A brief outline of the case and history
This patient is a 39-year-old man who returned to live in Australia after two years living in Ireland. He returned after the relationship with his partner broke up. His partner and their then four-year-old daughter remained in Ireland. He is unemployed and last held down regular employment as a hospital porter several years ago. He lives alone in rented accommodation but has family living nearby who are socially, emotionally and financially supportive. A family member often accompanies him when he attends our medical centre.
His current medical problems include:
- Chronic drug addiction (Benzodiazepines regularly and frequent use of cannabis)
- Chronic alcohol dependence
- Depression, anxiety and post-traumatic stress disorder (related to previous experience in the armed forces) - currently under specialist management with a consultant psychiatrist
- Obesity
- Asthma with frequent exacerbations
- Psoriasis
His past relevant medical problems include:
- Previous seizure induced by alcohol withdrawal resulting in head trauma with subdural haemorrhage
- Previous episode of alcoholic pancreatitis
His current social problems include:
- Social isolation
- Unemployment
- Unwanted separation from his daughter
- Previous history of doctor/prescription shopping
Personal reflections on the case
When I first met this patient, it was difficult to form a therapeutic relationship with him, partly because of his demands for prescriptions which could easily lead to confrontation. However, over the last couple of years, we have got to know each other better and a level of trust has developed. He attends frequently and prefers to see me rather than one of the other doctors in the practice.
One of the particular challenges for me has been the level to which I am willing to acquiesce to his requests for medication to help maintain the relationship. This has required delicate but firm handling to avoid any degree of collusion. We ultimately came to an agreement that has formed a kind of unwritten contract between us in that I will supply prescriptions according to the agreed plan (also known to his consultant psychiatrist) and in return for this I make sure that he has access to me personally unless I am away from the practice. Another challenge has been to remain patient and to be grateful for small improvements. Nevertheless, we have made some progress.
Since his last admission to a private hospital for detoxification nine months ago he has not touched any alcohol. His mental state has improved markedly with less depression, lower anxiety levels and better relationships with his immediate family who remain extraordinarily supportive. He recently applied for work as a delivery driver and has undertaken some voluntary work at the local day centre but has yet to secure regular employment. He no longer shops around for doctors willing to prescribe for him.
I have had to learn a lot about the management of drug addiction and alcohol dependence while managing this patient. I have also learnt a lot about myself, not least the tendency to make hasty judgements when first meeting patients based on insufficient information. Although his behaviour can be challenging, he has also had considerable adverse life experiences that resulted in a downward spiral and but for the help he continues to receive from his family, the outcome could easily have been a lot worse.
We have also had to learn and adapt as a practice. Some of my partners still find him a little intimidating and some tend to make him feel as if he is being “told off” if he attends for a prescription. One of the issues is that he finds any disruption to his routine destabilising and this manifests itself in behaviours that are easily interpreted as aggression.
We have therefore devised an agreed plan between us such that if I am not going to be available, I try to notify him in advance so that there are no surprises. We have also agreed that if I am unexpectedly unavailable, he will be seen by one of two other doctors who know the case well enough and are willing to provide his agreed supply of medication, but no more.
One of the other key learning points for me has been the benefit of thorough record keeping, especially when detailing prescription plans. Also, it has been very helpful to make sure everyone dealing with this patient knows the plan, including a nominated pharmacist. This has been time-consuming to set up but has saved a lot of problems in the long run.
Finally, I have reflected that this patient has been extremely fortunate to have such a supportive family. Without their help, he would not have been able to be admitted to a private hospital for his alcohol detoxification and he would not have received such good care through the public system, particularly in terms of access to inpatient and outpatient specialist treatment. Although our health care system has many strengths, equality of access based on clinical need rather than the ability to pay sadly remains some way off.