Substance-misusing Patients in Primary Care: incidence, services provided and problems. A survey of general practitioners in Wiltshire

This research aimed to discover the monthly incidence of patients misusing illicit drugs or alcohol seen by general practitioners; services provided; difficulties encountered; and general practitioner willingness. The total population of general practitioners (n = 210) in the Health Commission for Wiltshire was sent a postal questionnaire: 49% responded (n = 103), and 10% of respondents were interviewed. The number of alcohol-misusing patients seen per month was much higher than illicit drug-misusing patients: 46% of respondents saw fewer than one patient for prescribed opiates, and 71% saw fewer than one solvent misuser, per month; in contrast, only 7% of respondents saw fewer than one alcohol-misusing patient per month. Ninety-two per cent of general practitioners provided general medical services for alcohol misusers, and 86% for illicit drug misusers. Fifty-four per cent of respondents provided substitute medication for illicit drugs, while 42% provided detoxification medication for illicit drugs. Sixty-five per cent provided medication for alcohol detoxification. Difficulties encountered included missed appointments, time-wasting, aggressive behaviour, communication difficulties and upset to other patients. Twelve per cent of general practitioners were willing to provide more services for illicit drug users, compared with 27% for alcohol users. The greater unwillingness to work with illicit drug users appeared disproportionate to the number previously encountered. Interventions to improve the situation for general practitioners and substance-misusing patients are discussed.     

Preliminary results of two nation-wide epidemiological studies of drug use in Greece: a study of known cases and a general population survey

Multidimensional epidemiological research on drug use in Greece comprising five studies--a study of known cases, a general population survey, a survey of high school students, a study of imprisoned drug addicts and a case identification study--has been undertaken by the Department of Psychiatry, University of Athens. This article summarizes preliminary results obtained in the study of known cases and the general population survey. A study of prevalence of known cases identified 9,689 cases of drug use in Greece (8,821 males and 868 females) who came to the attention of the authorities in 51 counties of the country from 1973 to 1983. Average-age adjusted rates of known drug users per 100,000 were 50 for males and 3 for females. Cannabis resin was the drug most often used by males and heroin and other opiates by females. The average age was 35.7 for male and 31.2 for female drug users. A nation-wide general population survey of drug use, carried out in 1984 on the basis of a probability sample covering the population aged 12 to 64 years, showed that at some time in their lives 5.5 per cent of the respondents (9.1 per cent of the males and 2.5 per cent of the females) used illicit drugs and 11.1 per cent (6.5 per cent of the males and 14.9 per cent of the females) licit drugs. Cannabis resin was the most frequently used illicit drug by both male and female respondents.(ABSTRACT TRUNCATED AT 250 WORDS)     

Cross‐sectional survey of medication used for headache in a general population

Objective To determine the level and types of medication used to treat headache in the general population and to compare this with current recommendations. Methods Cross‐sectional survey to an adult general population sample. A questionnaire gathered information on occurrence, characteristics of, and medication use for headaches in the previous three months. Setting Patients aged 18 years and over registered with five general practices in North Staffordshire, England. Key findings The response rate was 56%. Eighty‐five per cent of headache sufferers (60% of all questionnaire respondents) reported using medication for their headaches in the three months prior to the survey. Medication use was more likely to be reported by women, respondents aged 36 to 50 years, those reporting more painful and more disabling headaches, those experiencing at least five associated symptoms, and those whose untreated headaches lasted 4 to 24 hours. Paracetamol was by far the most widely used medication, with 74% of medication users taking it in the three‐month period. Fifty‐eight per cent of acute medication users took only one single therapy for their headaches. Only a small number of medication users (3%) took their headache medication before the pain began, with most (63%) taking it when the pain started and the remainder waiting until the pain was unbearable. Half of medication users (47%) reported that the medication completely relieved their headache, 51% obtained partial relief and 2% did not obtain relief. Conclusion Medication use for headache appears to be appropriate for most patients. Although only a minority used combination therapy, the high prevalence of headache means that this translates to substantial numbers in the population as a whole. Some headache sufferers might benefit from advice to make better use of the treatments available.     

