Post-its from practice

Now tell me yours…

Different lives require different approaches to treatment, says Dr Steve Brinksman. Read it in DDN.

Steve Brinksman is a GP in Birmingham and clinical lead for SMMGP and RCGP.

I had the privilege of speaking at the annual RCGP/SMMGP conference at the end of November. I have been attending these for 20 years now and the knowledge I have gained, alongside the peer support, has been invaluable in my career working with people who run into problems with their alcohol and/or other drug use.

I was talking about treatment optimisation. By that I don’t mean just increasing the dose of OST prescribed, but also increasing the psychosocial interventions and making sure that all aspects of treatment are in place long enough for people to make sustainable change.

There has been – to my mind – a climate change over the past decade or so where increasing pressure is being applied to get people out of services and signed off as ‘treatment complete’. This prevailing paradigm has the knock-on effect that anyone who is taking OST in the longer term almost feels they should be ashamed of it.

We should not feel guilty for providing good quality evidence-based treatment that protects and supports people and gives them the space to establish and manage their own recovery.

Jake came to see me at the surgery for a review. He had started in treatment three years ago and his buprenorphine had been titrated up to 16mg at which point he had stopped using heroin completely. His relationship with the mother of his two sons had improved and he had started a college course with a view to becoming an electrician.

About nine months after starting OST his recovery worker suggested he try reducing his dose. He managed to cut down to 10mg daily – but at that point he started using heroin again. His dose was titrated back up and he again stopped using heroin. Six months later he tried reducing again and the same thing happened.

By the time he came to see me he had made four attempts at reducing and he felt he was failing in treatment. He was guilt-ridden that he lacked willpower, because as he couldn’t cope with the craving, he had to use heroin when his dose reduced.

He seemed slightly surprised when I suggested to him that not only do we put his dose back up but that we leave it at that for an extended period of time. Six months on, he is well and happy and feeling confident in treatment. He has started work in a warehouse, sees his sons regularly and has them overnight every other week. He hasn’t used heroin since our last appointment.

He does say he would like to come off his OST at some point in the future but feels that time isn’t now. We will discuss this whenever we meet and I will always encourage him. However, it will be up to him to make the decision when – or if – he wants to undertake this.

Aneurin Bevan, one of the founders of the NHS, once said: ‘This is my truth, now tell me yours.’ I feel this encapsulates beautifully the different approaches to how we all live our lives and I think it adapts to our field. So to paraphrase, ‘This is my recovery, now tell me yours.’

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

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