Findings of a national survey of the role of general practitioners in the treatment of opiate misuse: views on treatment.

An important component of government policy on services for drug misusers is to encourage general practitioners to take a more active role. There are, however, some indications that general practitioners regard drug misusers as undesirable patients, although no evidence is available. As part of a wider investigation of the role of general practitioners in the treatment of opiate misuse, a questionnaire, which was sent in mid-1985 to a 5% random sample of general practitioners in England and Wales, included a section designed to elicit their views on policy and treatment connected with opiate misuse. The results showed that although most general practitioners consider opiate misuse to be a priority concern for the Health Service, they also generally regard opiate misusers as especially difficult to manage, beyond their competence to treat, and less acceptable as patients than others in need of care. General practitioners who have qualified recently were somewhat less unfavourable in their views. These findings suggest that the effective implementation of government policy will require trying to modify general practitioners'' attitudes and providing support for them.     

Findings of a national survey of the role of general practitioners in the treatment of opiate misuse: extent of contact with opiate misusers.

With the recent unprecedented growth in the spread of drug misuse in the United Kingdom the role of the general practitioner has become more and more prominent, both in response to demands for treatment and as the focus of national policy on drug misuse. Although general practitioners may be the first contact, few data are available on the extent of their contact with drug misusers. A postal survey was carried out in mid-1985 of a 5% national sample of general practitioners in England and Wales concerning their role in and views on the treatment of opiate misusers, including the extent of their contact with such patients during a four week period. Of the 1166 general practitioners surveyed, 845 replied, a response rate of 72%. The results show that roughly one in five general practitioners in England and Wales attended an opiate misuser during this four week period, seeing an estimated 6000 to 9000 patients, one third of whom were "new" to the general practitioner. A cautious estimate of between 30,000 and 44,000 new cases of opiate misuse presenting to general practitioners in a year is suggested, with some adjustment necessary because of double counting. A wide variation in the prevalence of consultations among regional health authorities was found, and several of the regions with a high prevalence are outside the London area. The scale of contact thus confirms the importance of the general practitioner in the national response to drug misuse.     

Methadone maintenance in general practice: patients,workload, and outcomes.

OBJECTIVE--To assess recruitment to and work-load associated with methadone maintenance clinics in general practice; to investigate the characteristics of patients and outcomes associated with treatment. DESIGN--Study of case notes. SETTING--Methadone maintenance clinics run jointly by general practitioners and drug counsellors in two practices in Glasgow. PARTICIPANTS--46 injecting drug users receiving methadone maintenance during an 18 month period, 31 of whom were recruited to clinic based methadone maintenance treatment and 15 of whom were already receiving methadone maintenance treatment from the general practitioners. Mean (SD) age of patients entering treatment was 29.6 (5.5) years; 29 were male. They had been injecting opiates for a mean 9.9 (5.1) years, and most had a concurrent history of benzodiazepine misuse. Average reported daily intake of heroin was approximately 0.75 g. Participants in treatment had high levels of preexisting morbidity, and most stated that they committed crime daily. RESULTS--2232 patient weeks of treatment were studied. Mean duration of treatment during the study period was 50.7 (21.1) weeks and retention in treatment at 26 weeks was 83%. No evidence of illicit opiate use was obtained at an average of 78% of patients'' consultations where methadone had been prescribed in the previous week; for opiate injection the corresponding figure was 86%. CONCLUSIONS--Providing methadone maintenance in general practice is feasible. Although costs are considerable, the reduction in drug use, especially of intravenous opiates, is encouraging. Attending clinics also allows this population, in which morbidity is considerable, to receive other health care.     

Effects of the opiate antagonists diprenorphine and naloxone and of selected opiate agonists on feeding behavior in guinea pigs

Opiate-sensitive feeding behavior has now been demonstrated in a number of species. We sought information on which opioid receptors might be involved in the observed feeding behaviors. Guinea pigs are known to have higher concentrations of the opioid kappa receptor than any other laboratory animal, so we compared the feeding suppressive potency of the general opiate antagonist, diprenorphine to that of the relatively more mu-specific antagonist, naloxone in that species. We found that diprenorphine was over twenty times more effective than naloxone in suppressing feeding in guinea pigs, suggesting the importance of receptors other than mu in feeding initiation in the guinea pig. Confirmatory evidence for the role of kappa receptors was sought, but not found, in comparisons of the effectiveness of different types of opiate agonists in promoting feeding in these animals. These agonists suppressed, rather than stimulated feeding. We conclude that no feeding stimulatory effects of opiates can be demonstrated in guinea pigs. This observation may indicate that opioids play little role in the natural regulation of feeding in this species or that opioids result in prolonged sedation during which the animals fail to eat. The greater feeding suppressive potency of diprenorphine, a general opiate antagonist, versus naloxone, a mu-preferential antagonist, indicates that to whatever extent opiates are involved in guinea pig feeding, the opiate effect is probably not a mu receptor effect.     

