Background
The social and economic effects of alcohol and other drugs on society are substantial, but they largely depend on the type of drug. In 2010, alcohol use was the third leading risk factor for global disease burden [
1]. Alcohol use plays a role in more than 60 major diseases and injuries. Worldwide, it results in approximately 2.5 million deaths each year [
2]. Occasional or regular heavy drinking can damage health [
3]. In addition, the use of illicit drugs is an important and increasing contributor to the global burden of disease [
1,
4]. The United Nations Office on Drugs and Crime (UNODC) estimates that between 102,000 and 247,000 drug-related deaths occurred in 2011 [
5]. Cannabis is the most frequently used illegal substance in Europe [
6]. Benzodiazepine abuse is a problem that remains largely unrecognised in many countries [
7]. Europe has the highest average consumption of sedative-hypnotics and anxiolytics [
7].
In Belgium, 10% of alcohol consumers aged 15 or older are problematic drinkers [
3]. In 2008, 15% of Belgians reported having used painkillers, tranquilisers, or sleeping aids over the past two weeks. Over the past 12 months, 5% and 1.5% of the population had used cannabis and another illegal drug (e.g., MDMA, cocaine, and heroin), respectively [
3].
General practitioners (GPs) are considered to play a major role in detecting and managing the problems related to substance abuse, regardless of its legality. However, previous work by Glanz, Gabbay and Deehan in the United Kingdom demonstrated that GPs view alcohol or drug misusers as undesirable patients [
8‐
11]. Difficulty in managing and treating these patients raises concerns about the GPs’ feeling of competence and their confidence [
12]. Attempts to provide specific training on this topic by Strang and McCambridge showed a limited impact, particularly regarding motivational aspects; thus, a better understanding of GP views and perspectives on substance misuse and misusers is essential [
13‐
15]. In Belgium, little is known concerning GPs’ interests and attitudes toward caring for these patients or their management skills with regard to substance abuse behaviour.
This study is part of the “Up to Date” research project seeking to describe the approaches of GPs and occupational physicians (OPs) to the detection and management of the abuse of alcohol, illegal drugs, hypnotics, and tranquilisers among the Belgian population and to recommend ways to promote multidisciplinary collaborative care for these patients [
16]. This paper describes only the GP arm of the study; the symmetry between the GP and the OP arms limited the topic to the working Belgian population (18-65 years old).
Results
Predisposing factors: the influence of practice location
Practice location was perceived as a strong influence on GPs’ experience with substance abuse management: Urban locations, patients of low socioeconomic class, and a high proportion of migrants were associated with a higher perceived prevalence of abuse, especially illegal drugs.
“In general, all goes well because we remain… [in] the privileged countryside; there are very, very few (and I am not a racist) foreigners. I do not have a single drug addict among my patients. There are no secrets; we deal with people who are clever and live in satisfactory socioeconomic conditions”. GP 16, Female (F), 35 year (y), French-speaking (Fr)
Abuse was mentioned among patients with low socioeconomic level, young age, psychiatric problems, social and professional dysfunctions, private life problems, social and ethnic origin (migrants from northern Africa), unemployment, relationship problems, and child protection problems.
“Unfortunately, I think that more alcohol abuse occurs in less privileged environments, although in certain privileged backgrounds alcohol abuse also exists, and, in my opinion, even more so…. There is also a problem of medication abuse among families who are a little less privileged; this is the feeling that I have”. GP14, Male (M), 62 y, Fr
Some GPs cited the facilitating role of the capitation payment system because it allows extended consultation times. However, it was also thought to improve access among illegal drug and alcohol abusers, increase the referral rate from addiction treatment centres, and increase the number of addicted patients.
“Expertise is increasing in the medical homes because it is well known that we work in multidisciplinary teams; there is more global care, better accessibility, [and] therefore, naturally, [one cares for] people who withdraw from therapy or leave the Alpha centre etc…. The [social] workers… will maybe say to themselves… that a medical home will be more suitable because [it is a] more integrated… type of care than service providers who are on their own”. GP17, M, 37 y, Fr
In contrast, the fee-for-service system and individual practices were mentioned as being less in favour of substance abuse management. Specifically, the GPs mentioned difficulties with regard to refusing prescriptions for hypnotics and tranquilisers.
“If a patient only comes for a prescription, which is common because it is fee-for-service, then it is sometimes difficult to say, ‘I am not going to prescribe [that drug]’. And then the patient stands there asking, ‘Will I have to pay, then?’ Yes, actually; but that does make it difficult, ethically speaking. In our community health centre, I simply tell them, ‘I’m sorry. We can’t do that’. We can easily refuse”. GP 9, F, 29 y, Dutch-speaking (Nl)
Awareness factors: abuse management requires specific and nonspecific skills
GPs did not use peer-reviewed literature to support their practices. GPs, especially those in Flanders, mentioned the lack of guidelines regarding illicit drugs. GPs who supervised trainees in their practice more easily accessed such information.
