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Senior partner’s addicted patients end up at your door

Three GPs share their approach to a practice problem

Three GPs share their approach to a practice problem

Case history

You have a policy of not prescribing codeine or similar drugs to your patients with drug addiction problems, but your senior partner is liberal with opiates and tranquilisers. He is popular, one of the ‘old school' – but angry that you don't share his approach and thinks you are unsympathetic to the plight of drug misusers.

He has taken a three-month sabbatical to study drug rehabilitation in the US so you now have all his patients seeing you for repeat prescriptions. They say that if you don't prescribe they will have to do ‘something illegal' to feed their habit. They point out that the senior partner has always kept them out of trouble. What do you do?

1

Dr Lucy Free

‘A team approach and strict protocols on prescribing are essential'

This is a no-win situation that should have been predicted and avoided.

Such differences of attitude rarely make for easy practice life.

Fortunately, doctors are different, and patients will gravitate towards ones that suit them – at least the GP who is now suffering doesn't have this lot on their list regularly.

I am suspicious of doctors who acquire such a following of specialist patients; there is something smugly self-gratifying, almost distasteful, in the provision of such a questionable service. He has obviously been targeted as an easy touch, encouraged by appreciation and plaudits from his dodgy followers; I wonder how many are pulling the wool over his eyes one way or another?

That is not to say such a service is not required, but a team approach and strict protocols are essential.

The mistake here is that the ground rules were not discussed before the situation arose, and it is now too late for another GP to impose their ideas on this mess. They don't have the luxury of simply being able to pass the buck back to where it belongs – they have to deal with it, and although it feels like submitting to blackmail they actually have no choice but to maintain the status quo.

My advice would be to supply the necessary scripts without fuss or argument.

The claim that the provision of regular medication is going to keep these people out of jail is pretty tenuous, although the GP would have to hope it was not their car or house that was the target of their attentions if they did not comply.

The temptation of course is to do what is perceived to be the ‘right thing', addressing the addiction problems in a more conventional way, but that's a hiding to nothing – these patients aren't going to change their ways in the three months the other partner is away or they would have come to you in the first place. The crusade will be wasted – the GP will spend a lot of time, use up a lot of energy and become very disheartened if they take on this load.

Dr Lucy Free is a GP in West Sussex

2

Dr Richard Stokell

‘The GP shouldn't care what their absent partner might think'

This situation is a complete disaster for the practice. Word on the street is that the good times are back and there is a practice prescribing drugs suitable for abuse or selling on. No doubt the local drug centre has also become aware of idiosyncratic prescribing in the area. The GP should assess the number of patients involved by searching for patients under 45 prescribed dihydrocodeine and benzodiazepines in the last six weeks.

The GP shouldn't care what their absent partner might think and they might well hope he learns something on his sabbatical about the evidence regarding methadone maintenance prescribing. The GP should offer to assess these patients with a view to converting opiate scripts to methadone and stopping benzodiazepine prescriptions. They should talk to other partners and staff to formulate a practice policy and warn staff there may be disgruntled patients around.

The first port of call should be the local shared care scheme. In my area, I am fortunate to be able to organise an assessment with urinalysis within three to four days. The drug service would be very keen to help bring prescribing into line with national guidelines. Patients would only be prescribed for if opiate positive and initially with supervised consumption. Benzodiazepines could almost all be stopped, but conversion to diazepam and a short detoxification course would be okay for those with very long-term scripts.

The GP should have no concerns about patients who threaten to do something illegal. I would suggest that it is up to them how they behave and say I have offered them the only treatment proven to work.

It would be unsafe to prescribe for the interval between me seeing them and the assessment. In my experience, opiate users are aware of the methadone service available through shared care but will still try to wear you down with sob stories about being unable to take medicines and fear of addiction to methadone because ‘withdrawal is so much worse'.