How do general practitioners manage alcohol-misusing patients? Results from a national survey of GPs in England and Wales

The appropriateness of the primary care setting to undertake health promotional activities has been emphasized, but little is known about the clinical work of GPs with patients misusing alcohol. This study examines how GPs managed alcohol-misusing patients. A 20% random sample of all general practitioners in England and Wales were surveyed using a postal questionnaire. A 44% response rate was achieved. GPs reported managing different levels of severity of drinking problems differently. Basic interventions, such as reporting the alcohol misuse diagnosis and the provision of advice and information, were routine. Health promotion leaflets were not used uniformly, even with the less severe problem drinkers. Detoxification, prescribing of drugs and the management of medical complications were undertaken mainly with dependent patients. Dependent drinkers were the most likely group to be referred to specialist services, while internal practice referrals occurred with all drinking status categories. Anti-depressants were the drugs most usually prescribed to alcohol-misusing patients. The data point to a need for basic guidelines, not only on how to manage and refer dependent drinkers, but also on how to detect and manage those who are not yet manifesting problems but are drinking above recommended guidelines. One of the most evident areas in which there appears to be a need for guidelines is that of prescribing within primary care.     

The Consultancy Liaison Addiction Service - the first 5 years of an integrated, primary care-based community drug and alcohol team

Government policy, running through the 10-Year Drug Strategy, Tackling Drugs to Build a Better Britain (The Stationery Office, 1998) and the New Drug Misuse Clinical Guidelines (Department of Health, The Scottish Office, 1999) highlights the need for health authorities and now PCGs to invest in shared care mechanisms to support primary care in its task of caring for drug misusers. Primary Care Trusts, as freestanding NHS organizations, will in time be able to commission, purchase and provide these services themselves, using primary care expertise alongside specialists. This paper describes a model of primary care-based shared care service, the Consultancy Liaison Addiction Service, that has been in operation for 5 years in South London, that predates these changes in the NHS yet could be considered by PCGs or PCTs when planning services for drug misusers. The service comprises a team of drug and alcohol community psychiatric nurses, supported and managed by a principal in general practice. Together they have worked with 72 neighbouring general practices, supporting the treatment of alcohol-misusing and drug-misusing patients. The team has a separate identity from, but is closely integrated into the secondary specialist addiction service producing effective continuum of care.     

The management of alcohol, tobacco and illicit drug use problems by general practitioners in Australia

The aim of this study was to document the frequency of the management of illicit drug, alcohol and tobacco problems in general practice in Australia. Data from the Bettering the Evaluation and Care of Health (BEACH) study of general practice, April 1998 to March 2003, were analysed. BEACH is an ongoing national study of general practice in Australia. Each year a random sample of approximately 1000 general practitioners (GPs) participate, each providing details of 100 patient encounters. Samples are drawn from the Medicare data held by the Health Insurance Commission. Patient demographic breakdowns, medication, other treatment, referrals and other medical procedures ordered were examined for all problems labelled by GPs as illicit, alcohol and tobacco problems. Annually in Australia, it was estimated that 615 000 GP encounters—or 0.6% of all encounters—involved the management of illicit drug use problems presumably most commonly for problematic heroin use. Despite a much higher population prevalence of use and use disorders, the management of alcohol or tobacco use problems was less common, with 0.4% and 0.3% of encounters, respectively, comprising treatment of these problems. Clear demographic differences existed across the groups. The management of problems also differed, with illicit drug use problems more likely to involve provision of medication, and alcohol and tobacco treatment more likely to involve counselling and/or health advice. Despite higher rates of alcohol and tobacco use problems among patients seeing GPs in Australia, the rate of treatment for such problems was relatively lower than it was for illicit drug use problems. More efforts need to be directed towards assisting GPs to identify and target problematic alcohol and tobacco use among their patients. [Degenhardt L, Knox S, Barker B, Britt H, Shakeshaft A. The management of alcohol, tobacco and illicit drug use problems by general practitioners in Australia. Drug Alcohol Rev 2005;24:499-506]     

The Consultancy Liaison Addiction Service - the first 5 years of an integrated,primary care-based community drug and alcohol team

