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Time to listen to patients about prescription problems

Dr Des Spence

dr des spence duo 3x2

The Scottish Government is considering a petition from patients around prescription drug dependency, calling for action to recognise the plight of patients who have become dependent on benzodiazepines and antidepressants and provide them with timely and appropriate support.[1]

It comes as the Department of Health has announced a review of addiction to prescription medicines in England.[2] Yet another medical calamity unfurls.

The patients have suffered greatly and inexcusably. The authorities will point the finger at general practice but the blame lies with the medical elites, flawed research, NICE, the MHRA and Big Pharma.

I submitted a statement as a personal narrative of my experience through the past three decades.

This inappropriate intimacy powered our current prescription problems

Firstly, we need to understand the relationship between doctors and the drugs industry. It’s hard to explain the closeness of this relationship to an outsider. In the past, industry representatives were everywhere. They provided lunch, freebies – Filofaxes, computers, pens and the rest – and, supposedly, ‘education’.

They engaged with doctors outside work as well, took us out at night as junior doctors, invited GPs and their spouses for evening meals, flew groups of doctors all over the world to ‘conferences’ (nobody actually went to the conference lectures). Cash everywhere. If it moved, industry sponsored it. Christmas parties, leaving dos – you asked, they coughed up the cash. They flattered you and puffed up our already large egos. To say it was wholly inappropriate would understate the truth. Much of it still goes on today. And the industry is still everywhere in the NHS, the media and of course in Parliament. Little has really changed.

This inappropriate intimacy powered our current prescription problems. The industry in the 1990s suddenly got a conscience about ‘chronic disease’ and pumped money into charities and advocacy groups. This was especially in mental health. Not benevolence but financial malevolence. You only take an antibiotic occasionally and for a few days but psychiatric conditions are common, life-long, incurable and involve taking multiple medications with dose escalation. A business opportunity like no other. So industry co-opted ‘the psychiatric specialist’ and built their careers for them, with their names helicoptered onto ghost written research.[3] When it came to setting up a national adversity panel, guess who got an invite? The guidelines always seemed to promote new medications, perhaps unsurprising when you consider that over 75 % of the authors of the DSM – the diagnostic and statistical manual of mental disorders, the holy text of mental health – had declared links to industry.[4]

Then came ‘clinical depression’. Low mood for two weeks now became an ‘illness’ and swathes of the population were sick. This is an subjective definition with an entirely arbitrary cut off. Why not three weeks or six weeks? Might low mood be a normal response to a situation? It was peddled as ‘chemical imbalance’ but this is a simple myth, with no proven biological basis. But business is business and industry had a new medication to sell: Prozac. Safe, non addictive and supposedly highly effective. So in 1992 industry sponsored a campaign called ‘Defeat Depression’, endorsed by their friends the doctors. Prescribing went stellar. GPs were repeatedly told by our betters that depression was ‘underdiagnosed and undertreated’.

But guess what, depression wasn’t defeated. Years later it became clear that SSRIs (like Prozac ) don’t actually work for the most part.[5] Also patients struggle to stop these medications experiencing significant withdrawal symptoms. And this withdrawal was assumed to be a return of depression, so doctors advised patients to carry on taking antidepressants for years and even decades. But this advice was simply the opinion of the same financially conflicted specialists.

Patients complained about severe side effects, but no one seemed to care or even listen. Talk based treatment like counselling are effective and would have been cheaper to provide. But these facts didn’t stop the march of the medications. This was the same story for diazepam and sleeping tablets a generation before. Drugs that poisoned and undermined entire communities. No one ever learned. No one was ever held accountable, no one prosecuted and no corporation held responsible. Just a perpetrator-less crime.

Today history is repeating itself with painkillers. Pain is common, so again is a big business opportunity. Industry peddled the idea that strong opioid painkillers were ‘non-addictive’ if used ‘therapeutically’. If you questioned the dogma you were an ‘opiophobe’ and dismissive of people suffering. So prescribing went up and up. The pharmaceutical reps were everywhere. They focused on the pain specialist, wined and dined them, flew them on all-expenses paid trips to ‘educational conferences’ and doled out big cash to them to act as advisers or speakers. The message to GPs was the same, ‘underdiagnosis’ and ‘undertreatment’ of pain. So prescribing of strong pain killers tripled in 10 years.[6]

But guess what? These medications are addictive, dangerous in combination and have no long-term data on safety. With 90% being used in non-cancer pain, these are causing huge problems across the UK. But there are no support services for affected patients. Tens of thousands of people are inadvertently addicted to these medications. Specialist pain clinics are making the problem worse and have no insight into the harm they are doing. All these problems are not the fault of patients. These problems are the responsibility of the medical profession. We are harming patients every day and everywhere across the country. We seem to have learnt nothing from history.

