Personal views: GPs and junkies
Authors: Andrew Dicker
Journal: BMJ (1998)

The stories which junkies tell about their attempts to get help from primary care present some hazardous options. A few GPs have become expert in managing substance misuse; a few have a go but lack the necessary support; but most NHS GPs refuse to have anything to do with junkies. A small group of doctors see junkies privately for large profits. 

The private system works as follows: the doctor takes on the patient with a substance misuse problem and negotiates a prescription. The doctor takes a fee and the junkie pays for the cost of the drugs. The junkies use a proportion of the supply themselves and sell the rest on the street in order to pay the doctor and the pharmacist. The stories of discriminatory and unethical behaviour among doctors are legion. 

Within their terms of service GPs can refuse to keep on their lists patients whom they do not wish to treat. This is an important option for doctors. Doctors are hesitant to cease the hypocritical refrain about putting patients first, and publicly acknowledge that unless doctors look after themselves they will not be able to look after their patients. 

There are, however, recent examples that doctors’ attitudes are changing. At the outset of fundholding there was no evidence of benefit for patients, so presumably the GPs who enthusiastically espoused it did so out of self interest. The recent proliferation of out of hours cooperatives is primarily to allow doctors to cope with a 24 hour contract which is impossible to fulfil; the patients may or may not benefit. Looking after junkies is stressful, so doctors refuse to do it. These examples could be construed as the behaviour of responsible doctors looking after themselves in order to do better for their patients. 

With the help of my practice computer I ran a short and not very scientific audit on the causes of deaths among the 82 of our patients who died during 1997. Most died of the consequences of arterial disease, chronic lung disease, and cancer. Thirteen per cent died of less common causes like pancreatitis, septicaemia, and meningitis. Diabetes and its complications was the cause of death in a further 5%. In another 5% overdose of intravenous heroin was the sole cause of death. The average age at death among this community was 69 (excluding those who died from heroin overdose). The average age of the junkies who died was 33. 

People with diabetes and drug misusers have much in common, apart from their mortality. They can both be demanding. They request unusual prescriptions for things which do not appear on the computer formulary and expect to have prescriptions written by hand. The management of diabetes and substance misuse are both forms of tertiary prevention. The object is to minimise the damaging effect of a pre-existing condition. 


The treatment of drug addiction is cheap and cost effective. There is an enormous health gain and the societal benefits have only just begun to be counted. Each junkie taken on for treatment ceases the criminal behaviour which is often necessary to sustain the habit. It is an area where the increasingly recognised tension between doctors’ moral obligation to their patients and the wider utilitarian duty to the population is suddenly relaxed. Both duties go hand in hand towards individual and public benefit. 


“Addictive behaviour is barely mentioned in the medical curriculum”



Why is it not negligent to exclude drug addicts from GPs’ NHS lists? The duty of the doctor is plain; the standard is set by the respectable body of doctors who do agree to treat addicts and causation is evident: withholding treatment maximises the harm to the patient. 

Heroin does not discriminate—it controls anyone who becomes dependent on it. It is no use to say that its victims had a choice and should have said no before it became a problem; dependency on drugs is endemic in our society and its victims cannot be deemed any less deserving than the victims of any other affliction. 

Can the duty of the doctor be met by appropriate referral to specialist clinics? The reason junkies seek help from GPs is that the clinics are underfunded, deprioritised, and woefully inadequate to meet the demand. Every junkie has a story to tell about how their attempt to access clinics has met with obstacles and a return to street chaos. 

GPs have the potential to provide the means of removing addicts from the street user environment immediately the addict engages with the service. Appropriate backup from the secondary care sector obviously remains essential and in some enlightened areas specialist services are already available in primary care. 

The management of diabetes is taught at every stage of medical education. The study of addictive behaviour is barely mentioned in the medical curriculum.