Comment

Treating drug-dependent patients — alternatives to licensing doctors By

By Jenny Scott, Chris Ford and Tom Waller

Doctors who prescribe heroin, dipipanone and cocaine for the treatment of addiction have to be licensed by the Home Office to do so. Prescribing of these drugs for such purposes is not undertaken on a large scale in the United Kingdom. A recent Home Office consultation document¹ has proposed that the current legislation should be extended to include:

• A licence requirement for prescribing for addiction of any Controlled Drug in schedule 2 or 3, with the exception of methadone liquid or mixture, on an NHS prescription
• A licence requirement for prescribing for addiction of any CD in Schedule 2 in an injectable form

This new licensing proposal has been recommended in order to reinforce the clinical standards set out in the current guidelines on drug dependence and to tackle the problems caused by inappropriate prescribing, especially death from overdose and leakage of prescribed drugs on to the illegal market.

However concern has been expressed by clinicians that, in itself, licensing will not be sufficient to achieve these aims since it will not necessarily counter inappropriate prescribing, and is likely to deter doctors from working in this area. This was why a similar licensing proposal was rejected in 1984. Since then, shared-care services have been developed widely in the UK to prevent the care of drug users falling on the shoulders of a few GPs and pharmacists and to widen access to treatment across communities. Treatment has been shown to benefit the health and social well-being of the individual through the consumption of a quality-assured medicinal product as opposed to an illicitly manufactured street drug. Since the drug user often needs to resort to crime to obtain street drugs, the community also benefits from treatment being given through the reduction of drug-related crime. Community benefits are further extended through the improvement of public health, including the reduction of blood-borne viruses such as HIV and hepatitis C.

It is important in the addictions field to have a choice of therapies available because one treatment does not suit every case. The availability of market-authorised alternatives to methadone is a relatively recent advance in the UK. Clinical experience of their use is important to contribute towards evidence-based practice. Under the proposed licensing changes the potential important contribution of methadone alternatives, such as high-dose buprenorphine could be stifled. Furthermore drug companies might not see it as profitable to invest in research for new and better drugs to treat addiction if they have the potential to be scheduled so that only licensed doctors will be able to prescribe them.

Licensing will impose additional workload on to pharmacists, as the licensed status of the prescriber will have to be checked before supply can be made. If only one partner in the practice is licensed, in the event of handwriting errors, replacement prescriptions might be delayed if that partner is not available to issue another. Practically, in a busy community pharmacy such requirements can be time-consuming and cause unnecessary difficulties.

To prevent the above scenarios and in line with clinical governance, the following alternatives to licensing should be considered to promote high quality practice within the addictions field:

• To combat inappropriate prescribing, substance misuse should be a core part of undergraduate medical and pharmaceutical education.
• Primary care groups and trusts should implement local prescribing guidelines, based on the national guidelines, through clinical governance mechanisms and the commissioning process.
• Both NHS and private doctors should adhere to minimum standards of care. Shared-care schemes should continue to be developed. Doctors and pharmacists providing care should be encouraged to undertake audits, attend ongoing training and be supported at local level. Each shared-care scheme should have a local monitoring and support group consisting of the director of public health (or deputy), GPs, pharmacists, representatives from specialist treatment agencies, the local medical committee, the local pharmaceutical committee and others. Regular analysis of prescribing data for each PCG and PCT area could inform each shared-care monitoring group.
• Pharmaceutical advisers could monitor the prescribing of individual NHS GPs through analysis of prescribing data and GPs who appear to prescribe outside expected practice could be approached. Cases of persistent prescribing irregularities, in spite of supportive advice, should be referred to an agreed local specialist with knowledge of primary care for further assessment and advice.
• If enforcement was considered necessary by the monitoring and support group, payments to GPs could be withheld from participants of formal shared-care schemes whose work falls outside locally agreed contracts and guidelines. If NHS doctors persistently act contrary to good practice, referral to the General Medical Council or to a tribunal under the Misuse of Drugs Act 1971 could be threatened. If such a referral occured, the GMC could suspend a doctor from addictions work until the case had been heard, while allowing them to continue general practice in all other respects.
• Comparable regulation of private doctors is more difficult beacuse prescribing data do not cover private prescriptions and there are no clinical governance arrangements. However, more use of local police pharmacy inspectors could be made. If the private prescription reference number was noted in the CD register entry, the inspector could compile prescribing information from the register and cross-refer to the prescription through use of the reference number. This would allow further information to be gathered and statistics on private doctor prescribing compiled. Using this information, the Home Office drugs inspectorate and local specialists could audit, advise, and regulate, with the ultimate threat of referral to the GMC or a tribunal if necessary.

We believe this system would encourage rather than restrict GP and pharmacist involvement in the treatment of addiction and raise standards of care, but would still deter and identify bad practice. It would provide access to high quality interventions following best practice guidelines, and be flexible enough to meet the needs of the range of potential users of services. It includes a system of clinical governance. There is a need for rational debate on licensing and consideration of all the options. We call for pharmacists to contribute to this discussion and debate before licensing is implemented.

Reference

1. Changes to the misuse of drugs legislation licensing of Controlled Drugs prescribed in the treatment of addiction. London: Home Office; 2000. Available here (accessed April 17, 2001).

Jenny Scott is lecturer in pharmacy practice at the University of Bath, Dr Chris Ford is a general practitioner in London, and Dr Tom Waller is specialist in substance misuse in Ipswich, Suffolk. The authors are members of the UK Harm Reduction Alliance steering committee. For further information see www.ukhra.org