Post-its from Practice:
Excluding people from treatment - is it ever justified? (Oct 2007)
I went to the waiting room to collect my next patient Imran. He was expressing his gratitude to one of our wonderful receptionists for treating him so well. It was odd to think that he had only come to us 6 weeks before having been discharged from a neighbouring borough specialist service for aggressive behaviour. His offence was shouting at his key worker who had promised to advance his housing application and had forgotten, and rather than just apologise she had implied to Imran that it wasn't important. He had been in bed and breakfast for over 2 years and he felt that sorting his housing was a key part in his recovery, and it was even in his care-plan! He also had moderately severe depression and was under the care of a psychiatrist.
The service had given him a 2 week reduction script from his maintenance dose of 80mg of methadone mixture to zero. They had offered him no alternative for care and in fact advised him that he couldn't get treatment from his then GP, as the GP was part of the same treatment system and if you got banned from one service you got banned from all services. This doesn't happen in our borough but it is not the first time I have heard of this rule.
Fortunately a friend of Imran's told him about the excellent Heroin Helpline, run by Release (Ref 1). who do amazing work offering advice and at getting people who have been excluded into treatment. A worker from Release rang and asked if we could offer immediate help as Imran's health had already deteriorated in the 3 weeks since losing his script. We agreed to see him that day. He arrived a few hours later looking unkempt, frightened and depressed. After an assessment, urine screening and examination he left with a prescription, a smile on his face and an appointment for the next day.
The new Clinical Guidelines on Drug Misuse and Dependence (Ref 2). which have just been issued state very clearly that "A decision to temporarily or permanently exclude a patient from a drug treatment service or provide coerced detoxification should not be taken lightly. Such a course of action can put the patient at an increased risk of overdose death, contracting a blood-borne virus or offending". It also goes on to state that if patients are excluded from a service they should be offered treatment at another local service. I feel Imran's service failed on both these points. I am not excusing his behaviour and he obviously needed to be talked to and boundaries set, but surely exclusion for reasonable frustration is both not acceptable and potentially dangerous to him?
In the six weeks since he has joined us he has been an exemplary patient, worked on his care-plan and can begin bidding for properties next week. So, might his behaviour be something to do with the way he has been treated?