1994 VOL 5 NO 2
Copyright© IJDP Ltd.
DRUG USERS AND THE GP
Tom Heller gives a personal account of his work with a group of opiate users in a small urban practice in Sheffield, England and contends that working with drug users from a general practice base can be rewarding and effective.
Drugs mask and defend against the real person within. What kind of person is that? . . . It is important to emphasise from the outset that it is that person that you, the worker, wishes to make contact with and work with.
Those with experience in the drug world say that it is impossible to tell from external appearances who is a 'user'. This is borne out by our experience. The grubby teenager with a scabby face and tatty jeans slouched in the corner of our waiting room has come for treatment for his in growing toenail and has never touched an illicit substance, whereas the smart young woman with bulging shopping bags and two small children has come for her methadone treatment and to continue our exploration of her life story. The aim of prescribing methadone is to allow drug users to receive a regular supply of their drugs from a legal source which will give them the opportunity to regularise their lives. Without this supply, for example, when they first approach the practice, their lives are frequently in chaos. Increasing debts and continuing problems with the illegal activities needed to finance their addiction get them into a deeper and deeper spiral of fringe activities which compound their marginalisation and their own feelings of rejection by and defiance of society. As they are outside the system, the chances of developing medical side effects of opiate drug use are much greater. Most drugs bought on the streets are heavily contaminated, and it is these contaminants rather than the pure opiate drugs themselves that cause the majority of the medical problems suffered by the users. If it is not possible to stereotype the people who become drug users, it certainly is possible to characterise the sorts of situations that they are in when they come to the practice for the first time. Almost all are heavily in debt, in trouble with the law and with many other authorities, housing etc., and they often feel ashamed with themselves and out of control. Many have had problems with doctors and other health-care workers who have appeared to be excessively preoccupied with their drug use and not been able to respond to their human predicament. The journey back for them to re-establish control over their own lives and to patch up their self-esteem relies on a positive relationship between users and those trying to help them. The doctor has to like the person who comes to him or her and to reach through the messy, confused outer shell to make contact with the 'person within'.
The basis of all our work with people who use opiate drugs is the contract we have between us. On my side of the contract I promise to treat them like human beings, give them the medical care they need for any intercurrent illness that develops and to supply them with the opiate substitute, methadone, at a dose that we negotiate at a regular review. In return, users contract to come for those reviews, to come at regular times to get their prescription for methadone, to be registered with the Home Office and to work at the other features of their life that they might be finding problematic. In our practice the contract is usually drawn up with the help of the workers at the Sheffield Community Drug Project ( Rockingham Drug Project ). It may be either written or verbal. Contracts that are too punitive, that rely on total abstinence from substances other than methadone, or that reduce the amount of methadone prescribed by set amounts over a short time span have simply proved to be non-workable. They break down and the relationship between the doctor and the user, which is at the core of all this work, degenerates into a series of tense and antagonist encounters with both sides feeling belittled.
The drug users come to see me regularly, usually once every fortnight. The range in quality of these interactions is exactly the same as the range that I experience with other consultations. Sometimes they degenerate into a short exchange of the barest pleasantries and a hand-over of the script. On other occasions real progress is made. We explore together the meaning of their experience and their psychodynamic make-up. The relationship between us develops in small bites, exactly as it does with other people who come for help on a regular basis. Their drug use is rarely the only centre of attention during the consultation and we usually try to focus on other aspects of their lives. In common with many other complex consultations I have learnt from Linda Gask (personal communication) to try to focus on three therapeutic elements:
- 1. Problem-solving.
- 2. Counteracting automatic or negative thoughts.
- 3. Stepwise goals.
Whenever I feel stuck within a consultation I remind myself of these elements.
This is a focus on real problems they might be experiencing and adopts a simple problem-solving approach. Although they are drug users, or more often because they are drug users, they may have compound problems which need sorting out before they can contemplate any work on reducing their opiate use. The doctor may not be the best person to help them sort these things out, but they may be the only person in authority with whom the drug user is regularly in contact. It may be possible to help them sort out for themselves what it is that needs attention within their complex lives, or identify others who are in a better position to help them. Many problem drug users have used drugs to anaesthetise themselves from their own overwhelming feelings or from the multiple problems that they feel they face.