What to do? Let’s see what the politicians come up with.

Dr Des Spence is a GP in Glasgow

References

1. Scottish Parliament Petitions: PE01615

2. Mahase E. Government launches major review into prescription drug addiction. Pulse; 24 January 2018 

3. Matheson A. Ghostwriting: the importance of definition and its place in contemporary drug marketing. BMJ 2016; 354: i4578 

4. Spence D. The psychiatric oligarchs who medicalise normality BMJ 2012; 344: e3135 

5. Spence D. Bad Medicine: The rise and rise of antidepressants. Br J Gen Pract 2016; 66: 573

6. Spence D. Bad Medicine: The medical untouchables Br J Gen Pract 2017; 67 (661): 363

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Readers' comments (26)

  • Cobblers

    Let's see what the politicians come up with?

    Hahahahaha!

    There is nothing, nothing, that the intervention of a politician cannot make many times worse.

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  • Thanks Des.

    I also submitted a response to this Petition: PE1615 Prescribed Drug Dependence and withdrawal.

    I listened carefully to the evidence given to this Scottish Parliamentary Committee on this petition by the Principal Medical Officer and the Minister for Mental Health.

    Noting the title of this PULSE post, "Time to listen to patients about prescription problems", I was concerned to find that neither the Principal Medical Officer nor the Minister for Mental Health were able to confirm that the experience of those who have submitted their experience of antidepressants was valid.

    Shocked and concerned about this, I wrote the following letter to a Scottish newspaper, but it was not published:

    I have now witnessed the Scottish Government’s Department of Health seeming to disbelieve the evidence presented in three separate health-related petitions and the experience of those who have petitioned. These included the petition by the Mesh survivors (PE1717); my petition for a Sunshine Act for Scotland (PE1493); and now Marion Brown’s petition on prescribed drug dependence and withdrawal (PE1651). The latest evidence session to the Scottish Parliament’s Petitions Committee once again would seem to demonstrate the Scottish Government’s starting position that its statements carry greater value than those made by individuals and groups challenging the status quo. This defensiveness may be understandable in terms of politics but does nothing to help advance the matter under consideration. Senior Scottish Government officials should not be considered more “credible” just because of they are in more powerful positions. The underlying research evidence in long-term prescribing of antidepressants is particularly poor.

    I support the appropriate use of antidepressants. However, we all share in the Scottish Government’s determination for there to be “fully informed consent” between doctor and patient and it is my view, in terms of antidepressant prescribing, this is not routinely happening in NHS Scotland. I have been a Scottish NHS psychiatrist for 20 years and it has never been routine practice to discuss with patients the possibility, when commencing antidepressants, that they may be on them for life. The potential for severe withdrawal effects with antidepressants needs to be recognised and without listening to a range of patients’ experiences we are unlikely to develop our scientific understanding.

    Dr Peter J. Gordon





    This is a letter that I sent

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  • And, as you outline Des, the medical and scientific community need to take responsibility.

    Following the publication and media reports of the Lancet meta-analysis on antidepressants, I have noticed how Psychiatry (my specialty) has seemed to be struggling with any threat to its authority:

    Psychiatry, dependent on its authority, is finding withdrawal seriously difficult:

    https://holeousia.com/2018/03/03/psychiatry-dependent-on-its-authority-is-finding-withdrawal-seriously-difficult/

    aye Dr Peter J Gordon

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  • I had hoped Scotland's Mental Welfare Commission might be able to help. Alas, I was too hopeful.


    Mental Welfare Commission: “This isn’t a priority for us”




    On the 6 March 2018, I asked the Mental Welfare Commission for Scotland if it supports Sunshine legislation. This was the reply that I received from the MWC Chief Executive:

    “We haven’t taken a position on it one way or another. We need to prioritise our activity in line with the specific statutory functions bestowed on us by Parliament, and we have concluded that this isn’t a priority for us.”

