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At the heart of general practice since 1960

The power of the prescription pad

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We should never, ever forget what a privilege it is to wield a prescription pad, or the power and responsibility that comes with it. Whenever I think about it, I am humbled by the potentially terrifying outcomes. The decisions we make can be, and occasionally are, definitive, in the life-defining and (luckily rarely) life-ending sense.

Alright, 90% of the time we are banging out scrips for trimethoprim or clotrimazole cream and no one is going to suffer much if we do or we don’t. But we have the other 10% to consider.

I have many times in this column expressed my opinion that, apart from dressings and other superficial stuff, prescribing should be left to those of us who have trained long and hard to earn the right to do it. But, from time to time, we get it wrong.

There have been an awful lot of distressing experiences during my 22 years as a GP, but the times that a patient has overdosed on medication I have prescribed are among the worst. There have not been many instances that I am aware of, although there will certainly be some of which I am not.

Twenty years ago, it was normal to give amitriptyline for depression. It now seems a bit odd to give something so toxic to such vulnerable people, but hey, at the time (pre-keyhole surgery) we were ripping open abdomens to get gallbladders out. Not that long before that (pre-PPIs), we were doing partial gastrectomies for stomach ulcers – and not long before that, GPs were doing tonsillectomies on kitchen tables, if we believe what our elders told us as students.

I once prescribed amitriptyline to a young man who was apparently suffering from anxiety and depression. I’m not making excuses because I was not long a GP at the time, and we all learn as we go along. These days, I would recognise that his ‘depression’ was an attempt to influence his upcoming court case for GBH on a young lady, and to cast himself as the victim rather than her.

Anyway, he collected the drugs but never took any. After he assaulted his next lady friend, in desperation she took four months worth of his amitriptyline in one go and died soon afterwards.

Although she wasn’t my patient, I doubt I’ll ever stop wondering about the life she might have had if I hadn’t prescribed the drugs.

One reason my surgeries run so late is I am very pedantic about what I prescribe, partly because the wonderful placebo effect means the more I bang on about a drug to the patient, the more effective it is likely to be. Recently, I changed the analgesia of a little old lady with osteoarthritic hips from paracetamol to co-dydramol, giving her a long, earnest talk about the seriousness of this opiate-derived drug.

Of course, trials show no difference between the effect of these two drugs, but my words clearly had some effect, as when she attempted to end it all, the letter from the hospital informed me she’d taken six of them at once.

She’s still around and I still feel good about my prescribing, and the way I prescribe. I see this as progress.

Dr Phil Peverley is a GP in Sunderland.

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Readers' comments (18)

  • Dreadful how doctors try to fob paracetamol on patients and then co-dydramol - neither of which are effective against any sort of proper pain - at least not in some people who appear to be non-responders to paracetamol's supposed analgesic effects.

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  • "Dreadful how doctors try to fob paracetamol on patients and then co-dydramol"

    You could look at it like this.

    Or you could say that using low-potency analgesics to harness the benefits of the placebo effect while minimising potential side effects is a humane and responsible first step in pain relief.

    Of course if the first step fails then by all means move onto more potent, more potentially toxic medications.

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  • 1.06
    There is a lot of evidence for the effectiveness of paracetamol for what you call "real" pain, for instance post-operative pain.
    I suspect that you are talking about "pain" from disorders such as ME or fibromyalgia.

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  • Clean, interesting & informative - for once:) Not sure modern antidepressants are much better though - citalopram made me feel suicidal and I would easily have overdosed if I hadn't rejected further prescriptions from an over-zealous GP.

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  • 2.44
    "There is a lot of evidence for the effectiveness of paracetamol for what you call "real" pain, for instance post-operative pain.
    I suspect that you are talking about "pain" from disorders such as ME or fibromyalgia."

    No, I'm talking about real pain, post-operative pain too. Paracetamol was suggested to me to take post cardiac surgery when the opiates had too many side effects. Of course it didn't work. Never worked for simple period pains in my youth either. I suspect that there are non-responders in this and that some more research needs to be done ?

    Yes the placebo effect can be very powerful in some patients, but definitely check up on them.

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  • If Dr Peverley had prescribed adequate analgesia, his patient might not have attempted suicide.
    It is very easy to overdose on Paracetamol and the effects are nasty as we all know. Many stronger drugs have a better therapeutic ratio.

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  • The power of the doctor-as-placebo should not be underestimated but it is utterly devalued and virtually ignored in modern medical training. The destruction of the 'doctor-patient relationship' has further eroded its power. Used car salesmen or even the homeopathic snake-oil crew could teach young medics a lot about this unsung but essential clinical skill.

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  • Peverley is the Katie Hopkins of general practice... And a prescribing snob.

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  • Working in primary care psychology services I see patients regularly who discuss their distress at forced medication changes. Some are valid & some appear not in the best interest of the patient. Giving paracetamol for pain does not work for everyone but the patient will not go back to the GP because they feel there is no point and they are not being listened to. So they then self medicate quite cheaply and do not consult for further complications. I find if the patient’s physical health is managed appropriately then mental health is easier to treat. When I do speak with GP’s and explain what is happening most have been supportive and worked with me to get the patient back in GP treatment. I see many suicidal patients in a week and as you know, when they haven’t slept due to their physical health complications (mostly pain) it increases suicide ideation & psychosis.

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  • So you emphasised that this super drug was the best thing available for her pain? And when it didn't work, of course there is no point going back to the GP as he had already prescribed the most effective drug.... so there is only one thing left to do which is to try to end it all. You didnt mention a pain clinic, or other drugs that may have been effective for this patient?

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