SMMGP - Substance Misuse Management Good Practice

Substance Misuse Management Good Practice

Supporting good practice in drug and alcohol treatment

Post-its from Practice:
When the time is right (Aug 2011)

I called Steve in and he entered my room with an enormous grin on his face, wishing me a belated happy birthday. As he took a seat, said "I don't really have a reason to be here" and I responded that it was always wonderful to see him, especially looking so well. For a fleeting moment I remembered what he had looked like on some of the other occasions when he had sat on that same seat: agitated and paranoid after a crack binge; suffering from severe withdrawals after going cold turkey following heroin and in many, many similar states. But he was always motivated to come back to see me.

Steve then said he really had come to tell me he had done "90 meetings in 90 days" and he knew I would understand. We hugged and cheered as I shared in his delight and he went on to say how different things were now. When I asked why, Steve answered "I really did it this time". I asked him to explain.

Steve had been registered with the practice since birth and had developed a severe crack and heroin habit over the two years prior to our first meeting, which was about ten years ago. He looked dreadful, with obvious loss of weight, multiple skin lesions and he couldn't sit still. Initially, he had appeared terrified but after a while, relaxed and enquired "So you aren't going to throw me out?" when I admitted that I didn't know much about crack but was happy to learn from him. I also told him that I knew a few people who knew much more than I did! He said "I'm not ready to stop yet, I just want to go back to using when I want to rather than 'cause I have to".

He settled well on low dose buprenorphine and was beginning to feel better. We then each went on a journey of learning how crack could be used more safely and efficiently. There were many tears and also much laughter during this time. I think I did both when Steve joked that he was going to the papers to tell them that his GP had shown him how to smoke crack better!

Over the next few years, Steve stopped and started using many times, went into rehab on two occasions. Following both those occasions he remained drug free for almost a year. Each time he slipped he was so hard on himself, feeling he had failed me and his parents. But each time he came back and asked for help, and we discussed all he had learnt.

After another relapse early last year, Steve came to say he had to do it for good this time. His parents had given him an ultimatum if not: they were going to throw him out. We discussed the risk of failure if this was his sole reason for wanting to get off, but we discovered there was also another reason: he was fed-up with using. He convinced the care and assessment team to fund him again for an intensive structured day programme. He seemed to do well and we went off to his graduation, but something was missing. I suggested he came and saw me and Mel, our counselor at least once a week, as well as keeping up meetings. I was sad when he dropped this after a couple of weeks. Just four weeks later he came back and said he had relapsed on heroin, diazepam and crack but that he only needed a short buprenorphine detox and he would be alright. I enquired what would be different and he so clearly said "Because I am doing it for me". I had grown so close to Steve over the years I just knew he would do it this time.

It took Steve two weeks and the odd meeting to complete his detox. He then set himself the target of "90 meetings in 90 days". He told no-one because he knew he had to start being honest with himself first, recognizing and fully accepting the basic ideas of the fellowship, which he hadn't done before. He felt he needed to "detox" himself not only from the drugs but more importantly, from his unhealthy emotional patterns, which he really felt he was now beginning to do.

In a parallel to the fellowship invitation to "keep coming back", the best thing about Steve was that he did just that - because in general practice you never get discharged! It's been a long, winding path for Steve (and at times incredibly difficult for him) on his self-defined journey. It's been a privilege for me to support him throughout and offer him a range of different responses and encouragement over time. We have to support people until they feel they are ready to change.

- Dr Chris Ford
GP Lonsdale Medical Centre, Clinical Director for IDHDP, and a Member of the Board of SMMGP