How do we ensure quality and equality of somatic healthcare provision for patients with serious substance abuse problems?
Individuals with serious substance abuse problems also have a marked excess of other diseases (1 – 3). Indeed, both somatic and mental illness are faithful companions of the long-term substance abuser. Undiagnosed and untreated, they can lead to an early death, while less serious cases can be an impediment to optimal treatment and rehabilitation and cause patients great discomfort in their daily lives. Personal experience from 15 years as a GP for 330 patients with substance abuse problems has taught me that a good patient-reported history and a set of supplementary tests will reveal somatic disease of varying severity in the majority. It is not just the usual suspects that are present (hepatitis, HIV and other infections), but also diseases of the pulmonary and digestive systems, as well as pain disorders and deficiencies due to improper or poor diet. Extremely poor dental health is common and contributes to poor nutrition and poor self-image.
In their study of the health status of patients undergoing drug-assisted rehabilitation, Ivar Skeie and co-workers identified 197 somatic conditions in 35 patients before the start of treatment and a marked reduction during treatment (1).
Addiction medicine has received much attention in recent years. One of the intentions of the GP scheme was to improve provision of GP services for vulnerable groups. Interdisciplinary addiction medicine became a dedicated specialty in Norway in 2014 and the first specialists in addiction medicine will be approved early in 2015 (4).
Have the increased attention directed at substance abuse problems and the changes to the organisation of treatment led to improved diagnosis and management of patients’ somatic diseases and ailments? There have been few attempts to address this question systematically. Erling Dalen and co-workers have therefore made a useful contribution with their examination of the somatic health of patients attending an outpatient clinic for substance abuse (5). Their article in this issue of the Journal of the Norwegian Medical Association suggests that there is still a long way to go before we can be satisfied with the state of affairs in this field. A thorough survey of the somatic health of 155 patients at the outpatient clinic uncovered a total of 769 diagnoses. The number could probably have been even higher, given that spirometry was not performed during the clinical examination and yet should have been mandatory in a patient population in which 83 % are daily nicotine users. Sex hormones and vitamin D status were also not examined. Only four of the patients were found to be completely physically healthy. The vast majority of the conditions that were identified can be diagnosed in general practice, and most can also be treated there. A lack of somatic health information in referrals may indicate that this has not traditionally been a focus for this outpatient clinic. But when the authors find that somatic health information is still insufficient for 61 % of patients even after a round of reminders, this might suggest that the GPs did not collect this information before making their referrals.
The article gives much food for thought. Firstly, it is sobering that this particular outpatient clinic has only now conducted a thorough survey of the health status of its patients. It is to be hoped that other institutions and outpatient clinics within interdisciplinary addiction medicine already have procedures in place for systematically examining the somatic health of their patients. Secondly, the dataset suggests that GPs too have not done enough in this regard. My own experience tallies with what I think I can deduce from this article, namely that the current state of affairs is not ideal. What can be done to improve the situation?
Knowledge and attitudes are key. A healthcare system characterised by moralising and rejection will struggle to provide good medical care for somatic diseases and ailments. The proposed guidelines for the treatment of substance abuse recommend examination of somatic health, evaluation of the need for dental treatment and assessment of nutritional status early in the course of treatment (6). In general practice, a systematic survey of somatic diseases and ailments should be performed at the initial consultation.
Patients with substance abuse disorders are concerned about their health, and a thorough physical examination is perceived as good care and can lay the foundations for subsequent cooperation regarding the drug problem itself. Some of the worst afflicted patients are unstable and struggle to keep appointments, and also have little willingness or ability to pay. A small step towards helping patients with substance abuse disorders to receive the GP care they are entitled to would be to introduce prepaid exemption cards for this group. District nurses or social workers could also be mobilised to help patients to attend GP appointments.
Those patients who are referred to the specialist health service should have been thoroughly assessed for somatic diseases and ailments by their GPs. But the specialist health service cannot simply assume that this has been done. Upon hospitalisation or initiation of outpatient care in institutions specialising in addiction medicine, an assessment and survey of somatic ailments and diseases should be performed, and any necessary supplementary tests and treatment carried out.
The responsibility for ensuring that patients with serious drug problems are evaluated and receive good quality treatment for their somatic diseases and ailments lies with both GPs and specialists. As the title of this article states, there are «needs enough for all». Both levels of the healthcare system must accept responsibility for the diagnosis and treatment of these patients.