Family Practice Vol. 21, No. 2, 150-154
Family Practice Vol. 21, No. 2 © Oxford University Press 2004, all rights reserved.
Article |
Engaging the reluctant GP in care of the opiate misuser
Pilot study of change-orientated reflective listening (CORL)
National Addiction Centre (The Maudsley/Institute of Psychiatry), Addiction Sciences Building, 4 Windsor Walk, Denmark Hill, London SE5 8AF and a Alcohol Advisory Service for Camden Islington, 309 Grays Inn Rd, London WC1, UK
Received 20 June 2003; Revised 21 October 2003; Accepted 3 November 2003.
Strang J, McCambridge J, Platts S and Groves P. Engaging the reluctant GP in care of the opiate misuser. Pilot study of change-orientated reflective listening (CORL). Family Practice 2004; 21: 150–154.
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Abstract |
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Background. The GP is central to plans for improved general health care and increased availability and delivery of addiction treatment to drug misusers in the UK. Attention to the actual quality of overall primary care, rather than just the treatment of dependence, has, however, been limited.
Objectives. The purpose of this study was to test the feasibility of delivery and potential value of a brief motivational enhancement intervention targeting the quality of primary care given to opiate misusers by GPs.
Method. This study had an observational ‘before and after’ design with follow-up assessment after 2–3 months. The target population was all GPs in two Primary Care Groups who had neither attended training events nor were involved in the treatment of drug dependence (n = 66), who were then approached via a telephone-administered change-orientated reflective listening intervention, based on principles of motivational interviewing, with informational adjunct. Outcome measures for the study sample (n = 29) were overall therapeutic commitment and motivation to follow up and actual clinical activity and willingness to deliver specified general health care interventions for drug misusers.
Results. Across the study sample, therapeutic commitment improved over time, whilst motivation did not. Change among individual practitioners in receipt of the intervention was observed in both positive and negative directions, and in four of the positive changers, this was judged attributable to the intervention. Positive changes were more than twice as frequent as negative changes.
Conclusions. The direction and extent of change detected were encouraging. Further initiatives are needed to influence practitioner motivation, based on improved understanding of GPs' views on the delivery of primary care for drug misusers.
Keywords. Drug misuse, general practice, opiate misuse, motivational interviewing.
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Introduction |
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The GP is central to plans for improved general health care and increased availability and delivery of addiction treatment to opiate misusers in the UK.1
As part of a national initiative, training events were provided across London to address the training deficit of many GPs, and to foster greater GP involvement in the management of drug misusers. Nevertheless, a substantial proportion of GPs neither provided care to this patient group nor attended the training sessions: these GPs were targeted for a novel intervention, whose objective was to effect substantial change in their attitudes and primary care of opiate misusers.
Attempts to encourage GPs to become more involved in similar areas of work, such as alcohol, have included personal and social marketing, though results have been disappointing.2 Changing practitioner behaviour, e.g. to deliver more patient-centred care, has also been found to be far from straightforward.3 There are motivational and other barriers to involvement in addiction-related practice among generalists, as has been known for several decades.4
Motivational interviewing (MI) is a counselling style primarily concerned with the resolution of ambivalence about change.5 Prescribing substitute drugs as a component of the treatment of drug dependence has hitherto been the main focus of attention for GP involvement with opiate misusers.6,7 Some practitioners, when deciding not to become involved in this area of practice, see themselves as not involved with drug users, and give no further attention to this population. Raising awareness of the broader health needs of drug users, improving attitudes, and thereby increasing the level of activity of GPs in general may make a significant contribution to enhancing the quality of general health care provided to drug users.1
The prescribing of drugs such as methadone is regarded as difficult or questionable by many GP.6,7 In line with the approach of MI, which seeks to minimize resistance and direct attention to areas where the resolution of ambivalence and change may be more likely, we decided not to focus on this subject unless it was raised by the practitioner and such a focus was judged likely to be constructive.
