Primary position

Judith‘I do believe that the best care for people who use drugs and alcohol is in their own GP surgeries where possible,’ says Dr Judith Yates, who – although retired from her GP practice since 2010 – is far from retired from the drugs field.

She’d wanted to go into medicine since childhood but dropped out halfway through medical school to ‘explore the world and myself a bit’, an experience that helped her decide that it was being a GP – as opposed to other areas of medicine – that would provide the most interesting challenge. As a young trainee in the late 1970s, and her practice’s only female GP, she soon discovered that the only way to see male patients was though consultations with those who had drink and drug problems. ‘At that time the psychiatric addiction services were struggling to find their way and the heroin was flooding in, and by the ’80s the waiting lists for treatment by the psychiatrists were rapidly building up,’ she says. ‘People were falling out of their care and turning up on my doorstep.’

Her other discovery, however, was just how rewarding helping this client group could be. ‘It just seemed to be something that I could easily do. The rest of general practice – which I was doing as well, of course – often involves the long-term care of physical ailments, some of which are quite gloomy, whereas these were young people with lots of potential who’d struck upon hard times and with a helping hand could get on with their lives. The transformations could be quite rapid.’ She went on to spend three decades as a Birmingham GP, working in the city’s first community drug team in the early ’90s at the same time, and after a while the group of patients at her surgery who used drugs numbered around a hundred. Clearly, not all practices were – or are – as accommodating. Does she feel that the stigmatising attitudes of some GPs are starting to change?

‘I think it’s very patchy and postcode-y,’ she says. ‘In Birmingham we were lucky in that when all the crime money came in with the NTA all the GPs working in this field – only about four or five of us – joined the newly formed shared care monitoring group and managed to use that money to set up probably one of the biggest primary carebased drug treatment services in the country. It’s been very effectively organised and managed in that drug workers go out into GP services as opposed to sitting in a centre somewhere waiting for patients to come to them. Around half the people who are scripted in Birmingham are treated in primary care, which is good but it does need proper focus. GPs on their own can’t do it – they need properly organised key workers coming in because there just isn’t the time in ordinary primary care.’

She still does a weekly clinical session with the community drug team and also helped to plan and set up a new residential detox and rehab clinic, working there for two ‘enormously enjoyable’ years after retiring from her surgery. But it’s policy work that’s been taking up most of her time lately.

‘I had a bit more time to pick my head up from the coalface and look around so I started to look at ways to reduce drug related deaths in Birmingham and work on our take-home naloxone project,’ she says. ‘I thought I’d be able to just put on a couple of training the trainer sessions and then someone else would take over and it would run itself, but that didn’t happen. I discovered that you have to chip and chip away at all these little tiny local barriers that prevent any change.’

It was through the naloxone project that she met Philippe Bonnet (DDN, October 2013, page 16) and started investigating the growing international evidence base for consumption rooms. Is she confident that the Independent Consortium on Drug Consumption Rooms (ICDCR) can achieve its aim of establishing a facility in Birmingham?

‘We’ve been waiting for the Birmingham re-commissioning to finish because – quite rightly and reasonably – we were asked to not take our plans forward in any concrete way while all the services were going through this enormously time-consuming recommissioning round, and we didn’t know who was going to be running treatment services anyway. So we’ve been collecting information and improving our understanding of what could be done and what would be costeffective. We’ve spoken to some people among the police and the local authority who are cautiously interested, but we obviously need the clinical arm.’

The city’s main clinical provider is likely to be announced this month and ICDCR is confident that they’ll be interested if it can be shown that consumption rooms are both necessary and value for money. ‘I think we can prove that it’s costeffective if we don’t have grandiose ideas. The Vancouver and Sydney ones are big, all-singing, all-dancing versions but we see a Birmingham version as being part of the existing needle and syringe and outreach programme – there’d be no new staff or new budget. If we could find a backroom associated with the existing services, with a few sinks for people to wash their hands and a kettle to offer people a cup of tea and a listening ear, that would be fine. It’s not a high-tech answer to anything – it’s not like heroin-assisted treatment, which is very expensive.’

What about the legal status of consumption rooms – how much of a barrier could that be? ‘In parts of Europe allowing your premises to be used for taking drugs is still against the law but there are local accords with the police, and we see that as the way it could happen in the UK, although we’d obviously like to change the law eventually,’ she states. ‘If you think about needle and syringe programmes, the police don’t arrest everyone going into those, which they could because they know they’ve got heroin on them. The same would apply to consumption rooms – they’d know they were people who used drugs but they’re not the big dealers, they’re people with a dependency who are street injectors.’

