Media savvy

The news and views from the national media

Laws against smoking have irreversibly shifted attitudes. The same drive is needed for alcohol consumption. The police, magistrates and judges must insist on rehab for alcoholics as they do for drug addiction. And finally, while the NHS must care for those already addicted, it needs to get tougher on those who won’t stop drinking till they are blotto. Inform their employers or the benefits office. Show them there is no such thing as a free bed. Shifting a culture is not easy but it can be done.

Yasmin Alibhai-Brown, Independent on Sunday, 6 September

The [charity] sector is crying out for rationalisation through merger. It’s been talked about for years; but the holier-than-thou approach many charities take to their cause, combined with their ad hoc back offices, means that there’s little motivation to develop in this way… We need a Big Bang in the sector, with potential and existing charities required to justify why they are not joining others sharing the same purpose.

Matthew Patten, Telegraph, 3 September

People refer to our culture as ‘alcogenic’. It isn’t, it is alcophiliac. Drink is not merely the socially acceptable addiction, but the socially approved fix. Alcohol is how our society detaches itself from stress, be it the angst of work or parenthood. It is how it celebrates and mourns, marks the holiday and the everyday. Millions of people – like me – come under the category ‘functional alcoholic’, as if the ‘functional’ somehow negates the disease.

Hannah Betts, Telegraph, 14 September

The debate on minimum pricing for alcohol will now switch from the courts to the academic arena and the researchers will be asked to provide the proof of the policy the government wants to implement. When a government looks to academia to provide evidence for its favoured policy we should all be uncomfortable. Universities love government funding – they depend upon it. So the temptation will be to accept the government’s largesse and to deliver the findings the government wants to hear. Only in this case, the audience will not be sympathetic Scottish Government ministers, but sceptical European legal experts.

Neil McKeganey, Scotsman, 7 September

A mother who paid £300 for a dozen packets of cocaine as a birthday present for her daughter’s 18th has been spared jail. Nicola Austen, 37, with six previous drugs convictions, expected to be sent to prison and turned up at Maidstone Crown Court with an overnight bag. But the judge gave her a suspended sentence and community service because she is a ‘carer’ for her 14-year-old son and her elderly grandmother. Run that by me again. A woman who buys cocaine for her teenage daughter is spared jail because she is considered a suitable person to look after a 14-year-old boy? Am I missing something here?

Richard Littlejohn, Mail, 11 September

Sometimes the drug or alcohol problem isn’t obvious, says Dr Steve Brinksman 

Marco rarely came to the surgery. He was a 44-year-old restaurant owner with two young children but on a routine screen had been picked up as having high blood pressure. He had been given advice to lose a little weight and exercise more, but this made no significant difference. He was started on an anti-hypertensive and his blood pressure improved; but 12 months later it was up again, and as he was adamant he was taking his medication every day, a second drug was added in.

Three months later one of our registrars noticed his blood pressure was again poorly controlled. Rather than add in a third drug she decided to discuss this with me as part of her learning portfolio.

We went through his notes. He had been overweight but his body mass index (BMI) was now 26, so this was unlikely to be a significant factor. He had stopped smoking when his first child was born seven years earlier, his renal function was normal and no significant past medical history was recorded. I asked her if he drank alcohol. ‘I’m not sure,’ she said and indeed nothing was recorded in his notes about alcohol consumption. I explained that excessive alcohol use was a major factor for hypertension and cardiovascular disease.

He was due for review the following week and after this we caught up. He had told her he drank a bottle of red wine every day, as it was good for his heart! She had explained to him about the effect alcohol has on high blood pressure and cardiovascular disease and he had been shocked by this. He decided to try and cut his alcohol down rather than take a third medication. His blood pressure improved over the next few weeks and it was possible to stop one of his tablets.

I was the next person to see him and this time his blood pressure was within the normal limits while he was still taking a single drug to control it. He told me he had reduced his alcohol to half a bottle one night during the week and half a bottle each day over the weekend.

