more_vert
This article is coauthored by Dr Mark Hardy, Kerry Mawson and Chris Ho.
JOE is 22 years old and requires transfer to the ICU due to unmanageable aggression requiring high-level sedation.
After injecting methamphetamine, he became delirious, psychotic and violent. Staff from the alcohol and other drug (AOD) service arrives to provide advice regarding treatment and are confronted by angry health professionals who state: “This is a total waste of our time and resources!”
A range of personal and professional attitudes are likely to underpin this real-life scenario. Drug users are frequently seen as directly responsible for the negative outcomes they experience, and therefore “undeserving” of optimum health care.
Health professionals may lack confidence in their ability to work with this patient group, and believe that it lacks role legitimacy. The stigmatised nature of drug use often leads to feelings of blame, anger and disapproval towards the drug user.
At the same time, AOD problems form a significant component of any medical practitioner’s workload and doctors have a duty of care to address these issues.
Of most concern are the high rates of missed pathology in such patients. In a Queensland study, underlying organic pathology was initially missed in 22% of emergency department patients presenting with suspected drug-seeking behaviour, including leg cellulitis with septicaemia, perforated duodenal ulcer, and ilioinguinal nerve entrapment.
Consideration of some of the common myths around addiction may address some of the negative perceptions that drug users elicit:
Myth 1. Drug use is voluntary. It’s easy to “Just say no”.
Substance use is a complex interaction of biopsychosocial factors, including genetics, social disadvantage, childhood experiences, life trauma, and mental illness. This is why 90% of Australians try drugs or alcohol, but only about 5% will become dependent.
What may start as individual choice becomes subsumed by biological factors as dependence develops, including intolerable withdrawal symptoms, unmanageable cravings and socially destructive, substance-seeking behaviours.
Myth 2. Interventions for AOD problems are ineffective and a waste of time.
Treatment success and compliance rates in AOD settings compare favourably with other chronic illnesses, including hypertension, diabetes mellitus and asthma.
The menu of pharmacological and psychotherapeutic treatment options in addiction medicine has expanded over the past 15 years. When doctors and nurses give brief advice to problem drinkers, significant reductions occur in alcohol use, emergency department presentations and hospital admissions.
Brief interventions don’t take up much time, but are often overlooked once the physical consequences of alcohol misuse are addressed.
Having a structured, evidence-based approach to common AOD problems can lead to a sense of mastery and satisfaction with even the most challenging scenarios. For those who don’t have this knowledge, asking your local AOD service for advice, education and training is a good start.
Myth 3. AOD problems happen somewhere else, not in my back yard.
Doctors are as likely to experience AOD addiction as anyone else, and even more likely to misuse prescription medications.
A study of impaired doctors referred to the NSW Medical Board between 1981 and 2001 found that 56% presented with AOD disorders. Most medical boards treat this as a health issue, which is treated and monitored with enviable success rates of 80%–85%, rather than punished with disciplinary action.
Why don’t we take this approach with our drug-using patients?
Myth 4. Drug users are in denial and require aggressive confrontational strategies to change.
Punitive and combative approaches are mostly counterproductive, serving only to create and enhance denial, resistance and shame, rather than breaking it down.
Motivational interviewing is highly effective for reducing denial and promoting motivation for change in drug users, and at its core is a non-judgmental and respectful approach — just how we would treat any other patient and certainly how we would want ourselves, a family member or a close friend to be treated.
Dr Glenys Dore is the clinical director and a consultant psychiatrist at the Northern Sydney Drug & Alcohol Service, and clinical senior lecturer at the University of Sydney, Medical School — Northern.
Dr Mark Hardy is staff specialist in addiction medicine at the Northern Beaches Health Service and Herbert Street Clinic, Royal North Shore Hospital, Sydney; Kerry Mawson is clinical nurse specialist and clinical co-ordinator of the mental health mentorship program at the School of Nursing, Midwifery and Paramedicine at the Australian Catholic University; and Chris Ho.
