Family matters
Always look beyond the symptoms at the wider picture, says Dr Steve Brinksman.
I have just returned from the RCGP/SMMGP annual substance misuse conference in Birmingham. The theme of the conference was ‘Joining the dots’, encouraging us to look at the wider picture and consider the impact of substance use on more than the individual. I was asked to talk about the role of families and their impact – positive and negative – on someone who uses substances problematically, but also the effects that their addiction can have on their family.
If you have read this column before, you will know that I am a passionate advocate of the role that primary care can play in working with those using drugs and alcohol, and a key part of this is the continuity that helps build a relationship with a patient, sometimes over many years.
Despite this I can be a bit slow on the uptake at times! I had been seeing John for about three years for his heroin and crack use; he was fairly chaotic, injecting and funding his use through acquisitive crime and borrowing money from family. His engagement with treatment at that time would be best described as tangential and he was a frequent non-attender. After a couple of consecutive failures to keep appointments, I found out from our shared care worker that he had been sentenced to 18 months in prison for drugs-related offences.
Over the same period I had been seeing Linda, a 40-year-old woman who had significant anxiety and depression. I had started her on citalopram – an SSRI antidepressant – and referred her to our primary care based counsellor, and she had had a couple of short courses of diazepam over the last few years when she had presented ‘at the end of my tether’.
I saw her one day and she seemed much more relaxed than usual. She told me that she felt much calmer as her son had been sent to prison for 18 months and she felt this would give her the chance to try to sort herself out – and it was then that the penny dropped. She was John’s mother, and although they shared the same (albeit relatively common) surname, I had not made the connection as they were registered at different addresses and I hadn’t thought to ask her if her anxiety related to caring for someone with substance misuse problems.
I had made the common mistake of focusing on Linda’s symptoms and not exploring the wider context of things happening in her life by direct questioning. Instead I assumed I would be told all the issues by the patient. Linda felt stigmatised because her son was someone who uses drugs. She had lost friends, and she also expected us to treat her as if she wasn’t worthy because of this, so she didn’t volunteer the information.
The time John spent in prison did help him to make some progress and he engaged with treatment services. Over the five years since he was released he has been more compliant with medication and (usually) keeps his appointments, but he does still use a couple of times a week. However Linda feels she has the ability to cope with the situation and no longer blames herself for all of his problems. Interestingly, as John has had more appointments, she has had less.
As for me, I hope I try to look at a wider picture when seeing those patients presenting with anxiety and depression – even if this means sometimes asking difficult questions.
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.