“Mr. X reported that he occasionally uses cocaine. I think that is okay, but is it really okay? I would like to [review] the guideline; that [might] help me. [Then], if he comes back another time, I [would] know exactly what I should ask so that there is less guess work.... It does not have to be a novel or anything like that; something short… a consensus text, a guide… [that helps] you proceed with someone who reports [drug abuse]”. GP10, F, 43 y, Nl
The classifications of “misuse,” “addiction,” or “problematic use” were rarely known or used. The recommended maximum intake for alcoholic beverages by the World Health Organisation (WHO) was much better known than that for illicit drugs. Few GPs used screening tests for patients at risk, and some used the CAGE-test [
28]. GPs did not consider systematic screening as part of their job, or they did not feel comfortable doing so. Only a few GPs mentioned the use of blood or urine tests.
“Yes. Imagine that you have come for a consultation for the first time, and you have [dysmenorrhea]. Should I ask whether you use drugs? Yes, I am somewhat reluctant to ask that of everyone as a standard question.... No, I do not do that. Maybe I should; I do not know…” GP 2, M, 51 y, Nl
A confident relationship based on strong interpersonal skills and a patient-centred approach seemed to predict the successful management of substance abuse. Although this competency was central, it seemed to be due to the personalities of the GPs in Wallonia; specific training to encourage this behaviour rarely occurred. In Flanders, GPs more often considered communication skills training as conditio sine qua non to manage these types of patients. These skills included motivational interviewing, cognitive behavioural therapy, and systems thinking. GPs described patient management as a package of tailored and flexible interventions, built around shared and realistic objectives, appropriate to the real world.
“That depends on the objectives that you set [for] yourself: Is it to reduce risk, or is it to put an end to substance abuse? It is important to define that at the beginning”. GP17, M, 37 y, Fr
“Yes, the first thing is to open it [up] for discussion. They have to feel that they can discuss anything here. And that it can be discussed in a non-normative manner, now and in the future.… I frame it as a dilemma. You have to be able to come up with your own agenda. And I should not be able to determine your agenda; that is one ideal”. GP 2, M, 51 y, Nl
Important differences in training among the GPs were reported. Those who were most involved in substance abuse management had undertaken Continuous Professional Development (CPD) or network collaborations concerning this topic. Young Flemish GPs trained in communication skills specifically expressed that this training was particularly helpful for substance abuse management.
“You see, I guess you could say that I was trained before the war. We read a bit of theory about substance [abuse], but we did not know anything about conversational techniques. And that is what you need: how you should address it with this person or that person”. GP 8, M, 59 y, Nl
The GPs discussed how their attitudes changed as a result of becoming more experienced. Starting from an idealistic or anxious point of view, feeling intrusive, with little life experience and only their education, some of them gradually moved toward a more pragmatic method of addressing abuse without antagonising the patient.
“For example, with a 60-year-old man with an alcohol problem… because of my age and the comfortable life that I lead, you almost feel guilty pointing fingers and saying, ‘You have a problem,’ you see. I cannot imagine it; I say that as well”. GP 1, F, 29 y, Nl
Motivation factors: GPs’ personal representations influence management
Personal, familial, or professional experiences of substance abuse were mentioned as influencing GPs’ behaviours toward patients who exhibited these behaviours. Some GPs refused to treat these patients, whereas others cared for them with increased empathy and consideration. Personal histories, deep emotions, or emotional burdens influenced the GP’s choices with regard to addressing and managing patients who abuse substances. The balance between caring for one’s patients and caring for oneself seemed to directly affect GPs’ behaviour.
“I fell into a depression then as well. I learned a lot from it personally, but I certainly use it in my daily work as well. And I think that I can sense very quickly if someone is not feeling mentally up to par; I can recognise it quickly. The personal experience makes me more sensitive, I think. It certainly plays a role”. GP 3, F, 35 y, Nl
Because substance abuse management can be challenging and stressful, the GPs said they had to identify, assess, and control their own emotions when dealing with it. With experience, certain skills are developed and additional self-care strategies are adopted. Even when their motivations (i.e., attitudes, social influence, and self-efficacy) were highly positive, the fear of not being able to personally or emotionally cope might cause GPs to refrain from becoming involved.
“Is it artificial [to find a meaning in becoming involved with these patients]… to hold on and be happy in my job, even if it does not pay dividends? Or is it therapeutically useful? Well, that is my question”. GP 18, F, 32 y, Fr
The GPs’ perceived self-efficacy depended on positive physician-patient relationships, confidence in their own skills, and positive emotions. Time constraints and personal involvement were cited as important barriers for managing patients who required more time, especially when the chances for success are limited.
“No. That is not very easy for me. It is a sort of intimacy, like when you are talking about sex. Or… it has a normative character… or something like, “How dare you ask me that?”… I think that I project that onto the patient. I do not know whether the patient thinks that. Perhaps the patient thinks that it is a normal medical question”. GP 2, M, 51 y, Nl
When treating addicted patients face-to-face, two attitudes emerged: The GPs either considered substance abuse as a chronic disease (and therefore part of their routine clinical activities) or they expressed moral judgements about these patients, highlighting their faults and responsibilities with regard to clinical and social damages, and considering them untrustworthy. This second attitude reduced GPs’ willingness to manage substance abuse.