COUNTERACTING AUTOMATIC OR NEGATIVE THOUGHTS
Many drug users feel bad about themselves and have developed ways of looking at themselves that are highly self-destructive. When they say things like 'I know I'm just bad at relationships', I feel it is important to remind them of the relationships they have been able to forge and to try to make this positive response their own automatic thought rather than negative ones. The people who have come to see me have had a range of experiences in their formative years, but many have been abused or undervalued all their lives. Too easily they consider themselves worthless, therefore why not destroy themselves through drug use?
The way out of the morass of drug use, or from any destructive behaviour, seems to be through small steps. Sustained changes in health-related behaviour seem to be best attained through a series of achievable goals which are then reinforced and built upon. Relapses do occur and are part of the human condition, not necessarily a cause for abandoning the programme. In each consultation we try to establish the next goal. This may be comparatively trivial, but will often have major significance for the drug user. Examples might include looking at the possibility of a college course, making contact again with a family member or be a goal associated with their drug use, such as cutting down on 'extra' substances bought on the street. In this way the consultations take shape and direction. We are working together to achieve human targets. If the steps are too big then we will fall and have to start again.
I have to report that with some people who come for help there is no bonding at all. They reject me and I find it hard to feel warmly towards them. They usually move on to other situations.
Some people I am seeing currently I do not feel very warmly towards, and find it hard to think that the outcome will be very promising. My notes about one person with whom I had a poor relationship tell the story of our mutual failure:
Another plausible story. He's had a bad time with lots of other members of the medical profession. He's split up with his girlfriend, a nurse, because of his habit, and he now wants to get the dragon off his back to show her. Articulate if rather sluggish. Talented, but not quite got it together. We decide on a reducing dose of methadone and a firm written contract between us. Soon obfuscation and variation set in. He never quite appears at his appointment times, although always with good reasons. He asks for a home visit and it isn't at the address he gave us when signing with the practice. He's been injecting and has a thrombosed femoral vein. He's evasive, abusive, pitiful, beseeching, obviously in need of help at all sorts of levels. . . but is the person he betrayed the one to give him the help he needs? I feel angry, exasperated, compassionate for his plight, but paralysed. I can't think quickly enough about the strategies that would help him out of his mess and I revert to professional type. Strictly simple analgesia for this one my son. Translate this as . . 'you've got yourself into this mess and you must suffer. Go to the hospital they will sort your leg out'. Is this an over the top reaction, or is it justified because he really has reneged on every component of our contract? Strike him off the list or clasp him to the bosom ? What is the personal cost of all this to me, and what am I getting out of it? Certainly no thanks as he roundly tells me off for treating him exactly as all the other doctors have done. In his eyes I'm the same as all the others, a powerful other, controlling his life and refusing to give him the one thing he wants/needs/craves. I'm stereotyping him, he's just a junkie, same as all the others, can't I see the pain? Our relationship never recovered from this episode. He finished his reducing course of methadone according to our original contract and sloped off, presumably to hound other doctors.
Measuring outcomes of this sort of work is notoriously problematic. Although it would be tempting to categorise the people who have come off drugs as being 'successes', and the others as 'failures', it may be possible to measure outcomes on a variety of more realistic intermediate health goals. For example, the stability of a person's drug use might be more important from a health viewpoint than their actual level of drug use. It can be hard to follow up what has happened to people when they no longer attend regularly, and of course there is always the problem of inaccurate reporting of levels of drug use, even with rigorous urine sampling for 'extra' substances. Of the 40 people with opiate problems whom I have seen over the last 4 years, 21 are no longer coming to see me for methadone prescriptions. In this group are eight who I would certainly describe as 'non-bonders' (including the person described above ) . Some of them fought and struggled, cheated, stole prescriptions and devalued what I had to offer them . Others were never honest to themselves or to me and didn't do any work during the consultations. The cost of coming to see me regularly was too great for them and I didn't do much to make them feel welcome at the surgery either. We parted company and my heart felt lighter when I didn't have to have anything to do with them any more.
