Chronicle of a medical practice.

Family doctors began in summer 1994 to treat patients with opiate drug-addiction problems, by giving them the methadone substitute therapy within therapeutic programs decided in surgeries.

This practice has been made possible by the referndum Popolare in April 1993 repealing some parts of the "Only text on drugs and psychotropic substances", a law regulating the whole field related to drug-addiction.

It specifically repealed some subsectios or parts of subsections of the following articles that are listed below:

Art.2 subsection1,letter e), point 4 (limits and conditions of use of substitute drugs)

Art.72 subsection 1 and 2 (illicit activities)

Art 73 subsection 1 (production and illicit trading of drugs)

Art 75 subsection 1, 12 and 13 (actions of judicial authorities, sanctions for non-fulfilment)

Art 78 subsection 1, letter b and c (quantity of drug)

Art 80 subsection 5 specific aggravating circumstances)

Art 120 subsection 5 (voluntary therapy and anonimity)

Art 121 subsection 1 (reports to the public service for drug-addiction)

As the matter was complex and delicate, only after some months the Ministry of Health, urged by many requests, gave instructions in the circular 1110/1993 in order to interpret the remaining rules on drug-addiction.

The role of the family-doctor changes completely as for the clinical procedure. Before the referendum the family-doctor had as his only duty almost that of reporting the drug-addict in his care to the Public Service that took complete care of them (from the medical and welfare point of view).

After the referendum the family doctor has a role of relevant social importance, that is, he has the power to prescribe substitute medicines for opiate, restricted to methadone syrup, he is not compelled anymore to report, a cooperation with the Public Service being only recommended.

He is therefore guaranteed an autonomy revaluing the doctor-patient relationship, which is basic for any successful treatment.

The drug-addict is just a patient once again, often a chronic patient to be treated even in the family-docytor’s surgery.

The relationship is based more on trust than on control.

The circular also gave general instructions in the distribution and procedure of prescribing the substitute medicine.

In spite of this circular and others from the Italian Pharmacist Association, pharmacies and storages were still without methadone.

In July 1994 thanks to the cooperation of some political parties we could gain the general public’s interest by a number of articles pointing out the seriouness of the situation. Both doctors and the abovementioned political representatives held lectures and talks on local televisions. At last in July 1994 a substitute therapy colud be begun.

Pharmacists were diffident at the beginning, ma the ever-increasing number of prescriptions and the patients’ polite behaviour had a positive effect. Nowadays the presence of a drug-addict in a pharmacy is neither a source of embarrassment nor of problems.

In that period on our initiative we formed the Organization of Family Doctors for Drug-addiction District Aid(Coordinamento Medici di Base per l’Assistenza Territoriale alle TossicodipendenzeCOMBATT) , connected with the Italian Drug-addiction Society (Società Italiana Tossicodipendenze-SITD), which allowed doctors pioneering in thid field to meet regularly in order to discuss results and to devise a common procedure.

Following COMBATT’s pressing requests, circulars from the Health Regional Office and the Sert showed the importance and the obligatoriness for pharmacists to have always the medicine, at least enough of it to last for a two days’ therapy, as it was considered a life-saving medicine included among the class "A" medicines.

As for the prescription, we followed the instructions of the article 43 (CTU 309/90), using the prescription-book for drugs marked by the Order of Doctors, and prescribing an amount of medicine enough for a maximum of eight days’ therapy.

No doctor took into consideration the administering procedure which follows article 42 ( which considers it likely for the doctor to obtain methadone from a pharmacy after a request in triple copy, to keep it in the surgery and to have a proper register authenticated by the Local Health Authority) as less practical, more complicated and risky ( keeping methadone in a surgery makes a breaking more likely).

In the same period the Organization took part in the activity of the County Agency fot Drug-addiction and regularly held meetings with the Public Service, in order to coordinate the work of Family Doctors with the work of all the people employedin the field whose aim is a damage reduction, though having different aims.

