Addiction care often has to deal with ‘care avoiders’. Care avoiders are people with problems who do not or hardly accept help. Emergency services increasingly have to operate independently. Primary care must also be strengthened. There must be space and sufficient time for the care provider in the field to approach his or her clients creatively and provide the right care. Addiction care requires patience and creativity to provide appropriate care. In many cases, people do not ask for help to quit, but rather practical solutions. To get a good idea of what a care provider has to deal with, we first outline a number of practical cases.
Case 1 Delirium
59 year old man, heavy problem drinker, drinks 1 liter of gin per day. Been admitted several times for treatment. Comes for an interview on Friday afternoon. Want to stop drinking immediately. Consult with your GP about supporting medication to suppress withdrawal symptoms. However, the GP does not want to see the client during consultation hours because it is five to five on a Friday afternoon. The GP also wants to prevent a crisis situation for colleagues during the weekend. The GP advises that the client continue drinking during the coming weekend and that after the weekend he or she can stop drinking and start taking medication.
Contact your GP
This case requires knowledge, competencies and confidence in which a care provider should have good connections and cooperation with primary and secondary care, in this case the general practitioner. There is a need for medical support, especially in the evenings and weekends. Most institutions are often unable to provide this care and can only provide (telephone) support, but that is still limited. What is recommended in this case:
- Do not stop drinking immediately. There is a risk of delirium or psychosis. After all, the client has been drinking for quite some time, sometimes for decades.
- Make good agreements with your GP. Make an appointment for Monday.
- Make quarters. Ask or motivate who can be informed of his intention to quit.
A 42-year-old man, a serious problem drinker, divorced and living alone. Has good and bad periods. A care provider has good structural contact with him. Despite the good contact, this cannot prevent the man from having at least one bad period every year. He drinks a few liters of strong beer, port, and sometimes if he has extra money to spend, whiskey or other spirits every day. The bad period varies from three weeks to three or more months. He then hardly eats or eats at all. The man has been admitted several times and he no longer does so. Has characteristics of Narcissism and/or PTSD. There is a suspicion that he may have acquired the latter during a deployment to a war zone, but he has never been diagnosed with that. Is often emotional during the bad period and constantly falls into the role of victim and is ambivalent towards a (detox) admission. Want to and don’t want to and, know everything better. The GP deals critically with his requests for help and the crisis service also prefers not to come immediately. He reverses his day and night rhythm and sometimes spends days in bed with a bucket next to him to vomit. Sometimes he neglects himself so much that he has to be taken away by ambulance and admitted to the hospital emergency room.
Collaboration with the general practitioner in addiction care
In this case, the care provider could achieve good connections and cooperation with primary and secondary care. The care provider can take a correct history during the bad period, giving the client new insight into his addiction and clinical picture. This allows him to be reassured and guided at home until further action appears necessary. This can prevent (frequent) contact with the GP or a hospital admission. The risk for heavy alcoholics is that those around them are powerless to prevent him or her from reaching for the bottle again. Alcoholics are often or feel lonely. In most cases this is simply due to the drink, but sometimes they could not do anything about the actual cause. As a care provider, try to clarify this. What is striking in this case is that it is mainly the loneliness that causes the client to drink. In this case too, it is recommended to take 15 minutes. Inform people in his area to visit regularly or throw a card through the mail. However, it also appears that the man lacks the capacity to judge and can therefore become a danger to himself. One can then possibly use a Judicial Authorization (RM) as an emergency measure. However, this is a means of deprivation of liberty and therefore the mayor must always be involved.
Boy 30 years old, living alone, heavy problem drinker, cocaine and cannabis use. Admitted to mental health care with dual diagnostic treatment. Medication was coordinated during admission. Is open about his use, and sometimes in denial. Little or no recognition of its problematic use. Recognizes his psychiatric problems. The house is a place that is used structurally with friends. The young man and five friends can be classified as ‘care avoiders’. Police and emergency services regularly visit. Mental and somatic health is visibly deteriorating. Personal social and financial circumstances are also deteriorating. In the past, ‘crisis situations’ have arisen regularly. After several contacts with the GP and a visit from a psychiatrist from the crisis service, he was still not motivated for admission.
Short lines of communication with the GP
In this case, good judgment is needed during critical moments. The man does not have a direct request for help about his use, but he does need good advice and support. The group around him also uses alcohol and cocaine excessively. As a result, they may develop psychological and somatic health problems. In this situation, the care provider can provide advice and support regarding medication and, if necessary, referral to treatment.
Healthcare worker as a jack-of-all-trades
Addiction care providers have more and more on their plate. He or she must be confident and have a number of basic competencies:
- Connects to current developments in the field such as strengthening primary health care and outpatient care.
- Making a ‘good’ diagnosis.
- Can work independently.
- Has good contact with general practitioners.
- Has connections and collaboration with mental health care and addiction care.
- Sufficient social skills
- Sufficient knowledge of medication and psychiatric conditions
- Knowledge of diagnostics and treatment
- Can approach client system and network well
- Has knowledge of Public Mental Health Care (OGGZ)
- Is stress-resistant
- Knowledge of addictive substances
- Has a vision on policy, quality, innovation and further development of care
- Is empathetic, humorous, creative, patient and tactical