Two other people have had serious drug-related health problems and have gone back to be with their own family of origin. One of these has AIDS and the other lost an arm and a leg at separate times through injection mishaps. Five of my group have become drug free. Three went through apparently successful residential rehabilitation programmes and two just did their own thing, reducing little by little and then stopping.
Six others have moved out of Sheffield and I am not entirely sure what has happened to them. One went to a drug rehab house for a long residential programme and one went to prison. I am not sure what has happened to either of them in the long term. The remaining four went to live in other towns for a variety of reasons and almost certainly remain drug users.
I continue to see 19 people from this group currently, and with most of them it is too early to talk about definite or sustained outcomes. Some of them have been coming to see me for a long time now, up to 4years. Oneofthemajorlessonsl haveleamt isthatall this work does take a very long time and that the slow development of strategies and relationships requires, patience and the cooperation of other agencies.
When tentatively starting to think about how to categorise the intermediate outcome for these 19 people for the purpose of this review. I have divided them into four groups:
- 1. High dose maintainers.
- 2. Low dose maintainers.
- 3. Transitional group
- 4. Active reducers.
These are not permanent groupings and people will almost certainly switch their status between the groups in the coming months and years.
High dose maintainers
Three people have been on comparatively large doses of substitution therapy (80-100 mg daily) for a long time and I am categorising them as high dose maintainers. It is hard to imagine that they will suddenly be able to reduce or stop their prescriptions. One of them is back studying at college again and doing well academically, whereas the others remain unemployed, but relatively stable. We no longer talk much about the reduction of their 'script', but my hope is that in the future after a long period of stability they will be able to consider the possibility of making the necessary effort to think about changes. Over the last year I have started giving 'scripts' for injectable methadone to these three people. The oral methadone was achieving no goals for them and they were resorting chaotically to other street-purchased substances, particularly cyclizine. With this group using prescribed injectables we have developed a new tighter contract and are actively working hard on the other areas of their lives where they have problems. In particular the enormous psychological problems that they have will need some sort of resolution before it will be possible for them to have the courage to think about adjusting their use of opiates .
For the 'high dose maintainers' their use of drugs seems to be a positive decision to flee from their other problems; they have all been round the circuit of various intimidating institutions (children's homes, hospitals, prisons, drug rehab houses etc.) and entrenched in complex situations for many years. They come regularly to see me, although they do find keeping to particular appointment times can be a problem. During some consultations I believe we are able to make contact with each other and they do use me as a fixed point of reference within their complicated situations. I think that the prescribed drugs and their relationship with me and the normalising surgery structure do have a value for them, or at the very least the absence of these elements would be detrimental to their lives and to the possibility of future progress.
Low dose maintainers
Three people are taking comparatively small doses of methadone each day ( 10-25 ml). They feel themselves to be truly addicted and are taking this small amount just to keep themselves going. They don't seem to have much motivation either to stop using or to go out and get additional opiates from other sources. I think they are using the methadone rather like other addicts' might use alcohol, tobacco or minor tranquillisers. It does not seem to be a problem for them and they are certainly much improved in their general health, in the absence of harmful side effects and in their general social situations than when they were chaotically using street opiates.
I have placed eight people provisionally in the transitional' group. Things are changing for them; there is movement and the possibility of change. We are doing active work in our consultations together; often they are also in contact with the community drug project for other forms of help and support. Some of these people remain on quite large doses of oral methadone (20-80 ml) but they are positively working at a number of levels about their lives and the place of addiction within it.
Four of this group have tried periods of time in residential rehabilitation projects previously, but relapsed after discharge. In our consultations we talk about the positive things that they learnt from their other attempts at withdrawal and the ways that they can use their relapse experience next time round.
Who knows how many times they might have to go round the cycle before they get clear ?
Six people are currently reducing the amounts of methadone that they take daily. This process seems to take a long time and I try to take the lead from them each as individuals when they tell me they want to come down the next step. Quite a few of them have been coming down slowly for many months and are now on very small doses indeed. In my naive way I would have thought that the last few millilitres each day would be comparatively easy to stop, but this has not proved to be the case. I have divided this group into two equal groups: three with strong internal motivation to reduce and the other three where external factors have apparently provided the impetus for reduction and withdrawal.
