Looking after Substance Users in Primary Care

Introduction

In response of Carl Steylaerts’ propositions towards a common statement from the mini-symposium held in Brussels the 14^th of June 2014, and reflecting on them, I would like to submit my own ideas on the subject.

I shall point out at least a few things:

• That the treatment of addiction in Primary Care goes beyond Harm Reduction;
• That primary care offers the best treatment option for most cases;
• That all stakeholders are best served with a combined model of services;
• That we need a change of mentality;
• That the process of education should deliver better knowledge and skills in the field of addiction and care.

I think I understand, what Carl is trying to tell us here, and I agree with most of it, but not all.

Let’s start with the rather blunt statement of his, that “substitution therapy is harm reduction, no more, no less.” This proposition has the benefit of clarity. I appreciate the radical approach, and I am all for harm reduction, but I may be forgiven for believing that we can do no less but rather more, than just harm reduction.

Addiction is a chronic disease which marks the life of those attained during many years, in a tall number of patients

Medical care provides several tools that may help to contain the risk of drug using.

Those tools (methods, counselling, pharmaceuticals) should be made available in a low threshold setting at low cost to the user.

Harm Reduction is the first platform of care, from which we can try to get on to other levels. It may be a good starting point and one of the first goals to achieve early in the therapeutic process, but as the story unfolds, we might have the opportunity to explore alleys beyond that first objective.

Primary Care might be well advised to incorporate the philosophy of Harm Reduction, but this is a goal, not a method.

Harm Reduction strategies need to be built into the global and integral approach, supposedly the hallmark of Primary Care. This care model is not exhausted when Harm Reduction requirements are met.

When sitting across the patient, one needs an open eye, an open ear and an open mind.

We will have to see eye to eye with this particular person, who calls in here and today, in order to submit some kind of daily life problem, part of which might be an issue about addiction. What we see is not always what we get.

We need an open ear because much of the work consists of listening. We should refrain of trying to do too much too soon, and not hammer on harm reduction all the time, lest we not hear what they are really trying to tell us.

We need an open mind, which is less evident than it seems when dealing with ailments of the mind. We should at least try to deal with our own prior views, presumptions and fears.

In my experience, as I already stated elsewhere, this is where the peer interaction comes in, during monthly sessions in a Balint-like setting. This experience for the past twenty years has been extremely useful to me personally, not only at the informative, but on the emotional level as well.

In the clinical setting two people meet in an asymmetrical relation.

The patient wants our services in order to accomplish a goal of his own. The physician has only so many tools at his disposal. Both do not necessarily agree on the best course taken. What the patient wants is not necessarily translatable to what the physician has to offer.

Much depends on the therapeutic objective that each party has in mind. Will they find some common ground to start working on? We could imagine for instance a patient devoted to abstinence as a goal of treatment, while the physician is intent on harm reduction. It might be the other way round as well. The fact is that we cannot be sure beforehand.

What matters here is to be able to identify the source of a possible hidden disagreement. At such times it can be useful to clear up the confusion by trying to make explicit, something whch has remained implicit for so long, and that both parties may state what they expect to come out of the therapeutic process.

Abstinence and Harm Reduction are just two possible therapeutic objectives, most of the time on opposite ends. We can imagine other goals though.

The one I cherish most is emancipatory in nature.

Medical Care at large should be ready to provide the means and methods i.e. the tools which people need to operate their own choices.

Care for users is no exception to that general principle. It is my true conviction that I am there to help people realize themselves, and enable them to make their own decisions as a result.

In order to do that, they need to get better control over their outer environment, and their own inner self. It is my job to provide the skills necessary to help them realize that sense of control.

Opioid replacement therapy, for a limited number of people after all, as compared to the population at large, is just a tool to provide more control over the patient’s own life. It works because so many patients discover that they are able to do more, and rely less on others, let alone the social security system.

There is probably no chronic disease which requires such frequent contact over such a long time as is the case in people depending on methadone replacement therapy.

Inevitably, as any two humans who communicate with each other, you get to know each other, and this will hopefully lead to the installation of a climate of trust. That process is called the therapeutic relationship.

I, from my side, will be looking for chances to do whatever is required during the particular stage the patient is in, to help him or her along. Let’s take two instances.

