Saturday, 19 March 2011

Drugs

I've been seeing a patient for some time, withdrawing their benzodiazepines with them. Mentally well all his life, the patient had felt anxious and when he retired, then widowed, had declined talking therapies and sought medication to help. His GP is a sensible soul but over time and by accident and through locums whilst on holiday ended up with a patient being prescribed and taking very hefty doses of two benzodiazepines and wanting more.

The drugs weren't working any more. On mornings and after coming down off the drugs' peak effects, he was restless and irritable and more anxious. He'd started falling. Alcohol intake was modest (a couple glasses of wine a week) with normal liver function.

I had never seen the patient before being involved this time. I had not started the benzodiazepines. Our PCT has commissioned neither drug and alcohol services nor my corner to manage iatrogenic addiction (ie the doctor caused it), feeling if one doctor's caused dependence through their prescribing, they need to sort it out. I'm no expert at substance misuse at all. The patient had no wish to see me to reduce benzodiazepines, quite the opposite, he wanted more.

I've massive sympathy for the patient and for the GP. Both were trying to do their best at the original point in time, managing the few poor choices they felt were laid out before them. The GP wrote an excellent detailed helpful referral letter to me, asking if I could sort it all out. She's a good GP. She's helpful. We both collude in working to do what's best for her patients despite the local policies and care pathways and frameworks and shared care arrangements; she's sensible in ignorning most of the bureaucracy and instead we just crack on with what's best. I might prescribe when it should sit within her budget. She might prescribe when it hasn't been the exact blah months needed for a shared care to start. She's a good clinician and she works hard, very hard, to support her patients as best she can.

When she wrote saying she'd messed up and got herself into a tricky position, she knew I wasn't a drug and alcohol expert, but she felt stuck and uneasy, well as said within Jerry Maguire she had me at "hello" and I couldn't leave her to flounder.

The patient loves his GP, thinks his GP is ace. I've been involved for many months and soon will be discharging the patient, benzodiazepine free. The patient suffers my visits and has a less than favourable view of what I've done. He understands why, but it's not what he wanted. But as he 'fesses up, he was addicted. I won't need to see him again, hopefully. His GP hopefully will be seeing him for many years.

Even if it's not my mess, not my work, not my problem, sometimes it's better for the GP to be the good guy and me to be the bad guy.

I wonder if the new NHS commissioning and structures will facilitate helpful working arrangement . . .

6 comments:

E said...

A bit off topic but does any one know what has happened to "mental nurse" the site appears to have been hijacked either that or Zarathustra has sold out and is at this moment lying on a Caribbean beach having oil massaged into his shoulders by someone young enough to be his daughter, lucky bugger.

Zarathustra said...

The former, sadly. It got hijacked.

:(

Shrinky, gimme an e-mail on zarathustra at hush dot com

E said...

Hope you mange to get things back on line soon.

The Shrink said...

Done!

E said...

done?

The Shrink said...

Done, emailed Zarathusta as he asked . . . it's so hard to say no to him :P