The core skills of Australian general practice provide a strong foundation for the provision of quality care to individuals struggling with the complexities of addiction and for enabling general practitioners (GPs) to provide the holistic continuity of care required to treat addiction like any other chronic disease, and to consequently minimise the risk of harm. High-quality primary care is an integral part of identification, support and treatment of individuals with alcohol and other substance addictions.1
Australia is a drug-using society. In 2007, the prevalence of substance use disorder in Australia was 5% of the population who self-reported in the 12 months prior.2,3 National household surveys demonstrate that consumption of alcohol occurs in the majority of the population and that cannabis is the most commonly used illicit drug.3 In 2011–12, 16% of the population smoked cigarettes daily and 17% of men aged 25–34 years and 14% of women aged 18–24 years drank alcohol to harmful levels.4
There is no doubt that illicit substance use is a significant issue in this country. However, alcohol and tobacco are the two most significant causes of preventable disease and death. Tobacco use contributes significantly to morbidity and mortality caused by lung cancer, ischaemic heart disease and chronic obstructive pulmonary disease, while alcohol contributes to pancreatic and various other cancers, alcoholic liver cirrhosis, family breakdown, violence (particularly intimate partner violence) and road trauma. Alcohol and substance use are undoubtedly a significant public health issue that can contribute to and reinforce social disadvantage and health disparities. It is important to recognise that daily smokers are more likely to consume alcohol at risky levels, thus compounding their risk status. In 2012, tobacco contributed 9.6% of the total burden of disease in Australia for men and 5.8% for women.5
There are significant social inequities in the risk of exposure to addictions and ability of individuals to access appropriate support. Vulnerable groups include lesbian, gay, bisexual, transgender, intersex and queer (LGBTIQ) populations, who, compared to other groups, may experience more difficulty in accessing drug treatment and achieving successful outcomes from that treatment unless it is appropriate for their particular needs. Others who are particularly at risk are people with multiple and complex needs. These complexities may involve a combination of drug use, mental illness, disability and injury, family breakdown, unemployment, homelessness and/or time in prison. Aboriginal and Torres Strait Islander populations have poorer health outcomes from similar levels of smoking, alcohol intake at risky levels, and illicit substance use than do non-Indigenous Australians.6
Addiction encompasses a broad spectrum of disorders. For many, it is a chronic, relapsing disease that can be managed and its consequent harms minimised, but it is rarely cured.7,8 The umbrella of addictive disorders also encompasses behavioural addictions, particularly gambling disorder. The spectrum of individuals presenting to general practice with dependence and addiction issues is broad ranging – from substance addiction (including drug-seeking for prescription medications, particularly opioids), to requests for nicotine and opioid replacement therapies, to the presentation of withdrawal symptoms or common comorbidities of substance use, such as mental health conditions and blood-borne viral infections like hepatitis B and C.
The consequences of substance use are often intergenerational. Infants born to women who are addicted to opiates, alcohol, stimulants and some sedatives are at risk of immediate harm as well as long-term developmental problems. Children living in households where parents misuse drugs are more likely to develop behavioural and emotional problems, tend to perform more poorly in school and are more likely to be the victims of child maltreatment. Children with parents who drink heavily, smoke or take drugs are more likely to do so themselves, leading to intergenerational patterns of misuse and harms.3
Regardless of where an individual presents across this spectrum, in order to provide holistic care there is a necessity for GPs to understand the plethora of causes of addiction, including genetic factors, personality, and physical and psychosocial factors such as co-existent acquired brain injury and/or chronic pain manifestations that require a complete and compassionate person-centred approach. Equally important is having an understanding of the consequences of addiction, these include physical and mental health effects, social impacts on relationships and employment as well as the vicious cycle of involvement in crime with subsequent judicial issues and social dysfunction that commonly occur. GPs with a non-judgemental approach to individuals caught in addictive cycles may facilitate the development of an effective therapeutic relationship, with clear boundaries (discussed below) to enable continuity of care and thus an enhanced possibility that the impacts of an individual’s substance dependence may be minimised using effective evidence-based interventions.
The identification and management of drug and alcohol conditions requires a multidisciplinary approach to patient management. Appropriate integrated service approaches may include drug withdrawal services, forensic services, local psychiatric services, and drug and alcohol physicians. Collaboration with social welfare, income support and job services, housing and homelessness services, mental healthcare providers and correctional services is needed if people with multiple and complex needs are to be assisted in stabilising their lives, reintegrating with the community and recovering from alcohol and other drug-related problems.
Establishing and maintaining clear boundaries is an important aspect of the provision of quality care, particularly with individuals who are drug seeking or engaged in manipulative behaviour. GPs need to know where and when to refer patients, and clinicians working in communities with a high rate of substance use disorders should consider incorporating more specialised skills into their everyday work. This may involve undertaking further training in drug and alcohol medicine as required, such as training in provision of opioid pharmacotherapy and managing withdrawal syndromes. In 2014, 48,000 Australians were receiving opioid pharmacotherapy.9
Unfortunately, many GPs resist intervening when an individual with substance use issues presents, and may find it difficult maintaining appropriate boundaries, to avoid manipulation and to enhance the potential for a high-quality therapeutic relationship with their patients.10–12 This reticence to intervene may stem from lack of confidence and skills in the area, or a belief that intervention is doomed to failure. Other perceived barriers are lack of time, difficulties in raising the topic during the consultation, and having a negative attitude toward individuals with alcohol and other drug problems. Yet the results of interventions by general practitioners can be very significant.12,13 Brief interventions for alcohol abuse and opiate pharmacotherapies for heroin addiction are two common examples of effective GP-initiated treatments, proven by multiple studies in Australia and overseas.12–14 The majority of individuals who are dependent on substances prefer to see their own GP than be seen in outpatient drug dependence clinics.15
Emerging drug and alcohol problems can present new challenges for GPs – for example, patients presenting with methamphetamine use or requesting medicinal cannabis, or discussing electronic cigarettes (e-cigarettes). The ever-changing face of substance use in Australia necessitates that GPs maintain currency of knowledge. Developing and maintaining an understanding of legislative frameworks around drugs of dependency, prescribing, and obtaining permits is essential for all GPs.