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Independents' Day

Let’s not throw the Gabas out with the Benzos

Dr David Turner

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The medical profession loves a bogey man.

Back at the start of my career Benzodiazepines were the bad boy on the block. As newly qualified doctors we were drilled, with zealousness that would make a cult leader envious, that it was our job to wean patients off ‘mothers’ little helper’.

A few years later it was HRT’s turn. At medical school we were taught hormone replacement therapy was the panacea for the menopause and that, more or less, it should be put in the water. Then suddenly it was about turn and we were told to stop all HRT as it’ll give you breast cancer.

A few more years pass and ‘oops, sorry guys we cocked up the number crunching there and it seems you can prescribe it after all’, except hardly any women wanted it by then because of the bad press.

Even a 10% reduction in bloody awful pain is worth having

Now it’s the gabapentinoids turn for a beating.

Don’t get me wrong, I accept the need to be evidence based in our prescribing, and that metanalysis has shown that there is no evidence for use of gabapentinoids in low back pain.

Also that, yes, some patients will abuse them, but this abuse is largely in the prison and opiate-abusing population, who in my experience would abuse toothpaste if it was illegal.

I think therefore we need a balanced approach. Let’s take a hypothetical, but not untypical patient with chronic pain:

- Paracetamol/NSAIDS – ‘No help, may as well be smarties’

- CBT – ‘Tried it, didn’t work.’

- Opiates – Addictive, can’t drive on them, make you nauseated plus they don’t work.

- Pain clinic – ‘Been there, had injections, helped for a while then wore off.’

- Acupunture, TENS, hypnotherapy, reiki, crystal healing – see above.

In some of these patients, gabapentinoids give some reduction in their pain – and even a 10% reduction in bloody awful pain is worth having.

I accept some of this may be placebo, and we need to be careful about which patients we prescribe for, but sometimes just because it’s a placebo doesn’t mean it doesn’t work.

Dr David Turner is a GP in West London 

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Readers' comments (13)

  • Well put this was an effective injection of pragmatism something missing in the missives.

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  • Perhaps we should admit that some problems do not have an answer in tablet form.

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  • I am sceptical about papers now. Just someone trying to further their careers. No evidence paracetamol works for chronic pain. I just took one and there is no pain. How do you explain that? Next year someone will publish a paper that says it does work.

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  • Dr Turner, I strongly disagree with you, and I am an ordinary GP who just happened to notice how dreadfully addictive these things were before it was even in the press or public arena.
    If the problem really is physical pain, analgesics do work.
    When the problem is psychological, we should avoid using addictive mood-numbing drugs and concentrate on relieving the mental pain , or addiction.
    As someone said, maybe we should think beyond tablets. We should certainly not inflict addiction on the patient by prescription.
    And, contrary to the statement given, patients on gabapentinoids are NOT any more fit to drive that patients abusing other addictive substances! They also affect driving ability.

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  • David Banner

    Sure, gabapentinoid have a role, but the explosion in prescribing has led to the current impasse, and we cannot dismiss the rapid growth of abuse and leakage on to the streets.
    We need Pain Clinics to take more responsibility, not just a discharge letter asking us to titrate up pregabalin. If these drugs can only be initiated in Secondary Care, then kept on a Shared Care protocol, there would be a sharp reduction in prescribing, whilst ensuring that those patients in genuine need will still receive their pain relief.

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  • As with most studies, the results you get are dependant on the patients that are recruited along with the metrics that are used to assess the endpoint.

    Who it is appropriate to treat and for how long are of course difficult questions to answer. But if it was straightforward a dispensing machine would be adequate rather than a healthcare professional.

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  • It all boils down to a lack of time and resources to do anything apart from push another pill. I was working in a WIC the other day and the snow had kept a lot of punters away. One lady came in with chronic pain and was on a shopping list of serious analgesia with no wiggle room for manoeuvre- high strength opiates, nsaids, pregabalin, antidepressants. But with no one else waiting I gave her as much time as was needed to reflect on things and talk about the model of chronic pain. I’m not naive and would only suggest a 10% chance she won’t be back at her GPs soon but I just tried to make her feel empowered and it seemed to help. But this can’t be done in 7 mins with yout other eye on the ever increasing list of extras, phone calls and visits that are about to ruin your day.

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  • Northwestdoc spot on. you cannot really do justice with your patients in 10minutes consultation models.Easiest way is to push another pill.

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  • It's very easy to blame the 10 min consultation model on our poor prescribing. I agree that 10 mins is totally unrealistic for the challenges of modern general practice

    But what I don't agree is that, with limited time, the only option is to prescribe. If it is that easy for patients, why aren't these drugs available for them to purchase? If we can't do our prescribing gate keeper role, we should really be questioning our positions.

    We need to change the narrative about fixing patients, stop colluding with their health beliefs and start facilitating their personal responsibility

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  • Macaque

    @Shaba Nabi Opening the door to complaints galore!

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