Compliments of the season folks. Like many of you I am sure, I spent my time seeing the New Year in, reading the latest copy of “Addiction”. There was a very interesting commentary titled “Why we do what we do” in which the author questioned the “received wisdom” of frequent attendances being required of drug users on maintenance prescribing, and I reproduce some of it here:
“….Perhaps the issue is not so much about whether required clinic attendance is good or bad for patients, but about why we do things the way we do. Could it be that at some level we recognize that requiring frequent clinic attendance is a burden on our patients but we make these requirements for other than research-based reasons? Perhaps we do not trust our patients enough, perhaps with good reason, or perhaps traditional treatment approaches are overly reflective of societal expectations more than based on scientific rationale. Even if we clinicians consider these matters consciously, we are unlikely to engage patients in the process. We do not say to our patients that we understand it is a burden to attend clinic, but that it is necessary because society wants us to adhere to certain expectations in order to improve outcomes, ostensibly to exert control, or for whatever reason. In the final analysis, we can only do what ‘Big Brother’ lets us do according to regulatory mandates. In that context, the real message is that we believe addicts are sick and need help but they are also sinners and must suffer a little, whether by required clinic attendance or supervised dosing or providing urine samples: but that ‘suffering’ may not he entirely bad. While the first principle of medicine is that the patient’s best interests are paramount, sometimes the needs of the greater society conflict with the physician’s judgement about what is best for the individual patient. This is particularly pertinent to addiction, which affects not only the individual, but society as a whole. In such cases it is perhaps also our responsibility to convey to our patients that giving consideration to societal needs is an integral part of their recovery, because in the end they will have to live as a member of that same society with its structured mandates, laws and expectations.”
I confess that this made me feel very uncomfortable – it seems to suggest that frequent attendances are “regulatory mandates” and are primarily designed to control and importune our patients rather than be in the interests of their health. And what is more, that this is allowable because the requirement is (allegedly) helping to shape the patient from social deviancy to social conformity. Does anyone agree?
“….Perhaps the issue is not so much about whether required clinic attendance is good or bad for patients, but about why we do things the way we do. Could it be that at some level we recognize that requiring frequent clinic attendance is a burden on our patients but we make these requirements for other than research-based reasons? Perhaps we do not trust our patients enough, perhaps with good reason, or perhaps traditional treatment approaches are overly reflective of societal expectations more than based on scientific rationale. Even if we clinicians consider these matters consciously, we are unlikely to engage patients in the process. We do not say to our patients that we understand it is a burden to attend clinic, but that it is necessary because society wants us to adhere to certain expectations in order to improve outcomes, ostensibly to exert control, or for whatever reason. In the final analysis, we can only do what ‘Big Brother’ lets us do according to regulatory mandates. In that context, the real message is that we believe addicts are sick and need help but they are also sinners and must suffer a little, whether by required clinic attendance or supervised dosing or providing urine samples: but that ‘suffering’ may not he entirely bad. While the first principle of medicine is that the patient’s best interests are paramount, sometimes the needs of the greater society conflict with the physician’s judgement about what is best for the individual patient. This is particularly pertinent to addiction, which affects not only the individual, but society as a whole. In such cases it is perhaps also our responsibility to convey to our patients that giving consideration to societal needs is an integral part of their recovery, because in the end they will have to live as a member of that same society with its structured mandates, laws and expectations.”
I confess that this made me feel very uncomfortable – it seems to suggest that frequent attendances are “regulatory mandates” and are primarily designed to control and importune our patients rather than be in the interests of their health. And what is more, that this is allowable because the requirement is (allegedly) helping to shape the patient from social deviancy to social conformity. Does anyone agree?
