Using medicines that don't work

Mena

Slashdot

"David H. Newman, M.D. has an interesting article in the NY Times where he discusses common medical treatments that aren't supported by the best available evidence. For example, doctors have administered 'beta-blockers' for decades to heart attack victims, although studies show that the early administration of beta-blockers does not save lives; patients with ear infections are more likely to be harmed by antibiotics than helped — the infections typically recede within days regardless of treatment and the same is true for bronchitis, sinusitis, and sore throats; no cough remedies have ever been proven better than a placebo.

Back surgeries to relieve pain are, in the majority of cases, no better than nonsurgical treatment, and knee surgery is no better than sham knee surgery where surgeons 'pretend' to do surgery while the patient is under light anesthesia. Newman says that treatment based on ideology is alluring, 'but the uncomfortable truth is that many expensive, invasive interventions are of little or no benefit and cause potentially uncomfortable, costly, and dangerous side effects and complications.'

The Obama administration's plan for reform includes identifying health care measures that work and those that don't, and there are signs of hope for evidence-based medicine: earlier this year hospital administrators were informed by the Centers for Medicare and Medicaid Services that beta-blocker treatment will be retired as a government indicator of quality care, beginning April 1, 2009.

'After years of advocacy that cemented immediate beta-blockers in the treatment protocols of virtually every hospital in the country,' writes Newman, 'the agency has demonstrated that minds can be changed.'

Anyone have any professional opinions on this? Either way, I found it interesting, probably just re-inforcing the placebo effect. Either way, focusing on evidence based-medicine would, in my unqualified opinion, be the far better way forward.

AmcD

Mena wrote: »

patients with ear infections are more likely to be harmed by antibiotics than helped — the infections typically recede within days regardless of treatment and the same is true for bronchitis, sinusitis, and sore throats; no cough remedies have ever been proven better than a placebo

You had better tell this to mothers with small children, but I don't think they will believe you. A lot of prescriptions are driven by patient demand. People generally expect there to be side-effects to medications, which is very reasonable. However antibiotics seem to be exempt from this rule.

The national medicines information centre in St.Jame's Hospital publishes a regular newsletter that gives updates about this kind of information. A lot of the points you quoted would be generally accepted, but there would be a huge placebo effect with doing any kind of surgical procedure (whether sham or not). This is the reason why sometimes people swear by injections of painkillers, even though giving them by mouth would be equally effective.

Prescribing habits do slowly change. Anti-hypertensive medications would be a good example. No matter what each drug rep tells you, it doesn't matter which drug you choose to treat hypertension, you just use whichever one works for a particular patient.

SomeDose

To be honest, I'd be a bit shocked if the US healthcare system is only waking up to evidence-based medicine now. I know it has been hammered into me for my last ~10years in science-based education. Cough remedies being no better than placebo has been a no-brainer for quite a while. The statement that early administartion of beta-blockers "does not save lives" during acute MI is surely a bit simplistic, though. Some specific beta-blockers (atenolol and metoprolol, the only ones licensed for such use) have been shown to reduce the recurrence of MI, and may reduce early mortality. However, many MI patients present with comorbidities that either contra-indicate their use or mean their potential benefit is blunted. I don't have full access to that Lancet study so I don't know if this was the case in those particular patient populations.

You had better tell this to mothers with small children, but I don't think they will believe you. A lot of prescriptions are driven by patient demand. People generally expect there to be side-effects to medications, which is very reasonable. However antibiotics seem to be exempt from this rule.

Very true. Only last week I had a prolonged discussion with a mother who brought a week-old prescription (the ubiquitous co-amoxiclav) for her child who'd been bitten by a dog. The kid was fine, bouncing around the waiting room as they do. I tried explaining that the child was more likely to get a bout of diarrhoea than any benefit from the antibiotic...but the lady was not for turning!

Prescribing habits do slowly change. Anti-hypertensive medications would be a good example. No matter what each drug rep tells you, it doesn't matter which drug you choose to treat hypertension, you just use whichever one works for a particular patient.

Generally true for individual branded drugs within a class, but there is clear evidence for certain classes of drugs working better in certain patient groups e.g. younger people respond better to ACE inhibitors rather than CCBs or diuretics.

RobFowl

I remember a lecturer in medicine telling us that at least 40% of what we were being taught would turn out to be wrong, we just wouldn't know which 40% until the evidence turned up :rolleyes:

ZYX

AmcD wrote: »

You had better tell this to mothers with small children, but I don't think they will believe you. A lot of prescriptions are driven by patient demand. People generally expect there to be side-effects to medications, which is very reasonable. However antibiotics seem to be exempt from this rule.

The national medicines information centre in St.Jame's Hospital publishes a regular newsletter that gives updates about this kind of information. A lot of the points you quoted would be generally accepted, but there would be a huge placebo effect with doing any kind of surgical procedure (whether sham or not). This is the reason why sometimes people swear by injections of painkillers, even though giving them by mouth would be equally effective.

However the fault here is the doctors not the patients. The doctor gives the prescription and should only do so where there is need, not because the "patient demands it".

