Pubdate: Sat, 06 Sep 1997 Source: British Medical Journal Contact: BMJ No 7108 Volume 315 Editorial Saturday 6 September 1997 Drug misusers: whose business is it? Shared care can work well, but drug misusers still need specialist services All indicators of illicit drug dependence have continued to climb over the past two decades, showing no sign of reversal. The one success has been the containment of HIV: through the provision of community services and the promotion of needle exchanges Britain has maintained one of the lowest HIV seroprevalence rates among injecting drug users globally.(1) The increasing tide of drug misuse has, however, continued to place additional burdens on public services, from the criminal justice system to health and social services.(2) How medical services should respond to drug dependence and its associated harms, and in particular which doctors should be responsible, is currently the subject of debate. In his personal view in this issue (p 613) Scott argues that psychiatrists have neither the skills or the attitudes appropriate to looking after drug misusers and that general practitioners are far better at it(3) Primary care services are often the first port of call for users and their families and neighbours and, after a slow start, are now responding to the challenge of treating this disenfranchised group, as evidenced by this week's correspondence columns (p 601).(4) General practitioners are concerned about the increased workload and in some areas have obtained specific funding. Nevertheless, even in the best developed practices the multiplicity of problems presented by drug using patients means that a similar multiplicity of skills must be deployed, including skills held by those outside primary care. The new challenge is to develop closer integration between all providers of services, identify effective interventions, and then ensure that these interventions are delivered.(2) Such interventions may include methadone maintenance, behaviourally based therapies including motivational interviewing and relapse prevention, detoxification, targeted health promotion, and, when appropriate, residential rehabilitation. The new BMA report on drug misuse is a significant contribution to this broad based approach to services for drug misusers.(5) Encouraging primary care to take responsibility for drug misusers has been policy since the early 1980s.(6) Models of shared care developed in alcohol treatment have been applied to drug misuse services. Shared care involves joint participation of specialists and generalists (generally psychiatrists and general practitioners but also community pharmacists(2)) in planned delivery of care, supported by information exchange beyond routine discharge and referral letters. In many settings better communication and greater mutual awareness are at the heart of improved services. Such arrangements make explicit which clinician is responsible for different aspects of management. In most cases the general practitioner maintains the central coordinating role for the patient's long term health care. As the correspondents point out, good shared care requires training and support for general practitioners,(4) but it can work only in the context of a well developed specialist service. Specialist services are needed for patients with chaotic patterns of drug use, multiple dependencies, and serious physical or mental health problems, or other complex problems. The task force to review services for drug misusers reported that community drug services had expanded in response to the growth of drug problems and dependence but that many had problems with overall management, with poor delivery of hepatitis B vaccination and other aspects of health care.(2) The growing number of very young drug users presenting to services and the need for services tailored for amphetamine and cocaine users means that the staff of community agencies will require a combination of behavioural science training and basic health skills training. Specialist services have a critical role to play in providing such training and applying different models of consultancy and liaison as new patterns of drug use emerge. The future involves figuring out how to integrate the intake of new users into services, to match them to appropriate interventions, to plan long term management, and to integrate health and social care for rehabilitation. The national treatment outcome study showed that a quarter of those entering drug services had suicidal thoughts, a quarter had been admitted to general medical wards, and a tenth to psychiatric wards.(7) Other studies suggest that over half of drug dependent individuals in the community have mental health problems, and rates of mental health problems are significantly higher among those entering treatment services.(8) Separate reports indicate that 6070% of injectors are hepatitis C positive. With these levels of serious ill health associated with drug dependence it makes as much sense to argue against psychiatric involvement with drug users as to argue that hepatologists, gastroenterologists, genitourinary physicians, and prison medical officers have no role because they deal with only a particular dimension of the problem. Clearly, general practitioners retain their traditional role as providers of primary care to drug misusers, but simplification of the problems of, or responses to, drug misusers does no justice to their needs. Michael Farrell Senior lecturer and consultant psychiatrist National Addiction Centre, Maudsley Hospital and Institute of Psychiatry, London SE5 8AF References 1 Stimson G. AIDS and injecting drug use in the United Kingdom, 19871993: the policy response and the prevention of the epidemic. Soc Sci Med 1995;41:699716. 2 Department of Health. The task force to review services for drug misusers. London: Department of Health, 1995. 3 Scott R. Drug misuse: GPs' pivotal role. BMJ 1997;315:6134. 4 Van Teijlingen E, Porter M; Bury J, Sherval J; Preston A, CampionSmith C; Lester H, Bradley C; Mason J R [letters]. General practitioners' attitudes towards treatment of opiate misusers. BMJ 1997;315:6012. 5 British Medical Association. Misuse of drugs. Amsterdam: Harwood Academic Publishers, 1997. 6 Glanz A. The fall and rise of the general practitioner. In: Strang J, Gossop M, eds. Heroin addiction and British drug policy. Oxford: Oxford University Press, 1995:15166. 7 Gossop M, Marsden J, Edwards C, Wilson A, Segar G, Stewart D, et al. The October report. The national treatment outcome study. Report prepared for the Department of Health. London: National Addiction Centre, 1995. 8 Hall W, Farrell M. Comorbidity of mental disorders with substance misuse. Br J Psychiatry 1997;171:45