Sione broadened out the cascade and filled in many more steps from a consumer’s point of view. He started by reminding us of the difficult history that many people who use drugs have had with medical care, including discrimination, poor quality care, treatment refusal and lack of respect. He pointed out that many people who use drugs have complex challenges in their lives which they may prioritise over what a health professional sees as important. In addition, drug use in Australia can have a number of embedded inequalities, ie legal challenges, expense, vulnerable housing, cycles of withdrawal, demands of an opioid substitution program.
Some steps in the cascade may be much less obvious to the health professional but pose significant difficulties to the consumer. Knowing how to access CHC care can be difficult, especially with the disengagement of GPs from CHC care until very recently, resulting in many GPs being unfamiliar with current treatments or pathways. There is also the difficulty of venous access for blood tests for some, which can result in shame and embarrassment. Getting to appointments, arranging and attending a Fibroscan examination, getting to a chemist, can all be challenging, and then life brings along its own challenges, the “usual” ones, as well as the extra ones people who use drugs can face. Some services have used these barriers as a “test of readiness for treatment”, but is this fair if the consumer faces more challenges than most people and may have fewer resources to address them?
Sione expended the cascade in both directions with environmental factors enabling drug use harms and pretreatment support before the traditional cascade, and post treatment support following it.
I have often experienced people being “lost to follow up” (my “warehouse” of untreated people is most definitely not empty, I just can't contact them). Sione challenged me that people who use drugs “are not missing from our own lives”, and if we provide what they want, they will come running.
Thanks Sione for broadening our perspective and encouraging us to go the extra mile with people.
Dr Wendy Lawrance is an addiction medicine specialist and general practitioner working in a not-for-profit, the Fresh Start Recovery Programme, as well as in the public sector in Western Aaustralia. She has been treating hepatitis C since 2012, and is just starting out treating chronic hepatitis B.
Tuesday 14 August 2018