BMC Family Practice BioMed Central Research article Open Access Difficulties associated with outpatient management of drug abusers by general practitioners. A cross-sectional survey of general practitioners with and without methadone patients in Switzerland Anne Pelet1, Jacques Besson*2, Alain Pécoud1 and Bernard Favrat1 Address: 1Policlinique Médicale Universitaire, Lausanne, Switzerland and 2Centre Saint-Martin, Département de Psychiatrie Universitaire de l'Adulte, Rue Saint-Martin 7, 1003 Lausanne, Switzerland Email: Anne Pelet - [email protected]; Jacques Besson* - [email protected]; Alain Pécoud - [email protected]; Bernard Favrat - [email protected] * Corresponding author Published: 19 December 2005 Received: 16 May 2005 Accepted: 19 December 2005 BMC Family Practice 2005, 6:51 doi:10.1186/1471-2296-6-51 This article is available from: http://www.biomedcentral.com/1471-2296/6/51 © 2005 Pelet et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Background: In Switzerland, general practitioners (GPs) manage most of the patients receiving methadone maintenance treatment (MMT). Methods: Using a cross-sectional postal survey of GPs who treat MMT patients and GPs who do not, we studied the difficulties encountered in the out-patient management of drug-addicted patients. We sent a questionnaire to every GP with MMT patients (556) in the French-speaking part of Switzerland (1,757,000 inhabitants). We sent another shorter questionnaire to primary care physicians without MMT patients living in the Swiss Canton of Vaud. Results: The response rate was 63.3%. The highest methadone dose given by GPs to MMT patients averaged 120.4 mg/day. When asked about help they would like to be given, GPs with MMT patients primarily mentioned the importance of receiving adequate fees for the care they provide. Secondly, they mentioned the importance of better training, better knowledge of psychiatric pathologies, and discussion groups on practical cases. GPs without MMT patients refuse to treat these patients mostly for emotional and relational reasons. Conclusion: GPs encounter financial, relational and emotional difficulties with MMT patients. They desire better fees for services and better training. Background encourages employment rehabilitation and retention in Methadone maintenance treatment (MMT) is extensively treatment [4]. However, GPs encounter specific difficul- used for opiate addiction. Providing care in an office- ties with this population: burnout, lack of training, a neg- based practice is feasible [1,2] and produces outcomes ative attitude and a lack of motivation have been widely comparable to those from specialist treatment [1,3-7]. reported [3,8,9]. These difficulties prevent some GPs from Furthermore, it reduces the stigma associated with the accepting MMT patients. diagnosis and treatment of substance abuse and increases the amount of attention paid to medical and psychiatric Furthermore, each country manages MMT in a different conditions [3,4]. Easy geographical access to treatment way: the UK encourages every general practitioner to pre- Page 1 of 7 (page number not for citation purposes) BMC Family Practice 2005, 6:51 http://www.biomedcentral.com/1471-2296/6/51 Table 1: Profile of office-based physicians with and without methadone substitution treatment PT (n = 352) PWT (n = 231) X2, p value Male 84.9% 82.7% X2 = 0.4; p = 0.563 Practice in a town with >10,000 inhabitants 60% 66.2% Practice in a town with <10,000 inhabitants 40% 33.8% X2 = 2.3; p = 0.136 Works alone 57.9% 65.7% Works in a group practice (with other doctors) 42.1% 34.3% X2 = 3.5; p = 0.068 Median no. of years in practice* (mean SD) 15 (14.8 ± 7.4) 17 (17 ± 8.6) Z = -3.2; p = 0.001 PT = General practitioners with patients receiving methadone substitution treatment PWT = General practitioners without patients receiving methadone substitution treatment *P value was calculated using the Mann-Whitney test; other P values were calculated using Fisher's exact test scribe methadone through national policies and guide- lack of motivation have been reported widely among the lines; France usually reserves MMT for specialized centers GP population [3,8,9]. These difficulties discourage and and promotes the use of buprenorphine [10]; and the prevent primary care physicians from accepting drug United States only recently began to allow GPs to pre- abusers for substitution treatment. scribe MMT. The aims of this study were to (1) to describe the specific In Switzerland, most patients on MMT are treated by GPs, difficulties with the MMT population encountered by pri- currently using the oral liquid form of methadone. mary care physicians and to identify why primary care Buprenorphine use is very rare and codeine is not encour- physicians are reluctant to manage drug-abusing patients aged. Only some specialized centers treat opiate abusers in Switzerland; and (2) to identify primary care physi- with injectable heroin. GPs have to register for every opi- cians' needs