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Your first... heroin addict

Dr Stefan Cembrowicz offers advice on when to prescribe methadone for a drug user – and when you should just say no

Dr Stefan Cembrowicz offers advice on when to prescribe methadone for a drug user – and when you should just say no

It's 6pm on a Friday. There's a new temporary resident who has just come into your surgery as you're closing, insisting it's urgent. He looks dodgy, and says he is a 'registered' heroin addict from another area, and wants his methadone to see him over the weekend.

Avoiding pitfalls

This type of situation has the potential to go badly wrong. So for your own safety, and that of your patient, it is essential that you:

  • understand that you can say no, yet offer a patient access to a safe and effective service
  • enlist the help of a more experienced colleague – a drugs worker, a GPSI or your specialist drugs service – if you feel put under any pressure
  • read the Orange Book guidelines on opiate prescribing
  • never prescribe anything addictive (including benzodiazepines) without a detailed assessment, including urine testing results and phone calls to previous prescribers

Know how the system works

Patients who move practices, or are discharged from hospital or prison, should have their prescriptions covered by the original prescriber (who can liaise with your local chemist to ensure they have capacity) while an appointment with a local drugs scheme is arranged. Drugs workers are attached to many practices now.

Effective drug maintenance reduces crime, needle sharing and on top use of heroin. Patients without complex needs (such as HIV, multiple addictions, homelessness or dual diagnoses) are usually suitable for GP prescribing schemes. Annual abstinence rates are low (<20%) according to the National Treatment Outcome Research Study figures, but between 20% and 40% will at least reduce and maybe stabilise their on-top use. All aid can be abused; street methadone in some areas costs as little as £10 per 100ml. Good practice includes daily witnessed consumption via a chemist for several months – if not indefinitely.

Managing the user

Explain to your new patient that, however much you sympathise, it is national policy that they have a full drug and alcohol history taken, that dates and doses are confirmed with previous prescribers, plus the results of a fresh, witnessed urine test before they can be considered for substitute prescribing.

Those who have been off methadone for several days will need to be re-titrated safely to avoid overdose; 50ml could kill a naive user. This means that you will not be able to prescribe safely for them tonight. Most opiate users are well aware of how the system works; if they say 'so you won't help me, doctor', explain that on the contrary you are going to help them in a planned and safe way.

Opiate users have poor general health – sepsis, thrombosis, infection and malnutrition are common. They have often experienced violence, deprivation, childhood abuse and prison. Offer testing for HIV (uncommon), hepatitis B (more common) and hepatitis C (very common), with hepatitis B vaccination if indicated. Advise where your local needle exchange is. Learn more from the Substance Misuse Management in General Practice website, or for further interest take the RCGP substance abuse course.

Dr Stefan Cembrowicz is a GP trainer in Bristol

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