Methadone Man and Buprenorphine Babe
The video is 100% cheese but the underlying message is seriously enough. The situation in countries like Russia may be dire but there is plenty of nonsense floating around in the UK. One rumour circulating this month touts a move to ‘value-based’ policies (ie not evidence-based) which could involve time-limiting methadone treatment and abstinence/maintenance quotas. The NTA looks to have about as much long term viability as your average PCT and goodness knows what evidence-based policy it is going to drag down with it in its death throes.
If you think there is a place for methadone and buprenorphine as part of the treatment of opiate dependence then please sign the petition at http://wheresthemethadone.org. Their main concern is the spread of HIV: globally 1 in 10 cases are related to injecting drug use and outside of Africa it rises to 1 in 3 cases. But don’t just listen to Buprenorphine Babe (@bupebabe)- she is only quoting the WHO.
If opioid substitution therapy was made readily available globally, it could prevent up to 130,000 new HIV infections annually, reduce the spread of hepatitis C and other blood-borne diseases, and decrease deaths from opioid overdose by90 percent.
If you can’t cope with the video cheese then I can recommend the graphic novel:
Another bloody Copperfield book review
As much as it pains me I am going to have to disagree with Dr Grumble about this book (and Dr Zorro too as it turns out).
I’ve left it a few weeks and mulled over my reaction.
Copperfield has a distinctive voice, writing succinctly and with humour on the daily frustrations of life as a GP in the NHS. However, it never really engaged me and, on reflection, I’ve always felt some discomfort when reading Copperfield’s columns over the years. Copperfield lacks humility and efforts at compassion feel contrived and tokenistic. Until I opened the book I wasn’t aware that Copperfield is written by two GPs and I think this goes some way to explaining this feeling. Copperfield is a mechanism, not a person, and it feels like it is missing some essential human element.
I can see that the autorant nature of Copperfield is possibly a deliberate device of the writers and it certainly means Copperfield can speak the unspeakable. It may be therapeutic in small doses but a whole book left me feeling mainly demoralised.
On the positive side, it beautifully highlights some of the more ludicrous examples of the NHS at it’s most wasteful. When it comes to shooting bureaucratic fish in a barrel Copperfield is one of the finest shots in the NHS.
There are many who should read the book but I’m not sure that GPs need bother; however, it may be my GP perspective that makes it difficult to be more positive. We all have Copperfield days and he articulates well the dumb rage we can all experience. Unfortunately, it seems to be a bad day almost every day for Copperfield.
Geriaddicts – the older drug user
Image: www.ispub.com
There is a long list of chronic diseases we see as a consequence of illicit drug use. One issue that wasn’t really touched on in this editorial* is the premature ageing effect of drugs. A good example is the state of an intravenous drug user’s legs – the acute risks of DVT and infection are well known and the picture above is from a case of bilateral septic lower limb ulceration.
Anyone who has injected in the legs, and particularly in the groin, seems to have a measure of chronic venous insufficiency. This may seem fairly innocuous but can have devastating effects. GPs deal with lots of these in the elderly population. They are often not a pretty sight: crippingly painful leg ulcers that won’t heal; mottled and pigmented with venous eczema; and bloated with poor venous return. It seriously damages quality of life.
For intravenous drug users who inject in their legs it seems to hit 20 years younger than you’d normally expect. There is some research around this but it remains a low priority area. We see young men and women in their 30s who have legs that are in their 60s. As the authors of this study suggest:
Even those who stop abusing drugs remain at risk for venous disease; damage that occurred during the active period of injecting persists and advances long after drug use ceases and venous disease may be advanced in mid-life.
They are not quite ‘geriaddicts’. The term perhaps implies continued use but many will stop using long before they get officially elderly. Unfortunately, many will carry the consequences of their use with them.
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*COI. The very observant will notice that I am third author on this editorial.
