RECOVERY is at the heart of the UK government’s current drug strategy, encouraging a focus on wellbeing, citizenship and freedom from dependence.
It envisions patients being supported on an “individual, person-centred journey” by a broad range of healthcare staff, emphasising that “no one professional can expect to meet all the recovery needs of any of the people they work with”.
Playing a key role within this multidisciplinary team are GPs with a special interest (GPwSI) in substance misuse working collaboratively to build recovery in communities. Their specialist training and additional skills in this field means they are well placed to work with more complex cases.
Supporting people who use drugs or alcohol means looking beyond a simple clinical model by helping patients with a variety of needs in all areas of their life. This is ideally done in a coordinated way and through interventions such as psychosocial approaches, harm reduction, addictions-specific prescribing and medically assisted recovery. With improved mental and physical health and appropriate support, other positive outcomes can often be realised, including employment, living in suitable accommodation, improved personal relationships and reduction in criminal activity.
Entry and training
GPs developing a special interest in any field can acquire training in both practical and theoretical ways. This can include experience of working in relevant departments, self-directed learning, attendance at relevant recognised meetings/lectures/tutorials, vocational training programmes or a recognised university course.
A good way of obtaining structured learning is to complete specialist substance misuse training to certificate or diploma level. And while GPs are already able to prescribe opioid substitution treatment, those developing a special interest in the field of addiction may opt to sit in and shadow an experienced prescriber in order to improve their skill set.
The RCGP’s Substance Misuse and Associated Health (SMAH) unit also offers a range of courses, including the Certificate in the Detection, Diagnosis and Management of Hepatitis B and C in Primary Care; the Certificate in the Management of Alcohol Problems in Primary Care (involving an eLearning module and a six-hour training day); and the Certificate in the Management of Drug Misuse. This course is spread over six months (equivalent to nine study days), running annually from February to November.
Other training is offered by Substance Misuse Management in General Practice (SMMGP), including the Advanced Certificate in Community Management of Alcohol Use Disorders. It is worth checking CPD requirements for GPwSIs in your area as some training may be deemed compulsory.
All doctors should be able to identify patients using drugs and alcohol, carry out a basic assessment and refer where needed. Some will also provide opioid substitution treatment (OST), however GPs with a special interest in substance misuse can offer a greater level of care to patients with more complex needs, often those who have struggled to engage consistently with recovery services. Patients may present with complicating factors such as pregnancy, mental illness, physical health complications (e.g. alcohol-related liver problems) or complicated issues relating to the care of children.
GPwSIs may also manage complex prescribing; work with acute hospital and psychiatric liaison services; help to design new treatment pathways for emerging drugs of misuse; and take part in clinical governance activities, for example GPs participating in an annual audit of uptake of vaccinations for blood-borne viruses. The framework for the provision of services by GPwSIs in substance misuse lists some of the different types of services they can deliver, including:
• Providing a service to drug users in special circumstances, for example custodial settings, dose assessment services, supervised consumption services
• Facilitating support for secondary care teams managing substance misuse patients during hospital admissions
• Identifying and addressing the needs of vulnerable and disadvantaged groups
• Providing services to substance misusers with special needs, e.g. pregnant women and young people
• Incorporating a significant service development role, e.g. GP lead for substance misuse in a primary care trust
• Advising commissioners and providers on short, medium and long-term planning for prevention, treatment and care for substance misuse
• Input into local substance misuse strategies
• Using skills in a specialist setting working to provide primary care services to drug users, e.g. within a rehabilitation unit.
Helping people who use drugs and alcohol recover presents a continuing, ever-changing challenge. The use of recognised drugs such as heroin and cocaine may be stable or falling, but new drugs such as so-called “legal highs” are rising in popularity while long-term drug and alcohol use amongst older people is on the increase. GPs specialising in substance abuse must find new and innovative ways to support patients on their journey to recovery.
Sources and useful links:
• Delivering quality care for drug and alcohol users: the roles and competencies of doctors - A guide for commissioners, providers and clinicians. Royal College of Psychiatrists and RCGP London, 2012
• Guidance and competences for the provision of services using practitioners with special interests – substance misuse. RCGP and Royal Pharmaceutical Society
• Substance Misuse Management in General Practice – www.smmgp.org.uk
Dr Steve Brinksman is a GP in Birmingham and clinical lead of SMMGP. He is also the RCGP regional lead in substance misuse for the West Midlands.
Q&A Dr Steve Brinksman, GP, clinical lead of SMMGP and RCGP regional lead in substance misuse for the West Midlands
What attracted you to a career as a GPwSI in substance misuse?
I came to realise that this is an area of medicine that not only improves the life of those that I treat but also improves the lives of their family, their community and even wider general society through reduced crime and many other factors. I can’t think of another aspect of medicine that has such wideranging effects.
What do you enjoy most about the job?
It is very rewarding helping to support someone who is essentially turning their life around. I think in general practice we spend a lot of time managing long term conditions and, whilst this can be a chronic condition, many people do recover either to long-term abstinence or to a state of medicalassisted recovery where they are supported in long-term improvement whilst having a prescription for opioid substitution treatment.
Are there any downsides?
Illicit drug use is a very risky business and a few of the patients I have treated have died. This is always difficult to deal with.
What do you find most challenging?
Sometimes people are either not ready or even unwilling to change which can be frustrating as I am aware of how well patients can do if they engage in the process. To be fair this applies across a lot of general practice and not just to those who use drugs and alcohol. It requires flexibility in trying to find the right approach for each individual.
What about the role has most surprised you?
That despite a plethora of evidence on the value to both the individuals and the health service of treating patients with drug and alcohol dependency, many GPs remain cynical and actively avoid working with this group.
What is your most memorable experience so far?
It is an area of general practice that provides a lot of memorable experiences. I had been treating a heroin user for several years until he moved away. Three years later he wrote to tell me he had stopped using all illicit drugs and was working as a volunteer at the drugs agency near where he now lived. He was kind enough to tell me that he didn’t think he would still be alive if he hadn’t been in treatment with us and that this then gave him the chance to subsequently make the most of the opportunities that he had.
What advice would you give to a trainee GP considering a career as a GPwSI in substance misuse?
It makes a lot of difference to a range of people so is well worth doing. Use the training opportunities that are available from organisations such as RCGP , SMMGP and others. Make links with more experienced practitioners in the field – finding a mentor to offer advice and support can be a huge help. SMMGP has an online forum at www.smmgp. org.uk that helps connect and support clinicians who work with drug and alcohol users.