A majority of this sample of Norwegian GPs accept the DAR model, as the surveys of 2000 and 2006 also showed (7). The proportion who are negative towards it is low, while around a third are neutral. A significant minority still have reservations about being the prescribing doctor for the treatment. This proportion was 33 % in 2006, and is at the same level in this survey.
Some have stated that the DAR model is too cumbersome (10) or that the GPs can take on a greater share of the responsibility in the cross-disciplinary collaboration (11). The survey provides little support for this. The majority see a need for cross-disciplinary integration and few wish to take on the sole responsibility. The typical DAR doctor finds it reassuring to work within a collaborative structure with shared responsibility. Very few believe that the role of the specialist health services is an obstacle to treatment, and almost all consider the social services to be important. These considerations are consistent with the bulk of the evaluatory literature, which recommends collaboration between specialist and primary care (13) – (15). The survey shows that doctors take a sober view of what is achieved through drug-assisted rehabilitation, and many judge that the achievement is largely harm reduction, i.e. that the rehabilitation effect is small. However, the evaluations are mainly positive. The implication is that many doctors accept harm reduction as a relevant goal.
Much of the criticism of drug-assisted rehabilitation is linked to the heavy emphasis on monitoring and management of the treatment at the specialist level (10, 12, 16). This has little support among the DAR doctors. The majority do not think that the monitoring is too strict. Urine-test monitoring is well supported. However, a significant minority believe that urine tests could be replaced by counselling and personal contact, and some also believe that it should be possible to prescribe benzodiazepines. Almost no-one supports the proposals by the Stoltenberg Committee for trials of heroin-assisted treatment (17).
In the surveys of 2000 and 2006, gender, age and political orientation were significant for the evaluation of drug-assisted rehabilitation. In this survey political views are not included, and demographic conditions are of little significance. A certain polarity can be detected between younger and more restrictive doctors on the one hand and more DAR-experienced and liberal doctors on the other. The typical doctor has treated approximately five DAR patients and is most satisfied with the guidelines, while those who have most experience appear to want fine-tuning and relaxation of the model. This could be a basis for debate as to whether some doctors, possibly with special training, might have a more independent role.
Opinions about certain aspects of drug-assisted rehabilitation vary among health regions. It is regarded most positively in South and Central Norway, where there is more active collaboration between GPs and the specialist health services (8, 9). This can be viewed as supporting the development of drug-assisted rehabilitation as a collaboration between GPs and a specialist health service with responsibility for follow-up. Similar experiences have been described in Scotland, Australia (18) the US (13, 19) and Canada (20).Also, experience from Ireland, for example, shows that GPs who provide substitution treatment without specialist support may have moderate results (21). However, French experience of GPs issuing prescriptions without any training requirements or any particular guidelines is judged as positive, although the evaluation is mostly not based on systematic surveys. All in all, knowledge of GPs’ experience is somewhat limited. This Norwegian survey is therefore an important contribution.
Despite four reminders, survey participation was relatively low. This is a common experience with questionnaire surveys sent to doctors (22), in particular to GPs (22, 23). A number of international studies have lower participation (24) – (26). Selection bias cannot be ruled out, but the findings are supported by previous representative panels of Norwegian GPs (7). Moreover, the selection is representative of Norwegian GPs in terms of gender, age and list size. Furthermore, the findings correspond to a 2002 survey conducted by the Norwegian General Practitioners’ Association. (27).
There is an over-representation of DAR doctors in the study. This is regarded as favourable, in that the main purpose is to investigate the experience that doctors have of participating in DAR treatment. It is worth noting that the DAR doctors who responded to the survey have treated over half of all DAR patients to whom prescriptions have been issued by GPs. The responses therefore represent a majority of DAR-active doctors. It is possible that doctors with negative experiences of drug-assisted rehabilitation have not wished to participate. However, it is judged to be equally probable that doctors with clear opinions, both positive and negative, are more easily motivated to participate, while doctors with less interest and no clear standpoints may have failed to respond. Moreover, the DAR doctors are representative of the doctors who participated, and the latter in their turn are representative of Norway’s GPs in terms of age, gender and list size, and do not distinguish themselves particularly when it comes to workload and geographical affiliation.
The conclusion is that the DAR model is well adapted to the health-care situation in Norway. There was little opposition to the use of a collaborative model although this does to some extent restrict the autonomy of the individual GP.