Government policy, running through the 10-Year Drug Strategy, Tackling Drugs to Build a Better Britain (The Stationery Office, 1998) and the New Drug Misuse Clinical Guidelines (Department of Health, The Scottish Office, 1999) highlights the need for health authorities and now PCGs to invest in shared care mechanisms to support primary care in its task of caring for drug misusers. Primary Care Trusts, as freestanding NHS organizations, will in time be able to commission, purchase and provide these services themselves, using primary care expertise alongside specialists. This paper describes a model of primary care-based shared care service, the Consultancy Liaison Addiction Service, that has been in operation for 5 years in South London, that predates these changes in the NHS yet could be considered by PCGs or PCTs when planning services for drug misusers. The service comprises a team of drug and alcohol community psychiatric nurses, supported and managed by a principal in general practice. Together they have worked with 72 neighbouring general practices, supporting the treatment of alcohol-misusing and drug-misusing patients. The team has a separate identity from, but is closely integrated into the secondary specialist addiction service producing effective continuum of care.     

Drug use and problem drinking associated with primary care and emergency room utilization in the US general population: data from the 2005 national alcohol survey

BACKGROUND: Substance use problems are overrepresented in probability samples of patients in primary care settings including the emergency room (ER) compared to the general population. While large proportions of those with alcohol or drug use disorders are most likely to obtain services for these problems outside the mental health or substance abuse treatment system, accounting, in part, for this overrepresentation, little is known about the association of alcohol misuse or drug use with health services utilization in the general population. METHODS: The prevalence and predictive value of alcohol misuse and drug use on ER and primary care use was analyzed on 6919 respondents from the 2005 National Alcohol Survey (NAS). RESULTS: Among those reporting an ER visit during the last year, 24% were positive for risky drinking (14+ drinks weekly for men and 7+ for females and/or 5+/4+ in a day in the last 12 months), 8% for problem drinking, 3% for alcohol dependence, and 7% for illicit drug use greater than monthly. Figures for primary care users were, respectively: 24%, 5%, 3%, and 3%. ER users were more likely to be positive for problem drinking and greater than monthly illicit drug use compared to non-ER users, while no significant differences were found in substance use for users and non-users of primary care. In logistic regression controlling for gender, age, and health insurance, problem drinkers were twice as likely as non-problem drinkers (Odds ratio, OR=1.99) (p<0.01), and those reporting greater than monthly drug use were almost twice as likely as those using drugs less frequently or not at all (OR=1.92; p=0.01) to report ER use, while those reporting alcohol dependence were 1.63 times more likely to report primary care use (p<0.05). CONCLUSION: These data support the belief that both the ER and other primary care settings are important sites for identifying those with substance use problems and for initiating a brief intervention.     

Recreational drug use: patterns from a South Wales self-report survey

This study aimed to examine patterns of illicit recreational drug use, alcohol consumption, and smoking in a community-based population sample. A postal questionnaire survey was conducted of people who were selected at random from the Electoral registers of Cardiff and Merthyr Tydfil. Twelve percent of respondents reported illicit recreational drug use in the last year, and 7% in the last month. Among respondents aged under 25 years, 34% (39% of males and 31% of females) had used illicit drugs in the last year, and 19% (23% of males and 17% of females) in the last month. Twenty-one percent of respondents smoked (20% of males and 22% of females). Twenty-seven percent of respondents reported drinking more alcohol than currently recommended sensible limits (36% of males and 21% of females). Among respondents aged under 25 years, 53% of men and 38% of women drank over these limits. Illicit drug use was associated with heavy alcohol consumption and, in particular, with smoking. Smoking and heavy alcohol consumption combined was most strongly associated with illicit drug use. Rates of illicit recreational drug use were higher than have previously been reported for Wales. Illicit drug use and smoking varied with age, sex, work status and geographical location, whereas heavy alcohol consumption varied with age, sex and work status, but not geographical location. Both smoking and alcohol consumption were associated with illicit drug use, with smokers who were also heavy drinkers being those most likely to report illicit drug use.     

