Family Practice Vol. 20, No. 2, 120-125
© Oxford University Press 2003
Clinical Research |
A qualitative study of GPs’ attitudes to drug misusers and drug misuse services in primary care
Department of General Practice and Primary Care, Foresterhill Health Centre, Westburn Road, University of Aberdeen, Aberdeen, UK.
Correspondence to Dr Catriona Matheson; E-mail: c.i.math{at}abdn.ac.uk
McKeown A, Matheson C and Bond C. A qualitative study of GPs’ attitudes to drug misusers and drug misuse services in primary care. Family Practice 2003; 20: 120–125.
Received 5 March 2002; Revised 23 August 2002; Accepted 4 November 2002.
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Abstract |
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Background. Due to a growing drug misuse problem in Scotland, GPs increasingly are being called upon to deal with and treat misusers. With the publication of government guidelines in 1999, debate on this subject has intensified, with some GPs questioning their role in the treatment of drug misuse.
Objectives. This study explored, in depth, GPs’ views and experiences of providing services for drug misusers such as methadone maintenance, use of guidelines and shared care schemes. Factors influencing their treatment of drug misusers were covered.
Methods. Forty-eight semi-structured GP telephone interviews were conducted and their responses recorded, transcribed and analysed using qualitative content analysis. The sample was purposive and included a spread of individuals from varying age groups, levels of involvement with drug misuse and training, as well as gender and health board. Transcripts were validated with a 50% sample of interviewees, allowing them to correct any opinions they felt were not represented accurately.
Results. GPs increasingly accept a role in the treatment of drug dependency, although a shared care model was preferred due to the workload implications of this patient group. A drawback of shared care was long waiting lists. Patient behaviour emerged as a strong theme influencing treatment, and safety concerns were evident. Views of methadone maintenance were mixed, and it was considered as the only real option available.
Conclusion. Themes identified from the interviews reinforced the patterns of past research. GPs are becoming more confident and comfortable with misusers, and more positive towards methadone and methadone maintenance treatment, but still feel that they lack the necessary knowledge and skills.
Keywords. Drug misuse, general practice, qualitative, shared care.
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Introduction |
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With an increasing drug problem throughout Scotland1,2 and the UK in general,3 GPs are required to deal with and treat a growing number of drug misusers.4 However, GP opinion is divided, and not all are prepared or confident to treat misusers, or satisfied with the back up provided by the specialist drug misuse services.5 Indeed, some would argue that the treatment of drug dependence does not fall within the remit of General Medical Services (GMS), and that GPs are far from ideal as a first line of treatment for drug misusers.5
With the publication of the Department of Health Guidelines on Clinical Management of Drug Misuse in 1999,3 the treatment debate intensified. Seen by some as laying the problems of drug misuse squarely at the feet of GPs, it presented a pro-methadone, generalist approach to treating drug dependency with ‘shared care’ support services provided by commissioning bodies. It also outlined the need for all GPs to provide a basic service to deal with drugs and drug-related issues, as well as defining new levels of care for the ‘specialist-generalist’. The attitudes of GPs to this more proactive role are unknown. This qualitative study was designed to complement a recently completed quantitative survey of GPs attitudes and practice.6 The study aimed to explore GPs’ views and experiences of providing services for drug misusers. Attitudes to shared care schemes, methadone maintenance, knowledge and guidelines, and factors affecting their practice were covered.
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Methods |
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The study population was drawn from responders to a postal survey7 who had volunteered to take part in telephone interviews (n = 130). This subgroup was stratified by attitude, level of involvement and health board area, and a sample of 50 was identified.
The quantitative study7 included an attitude scale, that calculated a score for each respondent from 1 (most positive) to 5 (least positive) towards treating drug misusers in general practice. Level of involvement was based on the number of misusers treated. The mean score for the group was 2, so 0–1 was categorized ‘low’, >4 ‘high’ and >10 ‘highly involved’. Health board area was determined by postcode.
The sample selection was purposive,8 i.e. interviewees were selected to include all demographic factors that may influence views. Examination of the literature suggested that age and training in drug misuse had been shown to affect attitude.9 Gender was also considered to have a theoretical impact on views, so was included. The final range of factors covered in the sample were age, involvement, attitude, gender, training and area, and, as far as was possible, similar numbers of each demographic factor were included. Each interview volunteer was identified by an ID number.
An interview schedule was constructed based on responses from the earlier postal surveys. Areas identified for in-depth study included attitudes to methadone, knowledge and training, patient behaviour and other factors affecting treatment, guidelines and shared care schemes. General attitudes and opportunities for interviewees to express any additional opinions were also included.
