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Gold, incentives and meh

Sorry but the drugs do work

Dr Ellie Cannon

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In my GP surgery we have spent the past five years or so trying to avoid prescribing antibiotics. This has been a concerted collaborative effort, alongside the entire medical community, to play our part in reducing AMR and encourage the use of self care for self-limiting viral infections.

We have done this safely and consistently, with strong messaging to patients, patient information leaflets and of course robust safety-netting. It is unusual now to see a prescription for amoxicillin in the practice, and patients have stopped asking for it.

We sit with pride in our medicine management meetings, seeing our practice top of the leader board as lowest prescribers in this area.

We’ve turned our attentions to benzos now; it’s far harder but with the consistent messaging and dedication we are certainly reducing the prescriptions. Next up: bath emollients. We genuinely are the doctors who give up drugs.

Real patients may not have time for lifestyle changes whilst holding down two jobs just to stay above the breadline

And it seems without realising it, we’re bang on trend. De-prescribing has become de rigeur. Yet, despite my standpoint on the leader board of non-prescribers, I’m unimpressed.

We seem to be under a tidal wave of media and health programming that is dismissing drugs and even actively attacking their use. There are swathes of commentaries on why we should be ditching drugs for ADHD, depression, type 2 diabetes, you name it. The message is clear – this chap didn’t need tablets, and nor should you.

ADHD is a common target. Once derided as an excuse for naughty inattentive children, it is now classified as a neurodevelopmental disorder. We are really only beginning to understand it. Ritalin had a bad press in the 90s as a sedative to silence feisty children, but the medical profession has thankfully moved on. Using medication for ADHD is not simply a chemical cosh to silence or control: it is an evidenced-based approach used in the context of a multidisciplinary team, other medications, other therapies and parenting approaches. And it is no quick fix. Parents do not undertake these decisions lightly as a ‘lazy option’ to get some quiet time.

Many of my young patients with ADHD have issues sleeping, and missing a melatonin prescription means the whole family spends the entire night awake – these are not simply fidgety kids who can’t concentrate during maths. Musician recently made headlines denouncing lazy mothers who drug their kids – unlike his own mother who encouraged him to be creative instead. But for the majority of families I see in general practice this is patronizing, unrealistic and quite frankly offensive – to both patients and doctors.

I take umbrage with the notion that GPs only want to hand out pills because it’s easier than taking the time to extol lifestyle therapies. As GPs, when we sit with patients who are facing medical issues, it is clear there often isn’t a choice – it’s not a lazy, over-stretched GP just shoving medicine to get them out the door. In real-life general practice, many patients don’t have the oft-discussed ‘choice’. A whole host of factors come into play when selecting treatments – health beliefs, convenience, co-morbidities, other patient needs: real patients may not have time for lifestyle changes whilst holding down two jobs just to stay above the breadline.

They don’t need drugs to be the best they can be or make their lives easier – they need medicine to survive.

Furthermore this perception stigmatises people who do take medication. We’ve fought to break down the stigma of certain conditions, but now there’s a judgement of people taking medication for them. There is no point society opening up about mental illness, if the average person is judged because he or she opts to take a drug for it.

Unlike the clear clinical need to reduce antibiotic and benzo prescribing, I cannot say where this trend to ditch drugs has appeared from. The anecdotes certainly make good telly and first-person disclosure pieces. Maybe it’s the current desire to distrust experts and the trendy misconceived notion that ‘big pharma’ is the source of all medicine’s wrongs.

Perhaps it’s the spurious alternative health view that anything au naturel has always got to be better than a chemical answer; a binary view revealing negligible scientific insight.

The fad for ditching drugs is at best tokenistic and at worst damaging to a large cohort of patients. The power of the lived experience makes for great telly but I’ll carry on doing the best for my patients, thank you.

Dr Ellie Cannon is a portfolio NHS GP in London and broadcast media doctor

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Readers' comments (15)

  • Excellent article.
    Trend seems to be for patients to want 'something natural doc' then I remind them many modern drugs originated from 'natural' or 'herbal' sources.