One young woman is pregnant and is determined to reduce quite quickly before the expected date of delivery. One man has developed hepatitis C and has been told that he has to reduce before he gets a chance to have interferon therapy. The third has the chance to live abroad with his family and wants to be drug free before he goes. Strong external motivation does seem to be working for the people in this group and provides them with the impetus for change. When they come to see me I remind them of their resolve and try to keep the pressure on them at a sufficient level for them to keep to their resolution and schedule.
Some of the group have just become fed up with using drugs; they have decided for themselves to reduce and stop their usage. It is a hard journey, but I am impressed by their resolve. During the consultations we talk about all sorts of things. They do not, in general, seem to have suffered the same level of damage as the people in the other groups; they may have drifted into heavy use through their partners or become involved in particular social situations where the norm was drug use. Many of them now are on very small (almost homoeopathic) doses of methadone, and although movement towards abstention is slow, their 'problem' is perhaps comparable with people who find it hard to rid themselves of the last step of tranquilliser use. The drug has become a crutch for them and they are fearful of throwing it away and walking for themselves.
IS THE WORK WORTH THE EFFORT ?
In all areas of our work we are increasingly being asked to determine if the work we do, and the way we do it, is effective and if it is worth the effort being expended. Usually this is dealt with in terms of predetermined outcome measures and subject to traditional cost-benefit analysis. Although more formal audit of this type of work is possible, and has been attempted within primary care settings ( Cohen et al., 1992), the problems of simplistic analysis in this subject area are very great.
Because of the complex nature of the individual problems that each person coming for help has at the time of their presentation, and during the course of their work with their 'problem' drug usage, it is very difficult to provide controls or to be certain if the work is having any positive effects. Most of the measurement of effectiveness will depend on a comparison with the individual drug user's career before they came into treatment, or on an informed guess about what would have happened to them if they hadn't come for treatment.
Possible measures of treatment effectiveness
- Abstention from drugs
- Reduction of chaotic use of illegal drugs
- Reduction of harmful side effects of drug use.
Other outcomes from treatment
- Constant, positive contact with authority
- Relationship with therapist
- Work on practical problems, welfare rights, housing etc.
Counting the number of people who have become drug free is rather unrewarding. Only seven out of the 40 people I have seen over the period of 4 years are now not using opiates as far as I am aware. Three others have had periods of non-use followed by relapse and further prescriptions. However, all the people currently attending for treatment are on regular doses of prescribed pure methadone, which is a great improvement compared with the large doses of contaminated illegal opiates they were taking at the start of the treatment. Although some people who come for regular methadone are taking additional illegal drugs, almost all the people under treatment have been able to reduce their chaotic use of these drugs. Very few ever turn up intoxicated and most report on, and are able to discuss, the value of stable treatment regimens.
Among the people I have been seeing, some have had medical complications as a direct result of their drug usage. Ten people have had treatment from me For problems with their injection technique after they had either injected into arteries, thrombosed their veins or generally dug around with needles in the wrong places. I imagine that others might have had problems of this nature, but not shared them with me. Only three of these episodes were serious enough to warrant hospital admission, of which one resulted in the amputation of the limb involved.
Three people have developed hepatitis C and one has had hepatitis B. It is not clear if infection occurred while under treatment with me or whether it was a result of previous illegal use. My impression is that the stability of attending for regular methadone treatment and the ready availability of clean needles through the needle-exchange scheme has enormously reduced the incidence of medical side effects among those coming for treatment. Many of these people were medically very unwell at the start of their treatment, with frequent intercurrent infections, malnourishment and constant problems with their injection sites. Comparing them now as a group with the physical state they were in at the start of treatment demonstrates the medical (harm reduction) value of the work.
For drug users, working through their own personal issues can be complex and painful. The psychological work that we all need to do to find out about the purpose of our own lives and our own role in society is especially poignant for many of the people who have chosen to anaesthetise themselves from the pain of this search through the use of mind-altering drugs. A proportion have sustained psychological damage in their journey through the early part of their lives, and have apparently chosen to self-destruct to prove to themselves their lack of worth. Others chose the excitement and thrill of living on the edge of society when first using drugs, and have forgotten the way back to the more stable, domesticated lives many people seem to look for as they get a bit older. Many of them think that they are not very good at relation ships, and have forgotten, or never knew, how to develop 'ordinary' relationships not based on the drug scene and illegal subcultures. For many of them the time of looking at their drug use is a time for also reconsidering their relationships, and many of these have undergone transformation or disintegration during the time of therapy.
