metricas
covid
Buscar en
Atención Primaria
Toda la web
Inicio Atención Primaria Commentary: Adapting Resources to the Needs of Drug Dependent Persons: How Much ...
Información de la revista
Vol. 32. Núm. 6.
Páginas 327-329 (octubre 2003)
Vol. 32. Núm. 6.
Páginas 327-329 (octubre 2003)
Acceso a texto completo
Commentary: Adapting Resources to the Needs of Drug Dependent Persons: How Much Longer Will Standardization Take?
Comentario: Acomodar la oferta a las necesidades de los drogodependientes: ¿para cuándo la normalización?
Visitas
2976
M. Melguizo
Contenido relacionado
C Navarro Cañadas, P Bachiller Luque, T Palacios Martín, P Ruiz Muñoz, M Herrero Baladrón, I Sánchez Litea
Este artículo ha recibido
Información del artículo
Texto completo
In the last 30 years Spanish society has faced serious health and social problems arising from drug dependence, and it cannot be said that care for drug dependent individuals has been standardized. Recent years have seen important changes in tendencies and patterns of drug use: the percentage of women addicts is increasing, and the age of first contact with toxic substances is now as low as 13 to 15 years—a factor that increases the risk of addiction. Moreover, an increasing variety of toxic substances are now being consumed, and the use of substances viewed as «normal» as well as access to them are on the rise. Multiple drug dependence is now the rule rather than the exception, and this makes it difficult to develop effective therapies. Substance use, for many, has ceased to be a daily, compulsive activity and has become an occasional but habitual behavior associated with leisure time activities on evenings and at night, during parties and on weekends. The route of administration has changed, mainly among consumers of heroin and opioids, such that pulmonary (smoking heroin in a pipe or inhaling fumes from aluminum foil) and intranasal routes (sniffing powdered material) have replaced intravenous use.

Drug addiction has also changed from a social standpoint, and is now viewed as a «normal» situation removed from marginality and delinquency. The view of the junkie as a jobless outlaw living in poverty and suffering from associated infectious diseases has been superseded, although not entirely forgotten. In its place has emerged a new type of addict: the younger, weekend user who consumes multiple drugs and is socially well adapted (at least initially), and who has fewer associated infectious diseases. However, because of variations in the types of substance consumed, their affordability, and the duration of drug use, these persons form a heterogeneous group in which social stereotypes have blurred. Some dependent persons are extremely marginalized, increasingly ostracized and condemned to social euthanasia, whereas others are part of a distinguished crowd living the superficial life of a socialite addict.

With regard to health care, we are facing a situation marked by transition in which the epidemic spread of hepatitis C, hepatitis B, HIV infection and tuberculosis in persons dependent on opiate drugs has largely been contained. Current alarm originates not from the health service, but from rising AIDS-associated morbidity and mortality, which has triggered the search for «clean» drugs that avoid needle sharing and intravenous injection. The study in this issue by Navarro Cañada et al reports alarming figures for the prevalence of HIV and hepatitis C infection, the consequences of which will be felt in the middle and long term. The recurrent but largely neglected tuberculosis problem merits particular attention. In addition, we should realize that prevalence studies always miss the most severely marginalized group of opiate dependent persons who constitute an «unassailable stronghold» that social and health services fail to reach.

As in other levels of health care, the involvement of primary care in providing help for drug dependence has been inadequate, and it is only in recent times that there has been a firm commitment on the part of regional health systems to do their part in caring for these patients. The response to this problem has historically been to outsource care for drug dependent persons. The causes of this neglect have included:

– Non-appreciation of drug dependent individuals as patients

– Inadequate involvement of the health system in care for drug dependent persons until they come to be considered infectious disease patients. This has favored the appearance of poorly coordinated parallel systems.

– Lack of flexibility (based on a cure-oriented mentality) in considering detoxification and quitting the only possible treatment for drug dependence.

In the near future we may hope to see health professionals commit to three specific goals: accepting heterogeneity among drug dependent individuals, diversifying therapeutic strategies, and devoting greater resources to health care and coordination between programs.

Drug dependent persons differ in the number of substances they use (one or more than one), the type of consumption, and their attitude toward drug use. Users of illegal drugs are always one step ahead of health care professionals in terms of knowledge about the substances they consume, and this obliges us to constantly update our own knowledge. Although we have traditionally associated drug dependence with opiates and their derivatives, the use of (for example) synthetic drugs is a reality, and their consumption is increasing as reflected in the changing patterns of drug use in the last decade. These drugs are associated with other substances, a feature that increases the risk of acute intoxication and makes treatment difficult. Antidotes are not available for some synthetic drugs, and there is already evidence of irreversible neurotoxic damage whose middle and long term effects remain unknown. Therapeutic options need to be diversified in accordance with the health needs and the wishes of drug dependent patients. As the article by Navarro Cañada et al points out, activities aimed at damage reduction (e.g., needle exchange and heroin prescriptions) are just as legitimate as high-commitment, drug-free programs. Three degrees of intervention have been established depending on the level of commitment required from the drug dependent patient:

– Low: administration of opioid agonists and medical supervision.

– Moderate: As in low-commitment programs but with social and educational support in the form of workshops and resources for economic and judicial rehabilitation.

– High: As above but with psychotherapeutic support in the form of educational therapy and treatment for psychological disorders.

Another issue centers on cost effectiveness evaluations for each type of intervention. Any option that leads to improvements in the health, social situation or social cohesion and integration of drug dependent persons and their families is acceptable.

Increased efforts on the part of the health care system, and particularly primary care services, are indispensable. Drug dependent persons should be considered persons who are ill, and therefore as patients who can benefit from preventive interventions or specific treatments. In addition, they should be considered as persons who have asked for help. No other type of user has the potential to benefit more from the features intrinsic to primary care: access, integral care, continuity and a biopsychosocial approach to care. Thus the commitment of primary care teams needs to go beyond mere gestures.

Naturally there will be situations for which there is no appropriate treatment. Such patients should receive care that maximizes their chances of staying alive and enjoying an acceptable quality of life. This, in fact, is the same approach as is desirable for patients with any chronic illness.

When this approach is used for all patients with chronic health problems, we will have achieved the standardization that Navarro Cañadas and colleagues urge us to aspire to, and that is surely within our reach.

General references

Barrio G, Bravo MJ, De la Fuente L. Consumo de drogas en España: hacia una diversificación de los patrones de consumo y los problemas asociados. Enf Emergencias 2000;2:88-102.

Cabrera J. Ante un cambio, una respuesta: drogas de síntesis en España. FMC 2002;9:514-23.

Claramonte X, Nogué S, Monsalve C. ¿Nuevas drogas de diseño?, ¿nuevas drogas de síntesis? FMC 2002;9:323-34.

Puigdolers E, Cots F, Brugal MT,Torralba L, Domingo-Salvany A. Programas de mantenimiento de metadona con servicios auxiliares: un estudio de coste efectividad. Gaceta Sanitaria 2003; 17:123-30.

Opciones de artículo
es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos