French General Practitioners' Attitudes Toward Maintenance Drug Abuse Treatment With Buprenorphine

Abstract

Aims. To assess attitudes of general practitioners (GPs) toward buprenorphine maintenance drug abuse treatment just after its introduction in French ambulatory care (February, 1996). Design. Cross-sectional survey by telephone interviews in a national random sample of French GPs (n= 1,186; response rate= 70.3 %) carried out in April 1996. Measurements. GPs' experience with care for IDU patients and HIV infection during the last 12 months. Logistic regression model to identify GPs' characteristics associated with readiness to prescribe buprenorphine for maintenance treatment. Findings. A minority (24. 0 %) of GPs took care of IDU patients and 30.8 % of these were prepared to prescribe buprenorphine (vs. only 7.5 % in the rest of the sample). A positive attitude toward buprenorphine was related to GPs' experience with carefor IDUs and with prescription of opiates for pain management and palliative care, tolerance toward drug use and personal characteristics such as tobacco use and interest in psychoanalysis. Conclusions. Giving general freedom of prescription of buprenorphine (rather than methadone) to all GPs did not lead to widespread acceptance of the drug's use in treating IDUs. The development of organized networks between specialist services for drug abuse treatment and motivated GPs may be necessary to maximize appropriate prescribing practices.

Introduction

Until 1995, diffusion of maintenance drug abuse treatment has been slow in France due to legal barriers; methadone maintenance treatment was strictly restricted to experimental settings (involving fewer than 300 patients at a national level), and some prescriptions of morphine sulphate to injecting drug users (IDUs) were tolerated although prescribing physicians were under the threat of legal penalties.(1) Because of the increasing importance of injecting drug use in transmission of HIV infection (IDUs accounted for 25% of new French AIDS cases in 1996, this proportion reaching more than 35% in some geographic areas such as South Eastern France and the Paris region), a drastic and very rapid change in public policy toward maintenance drug abuse treatment has recently occurred in the country.

Pre-market approval of methadone for maintenance treatment was introduced in March 1995 with the number of patients included in such programmes reaching 3,000 1 year later; initial prescription of methadone remains, however, restricted to a limited number of specialist services (hospitals or specialized units), ambulatory physicians in contact with these services being authorized to renew these prescriptions. Use of buprenorphine for maintenance treatment was authorized in July 1995 and three dosages of buprenorphine (0.4, 2 and 8 mg under the brand of Subutex R) have been available in French pharmacies since February 1996, providing the possibility for any physician, including GPs, to prescribe such treatment. Each prescription can legally cover a maximum of 28 days of treatment. Clinical recommendations suggest prescriptions of daily doses of 8-10 mg with a maximum of 16 mg.(2) Prescription of morphine sulphates for maintenance drug abuse treatment was strictly forbidden in June 1996, making buprenorphine the treatment of choice in French general practice.

Because responsibility for many of the problems of drug abuse and HIV infection lies with general practice, it has been suggested in many countries that linking primary medical care with maintenance drug abuse treatment can bring critical services to HIV-infected IDUs.(3-7) Many IDUs would prefer to be treated by their GPs, and HIV-infected IDUs tend to consult GPs more than those who are not.(8-9) However, a majority of GPs and community pharmacists find IDUs difficult to manage and are reluctant to be involved in care for these patients.(10-15) Experience from countries such as the United Kingdom, where maintenance drug abuse treatment has been introduced in ambulatory care earlier than in France, also suggests that the level of management of opiate misusers which may legitimately be expected of GPs remains unclear, and that prescribing opiates as maintenance treatment may not be an acceptable and feasible role for the majority of GPs.(10),(16) To the extent that the new French policy is based on a general freedom of prescription of buprenorphine given to all GPs, without any specific requirements in terms of training and experience with drug maintenance treatment, problems in implementing such policy could therefore be expected.

The first national survey among a representative sample of French GPs about care for HIV infection and drug abuse, carried out in April 1996, gave us the opportunity to assess GPs' attitudes toward buprenorphine simultaneously with its introduction for maintenance drug abuse treatment in ambulatory care.

