Glenys Dore: Welcoming addicts

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