Role of community pharmacies in prevention of AIDS among injecting drug misusers: findings of a survey in England and Wales.

OBJECTIVE--To determine the current and potential roles of community pharmacists in the prevention of AIDS among misusers of injected drugs. DESIGN--Cross sectional postal survey of a one in four random sample of registered pharmacies in England and Wales. SETTING--Project conducted in the addiction research unit of the Institute of Psychiatry, London. SUBJECTS--2469 Community pharmacies in the 15 regional health authorities in England and Wales. MAIN OUTCOME MEASURES--Willingness of pharmacists to sell injecting equipment to known or suspected misusers of drugs; pharmacists'' attitudes to syringe exchange schemes, keeping a "sharps" box for use by misusers of drugs, and offering face to face advice and leaflets; and opinions of community pharmacists on their role in AIDS prevention and drug misuse. RESULTS--1946 Questionnaires were returned, representing a response rate of 79%. This fell short of the target of one in four pharmacies in each family practitioner committee area in England and Wales, and total numbers of respondents were therefore weighted in inverse proportion to the response rate in each area. The findings disclosed a substantial demand for injecting equipment by drug misusers. After weighting of numbers of respondents an estimated 676 of 2434 pharmacies were currently selling injecting equipment and 65 of 2415 (3%) were participating in local syringe exchange schemes; only 94 of 2410 pharmacies (4%) had a sharps box for used equipment. There was a high degree of concern among pharmacists about particular consequences of drug misusers visiting their premises, along with a widespread acceptance that the community pharmacist had an important part to play. CONCLUSIONS--Promoting the participation of community pharmacists in the prevention of AIDS among misusers of injected drugs is a viable policy, but several problems would need to be overcome before it was implemented.     

Communication of results of necropsies in north east Thames region.

OBJECTIVE--To evaluate the adequacy of reporting of results of necropsy to referring clinicians and to general practitioners. DESIGN--Questionnaire survey of referring clinicians and general practitioners of deceased patients in four districts in North East Thames region. Patients were selected by retrospective systematic sampling of 50 or more necropsy reports in each district. SETTING--One teaching hospital, one inner London district general hospital, and two outer London district general hospitals. PARTICIPANTS--70 consultants and 146 general practitioners who were asked about 214 necropsy reports; coroners'' reports were excluded. MAIN OUTCOME MEASURES--Time taken for dispatch of final reports after necropsy, consultants'' recognition of the reports, general practitioners'' recognition of the reports or of their findings, and consultants'' recall of having discussed the findings with relatives. RESULTS--Only two hospitals dispatched final reports including histological findings (mean time to dispatch 144 days and 22 days respectively). 42 (60%) consultants and 83 (57%) general practitioners responded to the survey. The percentage of reports seen by consultants varied from 37% (n = 13) to 87% (n = 36); in all, only 47% (39/83) of general practitioners had been informed of the findings by any method. Consultants could recall having discussed findings with only 42% (47/112) of relatives. CONCLUSIONS--Communication of results of necropsies to hospital clinicians, general practitioners, and relatives is currently inadequate in these hospitals. IMPLICATIONS AND ACTION--A report of the macroscopic findings should be dispatched immediately after necropsy to clinicians and general practitioners; relatives should routinely be invited to discuss the necroscopic findings. One department has already altered its practice.     

Bremazocine: a potent, long-acting opiate kappa-agonist

The benzomorphan analogue bremazocine is a potent, centrally-acting analgesic with a long duration of action. In animal models it is free of physical and psychological dependence liability, produces no respiratory depression, and has a variety of other properties which justify its classification as a putative opiate kappa-receptor agonist.Binding studies with tritiated (?)-bremazocine on rat brain membrane preparations show that this molecule differs in its binding properties from previously investigated exogenous or endogenous opioids. Studies on isolated guinea-pig ileum and mouse vas deferens indicate a preference for opiate kappa-receptors.In mice (hot plate, tail flick) and rhesus monkeys (shock titration), bremazocine is a potent analgesic with a long duration of action. Here also, the actions of the antagonists naloxone and Mr 2266 suggest a preference for opiate kappa-receptors.Bremazocine differs from morphine in the non-production of mydriasis and the Straub tail phenomenon in mice, in its lack of effects on respiration in rats, in that it is not self-administered by rhesus monkeys, and in that programmed administration in the same species does not lead to a morphine-like withdrawal syndrome upon cessation of drug treatment or upon naloxone challenge. Prolonged treatment of animals with bremazocine leads to tolerance to its analgesic effects; morphine treatment of such tolerant animals causes analgesia. Conversely, treatment of morphine-tolerant animals with bremazocine does not cause analgesia; these findings suggest that morphine and bremazocine interact with different subpopulations of opiate receptors.     

