Navigating drug and alcohol rehabilitation in general practice

Amanda Lyons

4/06/2019 3:55:52 PM

Australia is home to hundreds of rehabilitation services, both privately and publicly funded. How can GPs best support patients on what can be a life-long journey?

Claiming freedom
Rehabilitation services have their place, but should not be regarded as the whole solution to substance-use disorder, an expert says.

‘Are you battling with addiction? Don’t settle for this – we can help you.’
This text is from a pamphlet advertising free help for people experiencing drug addiction. The organisation is just one of the widely varied rehabilitation services offered throughout the country.
Australia is home to almost 1000 publicly funded services, plus hundreds more private facilities, in a space that is lacking in overarching regulation.
This situation makes rehabilitation services difficult to navigate for GPs – let alone patients.
‘Drug and alcohol NGOs [non-governmental organisations] have different funding models, models of care, ways people can get admitted, treatment plans,’ Dr Hester Wilson, Chair of the RACGP Specific Interests Addiction Medicine network, told newsGP.
‘And then we have the public system and, depending on which particular area you’re in, there will be different models.
‘So as a GP it can be really confusing to work out and know what’s appropriate for your patient. There’s lots of complexity.’
Limited availability of public services, combined with a lack of oversight of the private rehabilitation sector, has led to concerns around exploitation of vulnerable people by unscrupulous providers charging high fees – up to $50,000, in some cases – with no guarantee of effective results.
‘Families are in a desperate situation to get their loved one help and because they often have to resort to the privately funded provider, they’re almost forced to pay whatever they’re asking,’ Victoria’s Health Complaints Commissioner, Karen Cusack, told The Age.
‘It is an area of concern.’
Ms Cusack has launched an investigation in Victoria in an attempt weed out some of the more problematic rehabilitation services.
But there are also many quality providers in the sector and Dr Wilson believes that, chosen correctly, these services play a valuable role in treatment for substance-use disorder.

However, Dr Wilson cautions against people – doctors and patients – viewing rehab services as a magic bullet that will put an end to struggles with substance misuse. Rather, people should look at them as the beginning of a life-long process.
‘People think, “I’ll detox and then I’ll be okay”. You might successfully stop in detox, but what happens then?’ Dr Wilson said.
‘And then it’s, “I’ll go into rehab and that will fix everything”. But rehab doesn’t cure, detox doesn’t cure – it’s a long process back to doing things differently.’
‘Rehab gives you the space to actually continue behaviour change. It means you have a bit of a break from your everyday life, you can perhaps learn some skills,’ she said.

Dr Hester Wilson believes GPs should be better remunerated for helping patients with substance use disorder.
There is generally very little engagement between detox and rehabilitation services and general practice. For example, GPs are not notified if a patient enters or exits these services. But the chronic nature of substance-use disorder is exactly why Dr Wilson believes GPs should have a greater role in its treatment and rehabilitation.
‘You’re setting up a relationship with the ongoing care of that person, and that’s one of the brilliant things for us as GPs, that we have this relationship with our patients where we see people over many years and are integral to their wellbeing,’ she said.
‘Cutting us out of the picture in the first place means it’s siloed, it’s isolated, and it doesn’t actually assist the person to access the care and to continue their recovery journey after they leave the service.
‘People can be quite successful at not doing the behaviours they wanted to change while they’re in rehab. But when they come out, they go back to their communities, they go back to their lives. So, quite often, they will then relapse.
‘A really important area for us as GPs is thinking, with the patient who’s been to detox, who’s done some rehab – what happens when they come home? What role can we play in supporting that type of care?’
Dr Wilson believes substance-use disorder is a chronic condition that, like any other, requires constant management.
‘It is a life-long journey around managing that condition – a bit like someone with asthma, someone with diabetes. It doesn’t go away,’ she said.
‘You’ve got to be vigilant, you’ve got to know where your areas of risk are, so that you continue to manage it and remain as well as you can be.
‘And that’s what recovery is.’
However, Dr Wilson acknowledges a significant problem GPs face in this area – a lack of funding and appreciation for what can be very time-consuming work.
‘The reality is, if someone is that unwell with substance-use disorder that they’re looking at detox and rehab, they’re going to be a complex patient and they’re going to take a lot of time. And we’re not remunerated to do that,’ she said.
‘The way that the system is set up, many of us make the choice, because we want to give the best possible care for our patients, to actually earn less to do that.
‘If you’re not remunerated, it means that that is not that valued, in one way.’
In spite of such difficulties, Dr Wilson has found that helping patients with substance use disorder navigate their treatment options and manage their condition to be worth the effort.
‘Part of the challenge, for us as GPs, is knowing that this is a long-term proposal, and the gains may be small in the short-term,’ she said. ‘But if we can have that long-term therapeutic relationship where we know that this is a chronic illness, there can be change and there can be really good outcomes.’

addiction detox rehabilitation substance-use disorder

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Dr Dave Jones   5/06/2019 9:42:30 PM

I am currently looking after a patient aged 24 who has probably one of the most upsetting and dressing stories for a young person - essentially beaten, abused, utterly neglected by drug using parents as a young child. Raped at 12, administered heroin by a dealer for free at 13 and developed a habit ever since. Massive MH difficulties particularly deep depression and several unsuccessful suicide attempts (unsuccessful by pure luck each time: this person had made detailed plans there was literally nothing left.

I got her into Salvos rehab and subsequently a 6/12 stay in a rehab centre. My problem now, is the utterly appalling lack of MH resources via medicare - begging for an hour psychiatry on a 291. This patient needs regular FU/review, probably ECT, ongoing longterm drug support and social support but I might as well p**s into the wind for all the ACTUAL help I get.