None of the work with drug users is possible for people within primary care to undertake without the active support of other workers both inside and outside their practice . Within the practice as a whole there is always tension about work with drug users. At times they muck up the systems; they don't find it easy to come for appointments especially in their chaotic early days. They take up a lot of time, they come with friends and do tend to clutter up the waiting room. They do their injections in the toilets and they deal in the alleys. Every now and again there are panics and punch-ups which are genuinely frightening for everyone around at the time, especially the reception workers and other people in the waiting room. There is a tension between wanting to be the sort of practice where any one can come for help, including the most marginalised members of the community, and at the same time creating a work place where it is not frightening to come to work.
It is wrong to make assumptions about the attitudes of the other members of the team about these issues without checking them out in detailed discussions. Working through these issues with all the members of the team continues to be fruitful. Practical protocols need to be developed. What should be done if a fight develops? Who should take the decisions about seeing people if they attend late for their appointments ? It feels as though, in our practice, we have all got better at working with drug users and with defusing potentially difficult situations, but I know that problematic things will always continue to happen if risks are taken. We make ourselves open and available, and every now and again people will take advantage of this, not just drug users.
The drug workers from the Sheffield Rockingham Drug Project have been excellent and constant companions in my voyage of discovery. We often work together to look at particular situations and to help the drug user decide which option might be worth trying next. They have helped me understand some of the things that I have tried to communicate in this article and are patient with me when I seem slow to comprehend or when I revert to professional type. In many instances, advances for the drug users have come through the detailed work at many different levels that the user has been able to undertake with the specialist drugs worker from the project, and my input has been very much of secondary importance. They help to sort out practical sources of help and provide the basis for the necessary detailed psychological work also. They have taught me not to be scared of seeing drug users as human beings and of trying to respond accordingly.
Similarly the local pharmacist has been supportive and has the right degree of flexibility that is necessary to work with this client group. I feel as though we are learning together how to do this compelling and complex work. One of the other partners in the practice (Roger Smith) has also developed a special interest in helping people with problem drug use . He has built up a client group of approximately the same size as mine over the years. Throughout the years of working together we have continually been able to debate and discuss our own approaches and attitudes and this interchange has been an essential element of my own work. Individual doctors should think hard about the support and supervision they get at their place of work before undertaking this type of work.
I have tried to describe my work as honestly as I can. I try not to be under the illusion that all is sweetness and light, and that eventually all my 'children' will grow up to be concert pianists. I think some of the drug users, especially in the early days, may well have been laughing up their sleeves at having found such an easy source of methadone and some may still' be, doing this. I guess that I will still be disappointed, frustrated and terribly hurt in the future about particular relationships. I am aware that the more I invest in the relationships the more likely it is for deeper hurt and disillusionment to set in if progress is not made, or if they find the going too difficult and revert to chaotic use, or if they develop serious complications from their drug use.
CONCLUSIONS AND POLICY IMPLICATIONS
In policy terms it is apparent that with adequate support and training the treatment of drug users from within general practice can be both practical and effective. Some practical elements need to be considered at a policy level:
- Is the treatment of drug users in general practice part of a coherent local and national policy. Although our work in Sheffield has gone or without the benefit of a coherent local policy it would be sensible to develop this to support any general practice initiatives in the future. Similarly at a national level, the shifting swings of a variety of policies over the post-war years have given individual general practitioners the excuse to not become engaged in work with this client group. A clear policy needs to be developed at the national level about the place or places where this client group should be treated. If this includes the primary care level then this should be spelt out clearly.
- What training is required by those primary care teams wanting to undertake this work? The effectiveness of special training for local GPs who want to become involved in this work has already been established (Blank and Nelles, 1993 ) . The detailed training that is needed before GPs start this work should become widely available. Training should involve all members of the primary care teams, especially reception workers and all those involved in direct contact with drug users.
