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O'Sullivan, Michael (2018) Optimising treatment in opioid dependency in primary care. Drugnet Ireland , Issue 67, Autumn 2018 , pp. 26-27.

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The majority of opioid agonist treatment (OAT) in Ireland is provided through general practitioners (GPs), who undergo additional training, and through the Methadone Treatment Programme (MTP), which has been running for 20 years. Over this period, however, misuse of over-the-counter (OTC) and prescription medication use has increased. Increases in waiting times for treatment and drug-related deaths have occurred despite a scaling up of OAT in Ireland. The aim of this study1 was to make recommendations to improve OAT and MTP treatment.

 

Methods

A single focus group containing 11 pre-selected national key stakeholders and experts took part in a guided one-off discussion. A broad range of expertise was represented, including clinical, addiction and social inclusion management, harm reduction, homelessness, specialist GPs, and academics. Three participants came from national non-statutory agencies, while the majority of the panel oversaw OAT design and implementation. A written guide exploring relevant issues around OAT and MTP was used in the focus group discussion. Transcripts of the audio recording were subjected to content analysis to generate overall themes.

 

Results

Four themes emerged from the content analysis of the discussion on current barriers within treatment and possible solutions: OAT choices and patient characteristics; systemic barriers to optimal OAT service provision; GP training and registration in the MTP; and solutions and models of good practice: using what you have. The main barriers and solutions raised were as follows.

 

OAT choices and patient characteristics

  • There was lack of choice in OAT; Suboxone® use is restricted, whereas methadone is widely available yet viewed more negatively by patients.
  • There was a change in characteristics of those seeking OAT; with OTC opioid abuse becoming more prevalent, accessing treatment is proving difficult for the new cohort of patients both in terms of location and stigma associated with some addiction services.
  • Treatment pathways for polydrug use are lacking.
  • Patients’ behavioural issues often require measures at methadone dispensing pharmacies. This was keenly felt in regard to all female practices supervising male patients.
  • The age profile of long-term methadone users may limit the relevance of any new treatment models.
  • The current long-term MTP was described as complex and overly medicalised (e.g. tapering) and requires a broader approach. 

Systemic barriers to optimal OAT service provision

  • Provision of OAT was described as urban-centric, creating a logistical barrier for rural patients.
  • The sole route of treatment is often through large methadone clinics that may be off-putting for some patients.
  • Complexities around patient’s addresses can limit the available services.
  • Waiting lists for treatment and the requirement for regular consultations exist.
  • Stipulations on referring patients to Level 1 GPs2 and restrictions in numbers managed by Level 1 GPs exist. 

GP training and registration in the MTP

  • Complexity around registration with the Health Service Executive (HSE) and the negative perception of OAT were viewed as affecting the uptake of Level 1 and 2 training.
  • GP registrars not exposed to the opioid-dependent cohort were seen to be less willing to be involved in training and OAT.
  • Level 1 and 2 structures were viewed as too complex for new GPs entering employment in services that do not currently have MTP.
  • Difficulties around becoming a Level 2 prescriber exist.
  • In some areas, GPs were seen as unwilling to take on complex patients due to a lack of resources. 

Solutions and models of good practice: using what you have

  • The training of all GPs in methadone prescribing and other OAT was seen as a way to change attitudes.
  • Supports, such as counselling, that are available in clinics should be available in some capacity to GP services.
  • Informal support meetings within GP practices or telemedicine to deal with the complexity of some cases should be available.
  • Family support systems should be used from the outset, in addition to shared care and key working.
  • The potential for community pharmacies and nurses to contribute to care, including necessary vaccinations, should be realised. 

Conclusions

This study was a first step in identifying barriers to optimal OAT provision. Key experts identified a number of possible solutions that the Irish College of General Practitioners (ICGP) will seek to advance in the relevant arenas and expand upon through further independently run research.

 

Limitations

The authors acknowledge a number of limitations to the research, including the use of a single focus group containing 11 pre-selected experts; the sample not likely to be nationally representative of experiences or opinions; no patient voices were included; and involvement of members of the ICGP’s Substance Misuse Programme in discussion and facilitation may have limited the views shared by others in the group.

 

 

1  Van Hout MC, Crowley D, McBride A and Delargy I (2018) Optimising treatment in opioid dependency in primary care: results from a national key stakeholder and expert focus group in Ireland. BMC Family Practice, 19(1): 103. https://www.drugsandalcohol.ie/29270/

2  Level 1 refers to GPs trained in addiction treatment but not to an advanced level. Level 2 registration refers to GPs with advanced addiction specialist training.

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