1. P RIMARY H EALTH C ARE FOR IDU S Dr Hester Wilson

2. I NTRODUCTION Chronic illness Accessing care Barriers to care The challenge of working with IDUs Solutions?

3. IDU S ARE AGING Median age in my general practice 47yo (27-63) Median age at NSPs 36yo (2008) Median age new registants at MSIC 30.9yrs (2001) 35.3yrs (2009) Older IDU more likely to be male, have prison history and inject morphine (IDRS 2009)

4. C HRONIC ILLNESS 77% of Australians over age 65 have at least one chronic illness National health survey 2008 ABS CVD 16% Arthritis 15% most OA Mental health 11% Asthma 10% Diabetes 4% Osteoporosis 3% Cancer 2%

5. C HRONIC ILLNESS AND POVERTY Graded relationship between death rates and SES (4yrs for men and 2 yrs for women) Higher rates of disability (3.1% in low SES compared to 1.3% in high SES)

6. I LLNESSES DIRECTLY AS A RESULT OF INJECTING OD 1/10 non fatal OD in past 12 months Organic brain injury BBV Injecting related harm Acute issues cellulitis, SBE, DVT, septic arthritis, arterial occlusion etc, leading to chronic issues, Disability Chronic pain Chronic venous disorders

7. IDU S AT INCREASED RISK OF C HRONIC ILLNESS Lifestyle Smoking Other drug/ETOH use Poor nutrition Under/overweight Not undertaking preventative measures ie pap smears

8. B URDEN OF ILLNESS Pilot study of 3 large GP in Dublin, patients on methadone Mean age 37.2 90% at least one other chronic disease (significant difference to control group) Most commonly HCV, depression, asthma, HIV, back pain, GORD, DVT/varicose veins 68% other regular medication US study in 2007 part of longitudinal study of risk factors for heart disease 3000+ used a general scale predicting mortality and health care use found health decline in young users that continued after ceasing use

9. Chronic venous disorders Pain, heaviness, fatigue, oedema, non healing ulcers Occurring in young IDUs Increased risk with injecting in legs and feet ?increased with pills and methadone Due to DVT, injury, immobility, mobility restriction (calf muscle function) Next slide graphic! Pieper et al Archives Internal Med 2007

10. C HRONIC ULCER DUE TO TEMAZEPAM GELCAPS

11. M ENTAL H EALTH IDUs higher incidence of than general community of depression Anxiety Higher levels of psychological distress (K10) DUI Treatment of co morbidity complex and little evidence to guide treatment

12. CVD Smoking Weight BP Cholesterol Diabetes/insulin resistance GPs underestimate absolute risk of CVD in general population and under treat Heeley et al 2010

13. O STEOPOROSIS Risk factors; Underweight Family history Smoking ETOH Caffeine Liver disease 20-53% in cirrhotic viral hepatitis Significantly reduced BMD, correlates with degree of fibrosis Hypogonadism Decreased free testosterone Amenorrhoea for >6months before age of 40 Women early onset with increased morbidity and mortality Are they being screened?

14. C ANCER Smoking Poor diet Not getting screening Mammograms Pap smears FOB Prostate

15. A CCESSING CARE What evidence that IDUs access care? Dublin WA study, MJA 2010 Do access care but.....

16. C ONCLUSION FROM WA STUDY ‘Relying solely on GPs to provide preventive services may be insufficient, given the complex care needs in this group of people. A system-wide, multidisciplinary and coordinated approach,.. with building a strong community-based MHS system,... may be part of the eventual solution to health inequities in this vulnerable and sizeable population.’

17. B ARRIERS TO CARE -C LIENT ISSUES Life still focused around drug use and health secondary Organic brain injury Access Stigma Stops drug users seeking treatment (Kelly & Westerhoff 2010) Stigma about drug use Community survey in UK 45% pop think heroin users only have themselves to blame 1998-2003 change from 68%-60% Didn’t think would still be here Don’t deserve it

18. B ARRIERS TO CARE -P RESCRIBER ISSUES Get caught up in dealing with pharmacotherapy Clients often have separate GP Very little communication between prescriber/service and GP Dealing with crisis issues Lack of focus on recovery model?

19. T HE ROLE OF AOD SERVICES Can AOD services manage complex chronic medical conditions in the aging IDU? Should they? The ‘one stop shop’ ‘GPs ideally placed to do everything’ see 80% of community each year

20. B ARRIERS TO CARE -GP ISSUES Don’t assess Don’t know what to do with results of assessment Don’t feel supported Don’t have time Difficult, resistant, manipulative patients Frightened Non attendance Dealing with AOD issues not part of core business Dealing with crisis presentation

21. GP KNOWLEDGE OF HCV Confused about testing 42% aware of effectiveness of treatment 28% aware of eligibility criteria 52% people referred MJA 2009

22. G ENERAL P RACTICE Private fee for service- small business If people don't attend don't get paid Not adequately remunerated for managing complex conditions over time Appointment versus walk in Waiting room Isolation Untrained receptionists The case manager GP

23. C ULTURE C HANGE Experience with MH SSRIs GP training Increased confidence dealing with high prevalence conditions ATAPS Medicare access Better engagement with specialist services New initiatives- through GP agencies These changes haven’t transferred to AOD

24. W HAT ARE THE GOALS OF TREATMENT ? Harm reduction from drug use Assist client to have a life of meaning Respect Connection to community Good physical and mental health outcomes Clients needs met through mainstream services where possible

25. H OW DO WE DEAL WITH THIS ? If this were easy, would be solved More funding, new, novel ways to deal with this What role can AOD services have to assist with care Engagement Up skill GPs Provide support Share care- more fluid model Better communication Assist patients to access GP Be proactive doing this More research