“I cannot stand drug addicts because they are liars, and I do not like liars; alcoholics are liars too, but the former are the worse, especially because of substitution therapies…. Drug addicts are utter and complete liars, and I believe that [caring for them is not my responsibility], it is the medical centres’”. GP 19, M, 58 y, Fr
GPs perceived a primary responsibility to manage substance abuse. Some GPs were strongly engaged in their coaching role, supporting patients with regard to accepting their responsibilities and providing strength to allow them to face life’s difficulties.
“When [I] treat an alcoholic who drinks and knocks someone over, I feel personally responsible…“. GP 11, M, 51 y, Fr
Some GPs also reported having a positive attitude with regard to this aspect of their job. In fact, many said that these responsibilities are what being a GP is all about.
“I always find it rewarding [to see] an alcoholic who is no longer dependent, who moves forward in life, who is more autonomous than before, who has a better quality of life in the broad sense. It is his life, it is his quality of life; but I think that if I, at any given moment, have been able to help him to reach this autonomy, well, that is good. […] I think that this is our role as doctors”. GP 13, M, 43 y, Fr
However, satisfaction with regard to dealing with addicted patients was rare. Substance abuse was described as a complex problem that requires long-term, staged follow-up assessments that proceed at the patient’s pace and are associated with many relapses without any outcome certainties. GPs often considered abstinence to be a long-term goal. Negative past experiences gave some GPs a feeling of impotence.
“There is weariness with regard to morally supporting people. We must accept (and the patients must also accept) that we may not be able to cure them, but that we are there to help them…. It is difficult to unceasingly return [to] a problem that one cannot solve; it is not very rewarding on a medical level; it is easier to cure people…” GP 12, F, 55 y, Fr
Some GPs considered the use of all illegal drugs as abuse, whereas others considered this use as abuse only when it affected the patient’s health or social life. Cannabis was often tolerated for recreational use and was considered common among young people. Alcohol was much more socially acceptable than other substances; moreover, alcoholism was easier to address than psychotropic drug abuse. Some GPs were more tolerant of psychotropic drug abuse (particularly among elderly people), whereas others considered it to be a growing problem, and some of them felt partly responsible for initiating psychotropic treatment among patients looking for help with critical life events.
Intention state: GPs also proceed through a motivational process
The GPs were concerned about possible breakdowns in the therapeutic relationship; therefore, they often delayed the beginning of interventions until they perceived an opportunity to discuss the abuse with their patient. After the problem was broached, the patients were made aware that the GP’s door was open for additional dialogue. This behaviour was part of the contemplation stage.
During the preparation stage, the GPs sought opportunities to broach the subject with the patient, for example, when both parties had sufficient time and when the context was appropriate (i.e., not during mourning or immediately following job loss, divorce, and so on).
“Sometimes you ask about [the drug abuse], and you know that they are lying. Then you know, [now] is certainly not the time to go into any depth because the patient does not want to hear about it.... Then you just leave it alone for a while. In many cases, these are the types of patients who will be back. You just know that”. GP 1, F, 29 y, Nl
GPs relied on their clinical competence, and various reasons were used as opportunities to broach the problem of abuse, including repeated requests for sickness-absence certificates or drug prescriptions, physical stigmas and symptoms of acute trauma, social malfunctioning reported by either the patient (sometimes) or his or her relatives (more often), or simple intuition (i.e., a “gut feeling”).
“The family also puts pressure on us, especially the parents. There are parents who beg us to do something, really; and then we initially see the parents 3-4 times before seeing the child because the latter does not want to see us at all”. GP 14, M, 62 y, Fr
Ability factors (and barriers): one cannot handle this alone
The GPs expressed their need to collaborate with other caregivers in multidisciplinary networks, primarily for psychological and social reasons. The opportunity to collaborate easily with other professionals was perceived as an advantage of multidisciplinary teams. Some GPs asked about a place for information and peer exchange for support in case of pitfalls and feelings of impotence. Others asked for financial and organisational incentives. In group practices, electronic medical records provide the opportunity to share information and alert GPs to possible drug abuse or patients at risk for aggression.
Referrals to psychiatrists or psychologists were difficult and often too expensive for most patients. The waiting list at specialised care centres was a major concern among the GPs.
“If you have a patient who has been addicted for a very long time, [then it is frustrating] once you have finally gotten him motivated to go into detox, and there is nothing available. People often drop out then, you know. They say, ‘I just don’t care anymore’ or ‘I don’t want it anymore’ or ‘I can solve my own problems’. And it is with precisely these people that you need to strike while the iron is hot, so to speak. This is the ideal time to admit someone. But then the moment is gone, and it is actually too late”. GP 7, M, 39 y, Nl
Authors’ contributions
All authors participated in the design of the study and construction of the interview guide.
FK, LS, ML and MV conducted the interviews; FK, LS and ML analysed the results with the help of LP and MV. FK drafted the manuscript. MV was the coordinator of the Up to Date research project, which includes this study. All authors read and approved the final manuscript.