The interview design chosen was based on the general interview guide approach.10 This involves compiling a list of topics which are to be covered during the interview. No specific questions are written in advance, as the wordings and sequence of questions may be altered in relation to the interview. This type of interview allows flexibility whilst ensuring a systematic approach, and consistency across interviewees. It also facilitates good usage of time.
The interview schedule was piloted by four faceto-face interviews with a convenience sample of GPs known to have practical experience in this field. Subsequently, changes were made to the structure and flow of the schedule. Interviews were conducted by telephone, at a convenient pre-arranged time. With the permission of the interviewees, interviews were taped and transcribed. Selected GPs unable to be interviewed were replaced with interviewees of similar demographic characteristics as far as was possible, with the study aiming to interview 50 GPs, or until data saturation was reached.
All tapes and transcripts were kept anonymous, identified only by an ID number, and stored on computer. Data were analysed using Nud*ist, a qualitative content analysis software package.
To validate data, transcripts were sent to a random 50% sample of the interviewees, asking them if the transcript accurately represented their views. A stamped addressed envelope was enclosed to allow them to return amended transcripts. They were advised that that a null return would be taken as indicating their agreement with the original script.
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Results |
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Table 1
shows the response rate for the interviews, problems encountered, number completed, numbers withdrawn and numbers replaced. Table 2 shows the demographic features of the interviewees.
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Ten transcripts were coded to begin with, to allow the development of themes, and these were then revised with the coding structure that had been developed. The themes that initially developed were along the lines of the interview headings but, as the transcripts were examined, cross themes emerged and were incorporated into the coding sequence.
Interviewees’ views
The themes that presented were, encouragingly, often common throughout many of the respondents. Below is presented an overview of the opinions expressed on the management of drug misusers in primary care, with examples of supporting quotes.
Drug misuse is a societal versus medical issue.. Drug misuse was generally considered a societal issue rather than a medical one:
"Because it’s a disease of poverty, poverty, people who are unemployed, poor, socially disadvantaged, often looks for ways of escape, and alcohol, drugs, provide them." (Female, Borders)
Access to GMS.. The majority of GPs are happy to give misusers access to GMS.
"I treat them as human beings. If they come to me with other illnesses they get the same care as any other person." (Male, Lanarkshire)
Interestingly, interviewees acknowledged that not all GPs had such egalitarian views:
"A lot of them are a group that find it difficult to access medical help because people pre-judge them." (Female, Highland)
Indeed, even when drug users have a GP, their drug problems can overshadow general medical problems:
"... the biggest problem for the treatment of patients with drug problems in general practice is that they are not getting an adequate standard of general practice care, because they are seen frequently with a drug problem, and it is sometimes very difficult to get past that," (Male, Greater Glasgow)
Shared care.. Most interviewees believed shared care was a good option; support from specialist services was seen as important, not only in helping the GP treat the misuser, but also in providing better care.
"We can quite adequately in a normal consultation deal with somebody who doesn’t have any complex problems, but for those with more complex problems then we need the back up services that we already have." (Female, Grampian)
Drawbacks of shared care were considered to be waiting times and resources, which are interlinked:
"The main drawback is it takes a while. It can take four to six weeks to get someone seen at a drug clinic." (Male, Dumfries and Galloway)
Along with the access to specialists, general practice involvement was considered by many to make an important contribution to shared care:
"Well I do think that GPs have an important role to play because they have quite a lot of knowledge about the background of the abusers often and they can have some form of relationship ..." (Female, Forth Valley)
However, as the same interviewee went on to say:
"... The pressures of general practice on the whole mean that I struggle with my workload as it is and I don’t have the time that I would need to deal with this adequately." (Female, Forth Valley)
Thus shared care also relieved GPs of what is considered a time-consuming area of practice.
Factors affecting treatment.. Several factors affect whether drug users would be treated or continue to be treated: these included factors relating to the GP such as their attitudes, knowledge and views of the benefits of treatment; as well as factors relating to the patient such as behaviour, motivation and commitment. Of these, the behaviour of the patient emerged as a strong common theme:
"If a punter is aggressive verbally, swearing or aggressive physically then we are fairly intolerant of that so if somebody alters a prescription, if somebody swears at staff ... then that person will be discharged." (Male, Argyll and Clyde)
Whether the drug user was an existing patient was mentioned by many interviewees:
"I tend only to treat patients of ours who were patients before they approached us about that (their drug problem). I am not so keen on taking on somebody unknown who has just come to temporary lodgings in our area." (Female, Tayside)
Other factors noted by fewer interviewees related to wider societal benefits of treatment such as reducing crime and having positive family support.
