Hi - we have come across a client who holds a responsible position, and is using small amounts of heroin illicitly.
Wants Rx and is going on hols shortly (abroad).
Also doesn't want to tell GP or their own family or employers.
Possibly drives but doesn't want to say.
We have given all the advice about safety, health, risks of OD, carying card etc. and appreciate that it is difficult in one consultation to gain trust with a client with such a lot to lose.
We think we have a plan, having discussed it confidentially as a team - but any ideas or experience appreciated
thanks
Gill

Hi Gill,
Tough one and it would make a good case study.
My answer would be to put the patient first - whatever that might mean. I'd have a good dig around though and document everything well.
The real and by the book answer could be quite different.

I had the difficult experience of having to refer another healthcare professional to their regulatory body. Fortunately said body was very understanding, and simply suspended him from practice, pending recovery, which I'm glad to say he achieved rapidly. They kept a close eye on things and were generally supportive. After reassessment post-detox, he was allowed his registration back.

We've had a very similar case involving a senior manager in a public organisation. We said that we promise confidentiality (subject to clear rules which we explain) but we urge them to tell their GP or let us do it for two reasons. The GP can't prescribe safely for other conditions unless they have the whole picture, and since (despite our occasional snipes) they aren't idiots, they may well recognise the signs of illicit use anyway and certainty is better than guesswork. We also point out that GPs are as bound by confidentiality rules as we are and try to find out whether the client has any concrete concerns about their GP being told.

Over and over again I come back to the same argument. No healthcare professional should have an issue with someone who wants treatment for their habit, because they're doing the right thing. It's the ones who don't want treatment who pose us a problem.

What would you do if your patient was adamant that he did not want his GP to know he was receiving an opiate sub. script? I agree with Graham that this would be less than safe - I got in to this situation once myself and it was only later that I realised how dangerous it could have been. I think we can go too far in trying to please/ protect/put our patients first. Safety must come first surely - and this might mean not giving them the option of not writing to GP and to professional bodies, where relevant. Or else it starts to feel like collusion in a dangerous situation, I think.

Has the NTA asked for or received statements from professional and regulatory bodies about their likely attitudes/response to members being treated for opiate addiction?

Jeff

NOT SURE - SUGGEST YOU ASK JOHN DUNN at the NTA

Agree default is that GPs should at least know medication. we make a point of only writing down an outline of full assessment once at initiation, after that pretty much all the GPs get is a note of medication being prescribed /immunisations given each time they have a medical review

Hi Gill and Sally,

Good clear information about confidentiality and about sharing information can be found on the GMC website...
http://www.gmc-uk.org/guidance...ring_information.asp

particularly in the "Good Medical Practice" document, paragraphs 50-53.. under communicating with colleagues::
"52: If you provide treatment or advice for a patient, but are not the patient’s general practitioner, you should tell the general practitioner the results of the investigations, the treatment provided and any other information necessary for the continuing care of the patient, unless the patient objects."

i think the relevant phrase is "unless the patient objects"

And: in "protecting confidentiality.. protecting and providing information" paragraph 10..
http://www.gmc-uk.org/guidance...s%20providing%20care

This states that "You must respect the wishes of any patient who objects to particular information being shared with others providing care, except where this would put others at risk of death or serious harm"

So in general, if the patient objects, we have NO right to inform their GP, unless we judge that withholding info would put OTHERS at risk of "death or serious harm" .

It will be seen from the above, except in extreme circumstances, it is the patient's right to be treated by us without allowing us to inform their GP . As we are all aware, breaching confidentiality is taken very seriously by all our professional bodies.

quote:

Originally posted by Jeff Green:
Has the NTA asked for or received statements from professional and regulatory bodies about their likely attitudes/response to members being treated for opiate addiction?

Jeff

I had a patient I sought advice from the NMC about. The NMC believes a Nurse has the same rights to confidentiality as anyone else. They would not expect to be informed of a Nurse having treatment for an addiction unless there is any misconduct.

All true, but...

The patient's right to confidentiality, whoever they are, is definite but I think we ought to point out the consequences of not informing the GP and then ask again if they still object.

And wearing my hat as Deputy Accountable Officer, I'm very aware (and we have been told by CQC) that if a healthcare professional is known to be misusing controlled drugs, Trusts may have a duty to share that within the Locality Intelligence Network (depending on circumstances). I interpret that as not necessarily applying if someone is seeking treatment, because the risk is then already being managed on a case by case basis. But we recently received the details of an agency nurse whose performance had been judged elsewhere as impaired due to her overuse of Temgesic. While the NMC weren't interested in her misuse per se, they became involved on the matter of performance.

Agree about performance - maybe the approach should be similar to a diabetic who is stable on medication or out of control, or someone has more serious mental health problems, epilepsy ? etc
But in most of these cases the employer should probably at least be aware, especially if the client is driving, or taking on a level of responsibility for which any drug use could impair judgement.
I imagine reluctance to talk about this is due to a fear of an unenlightened response from employers, so we might try to find out what the reponse would be in this situation. Some of this also comes back to talking squarely with the client and explaining why we might be concerned. Myabe their union could help out too.
I wonder where we stand if we don't inform the employer, because the client is seeking and appears to be stabilising on Rx, but then things escalate out of control ending up in an incident at work ? Strongly advising sick leave till stable feels safer to me.

One of our team has spoken to the MPS who gave the GMC guidance as above. I will ring them again to ask a few more specific questions
thanks
Gill

My experience of this type of client is limited, but I have insisted that they stay off sick until stable.

I am more restrictive when it comes to professional drivers and reporting to the DVLA, mainly because I cannot assess their safety to drive whilst on a script, and so far, I have not had any surgeons or pilots in my clinic (as far as I am aware).