Promising new technologies for changing health behaviours, such as MI, have not yet been applied to the practice of health professionals themselves. For these reasons, we decided to investigate both the feasibility and the potential value of a brief practitioner-targeted intervention based on the principles of MI. The primary objectives of the intervention were to enhance attitudes and activity in relation to the general health care of drug misusers.
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Methods |
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Intervention
MI has been defined as "a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence".5 Adaptations of MI have addressed a wide range of health-related behaviours including cigarette smoking, alcohol and other drug use, medication adherence, eating disorders, asthma management, diet and exercise. Alongside the use of a set of specified conversational skills, the spirit of MI embraces collaboration to resolve ambivalence, evocation of the client's own resources for so doing, and respect for the autonomy of the client.5
In this adaptation, the GP became the ‘client’. A brief adaptation of the core principles of MI was constructed as ‘change-orientated reflective listening’ (CORL). CORL statements were used to guide the conduct of the interview in an exploratory practitioner-centred manner and selectively employed to reinforce consideration of issues, about which change in attitudes or behaviour was judged to be possible. This CORL method was designed to encourage consideration of the quality of primary care given to opiate misusers in such a way as to stimulate intent to change clinical practice.
This discussion took the form of a brief telephone conversation (15–20 min), in which reflective listening statements were interspersed with open questions about this area of work. A menu of questions was constructed in advance, which addressed the range of possible areas for discussion. These included the role of the GP; practice experiences, issues and problems; views on possible changes to existing practice; and practice development needs. The target population in this study was defined as being reluctant towards involvement with opiate misusers (see below). The reasons for reluctance or other sources of non-involvement were targeted specifically during these discussions. Interventions were delivered by JM and PG (who are a researcher and an addictions specialist clinician in the targeted area, respectively).
A further intervention component was the provision of information to all those interested in or willing to receive it. This information contained general guidance on the management of drug misuse and dependence.
Procedures and participants
In two Primary Care Groups in north London, 66 of the 114 currently practising local GPs had neither attended training events nor were known by local agencies to be involved in methadone prescribing; these 66 became our target population. After receiving invitations to participate, targeted GPs were contacted 1 week later by telephone to arrange a time for interview. Appointments for telephone interviews were made and interventions were delivered successfully to 29 (44%) of those targeted. Repeat attempts at contact were made until either participation or non-participation had been ascertained.
No differences were observed between participants and non-participants on available data such as gender, ethnicity and whether a single-handed practice.
Practitioners were asked to return by post the baseline instrument, which was enclosed with the invitation to participate. Where this was not received (n = 4), the instrument was administered by the interviewer prior to the delivery of the intervention. Participants were paid £40 for their involvement with the study. Ethical approval was obtained.
Outcome measures
Attitudes among generalists to providing care for substance-dependent populations have been investigated for more than two decades. ‘Overall therapeutic commitment’ summarizes these attitudes and is comprised of components including role legitimacy (seeing the activity as coherent with and necessary for professional performance); role adequacy (having the required skills to undertake activity); role support (having recourse to assistance when required); and motivation.4 In light of the nature of this intervention, we have selected the brief measure of overall therapeutic commitment and the full measure of the motivational subscale on the Drug and Drug Problems Perceptions Questionnaire (DDPPQ), in order to assess outcomes.8,9
Decision rules were set a priori for ascertainment of change among individual practitioners: categorical change (from ‘not willing to be involved’, to ‘willing in the event of local demand’, to ‘current activity’ in six selected interventions; see Table 1); or change of 
1 SD on attitudinal measures (change score of 4 on 10-item short DDPPQ or of 3 on 5-item DDPPQ motivational subscale8,9) for criterion 1 (the full DDPPQ comprises 30 items8). These latter measures assessed change in overall therapeutic commitment and motivation to work with drug misusers on a 5-point Likert scale.
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A second and more stringent criterion for individual-level change was also adopted: where there was evidence of change on more than one variable, with no contradictory change (criterion 2). Where change was detected, practitioner views on whether this was attributable to the intervention were sought in a semi-structured interview component.
