EPISODE 4: The simple act of renewing a script

In episode 3 we heard from the ‘gatekeepers to the demigod’ – if the receptionists are the gate keepers, I guess it’s time to meet the demigods! Let’s enter the GPs office and get a script.

Kim : How important is having a good doctor to you?

Jude : More important than having a good lover, actually, like your doctor is just so important too, because he's the guy with the keys. If I can't have my script, he takes my methadone and that puts me into a shit hole.

In our conversations with the community, there was a common concern around honesty, trust, fair treatment and being ‘kicked out’ of the methadone program. There’s a real fear that ending up back on the streets will end up being the alternative.

Kim : What's the outcome for you in that situation?

Jude : I don't know after all this time. I'd probably get a rap and the knuckles and be threatened with losing my take away privileges, because it's something that they don't like at all, and people get thrown off their programme for having a dirty urine.

Kim : What's the result of that, if you're [crosstalk 00:10:14]?

Jude : Then you're back on the streets again, so you're buying from people who are trying to make money themselves because they've got ... You're just thrown back into a world of chaos where nothing can be predicted until you've scored, and that's what your day has to be about.

A urine drug test, also known as a urine drug screen or a UDS, analyses patients’ urine for the presence of certain illegal drugs and prescription medications. Taking urine drug tests throughout drug treatment helps the GP to ensure that the plan is working and that the patient is no longer taking drugs, Finn describes his experience with his GP after his motorcycle accident.

Finn : He got a letter from the hospital when I was discharged, from the pain management team asking him to prescribe for me, with no drug history whatsoever. He still makes me piss in front of him every time I go in.

Finn has been on buprenorphine for almost two years for pain relief due to his accident, and request for urine testing continues despite a continuous history of clean urines tests.

We asked one our GPs, David, a mild-mannered guy who has been working in the Darlinghurst area in Sydney’s East for about 25 years, does honesty get you booted off the program?

David : Because if people are upfront with me, it's not like I will say, "Oh, now you've told me what you're really doing, I'm going to now" ... You'll never be stopped, kicked off a programme. That just doesn't happen. All that would happen is we'd have to have a discussion about what your aims are and is the treatment working for you? Can we modify the treatment in some way so it's going to be more helpful for you?

OK so what about of someone like Christian who has come into see his GP regarding something completely non-drug related?

Christian : I really am not honest with ... I don't discuss my drug use with my GP, mainly because I don't see them about drug-related issues, if you like. My concern is that as soon as I mention drug use, that's what the engagement is going to become about rather than the actual presenting issue that I'm coming to see them for. I think the decision to not disclose, again, it's kind of that default setting of being very apprehensive about the engagements you have with other people.

Dr David, our GP from Darlinghurst ponders the question of whether it is anyone else’s business if someone chooses to use drugs.

David : I do agree with that sentiment. I mean, I think all of drugs should be decriminalised so I support people's choices in using whatever drugs they want to use. The only point I have to make, though, is that that's up to them, what people use, but if you are receiving opioid substitution therapy, like methadone or buprenorphine, then the people involved in supporting you with that programme, which is the prescriber and the pharmacist, they have a duty of care to ensure that medications provided in a safe way, because they are totally liable medically and legally if something happens to you that may have been caused by the prescribing of that drug.

I think people who use have to understand the pressure that we're under to supervise the programme in a safe way, and that sometimes means that people may feel that programme is over structured or unfair. But from our point of view, unfortunately we see the disasters that happen when the programme is not properly run and this creates a fair amount of anxiety for us as prescribers, and also for pharmacists who dispense, because everyone's constantly worried about the very rare times when people overdose or get given too much medication.

Kim raises with David that many of drug users we have spoken to don’t necessarily want all their problems solved by their GP…

David : Well, most of the people we see, we are their GP, as well as their opioid substitution therapy prescriber, and we're very concerned about their overall health. I mean, a big example of that recently is hepatitis C that we have over 1000 patients at our practise who have hepatitis C, and bout 1500 with HIV, so we are very concerned about patients' total wellbeing, and drug use is often only a small part of that. I don't really like I guess the idea of people running and running out and just getting a script, because I don't see that as being what we stand for in being a thorough GP.

So, for David, it’s important to know about a person’s drug use because he wants to provide the best, most holistic care that he can.! The role and oath of a GP is wrapped tightly around a duty of care. David takes pride in the fact that as a GP, he has a lot more concern for a drug-user’s well-being than a dealer on the streets – and he’s just fine with that. Have any of our drug-users thought about the health implications of their use? We ask Jude about her experience.

