Practice What Your Patient is Thinking

If you only have a few minutes with a drug addict

BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h4211 (Published 23 September 2015) Cite this as: BMJ 2015;351:h4211
  1. S D Williams

S D Williams is currently completing a therapeutic recovery programme in the Ley Community (www.leycommunity.co.uk), a drug and alcohol rehabilitation centre. He draws on his personal experience to help doctors find ways to work with people like him

I was going through a particularly bad time some years ago when I went to my general practitioner to try and get a prescription for diazepam (Valium). I had been buying it illicitly for some time so knew that I had a problem and genuinely wanted help. I also knew that most GPs were reluctant to prescribe this type of drug because it is so open to misuse.

I had a pre-prepared script ready to use that I hoped would come across as sincere. This dialogue was the result of much trial and error in trying to obtain prescriptions and the trading of information between myself and other drug users about which doctors would prescribe and what had been successful in the past.

I began by telling the doctor how I’d been depressed and started using tablets off the internet or the street and telling her that I could no longer cope. While I was in mid flow she asked: “How’s your mum these days? How’s your family? Is there anyone else who can support you at the moment?”

I was not expecting this line of questioning and it threw me; I found myself being honest with a doctor for the first time in a long while.

I have had a lot of experience with GPs because I have spent most of my adult life (more than two decades) in opiate addiction. The GPs I came across fell into one of three broad categories. The first type judged me by my addiction and straight away presumed that my motives were nefarious and my sole intention was to exhort as many drugs as possible from them. (I don’t deny that in many instances this was true.)

The second kind made the same judgments but tried to get me out of their surgery as soon as possible by prescribing whatever I asked for with little or no preamble or questioning.

The third type didn’t judge me and asked pertinent questions about how I felt psychologically as well as physically, listening to what I had to say. They then made a professional diagnosis and prescribed what would cause the least harm, both short term and long term, and would ease my emotional suffering most effectively.

At the time I knew I looked like the stereotype of a drug addict and it was often difficult to walk into a GP’s surgery. I felt self conscious about the way I looked and my past experiences with doctors also dictated how I felt.

I realise that doctors have to be aware of patients’ motives in coming to see them, especially those who ask for specific drugs, but this needs to be offset by what is best at that time for that particular patient.

For example, I had a longstanding problem with benzodiazepines, mainly diazepam, and more than once asked for help to become stable and then reduce my intake. My GP at the time was reluctant to do this, but through a prolonged conversation where we discussed my needs and my hopes, and also what responsibilities I had to myself and my own recovery, we came to a compromise. This doctor’s questions about what I hoped to achieve were a lot less formal than usual—questions such as what I would like for my future, what my job aspirations were, and whether I saw myself with a partner or having more children. This allowed me to let down my guard and answer his questions truthfully. The more it felt like a conversation the harder it was to keep up any pretence.

Although that surgery had a general policy against using benzodiazepines, he was able to use his discretion to come up with a solution that ultimately benefited me enormously: he agreed to prescribe a short maintenance course until I became stable and then to oversee a reduction in my dose. At first I was put on a daily pick-up (coming back each day for a small prescription) to ensure I didn’t misuse the tablets. It was made clear that if I didn’t behave responsibly towards my prescription I would lose it. This covered the doctor while also giving me some autonomy in my recovery.

I understand that GPs are under pressure and have time constraints that make it difficult to get a full picture of a situation in a 10 or 15 minute consultation, but it can make all the difference to someone in addiction just to be treated as a human being and an individual. Being asked to come back for return visits to the doctor, to talk about my progress, and to consider what action to take next also helped me feel like the doctor was really interested in giving me the best help that he could.

The bottom line

  • Not all drug users are the same—they are all individuals with individual needs. Ask what their hopes and plans are for the future and how they see their own responsibility for their recovery; listen without judging

  • Don’t dismiss patients who ask for a specific drug out of hand. If they seem to have a prepared dialogue ask some questions that they might not be expecting—ones that will test their sincerity, such as questions about their family and how they are emotionally

  • Whenever possible try to give the patient some autonomy and responsibility. I found that I responded better when I had a modicum of control over the direction my treatment was taking. I also found it beneficial to know exactly where the boundaries were, such as when I was told that my prescription was my responsibility and that if I lost it I would not get a replacement

Notes

Cite this as: BMJ 2015;351:h4211

Footnotes

  • Competing interests: I have read and understood BMJ policy on declaration of interests and declare the following interests: none.

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