Working effectively in primary health with people who inject drugs

By Barb Williams, Credentialed Mental Health Nurse, North Richmond Community Health, Shelley Cogger, Policy and Projects, Medically Supervised Injecting Room, North Richmond Community Health, and Helen Easterby, Quality and Evaluation, Health Independence Program, St Vincent’s Hospital 

Source: APNA Primary Times Winter 2023 (Volume 23 Issue 1)

In order to access the health care they need in a timely manner, people who inject drugs need support to establish a therapeutic and trauma-informed relationship with primary health care (PHC) providers. Here, we describe the findings and recommendations of a recent study exploring the barriers and enablers to accessing PHC among a community of people who inject drugs in Melbourne.  

People who inject drugs often report their experiences of accessing PHC as stigmatising and discriminatory.1 This can lead to avoidance of PHC services, resulting in acute presentations to hospital emergency departments (EDs).2 

People who inject drugs are at risk of a variety of health conditions related to their drug use and socio-economic status.3 These include skin infections at injection sites, abscesses, emboli, blood-borne viruses, sexually transmitted infections and mental health conditions.4 Many of these conditions can be effectively diagnosed and treated at the PHC level, reducing the need for an ED presentation. Histories of childhood trauma and post-traumatic stress disorder are prevalent in people who inject drugs.5 It is incumbent on PHC nurses and other health professionals to understand how trauma can affect a person’s physical and mental health in the short and long term. Providing all health professionals with training on trauma-informed care is critical to the development of a therapeutic alliance with all patients, regardless of a history of injecting drug use.6  

In 2021, a mixed-methods study using a sequential explanatory design was conducted with people who inject drugs to explore what they saw as the barriers and enablers to accessing PHC. Whilst questions specifically related to general practitioners (GPs) and EDs, the results can be translated to all health professionals in all health-care settings. Surveys were conducted with 100 people who regularly inject drugs, primarily heroin. Prevalence of self-reported diagnosed physical health (87%) and mental health conditions (80%) was high. The two main barriers identified by participants to seeing a GP were not being listened to and being judged negatively. Similarly, the two main enablers were being listened to and not being judged. These enablers contribute to the development of trust and rapport between health professionals and their patients. Semi-structured interviews were conducted with 17 survey respondents for a more in-depth exploration. 

Barriers 

Five main themes were identified as barriers: 

  • “Why do you treat me differently to everybody else?” 
  • “I want to be honest with you, but I don’t like the consequences.” 
  • “I feel pain like anyone else so why do you expect me to put up with it?” 
  • “Why won’t you listen to me?” 
  • “Withdrawal is the worst.” 

All participants reported feeling negatively judged by health professionals at some stage due to injecting drug use. When asked to describe what this negative judgment looked like, they described perceiving subtle signs from the GP, such as changes in body language; being spoken to in a curt, rude or patronising manner; and the GP opening the door and prematurely ending the consultation. Some participants also described experiences of overt judgement when it was known that they had a history of injecting drug use. One participant reported being accused of using pain relief for “pleasure” during childbirth. This stereotyping of people who inject drugs was distressing to participants and contributed to their perception that they were not treated like other people.

Practising through a trauma-informed lens should be an essential component of all health professionals’ practice. 

Participants expressed a desire to disclose their injecting drug use to health professionals to enable more appropriate treatment of their presenting health problem. However, they often found disclosure led to the health professional not listening to them and ignoring their symptoms, or all of their symptoms being attributed to injecting drug use and not being investigated. Complaints of pain were often ignored or viewed as drug seeking. Withdrawal was experienced by participants as something to avoid at all costs. As a barrier to care, withdrawal prevented participants from riding out long waiting times for GP appointments and staying in hospital, particularly when withdrawal management was not offered in a timely manner. 

 

Enablers 

Three main themes were identified as enablers: 

  • “Treat me like a human being.” 
  • “I need to know you care about me as a person.” 
  • “It’s so much easier when they know about injecting drug use.” 