Detailed references available on request to editor@mjainsight.com.au
Posted 18 June 2012
Ray Seidler and Glenys Dore et al represent addiction treatment “insiders”. Dr Seidler from the point of view of running a large commercial opiate substitution practice. Dr Dore as a consultant to major state run clinic. The thrust of the article is for the majority of the profession to take an open minded evidence based approach to treating addictions. I agree with this. The current system leaves many interested, capable and trained professionals as “outsiders”. The problem would be better managed if many professionals who have the interest skills and patience to treat addictions, as in my previous post, community psychologists, community mental health GPs, who treat addiction as part of their practice already, after hours and at the coal face, and unsalaried Fellows of the Chapter of Addiction Medicine (RACP), who were created as part of the solution, had addiction specific session uncapped, realistically renumerated rebates. For the aims of the article to be achieved, addiction-specific renumeration is required. For example, for a busy compassionate community GP to take on an extra share of methadone patients there needs to be a tangible incentive eg, for time faxing the pharmaceutical services and the pharmacy. There needs to be help from the “expert clinic”, when the patient is not exactly as stable as sold, eg, legal problems and benzo raging.
Fantastic piece – well overdue for the MJA.
As someone who treats over 175 patients with methadone or buprenorphine, it can be done within the milieu of general practice. My office is a place of tranquillity and peace depsite treating drug users who choose to respect the service they get as valued patients in the pratice. I have treated many of them since 1985. Recently I looked after a 75 year old nursing home resident who had been on methadone for 40 years and had survived the death of his entire cohort. We will need specialised units to look after old drug users any day soon. It is rewarding work.
Well written Glenys
Persons flaming authors because of failure to “incorporate all of what is known within the relevant disciplines of psychopharmacology, neuroscience, ethics, neuroethics, sociology, history and philosophy” should themselves put up, ie “incorporate all of what is known within the relevant disciplines of psychopharmacology, neuroscience, ethics, neuroethics, sociology, history and philosophy”, or …
Re Emaitch and children injecting-because these children do not present to Emaitch, does Emaitch believe they do not exist?
Healthbroker has a point-I once prescribed Durogesic patches to a “chronic pain” patient as advised by the Pain Specialist-said patient was soon after admitted to ICU after injecting contents of patch etc-fortunately patient survived, saving my and Pain Specialist appearance at a coronial inquiry. Disagree with Simon Holliday re “all colleagues to take on more routine AOD patients such as Methadone maintenance patients. ” Sorry, but this colleague as a solo bulk-billing GP is refused VMO access by the local GP powerbase,so has no access to detox inpatient beds, and has limited access to Medicare-billing allied health workers (2 Psychologists), so count me out. When Medicare recognises and lists substance addiction as a chronic disease, with an item number,for GP and allied health, please let me know, as these patients do not even qualify for a chronic disease management and team care arrangements . Sugar addiction is OK if you get it to the extent of diabetes, tobacco addiction qualifies if you get COAD, alcohol addiction is fine if you get cirrhosis or Wernicke’s encephalopathy , but any other drug, not on your Medicare life.
Much of this debate naturally is about stigma. Terms like “drugs” and “addicts” are perjorative as demonstrated by the Temperance movement campaigners at the beginning of the last century crusading against alcohol before retiring for a drink of laudanum (opium).
The point about the fear of the impact of welcomed drug addicts on our waiting rooms was addressed in the following paper in April: https://www.mja.com.au/journal/2012/196/6/waiting-room-ambience-and-prov…
Dr Dore’s call for increased confidence and familiarity with Addiction related issues will benefit our practices. As Gourley writes, “Drug and alcohol misuse and addiction often remain undiagnosed confounders in a myriad of refractory clinical disorders including essential hypertension, insomnia, sexual dysfunction, and depression, to mention only a few. Failure to diagnose and to treat a latent substance-use disorder will frustrate the most ardent efforts at achieving even the most modest therapeutic goals.
Finally, the vast majority of those with AOD disorders do not seek or want treatment. A UN report states, “The latest US data show that, on average, three persons per 100 annual drug users had to undergo treatment for drug use in 2008.” The treatment of an aggressive person, whether intoxicated or not, or whether in a health facility or not, is partially the domain of security or police, not just medical. Drug and Alcohol services are marginalised services, especially funding-wise, looking after a marginalised clientele for a problem which permeates our society. I agree AOD teams should be more available for in-patient and out-patient services, but this will require funding and will require all colleagues to take on more routine AOD patients such as Methadone maintenance patients.
Refs
Gourlay DL, Heit HA. Universal Precautions: It’s Not About the Molecule! The Journal of Pain. 2011;12(6):722.
United Nations Office on Drugs and Crime. The World Drug Report 2011. Vienna: United Nations 2011.
Great.
