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At the heart of general practice since 1960

GPs can throw addicts a lifeline through substitute prescribing

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I spend part of my week in the substance misuse service. It’s a very different set up to general practice: I have half an hour with every patient and I see them at least once a month, sometimes more.

I know everything about them, from family woes to pending court cases. I know about their rising rent arrears, their dirty urine samples and their clapped-out cars, and I help them make agonising decisions. I’ve seen at first hand what the dragging weight of poverty does to a person; it slowly drowns them.

I think we’re being too soft on them,’ said the medical student who was sitting in with me. She sat sour-faced and truculent in the corner and clearly thought that what I was doing was a waste of time. ‘They’re still on methadone so it means it hasn’t worked,’ she said.

For her, long-term substitute prescribing was the clear chemical marker of failure and no arguments about harm reduction would wash. She explained that patients’ benefits should be slashed if they injected and that someone, perhaps a social worker, should shout at them if they misbehaved. But then she became even more interesting. She intimated that the real reason there’s such a big drug problem in Scotland is because unlike in the Far East we don’t have the death penalty for drugs offences.

‘The death penalty in the Philippines is a deterrent,’ she said confidently, ‘which is why there are hardly any addicts there.’

I didn’t have the strength to argue. It seems that a supposedly enlightened medical student, just a year away from qualifying, would rather see a human life extinguished at the end of a taut rope than accept the shortcomings of our western medical liberalism.

I asked her if she really wanted to live in a society like the Philippines or any other society which carries the death penalty for drugs offences. I asked her if she’d be prepared to work as a prison doctor and inject the lethal cocktail into guilty veins. I asked her what she’d feel like walking into the execution chamber to pronounce life extinct, and I asked her to imagine looking at the freshly dug earth next to the prison each morning on her way to work.

I didn’t get any straight answers from her and she just asked me to sign her off as having attended a speciality clinic.

If someone is trying to swim across the green river of methadone to get to the other side, shouldn’t we lighten their load rather than weighing them down? Shouldn’t we throw them a rope rather than looking on as they’re swept away and drowned in the current?

Dr Kevin Hinkley is a GP in Aberdeen.

Readers' comments (7)

  • did you sign her off? I hate this box ticking culture. I am glad that she engaged. I do hope that she has realised that our roles are complex. I would like to see that she has reflected on her views. It is not for us to judge our views as right or wrong. I do want to see that she needs to construct a reasonable argument and then defend her point of view and change it if applicable. I am sure that she gained as a result of that experience. This is what having an education is all about. one of the most powerful lessons I learnt early on in my career was to never judge my patients.

    - anonymous salaried!

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  • thanks very interesting article and thought provoking as ever

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  • Eileen Murphy

    Very eloquent speech you gave the medical student. I would not have signed her form until she had been able to respond with an equally eloquent acceptance that she should not be allowed anywhere near a patient until she understand what a Doctor is. If a Social Work student expressed views like this, the box would not be ticked at all.

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  • Eileen Murphy

    Very eloquent speech you gave the medical student. I would not have signed her form until she had been able to respond with an equally eloquent acceptance that she should not be allowed anywhere near a patient until she understand what a Doctor is. If a Social Work student expressed views like this, the box would not be ticked at all.

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  • Eileen - are you seriously suggesting we do not sign off trainees on the basis of personally held views? Sounds rather big brother to me.

    I am completely opposed to capital punishment but there are significant numbers of doctors who are not.

    I agree with the first poster - whilst holding extreme views, at least she engaged. I would rather have a colourful conversation with someone than for a trainee to sit in a corner and say nothing.

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  • Eileen Murphy

    Shaba - arrgh, ironically I clicked the Report This Comment button by mistake on your comment (now how Big Brother is that!) My profuse apologies.
    Regarding my comment, I considered that if the medical student needed evidence that she had attended a speciality clinic, that would have been for her "education" would it not? One day she will be responsible for the treatment of an addict and given her views, the patient may not receive unbiased and non-judgemental care so for that reason I would hesitate to sign her off. Equally if a police cadet expressed racial or homophobic views, given the power he will have at a later stage - I wouldn't tick his box either. Views are one thing but views backed up with real power are everyone's business.

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  • Opinions usually change when someones family or close friends are affected by addiction - or even themselves. There is no "us and them" - "we" are all potentially "them" so there is no room for looking down on people. Thats even before we look at the evidence that treatment helps and is very cost effective!

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