Heroes Not Zombies

Two papers published in the Lancet recently present contrasting views of the future of health care. Researchers in Scotland highlighted the fact that many people with chronic conditions suffer from more than one disease at a time.

The study looked for 40 chronic conditions among the participants’ data. Researchers found that 42% of patients had one or more conditions and 23% had two or more. It also found that only 9% of those with coronary heart disease, had that one disease alone. Similarly, only 23% of those with cancer, had only cancer and no other long-term disease

Why is this such an important point? Well, as the authors of the paper say

“Any country with an ageing population is heading in this direction. All these countries are waking up to the problem. “The status quo isn’t an option because it leads in the wrong direction.” Prof Watt said that rather than more specialists, patients with multiple conditions “need someone who can oversee all the problems of a patient”. “These patients need continuity, and we need ways of measuring how well care is joined-up.”

They highlight the need for more generalist approaches where the patient is seen in the context of their whole life, and that in particular people need continuity of care, co-ordination of care, and individualised care.

we’ve actually learned is that, whatever your level of cholesterol, reducing it further is beneficial.

“If we are going to prevent that half of cardiac or stroke deaths, then we’ve got to consider treating healthy people. “It can’t be done any other way.”

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Quite a headline, huh? It caught my eye on ScienceDaily.

The article is about a Norwegian research study which has estimated the amount of morbidity caused by prescribed drugs. By morbidity they mean things like –

new medical problems (adverse drug reactions, drug dependence and intoxication by overdose) and therapeutic failure (insufficient effect of medicines and untreated indications).

Of course if you have a look at the fine print on the little bits of paper included in packets of prescribed drugs you’ll be aware that the potential “new medical problems” they can cause is often a pretty extensive list. It’s interesting to see them considered as three separate categories however. All drugs have the potential to cause direct harm in the form of “adverse drug reactions”. We call these “side effects” and some are pretty minor, but some can end a person up in hospital, or even cause death (10,000 deaths a year in England was one estimate ). Most people are pretty aware of the potential that drugs can cause side effects. I think most people are probably also aware that too much of any drug will likely cause harm, and that’s the category “drug overdose”. Most frequently this is not a deliberate act of self-harm, but the taking of too high a dose to try and achieve the claimed effect of the drug – more painkillers, more sleeping tablets, more tranquilisers. The third category is “drug dependence” and I think a lot of people associate that with illegal drugs – heroin, cocaine etc. But in fact, drug dependence has both physical/chemical aspects related to the way a drug changes our inner environment, and psychological ones where people begin to believe they couldn’t stop or reduce their prescribed drugs.

This study goes beyond these three categories however, and includes “therapeutic failure”, again subdivided, this time into two categories – “insufficient effect” and “untreated indications”. In other words, where people take a prescribed drug and it doesn’t do what the doctor intended it to do. This occurs much more frequently than people think (despite the young doctor who told me she’d been trained – “if a patient takes an evidence based drug and doesn’t get better, either they haven’t taken the drug, or they are lying”). Dr Roses of Smith Kline Glaxo said –

“The vast majority of drugs – more than 90 per cent – only work in 30 or 50 per cent of the people,” Dr Roses said. “I wouldn’t say that most drugs don’t work. I would say that most drugs work in 30 to 50 per cent of people. Drugs out there on the market work, but they don’t work in everybody.”

The estimate of this drug-related morbidity in this study is just over a half of all the people who take a prescribed medicine. Is that a shocking figure? I think so.

When I trained as a GP, I was taught to take a holistic approach to patients, and to be cautious about prescribing. I was taught values which included not prescribing a “pill for every ill”. It seems that prescribing is on the up. (“Prescriptions for antidepressants have risen by 43% in the past four years to nearly 23 million a year, NHS figures reveal.” and “The total number of prescription items dispensed increased by nearly two thirds between 1998 and 2008,” )

Not only is there a pill for every ill now, but even people with no symptoms of illness are being prescribed life long medication in an attempt to prevent them becoming ill. Sadly, over half of those people, who aren’t actually sick, will suffer from this preventive strategy.

What happened to the medical value of “first do no harm”? Shouldn’t we developing ways of improving and sustaining human health which don’t involve using drugs which have such a potential to cause harm? And saving the drugs for the situations where their potential harms are outweighed by their potential benefits? That’s the strategy we employ at the NHS Centre for Integrative Care in Glasgow. It’s a strategy I’d like to see more of.

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