- What support is available for workers within primary care to undertake work with drug users? Considerable support is required by general practitioners and other workers within primary care. This involves individual supervision and the back-up of the community drugs workers.
- What structure is required to plan for the adequate treatment of drug users within a locality? Within any locality not every primary care team needs to become involved in this work. It may be possible to identify a number of practices within a particular city, for example, who have developed this particular form of expertise.
- What reward system can be introduced to pay for the extra work that this client group entails? The new GP contract and many other current changes within the structure and remuneration arrangements of general practice seem to work against this type of detailed work with drug users. In particular the growth of fund holding, the restrictions of prescribing and the emphasis on capitation payments will all tend to make work with drug users increasingly unattractive financially. Enthusiasts have been doing this work, arranging the support and training they require, and developing the service at their own expense. The developing policies will have to consider this aspect and find adequate ways of paying for the service to be provided at primary care level.
PRESCRIBING ARRANGEMENTS FOR M
These arrangements have been agreed between M, Tom Heller and KM (Rockingham Drug Project Worker).
M wishes to be prescribed injectable Physeptone for a period of time believing that this will help him stabilise his drug use and as a consequence his lifestyle will become less chaotic and more rewarding.
His particular problems at the moment relate to his use of black market drugs which he is injecting 'on top of' his regular oral methadone prescription. He has several financial and legal problems which he feels have arisen out of his use of these additional drugs. He has also been unable to concentrate on his college course which has subsequently suffered due to his lack of attendance and not handing work in.
After a long discussion where many of these issues and others were discussed, the following arrangements have been suggested:
1 M is to receive a daily prescription of six ml ampoules of Physeptone ( 10 mg/ml).
2 He is to pick up his prescription every . . days on . . . day and . . . day.
3 The prescription will be given on this basis for the next 3 months contingent upon all the conditions in these arrangements being adhered to
4 These arrangements and the prescription will be reviewed on ........M is not to use any other substances 'on top of' his prescription.
5 A urine sample will be taken on a regular basis (at least one per fortnight) and will have a full drug screen test. The result will be relayed to all involved in these arrangements
6 M has requested to see someone to discuss, in depth, issues relating to his past that he feels need to be resolved. To that end a referral has been sent to central sector mental health team for discussion.
7 The point of altering the prescribing regime is to help M stablise his drug use and minimise the problems that he experiences. It is felt that for the prescription to be continued, some progress should be made in terms of sorting out issues such as rent arrears, legal problems and other pertinent issues. KM has agreed to give what assistance he can in this respect.
8 These arrangements will be monitored by a monthly meeting between all the parties involved. If at any time it is felt that the arrangements need urgent review, then all parties agree to make themselves available at the earliest convenient time.
9 It is important to stress that this period of prescribing is seen as the first stage in a long-term plan. Tom Heller and KM both feel that it is important to work to the goals of withdrawal and eventual abstinence. It is therefore stressed that the prescription of injectables has been agreed for a fixed period of time and will end with the review of this contract. After which, depending on progress and results attained during this period, new arrangements for prescribing, monitoring and supporting M will be discussed.
10 M is to see Tom Heller and KM on a regular basis . through the period of the prescribing agreement
11 Finally, and to reiterate, any deviation or problems arising from or with these arrangements will prompt their early review and possible curtailment.
- Tom Heller, General Practitioner, Sheffield
Blank, M. And Nelles, W. ( 1993 ) . Educating and training GPs in the management and treatment of drug users. International Journal of Drug Policy, 4, 49-55.
Cohen, J., Schamroth, A., Nazareth, 1. et al. ( 1992). Problem drug use in a central London general practice . Brinsh Medical Journal,304, 1158-1160.
Glanz, A. ( 1986). Findings of a national survey of the role of general practitioners in the treatment of opiate misuse: views on treatment. British Medical Journal, 293, 260-263 .
Thorley, A. ( 1987). Some practical approaches to the problem drug taker. In T. Heller, M. Grant and C. Jeffrey (Eds), Drug Use and Misuse . Chichester: John Wiley & Sons,