‘We don’t always have to curb our enthusiasm in general practice’

Dr Paul O’Reilly on how even the rarest wins in working with addiction and homelessness can defy GPs’ usual scepticism

The world of street-homeless, injecting drug users is not one commonly filled with bright new hopes. Having worked in it for a quarter century, I have seen countless panaceas come and go; all different formulations of the same drugs – methadone and buprenorphine – reformulated into newly patented products. They all have little apparent improvement in patient outcomes, but greatly increased price points.

So, I must admit that the licensing some years ago of Buvidal, a prolonged-release injectable version of buprenorphine (which supposedly has great advantages of stable plasma bioavailability and patient acceptability through not requiring daily attendance at a pharmacy), filled me with the righteous scepticism worthy of a cynical old GP who has seen all this before. Think Larry David with a stethoscope.

It was not until five months ago when one of mine came to see me after a spell ‘away’ that I took notice. Normally, when at liberty, this patient is estimated by the community coppers to account for 10-15% of local antisocial behaviour. If his conduct in the surgery is anything to go by, I am inclined to believe them.

What I noticed first was the hair – I had not previously noticed that he had red hair. Typically, it existed as a dark matted oily mane that stretched like a mop-head in all directions. He sat quietly and at peace with his tea and sandwich. When I called him, even his walk was different. The jerky anxious stagger of a withdrawing addict ‘on a mission’ was now a casual stroll. His voice was four or five semitones lower in pitch. And he asked me to arrange for the next dose of his Buvidal which had been started in prison and had, in his view, transformed his life.

I curbed my enthusiasm. Prison for our lot is often the great reset button of life and can indeed be lifesaving, enabling a man stuck in vicious cycle of deterioration to secure involuntarily three square meals a day, eight hours sleep a night and relatively minimal access to drugs and alcohol. People typically emerge looking six inches taller and broader – and with a burning hope that this time it will be different.

Sadly, it rarely is. Just like restarting my office desktop, the initial hope of an effective and functional life soon breaks down into the bitter reality that nothing much has changed in the system and normal service is quickly resumed. So, I smiled sweetly, made the arrangements with our local specialist drug service and forbore to remind him of the many occasions, over many years and consultations, when he had vowed never again to darken their doors.

But I was wrong. He attended his appointments. He charmed the keyworkers. He turned up for their group sessions. And he was nowhere to be found among the desperate groups of half-intoxicated half-withdrawing street folk roaming the deserted shopping centres at night. Other patients began to comment on this. After a couple of weeks, the community coppers rang up wondering what this Buvidal stuff was and whether there was some way of putting it in the water. And then a steady trickle of our other addicts began to come to us asking for the same. For a while we resisted; not out of dogma, but because in general practice every new service has implications for time, training, and risk. But vox populi, vox dei.

So, we have bent with the wind, and, after due diligence and training, we now offer this service ourselves. It is early days yet, but we now have 20 people on it. All of them are visibly improved. All of them describe it as the best treatment they have ever had for their disease. Most wonder why they didn’t do this years ago. For a GP trained to manage expectations rather than celebrate outcomes, this felt dangerously close to optimism.

But my favourite is the only one of them to have been 10 minutes late for his follow-up appointment. He apologised and explained that he had decided to use his first week of freedom in living memory to cycle to Liverpool and back and had struggled on the last leg from Rickmansworth.

I let him off with a warning. It’s what Larry David would have done.

Dr Paul O’Reilly is a GP partner in London who works for homeless people