Knowledge of drug misuse.. The majority of interviewees felt they had insufficient knowledge of drug misuse:
"I never had training in the past, I’ve never been exposed to situations where I’ve needed to deal with drug abusers, so I haven’t been in the situation where I’ve had to learn" (Female, Highland)
Others felt confident with some areas of their knowledge but recognized their limitations:
"when it comes to methadone prescribing and maintenance and things I am comfortable with that but in terms of other forms of treatment then probably not" (Male, Argyll and Clyde)
Awareness of guidelines.. Interviewees were often aware of guidelines, but a much smaller number could comment on them.
"Ha I think I have to hold my hands up and confess, I can’t remember at this stage what it (the ‘Orange Guide’) said!" (Male, Ayrshire and Arran)
Opinions of methadone.. Opinions about methadone were mixed; a few were very negative:
"... tell you something for sure, we’re going to look back at what we’ve done in Scotland in particular in Glasgow with the methadone programme in horror in a few years time I think." (male, Glasgow)
Most interviewees were more positive:
"Certainly better than nothing, it is better than allowing them to continue taking street drugs, injecting, sharing needles, all the things that they tend to fall into when they are using street drugs I think things are definitely improved by offering methadone maintenance" (Male, Fife)
but even those with positive views had concerns which seemed widespread:
"... we are particularly concerned about having methadone lying around because it is potentially a dangerous drug and a lot of these people have families and children as well." (Male, Tayside)
However, methadone was considered the only option available in treatment:
"... what I’m experienced at is methadone prescribing. I appreciate it has its problems but at the minute it’s the best I’ve got." (Female, Grampian)
Methadone was thought of increasingly as a harm reduction and maintenance drug, rather than a means of reducing to abstinence.
"I see it as stabilization and harm reduction. I originally saw it also as a means of getting drug addicts drug free but I have had to amend that belief from experience." (Male, Lothian)
Furthermore, the issue of legality of methadone prescribing was raised as a concern as interviews were conducted shortly after cases of GPs in England being arrested following methadone prescribing.
Opinions of misusers.. The opinions about drug misusers remain mixed, with the majority of GPs holding at least some negative viewpoints.
"Difficult. They are difficult to manage, sometimes manipulative. They may attempt to mislead you in ways that other patients wouldn’t." (Male, Western Isles)
Safety.. Several GPs had safety concerns surrounding misusers within their practices, although few had had violent incidents.
"I have only had one or two episodes in four years that I have been concerned with a patient potentially being violent although it has never come to anything." (Male, Argyll and Clyde)
Resources.. Money and resources were raised as a means of improving treatment, but there were also calls for changes at a legal and societal level.
"We need more money, we need more people, we need more drug counsellors, we need more CPNs who are specializing and more psychiatrists who are specializing and we need to give extra resources to GPs so that they can devote more time to it and I think that ultimately it does come down to more money." (Male, Argyll and Clyde)
Validity
Only five individuals returned their transcripts and these were solely for reasons of grammar and blanks left due to poor recording. This indicates that the interviews were a valid representation of interviewees’ beliefs.
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Discussion |
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Strengths and weaknesses of the study
This qualitative study explored the range of opinions currently held by GPs. After conducting 48 interviews, no new themes were emerging, indicating data saturation. Since the study included a range of demographic factors and a geographical spread, it is unlikely that significant other opinion was missed.
As with all interview-based studies, there may have been some selective interpretation of the interviews by the researchers: however, the lack of prejudice by the interviewer, and the 50% satisfactorily returned transcripts indicates that if this did occur, it was to no great extent.
Findings
There was an overall consensus that shared care was the best method for the treatment of drug misusers. However, the recognition of the need for some primary care management of drug misuse could indicate support for GP involvement with misusers and an improved attitude to this area of service provision.
The discussion of shared care raised several other issues. The particular benefit of shared care was the support of specialists, perhaps pointing to the lack of knowledge and skills that some GPs felt they had. This corresponds to other findings.4 Another benefit was seen to be a reduction of workload possibly reflecting the lack of resources and overwork that GPs referred to. This lack of resources was also indicated as the most common drawback of shared care, in that waiting lists could be long, and specialist services insufficient. This echoes the findings of previous studies across a decade.9,11
Methadone raised a number of issues, with most GPs feeling that it was the best option available to them and, despite multiple concerns surrounding overdose and diversion, many were happy to deal with it on some level. The aim of methadone prescription was believed to be maintenance, and several believed it to be unrealistic to expect reduction treatments to be successful. This again is in line with the evidence, as multiple studies have shown that maintenance is the more realistic of the two options.12
The legality of methadone prescribing was a concern to some as arrests of GPs in England were mentioned. Clarification and support from the Police and Government regarding GPs’ position would be beneficial and might allay some fears and encourage some practitioners to treat misuse.
