A. Michelazzi* – F.Vecchiet
**. (Trieste,Italy)
Before
describing the results of the study carried out in Trieste, Italy, with a group
of general practitioners involved in the treatment of heroin addicts, I think
it is important to make a few preliminary comments.
Since 1994,
around 50 family doctors have been treating heroin addicts in the Trieste area,
and our total case-load is about 250 patients.
At the
beginning, our day-to-day practice was disorganized, haphazard and perhaps also rather
improvised. It was made possible by a national referendum held in Italy in
1993, which changed the existing law on narcotics (Law 309) and made it
possible for general practitioners to prescribe the substitute drug methadone.
Our original
aim was, and still is, to make sure that patients who
have been diagnosed as heroin addicts receive a personalized form of treatment.
In fact, we regard heroin addiction as a chronic illness at risk of relapse,
which should be treated with every instrument legitimate from the scientific
point of view.
The
predominant situation in Italy was, and still is, a situation whereby the law
gives the monopoly for treating addicts to the Public Services for Drug
Addictions. The result has been a concentration of these patients in large
centres, which we had no hesitation in describing as “drug-addict asylums” on a
par with those “lunatic asylums” which once existed in Italy (and which still exist
in some parts of the world), where people thought to be suffering from some
form of mild or severe mental illness were locked up.
The drawbacks
of such a situation are obvious: the difficulty involved in personalizing
treatment, the risk of a poor quality doctor-patient relationship, the abnormal
change in identity and habits, the patient’s limited autonomy as regards
timetabling of treatment, with repercussions for employment opportunities, and
finally, the isolation of the staff working in the dedicated facility from the
other treatment services available in the area.
Our role has
been crucial in giving new choices to patients with heroin addiction, and by
doing so, restoring their dignity and their right to a choice of treatment, a
right which we felt they had been denied arbitrarily. (1)
In the case
of madness, when the doors of the lunatic asylums were opened it emerged that
many of the attitudes and kinds of behaviour considered part of the clinical
picture were actually induced by the institutional setting; similarly, it soon
became clear in our case that certain features attributed to drug addiction in
itself were in fact a consequence of the institutional pressure the patients
were subjected to.(2) In fact, the unreliability and aggressiveness, the
self-harming behaviour and extreme self-centredness, but also certain
antisocial or borderline personality traits
disappeared or became much less obvious, once
our subjects began to be treated properly, in a different context which they
preferred.
We realised
very soon that we had to make sure our everyday practice was evidence-based,
and provide ourselves with a governance which would
make it perfectly legitimate for us treat heroin addicts. For this reason, to
be sure we used, doses, and treatment protocols approved by the scientific
community, we began collaborating almost immediately with the Italian
Association for Addictions (SITD) and the University of Pisa, and also with our
local Regional Centre for Training in General Medicine (now Primary Care).
At the same
time, we set up a treatment network throughout the area, which involved
agreeing on our treatment protocols with the Public Service for Drug
Addictions, as well as working in some district health centres (our city is
divided into four health districts) in order to handle the various types of patient
(those posing fewer or greater problems).
With this
very aim of better identifying the characteristics of those patients most
“suited” to treatment
in the family doctor’s surgery, we designed a study together with our Centre
for Training in General Medicine and the University of Pisa. For three years,
we collected the data regarding 33 of our patients, chosen at random from those
followed by approximately 20 family doctors.
The study,
which will be published this year, analysed the baseline-endpoint variations in
a series of variables considered relevant for indicating the factors predictive
of a positive outcome (measured by retention rate, by substance use, by overall
clinical improvement, by quality of life, and by abnormal psychological
symptoms).
Aware of the
limited number of patients involved, but convinced of the usefulness of the
work, also as an example of clinical governance, we decided to process the data
for statistical purposes. Without going into detail, it emerged that during the
period under observation, no treatment was stopped because of violent
behaviour, no patient was hospitalized, and there were no deaths from overdose.
The baseline-endpoint differences were significant for all the substances
analysed. Compared to their starting point, all of those patients who stayed in
the treatment programme showed improvement, and their craving for heroin,
alcohol and cocaine significantly diminished. In these non drop-outs, all the
dimensions investigated using the SCL 90 scale improved (depression factors –
paranoid ideas and somatization, psychosis), as did
quality of life.
