GPs working in disadvantaged areas have reiterated their call to address the “severe lack” of dual diagnosis services, among other requirements.
Dr Bríd Shanahan, Clinical Lead of Deep End Ireland, informed the Medical Independent that the group welcomed the recommendations in a new Medical Council report on overprescribing of addictive medications – particularly the need for greater access to counselling, addiction services, and pain management (see news feature, page 10).
However, she said the primary issue faced by GPs in Deep End practices was the “widespread” use of non-prescribed benzodiazepines, rather than the overprescribing of these drugs.
“Many of our patients self-medicate with these drugs to cope with distress and anxiety stemming from significant trauma. Unfortunately, there is a severe lack of dual diagnosis services, meaning that patients with both mental health and addiction issues struggle to access appropriate care,” according to Dr Shanahan.
Due to drug use, many patients are denied access to services such as community mental health, Counselling in Primary Care, and longer-term therapy through the Rape Crisis Centre following sexual violence. In addition, only a fraction of the HSE dual diagnosis teams recommended in the model of care in 2023 have been established to date.
“While voluntary sector services provide excellent addiction counselling, their availability varies significantly depending on the area, leaving many patients without access to support. Furthermore, many of these patients require psychiatric input, which is simply unavailable. This leaves prescribers in Deep End practices with very limited options to support these vulnerable individuals effectively.”
Dr Shanahan also cautioned that Deep End GPs are seeing “rising levels” of crack cocaine use, further exacerbating the need for appropriate addiction services.
“Unlike heroin, which could often be managed in the community with opioid substitution treatment, crack cocaine use requires residential detox. Many patients using crack cocaine also have concurrent benzodiazepine dependence. It is not possible to tackle their benzodiazepine addiction while they are still using crack cocaine. The lack of available residential detox and stabilisation services means that many of these patients are left without any viable treatment options, further entrenching their addiction and associated health risks.”
Asked if the HSE’s social deprivation grant has been useful in implementing deprescribing clinics, Dr Shanahan stated that some Deep End practices have used the grant to fund addiction counselling for their patients.
“However, this has been difficult to sustain, as the grant has not always been paid when expected, and addiction counselling represents an additional service within already stretched practices. Many other practices have used the grant to fund extra doctor hours, allowing GPs more time to manage their complex patients, many of whom have addiction issues. While this additional time has been invaluable, the underlying lack of specialist services means that GPs are still left managing highly complex addiction cases without adequate external support.”
Dr Shanahan emphasised the need for increased investment in trauma-informed care within primary care settings.
“This should include enhanced funding for existing services such as the National Counselling Service, enabling them to manage complex dual diagnosis patients and ensuring these services are accessible within deprived communities, where the need is greatest.”
She concluded: “Overall, while resourcing prescribers is important, the real issue is the absence of appropriate services for our patients. Without these, GPs are left managing patients in impossible circumstances with few viable options beyond continued prescribing in cases where patients are already on prescribed benzodiazepines.”
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