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How to sail through the MRCGP orals without stress

MRCGP orals are looming, to test your decision-making skills and professional values. In two 20-minute exams you will be asked to talk about five topics, spending about four minutes on each. Pulse has spoken to GP tutors and registrars who recently passed the orals about what hot topics could be fired at you. We've distilled their advice into simple points on the clinical and ethical dimensions in each subject, to help you pick up maximum marks with minimum stress.

Is there a role for cannabis in medicine?

The 2000 British Crime Survey found 27 per cent of

20-24-year-olds had used cannabis in the past 12 months

in England and Wales.

Is there a possible use for cannabis in patient care?

lCAMS trial in multiple sclerosis1

•Poorly blinded, three-quarters on cannabis guessed, half

on placebo guessed.

•No improvement in spasticity on Ashworth scale.

•Subjective reporting of pain, spasms and spasticity.

lUse as an anti-emetic in moderately emetic chemotherapy setting2.

lPain control.

lPossibly as effective as codeine for acute/chronic pain3.

•Significant CNS depression side-effects.

•No benefit over current regimes.

lUse as appetite enhancer in cancer and AIDS.

Is cannabis detrimental to health?

lThree joints of modern cannabis, roughly equivalent to 20 cigarettes4.

•'60 per cent more smoke, 30 per cent deeper inhaled, held

for four times longer.'

lTwice as carcinogenic as tobacco smoke5.

lUp to 30 times stronger today than in 19806.

lPsychiatric sequelae.

•Depression and anxiety increase with greater cannabis use7.

•Increased risk of developing schizophrenia6.

•5-10 per cent become dependent.

Application of the concept of public welfare

A Utilitarian-based concept where health is seen a major component of public welfare, but not as its sole determinant.

It therefore allows practices that are detrimental to health, as

long as they result in an overall increase in 'public welfare'.

In what ways does cannabis promote public welfare?

lFeeling for individuals of mild euphoria, relaxation, increased sex drive, increased tendency to laugh and talk.

lRespect for autonomy in their choice to take cannabis.

Current significant political debate regarding the balance of health risks versus benefits and public welfare

lThe BMA believes the law should be changed to allow

'the therapeutic use of cannabis-based medicines so that certain cannabinoids – cannabis derivatives – can be prescribed to patients with particular medical conditions that are not adequately controlled by existing treatments'8.

•Recognise that personal views may be prevalent but we

'must make sure our personal beliefs do not prejudice our patients' care'9.

lThe Advisory Council on the Misuse of Drugs recommended10 reclassification under the Misuse of Drugs

Act 1971.

•Cannabis buds were classified a class C11 drug from January 29, 2004 (same as valium, though cannabis resin will remain class B and cannabis oil, class A)11.

lRCGP position statement regarding the dangers of Cannabis6.

•Cannabis is still a schedule 1 drug and as such has not been used conventionally for medical purposes.

lThe GMC also compels us to keep up to date with laws that may affect our practice9.

lConclusion to debate

•At this point, therefore, a patient may choose to take a drug that the BMA says has a therapeutic use, but as a doctor one cannot recommend or promote its use and stay within the law.

References

11 Cannabinoids for treatment of spasticity and other symptoms related to multiple sclerosis (CAMS study): multicentre randomised placebo-controlled trial .The Lancet volume 362 Issue 9395 Page 1517

12 Tramer MR et al. Cannabinoids for control of chemotherapy-induced nausea and vomiting: quantitative systematic review. BMJ 2001;323: 6-21

13 Campbell FA et al. Are cannabinoids an effective and safe treatment option in the management of pain?

A qualitative systematic review. BMJ, Jul 2001; 23: 3

14 British Lung Foundation report 2002

15 World Health Organisation. Programme on substance abuse. Cannabis: a health perspective and research agenda. Geneva: WHO, 1997

16 RCGP. Position Statement September 2000

17 BMJ. Volume 325, Number 7374, Issue Nov 23, 2002

18 BMA August 2001 www.bma.org

19 GMC . Duties of a Doctor

10 Advisory Council on the Misuse of Drugs Report . March 2002

11 www.drugs.gov.uk (Home Office drugs website)

Rob Wheatley is a registrar at Bulford Camp army barracks in Salisbury, Wiltshire

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