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Beynon C, Stimson G, & Lawson E (2010). Illegal drug use in the age of ageing. The British journal of general practice : the journal of the Royal College of General Practitioners, 60 (576), 481-2 PMID: 20594437
Labour party losing the Justice Game
One of the single biggest disappointments of the last Labour government was their apparently unfathomable approach to the criminal justice system and a persistent disregard of civil liberties. Yesterday, the Home Secretary announced that the rules on ‘stop and search’ had changed after the European Court of Human Rights ruled last month that Section 44 of the Terrorism Act 2000 was illegal. The first couple of minutes of Theresa May’s statement gives the picture.
Coincidentally, yesterday I came across the following passage in a Geoffrey Robertson QC book – his compelling and inspiring The Justice Game.
The jury-vetting episode [in the ABC trial] provided further evidence for the uncomfortable proposition that civil liberties are less secure in the hands of Labour politicians, nervously striving to prove their responsibility by bowing to pressure from the police and the security services, than of dyed-in-the-wool Conservatives who have no need to prove their law and order credentials.
The book was published in 1998, so was presumably largely written before New Labour gained power, and the ABC trial was at the time of the Callaghan administration in 1978. The Lib-Con coalition now look well set to seize the civil liberties agenda. Who’d have thought it? Well, Geoffrey Robertson may not be surprised and he knows a thing or two about human rights.
Placebo schmebo – fostering ‘caring effects’
Tasty little sugar pills
The BMA, James Le Fanu and Martin Robbins are all discussing homeopathy and the issue of placebo has raised its head.
I agree with Margaret McCartney’s comment on this – the debate needs to move on to the recognition that ‘caring effects’ are what we need and they shouldn’t be confused with the little sugar pill itself. She states:
The missing link is what placebo actually means: caring effects. We can get good caring effects when we spend time listening, when we follow people up carefully and consistently, when we take longer appointments, when we explain properly and usefully what the problems are and what might help. There is evidence for this: we know that using such ‘caring effects’ makes people better, faster, and for longer.
People talk about placebo effect but we need to start separating out these ‘caring effects’. They are not properties of the sugar tablet – they are real and tangible actions taken by the doctor or properties of the system within which the person gets their care.
Some evidence on placebo
Bandolier’s Little Book of Making Sense of the Medical Evidence looked at some of the trials that suggest placebo effect. They showed placebo effect ranging from 18-88%. But when aggregated (12,000 patients) the proportion of patients achieving 50% pain relief with placebo in post-op pain was 18%. They say:
Statements suggesting that one-third of people respond to placebo or that people respond to the placebo at one-third of the maximum response are wrong. The information above shows that both are wrong. It takes a long time to debunk widely held beliefs.
Exactly the same criticism that is so often levelled at shoddy CAM trials has been used, unchallenged by skeptics, to build up the placebo myth. The fact is that the large placebo responses in some smaller trials can be explained by chance alone.
This makes much more sense and I think we need to be a darn sight more discerning about placebos. The problem with over-egging placebo is that it’s one of the issues at the heart of the problem when persuading people that some of the more outlandish alternative therapies are ludicrous. Many people are prepared to accept CAM because of the widely perceived wonderfulness of placebo.
Ben Goldacre’s Radio 4 programme on placebo (part 2 available here) stated that it is:
One of the most effective and neglected evidence based treatments known to man.
Cochrane is fairly well accepted to know their way around the evidence. What do they say about this ‘neglected’ option?
Placebo interventions for all clinical conditions (Review)
It has been widely believed that placebo (dummy) treatments (for example sugar tablets) are associated with substantial effects on a wide range of health problems. However, this belief is not based on evidence from randomised trials that use a placebo treatment for one group of people, while another group receives no treatment. The effect of placebo treatments was studied by reviewing more than 150 such trials covering many types of health care problems. Placebo treatments caused no major health benefits, although they possibly had a small effect on outcomes reported by patients, for example pain.
They also added:
There was no evidence that placebo interventions in general have clinically important effects. A possible small effect on continuous patient-reported outcomes, especially pain, could not be clearly distinguished from bias.