As
regards the factors predictive of response to treatment, demographic factors
were not predictive, and neither was an history of
multi-substance use (polyabuse) or a clinical history
of heroin abuse whereas the presence of a double diagnosis (especially of a
bipolar disorder), and more serious illness at the beginning, were predictive
of dropping out of treatment. Moreover, among the drop-outs, the abnormal
psychological symptoms were more serious, and linked to obsessive-compulsive
disorders, depression and aggressiveness. Also they had more socialization problems, and worse relationship with their
partners-spouses.
Finally,
the non drop-outs were treated with higher stabilizing doses (and not low doses).
These
results, though referring to a small number of patients, confirm our opinion of
the importance of certain structural aspects of our practice. Firstly, the
importance of training, which enables the general practitioner to identify
certain aspects of the patient-addict, such as psychiatric co-morbidity , as
unfavourable prognostic factors for successful treatment in the doctor’s
surgery. Secondly, the importance of the link with the Public Service for Drug
Addictions, which can provide invaluable assistance in the handling of these
patients; its possible organisational models may be different, but this is not
the place to discuss them. Suffice it to say that the law in force in Italy is
totally inadequate for fostering good practice on the part of family doctors:
it presently seems to require that every treatment started, and any change in
dose must be accompanied every three months by a treatment plan done by the
Public Service for Addictions, and prescriptions which in some cases must not
exceed two boxes of methadone per prescription; this burdens the family doctor
with pointless red tape, and ends up limiting the doctor’s professional responsability and freedom to treat, once again to the
detriment of the patient and his independence.
We also
believe that this study shows the importance of governance, of an attention to
good practice sensitive to the multiplicity of variables which this kind of
treatment involves. Hence the professional commitment necessary and hence the
importance of financial incentives.
In conclusion,
I would like to make a few observations about the importance of the form we
give to an illness, when we consider it in relationship to the “small”
institutions in which it is being treated. This applies especially to those
illnesses where the psychological and behavioural aspects are the most evident
features, such as in madness, but also in heroin addiction and in others
besides.
The degree of
danger presented to themselves or to others, the negativism, the rejection, the
ambivalence, but also the intensity of the compulsive or impulsive trait, are
only a few of the aspects which are undoubtedly shaped by the type of
institution responsable for treatment; they also
shape the clinical form which we professionals give to the psychiatric or other
illness connected to the addiction. But in my opinion, these considerations
cannot be limited to the “microinstitutional” context
alone; the “macroinstitutional”context must be
considered too, and becomes vitally important for understanding the real nature
of the illness we are dealing with. By ‘macroinstitutional’
context, I mean the social structure which affects us with its economic “laws”
but also with its juridical laws and with its ethical and religious principles.
(3)Only in this way can the neurobiology of psychiatric suffering or the
suffering connected to addiction avoid the risk of becoming little more than a
kind of ‘psychocosmetics’ with varying degrees of
sophistication. This helps to explain why the incidence of certain disorders,
such as conversion hysteria or obsessive-compulsive disorder, changes, in
correlation with the form of illness assigned to them (whether psychotic or
psychosomatic or paranoic). It also helps to explain the reason for the great
increase, in our contemporary globalized society, of
the illnesses grouped together as the so-called “disorders of emptiness” (addictions,
anorexia, bulimia, and borderline disorders as well as some of psychosexual
identity).
As family
doctors, it is our job to do what we can to alleviate the suffering of those
who ask us for help, making responsible use of the scientific instruments
available, trying to free ourselves from prejudice and whenever possible,
taking into account the times and the social context in which we live.
Bibliography:
(1)General Practitioners and heroin addiction. Chronicle of a
Medical practice. Michelazzi A. Vecchiet F.
Cimolino T., Heroin Add § Rel. Clin.
Probl. 1999; 1(2): 39-42
(2) Crimini di pace in Scritti II. Basaglia F. ,Einaudi, Torino, 1982; 330-336
(3) Vocazione terapeutica e lotta di classe. Per un analisi critica del modello italiano. Basaglia F. Gallio G., testo presentato al Convegno franco-italiano di psichiatria (Parigi novembre 1979) organizzato dal C.N.R.; p.26