Training Program in the Field of Addiction Medicine – An Experience of Learning While Abroad

Abstract

This paper illustrates the training program in the field of Addiction Medicine designed for primary care doctors by the Department of General Practice, School of Primary Care at Monash University in Melbourne. The nine month program was based around coursework, field visits and clinical observations. There were five modules that were completed and passed, twenty six Continuous Medical Education sessions attended, twenty nine field visits on Drug & Alcohol services, forty seven clinical visits and a total of three hundred and sixty clinical observations made. The comprehensive training program has benefited the first author in several ways to improve the Drugs & Alcohol services in Malaysia.

INTRODUCTION

Drug addiction is a major legal, social and health issue in Malaysia. The situation has become worse in recent years with the emergence of blood borne virus diseases associated with injecting drug use The health needs of the drug users have become more complex. According to a joint study conducted by the World Health Organization, Ministry of Health Malaysia and the Northern University of Malaysia in 2002,1 there were 897,624 drug users in the country, of whom 117,955 were injecting drug users (13.15%). This study also found that eight percent of drug users were HIV positive and there was an 18% HIV positive rate among injecting drug users (IDUs). It has been projected that by the year 2015, the number for HIV carriers will escalate to 300,000 and the cost of treating HIV and AIDS cases will be enormous2. The national drug policy was formulated to create a drug free Malaysia by 2015 and to ensure a peaceful life for the citizens as well as to strengthen the stability and security of the country3. However as individuals with drug addiction have a chronic relapsing disease that has many medical and social consequences and as patients with addiction attend medically trained doctors seeking medication to relieve their symptoms and stabilize their lives. There is a need to have more expertise in this field particularly to reduce the high disease burden in the community due to these disorders. Australia was chosen as a place to learn as that country has over the last 25 years developed a comprehensive service delivery system that includes treatment delivered in the community as well as at specialists clinics and incorporates harm reduction strategies that has been proven to be very cost effective and successful in minimizing the spread of blood borne viruses within the injecting drug population and into the community. The Department of General Practice, Monash University was chosen as the place for training as it offers a training program and had excellent connections to community programs where individuals with drug and alcohol problems sought health care treatment. It was well suited to give me experience that I could utilize in my role as a community based Family Medicine Specialist when I returned to Malaysia. As the health care service delivery system in Australia differs from that in Malaysia, a description of how it works should assist in reading the following.

Primary care in Australia is predominately delivered by general medical practitioners who work in private clinics that are either medical only or multi-disciplinary in nature. These clinics are funded by a payment from the patient, some or all of which can be reimbursed to the patient by application to the Commonwealth Government tax payer funded Medicare scheme. Some general medical practitioner deliver primary care by working as salaried medical officers in community health centres that are state government funded. Some community health services, including many alcohol and drug services in the community, have health care staff but no medically trained staff. All citizens are entitled to receive specialist health care from public hospitals. There is a parallel private hospital scheme for those who pay for private health care insurance.

Thus an individual with a drug and or alcohol health care problem may receive his initial treatment from a general medical practitioner in primary care or from a public hospital emergency treatment service prior to being referred for ongoing care to a publicly funded clinic (such as is described in the body of this report) or to another service inn the privately funded system.

OBJECTIVES

The main objective of the training program is was to increase my knowledge and skill in management of patients with substance abuse and related complications (physical, mental and social), to appreciate understand the services available in this area and to identify challenges faced in Australia that may be similar to those in Malaysia and to study ways to handle them that should be applicable on my return to Malaysia.

The learning objectives were designed to fulfill the need to deliver an addiction medicine service at primary care level in Malaysia. It was also based the requirement in the curriculum for general practice training in addiction medicine within the Royal Australian College of General Practitioners and included some important aspect of Addiction Medicine Specialist training in the Fellowship of the Australasian Chapter of Addiction Medicine (FAChAM). I was particularly interested to learn the Australian approach to the prevention and management of medical complications such as blood borne virus infections (HIV, viral hepatitis) as this is a major medical issue among injecting drugs users in Malaysia.

METHODOLOGY

The program I completed was based around course work, field visits and clinical attachments. The course work consisted of five modules that when completed were assigned to a designated marker for assessment. Each course work must be passed. Four of the modules involved writing case commentaries and journal writings. Background Australian statistics and information was obtained from various websites and visits to the Australian Drug Foundation Library and resource centre. I took the opportunities to increase my knowledge in addiction medicine by attending several lectures, group discussions, workshops and conferences Clinical attachments to clinics where individuals with Drugs & Alcohol health care problems enabled me to see at first hand patients receiving treatment inn the addiction services available. Field visits were designed to support my understanding about services available to individuals with related to Drugs & Alcohol health care problems These visits and enabled me to have discussions with the key persons Through out the training program, regular meetings were held with supervisors in order to ensure that the objectives of the training program were achieved well. At the end of the training program, a report was produced. This mainly consisted of a description of the findings in the training program and an analysis of the clinical works that had been done.