Within three months, the GP should hope to have a fully operational shared care system running with support from a drug worker and should try to see patients outside normal surgeries. I would hope to persuade my partner to come into line and I would be surprised if he didn't see the benefits fairly quickly. If not, I might have to look for clinical governance support.

Dr Richard Stokell is a GP and trainer in Birkenhead, Merseyside

3

Dr Keli Thorsteinsson

‘There is little choice but to make the best of a bad situation'

What is the point of working in a partnership if you can't agree on basic prescribing issues? Partners should support each other and come up with solutions to potential problems like this before they arise. Obviously, each doctor should be allowed as much autonomy as possible, but the senior partner's expectations of the other GPs are bordering on bullying.

This GP's feelings about prescribing drugs of abuse were presumably clear to the senior partner long before he left for the US. The onus was on the latter to ensure his patients had access to the medications they wanted or needed during his absence. On the other hand, perhaps it was naive of this GP not to tackle him on this point before he left.

As it is, the GP has little option but to make the best of a difficult situation. They should try to be firm but fair and stick strictly to any agreements between this partner and the individual patient. When possible, they could put the weekly amount of medications on repeat prescription or daily collection at a pharmacy.

The GP should avoid seeing these patients, unless they are requesting medication inappropriately. If so, the GP should call them in and consider referring to a local specialist prescribing service. They should try to avoid confrontations; it is unwise to play the tough guy with a drug addict. If anybody expressed severe displeasure with the GP's prescribing, a reasonable compromise must be found. If a patient turned to threats it might be best to give in, but report the behaviour to the police and the PCT. With luck they would be removed from the list, or at the very least only be seen by prior arrangement with a security guard.

I frankly wouldn't care what the senior partner said about that on his return. The situation cited here should have been anticipated and plans should have been made for these patients. The practice needs to have a meeting or two with the senior partner about this matter and any other important areas of clinical practice you disagree on.

Dr Keli Thorsteinsson is a GP in Shrewsbury, Shropshire

What does this incident teach us

What does this incident teach us

LEARNING CHECKLIST

Use of benzodiazepines and opiates

• See The Misuse of Drugs Regulations 2001. Opiates fall into category 2, benzodiazepines into schedule 4.
• NICE has just published a care guideline (CG52) Drug Misuse: opioid detoxification.
• CSM advises that use of benzodiazepines for short-term relief (two to four weeks only) of severe or disabling anxiety.
• The BNF advises that withdrawal of a benzodiazepine should be gradual to avoid possible confusion, toxic psychosis, convulsions or delirium.
• Drug misusers using both prescribed and street opiates may be at risk of accidental overdose because of differences in purity.
• Doctors must report cases of drug misuse to their drug misuse centre when a patient starts treatment. All types should be reported including opioid and benzodiazepine.
• PCTs substance misuse services may be provided by community drug teams, GPSIs or by suitably qualified GPs as an LES under the nGMS contract.
•RCGP offers online courses on drug misuse, harm reduction and treatment planning based on national guidelines.

Partnership working

•What should a partnership agreement cover? Is there a ‘green socks' clause, whereby one partner can be expelled if all the others agree, good or bad?
•How are decisions made and voted on?
•Do full- and part-timers get equal votes?
•Which activities require consensus or compliance with guidelines?
•What are the duties of a GP who thinks a colleague is performing poorly?
•How should one deal with attempts to play one doctor off against another?

Sabbaticals

Rules should be set out in advance and included in partnership agreement covering:
•Frequency and duration
•Who gets first turn, second turn and so on? Is a missed turn forfeited?
•How is locum cover decided? Consider all aspects of partner's work
•What cover to be provided if absent partner is the only person with certain skills such as managing drug misusers?
•Who pays for locum cover; what happens if locum is unavailable?
•How will other partners' leave be managed?
•What decisions can be made in the partner's absence?
•Are salaried doctors entitled to sabbatical leave?

Dr Melanie Wynne-Jones is a GP and GP trainer in Marple, Cheshire

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