The survey set out to determine: (1) which primary care physicians had experience with care for IDUs and how such previous experience may influence their willingness to prescribe buprenorphine for drug maintenance treatment; and (2) what attitudinal and structural barriers may interfere with GPs providing care for IDUs in general, and taking a more active role in buprenorphine maintenance treatment in particular. Attitudinal barriers measured included negativity toward IDUs and/or HIV-infected patients and GPs' personal opinions about drug misuse and public health policy issues. The survey also tried to approach structural barriers, including physicians' lack of experience and information with care for IDUs and prescription of opiates in general as well as some practitioners' professional and personal characteristics.

Material and Methods Sample

A sample of 1785 GPs was selected randomly from the comprehensive national administrative directory of the Sickness Fund of French Social Security. This directory includes all types of general practices (individual and group practices, GPs working full-time in private practices on a fee-for-service basis or having part-time activities on a salary-basis). Two letters, one from the President of the French National Board of Physicians ("Ordre des Medecins", the official professional body in charge of deontology and ethical issues), and the other from the directors of the two research teams involved in the study (South-Eastern France Regional Centre for Disease Control and INSERM Research Unit no.379) were sent to all GPs included in the sample in order to inform them, in very general terms, that they were going to be contacted for a survey on injecting drug use and HIV infection and to encourage them to participate. A few days later GP practices were contacted by telephone by trained interviewers in order to make an appointment for a telephone interview. A maximum of eight phone calls, at different weekdays and at different times of the day, were performed in order to obtain the appointment. All interviews were carried out using the Computer Assisted Telephone Interview system, which guarantees anonymity of the respondent.

Questionnaire

The questionnaire included a total of 60 questions: 24 questions dealing with the socio-demographic, professional and personal characteristics of the respondent; 16 questions about attitudes toward IDUs and/or HIV-infected patients as well as ethical and public health issues associated with care for IDUs recorded on five-point Likert scales; 20 questions about GPs' experience with care for these patients. The questionnaire included one short "vignette" which confronted GPs with the issue of prescribing buprenorphine for maintenance drug abuse treatment:

A young heroin addict, around thirty years of age, with a long history of drug dependence (more than 10 years) comes to your practice asking for maintenance drug abuse treatment. What would be your preferred option:

• You would refuse to treat him and refer him to a specialist service for drug abuse treatment?
• You would prescribe benzodiazepines (or other anxiolytic and hypnotic drugs) and suggest opiate detoxification?
• You would prescribe buprenorphine for a few days and ask him to come back?

Statistical analysis

x2 tests and one-way analysis of variance were used for univariate analyses. Forward stepwise logistic regression analysis was used to examine factors linked to the odds of GPs agreeing with prescription of buprenorphine for maintenance drug abuse treatment. Independent variables significantly associated with the dependent variable (p < 0.05) in bivariate analyses were initially selected for testing in the logistic regression model, and possible interactions between variables in the model were also examined.

Results

Rate of participation in the survey

Among the 1,785 physicians initially selected at random, 99 did not satisfy the criteria for participating in the survey (they had either given up their practices, moved away, or were medical specialists). Among the 1,686 eligible GPs, 11.2% (n= 188) could not be contacted. An additional 16.4% (n = 276) refused to take part in the survey, and 2.1% (n=36) of the interviews were not completed. The total number of respondents was therefore 1,186 GPs (response rate=70.3%). The mean duration of the interview was 24 min.

Characteristics of the sample

No significant differences were observed between the respondents and the non-respondents in terms of any of the variables which could be determined from the initial file (age, gender, region, size of town, mode of practice). Comparison of our sample of respondents to the general population of French GPs showed no significant differences for these main sociodemographic characteristics (Table 1).

GP's experience with care for IDUs

During the 12-month period prior to the survey, a majority of the respondents (53.3%; n = 632) had at least one consultation with an IDU, but less than half of them (n= 285; 24.0% of the total sample) had taken care of IDU patients. An even smaller minority (8.4%; n = 100) had taken care of three or more IDUs, and these GPs alone accounted for 73.9% of the total number of IDUs who were given ambulatory care by this sample of physicians. Not surprisingly, a majority (59.1%; n= 169) of GPs who took care of IDU patients (n = 285) also participated in care for HIV-infected patients during the previous year, either because their IDU patients were already HIV-infected or because they had both types of patients in their practice. One-third (35.2%) of the 480 GPs involved in HIV care had taken care of IDU patients.