AmcD

ZYX wrote: »

However the fault here is the doctors not the patients. The doctor gives the prescription and should only do so where there is need, not because the "patient demands it".

I agree that it is ultimately the doctor who makes the decision and does the script. But if you are a medic, can you seriously say that you have never negotiated antibiotics, sleepers or benzos? If you can say no, well then fair play to your rock solid principles. I would love to be able to do that, but it isn't always possible.

ZYX

AmcD wrote: »

I agree that it is ultimately the doctor who makes the decision and does the script. But if you are a medic, can you seriously say that you have never negotiated antibiotics, sleepers or benzos? If you can say no, well then fair play to your rock solid principles. I would love to be able to do that, but it isn't always possible.

Why isn't it possible? What could posssibly happen? At worst the patient leaves your practice and moves to a different doctor. So what. If you prescribed an unnecessary antibiotic tomorrow and the child died of an anaphylactic reaction then I am pretty sure you would never prescribe an unnesscessary antibiotic for the rest of your life. Why not do it before something happens.
On the point of prescribing benzos when you feel they are not warrented, I feel that is disgraceful. Benzos have destroyed thousands of lives in this country. Over 90% of sufferers became addicted through doctors, either directly or indirectly. This is to the great shame of the entire medical community.

AmcD

ZYX wrote: »

Why isn't it possible? What could posssibly happen? At worst the patient leaves your practice and moves to a different doctor. So what. If you prescribed an unnecessary antibiotic tomorrow and the child died of an anaphylactic reaction then I am pretty sure you would never prescribe an unnesscessary antibiotic for the rest of your life. Why not do it before something happens.
On the point of prescribing benzos when you feel they are not warrented, I feel that is disgraceful. Benzos have destroyed thousands of lives in this country. Over 90% of sufferers became addicted through doctors, either directly or indirectly. This is to the great shame of the entire medical community.

Just out of curiosity, are you a surgeon? They generally have a black and white view of most issues. If you are seeing patients on a regular basis you do have to engage in some negotiation. There is no point having a showdown every time somebody asks for sleepers. The benefit of continuity of care means that people who are addicted to benzodiazepines can at least be gradually weaned off them (often against their wishes). Also continuity of care helps with educating about the pointlessness of antibiotics for viral infections. The benefit of being a hospital-based NCHD is that you can be much more upfront in refusing unnecessary medications for a patient you are unlikely to see again.

Can any other medics back me up here before I get reported to the medical council?

RobFowl

ZYX wrote: »

Over 90% of sufferers became addicted through doctors, either directly or indirectly. This is to the great shame of the entire medical community.

My only quibble with this is that I feel doctors are pretty much responsable for nearer 100% of benzo abuse either directly or by inappropriate prescribing leading to increased supply.

BTW am a GP and get the feeling ZYX is as well.

At the front line the easy option is to give in to pressure to prescribe, while often the best practice is to refuse or defer. It's a fault of the private GP system that Gp's who prescribe quickly are often more popular that those who stick to best practice guide lines.

AmcD

Benzodiazepine prescribing is a major dilemma. ZYX may not believe me, but I very rarely ever believe that they are warranted. However many of my patients would not agree. I am not interested in winning popularity contests, but I am working in an area where benzodiazepine use is regarded by patients as quite normal. Luckily the practice policy is that benzodiazepines/sleepers are only allowed in emergency circumstances. I often get told by my patients that they are buying these tablets, which I have little control over.
I have worked in practices with less strict rules regarding benzodiazepine use and it is incredibly frustrating when you know that a fellow colleague is dishing out the tablets in large quantities. I would be delighted if the HSE proposals, about limiting scripts to one month, became law.

ergo

AmcD wrote: »

Can any other medics back me up here before I get reported to the medical council?

AmcD what is your IMC number so I can do the necessary complaining....?

seriously though, hospital-based medics do not have an idea what it's like out in GP world

everyone starts out idealistic "I will never prescribe inappropriately etc"

but that's easy to say, at the end of a long day when you've had to deal with maybe 30 demanding patients and the next one comes in demanding an antibiotic you can tell them "well it probably won't work because it's a virus" but some patients just won't listen/ will never listen and won't leave til they have their script

it's all about picking your battles because it is a battle, let's face it, some will never be won, others are more open to compromise

I hope things are slowly changing and I tend to highlight the side effects like diarrhoea / rashes/allergies and the contribution towards increasing MRSA etc but some people will never listen to that. The HSE needs to play a role here too in increasing public awareness. Some people will never listen. My own mother will not listen to me about this! I'm blue in the face trying to correct her when she tells me to get an antibiotic for a cough, it's very hard to change that sort of mindset

it's also about bargaining and compromising especially with benzos re short courses, and having unifom practice policies. If the HSE brought in a nationwide policy that would be fantastic, I also believe they are never warranted except in short term use in emergency circumstances

DrIndy

Its easy in A&E to be a hardass on this issue - in fact - what we often do is deflect the issue to back to the GP which is not always the best approach.

I had an interesting experience with this once.

A young patient came in with an overdose of an unknown medication - but he got it from his mothers medicine bag. They had a lot accumulated over the years of unused medicines that were lying about the house.

