Post-its from Practice

The three Rs

It’s all about the right treatment, at the right place, and the right time, says Dr Steve Brinksman

There are many things I love about being a GP but above all I value the long-term relationships I have with my patients. The other night while doing a routine surgery session, I recognised the name of a man on my list who was booked in to have a minor cyst removed.
Dave and his partner Sarah had been using heroin for a number of years when they first joined our practice a while ago now, because they had heard we treated substance misuse in primary care. In fact at the time they joined us we had the slightly bizarre situation that the practice was only accepting new patients if they used heroin!
They engaged well in treatment and both managed to stop using heroin on top of their script, and that was as far as it went for a couple of years. They had a daughter who was about eight at the time when Dave and Sarah came in to see me together one day. They had decided that they wanted to be not only heroin free but also off prescribed opiates. We discussed the various options and it was obvious that they felt a residential rehab programme incorporating a detoxification was the right way forward. Sarah’s mother lived locally and would provide childcare, so through our primary care based key worker all the paperwork was done and a place was arranged for them.
They had a date to go in and all was in place, scripts cancelled, no further appointments with the drug worker or me till they returned. Two weeks later Sarah came in for an emergency appointment. She had been unable to cope with being apart from her daughter and had discharged herself, although Dave had decided to stay. She was still determined to become opiate free but had realised that what she thought was the right option to pursue this goal would not work for her. We restarted her methadone prescription and devised a slow reduction programme. She found this worked for her and was proud of her ability to cope with both caring for her daughter and reducing her prescribed medication.
Dave found the support offered by the rehab facility invaluable and stayed for the full six months. By the time he returned Sarah was on 8mls of methadone daily and a month later she had stopped all prescribed opiates.
The family remain patients on our list and Dave and Sarah remain drug free. Dave has been promoted at work and their daughter does her GCSEs this year. For me the joy of treating people in primary care is that not only could we find an option that suited each of them, but also unless patients move away, I will in all probability see them again.
Recovery happens in primary care, sometimes with patients who stay with us, sometimes with those who go away to other treatment systems. We should be proud of these patients – as I am of Dave and Sarah – and yet accept each person is different.
We’re equally as proud of the progress that Dave’s brother, who remains on a methadone prescription, has made. Rehab didn’t work for him and he felt safer with a longer term prescription. I haven’t given up on regularly discussing options for change with him, but he doesn’t feel ready yet; that is his decision to make, not mine. If he decides it’s time for a change again, I and the rest of the practice will help him, but till then we will keep him as safe as we can.
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.