A majority of the 285 GPs who took care of IDU patients prescribed opiates for palliative care and pain treatment which are under strict regulatory control in France (each prescription has to be made on a specific delivery sheet and to be declared to the public health authorities in order for a pharmacist to deliver the drug to the patient): 60.5% vs. 35.7% in the rest of the sample (x² = 54.71; 1 df; P < 0.001) made more than 10 such prescriptions in the previous year. Confronted by the hypothetical case of a terminally ill cancer patient, whose pain persisted in spite of daily prescription of 300 ing of morphine sulphate, only 45.5% of respondents would agree to increase the dosage to achieve pain relief, but this proportion was significantly higher among the 285 GPs with experience of IDU care (53.6% vs. 42.9%) (x² = 16.55; 2 df; p < 0.001).

It must be noted that one-third (34.7%) of the 285 GPs who took care of IDU patients had regular collaboration with specialist services for maintenance drug abuse treatment. However, only 35 of them (12.3%) were already members of formal "HIV and IDU care networks" supported by French public health authorities in order to organize collaboration between primary care physicians and hospitals and specialist services; a majority of the others (63.2%) declared, however, that they would be ready to join such a network if the opportunity was offered to them.

GPs who took care of IDU patients (n = 285) differed significantly from the rest of the sample (n= 901) in terms of personal characteristics: they were younger (64.6% were less than 45 years of age vs. 52.9% in the rest of the sample; x² = 12.14; 1 df; p<0.001); they were more likely to be located in cities with more than 100,000 inhabitants (53.8% vs. 39.1%; x² = 18.33; 1 df; p<0.001); they had a larger practice (their mean number of consultations per day was 23.8 [SD = 8.6] vs. 21.7 [SD 8.11 in the rest of the sample [F= 14.23; p < 0.001]) and tended to have a significant proportion of patients with HIV-related risk behaviours in their practice (31.9% vs. 12.2%; x² = 59.83; 1 df; p<0.001). This group of GPs was also distinctive in specific professional characteristics: they expressed a greater comfort level with the idea of caring for IDU patients (55.6% vs. 42.5% declared that they "felt at ease in consultation with IDU patients"; x²= 18.26; 2 df; p < 0.001); they were more often satisfied with their collaboration with hospital specialists (61.1% vs. 45.7%; x² = 51.03; 2 df; p < 0.001); they more frequently participated in continuing medical education about care for drug abuse and/or HIV infection (62.2% vs. 50.2%; x² = 12.70; 1 df; p < 0.001); availability of condoms at their office was more frequent (49.1% vs. 37.0%; x² = 13.36; 1 df; p < 0.001).

GPs with experience in care for IDU patients were also more inclined to express tolerance toward injecting drug use and to oppose coercive public health policies against drug use: 52.8% opposed the idea that "IDUs should be considered as criminal offenders" versus 41.6% in the rest of the sample (x² = 12.39; 2 df; p < 0.005); 36.8% (vs. 28.1%; x² = 7.99; 2 df; p<0.05) opposed the idea of HIV mandatory screening for IDUs. A majority of GPs (58.4%) who took care of IDU patients, however, declared that they "understand GPs who refuse IDU patients", although this proportion was even higher (68.5%; x²= 10.44; 2 df; p<0.01) among the rest of the respondents.

Attitudes toward buprenorphine maintenance drug abuse treatment

Table 2 shows that the 285 respondents who took care of IDUs were much more likely to adopt a positive attitude toward prescription of buprenorphine (x² = 141.76; 4 df; p<0.001). Among GPs with such experience in the last 12 months, those who cared for three IDUs or more were more likely to support prescription of buprenorphine (40.0%) than those who had a more limited experience with only one or two IDU patients (25.9%) (x² = 7.72; 2 df; p < 0.05). Table 2 also shows that only a very limited number of GPs (7.5%) with no experience of care, or only occasional confrontation, with IDUs were ready to participate in ambulatory maintenance drug abuse treatment, in spite of the recent legalisation of buprenorphine for such purpose.

Multiple regression (Table 3) confirmed that previous experience with care for IDUs as well as familiarity with use of opiates for pain management and palliative care was associated with a positive attitude toward prescription of buprenorphine. More "liberal" attitudes toward IDUs (such as opposing coercive policies for drug control) and public health policies in general (e.g. support for liberalization of abortion) were also associated with GPs' favouring of buprenorphine maintenance treatment. Some physicians' individual characteristics, such as declaring an open attitude toward psychoanalysis in clinical practice, and even personal experience with tobacco use, were also directly associated with GPs' attitudes toward buprenorphine.