What happens to opiate addicts immediately after treatment: a prospective follow up study.

In the first British study to investigate systematically what happens to opiate addicts after treatment 50 opiate addicts admitted for inpatient treatment of their drug dependence were followed up for six months after discharge. All had been withdrawn from opiates before follow up. Six months later 26 were not using opiates: 12 had not used opiates at any time since discharge. When subjects in hospital or in prison were excluded from the analysis 21 (47%) of the subjects living in the community were not taking opiates. Many subjects used opiates within days of leaving the inpatient unit, but this first lapse did not necessarily lead to a full relapse into addictive use. During the six months after discharge several subjects used opiates on a less than daily basis. During each two month period throughout the six months of follow up the proportion of subjects who were occasional users fell, the proportion of abstinent subjects grew, and the proportion of daily users (assumed to be readdicted) remained constant. Although many of the addicts relapsed soon after treatment, it was encouraging that almost half were opiate free after six months. These results have important implications for the treatment of drug addicts.     

Can general practitioners use training in relaxation and management of stress to reduce mild hypertension?

To see whether general practitioners could effectively carry out training in relaxation and management of stress to reduce mild hypertension a study was carried out with a subsample of phase 2 of the Medical Research Council''s treatment of mild hypertension trial.¹ In the main mild hypertension trial patients had been receiving either an active drug or placebo for six years. In phase 2 a subsample of these patients were randomly allocated either to continue or to stop receiving the active drug or placebo. In a further subsample patients were again randomised to receive or not to receive relaxation therapy. This factorial design presented an additional opportunity to assess whether patients controlled with active drugs might have their blood pressure maintained by this behavioural therapy once drug treatment was stopped and to assess whether blood pressure might be further reduced by this therapy in patients who had been under regular medical supervision for as long as six years and who had already received non-pharmacological advice. The therapy was conducted by general practitioners in group sessions once a week for eight weeks. The training in relaxation was accompanied by galvanic skin resistance biofeedback. At one year follow up blood pressure in the relaxation subgroups was either maintained (in the group who had stopped receiving drugs) or reduced further (in the group who had continued receiving drugs and in both placebo groups), while in the control group it had increased in all the subgroups, but particularly in those who had stopped receiving drugs. Differences in changes in blood pressure between the relaxation and control groups were significant. There were five new cardiovascular events, including evidence of myocardial ischaemia in blindly coded electrocardiograms in the control group, compared with one in the treatment group.General practitioners, if motivated, can successfully apply this technique of training those with mild hypertension in relaxation and management of stress.     

Prescribing new drugs: qualitative study of influences on consultants and general practitioners

ObjectiveTo explore consultants'' and general practitioners'' perceptions of the factors that influence their decisions to introduce new drugs into their clinical practice.DesignQualitative study using semistructured interviews. Monitoring of hospital and general practice prescribing data for eight new drugs.SettingTeaching hospital and nearby general hospital plus general practices in Birmingham.Participants38 consultants and 56 general practitioners who regularly referred to the teaching hospital.ResultsConsultants usually prescribed new drugs only in their specialty, used few new drugs, and used scientific evidence to inform their decisions. General practitioners generally prescribed more new drugs and for a wider range of conditions, but their approach varied considerably both between general practitioners and between drugs for the same general practitioner. Drug company representatives were an important source of information for general practitioners. Prescribing data were consistent with statements made by respondents.ConclusionsThe factors influencing the introduction of new drugs, particularly in primary care, are more multiple and complex than suggested by early theories of drug innovation. Early experience of using a new drug seems to strongly influence future use.

What is already known on this topic

UK studies show that use of new drugs by general practitioners is influenced by consultants, the nature of the drug, and perceived risk

What this study adds

Consultants generally introduced fewer drugs than general practitioners, usually within their specialtyDecisions were said to be based mainly on the evidence from the scientific literature and meetingsGeneral practitioners prescribed more new drugs and the basis of decisions was more variedDoctors'' interpretations of using a new drug were not consistent     

District programme to reduce smoking: effect of clinic supported brief intervention by general practitioners.