One example might be a woman needing to break out of an abusive relationship which perpetuates her addiction. Maybe she can be encouraged to do so by some kind of empowerment, and the message that violence and abuse can never do any good.

The next patient may be someone who struggles with the consequences of past damage. It may be something difficult to express and it may take a lot of time before the unspeakable can be said. In the meantime all we can do is offer trust and empathy, and never hurry.

There is always a story, and it is always different. The individual approach, tailored to the needs and means of the patient, will therefore obtain the best results.

Opioid substitution therapy in ambulatory settings can be offered, meeting all the requirements of the harm reduction strategy, but goes beyond that approach, in order to provide global and integral care, available and accessible to all who need it.

Beyond harm reduction there may be healing, in a holistic sense.

We share the impression that in many areas of our countries today, the need for ambulatory opioid substitution therapy in primary care setting is not met, to the extent it ought to be.

Some of the obstacles are due to an outdated but still prevailing mentality of prejudice, which will have to change. We need to work on a change of minds, inside the medical community, such as is already taking place in the other countries as well.

For a change of mentality to happen we ought to provide the true facts and odds about opioid addiction and its treatment. Only the truth will convince. The knowledge we possess through experience, needs to penetrate all the levels of the primary care system.

Efforts should be made to improve the quality, accessibility and affordability of the care, and at the same time, the general public should be made aware that good care is available for everyone. People having a problem with drug use should be encouraged to look for counselling.

If we do that, we better be able to deliver what we promise, and be welcoming towards the very people we induced to consult us. Some process of continuing education about the subject will be necessary.

Primary Care should be a ‘no exclusion’ zone.

We have to be brave enough to ask ourselves: ‘what do we in primary care have to offer to those who need help with a drug problem?”

If we want them reintegrate in the society, it seems only rational that they are invited to use the same care facilities as everyone else, in primary care, and not be concentrated in specialized initiatives.

The knowledge, skills and competences necessary to cope with the care for users should be present in multidisciplinary General Practice group practices and be part and parcel of primary care, which by nature does not limit itself to one particular group of people.

This model is preferable to either the one represented by Methadone Clinics seen as stand-alone houses, with fragmented care by physicians unqualified for general practice, or at the other extreme a model were users would have to rely on isolated physicians, without any network of psychosocial support.

Primary Care should strive for integral, global and long term ‘taking care’ of the user, just like any other person applying for care.

This will help to prevent overload of more specialized or residential care, which because of the scarcity of the resources can only treat a fraction of the total number of cases.

I believe there will always remain a need for such facilities for those cases where the primary care approach proves to be insufficient.

Primary care as we see it, should be able to provide "microstructures" on the basis of local cooperation with mental health centers and the like.

Wherever applicable the substitution therapy provided should comply with strategies to maximize adherence and safe use of the substance provided. Illicit use should be prevented by pharmaceutical measures and the delivery should be sure, safe and sound.

The role of the pharmacist should never be underestimated if we want neighboring care to succeed in meeting the needs of the treated population.

Other than that, he distribution of the substitution therapy should be as decentralized as possible, to avoid concentration of addicted people in certain waiting rooms.

Drug addiction is a chronic disease and should be managed like any other chronic disease in a suitable primary care setting on the basis of the principles of shared knowledge, complementarity and subsidiarity.

As opposed to some thought expressed by Carl, I believe the choice of the patient should not be limited, not even by measures aiming at more quality of care.

Any kind of health care as a matter of course should be regularly assessed according to the quality of care provided, the accessibility for all, and the affordability including the common cost through social security.

I think the combination of highest quality, best accessibility, and lowest prices will occur in a care market, where people have a choice between alternatives.

If we want people to commit themselves to a therapeutic process, then we will have to allow their freedom of choice of a practitioner they can relate to.

The provider side should ensure that enough competence and skills are present among the care teams and that people can choose between valid alternatives.

This is only possible if adequate training and ongoing education are offered throughout the careers of health care professionals.

I therefore applaud any This is only possible if adequate training and ongoing education are offered throughout the careers of health care initiative that would succeed in enhancing the knowledge and skills needed, from different backgrounds such as Carl indicates: “neurology, psychiatry, family context therapy, motivational interviewing, prescription strategies, management of infections related to drug addiction, efficient reporting and research etc.”

Peer supported feedback in my own view is an excellent strategy and it should develop its own ‘well-defined set of parameters.’