Acknowledging rural context, local and generalist care

Sur and Loh are to be commended for their article on the management of a man disclosing crack cocaine use at a rural clinic.1 However, they do not elaborate on the rural context or acknowledge their recommendations’ potential limitations in rural Canada.

Their guidance focuses on taking a history, ordering a battery of tests and referring to specialized services outside the primary care clinic. This does not recognize shortages of rural addiction services or the potential for skilled generalists to offer excellent care at the very clinic where the patient presented.2^,3 The authors offer little guidance for how a generalist might care for the patient comprehensively, locally and realistically.

Serious drug misuse can be viewed as a disastrous form of “self-treatment.” Our task as caregivers might include identifying and treating underlying mental health disorders and trauma within the comprehensive family practice clinic.4 A discussion of these issues might seem a good starting point.

The article concludes that the “physician ... subsequently referred the patient to a harm-reduction clinic for education and counselling and ongoing access to support services and the local safe inhalation kit distribution program.” These services exist in some rural settings, but they are not the rural norm. The authors unfortunately identify decontextualized guidelines, urban evidence and largely nonexistent rural services.

Patients living in rural areas typically receive excellent care through a generalist model. Although some may need to be referred to specialized urban centres, rural patients and clinicians need robust strategies and guidance for treatment close to home.5