Jude : If your immune system's always jumping up, it gets tired and it takes a little holiday. It has a little holiday and you get an abcess somewhere in your spine or endocarditis or something like that. It does. Then there's hepatitis. Most of us have hepatitis, because hepatitis wasn't anything the government worried about because we didn't give it to anybody else and they didn't even know about hep C in the beginning, and when they did they didn't really care about it until they realised how much money we were going to cost them. The toll on my body, so I've had a couple of quite serious abscesses internally that's a result of just my body being tired, and I had hepatitis C. I've got a healthy respect for doctors and nurses because I spent a lot of time with them.

When you get hepatitis, you go yellow, so you've got yellow eyes, you've got yellow skin. I didn't think it was my best look, so I've never been able to deal with the colour yellow again, so my kids never give me yellow flowers or anything to do with yellow, because I just think hepatitis, and I don't need that.

The problem though, as Christian will reveal, is the danger of not feeling comfortable disclosing drug use to the GP, or just avoiding the GP regarding drug-related and non-drug related health issues completely. There are real consequences in this locked dance between drug-users and GPs.

Christian : They've got so much riding on their medical career, and I think really had the fear put in them, that if they don't work exactly within the rules of prescribing S8s, like your oxycodone, and your OxyContin, that they'll get de-registered and their lives will just be shattered. So, they tend to over-engineer their response.

The result of this over-engineered response can mean that if a patient comes in who legitimately requires an analgesic that happens to be an opiate – the GP’s fears kick in and can affect the way they respond to these patients.

Lincoln : … but because you fit into a certain demographic, the doctor will go "Oh oh. This patient's seeking this for recreational use rather than legitimate use." So if they ever get the idea that an S8 is being used for that reason, it's really quite scary for a practitioner.

Associate Professor Gowing tells us that in Australia, medicines defined as Schedule 8 (S8) under the Standard for the Uniform Scheduling of Medicines and Poisons are strictly regulated because of the high risk of misuse and/or physical and psychological dependence associated with them. They have to be prescribed, dispensed, documented and destroyed in specific ways that are in compliance with each state and territory’s different drug regulations. Methadone is listed as a schedule 8 (S8) drug, reserved for therapeutic use, and has high potential for abuse and addiction. The possession of drugs such as methadone without authority is an offence.

Linda : Most states and territories have regulations in place that govern the prescribing of methadone and because methadone is a more dangerous drug than buprenorphine in the sense that it's easier to overdose on methadone than it is on buprenorphine.

Aside from being wedged firmly between government imposed regulations and adhering to a duty of care, we hope that there can be a better shared understanding of some of the fears that are experienced by both drug users and healthcare professionals.

Kim : Overall do you think they do a good job?

Jude : They try. Absolutely they try and most of them are really, really lovely and kind.

Kim : But to those drug users who are struggling, some advice from Jude.

Jude : Absolutely. You don't have to wear what they throw at you. You absolutely don't. The problem is though when people or doctors, and people, or pharmacists, or people in power, you do have to interact with them. You can't not, but you have to learn ways to manage it. You can always take someone with you. You don't have to bear the brunt of that ugliness yourself, and don't take that ugliness on. You're a good person living in a world that's really problematic and everybody's struggling and no one knows what's happening half the time. You are what you are and you're good.

In this episode, we’ve focused on two perspectives; drug users and medical professionals and what it means to visit a GP. Whether it be for a methadone script, or when you just need to go to the doctor that requires another prescription, drug users have told us that their drug use isn’t anyone’s business. The GPs stated that they are in a highly regulated, but caring profession and, if they know or suspect about a patient’s drug use, that they see their service as holistic, they ensure their patient is healthy.

We also heard that some drug users don’t want to be questioned and so will not go to their GPs at all. We wondered that if the opportunity was identified to have a conversation between the patient and the doctor, that a balance could be found that meets both of their needs. Make sure you check out the resources to help you feel comfortable in initiating these conservations.

In the next, and final episode of our series, Jude finally gets her script and heads into the pharmacy.

Jude : By the time you've got home and got your prescription, you must be exhausted. Yes. A Bex and a good lie down. Every one of those interactions reinforces your difference, or they think you're different, and even if you don't care, it does get tiring.