I am not convinced that we are neglecting a major therapeutic option.
The ‘caring effects’
I would argue that doctors that have a positive attitude do not ‘amplify’ the placebo effect. It is quite simply an obvious and rational intervention and not some latent property of the pill. It’s one of Margaret McCartney’s ‘caring effects’ and we need to recognise them in order to foster them within the healthcare system.
Placebo seems to have an almost mythic status as a health intervention. The danger is that it is interpreted as some kind of magical effect; one that is beyond science and rational thought.
We can quite possibly learn a lot about we how deliver care to maximise ‘caring effects’ by studying placebo. However, we need to temper this with a dose of reality – it is really the little sugar pill having the effect?
The article on the drug addict who got compensation for his mistreated kidney stones is classic Daily Mail territory. The whole article is written with the express purpose of whipping the reader into a foam of righteous indignation. It’s all there – the scrounging drug addict “still receiving full benefits” who assaults doctors and the good copper fighting against the “permanent drain on society” but facing the injustice that the “career criminal” is paid £27,000 by a politically-correct society for his self-inflicted illness.
I can’t get access to the Police Review article and the officer’s comments may well have been shamelessly cherry-picked for the Mail’s editorial purposes but the general tone is that of an embittered valedictory rant at a drunken retirement do. That said, my personal experience is that this article neatly encapsulates the issues when it comes to treating substance users. There’s no doubt that many in the police have similar views about users. Equally, I’ve lost count of the number of times I’ve seen pisspoor healthcare for users. GPs that have let alcoholics withdraw unsupported at home or doctors that have reduced methadone as a punitive measure for using ‘on top’. When these type of cases are presented in courts it’s no surprise when they win compensation. We have to admit that users can still receive standards of care and face attitudes that wouldn’t be tolerated in any other group in society.
Of course, some of it is a consequence of the users approach to health services. But it’s such a depressing merry-go-round and it all adds to a vicious circle where users are criminalised and ostracised. It’s quite possible that the individual involved here is a wrong ‘un but the answer isn’t an ongoing spiral of recrimination but a policy of decriminalisation that can break the cycle.
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HT @TransformDrugs for pointer to International Centre for Science in Drug Policy video.
Image from Parkin and Coomber paper below
This study reports on the findings of an intriguing qualitative study with intravenous drug users (IDUs) in Plymouth.
Apparently, but I readily admit I had no idea this was happening, there are now a number of public toilets that have fluorescent blue lights (FBL). The aim is to discourage IDUs from using public places to inject as the blue colouration makes it difficult to find and use veins.
Over the period Feb-Jun 2008 they recruited current IDUs who had injected in a public setting within the previous month. All of the 31 respondents were familiar with the blue light phenomenon and could name at least one location with FBL. All but one of them believed they were installed to deter injecting. Over one fifth (7/31) of the sample thought they were a ‘good idea’ to deter drug use and thus maintain the ‘safety’ of the public. FBL deterred 13 out of 31 of the sample but only had a partial deterrent effect on 7 out of 31. This group modified they way they used drugs. Some found alternative physical sites – one described going in the neck as those veins could still be found under the FBL. One quote from an IDU in the study:
I don’t think they’re a good idea at all. Really. I think if people are gonna have a hit, they’ll do it anyway, you know? If that’s the only place they can go, they’ll still have a go at doing it in there. If it makes it harder for them to get it, then you’re just doing that bloke no favours whatsoever at the end of the day. He’s still in there having a hit ain’t he? And all you’re doing is fucking his arms up for him.
In over one-third (11/31) of the sample there was no deterrent effect. Some of this group claimed to be attracted to blue light environments as they felt they were less likely to be detected there.
This paper shows that blue lights are only having, at best, a partial effect in deterring IDUs. One common theme running through this paper is that they can increase risky injecting – groin injecting or neck injecting are not affected by the need to see veins and it is harder to detect the difference between venous and arterial blood under FBL.