The treatment of drug misuse may be considered a medical issue, but it was in society that many interviewers believed the roots of the drug problem lie. Those who claimed to put it into the ‘medical’ category, by comparison often had little to say to back this up, other than they could not see anyone else available to deal with the problem. This suggests that GPs firmly believe drug misuse to be societal in its cause but medical in its expression, as found in other studies.11,13 Therefore, there should be socially based initiatives to deal with it, but it is appropriate that those ‘suffering’ sequelae should receive medical attention.
The prevalence of negative attitudes to misuse was juxtaposed interestingly in some individuals with the willingness to deal with misusers. Many of the positive comments made were along the lines of treating drug addiction as any other illness or addiction, again indicating an acceptance of an active role in this field, and recognizing the ‘medical’ aspect of the condition. This is mirrored in other studies, where improved attitudes have been noted.4,11,14
Negative attitudes were formed almost uniformly by patients’ behaviour, whether because of their threat to safety, or in their chaotic behaviour in terms of missing appointments. The most common used terms were ‘difficult’ and ‘manipulative’.
The lack of knowledge was put down to a lack of training or a lack of contact and experience of misusers. Those who felt they did have enough knowledge admitted that this was in a limited field, and being asked to exceed this would cause them problems. This was often the stance of those in regular contact with specialist services, particularly those in shared care situations, so, again, shared care was indicated as a favourable option. This has been shown previously by Huxley and Davies,9 who demonstrated that GPs in contact with specialist services held more positive views of misusers.
Discussion on guidelines (i.e. the Orange Guide) yielded interesting data. Despite the majority of GPs actually being familiar with the guidelines, and several of them claiming to have read them, few could actually comment on the document. Huxley and Davies9 also showed that the minority of GPs read guidelines and those that do often do not read them thoroughly. When individuals did feel guidelines were useful, it was often for their value as a concise version of ‘what to do’, knowledge that they often felt they were lacking in other parts of the interviews.9
Behaviour, compliance and motivation are all factors considered to be within the patient’s control. They are also factors that should really relate to all patients, as GPs are unlikely to put up with threatening behaviour from any patient, and motivation and compliance would have some effect on treatment, irrespective of the patient’s complaint. The question is whether drug misusers are treated any more harshly because of their condition. Indeed, there is evidence that this is the case as some interviewees admitted the drug problem can overshadow general health and access to general health services.
Other factors outside a patient’s control, such as whether or not he is an ‘existing patient’ have slightly more serious implications. A patient applying to be treated for any ‘normal’ condition would rarely face any difficulties, but drug misusers appear to have ‘hurdles’ to overcome—perhaps leading to less GMS access, despite GPs’ statements to the contrary. This corroborates survey findings in which some GPs admitted that whilst having a drug dependency problem should not affect access to general health services it clearly does.6
As probably may have been expected, GPs called for increases in resources in a number of areas. This was not only for remuneration for the GPs for dealing with a ‘difficult’ group of patients, but for improving access to care through more specialist services. Since this study, there have indeed been several significant changes, most notably the Royal College of General Practitioner’s certificate in drug dependence. This will give rise to higher levels of training in the general GP population and a greater number of GP specialists. However, there is a shortage of specialist addiction psychiatrists and it is this level of specialist input that GPs value and depend upon for support.
Conclusion
In common with other reports, this study provided evidence that GPs’ attitudes to drug misusers may be improving, despite many negative opinions still being held.
GPs feel that drug misuse must also be tackled on a societal level if we are to deal with it effectively, and that the medical aspect of misuse is only the tip of the iceberg. Despite this, GPs are increasingly willing to deal with misusers, particularly in a shared care environment, and play their part provided that the necessary training, support and resources are available.
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Acknowledgments |
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We would like to thank all the GPs who voluntarily took part in the interviews, Mrs Netta Clark who transcribed the tapes, and the Chief Scientist Office, Scottish Executive, for supporting the study.
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References |
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12 Farrell M, Ward J, Mattick R. Fortnightly review: methadone maintenance treatment in opiate dependence: a review. Br Med J 1994; 309:997–1001.
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