Discussion

France is one country where the AIDS epidemic has had the most impact, in a short period of time (1995-96), on the organization and delivery of clinical services for drug abuse treatment. Our survey was the first to be carried out on a national representative sample of French GPs, immediately after the legal introduction of buprenorphine for maintenance drug abuse treatment in ambulatory care. It confirmed, in the French context, that the GP work-force is only minimally involved with drug misusers, that a large majority of GPs express difficulties with care for IDUs, that these difficulties are often present even among those who have already gained experience with HIV infection in general, and that GPs are even more resistant to drug maintenance therapy than they are to general involvement in care for IDUs. (12, 13, 17)

In spite of physicians' adherence to a universal code of ethics, discriminatory attitudes toward HIV-infected patients have been well documented among health care professionals,(18-21) and our survey among French GPs confirms that such attitudes are exacerbated in case these patients are IDUs. Like other recent studies,(16) our survey points out the importance of additional barriers to GPs' involvement in drug maintenance treatment, that may be even more difficult to abolish by additional training, support or incentives. These barriers are either related to a general preference for coercive public health policies or to specific professional and even personal characteristics.

As in other countries,(22) some grounds for optimism can, however, be found in the fact that increased contact with IDUs is associated with GPs' greater confidence in caring for these patients in general, and prescribing drug maintenance treatment in particular. It must also be noted that French GPs who declared an interest in psychoanalysis in their clinical practice were most supportive of introduction of buprenorphine, suggesting, at least before they gained practical experience of such prescription, that they did not view it as contradictory to other forms of care.

One of our main findings was that willingness to prescribe buprenorphine was actually very low among French GPs without any previous experience of care for IDUs. This may be related to the fact that morphine has long been feared by both the general public and doctors, and the mistaken belief that problems associated with abuse of opiates are inextricably linked with their therapeutic use is still widespread.(23) Those GPs in our sample with the greater familiarity with prescription of opiates for management of pain were also more ready to prescribe buprenorphine for maintenance drug abuse treatment.

Whether cooperation of GPs with long-term drug management, in the context of the AIDS epidemic, may represent "good husbandry" or "a recipe for chaos" remains a matter of controversy.(24) Because our results strongly suggest that few GPs, with particular professional and individual characteristics and previous familiarity with prescription of opiates, are ready to be actively involved in maintenance drug abuse treatment, they raise concerns about the way introduction of buprenorphine in the French ambulatory care system of "liberal" medicine has been implemented. In countries with a longer experience than France in this field, concerns have already been raised that pressure from large numbers of IDUs in the practice may make some GPs prescribe replacement drugs in an insufficiently controlled way,(17), (25) and risks of buprenorphine intravenous misuse by drug takers have been documented.(26, 27) In the current context, where a shift away from injecting mainly heroin to multiple drug use has been observed in many countries, including France, (28, 29) such concerns are especially disturbing.

Making reference to some UK experiences,(30), (31) French authorities are currently trying to organize networks between specialist services and motivated GPs in order to promote shared schemes for prescription and follow-up of drug maintenance treatment. Our survey revealed that, at the time of introduction of buprenorphine in ambulatory care, only a very limited number of experienced GPs in the field of care for drug misusers were already enrolled in that kind of network, but about two-thirds of this group of experienced GPs declared some interest in participating in the future if they had the opportunity to do so.

Since our survey was carried out in April 1996, diffusion of buprenorphine drug maintenance treatment has been very rapid in French ambulatory care: 1 year after the commercial availability of Subutex R, it was estimated that 25,000 IDUs were under treatment by their GPs. The impact of such diffusion, as well as the contribution of organized networks involving specialist services and GPs, to the effectiveness of drug abuse treatment and care for HIV-infection among IDUs remains to be carefully assessed in France.

Acknowledgements

This work was supported by a grant from the 15. charity organization Sidaction (France).

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Notes

1. INSERM Research Unit 379, "Social Sciences Applied to Medical Innovation", Institut Paoli-Calmettes, 232 Boulevard Sainte Marguerite 13009 Marseille.

2. Laboratory of Social Psychology (University of Provence).

3. Regional Center for Disease Control of South-Eastern France (ORS-PACA), France.