A woman in her fifties comes to request more diazepam for long-standing anxiety. As you start discussing the possible need to reduce or stop this treatment she becomes quite abrupt, then bursts into tears and admits that she sells the medication on the street to help her son with his drug problem. What do you do?
- DR VIBHORE PRASAD'S VIEW
The patient comes first. Here is your chance to enhance the patient-doctor relationship. Feel privileged that she opened up to you. The last thing you want is for her to regret this action. Explore her ideas, concerns and expectations. Ask what she would do in your situation. This is her chance to handle her own problem.
There may be phone numbers you can give her for support agencies. If her son is young, there may be youth counselling services available that she can tell him about. You could offer her a joint appointment to enable her to confront their problem in a safer environment, with you as a mediator.
Do not inadvertently collude with her problem by simply prescribing her with more medication. If she is selling it on the street she might be putting others' lives at risk. Share this concern with her. As a doctor you have a responsibility not to harm the local population by supplying the illegal drugs market.
You do not necessarily have to wave your magic wand and fix everything in that particular consultation. With the patient's consent and hopefully in conjunction with her, you can link her and her son to other networks to help her out of the situation.
- Dr Prasad is a GP registrar in Banbury, Oxfordshire
- DR TILLMAN JACOBI'S VIEW
The patient's admission is significant and has a number of implications.
As you are now aware of where the diazepam is going, further prescribing is impossible for obvious reasons. You would have reasons enough to justify removing her from your list, but who would really benefit from this radical step?
It is probably unwise to blame or threaten her in any specific way at this point as she is, hopefully, well aware of the act of deception. However, this situation will require follow-up at some point. This incident will need to be added to her notes to be considered for future prescriptions of medicines with potential for misuse. You may consider cross-referencing this entry to records of other members of the household.
Apart from this, the woman herself and the family will need some sort of support - simply taking options away will damage the relationship.
Only by taking a step-wise approach will you be able to understand the issues faced by this family and what could be done about the addiction.
The case should either be discussed in a 'significant event' meeting, or, less formally, actively communicated with all prescribing members of the practice.
- Dr Jacobi is a salaried GP in York. He qualified as a GP in February 2005
- DR DAVID CHURCH'S VIEW
I would ask myself the following questions. Does the patient sell all of the diazepam, or does she take some of it herself to reduce her own anxiety levels? Is she likely to be at risk from her son - or from a third party - if she does not have an adequate drug supply? Could she be taking any other drugs and is she aware of the consequences if caught by the police? Alternatively, has she been hoping to be found out so that she has an excuse to cease supplying and help her son.
A joint consultation with her son could be suggested. Benzodiazepine reduction in all patients, not just young multi-drug users, needs to be handled effectively by the local addiction team.
You could advise her to approach the police, together with her son, because doing so could offer them protection from a third party, as well as assistance with harm-reduction programmes and in obtaining the services of specialist drug agencies.
I would consider issuing a scrip for a small supply for personal use, to be repeated on a daily or weekly basis so that I can be happy that I am not effectively contributing to the black market.
I would explain to her that what she has been doing is wrong and that there are much better ways of helping her and her son.
Generally, I would be cautious when prescribing items that might be finding their way on to the street market because they might be dangerous and be taken by someone for whom they are not intended.
- Dr Church is a GP in Machynlleth, Powys, Wales
What to do
Benzodiazepine reduction in all patients, not just in young multi-drug users, needs to be handled effectively by the local addiction team.
Be cautious when prescribing items that might be finding their way on to the street market because they may be dangerous and be taken by someone for whom they are not intended.
As a doctor you have a responsibility not to harm the local population by supplying the illegal drugs market.
Enhance the patient-doctor relationship by exploring the patient's ideas, concerns and expectations.
Discuss difficult cases with your colleagues in a 'significant event' meeting, and in cases where drug addiction is involved, inform all prescribing members of staff.
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