Blue lights may be increasing the risks for IDUs and doing little to reduce public injecting. They are not a public health measure that balances risks to individuals and society but simply a form of nimbyism. Businesses and councils can, many would say understandably, choose to prioritise the interests of the wider public but ultimately it deepens the rift between users and society. There may be a more reasonable argument for blue lights if we had injecting rooms in the UK but currently all it’s doing is adding to the stigma associated with intravenous drug use.
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Parkin, S., & Coomber, R. (2010). Fluorescent blue lights, injecting drug use and related health risk in public conveniences: Findings from a qualitative study of micro-injecting environments Health & Place, 16 (4), 629-637 DOI: 10.1016/j.healthplace.2010.01.007
I’ve just signed the Vienna declaration. It’s pretty simple and here it is:
The criminalisation of illicit drug users is fuelling the HIV epidemic and has resulted in overwhelmingly negative health and social consequences. A full policy reorientation is needed.
The whole package is considerably more complicated but, in a nutshell, it is calling for the incorporation of scientific evidence into drug policies. They are asking for action to:
- Undertake a transparent review of the effectiveness of current drug policies.
- Implement and evaluate a science-based public health approach to address the individual and community harms stemming from illicit drug use.
- Decriminalise drug users, scale up evidence-based drug dependence treatment options and abolish ineffective compulsory drug treatment centres that violate the Universal Declaration of Human Rights.26
- Unequivocally endorse and scale up funding for the implementation of the comprehensive package of HIV interventions spelled out in the WHO, UNODC and UNAIDS Target Setting Guide.27
- Meaningfully involve members of the affected community in developing, monitoring and implementing services and policies that affect their lives.
The scale of the problem almost beggars belief and prohibition is failing. The excellent Transform Drug Policy Foundation have posted more information on the Vienna declaration.
Secrets of general practice – the quick examination
We all know that time is limited in general practice. One of the keys to managing the stress of the short consultation is to get really slick and efficient when examining patients.
The old system of learning how to examine patients was a haphazard and variable experience. Medicine has long been pervaded with a ‘see one, do one, teach one’ mentality of learning on the job and it was utterly dire. While there are plenty of the old and bold out there who will grumble at the modern medical curriculum I will happily defend the practice of systematically teaching clinical examination skills to students from day 1.
The students learn long and complete versions of the examination – however, they then struggle to adapt them to the time pressures of general practice. Abbreviated examinations are completely critical for general practice so we should acknowledge it and expressly teach the skills. The one above, plummy neurologist aside, is a great example.
Curiously, GPs often recognise the need to improve on communication skills but I’ve never done an appraisal with a GP who thought they needed to enhance their examination skills. I have met plenty who struggle with their ‘time-management’ (a GP euphemism for persistently running late). Perhaps it’s a sign of modern medical practice where examination has now been devalued but I feel there is still scope, even for experienced GPs, to refresh and to hone these fundamental skills.
The CUT report and adulteration of illicit drugs
CUT is a “A Guide to Adulterants, Bulking agents and other Contaminants found in illicit drugs” and is a report published by Liverpool John Moores University. It’s one of the most illuminating documents I’ve read this year and is a proper little myth buster.
This is a topic that is staggeringly prone to personal opinion. The facts are that most illicit drugs aren’t quite so tainted as people might suspect. Or at least not in the way one might expect. There’s not much brick dust or ground glass out there but there are plenty of other substances. There is a certain logic to this – people who deal drugs have an appreciation that if they deliberately adulterate or contaminate their product they may face some rather direct and unpleasant consumer feedback. And I don’t mean that they will risk choking on their Earl Grey when they open a stiff letter of complaint.
This assessment of the available evidence supports research undertaken in this area that reports of the routine adulteration of illicit drugs with ‘dangerous’ substances are a myth.
This is not to belittle the staggering health impact from illicit drugs.