I wonder how many patients have physical and mental health problems related to their drug or alcohol use that pass unnoticed because a health professional doesn’t ask. We are trained to ask difficult and/or embarrassing questions, yet so often we don’t.

As part of our commitment to improving the treatment of alcohol users, SMMGP have launched an online training module about the community management of alcohol use disorders which can be completed free of charge at www.smmgp-elearning.org.uk

Steve Brinksman is a GP in Birmingham and clinical lead of SMMGP, www.smmgp.org.uk. He is also the RCGP regional lead in substance misuse for the West Midlands.

Media savvy

The news and views from the national media

Buying ethically produced food, and making a statement about yourself by doing so, is now so easy it requires little or no thought. Thinking about where your narcotics come from, on the other hand, is so difficult it’s simply easier not to do so… We are, it seems, living in the age of the wonky moral compass: of middle-class couples who swear by their weekly organic veg box, and yet relax after dinner with a line of something produced by impoverished, subjugated Bolivian peasants.

Jay Rayner, Guardian, 19 August

Creating a fug of confusion, Public Health England suggests e-cigarettes should be dished out by the NHS, while the Welsh Government says they should be banned in enclosed public places. The Mail believes both are wrong… In different ways, both Public Health England and Labour-run Wales are behaving like nannies. How about treating the public like grown-ups?

Mail editorial, 20 August

The ‘public health’ lobby is a lumbering beast that goes from one extreme to another. If it is not trying to ban something, it is trying to subsidise it. What e-cigarettes and their users really need is to be left alone.

Christopher Snowdon, Telegraph, 19 August

Tobacco is the largest single cause of preventable deaths in England – e-cigarettes may have a part to play to curb tobacco use. But the reliance by PHE on work that the authors themselves accept is methodologically weak, and which is made all the more perilous by the declared conflicts of interest surrounding its funding, raises serious questions not only about the conclusions of the PHE report, but also about the quality of the agency’s peer review process. PHE claims that it protects and improves the nation’s health and wellbeing. To do so, it needs to rely on the highest quality evidence. On this occasion, it has fallen short of its mission.

Lancet editorial, 29 August

Our descendants will wonder if we were ourselves drugged as well as unhinged when, in future times, they mourn and regret our irreversible folly in legalising this dreadful poison [cannabis]. Haven’t alcohol and tobacco done enough damage, and made enough profit for cruel and greedy people?

Peter Hitchens, Mail on Sunday, 23 August

As someone who chooses to not drink, I have become acutely aware of how alcocentric the UK is, and how drinking is consistently tied in with having fun and being happy and relaxed. The predominant message is that alcohol is a prerequisite for letting your hair down and living it up.

Lucy Rocca, Guardian, 12 August

Too scared to prescribe

Dr Chris Ford finds that in the US, new restrictions have had negative consequences for patients in pain

I was recently discussing the increase in use of prescription opioids in the UK and the US with Alex, an American doctor, who specialises in pain treatment, and I asked whether their new restrictions were helping the situation and was shocked to learn of the negative consequences of these Drug Enforcement Administration (DEA) actions.

He began by telling me about his patient John. ‘John had returned from Iraq in 2013 in a very bad way. He had lost both his legs and part of his left hand, as well as having internal injuries and severe depression. John was very determined and progressed well in rehab, soon became mobile and his mood began to lift. But the thing that didn’t really improve was his pain. He tried everything but nothing helped until we hit on hydrocodone. With his pain under control, John was able to continue his rehabilitation, start a part-time job and even began to play football.’

Then Alex told me the regulations around hydrocodone had changed and so did John’s life. He had always regulated his own intake and sometimes took more and sometimes less, but always within the parameters of the prescription. His pharmacist was ever helpful but was now nervous of the new regulations and wanted John to go to another pharmacy. This unsettled John and he had again become suicidal.

Alex explained further that it is now much harder for him to prescribe opioids, leading to a dramatic reduction in his ability to provide appropriate care for his patients in pain.

