Managing drug misuse in general practice

Editor—The Republic of Ireland has adopted a similar approach to drug misuse to that discussed in Keen's editorial.¹ General practitioners are encouraged to become involved in the treatment of drug misusers by legislation introduced in October 1998 to regulate the prescribing and dispensing of methadone.²

Providing methadone maintenance in general practice has led to encouraging reductions in the use of illicit drugs,³ but concerns have been expressed about the problems of double prescribing and the availability of methadone on the black market. Despite the existence of a central methadone treatment list in Ireland since 1993, doctors were not legally obliged to register patients. An added problem was that the presence of large numbers of drug users attending individual private general practitioners or pharmacies had contributed to considerable local community resistance to health boards establishing locations for treatment.

The main points of the new protocol are as follows. All methadone treatment is now free. Only methadone of 1 mg/ml concentration can be prescribed. All patients for whom methadone is started must be registered on the central treatment list. For patients being prescribed methadone in general practice a treatment card, incorporating the patient's details and photograph plus the doctor's details, must be lodged in a specified dispensing pharmacy.

Doctors, depending on training, are limited to certain numbers of patients. Level 1 general practitioners can prescribe to 15 patients whose condition has been stabilised in a clinic. Level 2 general practitioners can prescribe to 35 patients, who can be a combination of patients whose condition has been stabilised and new patients. Training and regular audit are organised jointly by the relevant health board and the Irish College of General Practitioners. Pharmacists are also limited, to a total of 50 patients. Remuneration for both groups of professionals is provided centrally, with recognition given for daily dispensing by pharmacists. All the Irish health boards are represented on a methadone protocol implementation committee to oversee this initiative.

The success of this legislation, which aspires to normalise drug treatment in primary care, will only become apparent over time. Since October 1998 the numbers registered centrally have increased from 3200 to 3750, of whom 1000 are in treatment through general practice. Despite the stricter regulations the numbers of general practitioners and pharmacists involved continue to increase (table). This perhaps indicates that these professionals have overcome some of their fears about treating drug users and are prepared to give the new legislation a chance to work.

Table.

Numbers of general practitioners and pharmacies participating in Irish methadone regulations in May 1998 and May 1999, before and after legislative changes were introduced to regulate prescribing and dispensing of methadone

	31 May 1998	31 May 1999
General practitioners:
Within Eastern Health Board area	82	111
Outside Eastern Health Board area	10	28
Total	92	139
Pharmacies:
Within Eastern Health Board area	88	150
Outside Eastern Health Board area	0	37
Total	88	187