For participants, being treated equally as human beings involved respect and being listened to. Being enabled to speak honestly about injecting drug use was a fundamental component of positively engaging with health professionals. Participants’ accounts showed they had an acute awareness and heightened sensitivity to negative and judgemental behaviour towards them. Being conscious of using non-stigmatising language and not stereotyping people based on injecting drug use is particularly important in engaging patients in person-centred care. Participants described how having a health professional show interest in their health and wellbeing conveyed that they cared about them as a person. They also reported often receiving better and fairer treatment from health professionals with an interest in injecting drug use.  

 

Recommendations 

We provide six simple recommendations from the findings of this study to better engage people who inject drugs within the PHC setting: 

  • Recognise the inherent dignity and worth of all your patients. 
  • When a patient reveals they inject drugs, thank them for sharing this personal information and provide care in the same manner you would with anyone. 
  • Show the patient they have been heard by validating their experiences. 
  • Focus on what the patient first presents with, then ask them if they have any other physical or mental health concerns they would like to discuss.  
  • Be familiar with health problems that can occur with injecting drug use (such as skin infections) and manage these proactively. 
  • If you have a colleague who knows and understands about injecting drug use, ask them if they can assist you and learn from them. 

 

Conclusion 

Health care free of stigma and discrimination is what anyone would want or expect from PHC nurses and other health professionals. If you listen and show respect, concern, and care for a person who injects drugs, you are much more likely to have these values reciprocated. Understanding the effects of trauma and practising through a trauma-informed lens should be an essential component of all health professionals’ practice. Engaging people who inject drugs in their health care and building a therapeutic relationship will increase your ability to improve patient outcomes through the provision of health-promotion advice along with preventive and early intervention care. It will also enhance your capacity to provide harm-reduction advice and have honest and open conversations about reducing or ceasing drug use when your patient is ready.  

 

Acknowledgement 

This study was funded by a grant from St Vincent’s Health Melbourne’s Research Endowment Fund. 

 

Note: Barb Williams is a credentialed mental health nurse with expertise in trauma-informed care.

 

 

 

 

Shelley Cogger has extensive experience working with people who inject drugs in health and research settings.

 

 

 

 

Helen Easterby has wide-ranging experience in quality and research initiatives. 

 

 

 

 

 

 

References 

1 Jason Hargraves, We live with it almost every day of our lives: An AIVL report into experiences of stigma & discrimination, Australian Injecting and Illicit Drug Users League (AIVL), Canberra, 2015. 

2 A Farrugia, S Fraser, M Edwards, A Madden and S Hocking, ‘Lived experiences of stigma and discrimination among people accessing South Western Sydney Local Health District Drug Health Services’, La Trobe University website, 2019, accessed 30 June 2022. www.latrobe.edu.au 

3 B Muncan, SM Walters, J Ezell and DC Ompad, ‘“They look at us like junkies”: influences of drug use stigma on the healthcare engagement of people who inject drugs in New York City’, Harm Reduct J, 2020, 17(1):1-9, doi:10.1186/s12954-020-00399-8.https://doi.org/10.1186/s12954-020-00399-8 

4 J Saunders, K Conigrave, N Latt et al. (eds), Addiction medicine, 2nd edn, Oxford University Press, Oxford, 2016. 

5 E Somer, ‘Trauma, dissociation, and opiate use disorder’, Curr Addict Rep, 2019, 6:15–20, doi:10.1007/s40429-019-0236-0

6 R Wade, ‘Rapid review on trauma-informed care in primary care settings: summary report’, General Practice Mental Health Standards Collaboration website, May 2022, accessed 3 March 2023. https://gpmhsc.org.au 

The Australian Primary Health Care Nurses Association acknowledges the Traditional Custodians of country throughout Australia and their connections to land, sea and community. We pay our respects to elders past and present and extend that respect to all Aboriginal and Torres Strait Islander peoples today.


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