Primary care is a funny old world, heading in more or less the same direction as other services with our patients who use drugs and alcohol problematically, but with some major differences.
For a start I never discharge patients; they don’t ‘exit as treatment completed’. If one issue ceases to be a problem I may well see them for something else. Perhaps this colours my view, but to me getting to abstinence as soon as possible isn’t the be-all and end-all. What is desirable is having the person lead what they feel is a normal and hopefully enjoyable life and experiencing the freedom of choice that inevitably provides. Most diabetic or hypertensive patients – despite often expressing a desire to enjoy greater health and wellbeing – don’t change their lifestyle so much that they are effectively cured. And while some do make great strides – and that is something to celebrate – I continue at the same time to support those who haven’t managed that, because they are my patients.
Over the past couple of months I have seen two men, both in their mid-30s now, who have been in treatment for problematic drug use with us for a number of years.
John had been titrated up to 90mls of methadone before he stopped injecting heroin and crack – a big step forward. He had stayed on that dose for more than a year and had engaged with a local peer support group. Over the past nine months he had slowly been reducing down and then having ‘stuck’ at 25mls decided to do a lofexidine-assisted withdrawal. Two weeks after this concluded he came for his appointment and we were discussing next steps and what his options were. He decided not to take naltrexone, and he was intending to continue with his mutual aid group.
David had been with us a similar length of time. Twice previously he had stabilised on 60-70mls of methadone and then started to reduce, only to drop out of treatment and relapse. Fortunately on both occasions we were able to get him back into treatment rapidly. This time round he had reduced down to 30mls without mishap and we were discussing where to go from there. He was working, had a stable relationship and was in his own flat. He had been to some mutual aid meetings and felt he wanted to be abstinent in the future but, he said, he suspected that trying to achieve that now might risk what he currently had.
We will continue to discuss David’s feelings about this every time I see him and the offer of support to help him achieve abstinence will always be there. Equally, if John should relapse he will always have the option of returning to treatment. Because they are my patients!
As I said – a funny old world, primary care, and one that commissioners and politicians often struggle to understand.
Steve Brinksman is a GP in Birmingham and clinical lead of SMMGP, www.smmgp.org.uk. He is also the RCGP regional lead in substance misuse for the West Midlands.