On 30 September 1994 the Ministry of Health in its circular n.20, published on the Gazzetta Ufficiale n.241 of the 14 October 1994, gives guidelines on the treatment of opiate drug-addiction with substitute medicine.

The document points out the importance of treatment with substitute medicine especially for patients with a deep-rooted addiction and little intention of giving permanently up heroin. The importance is stressed by the fact that it could bring a reduction of the incidence of infectious viral diseases (hepatitis, HIV) a reduction of the incidence of deaths by overdose, and a decrease of criminal actions connected with drug-addiction (thefts, selling drugs or prostitution are often the only means to get the money necessary to buy heroin).

The opinion of the Ministry agreed with our indications, even if some criteria of substitute medicine prescription , contained in the same circular, seemed too restrictive and contradicting laws.

The circular infact requires the medicine to be entrusted to one of the patient’s relative, strictly related to him and able to guarantee the proper use of the medicine.

This procedure can take place for two days only, and if the patient undergoes a long treatment, if he has assuredly given up heroin or any other drug, in case of a clinical imporvement, if he has resumed work, and if the patient is unable to leave his house for proved causes.

Conscious of this contradiction in the law, and wishing to follow the laws as strictly as possible, we tried to mediate between the more restrictive regulation anfìd the less restrictive one, keeping weel in mind the purpose of our work.

In our opinion infact the drug-addict patient reacquiring dignity went along with his progressive taking the responsability and with the acknowledging his right to autonomously take the medicine.

In any case we keep in mind such parameters as the patient’s age, the absence of physical and psychological symptoms of abstinence, concomitant pathologies and their seriousness, the absence of behavioural problems, the adequacy of the patient’s social environment, the recovery potential of this therapic choice with reference to each patient.

The principle that characterized and still characterizes our decisions on family care is that of guaranteeing the patient a free and autonomous therapy according to his compliance.

The road to recovery can pass through a "relationship recovery" capable of progressively getting the patient to give up drugs and dependence, and capable also of making him face the responsibility and autonomy he had lost, he had been deprived of, or he had never acquired.

This happens within the psychoterapeutic relationship with the specialist, and most of all through his becoming a social subject again thanks to the structures and professional skills of the territory services. It is therefore clear how important the relationship among territory services, family doctors and public service is, also to relieve the latter of a part of the work which would burden it sometimes to the detriment of the quality of the action.

Not all drug-addict are unemployed, the result of social emargination, poverty and criminality, but many can become addict in their almost set road.

The problem of social recovery is very important and therefore we try to limit as much as possible (as for psychic patients) seclusion and to fight prejudice.

After the issuing of the circular, the doctors of the Organization held a refresher course on this subject, with the financial help of the County Agency fot Drug-addiction and the National Society of General Medicine.

Other courses have been organized with the cooperation of SITD and some doctors attended the "Master" course organized by the European Society for General Medicine (SEMG), on order to organize local courses. More than 50 doctors now prescribe substitute medicine in theis surgeries.

In cooperation with the Health Authority and the Public Service district surgeries have benne opened, where five doctors of general medicine and a professional nurse work on work- days, treating a maximum of fifteen patients each. At the moment four district surgeries are operational.

The basic idea of a family doctor treating a drug-addict patient is that of acknowledging such patient’s right to health and the right to choose as a sick person who to ask for help.

The drug addict could give the SERT a negative value, feeling this structure to be a sort of "container" where specialists do not recognize him as a unique individual, and where he could risk contacts with other drug-addicts or a loss of identity.

The possibility of choosing among treatment at the pubblic service, at a family doctor or at a district surgery gives strength to the idea of personal dignity and gives the individual back to his social environment.

A further goal achieved has been that of an economic reward for family doctors as an incentive, as stated in the agreement.

Having reached such goals a decision was taken to end the COMBATT and to form a "monothematic supraregional group" within this subject (family doctors and drug-addiction), within the Italian Drug-addiction Society in order to increase experience and to have a better organized scientific supervision.