Low detection rates, negative attitudes and the failure to meet the "Health of the Nation" alcohol targets: findings from a national survey of GPs in England and Wales

The appropriateness of the primary care setting to undertake the health promotional activities needed to meet 'Health of the Nation' alcohol targets has been acknowledged in UK government policy and the scientific literature. However, the latest data suggest these targets are not being met. A 20% random sample of all general practitioners in England and Wales were surveyed by postal questionnaire to examine their work in detecting alcohol misuse and their attitudes towards the work. Four mailing waves produced a 44% response rate. GPs had identified a mean of 3.2 patients per month drinking above recommended 'sensible' guidelines. These patients were mostly male (73%) and above 40 years of age (45%), with nearly half (45%) already dependent drinkers. Most GPs perceived alcohol misuse patients as a difficult group with whom to work. None the less, over half the respondents believed general practice was an appropriate setting for the detection of the problem. However, most did not feel trained or supported in this area of their work. More emphasis needs to be placed on the valuable contribution GPs can make with the larger number of patients who are drinking regularly above 'sensible' levels but not yet suffering adverse affects. Our findings point towards not an unwilling profession, but a profession lacking confidence. The provision of support and basic training are major factors in how GPs perceive alcohol misusers and their own role in this work. Twenty years after the Maudsley Alcohol Pilot Project research it is disappointing that, despite greater recognition by GPs of their potential impact, lack of training and lack of support are still so central to their continued low levels of therapeutic commitment.     

Extent and patterns of drug use by students at a Spanish university

A drug-use survey of 1,010 randomly chosen students at the University of Oviedo in Spain was carried out in 1986. The survey instrument used was a self-administered questionnaire. During the 12 months before the survey, 91 per cent of the students had used alcohol, 57 per cent tobacco, 17 per cent cannabis, 9 per cent tranquillizers, 5 per cent amphetamines, 2 per cent cocaine, 2 per cent hallucinogens, 1 per cent opiates and 0.6 per cent volatile solvents. At some time in their lives, 96 per cent of the students had used alcohol, 70 per cent tobacco, 31 per cent cannabis, 19 per cent tranquillizers, 15 per cent amphetamines, 5.5 per cent hallucinogens, 5 per cent cocaine, 3 per cent opiates and 3 per cent volatile solvents. Both male and female students had begun using volatile solvents early in life. The age of first cannabis use for the majority of users was between 16 and 18. The users of other illicit drugs covered by the study had not begun using them until they were 18 or older.     

Cannabis use in relation to illicit drug use and health problems among opiate misusers in treatment

The study investigated cannabis use among 200 opiate misusers attending out-patient treatment services at two sites. Three groups were classified according to the frequency of their cannabis use in the previous month; 40.5% were non-users, 40% daily users and the remaining 19.5% were classified as occasional users (they had used on between 1 and 29 days in the previous month). Non-users of cannabis had used heroin in the previous month on more occasions than either daily or occasional users (p < 0.001). Non-cannabis users also reported the highest average frequencies of use of alcohol (p < 0.01) and crack cocaine (p < 0.05). In contrast, daily users of cannabis reported more symptoms of anxiety (p < 0.01) and depression (p < 0.01) than either of the other groups. Finally, daily cannabis users were more likely to report dietary problems than either occasional users or non-users of cannabis. While cannabis use is highly prevalent among opiate misusers in treatment, its relationship to treatment outcome is complex and requires greater research scrutiny.     

Drugs prescribed for people aged 85 and over living in their own homes in an area of inner London

This study investigated drugs prescribed for people aged 85 and over and living in their own homes in an area of inner London, and explored associations between drug use and other factors including use of general medical practitioner (GP) services, mobility, mortality and self-perceived health. Data were collected by structured interview of 630 participants in their own homes, with a follow-up interview of survivors three years later. Respondents were taking a mean of 2.2 different drugs; 23 per cent were taking no prescribed drugs and 11 per cent were taking five or more. Of those on two or more drugs, 45 per cent were taking potentially interacting combinations. Although respondents on more drugs were more likely to have seen their GP recently, some on many different drugs had not. Nearly 15 per cent reported some sort of difficulty with their medication. There was no significant difference between the mean number of drugs prescribed, at the begining of the study, for survivors and for non-survivors. However, there was an inverse relationship between prescribed medication and mobility, self-perceived health and satisfaction with other aspects of life. Very elderly people living in their own homes, like those in institutions, will frequently be on drug regimens that should be monitored regularly for drug-related problems. Because of rising numbers, the provision of a cost-effective service would require the identification of those most likely to experience problems with their medication.     