Each practitioner was categorized as ‘changed’ or ‘not changed’ according to these criteria, with positive change being in the direction of increasing involvement or attitudinal positivity. Where there was contradictory evidence of change (in either positive or negative directions) in criterion 1, practitioners were categorized according to the balance of change (as evidencing positive, negative or no overall change).
Follow-up interviews were conducted 2–3 months later (64–91 days; mean interval 74 days). Twenty-seven of the 29 (93%) were contacted successfully for follow-up interview by SP. The two lost to follow-up comprised one refusal and one long-term sick, and these have been excluded from the analyses.
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Results |
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Practitioners ranged in age from 30 to 62 years (mean 46 years) and had worked as GPs for between 1 and 34 years (mean 13 years). Approximately half were of each gender (women n = 13, 48%; men n = 14, 52%), and just over one-fifth of practitioners (n = 6, 22%) were Asian or Black. Five practitioners (19%) worked single-handed and six (22%) worked for six or fewer sessions per week in general practice.
In the previous 4 weeks, six practitioners (22%) reported seeing no patients for problems associated with heroin or other opioid drugs. Eleven practitioners (41%) reported seeing one or two such patients, and 10 reported seeing three or more opioid users (mean number of 3.2 for sample). One practitioner prescribed a substitute drug to one patient in the previous 4 weeks, otherwise there was no evidence of prescribing drugs in the treatment of dependence.
Overall therapeutic commitment improved significantly for the sample as a whole; mean short DDPPQ score reduced from 38.7 to 37.0 (t = 2.46, P = 0.02). There was no significant change over time in the mean motivational subscale score, which reduced from 20.6 to 20.4.
Attitudinal or behavioural change was detected in 19 of the 27 GPs according to criterion 1 (70% of those followed-up; 66% of those interviewed; 29% of the originally targeted population); three-quarters (n = 14) in a positive direction, and a quarter (n = 5) in a negative direction. Individual-level changes are reported in Table 1.
For categorical variables, individual-level change refers to commencement of actual provision of clinical care or willingness to be involved in the event of local demand. The most substantial positive changes related to shared care and overall therapeutic commitment. Seven practitioners who changed positively are now either already involved in formal shared care or are willing to be so (confirmed with local specialist services in five cases). Among the five negative changers according to criterion 1, four reported only negative changes, and one individual reported mixed changes, which were adjudged overall to be negative.
Follow-up interview included enquiry as to the extent to which change may be attributable to the intervention. In only two positive cases did the practitioner give explicit and unambiguous attribution of change to the intervention. In two other cases, change was judged likely to result from intervention by the researcher. In eight cases, it was deemed not possible to form a judgement about the basis of change, and in the remaining two cases of positive change a possible intervention effect was ruled out. In the five cases of negative change, in four cases it was deemed not possible to form a judgement and, in the other case, less motivation and willingness to be involved with drug misusers was directly attributed to the intervention. This individual reported that the intervention provided a valuable opportunity to consider their views on this area of practice and that a subsequent decision in the opposite direction from that which was intended resulted.
According to the more stringent criterion 2, the total number of individual cases of positive and negative change reduced to nine and three, respectively (from 14 and five). All three practitioners (two positive, one negative change) previously identified as attributing change to the intervention met criterion 2 for change.
All those identified as positive changers according to criterion 1 (n = 14) were subsequently targeted for a further follow-up interview after another 6 months (
9 months after the intervention). Eleven of these 14 practitioners were re-contacted successfully and agreed both for the individual-level data collected in the course of the study to be shared with local agencies and to contact by the local shared care agency. Three reports were made of ongoing contact with shared care services.
All those originally targeted and not deemed to have changed by the original criterion (n = 52; including both those who did not enter the study and those who did) were subsequently invited to attend an evening meeting to discuss work with drug misusers. Only two of those originally targeted (and two others) attended, with none of those who chose not to enter the study accepting this invitation.
