SMMGP - Substance Misuse Management Good Practice

Substance Misuse Management Good Practice

Supporting good practice in drug and alcohol treatment

Post-its from Practice:
Getting into treatment - a long and tortuous business in some cases! (Jul 2007)

Stuart is the partner of one of my patients and came to see me the other day with a story that was difficult to believe. However the service in question has confirmed the facts of the matter.

Stuart took a day off work to attend our local drug service for an initial assessment. At his next appointment the drug worker made a partial assessment and so asked him to return for another one hour appointment. At this next appointment he learnt that his written assessment had been lost (the service does not yet use computers) and that all 15 pages of the local assessment form had to be completed again before he was put on the two week waiting list to see the doctor for assessment.

Surprisingly, he still attended, was assessed by the doctor, and chose methadone substitution. He was told at this point that prescribing would be dependent on attending 3 consecutive days of titration and dependant on his withdrawal symptoms which would be measured objectively. However when he attended, he was deemed not to be in "enough" withdrawal, although he felt and looked awful. Stuart heroically returned the next day and although his heroin use was >1g/day, was given only 20mls substitution of methadone mixture by supervised consumption. This was the final straw. Stuart had told them that he needed to leave for work at 7am in the morning and so supervised consumption would be difficult as there wasn't a late opening chemist close to where he lived or worked.

Stuart presented to us in withdrawal. He had an excellent assessment in 20 minutes by our specialist drugs counsellor who gained the necessary vital information and undertook a urine drug test which confirmed the use of heroin. This was followed by a 10 minute review of the assessment and a physical examination from me which confirmed Stuart had normal blood pressure, a clear chest, old and fresh track-marks up both arms and enormous pupils. He left the surgery that day with a prescription for 40mg of methadone mixture and another dated the next day for 40mg, with an appointment to return the following afternoon.

Four weeks into treatment Stuart is doing very well having settled on 90mls of methadone mixture. He still has his job and is now using his wages to pay back borrowed money to his partner; they are even planning a holiday.

Stuart's story raises several concerns: why was he not informed properly of the assessment process so that he could give properly informed consent to the treatment? Why is the service so unconcerned with their blunders, their lack of encouragement and timely care? If Stuart had been a young mother with children or had been more problematic, I don't think such a person would have managed to make the third, let alone the fifth appointment when the first methadone was dispensed. Finally, if staff apply guidelines as tramlines or are completely risk aversive, whether due to inexperience or to lack of clinical expertise or resources, then the final service will likely be a poor production line process.

Stuart won't be complaining about his experience at the local service, so they continue to be unaware that they are failing to provide a patient centred service but I'll use his promised postcard as a positive marker of ours.

- Dr Chris Ford