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At the heart of general practice since 1960

'Drug misuser' about to sit HGV driving test

Three GPs share their approach to a practice conundrum

Case history

Katie and her two pre-school children, aged two and four, are frequent attenders at your surgery. You have been treating her for postnatal depression and she is currently on

an SSRI. Unfortunately she seems to be

getting worse.

When you see her in surgery today she mentions that her husband, Paul, is spending £60 a week on cannabis and has recently started taking amphetamines. Paul is a 32-year-old labourer who has taken and failed his

HGV driving test twice. He is due to re-sit the exam next month.

What would you do with this information?

Dr Mark Wallace

'If Paul fails to attend I'd have no choice but to contact the DVLA'

This scenario raises a multitude of questions. Is Katie telling the truth? If so, how do I broach the subject with Paul? If Paul admits to drug misuse is he also abusing alcohol and will he accept help to stop? Will he stop driving if I tell him to, because it's illegal until he's been abstinent for at least six months?

He isn't eligible to re-sit his HGV medical until he's been abstinent for 12 months, which will seriously scupper his future job plans and the family's income. Finally, is there more going on at home than Katie has disclosed, such as domestic violence when Paul is under the influence of drugs, or serious debt?

Where do I start? First, I'd want to establish that Katie is sure about the drug misuse. I would then ask her to urge Paul to see me so I can corroborate this directly and explain the DVLA's guidelines.

If Katie feels unable to persuade Paul to see me I could explore the sensitive issue of mental and physical abuse at home, and the future of their relationship. I'd have to ask Katie if she'd give me permission to contact Paul directly and explain what she has told me.

If she rejects this option I am left with two choices. If Paul has already booked a surgery appointment for the next couple of weeks I'd ensure that whoever he consults raises the issue. If not, I'd ask his usual doctor to invite him to the surgery on another pretext, such as a well-man check.

If we are unable to extract a direct disclosure, we might have to resort to a covert urine drug screen under the guise of a health check. I'd discuss this with my medical defence society first.

If he fails to attend and Katie is adamant about his drug misuse then I'd have no choice but to contact the DVLA, initially keeping the patient's name confidential.

This case makes me wonder how many people out there are driving under the influence of alcohol and drugs. No wonder there are so many road traffic accidents.

Mark Wallace completed the VTS in 1995 and is a GP principal in Kidlington, Oxfordshire

Dr Harry Brown

'Because of the children, I would involve the health visitor'

I would start by asking Katie what impact her husband's drug-taking is having on her and the family. Could she have something more than postnatal depression? After all, her youngest child is two years old. Does Katie take drugs too?

As Paul isn't here, there's little I can do about his alleged problems now, but I would like to talk to him. I would ask Katie if she would mind me contacting Paul about his drug habit. If she is happy with this, and if Paul attends, I would ask him about his general health, including alcohol and drug intake. I would also ask him if he knows why he failed his HGV exams.

If Katie doesn't want me to broach the subject directly with Paul I will have to respect her wishes. But I could ask her to bring him along to discuss her postnatal depression. I'd engage him in conversation and see if the drug situation comes up. If it does, I would offer to refer him to an addiction unit and other local services.

I would explain that taking illegal drugs could affect his ability to hold an HGV licence and this may be another incentive to become free of drugs. I'd also point out that the financial cost of his drug habit could be affecting his wife's mental state and their children.

Because of the potential impact on their children, I would need to involve the health visitor. She would be able to determine how the family is being affected and, importantly, whether the children are at risk physically or emotionally.

At all times I must respect everyone's confidentiality, breaching it only after taking the best advice and keeping detailed records.

Harry Brown has been a full-time GP in Leeds since finishing VTS in 1987 – he is interested in clinical pharmacology and health informatics and is a GP trainer

Dr Sarah Humphery

'Is Katie worried Paul will leave her to cope with the kids alone?'

I need to be clear of the facts before I rush in. I would want to support Katie through her depression and help with her husband's drug problem, if he has one.

If Paul is registered with the practice I'd strongly urge Katie to get him to see me. Ideally, I'd like to see them together. If this isn't possible, I would emphasise to Katie how important it is that Paul seeks help, and I would give her details of local drug support agencies.

How is their relationship? Can Katie talk to Paul about his drug problem? Does she feel he supports her with her depression? Is she worried that if he gets his HGV licence she will be left to cope with the kids on her own? Anxiety may be a significant feature along with her depression, and this may be exacerbating the situation.

Her depression is getting worse, so I would consider referring her to local psychiatry services and changing her antidepressant. I would offer extra support by involving the health visitors and social services if she wants this.

If Paul agrees to see me, I would first ask general health questions and see whether he's willing to bring up the drug issue. I would ask him how he is coping with his wife's depression and with the two toddlers. Perhaps he is struggling to cope and has turned to drugs for an escape. I'd ask about his alcohol intake too. Does he accept he has a problem and is he willing to get help?

Finally, I would ask my medical defence body for advice. Do I have a responsibility to let the DVLA know about the drug taking? What about patient confidentiality? What proof do I have that Paul is definitely taking drugs? Does the HGV exam include random urine drug testing?

Sarah Humphery is a GP retainer in north London – she completed the VTS in 1997

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