Deliberate self-harm in alcohol and drug misusers: patient characteristics and patterns of clinical care

The aims of this study were to describe the characteristics of alcohol and drug misusers presenting to a general hospital following suicide attempts and to investigate the patterns of clinical care they received before and after the attempts. The Oxford Monitoring System for Attempted Suicide and patient case-notes were used to obtain information on alcohol and drug misusers assessed by the general hospital psychiatric services after deliberate self-harm in 1992. Of 724 patients, 200 (28%) were substance misusers (36% of males, 23% of females). Both alcoholics and drug misusers were more likely than other attempters to be male, have histories of personality disorder and criminal offences and to make repeat attempts, and the drug misusers were more likely to be living alone and unemployed. These are characteristics associated with particularly high risk of suicide. A large proportion of the substance misusers had received specific treatment for their misuse before their attempts and the majority were offered this afterwards. Over a quarter did not accept the care they were offered. The general hospital management of attempted suicide patients must include systematic assessment for evidence of alcohol and drug misuse and maintain close links with substance misuse services. Patients identified as having problems in the use of alcohol without having developed dependence and/or physical symptoms are a group that warrants specific attention. Audits should be conducted in general hospitals to ensure that sufficient attention is being paid to the detection and management of suicide attempters with substance misuse.     

The influence of structured education and clinical experience on the attitudes of medical students towards substance misusers

Negative attitudes to patients with substance misuse disorders form a well-recognised barrier to the implementation of best practice. The influence of structured education and clinical experience on the attitudes of medical students towards substance misusers was investigated at an Australian university. First-year students were surveyed before and after 3 weeks of drug and alcohol education and in the same year, fourth-year students were surveyed before and after a 9-week block. Males, older students and those with prior clinical experience tended to have more negative attitudes. Attitudes improved significantly after exposure to interactive learning modules which included contact with patients with substance dependence, including individuals in remission. The level of dislike of problem drinkers significantly decreased after teaching. After fourth-year education, students reported a greater sense of responsibility towards providing intervention and less anticipation of discomfort working with these patients. In particular, confidence and attitudes towards heroin users improved near the end of training after contact with illicit drug users in the small group or individual interview setting. By the end of drug and alcohol education, less than half (42%) of students reported they could not imagine working with substance misusers as a career. Findings support the provision of structured drug and alcohol education and supported clinical experience for every medical student if appropriate evidence-based treatment is to be provided. [Silins E, Conigrave KM, Rakvin C, Dobbins T, Curry K. The influence of structured education and clinical experience on the attitudes of medical students towards substance misusers. Drug Alcohol Rev 2007;26:191 - 200]     

The challenge of illicit drug addiction for general practice

Eighty-five drug misusers sought help and treatment from our central London practice in the 12 months between 1st November 1987 and 31st October 1988. They were all accepted for a short course of oral methadone reduction. At the end of the 12 months, according to the best information available from records, family, friends, neighbors, support agencies and patient reports, 19 (22%) were off all illicit drugs and 9 (16%) of those who had been unemployed at presentation had obtained regular employment. On average, our opiate misusers consumed 0.5 g of heroin daily at a daily street cost of approximately 40 pounds or 14,600 pounds annually. Sixty per cent of them admitted to financing their drug habit through criminal activities. Against the huge social cost of illicit drug misuse, the cost of providing primary health care to all these 85 addicts was 8% of each two doctors' consulting time at an annual cost of 2171 pounds per GP (25 pounds per hour of GP time). Thus for the methadone reduction programme for these 85 addicts to be judged effective based on cost alone, one would require a drug abstention ("success") rate of 0.003%.