Poppy Love Views & Reviews

VIEWS & REVIEWS What has changed in medical practice Poppy love that patients in 2008 seem to be in so much more pain than in 1988? PERSONAL VIEW Janet Gillespie I spread out the crumpled note the patient as a sedative and in larger doses as a powerful ber to December 2006 show that prescribing had given me while he spoke: he had been painkiller. People bought it in much the same of opioids rose by 62%, accounting for 25% to the pain clinic “for his back,” and they had way as they buy aspirin today: opium was of all analgesic prescribing (www.ppa.org.uk/ recommended this to help his pain. If he took more widely available in 1870 than tobacco news/pact-032007.htm). Notably, morphine the note to his (implied) trusty GP, he or she was a century later. Patent medicines such as prescribing rose by 57%. would sort it out for him; and if the treatment Dover’s powder were kept in the kitchen cup- Over my professional lifetime I have was unsuccessful, the pain clinic suggested, he board. Godfrey’s Cordial or Street’s Infants’ witnessed the consequences of iatrogenic could be referred to a neurosurgeon for assess- Quietness not only reduced colic in infants benzodiazepine dependency, these drugs ment. Mercifully, the trade name was scrawled but made it easier to sedate children so that having originally been promoted as a safer in block capitals. The British National Formulary they were indeed “seen and not heard.” The substitute for barbiturates. This was yet another revealed it to be a methadone transdermal intoxicant effects of opium were also appreci- example of the British love of problem solving patch. ated: one Ely brewer added it at source. by substitution: Wellington’s Beer Act (1830) I sat back and considered the matter. It was As early as the 1830s, however, it was recog- promoted beer to solve the misuse of gin, a not an entirely unreasonable suggestion: the nised that opium use reduced life expectancy, drink that was first promoted by William III patient was already taking paracetamol, tra- and by the 1860s it had become a matter of to reduce the wine trade with France, the old madol, and amitriptyline, with only moderate national concern. A third of all fatal poisonings enemy. So what are we prescribing opiates as control, and his sleep was still disturbed. What were opium related, and accidental poisonings a substitute for? Since the rise in opiate use surprised me was that the opiate prescrip- were so common that information leaflets were clearly predates the “loss” of co-proxamol, is tion had come before a referral for a surgical published to warn of the risks. The 1868 Poi- our prescribing a substitute for action? What opinion. sons and Pharmacy Act listed opium as one of has changed in medical practice that patients in In the mid-1980s, when I trained as a gen- 15 poisons whose use became restricted, but 2008 seem to be in so much more pain than in eral practitioner, opiate patches were only it wasn’t until 1920 that Britain had its first for- 1988, when treatments were fewer and surgical the proverbial twinkle in a pharmacologist’s mal legislation on the regulation of drugs, with techniques less refined? eye, and use in the community of “Bromp- the Dangerous Drugs Act. Today, we practise Or have the opiates ton cocktail” was considered avant-garde. Ten in the shadow of now become an end in years later, when I left the partnership, syringe Harold Shipman themselves—an easy, drivers and Macmillan nurses had become a and his profli- computer generated routine part of the primary healthcare serv- gate opiate mis- solution with the ice. But that was for terminal care; pain that use. It is somewhat slight annoyance of con- merited further investigation or had a possible paradoxical, then, that stipation and the benefits alternative solution was managed by an appro- prescriptions for opiates are of a mildly sedated patient? priate referral. now computer generated for If so, our profession is at risk of Perhaps part of the reason for this reluctance accuracy and legibility but by this sleepwalking into another iatrogenic to prescribe opiates was the need to handwrite method are less onerous to issue. dependency and forgetting the age old miser- prescriptions for “controlled drugs” in words I recently returned to general practice ies of opiate addiction. and figures. Individual doses were easily after a break of seven years and was My patient and I discussed the pain clinic’s remembered: scripts were for small amounts struck by the large number of opiate recommendation and assessed the risks and were therefore often repeated. In the days prescriptions. The NHS’s Prescription and benefits of such an action. He left with before computer searches, a straw poll of the Pricing Division confirms this increase: a prescription for opiates, and I am writ- partners would have produced a complete list from 2000 to 2005 the largest ing to expedite his assessment by of all patients