I insisted they bring ALL of it in so I could sort through it - the parents were not the brighest sparks in the fire and I nearly lost the plot after telling them for 30 minutes how important it was to bring it all in, however much it was collected - I knew they were all repeat prescriptions and would be much of the same.

So the parents brought in 2 huge, overfilled carrier bags of unused medicines accumulated over the 3 years.

I then showed the packet individually to the patient and he identified he too a large dose of diuretics - I should probably have twigged this from how often he was asking for the pee-bottle!

However - I was also able to draw further conclusions from analysing the medicines bag:

1) No preventer inhalers were used, but all the relievers were empty.
2) An SSRI could be viewed as being increased stepwise in dose every 2 months (as if it were not effective) - however the tablets were not actually being used constantly. (in fact only 1/4 to 1/3 of tablets were taken)
3) Every single anti-anxiety and sleeping tablet box was empty.
4) All antibiotic tablets were taken
5) Blood pressure tablets were only being taken half the time.
6) All pain prescriptions were by and large completed (notably codeine containing ones)

The public WILL take relievers, antibiotics and sleepers consistently - but always the rest.

This was a real eyeopener to me - and to the pharmacist when i gave them to her to dispose of the next day!

I changed my practise after this - I started asking patients what medicines they were on from their doctor but also insisting on knowing which ones they were actually taking!



On the issue of receiving a prescription from a GP - people feel they need something tangible and value for money from seeing a doctor and because they are paying - need a script at the end to justify it. If we had true universal health care - people would not feel this need.

ZYX

To AMcD and Ergo, I am a GP and have many years experience both in UK and Ireland. (while I was a partner in UK a survey revealed our practice was in the most deprived area of entire UK). You have to get strict about prescribing if only for your own sanity. People talk about getting into long discussions and negotiating about antibiotics and benzos. I cannot remember the last time I had to do this. People know not to ask for benzos as they will not get them. Antibiotics are only given when I feel there is a bacterial infection that will respond. Generally speaking parents do not want antibiotics for their children in my experience. Not only their fear of side effects but simply getting the antibiotic into the child can be difficult. Parents generally are happier to see a full examination done, see that you have listened to all their concerns and given a clear explaination of the problem eg explain why green sputum does not mean infection, why sticky eyes is not usually infection etc. You would be surprised how quickley patients respond to this approach and how much easier it will make your life.
Incidently talking to friends in UK now, many Primary Care Trusts send updates to the GPs every few months. This will show all your prescribing for last month but also every other GPs prescribing in your area. You can clearly see how much you are prescribing of antibiotics or benzos or anything else and it compares you directly with your colleagues. This type of info would be fantastic in Ireland.

Capt'n Midnight

DrIndy wrote:

The public WILL take relievers, antibiotics and sleepers consistently - but always the rest.

Good to hear

If we had true universal health care - people would not feel this need.

true IMHO

sam34

i saw an interesting case recently of what, to me, was blatant mis-prescribing of benzos....

(btw, im a psychiatrist and saw this patient following GP referral)

the patients husband had died after a long illness, his death was not unexpected.
the patient asked the GP to call out because she was "upset" (totally understandable)
Family and patient themselves confirm that she was tearful, but not inordinately so
GP comes and gives her 10mg of diazepam, IM!!!!!!!

a) there was no indication for this
b) there was doubly, triply, quadruply no indication to give it IM

now, a few months later this lady had a further bereavement. and this time she rings teh GP and asks "for the injection" which the GP duly administers.

I asked her why she felt she needed it and she replied "thats what you get when someone dies"

i mean, could that GP not have adopted a common sense approach, sympathised with and listened to teh patient, perhaps explained about grieving process etc, rather than giving her diazepam IM?

i know it was two once-off incidents, and to be fair teh GP didnt give a script for regular benzos, but still it set up a pattern of expectation in teh patient and her family etc.

i must say though, that in psych we tend to use benzos a fair bit, but would always attempt to wean them as much as possible.

major sympathy though to my GP colleagues, as i'd say they see the brunt of bargaining for them.

ergo

ZYX wrote: »

Incidently talking to friends in UK now, many Primary Care Trusts send updates to the GPs every few months. This will show all your prescribing for last month but also every other GPs prescribing in your area. You can clearly see how much you are prescribing of antibiotics or benzos or anything else and it compares you directly with your colleagues. This type of info would be fantastic in Ireland.

indeed, I am in the NHS at the moment, we get the graphs through of where we are compared to all the local practices, happily I'm in a "low prescribing" practice in terms of antibiotics. Would be fantastic if they introduced that in Ireland

Also there are lots of incentives to audit and change prescribing and make it more appropriate over here, I'm not sure any of that goes on in Ireland

quite often in the UK the patient will pop in just to get checked out to make sure that they don't need an antibiotic and go away happy if this is the case.

the difference as you know is that in the UK it is universal access ie. no-one pays to see the GP and patient then has to pay for their prescription so that has a role to play in the different patient drug-seeking behaviour in the UK I suspect...then those that pay €40 to €60 feel they should be coming away with something