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  • David Banner

    Excellent article.
    The recent ITV “cure T2DM with diet” is a classic example. In the real world we advise all prediabetics and new diabetics to shed weight, but the few that do rarely maintain their lifestyle change beyond a few months, with the usual list of (perfectly reasonable) excuses (holidays, stress, work, sprained ankle, bereavement etc), then inevitably need the evil drugs. Then they return years later that we should ditch the drugs because it said on the news that extreme dieting could cure them. D’oh!!

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  • I'm afraid I only partially agree with you Ellie.

    Of course we should be de-stigmatising mental illness and encourage people to take drugs for it, WHERE NECESSARY. Of course some type 2 diabetics have a genetic predisposition and will need drugs.

    But don't you think, as a nation, we are doing it all a bit wrong?

    Our drug spend is rising rapidly and the most common item prescribed is a statin. If you were to play around with those lovely shared decision making tools, you would see that interventions of exercise and smoking cessation far exceed expectations compared with statins in primary prevention. But we have medicalised all men over the age of 65, who appear to hit the 10% risk score, with a certain postcode.

    The crux of the problem is none of us have enough time to be involved in PROPER informed consent and shared decision making.

    The Choosing Wisely campaign is excellent but not properly embedded in most parts of the UK. Evidence suggests the more patients know about the risks/side effects of a treatment, the less likely they are to choose it.

    We should be throwing shedloads of money at the intervention of SDM - instead we dish out drugs and perform lots of useless screening tests.

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  • try working in Canada. Everyone has a natriopath wants dessicated thyroid wont vaccinate and thinks drug companies covered up the cure for diabetes ( well they would lose billions so you cant blame em). They still love antibiotics and benzos though. oh and opiates and adhd meds

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  • David Banner.

    I have sympathy with your view, but our mistake is to tell them to lose weight by eating less and moving more, when we know how futile and difficult that is.

    Change the advice to 'Cut the carbs ' and our advice would be more successful.

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  • Life expectancy 1000 years ago 23, 150 years ago 40, now 80.
    Of course, clean water and immunization and medication used correctly.
    Take Insulin for example or thyroxine or penicillin.
    We really do not want to go back to mud huts.
    Yes, Medication works and the more we understand molecular mechanisms of disease, the more there will be.

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  • The trend to ditch drugs hasn't reached North Wales. I wish it would.

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  • Personally I'm with Shaba on this one. I think too often patients come in looking for a quick fix. We need the tools available for proper shared decision making. We need to work harder to get the government to help the nation tackle the current crises in problem drinking, sedentary lifestyles and problem eating behaviours.

    Too often drugs are used to patch up the inevitable metabolic and musculoskeletal consequences of obesity.

    I also don't understand why you are highlighting ADHD medications as a bastion of good prescribing. Where is all your evidence for these medications - especially in adults, where we are being inundated by private psychiatrists to write prescriptions for these drugs?

    Medication definitely has a large role to play in general practice, but there is nowhere near enough debate on the way different drugs are actually used in every day practise.

    How can you justify the way the following drugs are used in the real world; anticholinergics for overactive bladder; gabapentintinoids for neuropathic pain; acetylcholinesterase inhibitors for dementia; tramadol for... well... tramadol for anything (given how many problems it causes and the unpredictable way different people metabolise it)...

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  • Drugs for type two diabetes are pretty crap. Metformin for a couple of years, then something a bit riskier, then insulin, then you go blind/ get legs cut off/ get OA from obesity/ MI/ stoke. Or you could loose some weight.
    This clearly doesn't apply to everyone. But by taking power away from patients by reaching for the pills early, I think we really aren't helping the majority.

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  • Cure for streptococcus is antibiotic. Natural methods and antibiotic aversion is going lead to few deaths and then there will be articles in newspapers about how terrible strep is and then we will start prescribing antibiotics properly for acute bacterial infections. My point is all this nonsense of superbug and antibiotic resistance and decreasing antibiotic prescriptions is causing more harm. If any government seriously wants to reduce resistance - ban antibiotics in farming and cattle and Improve infection control in underfunded hospitals by providing appropriate funding without penalising them.

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