GPs prescirbing drugs inappropriately

steddyeddy

There's an increasing trend of students going to their GP and getting Ritalin, beta blockers and other drugs to help concentrate or get over the nerves of giving a presentation. What are the ethical implications of this? What are the views of the medical community on prescribing drugs as performance enhancers or beta adrenergic receptor drugs for enhancing presentation performance?

The other fella

Give me his name and business address and ill report him.

steddyeddy

I'm not giving out names over a forum and I'm sure it's against the rules. I just want to know is it wrong to prescribe things like beta blockers for presentation nerves?

steddyeddy

steddyeddy wrote: »

I'm not giving out names over a forum and I'm sure it's against the rules. I just want to know is it wrong to prescribe things like beta blockers for presentation nerves?

Ot necessarily.

steddyeddy

Does that go for prescribing Ritalin for concentration/studying for exams?

Winning Hand

Sounds like a gunner

Xeyn

My cardiology professor suggested as long as there were no contraindications certain beta blockers should be considered for those with an anxiety about presenting. The Ritalin thing is very debatable. The risk profile would suggest it shouldn't be used for that purpose but I'm no expert an I would hope a proper consultation occurred with the prescribing doctor first.

locum-motion

The other fella wrote: »

Give me his name and business address and ill report him.

I'm sure the IMC wouldn't accept a complaint in the form of

I heard from some randomer on the interwebz that Dr Smith was prescribing Drug X for condition Y. Please strike him off.

I'd say they'd look for a rather higher standard of evidence than that!

RobFowl

Mod note
Can you please quite some evidence to back this up?
Rob

Mrs OBumble

locum-motion wrote: »

I'm sure the IMC wouldn't accept a complaint in the form of

I'd say they'd look for a rather higher standard of evidence than that!

I'm kinda picking that the other fella didn't have reporting in mind when he asked for the address!




OP, information about making a complaint about a doctor is found here: http://www.medicalcouncil.ie/Public-Information/Making-a-Complaint-/

If it's people in your school who you think are getting drugs for the wrong reasons, then you should tell your concerns to the guidance counsellor, school nurse or student health service (if you're in college).

steddyeddy

RobFowl wrote: »

Mod note
Can you please quite some evidence to back this up?
Rob

Back up evidence that the GP in question is providing these thing or that that students are being prescribed things like beta blockers for nerves and valium ect. Well I have teaching responsible at a university and students (and other PhDs) tell me they got them off their doctor. Some GPs refuse to prescribe them but some even seem to give advice e.g "don't take valium take beta blockers as you'll be high during your presentation".

It's not that I'm looking to report necessarily I'm just seeking opinion on the issue. Some GPs seem happy to prescribe them for the effects of adrenaline in presentations and some don't. I'm wondering what the rules are on the issue.

steddyeddy

Mrs OBumble wrote: »

I'm kinda picking that the other fella didn't have reporting in mind when he asked for the address!




OP, information about making a complaint about a doctor is found here: http://www.medicalcouncil.ie/Public-Information/Making-a-Complaint-/

If it's people in your school who you think are getting drugs for the wrong reasons, then you should tell your concerns to the guidance counsellor, school nurse or student health service (if you're in college).

I don't actually want to complain. I want to see what the opinion is on things like this.

steddyeddy

locum-motion wrote: »

I'm sure the IMC wouldn't accept a complaint in the form of

I'd say they'd look for a rather higher standard of evidence than that!

Well I don't want to complain. Imo I seems relatively harmless (beta blockers) but I would love to know the opinion of posters here.

my3cents

OP might be having flash backs to something he read http://www.irishexaminer.com/lifestyle/features/humaninterest/students-turning-to-legal-stimulants-for-exam-edge-230722.html .

steddyeddy

my3cents wrote: »

OP might be having flash backs to something he read http://www.irishexaminer.com/lifestyle/features/humaninterest/students-turning-to-legal-stimulants-for-exam-edge-230722.html .

Em no. I'm talking about people I know using GP obtained prescriptions to get beta blockers. I can't believe you don't think students don't use these things for these purposes.

Mrs OBumble

steddyeddy wrote: »

I don't actually want to complain. I want to see what the opinion is on things like this.

So why did your original post say:

steddyeddy wrote: »

... Who should I report this to if I know the GP in question?

steddyeddy

Mrs OBumble wrote: »

So why did your original post say:

Because I didn't think it through. My main question relates to the ethics of prescribing beta blockers ect for presentations and study aids ect. I think it's a fair question.

RobFowl

steddyeddy wrote: »

Because I didn't think it through. My main question relates to the ethics of prescribing beta blockers ect for presentations and study aids ect. I think it's a fair question.

