Bank Holiday Scripting

This is the time of year when FP10MDAs bounce back from pharmacies with (in my case) alarming frequency - causing distress to the patient, embarrasmment to the pharmacy and annoyance to me. So remember the golden wording which you can get your computer to add to EVERY FP10MDA you ever print from now on:

"Instalments on pharmacy closed days may be dispensed on the day immediatley prior to closure"

you won't ever have to worry about bank holidays or even Sundays ever again!

Whither (or wither) Shared Care?

Over a decade ago, there were just a handful of GPs in the UK who were delivering quality prescribing interventions to heroin users. Since the College created the Substance misuse certificate, more than 1,500 have completed the full certificate (PwSI level) and more than 6500 have completed the Part 1 and are actively involved in Shared Care - a fantastic achievement. In the UK today, more patients are getting their opiate replacement therapy from their GP than from a specialist service.....so why my double-entendre with the word "whither"?

I am worried: I feel a very subtle change in GP's attitude to working with drug users. Certainly many of the old prejudices have been allayed: this IS work that GPs can and should do effectively; it is NOT neccessarily a specialist concern; GPs WON'T get swamped or get into trouble; and treatment DOES work, it reduces mortality and morbidity to the individual and the family. These essential messages are now widely accepted and yet I feel it is becoming increasingly difficult to engage GPs in this work - why? well the GP contract has made GPs very well paid, and very busy: it has fostered a very commercial attitude to our profession, which is probably for the most part, a good thing - but more importantly, it has allowed GPs to opt out of areas that although worthy, are just too onerous and not well enough paid - notably out of hours care. And increasing numbers of GPs I fear are taking a similar view to the care of drug users: it's worthy, but just more work than I need - and that is a tough argument to oppose.

So I urge all of you who value this work and who read this column to spread the word - enthuse your colleagues - yes it can be challenging at times, and yes the money is crap compared with other revenue streams - but this work changes lives in ways that almost no other medical intervention can do - it is rewarding in ways that money can never be, and it is bloody good fun. We learn from each other, so get out there and evangelise!

Alcohol Training

The Department of Health has published a new website for training health professional about alcohol - and it's rather good. You can see the pilot pages by clicking here, and soon there will follow an e-module self testing quiz as well. I can also tell you, as intimated in previous posts that my colleagues at the RCGP are working on an alcohol certificate which will link into this e-learning, and it is hoped that this will be ready later this year. At last it seems that that core competencies and acreditted training for GPs are being identified, we can only hope that resources will be found to support GPs with this work. I'll keep you posted.

Talking Drugs Website

I am delighted to inform you about a new website hosted by that excellent charity Release: TalkingDrugs is exactly that – let’s talk about drugs. There is a huge, largely untapped audience of ordinary people around the world whose communities are being let down by failing drug policies. We believe that many of these people would like to see more economically and socially sustainable strategies for the control of illicit drugs.
TalkingDrugs will harness the immense power of these everyday human voices, bringing the issues alive through the recounting of their own experiences. The use of humour and satire will be key to engaging a wide variety of people who may, up to now, never have given this subject much thought. The Internet makes possible the global sharing of these narratives, encouraging the development of a cohesive and powerful voice through the use of video, photographs and multi-lingual text, allowing geographically and linguistically separated communities to communicate and interact.
TalkingDrugs is a unique participatory mechanism for global dialogue and action on drugs and drug policy – see for yourself and get involved by clicking here - and please let others around the world know about this website.

How fast should we Detox?

Here's a question with no answer in science: so your patient says "Yes", now is the time to wean off my dependency on methadone/buprenorphine/heroin etc... so how fast should you do it? Some favour the "Grasp the nettle" approach and just get it over with as quick as possible - others, believeing that stepping off a cliff will hurt whereas a gentle if long-winded descent will be much more bearable, favour the latter.

As a paragon of client-centredness I have always gone with whatever my patient feels most confident with, but my inner prejudice, based on overseeing many thousands of detoxes over the years, is that the quick rough ride, maxed up with lots of motivation and support, is the better way: it seems that over a long period of painfully drawn out reductions, something inevitably happens that sets the client back.

So I was interested in a piece of research in Addiction Vol.104 Feb 2009 by Ling et al in the USA that compared the outcomes (in terms of total abstinence) of 7 day and 28 day taperings of buprenorphine... and basically there was no significant difference, both groups maintaining around 13% abstinence at 28 days - which on the one hand appears disappointing, on the other could be seen as encouraging. The authors conclusion being that: "there appears to be no advantage in prolonging the duration of taper."

Happy New Year people - thank you for looking at these pages again. What do have we to look forward to on 2009? Well, I think that many areas are looking at developing alcohol services in general practice, and I look forward to telling you more about the RCGP Alcohol Certificate training when it becomes available.

I hear from some quarters that Primary Care has never been busier, with all manner of pressures on time and resources, and sometimes it might seem that substance misuse is yet another niche piece of work that is more trouble than it's worth: others however remind me that there are few areas of medicine where it is possible to make so much difference to someone's life, so easily - and it remains one of the most rewarding aspects of a GP's life. So keep the faith, and keep on top of your CPD - I hope to meet many more of you this year. You can keep an eye on the upcoming training events on the right which are continuously updated - and please, if you have anything that would be of interest to colleagues in the region, please contact me and I'll post it.

PS: For those of you not lucky enough to get to APSAD (no, me neither) - there are some excellent presentations now available on the web (click here)

Alcohol at last

I have been neglecting you, for which I apologise.... the months whip around and before you know it, I am behind on posts by 2 months. So what is new? well at last alcohol seems to be getting some priority: the pathetic little DES for screening new patients is sure to be followed up with locally commissioned more serious interventions, and I am pleased to report that the RCGP SMU is "on the case", and an Alcohol Certificate should be introduced next year: it will aim at screening, brief interventions, community detox etc and will be kite marked and DANOS referenced, we are very excited about it - watch this space.