Challenging behaviour


It is my firm belief that the majority of people with drug and alcohol problems can be managed in primary care, albeit with the proviso that appropriate access to psychosocial treatments are in place. I was initially therefore fairly downbeat about having to refer Bill back to our local secondary care provider.

He and his brother Jack are both registered at our practice and have been for a number of years. Now in their late forties, they each have a long history of chaotic IV polydrug use and alcohol dependency, punctuated by numerous prison sentences. Over the years their lifestyle has taken its toll and they both have a number of physical health problems, mainly related to alcohol use, and previous encounters with mental health services.

Jack, the older of the two, was being treated by the secondary care drug service for a number of years when we were approached to see if his care could transfer to our practice as, due to some of his other problems, attending treatment was becoming more difficult. In the three years since then there have been spells when he has lapsed into more problematic drug and alcohol use, but with a lot of input from his keyworker at our surgery we have succeeded in integrating his care into our practice. This is also testament to the skill of our receptionists who have managed to build a good rapport with him that on the whole nullifies his occasional outbursts.

Perhaps feeling flushed with success we then agreed that his brother Bill’s opioid prescribing could also be transferred from the secondary care provider. Despite trying the same approach, this has been much less successful. Three local pharmacies have barred him due to abusive language and he would regularly cancel or not attend key worker or doctor appointments. His alcohol use escalated and he was verbally offensive to the receptionists on several occasions.

We have a policy of discussing patients with any conditions whom we are struggling to manage either clinically or behaviourally at our weekly practice clinical meeting. As a result of one of these discussions it was decided to transfer Bill’s care back to the secondary care drug service.

This was a difficult decision and made me realise that whilst we may be fortunate to have the clinical and case management skills available to support less stable people, the roles of other staff and colleagues are equally important. Primary care is a fantastic place to deliver care to those using drugs and alcohol problematically, but some will need extra support and care and I am grateful that additional services are available.

Bill still comes to see me and we are now starting to address some of his physical and mental health issues. I hope that at some point he may again receive all of his care at the practice but for now transferring his opioid substitution treatment out has meant he has remained a patient at the practice.  For all concerned, a positive outcome.

Steve Brinksman is a GP in Birmingham and clinical lead of SMMGP, He is also the RCGP regional lead in substance misuse for the West Midlands.

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