No mission without the marginalized: the scope of family medicineBMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g1707 (Published 26 February 2014) Cite this as: BMJ 2014;348:g1707
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Dr Loxtercamp's plea for compassionate treatment of addicts is laudable, but many of the points he makes are unique to the USA and are not evidence based. The evidence base for methadone in opioid substitution therapy (ORT) is greater than for buprenorphine, but he is presumably unable to prescribe that because of US regulations restricting it to designated clinics. He is making a big mistake in time limiting his treatment with buprenorphine to two years. The evidence is overwhelming that with ORT there should be an orientation to maintenance and that any artificial time limits on treatment are only likely to lead to a rapid relapse to illicit use.
Reference. BMA Board of Science (2013). Drugs of Dependence: The Role of Medical Professionals. 8.4.4.
Competing interests: I prescribe methadone or buprenorphine to many patients. I have given many talks on opioid substitution therapy and have received travel grants and honoraria from manufactures of both.
I have to say, when I read this, I was so thankful we live in the UK which appears to be years ahead of the USA in helping people with drug and alcohol problems - if the author's experience is replicated in other parts of the country.
We have well developed treatment services from primary to community to residential care in most places. In primary care (UK general practice) we have many good shared care schemes which do exactly what David Loxterkamp wants from USA family medicine. We also have treatment for people with drug and alcohol problems firmly placed in the RCGP postgraduate curriculum.
There are increasing efforts to teach on alcohol problems in undergraduate medical courses - although I am not sure that treatment of drug problems is as keenly promoted. I would be very interested to hear of good undergraduate teaching schemes on substance misuse - particularly with regard to drug treatment.
The author describes the issues and difficulties of addicted people well and I wholeheartedly agree that we must be treating them with the same competent compassion as people with any other life threatening illness. I have more therapeutic hope though - I think borne out by our growing UK experience.
Marginalised people need our help - and we know it is often the most needy who get the worst treatment - sometimes because they don't know how to access or work the system and sometimes because we don't treat them as people who deserve help.
Even on economic grounds it is much better to spend money on treatment than not to - benefits of £3-£9 overall are quoted for every £1 spent.
So thanks, David, for your letter from America - but come over and see us sometime in the UK - you would be very welcome to see what goes on here if you haven't already. I am sure there are many things we could learn from each other.
Competing interests: I wrote the current RCGP curriculum statement on treating people with drug and alcohol problems.