In 2014 hydrocodone combination products were ‘rescheduled’ to be like codeine and oxycodone, which were already Schedule II under the US Controlled Substances Act. In the US, there are over 60,000 kg of hydrocodone prescribed a year, a medication that is essentially only available in North America. Primarily available as a combination product, the maximum dose per day has been limited by the amount of paracetamol in the combination. Rescheduling now means that the medicine cannot be called into pharmacies and refills are no longer allowed on a prescription.[1] Additionally, in some states prescribing authority will be limited to physicians, not nurses or physician assistants.

Add to this the increasing restrictions on pharmacies in some states. Many can’t serve their customers who need opioid analgesia because the wholesalers who supply the pharmacy will no longer distribute the amount of medications that is needed. In some areas DEA agents have visited pharmacies to review the quantity of opioids being dispensed. Some pharmacies have reported being warned of increasing DEA review, if the quantity of dispensed medication was greater than the state average. So pharmacies make adjustments to stay in line and that is why John was sent away from his pharmacy. None of this is based on patient need, demographics or doctors but is quite simply a policy developed by bureaucrats, who have no understanding of the problem. Alex has also heard of pharmacists asking patients if they could reduce their dose or change to a non-scheduled alternative. In some cases, patients with advanced cancer have had difficulty filling their opioid prescriptions.

Yet the DEA say they are ‘simply enforcing the law, taking bad people off the street and essentially, trying to interrupt the supply of illegal prescriptions.’ But the agency takes no responsibility about the effect on people who need these medications.

Neither Alex nor I are saying that there isn’t a problem with prescription opioids. But it is complex, and punishing patients who need pain relief is not the solution. There has been an increase in the USA in opioid associated deaths (causality is not often established). However 60 per cent of the deaths are associated with poly-pharmacy (opioids, benzodiazepines and alcohol) and 30 per cent are associated with methadone, although it only represents 3 per cent of pain prescriptions. These deaths are almost all from using methadone as pain relief, not from OST. Some states mandate the use of methadone as a second line opioid after morphine in order to save money, although most physicians have little education in its prescribing.

Concurrently some people who have become dependent on prescription opioids are turning to heroin, which is becoming increasingly available in US. There has been much in the press about this but the increase in deaths is only partially related to this change and more to do with increasing purity of heroin.[2] People then using this heroin-prescription drug combination are not the traditional population of people who use drugs. This problem is increased dramatically among white people and especially among young white men. Eliminating or restricting opioid analgesics doesn’t make the problem of dependency go away.

Khary K. Rigg, Assistant Professor of Mental Health Law and Policy, University of Southern Florida; and Shannon Monnat, Assistant Professor of Rural Sociology, Demography, and Sociology, have recently published on the complexity of this problem and identify three groups of opiate users, who are distinct demographically, socioeconomically and psychologically. While heroin use is typically characterised as being a problem in black, poor and urban areas, an increasing number of people who use heroin and prescription opioids are white, employed and live in rural and small urban areas. The third group they identified are people who are addicted to prescription opioids alone and tend to be the most socially connected of the three groups. This group is the least socioeconomically disadvantaged and have better physical and mental health[3].

Professionals who treat people with drug problems should recognise the unique needs of each group of addicts, according to the researchers.

So what is happening in the UK? Prescription opioid dependence is a growing problem here and best-practice management is as yet not well defined.[4] In 2013, 757 people died with a prescription opioid in their blood stream, almost the same number as for heroin and illicit morphine (765) and more than for methadone (429).[5] It is critical that we understand this problem and respond appropriately, and avoid falling into the trap that the US has set for the people caught up in this situation.

[1] DEA Schedule II rules. http://www.deadiversion.usdoj.gov/pubs/manuals/pract/section5.htm

[4] Bernadette Hard. BMJ, 2014

[5] Office of National Statistics, 2014

Dr Chris Ford is clinical director of IDHDP, www.idhdp.com. Full version at www.drinkanddrugsnews.com