By encouraging and supporting general practitioners to undertake brief intervention on a routine basis smokers'' clinics could reach many more smokers than are willing to attend for intensive treatment. In a study with 101 general practitioners from 27 practices 4445 cigarette smokers received brief intervention with the support of a smokers'' clinic, brief intervention without such support, or the general practitioners'' usual care. At one year follow up the numbers of smokers who reported that they were no longer smoking cigarettes were 51 (13%), 63 (9%), and 263 (8%), respectively (p less than 0.005). After an adjustment was made for those cases not validated by urine cotinine concentrations the respective success rates were 8%, 5%, and 5%. Use of nicotine chewing gum was associated with higher self reported success rates. General practitioners providing supported brief intervention encouraged not only more smokers to use the gum but also more effective use; gum users in this group reported a success rate of 27% at one year. Compliance by the general practitioners in recording smoking state averaged 45%, and significantly higher success rates were reported by patients whose smoking state had been recorded. Brief intervention by general practitioners with the support of a smokers'' clinic thus significantly enhanced success rates based on self reports. Better results might be obtained if general practitioners'' compliance with the procedure could be improved and if they encouraged more of their patients to try nicotine gum. Collaboration of this kind between a smokers'' clinic and local general practitioners could deliver effective help to many more smokers than are likely to be affected if the two continue to work separately.     

General practitioner response to elderly patients discharged from hospital.

OBJECTIVE--To determine the effect of discharge information given to general practitioners on their management of newly discharged elderly patients. DESIGN--A random sample of 133 elderly patients who had unplanned readmission to a district general hospital within 28 days of discharge was compared with a matched control sample of patients who were not readmitted. Information was gathered from the hospital, the patients, the carers, and the general practitioners about the information that the hospital had sent the general practitioner and the general practitioners'' response to this information. SETTING--All specialties in a district general hospital. PATIENTS--266 Patients aged over 65 representative in the main demographic indices of the population of elderly patients admitted to hospital. RESULTS--Ten weeks after discharge the doctors had received notice of discharge about 169 of the patients, but fewer than half the discharge notices were received within the first week. General practitioners were dissatisfied with the information in 60 cases. A general practitioner visited 174 of the patients after their discharge from hospital and three quarters of the visits took place within two weeks of the discharge. These visits were more likely to have been initiated by patients or families than by the doctor, and this was not influenced by the doctor receiving notice of the patient''s discharge. Older patients and those who had carers were the most likely to be visited. Nearly half of the carers were dissatisfied with some aspect of general practitioner care, problems with home visiting being the commonest source of complaint. CONCLUSIONS--Hospital communications to general practitioners about the discharge of elderly patients still cause concern, particularly in the time they take to arrive. Written instruction to vulnerable elderly patients asking them to inform their general practitioner of the discharge might be helpful. Carers complained of lack of support, and it is clearly important for someone (either the general practitioner or another health worker) to visit elderly people shortly after their discharge.     

Community care service for diabetics in the Poole area.

Because of an increasing work load at the hospital diabetic clinic in Poole general practitioners were asked to help in a community care service for diabetics. In this, general practitioners typically care for non-ketotic patients with maturity onset diabetes who are well controlled on diet or diet and oral hypoglycaemic agents, while the clinic concentrates on more difficult cases and screens patients for long-term complications. The hospital laboratory''s work load has been eased because patients may attend for two-hour interval blood sugar estimations when they like; most patients appreciate this flexibility and prefer being looked after by their own doctor. The service has not increased the general practitioners'' work load unduly, but it has heightened their awareness of diabetes in the community, thus allowing the diabetic consultant to deal with the problems for which he has been trained. The service has thus provided improved care for all diabetics in the Poole area.     

The interaction of ketamine with the opiate receptor

The analgesic effect of the anesthetic agent ketamine HCl is inhibited in rats by the narcotic receptor antagonist naloxone. Racemic (±) ketamine HCl also displaced ³H-naloxone in an opiate receptor binding-assay. The potency of ketamine in the assay was reduced nearly six-fold by sodium suggesting that the drug interacts as an agonist. However, some activity as an antagonist was not ruled out. The interaction of ketamine HCl with the opiate receptor was stereospecific with the (+) salt being more effective than the (-) salt. The stereoselective nature of the interaction is consistent with other studies (1) demonstrating that (+) ketamine HCl has a greater analgesic effect than the (-) salt.     