The international evidence also shows that people ‘tend to up their game’ once they start using consumption rooms, she says. ‘The staff wax lyrical about the transformation in their behaviour, and they carry on those learned habits when they’re not in the centre – their health improves, they no longer attend A&E and they begin to re-engage with society.’

Being able to provide the service without a new budget could clearly go some way towards making it more attractive in today’s environment – how optimistic is she about the state of the sector overall? ‘There’s no doubt that the money is tight and not ring-fenced any more, so we have to be smarter with it,’ she says. ‘Obviously the more resources you have the more quality you can offer but there isn’t any choice about it, I suppose. But in terms of human beings I tend to be an optimist and I’m hoping that we’re still learning.’

Indeed the whole of her involvement with the sector has been a learning curve, she states. ‘It has been for all of us – before the 1980s there wasn’t a big heroinusing population in the UK. It was small numbers of people, mostly dependent on pharmaceuticals – they’d blag their GPs for Diconal and all those things. So the huge flood of heroin that came into the country and the huge increase in people using it involved us initially working out how to keep people alive and help them with substitution treatment.’

As has been widely documented, that heroin-using population is now growing older, and so far the indications are that it’s not being replaced by a significant younger one. ‘I do hope that’s a societal change and gradually people will not get into this dependency on opiates, because it’s such a long-term trap,’ she says. ‘Some of the stimulants and novel psychoactives have their own problems but – even with cocaine – they’re things that you can walk away from a bit more easily than an opiate habit. So I’m hoping that we won’t be seeing families affected quite so much, and the policies have kind of followed that learning curve in a way. We’re kind of all learning together.’

She’d long been part of SMMGP (Substance Misuse Management in General Practice) and when SMMGP’s Chris Ford set up IDHDP (International Doctors for Healthier Drug Policies) she was asked to become a director. This year has seen her visit the Commission on Narcotic Drugs (CND) in Vienna, representing IDHDP’s rapidly growing membership of almost 600 doctors from more than 70 countries who ‘believe we need health-based rather than criminal justice based drug policies’, she says.

And it’s in arenas like this that real change can be brought about, she believes. ‘I’ve always supported the test-and-treat approach to hepatitis C and HIV, for example, but while you’ve got to do it on a one-to-one basis you do also need to have it as national and international policy to make a real difference. If you can get people into treatment you can also defeat the disease, because even if they’re not immediately completely cured their virus count goes down so they’re not so likely to pass on the infection, and it’s the same with HIV. The liver specialists are now very excited, saying that we’re on the “cusp of a new dawn” and that the new treatments mean that we could eliminate hepatitis C within 15 years.’

She praises the Scottish plan to treat more people for hep C each year than are becoming infected with it as a way to ultimately eradicate the virus. ‘Also you don’t end up bankrupted by the exponential growth of cirrhosis and liver failure,’ she says. ‘And they’ve got a national naloxone programme of course – if they vote to opt out of the UK, we should all vote to join Scotland!’

While there’s ‘no simple step’ to eradicating drug-related deaths or harm it’s essential to be part of the ‘international conversation’, she stresses. ‘Take-home naloxone has been shown to reduce drug-related deaths in parts of the US by up to 50 per cent, and I hope there’ll be new regulations to allow its even wider provision in the UK.’ It was also announced at the Vienna CND that forthcoming WHO guidelines will state that everybody who could potentially be at the scene of an opiate overdose should have access to naloxone, she adds.

‘I believe that it may come to be seen as negligent to prescribe methadone without also prescribing a take-home naloxone kit. Drug consumption rooms have also been shown to be a cost-effective step as part of existing treatment services around the world, and I believe we should look seriously at small pilots in parts of the UK where there’s a need. Applying a criminal penalties to drug use has never made any drug safer, and the sky hasn’t fallen in on countries like Portugal and the Czech Republic where steps towards decriminalisation have been in place for many years.

‘These are all areas where policy and central guidance and leadership are needed to drive change. I see my pension as a government grant that allows me time to apply my past clinical experience to these broader areas, where policy change can make such a difference to the wellbeing, not just of individuals, but of populations.’

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