taking opiates regularly. increase in painkiller pre- a neurosurgeon. That just Opiate prescribing dates back to Sir Tho- scribing was in opioid leaves the matter of our mas Sydenham, who, in the 1660s, promoted analgesics, with mor- poppy love. laudanum (from the Latin “laudare,” to praise), phine prescription Janet Gillespie is salaried a tincture of opium and alcohol. Writing at the increasing by 32% general practitioner, Buntingford end of the 19th century, William Osler called it and fentanyl patches Medical Centre, Buntingford, “God’s own medicine.” For the first time there nearly sixfold. This Hertfordshire gillespie. was a reliable means of controlling diarrhoeal trend continues: [email protected] symptoms, while in moderate doses it acted data from Octo- Cite this as: BMJ 2008;337:a2334 BMJ | 8 NOVEmbER 2008 | VOLUME 337 1115 VIEWS & REVIEWS A fat chance FROM THE I always enjoyed the university annual eating competi- already exist, and they are neither new nor complex. FRONTLINE tions: five contestants at the zenith of their ability, swal- We need to restore to people’s lives a balance between lowing whole pickled onions or boiled eggs, but only energy input and output. The scale of the problem, how- Des Spence one winner. Gluttony was celebrated, and like many ever, requires a political, not a medical, change. young people I never believed I would gain weight. But We have a decaying and neglected food culture, with times change. Obesity is now common in the young and families offering just readymade meals amid unconvinc- endemic to epidemic in adults. When we won the battle ing excuses of “pressure of time.” But the key problem is for wealth we lost the war of contentment. Doctors have our sedentary life. Current recommendations on activity foolishly rushed into this haemorrhaging of happiness. are woefully low, reflecting a poverty of expectation. Obesity is now a big medical business, with a rapid And the education system is so fevered with targets it is expansion in the number of specialist clinics. Likewise blind to our national disgrace: inactive children. Further- drug companies are active, lurking behind advocacy more, we are so plagued by spectres of mistrust that our groups that endorse drug treatment as a solution to the children are kept virtual prisoners indoors. irresistibly personalised pain of obese people. Recently, An urgent and fundamental change of infrastructure however, rimonabant, a cannabinoid receptor antagonist and schools policy is needed. We need to create safe anti-obesity drug, joined the long list of withdrawn drugs places for our children to play in, to allow them to cycle, (BMJ 2008;337:a2301). An all too familiar tale was the pedestrianised streets and to restrict car use, along with unforeseen side effects of the drug. education and financial incentives to get people to pre- We must stop the medical advance on obesity and pare food themselves. Medical interventions will serve bring the troops home, for once again we are destabilising only as an irrelevant policy distraction and have a fat self control and personal responsibility. Medicine alone chance of working. cannot solve the problem of obesity, and nor should Des Spence is general practitioner, Glasgow [email protected] it try—obesity is not an illness or syndrome. Solutions Cite this as: BMJ 2008;337:a2432 The bottom line StARTING OUT “I’ve just passed a 12 inch stool,” to irritable bowel syndrome approach. Time spent regularly Kinesh Patel said the voice over the telephone (gastroenterology seems to have with a patient is largely regarded as with a degree of solemnity more than its fair share). “waste” time that could have been commensurate with such a The bottom line is we’re not very used to see a new referral, thereby statement. “Is that normal?” good at assessing patients’ mental keeping the hallowed “follow-up “Well, I’m not sure,” replied state, let alone offering appropriate to new ratio” (abbreviated, rather the secretary, a little baffled as to treatment for their conditions. It ironically, to FUN) within target. what the appropriate response is much easier to comment matter And while I have no doubt was to such a question, while no of factly on the large ulcerating that such reforms have led to doubt at the same time wondering carcinoma you’ve discovered than shorter waiting times for patients why anyone would bother to to explore environmental influences with organic disease, those with measure a stool, let alone share that on diseases affecting the human debilitating conditions that do not information with anyone else. condition. fit neatly into any pathologically Although such an anecdote Patients with cancer need surgery, proved diagnosis have surely makes us snigger quietly to chemotherapy, and emotional suffered as they are bounced from ourselves, it does illustrate how support, whereas those with hospital to GP and then back again.

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