Reinforcement processes in opiate addiction: A homeostatic model

The development of tolerance and dependence has traditionally been considered an integral aspect of the drug addiction process, and opiate dependence has been studied extensively as a model system in this regard. However, recent emphasis on the positive reinforcing properties of drugs has led to the suggestion that tolerance, dependence, and withdrawal may be of secondary or even negligible importance in motivating compulsive drug use. The current article argues for an integrated view of addiction in the form of a homeostatic neuroadaptation model which emphasizes the motivational significance of both the positive affective state produced by opiates and the negative affective state characteristic of drug withdrawal. The model is supported by evidence at both the behavioral and neural systems levels of analysis. Understanding the important distinction between somatic and affective components of opiate withdrawal is key to recognizing the factors which contribute to the motivational significance of opiate dependence and withdrawal. In addition, the critical role of conditioning processes in the maintenance of compulsive drug use and relapse after periods of abstention is discussed. Finally, it is argued that both the positive reinforcement produced by acute administration of a drug and the negative affective state produced by withdrawal are common to multiple classes of abused drugs, suggesting that an understanding of homeostatic neuroadaptation within motivational systems provides a key to the etiology, treatment and prevention of drug addiction. Special issue dedicated to Dr. Eric J. Simon.     

A protein-lipid model of the opiate receptor

The complexity of the opiate analgesia receptor is indicated by several lines of evidence which are reviewed in this paper: (1) heterogeneity of opiate-receptor interactions; (2) the effect of various enzymatic and chemical treatments of brain membranes on opiate binding; and (3) physico-chemical properties of detergent-extracted membrane components. Based on these findings, a model of the opiate-receptor is proposed which consists of both protein and lipid; the former contains a binding site for enkephalins, and the latter a site for alkaloids, with β-endorphin interacting with both sites. Some implications of this model are briefly discussed.     

Heroin users: notifications to the Home Office Addict's Index by general practitioners.

In a study of 113 heroin users who attended a Scottish general practice of 11 doctors information was gathered retrospectively regarding notification of these patients to the Home Office. The doctors were questioned about their practices for notification. Surprisingly few of the patients had been correctly notified and renotified where appropriate, and there was great variation in the doctors'' notification practices, particularly with respect to defining addiction. General practitioners are now the largest source of notifications of controlled drug users, and the statistics issued by the Home Office must be interpreted in the light of their notification practices.     

Old people not known to the general practitioner: low risk group.

The elderly patients in a large general practice aged 75 and over who lived at home (n = 877) were divided into two groups according to the general practitioner''s knowledge of their risk status and were designated "risk status known" (n = 679) and "risk status not known" (n = 198). Forty-three high risk patients in the risk status known group had a functional disability score and experience of mortality that was not dissimilar to those of elderly people in institutions. The medical and social characteristics of a random sample (n = 150) of the risk status known group, after excluding the high risk patients, were compared with the risk status not known group using a Barber Wallis questionnaire. A response rate of 90% was achieved from both groups and a cumulative risk score was calculated by totalling unfavourable replies to the questions. The risk status not known group, which comprised 14% of the patients who lived at home after correcting for the number who had died and moved, had appreciably less contact with the general practitioners, had an appreciably lower cumulative risk score, were confined at home less because of ill health, were less concerned about their health, and were less in need of nursing attention. The findings of this study suggest that the elderly patients who are not known to their general practitioners are in relatively good health when compared with the patients that the general practitioner knows well.     

Neonatal animal models of opiate withdrawal

The symptoms of opiate withdrawal in infants are defined as neonatal abstinence syndrome (NAS). NAS is a significant cause of morbidity in term and preterm infants. Factors, such as polysubstance abuse, inadequate prenatal care, nutritional deprivation, and the biology of the developing central nervous system contribute to the challenge of evaluating and treating opiate-induced alterations in the newborn. Although research on the effects of opiates in neonatal animal models is limited, the data from adult animal models have greatly contributed to understanding and treating opiate tolerance, addiction, and withdrawal in adult humans. Yet the limited neonatal data that are available indicate that the mechanisms involved in these processes in the newborn differ from those in adult animals, and that neonatal models of opiate withdrawal are needed to understand and develop effective treatment regimens for NAS. In this review, the behavioral and neurochemical evidence from the literature is presented and suggests that mechanisms responsible for opiate tolerance, dependence, and withdrawal differ between adult and neonatal models. Also reviewed are studies that have used neonatal rodent models, the authors' preliminary data based on the use of neonatal rat and mouse models of opiate withdrawal, and other neonatal models that have been proposed for the study of neonatal opiate withdrawal.