The sensation of reward drives everything that higher forms of life do, and human ingenuity has created all manner of artificial ways to exploit reward mechanisms, from over eating to indolence, from risk taking to sex addiction, and most notably by directly exploiting reward pathways by putting drugs straight into them.
These unnatural behaviours almost universally come at a price in terms of morbidity and mortality, the very business of healthcare, and yet traditional undergraduate medical education pays very little attention to them, particularly to illicit drug use and misuse. Perhaps it is because of the paradox that medical care and doctors in particular are caught up in: the currency of healthcare is drugs – they are ubiquitous in the administration of relief from symptoms and disease processes. But drug administration is subject to perverse and arbitrary legislation, many legal drugs are far more harmful than illegal drugs, many drug users are far more knowledgeable in their use than medical practitioners. The worry is that it is easier somehow just to ignore it all.
But ignore it we can not. Illicit drug use and misuse is everywhere, and its consequences are seen by doctors on a daily basis. Doctors need to be equipped with the intelligence and the skills to respond to the challenges that arise, both in terms of the medical and disease challenges, and the challenges to their own innate prejudices.
Drug use is not a ‘fringe’ subject
Recent statistics show that more than 24% of the population use illicit drugs at some time or another; this use will result in a whole range of health consequences that doctors will be required to address either directly or indirectly. Yet the recent BMA Board of Science report notes with concern that in medical schools drug use is often taught within psychiatry or public health, with the result that it is often seen by students as ‘a specialised or peripheral subject’. Drug use is not a ‘fringe’ subject but one that directly relates to the delivery of healthcare and as such it merits sound basic training at undergraduate level.
Certificate in Substance Misuse
Some successful education schemes for qualified practitioners are already in place. The RCGP has been championing excellent education to generalists over the past 15 years. Nearly 10,000 GPs have undertaken the Certificate in Substance Misuse Part 1 and a new certificate is now being rolled out to manage alcohol problems. In my role as medical director for Turning Point and as an RCGP regional drugs training lead I contribute to the development of core education packages for practitioners and have personally delivered much of this training.
The Severn Deanery offers a range of scholarships to talented GP registrars in their final year of vocational training, one of which is the Turning Point substance misuse scholarship. Turning Point takes the successful applicants for one day a week for 15 months to train them in the delivery of specialist drug addiction treatment.
They also, over the course of the year, complete the full RCGP Certificate (Parts 1 and 2) so that on completion they will have the experience, skills and accreditation to become GPSIs in substance misuse and to progress their experience in the field. With specific regard to psychiatry specialist registrars, we offer a training scheme where they can learn about addiction, its treatment and how this impacts on mental health. This is usually done in partnership with their NHS mental health trust, which co-provides supervision.
This sort of contribution to training by specialist agencies is right, and should be built upon – but it is still ad hoc. As the BMA’s report last week highlighted, education should begin at undergraduate level and be incorporated into every medical school’s syllabus in the country.
Drug use and misuse will never go away – as long as there are unhappy individuals who struggle with social and psychological malaise, then there will always be a proportion of them who use mind affecting drugs to palliate their unhappiness. Although the pattern of drugs that are misused may change, the need to help people to manage their use and deal with the health consequences will always be an important skill for all doctors.
The consequences of drug misuse to the family and wider society, and directly and indirectly to health services and the affected individual will continue to be very costly in every sense of the word. It is time that the health profession realised that this is a mainstream problem for all of us, and not one that can be marginalised. We need to ensure that the medical profession are equipped to respond.
- Dr Morse is medical director for Turning Point, a social enterprise providing health and social care services for people with complex needs, including those affected by drug and alcohol misuse, mental health issues or those with a learning disability. For more information.