When a lo­cal GP sud­denly finds him­self in a scene from ‘Love/Hate’

The Irish Times - Tuesday - Health - - Front Page - Pat Harold

The con­sul­ta­tion was not ex­actly one from the text­book. He stood, I sat. He shook his fist in my face and roared threats about what he would do to me if I didn’t write the pre­scrip­tion he wanted. We had a com­mu­ni­ca­tion prob­lem, in that I had no idea if he re­ally was on the un­holy mix of ben­zo­di­azepines, neu­rolep­tics and opi­ates he was claim­ing as his due. I felt a bit like a guards­man on sen­try duty. The pun­ters can yell in­sults and pull faces, but the guards­man has to re­main im­per­turbable. It is called “pro­fes­sional de­tach­ment” when you are quak­ing in­side and as­sum­ing an ex­pres­sion of be­nign in­ter­est on the out­side.

He had been “as­signed” to me. I learned this in the way your GP al­ways learns these things, by let­ter, about the time he had been dis­charged from jail. Ei­ther his med­i­cal card had ex­pired when he was in pri­son, or his pre­vi­ous GP had de­cided not to have any­thing more to do with him. If the re­la­tion­ship be­tween a doc­tor and the pa­tient has ir­re­deemably bro­ken down, a GP can ask they be as­signed to an­other doc­tor. It is known as “putting them off your list”. The old doc­tors took pride in never do­ing this as they felt it was giv­ing up on their pa­tients and un­fair to their neigh­bour­ing GPs, but this was be­fore it be­came pos­si­ble to score any drug you can think of in ev­ery town and vil­lage in Ire­land.

Like the Olympics and the Tour de France, drugs have changed the game. Some con­sul­ta­tions could be a bit fraught, but you were un­likely to get as­saulted or killed. Now, even the most ru­ral of prac­tices have their ad­dicts, and pre­scrip­tion med­i­ca­tions are se­ri­ously and reg­u­larly abused by young drug tak­ers. I have been as­signed pa­tients who were deemed too dan­ger­ous to be seen by the lo­cal psy­chi­atric ser­vice (who have a whole team to back them up) and are made go to the hospi­tal in the city where they have pro­fes­sional se­cu­rity. Yet, I was ex­pected to see them on my own.

This un­ortho­dox con­sul­ta­tion took place on a Fri­day evening, when it was im­pos­si­ble to check out the facts. He said he needed his med­i­ca­tion, and pro­duced a hand-writ­ten and mis­spelled list. The pills had many in­di­ca­tions and they all had a street value. This was my dilemma. If he re­ally was on these drugs, and if he stopped them sud­denly he could have gone into con­vul­sions. You have to be hu­mane about it too, if the poor fel­low was that ad­dicted. It can be hard to be firm and kind-hearted at once, but you do not want to act like a drug dealer ei­ther.

But was there any clin­i­cal in­di­ca­tion to pre­scribe these drugs? Was he mak­ing it up? He could swap the tablets, or sell them. What if he over­dosed? You would not want to mix them with street drugs. I could imag­ine his griev­ing fam­ily com­ing to me for an­swers.

Abuse from the pub­lic

Lots of peo­ple face abuse from the pub­lic – po­lice, bounc­ers, bar-staff, nurses and teach­ers, and we all have a lot in com­mon. But GPs are in the unique po­si­tion they can pre­scribe a large quan­tity of highly valu­able and ad­dic­tive drugs. We are of­ten on our own in an of­fice, with­out any back-up. We are also emo­tion­ally wide open. It is part of our job to be sen­si­tive to nu­ance, to pick up on cues, to ask the per­ti­nent ques­tion. We put chil­dren at their ease and chat with lonely old peo­ple about sport as we won­der how to ex­plain their wors­en­ing blood re­sults. So when we sud­denly find our­selves in a scene from Love Hate, it can be dev­as­tat­ing.

The ad­dic­tion ser­vices are patchy and un­der­funded, with long wait­ing lists, and there is scant re­spect for those with the dual di­ag­no­sis of psy­chi­atric ill­ness and ad­dic­tion. There is no mul­ti­dis­ci­plinary ap­proach and GPs are ex­pected to man­age these un­for­tu­nate peo­ple’s com­plex prob­lems. In many other coun­tries, there is a com­mon data­base where GPs, hos­pi­tals and phar­ma­cists have com­monly held in­for­ma­tion, so they know ex­actly what med­i­ca­tion peo­ple are on, and why, at all times, which would be very help­ful. We do our best to do what is right for ad­dicts. We are will­ing to see them reg­u­larly, to sta­bilise them, to help them re­duce their doses and get their lives on track. No­body minds that, and it can be won­der­ful to be part of some­body’s jour­ney to re­cov­ery.

Scenes like the one I de­scribe do hap­pen. So if your GP seems dis­tracted, if their voice or hand shakes, they might have had a fright, and are ex­pected to get on with it.

when we sud­denly find our­selves in a scene from ‘Love Hate’ it can be dev­as­tat­ing

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