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Reference: Heroin Addiction and Related Clinical Problems (the official journal of EUROPAD, European Opiate Addiction Treatment Association), June 7, 1999; 1(2):39-42 Policy Initiatives; Andrea Michelazzi, Franco Vecchiet, Tiziana Cimolino
In the summer of 1994, family doctors in Trieste (Italy) began to treat patients who had opiate drug-addiction problems by giving them methadone substitute therapy within therapeutic programmes decided in surgeries. The drug-addict became just a patient once again, often a chronic patient who could be treated in the family doctor's surgery. More than 50 doctors now prescribe substitute medicine in their surgeries, in Trieste.
In cooperation with the Health Authority and the Public Service, district surgeries have been opened, where five doctors of general medicine and a professional nurse work on weekdays, treating at most fifteen patients each. The basic idea of a family doctor treating a drug-addict patient is that of acknowledging the patient's right to health and right to choose, as a sick person who is asking for help.
In the summer of 1994, family doctors in Trieste (Italy) began to treat patients who had opiate drug-addiction problems by giving them methadone substitute therapy within therapeutic programmes decided in surgeries. This practice has been made possible by the nationwide referendum in April 1993 repealing some parts of the "Consolidations Act on drugs and psychotropic substances", a law regulating all matters linked with drug addiction.
It specifically repealed some subsections, or parts of subsections, of several articles, as listed below:
As the question was complex and delicate, it took some months for the Ministry of Health, in response to many requests for instructions, to issue a circular (No. 1110/1993) on how to interpret the remaining rules on drug addiction.
The role of the family doctor with respect to clinical procedure has changed completely. Before the referendum almost the only duty of the family doctor was that of reporting the drug addicts in his care to the Public Service, which then took complete care of them (from medical and welfare viewpoints).
After the referendum the family doctor has a role of great social importance, that is, he has the power to prescribe substitute medicines for opiates, but only in the form of methadone syrup, and he is no longer compelled to write a report, as cooperation with the Public Service is only recommended. He is therefore guaranteed an autonomy that enhances the value of the doctor-patient relationship, which is basic for any successful treatment.
The drug-addict became just a patient once again, often a chronic patient who could be treated in the family doctor's surgery. The relationship is based more on trust than on control. The circular also gave general instructions on distribution and the procedure to be used in prescribing substitute treatment.
In spite of this circular and others from the Italian Pharmacists' Association, pharmacies and storage depots were still without methadone. In July 1994, thanks to the cooperation of some political parties we were able to win the general public's interest by a number of articles pointing out the seriousness of the situation. Both doctors and the most committed politicians held lectures and talks on local television stations. At last, in July 1994, a substitute therapy could be initiated. Pharmacists were diffident at the beginning, but the ever-increasing number of prescriptions and responsive attitudes of patients had a positive effect. Nowadays the presence of a drug addict in a pharmacy causes no embarrassment or 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 Tossicodipendenze – COMBATT), connected with the Italian Drug-addiction Society (Societa Italiana Tossicodipendenze – SITD), which allowed doctors pioneering in this field to meet regularly in order to discuss results and work out a common procedure.
Following COMBATT's pressing requests, circulars from the Regional Health Office and the Ser.T showed the importance of the obligation that pharmacists should always have medicine, at least enough to cover two days of therapy, as it was considered a life-saving medicine included in the class "A" list. As for the prescription, we followed the instructions of article 43 (CTU 309/90), using the prescription-book for drugs marked by the Order of Doctors, and prescribing an amount of medicine large enough for at most eight days' therapy. No doctor took into consideration the administering procedure envisaged by article 42 (which considers it likely that the doctor will obtain methadone from a pharmacy after a request in triple copy, keep it in his or her surgery and have a proper register authenticated by the Local Health Authority) because it is less practical, and more complicated and risky (keeping methadone in surgery increases the chances of a break-in).
In the same period the Organization took part in the activity of the County Agency for 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 employed working in this field, whose shared aim is damage reduction, though they have other aims as well.
On 30 September 1994 the Ministry of Health in its circular letter No. 20, published in the Gazzetta Ufficiale (No. 241, dated 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 deep-rooted addiction and little intention of permanently giving up heroin. This importance is stressed by the fact that it could bring a reduction of the incidence of infectious viral disease (hepatitis, HIV), a reduction in the incidence of deaths from overdose, and a decrease in criminal actions connected with drug-addiction (thefts, selling drugs or prostitution are often the only means for getting the money necessary to buy heroin).
The Ministry's view was in accordance with our indications, even if some criteria of substitute medicine prescription, contained in the same circular, seemed too restrictive, appearing to contradict the law. The circular in fact requires the medicine to be entrusted to one of the patient's relatives – a close relative able to guarantee the proper use of the medicine. This procedure can take place for two days only, and is only allowed if the patient is undergoing a long treatment, if he has definitely given up heroin or any other drug, in the case of a clinical improvement, if he has resumed work, or if the patient is unable to leave his house for proven causes.
Conscious of this contradiction in the law, and wishing to follow the laws as strictly as possible, we tried to street a middle course between the more restrictive regulations and the less restrictive one, bearing clearly in mind the purpose of our work. In our opinion, in fact, in reacquiring dignity, the drug-addict patient cooperated in progressively accepting greater responsibility and in acknowledging his or her right to autonomously take the medicine. In any case, we must take into account parameters such as the patient's age, the absence of physical and psychological symptoms of abstinence, concomitant pathologies and their seriousness, the absence of behavioral problems, the adequacy of the patient's social environment, and the recovery potential of this therapeutic choice with reference to each patient.
The principal that characterized and continue to characterize our decisions on family care is that of guaranteeing the patient a free and autonomous therapy on the basis of 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 also capable of making him face the responsibility and autonomy that he had lost, been deprived of, or never possessed. This happens within the psychotherapeutic relationship with the specialist, especially as a result of 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 between territory services, family doctors and public service is, partly in relieving the latter of some of the work which would otherwise burden it on some occasions to the detriment of the quality of the action. Not all drug-addicts are unemployed, or pressured by social marginalisation, poverty or a crime ridden environment; many become addicts as the result of an almost irrevocable decision. The problem of social recovery is very important, so we do try to limit as far as possible (as with patients who have psychic problems) seclusion and to combat prejudice.
After the circular had been issued the doctors of the Organization held a refresher course on this subject, with the financial help of the County Agency for 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), so as to organize local course. More than 50 doctors now prescribe substitute medicine in their surgeries. In cooperation with the Health Authority and the Public Service, district surgeries have been opened, where five doctors of general medicine and a professional nurse work on weekdays treating at most fifteen patients each. At the moment four district surgeries are operational.
The basis idea of a family doctor treating a drug-addict patient is that of acknowledging the patient's right to health and the right to choose, as a sick person who is asking 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 between treatment from the public service, a family doctor or a district surgery reinforces the idea of personal dignity and makes the individual feel more at home in 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.
After these goals had been achieved, the decision was taken to end COMBATT
and forma "monothematic supraregional group" working on the topic
of family doctors and drug-addiction, within the Italian Drug-addiction Society
in order to broaden experience and improve the organization of scientific
supervision.