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Pain, but nogain
Proactively monitoring repeat prescriptions can
save a patient from addiction to their medication,
says
Dr Steve Brinksman
Enterprise corner |
Post-its
April 2013 |
drinkanddrugsnews
| 15
www.drinkanddrugsnews.com
A FEWWEEKS AGO
I was handed a prescription
request for a man in his late 30s asking for
soluble tramadol to be put on his record as a
repeat prescription for back pain. Looking at his
notes, I saw he had three previous prescriptions
for this medication since joining our practice at
the end of last year. I decided to see Tom before
making this a repeat and asked the receptionist
to pass the message on to him that he needed
to arrange an appointment.
The next day I was the on-call doctor and
there was an urgent slot booked to request I
call this patient, as he had told the receptionist that he quite simply must
have the tablets as he was addicted to them. I made the requested call and
spoke to Tom and arranged for him to have enough tablets to last him until
he could get to an appointment with me.
Three years earlier he had injured his back at work and been given
tramadol by his GP. He told me that after a few days of nausea he had
started to look forward to each dose and felt less stressed after taking them.
He had gone back to work after a week but, having tablets left over from the
initial consultation, he had used these after a stressful day at work. Before
too long he had been back to the GP complaining of a recurrence of his back
pain, which led to a further prescription. By now he was using the tablets
every day and his usage went up even more after he lost his job.
Towards the end of last year he had seen a new GP who had challenged
him about his medication use and that had triggered him to change
practices, so he had registered with us. However, something about being
challenged by the previous doctor had struck a chord with him and by the
time I saw him, having accepted that he had a problem, he was open to the
idea of trying to change.
We discussed the available options and he decided to start an
incremental reduction in his daily dose, with regular reviews. We also
discussed a switch to buprenorphine and then withdrawing from that, so we
had a ‘plan B’ as well. He readily accepted a referral to our local IAPT
[improving access to psychological therapies] service and although at present
he doesn’t feel he wants to engage with a mutual aid group, we have raised
this as a possibility too.
Addiction to medicines is increasingly being recognised as a growing
problem and while it may be more obvious in the case of those who are also
using illicit drugs or repeat benzodiazepines, there are a lot of patients who
move almost imperceptibly from mild to moderate to strong prescribed
opioids. Our practice has now brought in a system whereby any patient who
is about to have strong opioid analgesia added as a repeat should be
discussed with a colleague and this documented so we can audit the
concordance.
Most patients don’t present – as Tom did – with the words ‘I’m addicted
to them’ on their appointment note, but as these are prescription-only
medicines, there are opportunities to ask questions and monitor usage. It is
important that practices develop consistent policies to address this.
Steve Brinksman is a GP in Birmingham and clinical lead of SMMGP.
www.smmgp.org.uk. He is also the RCGP regional lead in substance misuse
for the West Midlands
ENTERPRISE CORNER
AT STRATEGIC POINTS IN THE YEAR
I find it
important to reflect. At base camp, we are
striving for a vision of using entrepreneurship to
create an inclusive society that doesn’t hold
people back from becoming successful.
As the accountability of interventions
becomes ever more confusing, it’s important to
remember that our responsibility to transform
society hasn’t. This may sound ‘fluffy’, but it
really isn’t.
Statistics on the number of drug-related
offences demonstrate that we certainly have
some work to do. But at TSBC we view this as a massive opportunity to
transform the drug-offending population by helping them to transfer
existing negative enterprise skills into contributory ones that work
towards the growth of local economies and small businesses. These will
be hiring people, young and adult, not to run their drug rings but to help
with food preparation, social media, marketing and administration. We
know we have a lot to do and we need to think of new, more collaborative,
integrated, innovative and effective ways of doing this.
You may have seen our new Local Enterprise and Employability Service
(LEES), which is running from the heart of the CRI building in Barking,
featured on the BBC news last month. There, our ‘business experienced’
local enterprise and employability workers assess service users and work
alongside their key workers, police, social workers and the job centre to
ensure a planned exit from treatment which is coordinated and stakeholder-
led. They also help service users by matching them with jobs through our
job board and brokerage service, ‘Breaking the Cycle’. Service users are paid
subsistence and travel expenses and get their first exposure to the work
environment. At the same time, those wanting to set up their own micro-
enterprises and/or social enterprises work with our entrepreneur trainers in
an academy-style programme, usually outside of the treatment
environment, to create their own jobs. For TSBC, this is the future of
delivering a wraparound service in an innovative, integrated and informed
way.
Should we worry then, that the ringfence is coming off the London
Mayor’s MOPAC budget for substance misuse, which contributed 13 per cent
of the budget for substance misuse for London? Authorities in the capital are,
and will continue to, scramble with resources amid cuts and restructuring,
rehousing their services within a myriad of directorates from social care,
community safety and health.
What we have the power to do is to shape, transform, design and deliver
collaborative and innovative services which can continue to deliver even
more for less. We have managed to reduce the investment required per
service user to participate on our programme by 45 per cent, with a third of
that being paid on results (PbR). We call it the retributive rehabilitation
revolution and it is delivered through innovation, enterprise and
collaboration.
To view the BBC news clip you can visit our website, www.tsbccic.org.uk/press.
To get more information about TSBC, our work and new services, please email Sue
Rathe sue@tsbccic.org.uk or call 0203 651 3112.
Amar Lodhia is chief executive of The Small Business Consultancy CIC (TSBC)
EMPLOYMENT
REVOLUTION
Turning negatives into positives is the challenge
ahead, says
Amar Lodhia
POST-ITS FROM PRACTICE