However, the evidence suggests that heroin is far more likely to be adulterated with benign substances that will bulk out, enhance or mimic the heroin. Typically sugars or paracetamol might be used for this. Locally, we have a lot of issues with benzos in the heroin – these are presumably cheaper and mean the user still gets something of a gouch to compensate for lower levels of heroin. Other substances such as caffeine can facilitate smoking of the drug. The most common contaminants in cocaine are lidocaine, sugars and phenacetin (an analgesic no longer available because of links with renal failure and carcinogenicity).
There is no shortage of case reports highlighting some of the nasty poisonings associated with illicit drugs. In the past, heroin has been contaminated with lead (possibly a by-product from the use of lead pots in its manufacture) and the issues of bacterial contamination have been amply demonstrated recently with the anthrax outbreaks in the UK.
It’s important everyone is aware of the risks of taking illicit drugs. However, whether it’s heroin, cocaine, ecstasy or cannabis it’s tricky to give good quality advice to people without an accurate understanding of the nature of the risk. There’s a long list of myths, bias and prejudice associated with illicit drug use and this report goes some way to redressing the balance.
Red-green colour blindness and advanced bladder cancer
I am red-green colour blind and I’m well aware of my general inability to distinguish red particularly well. In particular, I often miss subtler shades of pink. Apart from a tendency to wear inappropriate shirt and tie combinations it’s hardly life threatening. However, it is perhaps rather more than an inconvenience that blood is red. People that are colour-blind may be unable to spot early signs of blood loss. And as any fule kno unexpected blood rings big fat alarm bells for the Big C.
A good example is blood in the urine. I doubt I would miss frank gross haematuria but a red-green colour deficiency makes it easy to miss an elegant pink tinge in my urine. This simple study from some urologists in Preston took 200 male patients with bladder cancer and assessed them for colour deficiency using an Ishihara plate test. They found 21 gents (10.5%) had red-green or ‘complete colour blindness’. The presentation at diagnosis was frank haematuria in 74% of the non-colour blind versus 62% of the colour blind (non-significant).
The study also looked at the histology and the non-colour blind had 69% with superficial disease and the rest had invasive bladder cancer. The colour-blind group had 42% with superficial disease and 58% with less favourable histology. This is statistically significant (p<0.01).
There is sound logic to back up these findings. Colour-blind men can’t pick up some of the early signs of disease when it involves spotting colour changes in bodily fluids. So they are presenting later with more advanced disease. Not good. However, this is a small study – only having 21 cases of bladder cancer in colour-blind men limits how far I would want to rely on the findings.
Colour-blindness is treated as nothing more than an evolutionary oddity; good for teaching the basics of X-linked inheritance but of no clinical significance. If you are a clinician when was the last time you asked someone if they were colour-blind before asking about blood in the urine or faeces? I’m guessing most GPs don’t give it a second thought.
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Katmawi-Sabbagh, S., Haq, A., Jain, S., Subhas, G., & Turnham, H. (2009). Impact of Colour Blindness on Recognition of Haematuria in Bladder Cancer Patients Urologia Internationalis, 83 (3), 289-290 DOI: 10.1159/000241669
Fifth Column (via Dr Aust’s Spleen)
Required reading: the excellent Dr Aust does “Spoof Jenkins” day in his own inimitable fashion.
via Dr Aust's Spleen
Oxygen and heart attacks – keep calm and carry on
A common mnemonic used by medical students to remember the initial treatment of myocardial infarction is NOMA. Nitrates. Oxygen. Morphine. Aspirin. They are not necessarily given in that order but this prescription has the benefit of clarity when confronted by the real thing.
Only it turns out it may not be quite so clear cut. There was recently a Cochrane review of oxygen therapy for acute myocardial infarction. Surprisingly, the issue of oxygen in MIs comes into the clichéd category of ‘more research needed’.
