buprenorphine, methadone should be given as the first choice. The methadone or buprenorphine should be taken daily in the presence of their doctor, nurse or community pharmacist for at least the first 3 months of treatment and until they are able to continue their treatment correctly without supervision.⁴
• Methadone: opioid agonist. Can be substituted for opioids, preventing the onset of withdrawal symptoms. Is itself addictive and should only be prescribed for those who are physically dependent on opioids. It is administered in a single daily dose usually as methadone oral solution 1 mg/ml. The dose is adjusted according to the degree of dependence with the aim of gradual reduction. Slow tapering with temporary substitution of long acting opioids such as methadone, accompanied by medical supervision and ancillary medications can reduce withdrawal severity but the majority of patients relapse to heroin use.⁵
• Buprenorphine: an opioid partial agonist. It also has abuse and dependence potential. It is effective in maintenance treatment and can be used as substitution therapy for patients with moderate opioid dependence. In patients dependent on high doses of opioids, buprenorphine may precipitate withdrawal due to its partial antagonist properties. In these patients, the daily opioid dose should be reduced gradually before initiating therapy with buprenorphine. Buprenorphine is more effective than clonidine and there is no significant difference between buprenorphine and methadone for the management of opioid withdrawal.⁶
• Naltrexone: recommended as a treatment option for people who have been opioid dependent but who have stopped using opioids, and who are highly motivated to stay free from the drugs in an abstinence programme. If there is evidence that the person has been using the drugs again then the naltrexone treatment should be discontinued.⁷
• The alpha-adrenergic agents clonidine and lofexidine have been used to aid withdrawal from opiates, but have not been shown to be more effective than the use of methadone or buprenorphine. Lofexidine has a lower incidence of hypotension.⁸
• Psychosocial treatments offered in addition to pharmacological detoxification treatments are effective in terms of completion of treatment, results at follow-up and compliance.⁹
• Family-couples therapy has been shown to be more effective than individual-based therapies.

Hypnotic or anxiolytic dependence

• Diazepam is known to be much less addictive than lorazepam and other short-acting drugs; therefore, the first step in withdrawal is to change the drug to diazepam.
• Aim for the lowest dosage of diazepam that will prevent withdrawal symptoms.
• The dosage of diazepam should then be reduced in fortnightly or monthly steps.¹⁰

• Opiate poisoning, overdose
• Dangers associated with drug misuse, particularly the risk of HIV, hepatitis B and C, and other blood-borne infections
• Risk of deep vein thrombosis and infections, including abscess formation, at injection sites
• Criminal activity to finance drug misuse

• In a substantial proportion of patients, drug misuse tends to improve with time and age.
• A long-term follow-up of heroin addicts showed they had a mortality risk nearly twelve times greater than the general population.¹¹
• Another study of injecting drug misusers showed that they were twenty-two times more likely to die than their non-injecting peers.¹²
• Recent research in the UK has shown that from 1985-1995 there was a marked increase in drug-related deaths amongst young people, aged 15-19 years.¹³
• Mortality from self-poisoning with opiates has increased over ninefold in the past two decades.¹⁴
• Effects on family: there are between 250,000 and 350,000 children of problem drug users in the UK.¹⁵

• Traditional school-based prevention programmes have produced disappointing results but more recent prevention models that focus on the psychosocial factors believed to promote substance abuse have been more effective.¹⁶
• In response to the increasing individual and social problems, support groups, governments and the World Health Organisation are running and developing education campaigns to prevent substance abuse.¹⁷