When specialist drug clinics were set up in the 1970s, drugs treatment—and substitute prescribing in particular—was taken out of the hands of individual GPs. With the emergence of HIV and AIDS in the 1980s and the recasting of drugs misuse as a problem of public health, pressure grew for GPs to become involved in treatment again, but in the absence of technical support many GPs with an interest in treating drug users became disinclined to do it. Substitute prescribing can be difficult to get right and the risks involved in the miscalculation of dosages are high.
In addition, according to the Royal College of General Practitioners, many doctors are reluctant to accept drug users as patients. Some have moral or practical objections to prescribing substitute drugs (or worry that their colleagues will have objections, given the expense involved), while others simply have little sympathy with illnesses they regard as self-inflicted. Some doctors find it hard to establish the necessary rapport with patients who often lead difficult and chaotic lives and who may in addition be involved in criminal activity. Many GPs also find drugs treatment unrewarding because they perceive the chances of successful treatment as being low, particularly when they are operating in sub-optimal conditions without adequate support from social services. Others find injecting practices distasteful and are worried about the risk of blood-borne viruses. Often their receptionists are afraid of disruption in the surgery and the effect that drug users may have on other patients. Perhaps most significantly, GPs – especially those operating single-handed - are aware that drug users are likely to take up a good deal of time. Drug use is often at its worst in deprived areas where all forms of ill health are more common and there are fewer doctors. The Royal College has estimated that drug users are likely to consult five times more often than other patients and generate a work load that may be up to twenty times as heavy.
Now, under the new General Medical Services contract offered to doctors since 2004, GPs have to opt into rather than out of providing drugs treatment, which ranks as an ‘enhanced’ rather than a ‘core’ or even an ‘additional’ service. Those electing to provide this ‘enhanced’ treatment service are paid per patient treated according to their level of experience and training. Although the current target of 35 per cent of all GPs to be involved in drugs treatment is being achieved, such a proportion can obviously not guarantee equal access to treatment to all those who need it. In particular, there are long waiting lists for thadone prescription, which will become even longer as the criminal justice system continues to generate increasing numbers of candidates for treatment. In addition, many of the participating GPs provide little else beside a limited methadone prescribing service. They cannot offer either a holistic treatment service for heroin dependency or treatment for any other types of illegal drug misuse.
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