Student: Rachael Stevenson
Supervisors: Dr Ian Sheerin, Dr David Kerr and Joy Drummond
Sponsor: Pegasus Health
From the 1960's, New Zealand saw a rapid increase in injected drug use, particularly the opioid heroin. Tougher law enforcement in the 1980's meant that heroin was difficult to access so the legal opioid, morphine, used for pain relief began to be abused by those addicted to opioids. Addiction to opioids means that if the person stops taking the drug they may experience negative feelings and a severe flu-like illness making it extremely difficult to stop using. As users inject the opioid, 84% were infected with viruses such as hepatitis B and C in the 1990s. The abuse of opioids also increases the risk the person dies by overdose, and that their family, friends, and work will be negatively affected. The average person addicted to opioids in Christchurch costs society $4,960 a month mostly in unsafe and illegal activity such as theft and prostitution as a way of obtaining money to acquire more drugs.
Methadone is a monitored medication for opioid addiction that removes negative withdrawal symptoms but provides no 'high' feeling. This may be a lifetime treatment. When patients initially start the Canterbury Methadone Programme (CMP) they must obtain prescriptions from Hillmorton hospital and have daily observed consumption. It can take several months before the person is stable on their methadone dose. Once stable, they can obtain methadone prescriptions from their General Practioners (GP) in a unique programme to Christchurch called 'GP Care'.
GP care aims normalize methadone treatment, provide holistic care to patients and reduce the waiting time for other people to start methadone. Over the past 13 years, the waiting time has dropped from 12 months to 3 months as more patients moved to GP Care. This study looks at how both GPs and patients involved find GP Care before potentially expanding nationwide.
To investigate the General Practitioners' perceptions of the Christchurch Methadone Maintenance Model of Care and the perceptions of methadone clients under GP Care.
Questionnaires were designed and distributed to 48 GPs who had at least one patient on GP Care. Questions focused on; dose adjustments, takeaways, management of other health conditions, prescribing medications that interact with methadone and support and training available. Patient questionnaires were designed to determine how they found GP Care compared to CMP. To maintain patient confidentiality patient questionnaires were sent to each GP's practice manager. The practice manager asked the GP who these patient's were and placed alerts on their screens. When the patient came in for their next monthly meeting an alert would pop up reminding the receptionist to make sure the patient filled out the questionnaire. All questionnaires from GPs and patients were returned with no personal identifying information and results entered into statistical programme; SPSS vs. 17 for analysis. GPs were invited to attend an audio-recorded focus group at Pegasus Health to further discuss issues. This was transcribed and analysed.
19/48 (40%) GPs returned questionnaires, within a month of receiving them. Three (6%) declined to be involved, and six (12.5%) were known to be away for the entire study period. 84% of respondents had been involved with GP Care for more than two years. Respondents had an average of four patients. Three GPs needed to contact GP Committee to clarify which patients were under their GP Care. Based on the questionnaire:
- 63% became involved to help current patients on methadone wanting to move to GP Care.
- 68% liked providing holistic care and help manage patient's addiction.
- 41% disliked patients not always paying fees and 32% disliked the extra time involved.
- Half the GPs had patients wanting dose increases and 95% had requests for dose decreases
- A quarter of the GPs had been asked to prescribe pain relief and a third had been asked to prescribe sedatives that are potentially addictive. Half of the time, GPs felt the request was appropriate.
- Takeaways are viewed as necessary for the patient having a 'normal life', one in four suspect some is diverted and one in ten want all consumption observed at the pharmacy.
- More GPs preferred having access to advice on issues of treatment rather than more training.
- All had a good relationship with their patients but felt funding and clear boundaries would improve this relationship.
- Two thirds would consider taking on more GP Care patients and 94% would recommend other GPs to be involved.
Eight GPs attended the focus group and the key findings were:
- Seven liked having to refer to GP Care committee before making dose or takeaway increases. This meant they weren't bullied by patients or seen as the 'bad guy'.
- Patients are more likely to initiate decreasing their dose than GPs. Whereas a GP is more likely to suggest a dose increase than a patient.
- Cost was a conflicting issue. GPs either charged a decreased fee, their standard fee for all patients or it would vary depending on how long the appointment lasted. All agreed this should be agreed upon with the patient before starting on GP Care.
- The group felt yearly meetings of GPs prescribing methadone would be beneficial, and that more GPs should become involved.
- They perceived GP Care patients as 'less neurotic' and more reliable than other patients and perhaps more GPs would be involved if they knew this.
23/137 (17%) of patient questionnaires were returned after 5 weeks. Most (67%) had been on methadone for more than 10 years. Based on these questionnaires:
- All preferred accessing methadone scripts from their GPs rather than CMP.
- For 85% of patients, GP Care had less travel time, impact on family, work and social commitments and improved their quality of life and health compare to CMP.
- Cost of paying for monthly appointments was the main issue.
- 57% wanted more flexibility with takeaways if they proved they were stable reliable patients.
- All were grateful for being on GP Care, and to their GPs for helping them live 'normal' lives.
The available evidence suggests that the Christchurch GP Care programme is well liked by GPs and patients. Future recommendations are that when initially starting the programme, clear rules and boundaries should be decided upon as well as funding options between the patient and GP. GPs should have the opportunity to meet to discuss issues regularly. If more GPs were recruited into the programme it would reduce the current work load and continue to help people overcome their opioid addictions and live 'normal lives'.