Post-its from Practice:
Family matters (Jun 2013)
I have just returned form the RCGP/SMMGP annual substance misuse conference, which this year was held in Birmingham. The theme of the conference was "Joining the Dots" encouraging us to look at the wider picture and consider the impact of substance use on more than the individual. I was asked to talk about the role of families, their role and impact (positive and negative) on someone who uses substances problematically but also the effects that their addiction can have on their family.
If you have read this column before you will know that I am a passionate advocate of the role that Primary Care can play in working with those using drugs and alcohol and a key part of this is the continuity that helps build a relationship with a patient, sometimes over many years. Despite this I can be a bit slow on the uptake at times! I had been seeing John for about 3 years for his heroin and crack use, he was fairly chaotic, injecting and funding his use through acquisitive crime and borrowing money from family. His engagement with treatment at that time would best be described as tangential and he was a frequent non-attender. After a couple of consecutive failures to keep appointments I found out from our Shared Care worker that he had been sentenced to 18 months in prison for drugs related offences.
Over the same period I had been seeing Linda, a 40-year-old woman who had significant anxiety and depression. I had started her on citalopram - an SSRI antidepressant - referred her to our primary care based counsellor and she had had a couple of short courses of diazepam over the last few years when she had presented "at the end of my tether".
It was only when I saw her one day and she seemed much more relaxed than usual, and she told me that she felt much calmer as her son had been sent to prison for 18 months and that she felt this would give her the chance to try and sort herself out, that the penny dropped. She was John's mother and although they shared the same (albeit relatively common surname) I had not made the connection as they were registered at different addresses and I hadn't thought to ask her if her anxiety related to the caring for someone with substance misuse problems.
I had made a common mistake of focussing on Linda's symptoms and not exploring the wider context of things happening in her life by direct questioning. Instead I assumed I would be told all the issues by the patient. Linda felt stigmatised because her son was someone who uses drugs, she had lost friends, and she expected us to treat her as if she wasn't worthy too because of this and so didn't volunteer the information.
The time John spent in prison did help him to make some progress and he did engage with treatment services, over the 5 years since he was released he has been more compliant with medication and keeps his appointments [usually!] but he does still use a couple of times a week, however Linda feels she has the ability to cope with the situation and no longer blames herself for all of his problems. Interestingly as John has had more appointments, she has had less. As for me I hope I try and look at a wider picture when seeing those patients presenting with anxiety and depression even if this means sometimes asking difficult questions.