    However, the Scottish public have been consulted on this and do consider it a priority. Realistic Medicine is also a Scottish Government initiative that has wide parliamentary support.


    Dr Peter J. Gordon

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  • Forgive me posting again.

    I submitted the following to the BMJ in response to this research news: Large meta-analysis ends doubts about efficacy of antidepressants:

    "Not uncommonly, as part of the scientific community, I will express concerns about the language used in the media to present mental health issues. Yet, on this occasion I find myself concerned by the imprecise language used by the experts giving opinions on the meta-analysis on short term antidepressant prescribing (8-12 weeks) for major depressive disorder.

    The lead authors of this systematic review, and a number of experts giving opinions on it through the Science Media Centre, used the general term depression and Professor Cipriani stated “Our findings are relevant for adults experiencing a first or second episode of depression – the typical population seen in general practice”. I agree with Dr Spence that major depression is not typical of primary care.

    It is also interesting to reflect on the language used by some professionals in the scientific community who rightly express concern about stigma associated with mental illness. At the same time, some of those in this very same community use terms such as “villains” or “demonisers” to describe individuals who share any negative experience of medication. This would seem to indicate that such experience is considered less valid.

    We all need to remember that words, as well as numbers, need to be used with care and consideration. Experience, after all, is more than both."

    Dr Peter J. Gordon

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  • Apologies again, but I think our approach to informed consent is very important:


    I submitted the following to the BMJ in response to this research news: Large meta-analysis ends doubts about efficacy of antidepressants:

    "In Scotland, it is estimated that 1 in 7 adults are taking antidepressants, and it seems that the majority are taking them either in the long term or indefinitely. This meta-analysis does not help us evidence the basis for such prescribing. Indeed, it is surely a concern that there is such a dearth of long term studies on antidepressants. This is an indictment against the scientific community given that antidepressants have been in use for well over 50 years.

    Scotland has had a number of parliamentary inquiries into medical treatments in recent years and our Chief Medical Officer has, as part of her Realistic Medicine campaign, repeatedly stressed the importance of “fully informed consent”.

    I welcome this meta-analysis. I hope that it will act as a “wake up call”. When prescribing antidepressants, as part of fully informed consent, we should be explaining to patients that they may find that they will be taking antidepressants in the long term or perhaps indefinitely and that there is a lack of evidence to support this practice."

    Dr Peter J. Gordon

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  • The opinions of pragmatic medical professionals delivering the services has been igniored for decades. Everybody wants doctors to simply, effectively and cheaply resolve distress and discomfort and won't tolerate any caveats. Doomed!

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  • Peter J Gordon
    enough already
    you'll be posting your school swim certificates next

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  • This comment has been moderated

  • Monty, I note that you hide your name, as well as being rude.

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  • Vinci Ho

    Healthy debates:
    (1) I agree to the author’s criticism of the influences on clinicians. Let’s be honest , we are classified as middle class and would prefer ‘polite’ and ‘well presenting’ demeanour with some hospitalities. Whether these influences can impair our independent thinking and judgement is a more a matter of self-consciousness and introspection than a blaming game.
    (2) Clearly the arguments on scrapping opioids and gabapentinoids are gaining momentum . Perhaps an even more restrictive mechanism of prescribing these drugs is indicated . But we always should remind ourselves of falling into the trap of ‘one size fits all’ with zero flexibility.
    (3) Interesting time for Lancet to release this meta-analysis on anti-depressants for acute depression . This could be seen as a fight-back from those who backed anti-depressant all along but this is exactly what I do like to see with more polarising views on this matter . Clearly, talking therapy should be the mainstay for mild to moderate acute depression (have to stress the word acute more) . For moderate and certainly severe acute depression, anti-depressant has a role if patient is fully counselled and consented. Problem in general practice is time as well as expertise as our vital resources. Although , being already being discontinued in QOF , I still use PHQ9 as well as GAD7 to assess any new case of acute depression. Yes , if I have three cases like this a morning surgery , my time management is all messed up right away.
    But I do believe the ‘indictment’ on painkillers is rather than from anti-depressants.

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