Very very interesting and thought provoking discussion.
The risk of death or serious harm gives if not permission reasonable grounds for sharing information particularly around prescribing with the GP. It is always so much simpler when the GP is providing the care.
I am interested in why there should be a distinction bewteen "professional drivers" and the rest of us. Is ot the disances covered or the HGV aspect?

http://www.dft.gov.uk/dvla/medical/ataglance.aspx
Perseverance the rules can be downloaded in the above link.I have a HGV licence and own a private HGV. You need much higher levels of concentration to drive larger vehicles and can create much more damage if something goes wrong.
It's just like the reason helicopters can fly at lower altitudes in built up areas than aeroplanes.

THe professional driver bit in my personal set of rules relates to the greater likelihoood of drivng a large vehicle, or more frequently, or further, or under greater pressure than a privat motorist. Not perfect I know, but insurers see professional driving as a greater risk, so why not me.

Simon, Helichoppers are subject to the same rules as other aircraft unless they get a specific CAA exemption, and they usually require the pilot to have a commercial licence before granting it. Otherwise it's 1000ft above the surface and 500ft from any object, person or structure , except for the purposes of taking off or landing.

quote:

Originally posted by Perseverance:
sharing information particularly around prescribing with the GP.

Hi Perseverance ,
The confidentiality rules on the GMC website apply to all NHS services, and not just to "prescribing by the GP" , and they would apply to ALL communications with other agencies or people, not just for GP prescribing.
The bit I quoted above, "You must respect the wishes of any patient who objects to particular information being shared with others providing care, except where this would put others at risk of death or serious harm" would apply as much to drug workers, managers, nurses, and cleaning ladies, as to GPs.

http://www.gmc-uk.org/guidance...s%20providing%20care

Going back to the original question with respect to the driving - Gill KNOWS he is using illicitly but does NOT know he is driving - I think this is the let-out in this specific case and clearly this chap is bright enough to know this too. It is that other situation when the client is "stable", but, well ... dabbles. They tell me they do, its no secret, and worse (at least from the medico-legal point of view, if not the moral) the toxicology confirms it and it is documented. And I have seen them just drive up outside, or they tell me they are driving, or I have documented a driving job. What then? I think I know what I SHOULD do after, of course, going through the usual warnings etc http://smmgp.groupee.net/eve/f...=585109851#585109851 But the temptation must be to pretend not to know in order to "keep up the therapeutic relationship", but I suspect that the coroner and relatives of the road accident victim would call that collusion.

This is quite difficult - if we don't share information with another ( usual ) prescriber, are we putting the GP at risk of doing harm to their patient ? We currently have a policy of informing the client's GP whenever we prescribe opiates ......
And how are we to judge what harm the client may do to others if they are working / driving and using illicit drugs, or prescribed ones ?
I wonder if we should be balancing risks - of prescribing vs. not prescribing in unknown situations, and of informing GP vs. not informing. It's probably a bit like assessing response to a teenager who is pregnant and seeking TOP but doesn't want anyone to know - or a person with uncontrolled epilepsy or heart disease driving .

Some ideas in addition to usual harm reduction advice :
- full medical and social / drug use information from the client signed by them as accurate ( since we aren't being allowed to communicate with other prescribers )
- supervised consumption every day
- advice re risk of meds to others ( if going away or pharmacy not open at weekend etc.)
- Subutex card given to client
- disclaimer for Subs Misuse prescriber if client refuses info to be shared ?

I don't know what risk there is to others of death or serious harm, but I imagine driving under the influence is one, along with impaired judgement at work - which we have discussed but not sure how much has been taken on board.

From the other side - what might go wrong if we don't inform GP ?
We can still assess immediate risk, and unless we ask GP for info ( which we usually don't ) we would go ahead and prescibe according to our in house protocols, based on risk / benefit assessment. However the GP will not be aware of our Rx and could add opiates ( to methadone )or other sedatives ( eg TCAD / BZ ) even short term. Yes this sometimes happens anyway, but we have usually informed the doctor.
Predictably enough, our client now doesn't like being supervised.

All feels a bit murky, unless perhaps someone can enlighten me
Gill

This message has been edited. Last edited by: gill redshaw,

Specific guidance relating to confidentiality and DVLA has just been issued by the GMC to doctors (http://www.gmc-uk.org/guidance/news_consultation/confidentiality/Confidentiality-reporting%20concerns.pdf) and comes into force on the 12th. While the rest of us aren't bound by it, I tend to think that the concept of seamless care means that all of us should do the same thing wherever possible so that it makes no difference to the client whether their prescription is from a nurse, doctor or pharmacist.

quote:

Originally posted by Graham Brack:
Specific guidance relating to confidentiality and DVLA has just been issued by the GMC to doctors (http://www.gmc-uk.org/guidance/news_consultation/confidentiality/Confidentiality-reporting%20concerns.pdf) and comes into force on the 12th. While the rest of us aren't bound by it, I tend to think that the concept of seamless care means that all of us should do the same thing wherever possible so that it makes no difference to the client whether their prescription is from a nurse, doctor or pharmacist.

This isn't new, Graham, just a reiteration of well established (and clear) previous guidance. In this respect and despite the principal of seamless care, doctors ARE thought to differ from other professionals and until this is changed the default will also be to "inform the doctor, as they, at least, have the (??) benefit of clear guidance." It is not the clarity of guidance that is the problem, it is the fact that we take a risk every time we (knowingly and unknowingly) move away from it. Such is general practice, and this daily risk- taking with our careers is possibly a factor as to why we are paid better than the rest of you.