Prescribing drugs of dependence in general practice, Part A


3. General practice systems of care
3.5  Balancing patients’ needs with practice capacity (risk stratification)
 
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Practices should have policies regarding identification and stratification of patients with more complex problems and at higher risk to manage patient needs, clinical and occupational risks.

Often practices have to make clinical decisions regarding how to achieve the best outcome for the patient based on the capacity of the total practice, not just a single practitioner. This may mean developing referral standards that ensure patients can access services that exceed the capacity of the practice such as counselling, addiction agencies, mental health agencies and medication-assisted treatment of opioid dependence programs.

For example, a practice may deem the following populations or situations to be higher risk and in need of referral to public alcohol and drug facilities, or a GP with advanced training in addiction medicine, to support ongoing management:

  • patients with serious mental illness comorbidities, or antipsychotic medication
  • mixed use of opioids or illicit drugs
  • mixed use of opioids and benzodiazepines
  • recent discharge from correctional services facility
  • patients discharged from other general practices due to problematic behaviour
  • signs of potential high-risk behaviours.

Some practices, especially those in rural and remote locations, face significant issues accessing these services (Refer to Appendix I.3 in the PDF version).

 

3.5.1 Patient management according to mental health and drugs of dependence use

One of the goals in an initial assessment of a patient is to obtain a reasonable assessment of clinical complexity and risk in the context of concurrent SUD or mental illness. In this context, patients’ needs can be stratified into three basic groups. The following offers a practical framework to help determine which patients may be safely managed in the primary care setting, those who should be co-managed with specialist support and those who should be referred on for management in a specialist setting.36

GPs with advanced training (eg in addiction medicine, pain medicine) are suited to taking on higher responsibilities under this model.

Group 1 – Managed in primary care

Patients with no past or current history of SUDs. Patients in this group have a non-contributory family or past history with respect to SUDs and do not have a major or untreated mental illness. This group clearly represents the majority of patients who will present to primary care.36

Group 2 – Managed in primary care with specialist support

In this group, there may be a past history of a treated SUD or a significant family history of problematic drug use. They may also have a past or concurrent mental illness or chronic pain disorder. These patients are not actively addicted, but do represent increased risk, which may be managed in consultation with appropriate specialist support. This consultation may be formal and ongoing (co-managed) or simply with the option for referral back for reassessment should the need arise.36

Group 3 – Managed by specialist services

This group of patients represents the most complex cases. Patients may have a mix of diagnoses that include pain and addiction as well as mental illness and other medical comorbidities. These patients may be actively misusing prescription drugs and pose significant risk to themselves and to the practitioner.

It is important to remember that Groups 2 and 3 can be dynamic; Group 2 can become Group 3 with relapse to active addiction, while Group 3 patients can move to Group 2 with appropriate treatment. In some cases, as more information becomes available to the practitioner, the patient who was originally thought to be low risk (Group 1) may become Group 2 or even Group 3. It is important to continually reassess risk over time.36

According to the National Comorbidity Project, the evidence suggests that an integrated mental health and drug and alcohol treatment for people with a range of dual diagnoses is beneficial across both mental health and substance use outcomes.37

  1. Heit HA, Lipman AG. Pain: Substance Abuse Issue in the Treatment of Pain. In: Moore RJ, editor. Biobehavioral Approaches to Pain. New York: Springer Science+Business Media, LLC; 2009. p. 363–81.
  2. National Drug Stategy amd National Mental Health Strategy. National Comorbidity Project. Canberra: of Health and Aged Care; 2001.