OUTCOMES

Outcomes of this training program are divided into three sections:

1. Course work modules – completed, marked and passed.

2. Field visits:

   Mainly describing the current service deliver system in Australia and specifically Victoria the state where I worked and an overview of the treatment services for individuals with:

   • Drugs & Alcohol health care problems

   • HIV and other blood borne virus infections

   • Sexually Transmitted Diseases.

3. Clinical attachments where I saw patients with – Drugs & Alcohol health care problems – HIV and other blood borne virus infections – Sexually Transmitted Diseases

Course work modules Five modules were coordinated by the Department of General Practice, Monash University. Two modules related to Addiction Medicine areas and were sourced from elsewhere. All were completed and passed.

The Monash University course modules were:

1. CGP1004 : Alcohol and Drugs

2. CGP 1002 : Depression & Other Mood Disorders

3. CGP 1003 : Anxiety

4. MGP 1008 : Psychotic Disorders

5. MGP 1009 : Personality Disorders

   The other two modules were

6. Pharmacotherapy training program for opioid dependence 2006 by Department of Human Services, Victoria. This module is a requirement for any medical practitioner who wishes to become authorize to prescribe substitution opioid pharmacotherapy such as Methadone, buprenorphine or buprenorphine/ naloxone to any patients with heroin or other opioid dependence health care problem.

7. Australasia HIV Medicine Course work for S100 Prescribers in Victoria

Twenty six Continuous Medical Education sessions in various forms had been attended.

Field visits.

Most of the services visited were in Victoria. However I took the opportunity to visit two important services in New South Wales. The alcohol and drug service system varies a little across Australia however Most of health regions in Australia have these services for individuals with Drugs & Alcohol health care problems:

1. Counseling and Support services

2. Drug and alcohol Withdrawal Services

3. Methadone and Other Pharmacotherapy services

4. Rehabilitation and Post Withdrawal services

5. Services for Families

6. Services for Young People

7. Services for indigenous Communities

8. Needle & Syringe Program.

I visited 20 Drugs & Alcohol services and nine services related to blood borne viruses in order to increase my knowledge and understanding in this area.

Clinical attachment visits.

There were forty seven clinical visits to nine Drugs & Alcohol Clinics/Units in Victoria and a total of two hundred and fourteen patients were seen. There were ten visits to the Co Infection Clinic in the Alfred Hospital, Melbourne that handle patients with blood borne virus infections and having complex treatment needs. A total of forty eight patients were seen in this clinic. There were also forty seven case studies on HIV infected patients that had been done in Fairfield House, the Alfred’s Hospital which is a designated ward for sub acute management of HIV infected patients in Victoria. With regards to sexually transmitted illnesses, there were ten clinical visits and fifty one patients seen in Melbourne Sexual Health Centre.

DISCUSSION

The training program had assisted me in achieving my learning objectives. This comprehensive program outlined above enabled me to gain theoretical knowledge and to see patients being treated for drug and alcohol health care problems that included in some co-morbid blood borne virus infections, sexually transmitted diseases and mental illness. The program also allowed me to be aware of the need for and the delivery of various levels of management for patients with either straight forward of complex treatment needs & inter related issues had been seen and understood.

This training program has benefited me and Malaysia in a number of ways. Personally, it has increased my knowledge and skills in the field of Addiction Medicine. I am now able to appreciate various treatment and support services that are available in a developed country. The training program has thought me about various challenges in this field and possible solutions. Being abroad, it has also taught me to be independent and capable to interact with various categories of professionals and semi professionals in the field of Addiction Medicine. This is also an opportunity to develop contact with people working in Addiction Medicine field internationally.

With regards to benefit to Malaysia, the training program that I had undergone has given me ideas that I can utilize. Once implemented they can assist in enhancing clinical services in the field of Addiction Medicine, increasing the number of expertise and resource person in this area, implementing harm reduction strategy among drug users and hopefully will also be able to handle issues related to drugs & alcohol well.

Indirectly, the content of the program that I had completed may also be useful for the undergraduate and postgraduate training among doctors in the field of Medicine in Malaysia.

CONCLUSION

This is a good, comprehensive and useful training program and recommendable for future training in the field of Addiction Medicine especially among doctors working at primary care level. As a result of my experience, I believe that there is a need to enhance the training of doctors in Malaysia to be comfortable to work in the field of Addiction Medicine. We need to increase awareness among health care providers about the magnitude of the problem, to improve treatment services at various levels of prevention, to this end there is a need to develop a training program in the field of Addiction Medicine for both undergraduate and postgraduate training in Malaysia, to create more post for relevant human resources and to develop an advocacy team.