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Discussion |
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The explicit purpose of this project was to explore the fixed or movable status of GPs who were not currently providing care to opiate misusers. The target sample was deliberately constructed to identify those who were either uninterested or inactive in this area of work. Those most positive about work with drug misusers were excluded from this study. Those most negative about possible practice development in this area are highly likely to be among those initially targeted who chose not to enter the study. Indeed, not one of these practitioners subsequently took up the offer of attendance at an evening meeting designed to be both attractive and convenient. Nonetheless, 44% of these reluctant GPs have been engaged in this intervention. The extent of change, both in overall therapeutic commitment and among individual practitioners according to either criterion, is very encouraging. This potentially offers a route by which general health care provision for opiate misusers may be improved, with consequent health gain in this population with multiple, chronic and severe needs. GP attitudes to work with drug misusers are clearly not immovable.
The observational design of this pilot study precludes absolute attribution of change to the intervention and, in the absence of a comparison intervention, the benefit cannot be uncritically attributed to the specific CORL interview method. Indeed, in only two positive cases was observed positive change unambiguously attributed to the intervention. Other limitations of this study are also noteworthy. We have no means of knowing the adequacy of the change criteria that were adopted; we have thus chosen to present the observed data in as full a way as possible. The before and after measures were collected by different methods (self-completion and telephone-administered interview) and we do not know the extent of measurement bias. Also, we have not attempted to corroborate the self-report data, other than through contact with shared care services. Clearly, further study is needed of novel ways to influence the quality as well as quantity of primary care given to opiate misusers, and CORL based on the principles of MI, appears promising.
The reluctant GP is worth pursuing. Weary and rejected, the trainer and planner might be tempted to give up on the persistently non-participant GP. However, this would represent a gaping hole in the net of primary care health provision to this unpopular, but extremely important, group of patients. The encouraging finding is that, through the deliberate one-to-one targeting of GPs who are already actively or passively non-participant, positive change has been observed in nearly half of those interviewed; and these changes are still present at 2–3 months follow-up.
As a pilot study, it is appropriate to reflect on lessons learnt and implications for further study. It is somewhat puzzling that there was not more widespread attribution of change to the intervention. We do not know the extent to which the intended focus on the quality of primary care, rather than on other aspects of the care of drug misusers, was helpful. Data from a parallel study of cannabis attitudes and practice10 suggest that some subjects may be more fruitful to pursue than others, particularly areas where GPs have not previously developed established views. This accords with the targeting of doubt and uncertainty, which are characteristic of MI. The absence of previously dedicated guidance on the quality of primary care for drug misusers may somewhat perversely thus make this subject particularly appropriate for intervention of this type.
It may be interesting to explore how such interventions may be integrated with other attempts to encourage GPs to become more involved in this area. Targeting interventions of this type at those who did not participate in training was the approach taken here. Equally, it would have been possible to consider whether receipt of this intervention prior to training would have influenced training uptake.
Discussion of methadone prescribing, alcohol-related issues and material other than the intended focus of the intervention took place during the course of intervention delivery, usually at the instigation of the GP. In further development of the intervention approach, it may be desirable to seek to be as flexible as possible in pursuit of addiction-related benefit, rather than to restrict the scope of discussion somewhat artificially.
The feasibility of this approach to intervention has been established and the effectiveness of the method remains to be studied. This will require a study population larger, more geographically broad based and representative than has been the case in this pilot study within a single locality. It is not intended that such interventions may operate in isolation from other attempts to encourage activity in this area, and combination with other components of a strategy will require a fuller consideration of outcomes. Following further refinement of the intervention, a randomized trial is necessary to provide an appropriate test, which will identify the quality and quantity of available benefit.
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Acknowledgments |
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We are grateful to Mary O'Donnell, formerly of Camden & Islington Health Authority, for assistance with the study, and to Emily Gray (NAC) and Lisa Stanway (Islington Primary Care Trust) for assistance with the evening group meeting. This training project was funded by the London Region of the NHS Executive as part of a London-wide General Practitioner Training Initiative in the Management of Drug Misuse and Dependence.
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References |
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