Now that we’re all talking…The most popular new (non-tobacco) drug tried by first-time users in the USA (read Australia in 2-5 years) is a prescription pain-killer. Outstrips illicit opioids, cannabis, you name it.
The 2 most common sources of the said pain killer are 1. a family member or friend, and 2. us (MO’s). N.B. Most prescription opioid patients inject their drugs or sell among their cohort. I cannot remember the last unsuspecting school child I saw who procured oxycodone off a doctor-shopping dealer. Usually it comes from closer to home, sadly. I respect Shrink’s choice of practice. He assumes, wrongly, that the article suggests he must treat and welcome all drug users. He might be surprised how many of his current patients are holding out on him about their use. Maybe his practice has selected them out, but maybe their just playing possum with him on the issue. In most practices, about a third of patients are. We cannot over simplify addiction patients as “out of control” drug seekers, only to miss the point that many are indistinguishable from everyone else. Having seen too many die from ignorance and the choice to be completely abstinent, only to relapse and die, isn’t it time we thought about safe choices for drug users, like maintenance and legal access to supervised treatment, rather than pushing the problem underground? Happy to reference this stuff, Dr Dore’s “opinion” piece looks like it references about 15 journals. There are bits there from MJA, AIHW, The Lancet, BMJ. Not just opinion.
I agree with Anonymous, William, C and Shrink. Drug and Alcohol services should be on call for Emergency Departments in my opinion. I disagree with KC and Emaitch. Drug addicts behaving badly are not anecdotal, they are a fact of practice. They sell prescription drugs to unsuspecting children and to mental health patients to support their habits. I choose to refer them to the Drug and Alcohol service, just as I choose to refer excisions to the Surgical Clinic. If chronic pain may be an issue, I refer to the Pain Specialist for an opinion and management. Emaitch’s lack of respect for Shrink’s right to autonomy in practice, and Emaitch’s confusing right to autonomy with zero-tolerance and sabre-rattling , say that Emaitch describes himself. Eamitch has zero-tolerance for clinicians who choose there field of practice, rattling his sabre at them. Does Emaitch think that there may be no sub-specialty in practice-for example should sports physicians be obliged to treat patients who inject Sustanon at the gym, when they request Tamoxifen or Clomid?
A fundamental difficulty with addiction, when it is such that it can be satisfied by prescription medicines, is that the GP is often cast in the conflicting roles of “drug dealer” and “drug and alcohol counsellor”. Myself I feel way more comfortable with the latter role. But it is blown to hell because who wouldn’t lie to a GP if their next fix depended on it?
The two roles are incompatible and we need to find strategies to separate them. Until then, I have compassion for and good will towards drug addicted people but my attempts to engage in their care when there is a prescription pad at my elbow have rarely gone well.
Since I have stopped being a Methadone/OSP prescriber my hourly earning have increased 25%+, I have a LOT LESS no shows and I think I have only had 2-3 level D consults in 12 months!!!!!
The issue of fault, responsibility and harm with regards to drug use is a complex one. It is regarding this concept that Dr Dore and colleagues present what is essentially their opinion as fact. If they are going to write about the topic they should incorporate all of what is known within the relevant disciplines of psychopharmacology, neuroscience, ethics, neuroethics, sociology, history and philosophy. The concept they present (which could be summarized as “it’s not my fault doc, it’s my disease”) is ultimately an unsophisticated assessment of the issue and ignores vast swathes of the other relevant disciplines.
People who behave recklessly should be held accountable. The predisposition to take drugs is a function of the brain. But people do have the capacity to make the decision to seek help rather than selfishly continue on their reckless way. Long ago did we do away with the myth that the person who drink-drives when grossly over the limit can blame the bar tender or the brewery or society; they are held legally accountable. I highly doubt there would be support for less heavy criminal sanction for repeat severe drunk-drivers.
Ironically it is the myths that Dr Dore and colleagues propagate that are responsible for the stalemate in the war on drugs.
When taking on such a highly ideologically charged issue, MJA Insight would be well served by providing some balance.
Surgical inpatients after neural surgery given paracetamol because pain complaints are drug seeking;
Accident victims who put themselves in traffic just to acces hospital med’s;
Methadone patients turned away because ED doesn’t deal with junkies.
These aren’t the norm, but they are real experiences, and not too far from the average substance user’s experience.
Most medical staff are most compassionate most of the time, but heaven help the others’ patients.