in terms of future management of drug-abus- ate substitution with methadone to afford the double pre- ing patients in the French-speaking part of Switzerland scription. and to suggest solutions to help them. The Swiss government encourages substitution treatment Methods for drug-addicted individuals in the context of a harm- We mailed a multiple-choice questionnaire designed to reduction policy, but does not push GPs to accept these evaluate various aspects of the difficulties encountered in patients and has never distributed national guidelines treating MMT patients: pharmacological issues (highest broadly as has the UK. Generally, however, Swiss GPs are methadone dose), legal requirements, financial issues used to providing pharmacotherapies and other treat- (how GPs get paid), emotional and psychiatric aspects ments to drug users in our country. There is no shared care (including psychiatric medication and referral to a psychi- as in England, but Swiss GPs use a pragmatic approach, atrist), relationships, multidisciplinary interactions (e.g. including meeting with social workers and pharmacists in with social workers or with pharmacists), motivation of charge of MMT patients. Groups of GPs involved with the primary care physicians, and specific management in the drug-addicted have been created and receive support from office setting. We collected the material to develop this the Federal Office of Public Health for continuous forma- questionnaire during semi-formal interviews with the tion and clinical discussion. staff at Saint-Martin (a specialized center for managing drug abusers). MedRoTox practitioners (a group of gen- Specialized centers with psychiatrists, social workers, psy- eral practitioners concerned with the problem of depend- chologists and medical doctors offer multidisciplinary ency and supported by the Swiss Federal Office of Public management for unstable patients. However, in Switzer- Health) reviewed the questionnaire. During the calendar land as elsewhere, there are not enough specialized cent- year 2000, we mailed it for anonymous completion to ers for all drug addicts requiring treatment, and access is every primary care practitioner with MMT patients in the limited by geographical barriers and the restricted number French-speaking part of Switzerland (556 physicians). of treatment places that can be offered [11]. Furthermore, This figure includes every GP prescribing methadone in some geographical regions do not have specialized cent- this part of the country, which has a population of ers. 1,757,000. We sent the questionnaire again three months later to increase the response rate and received answers Office-based treatment provides clear advantages for over the following three months. drug-abusing patients. However, primary care practition- ers encounter specific difficulties with this patient popula- We sent another questionnaire to GPs without MMT tion. Burnout, lack of training, a negative attitude and a patients to evaluate more specifically the factors that kept Page 2 of 7 (page number not for citation purposes) BMC Family Practice 2005, 6:51 http://www.biomedcentral.com/1471-2296/6/51 Table 2: General practitioners who treat patients with methadone substitution (PT, n = 352) Would you accept new MMT patients? Yes: 23.9 % No: 73% (missing data: 3.1%) Mean (SD) Median Actual number of patients on methadone treatment? 6.2 (± 9.04) 4 How many patients would you like to have on MMT? 5.8 (± 6.9) 4 Highest daily dose of methadone you ever prescribed: 120.4 mg (± 95.9) 100 mg (mode: 100 mg) PT = General practitioners with patients receiving methadone substitution treatment PWT = General practitioners without patients receiving methadone substitution treatment MMT = Methadone maintenance treatment them from accepting these patients. We used the mailing Table 2: Of the total PTs respondents, 73% would not list kept by the outpatient clinic at Lausanne University accept more patients. The mean number (± SD) of MMT Hospital. These 365 GPs represent most of the primary patients that a PT would like to have (5.8 ± 6.9, median 4) care practitioners in the Swiss canton of Vaud. This ques- was slightly less than the mean number that they actually tionnaire, also for anonymous completion, was also sent treat (mean: 6.2 ± 9.04, median 4). Responding PTs twice at an interval of three months. reported an average highest daily methadone dose of 120.4 mg/day (median = 100 mg/day, mode = 100 mg). Both questionnaires are available from the corresponding author. The percentage of PWTs who had received requests for methadone treatment was 52%. Of the responding PWTs, We used descriptive statistics and the chi-square test for 42.9% had been involved in methadone treatment in the comparison. We performed all statistical analyses by SPSS past but were no longer treating such patients. Of the software, version 11. PWTs, 88.7% did not treat MMT patients because they refused to accept them into their practice.