Friday, 4 November 2011

Lines in the sand

A people that values its privileges above its principles, soon loses both – Dwight Eisenhower

‘Junkie’ is a word I detest. It's also a highly emotive word and has several different interpretations. Interestingly, it's used across the entire socio-economic spectrum and is almost universally considered derogatory. To a large number of people however, for whatever reason, it represents a line in the sand. Cross it and you're one of them. But is it really that black and white?  Who draws the line? And who controls the location of the line? Embarrassingly, I used to think it was pretty simple.

In 2005, a four year old boy from Mildura (VIC) died of a prescription drug overdose. Yes, four. The culprit – prescription opiates. His parents were both opiate dependent and the pill that ended his life was located in the family home.

Say opiates and most people think Heroin. But a much larger and more common problem is the prescription form of this medication - obtained from your local GP. With a street value of approximately one dollar per milligram, prescription opiates are popular items. Prescription opiates are also one of the best examples of the expansive grey area encompassing the line in the sand referred to earlier. 

On one side of the divide is ‘Steve’ a family man with a steady job and two children with chronic back pain requiring a prescription for ‘pain’ pills every two weeks from the local GP. 

The local doctor becomes uncomfortable about Steve’s opiate medication requirements and questions his increased use. Steve jokes heartily that he obviously isn’t addicted to them and clearly doesn’t look like a junkie. After all, he can control it, he holds down a job, tends to the needs of his family and plays guitar every weekend for the church band. The doctor nods, smiles and hands Steve a script.

A whole world away, on the other side of this line is ‘Eve’ - a woman who is unemployed, with no fixed address and presents to the local Emergency Department with vomiting and stomach pain. She soon discovers that she is pregnant.

There is both joy and shame as she informs staff of her injecting prescription opiate addiction. ‘Eve’ is keen to be a mother and is advised to commence methadone to ensure the safety of her baby.  ‘Just go and see your local GP’ the friendly staff member informs her.

The next day Eve enters the first GP surgery she can find and ironically ends up seeing the same GP as Steve.  Eve is very anxious and doesn’t want to sit down. She is acutely aware of the stares she received from the reception staff and shuts her eyes momentarily. Pleading with herself to ignore the perceived judgment, Eve makes a promise to no longer inject opiates.

‘I’m terribly sorry’ says the tired and sympathetic GP, ‘but I don’t prescribe methadone.’ Too ashamed and in a rush to end her discomfort, Eve neglects to inform the GP about her pregnancy. Instead she attempts to relay the gravity of her decision to stop injecting prescription opiates.

Remembering advice from hospital staff, Eve (choking back tears) asks about a tablet form of methadone. ‘Again Eve, I’m very sorry but according to medicare guidelines I’m only allowed to prescribe that medication for chronic pain and not for someone with opiate dependence such as yourself… tablet methadone is used for things like long term back pain for instance.’

Not exactly even stevens  - if you'll kindly excuse the pun. Prescribing opiates it seems, is not so simple, and has been described by some as a 'catch-22' situation. But putting prescription opiates in the too-hard basket is not the answer.

For too long our health system has danced around the multitude of issues associated with prescription opiates and definitions of dependence. At a recent inquest into the death of the four year old boy who overdosed on prescription opiates, coroner Jennifer Tregent called for mandatory GP education to ‘identify drug dependency and strategies to deal with it.’  

As a GP I welcome the mandatory education and training. It is long overdue. Maybe its time for all GP surgeries to reconsider the meaning of the sign in the waiting room that reads ‘we do not provide scripts for addictive medications.’ This clearly doesn’t help solve the problem. GP’s represent a privileged few that are able to have a major impact on prescription opiates... or we can keep pretending its impossible to shift a line in the sand. So next time you say the word 'junkie' - ask yourself what it means to you.

1 comment:

  1. Great post - thanks.

    Other factors that influence opiate prescribing by GPs is time and the availability of support resources (pain clinics, pain specialists, addiction specialists).

    I've spoken to GPs in strife over prescribing (and usuually working in large group practices) who have told me that they don't have time to read their colleagues' notes because of the workload pressure, and that's why they haven't noticed that a person has presented 3 times in 2 weeks for replacement of "lost" prescriptions. With all the education possible, without a fundamental change in practice they would probably still prescribe poorly. There are a few clinics where the "we do not provide scripts for addictive medications" sign may actually be a safer option than their current prescribing practice.

    Then again, I fully admit to bias. As an addiction specialist I tend to see more of the folk who have already run into problems.

    As for specialist reviews of patients on long term prescribed opiates... a good idea in principle but the availability of specilaist services is so thin that the waiting lists have all blown out. So where do GPs go to get the support they need to prescribe addictive and potentially high risk medications better?