Somewhat cynical? Some understatement. Thanks Shrink for your opinion, whatever its actually worth. Zero tolerance has been shown to be a failure in every domain apart from politician’s electoral ballot box-filling. The article is designed to inform AOD-naive people about a problem, and a guide to assist them in finding EVIDENCE-BASED treatments, not to give them another reason to jump out and rattle the sabre of ignorance. We have a revolving door approach to heart disease, hypertension, diabetes and mental health, but its not OK to do the same thing for AOD patients? Wake up.
As a PS I should add that my opinions above were formed from experience in Melbourne, and that I recognise conditions and policies may be different in another state.
I do not believe in the current “revolving door” approach to alcohol, or other drug, detoxification and “treatment”. Admissions need to be long enough to allow sufficient post-detox. assessment and then initiating an appropriate treatment plan and getting it started. Anything else is token and simply perpetuates the problem, and, in my somewhat cynical view, the growing drug user support industry.
So, I choose not the work in this area.
In general, I assert my right to autonomy and thus to choose not only where I practice, and what type of work I undertake. I don’t feel any social obligation to deal with every aspect of medical practice whether or not I enjoy it or agree with the general policies. Nor do I feel anyone has the right to tell me I should do so.
Many people with alcohol and drug issues sit in doctors surgeries every day without causing a problem. Part of the issue is that a single problem drug user displaying bad behaviour in a waiting room becomes the anecdote and justification for refusing access to any (identified) drug user. Replace ‘drug user’ with the words ‘person with a mental health issue’ and how acceptable then is treatment refusal?
Nice article! Three key coal face community clinician groups – GPs, psychologists and Fellows of the Australasian Chapter of Addiction Medicine (RACP), who can’t can’t break into the staff specialist, lunch and conference club – are currently hard done by in trying to help this situation, despite their committed professional interest.
The reduction in focused psychological strategies rebates and number of sessions from 18 sessions to 10 was a severe blow to psychologists and mental health GPs who treat addictions. Currently, when the patient requires long consultations from both the GP and psychologist, the GP and psychologist rebates are in effect both reduced and cannibalised by each other.
The lack of time-based Medicare rebates for private Fellows of the Australasian Chapter of Addiction medicine remains a disgrace. After a 3-year post fellowship training program, the initial referred rebate 104 is currently $71.40. The review rebate about half. The FAChAM (RACP) situation is further exacerbated by the selective employment of non-FAChAMs in state run addiction services. Currently, in Sydney West LHN of gastroenterologists, and Northern Sydney LHN of psychiatrists “willing to enrol in FAChAM training”. Are these tennis club or professionally based decisions?
Community-based clinicians need adequate renumeration that is uncapped in sessions, and/or addiction treatment specific, to pick up the increasing slack of the overwhelmed state-based clinics in NSW. Or we will continue to see their state clinic-based staff specialists as away on conference, cancelling their clinic for their registrar to do. An easy example of this is the NSW state-wide reluctance of the vast majority of staff specialist state-run methadone buprenorphine clinics “run by the experts” to benzodiazepine detox, or benzodiazepine harm reduce their own clinic patients. But refer these to the waiting rooms of community GPs, who are “non experts” to deal with the distress and aggression of comorbid benzodiazepine dependance in their waiting rooms and consulting rooms. Another is the need in Newcastle/Hunter for Justice Health methadone/buprenorphine to be treated by the community clinicians above, due the lack of state based places.
Psychologists, GPs and private FAChAMs remain committed and interested, but need urgent session uncapped financially appropriate (to the time and difficulty of the work), addiction-specific Medicare rebated funding to help achieve the worthy goals of the article.
These patients always cause mayhem on weekends / nights when drug & alcohol staff provide NO services. So it is the emergency department staff who have to deal with the abuse and violence. Yet the author is suprised that other health professionals get angry! Why doesn’t she and her colleagues come down to the coal-face next Saturday night, rather than waiting till Monday morning when these patients have sobered up?
I doubt too many doctors will have difficulties with the philosophy behind Dr Dore’s article. There remains the problem of the effect disruptive patients have on other patients in the waiting room. It is very difficult to justify to a young mother the treatment of an abusive patient who leaves her child traumatised by the behaviour surrounding their appointment. Unless the two patient streams can be separated I cannot justify the exposure of third parties to violence and aggression for which they are neither prepared nor trained to deal. There’s the rub.