These days we should perhaps know better than to unthinkingly trust oxygen. Too much oxygen is a risk factor for retinopathy of prematurity which can cause blindness in early arrivals – though to be fair too little (hypoxia) is a risk factor too. And every paramedic in the country is aware of the danger of giving high flow oxygen to some of those unfortunates with chronic lung disease who need some mild hypoxia to keep the respiratory centres in their brainstem ticking over.
This is all good news for the many poorly acted hospital dramas where the oxygen mask slips conveniently to one side but it can be depressing for aging doctors. Can nothing be trusted? The BMJ editorial is more sceptical and highlights the limitations of the studies used in the Cochrane review.
Methodology was poor in all three of the analysed articles
In other words they are crap studies. As well as being methodologically suspect they are also far too small and given there was only a total of 14 deaths the findings of more deaths in the oxygen group (versus air) are well within the realms of being a chance occurrence. Pisspoor studies and over-enthusiastic interpretation are the curse of evidence-based medicine. There is a strong argument, rarely it seems put into practice, that we should simply bin methodological weak studies at the first stage and read no further.
However, it is completely reasonable, some would say essential, to challenge everything. The defining characteristic of evidence-based medicine should be scepticism but sometimes the mindset of trusting nothing can leave one feeling a little panicky. Until we get a decent RCT sensible doctors will continue to give oxygen in heart attacks. In other words: keep calm and carry on.
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Atar, D. (2010). Should oxygen be given in myocardial infarction? BMJ, 340 (jun17 2) DOI: 10.1136/bmj.c3287
I hoped version 4.0 would provide some inspiration to address the issues of the GPs that are ‘special’. And there is a big group of doctors for whom the proposed revalidation just won’t fit: the peripatetic locums; the out of hours doctors; those in the armed forces or working in prisons; and all those on career breaks or in non-clinical posts.
Any appraiser will immediately highlight the type of problems – it’s challenging to do audits, significant event analysis without regular team meetings is a struggle, and multi-source feedback in a single-handed practice is seriously flawed. These groups have a problem with ticking the boxes.
The over-riding message seems to be that the groups will have to change the way they work in order to fit. There is a good argument that might not be a bad idea – for example, better mechanisms to give locums good peer support would be very welcome. However, it is in danger of straining the credibility of ‘strengthened’ appraisal to breaking point. Version 4.0 for us ‘specials’ is underwhelming. The RCGP version 4.0 states:
Not all the groups referred to above will be considered in detail in this section since the pilots for all these groups have not been completed yet. This section is therefore a work in progress [my emphasis].
I think we can all agree on that.
Running barefoot on the sand
I’ve been meaning to try out some barefoot running for a wee while now after watching this intriguing Nature video (which complements their paper) and I couldn’t have asked for a better opportunity than the past week on my hols in Scotland. The beaches of Galloway beckoned me as they stretched out at low tide.
I can’t say I’ve had an epiphany. Even on the sand my feet ended up feeling slightly raw as I inevitably couldn’t avoid all the shell fragments on the muddier foreshore. There is no question that I did have a different footstrike – it’s immediately uncomfortable to land on the heel and I quickly shifted forward on to my forefoot.
There is no inherent logic that just because we ran for thousand of years without footwear we should dispense with it now. Thousands of years ago we used to be very much smaller creatures than we are in these modern times. Obesity issues aside we are simply taller, stronger and unquestionably heavier. Given we now live long enough to be bothered by diseases of degeneration heavily cushioned running footwear may be beneficial. However, it is difficult to run with anything other than a bruising heel strike in some running shoes and it’s an interesting theory that some runners may do well to ignore the pseudo-science marketing spin and would benefit from a more natural, forefoot gait.
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Lieberman, D., Venkadesan, M., Werbel, W., Daoud, A., D’Andrea, S., Davis, I., Mang’Eni, R., & Pitsiladis, Y. (2010). Foot strike patterns and collision forces in habitually barefoot versus shod runners Nature, 463 (7280), 531-535 DOI: 10.1038/nature08723
