How I operate
A more detailed explanation of how I work with my clients and other professionals.
My clinic is a primary care setting. I am a dedicated opioid dependency doctor, it isn't something I fit in around the other work I do. After 15 years as a VMO in a public detox and opioid management service I came to believe that the most effective service delivery setting for virtually every opioid dependent person is away from such settings. The best service delivery is with well trained GP's who are interested in the field of opioid dependence and base their decisions in the real world in which the patient has to live. They provide comprehensive care and most importantly they develop a therapeutic alliance with their patients. I see many patients who were considered problematic, unstable and unsafe in the public clinic, yet they settle and become stable when they transfer to a GP-led program.
My time in the public system showed me without doubt that punitive judgemental management created more harm than good. Retention in treatment and attraction to treatment are two critical end points that determine the success of a program. A public system that survives only because there is no other alternative will neither attract or retain patients in the long term. OTP is lifesaving treatment. When people jump off the program or refuse to come on because of the shame, fear and punishment then that is a terrible and dangerous situation. People die when they leave the program because of conflict or rigidity: I have witnessed this. When buying drugs is easier and less stressful than participating in an unyielding system then people will choose to buy their drugs at great personal cost. An opioid treatment program has the core aim of assisting people to escape the chaos and pain of opioid dependency. It is not about creating saints: that is neither realistic nor achievable and is entirely inconsistent with the community in which these people live. If the bar is set too high then many patients won't even bother to jump.
My professional ethos is unashamedly one of empathy and compassion and I do not shy away from that. The effectiveness of opioid dependency treatment is largely determined by how that treatment is delivered - this is an evidence-based principle. Friendly and compassionate treatment equates to better outcomes. People who have a good relationship with their prescriber and their pharmacist do better. This should not be a surprise to any of us. Approximately half of my current patients are people who have wanted to get on the program for years but existing services were unacceptable to them. Providing patients with this treatment and establishing this clinic has been the most important and satisfying thing I have done in my professional life.
Evidence based medicine is critical in addiction medicine and in OTP especially. Our intuitions are often wrong. Many people feel that a tightly run program with very few takeaways, lots of checks, surprise reviews and random urine drug screenings have the best outcomes. Evidence tells us this is not true. An over-reliance on urine drug screens and arm checks for injecting sites can be harmful - people just use more dangerous sites for injecting. They stop sharing information for fear of punishment, they develop increasingly elaborate ways to get around the rules, the therapeutic relationship is irreversible destroyed and the culture of the clinic becomes one of an us-and-them power game. The atmosphere becomes adversarial and those pivotal power and authority psychological experiments from the 1960's become as relevant now as they were then (number 10, Stanford Prison Experiments)
The therapeutic relationship is to an OTP prescriber what a scalpel is to a surgeon - the core tool for therapeutic change within the client. A well run program and a healthy unit will work to enhance that relationship and nurture it. It is impossible to achieve if a doctor is not prepared to work collaboratively. A healthy therapeutic relationship starts with the clinician. He or she must model behaviours and attitudes, thus it requires willingness and a commitment to persist through the inevitable conflicts.
"Client centered care" cannot just be lip-service, it must do what it says and place the client at the centre of treatment formulation. Empowering clients to be able to verbalise their opinions without fear of reprisal takes time because they are not used to that approach, but once it exists, the clinician has access to the most valuable store of clinical options - the thoughts, beliefs and experiences of the person he or she is treating.
All my patients get adequately long appointments so other complex issues can be dealt with - sexual health, mental health, legal and state debt issues, Hepatitis C treatment and focused psychological strategies to prevent relapse and deal with other life stressors, skill acquisition and life coaching..
GP's with busy case loads often find it difficult to meet the needs of their opioid dependent patients and I manage many in a shared care arrangement whereby I deal with addiction and dependency, mental health, hepatitis C and their GP looks after their usual primary care needs. Naturally if a patient has a general practice-type issue on a day that I see them then I deal with that at the time.
I believe that opioid dependent people are one of the last marginalised health groups in Australia. The stigma associated with injecting drug use is such that they are often prevented from receiving adequate medical care. On this basis I am an advocate for my patients when they navigate their way through the public system. I have witnessed a great deal of cruel and unfair treatment of opioid dependent people, the kind of treatment that would be entirely unacceptable to the vast majority of Australians if it were directed toward them or their families. This is not a peripheral matter, it is a core issue for my patients as many of them avoid accessing important health care because of the fear of how they will be treated. I regularly and currently witness the heart-breaking consequences of that.
Helping clients to navigate the health system is a large part of my care, coaching people on how to present to hospital so they will provoke the least negative reaction. This also includes educating treating doctors about the levels of pain relief required if my patients are nil by mouth following surgery. The baseline opioid needs must be met first THEN the analgesic opioid requirements can be addressed.
If I take over the responsibility of opioid (and any benzodiazepines if required) then this allows the GP to focus on primary health care and they will not be scared off by the thought of being manipulated into providing extra drugs or being taken advantage of by doctor shoppers. The reality is that a significant few have damaged the reputation of opioid dependent people and that is not likely to change in the near future.
Educating, supporting and encouraging GP's to take on OTP prescribing for a few of their own patients is also part of my role. Even with the GP networks I have the success of that is modest to say the least, there are firm professional barriers to the uptake of OTP prescribing.
I try to be as available as possible to patients as well as pharmacists, community health workers, referring GP's and other health professionals. Health professionals do take priority as they are often dealing with patients in crisis. As such, I have a phone number that will get directly to me. If you telephone 0468 869 873 and identify as a health worker they will give you that number and transfer your call to me immediately. If that number goes through to voicemail then I will call you back within the hour.