Mod note
Could you edit your original post to reflect this please
Rob

steddyeddy

RobFowl wrote: »

Mod note
Could you edit your original post to reflect this please
Rob

Done Rob thanks. It should make for an interesting debate.

Icemancometh

I think there's a qualitative difference between using beta blockers for performance related anxiety, and using methylphenidate to improve academic performance. I can't imagine ever prescribing a controlled medication for an off-licence use like that. I would imagine most off-licence prescribing was being done by specialists rather than generalists, but I'm sure it happens.

Nonoperational

Agreed.

steddyeddy

Icemancometh wrote: »

I think there's a qualitative difference between using beta blockers for performance related anxiety, and using methylphenidate to improve academic performance. I can't imagine ever prescribing a controlled medication for an off-licence use like that. I would imagine most off-licence prescribing was being done by specialists rather than generalists, but I'm sure it happens.

It happens but what are the ethics involved? Is it frowned upon?

MrCreosote

If you're looking for a clear distinction between using a beta blocker to treat a situational anxiety and using it as a performance enhancer/"doping" agent, you're not going to find it. Too much of a grey area.

steddyeddy

MrCreosote wrote: »

If you're looking for a clear distinction between using a beta blocker to treat a situational anxiety and using it as a performance enhancer/"doping" agent, you're not going to find it. Too much of a grey area.

No I'm not but looking for one. I'm just getting views on the subject. I mean if I go to a GP and ask for beta blockers because I don't like presentations should I be prescribed them. I don't think you could describe "feeling nervous during presentations" as pathology.

Icemancometh

steddyeddy wrote: »

It happens but what are the ethics involved? Is it frowned upon?

It's all so situational as to make discussion on it quite difficult. I've thought about this reply for some time and found it hard. You can very easily construct cases in your head where the meds have been prescribed inappropriately, and conversely, construct cases where they are appropriate. Of course, everyone frowns on the latter! Without knowing the particulars of each case (and to be clear, I'm not asking for any) it's hard to comment.

echo beach

steddyeddy wrote: »

I mean if I go to a GP and ask for beta blockers because I don't like presentations should I be prescribed them. I don't think you could describe "feeling nervous during presentations" as pathology.

The decision to prescribe or not is made after a consultation with the patient, which is confidential so you can't know the factors that may have been taken into consideration.
Inderal, a beta-blocker, is licensed for the control of anxiety and anxiety tachycardia so it is perfectly reasonable to prescribe it for somebody who becomes anxious and suffers from an increase in heart-rate before and during presentations.
The issue is when does the normal nervousness at having to make a presentation become a pathology, and that point will be different for different people. For some people "feeling nervous during presentations" is a most definite pathology, they hyperventilate or become physically sick and may even faint. There are other treatments but if they aren't contraindicated beta-blockers are very helpful in most cases. They shouldn't be used in asthmatics.

steddyeddy

echo beach wrote: »

The decision to prescribe or not is made after a consultation with the patient, which is confidential so you can't know the factors that may have been taken into consideration.
Inderal, a beta-blocker, is licensed for the control of anxiety and anxiety tachycardia so it is perfectly reasonable to prescribe it for somebody who becomes anxious and suffers from an increase in heart-rate before and during presentations.
The issue is when does the normal nervousness at having to make a presentation become a pathology, and that point will be different for different people. For some people "feeling nervous during presentations" is a most definite pathology, they hyperventilate or become physically sick and may even faint. There are other treatments but if they aren't contraindicated beta-blockers are very helpful in most cases. They shouldn't be used in asthmatics.

I'm a biochemist so I would have some knowledge of pharmodynamics and kinetics (not a lot). Tachycardia is a resting heart rate exceeding the norm IMHO. Anxiety during presentations is a situation that will bring about an adrenergic response which leads to increased heart rate. This rate arises though hormonal input not normal physiological conditions or as a result of pacemaker cells.

I don't think it's suitable to correlate anxiety during anxiety generating situations (chased by lions ect) as tachycardia.

steddyeddy

I should add I think most of the "smart drugs" are obtained online and not prescribed.

Dingle_berry

steddyeddy wrote: »

No I'm not but looking for one. I'm just getting views on the subject. I mean if I go to a GP and ask for beta blockers because I don't like presentations should I be prescribed them. I don't think you could describe "feeling nervous during presentations" as pathology.

How do you know that the students just 'don't like presentations' or are only 'feeling nervous during presentations' and not experiencing genuine pathological anxiety? Excessive anxiety is a recognised pathology.

And if it's a concern of yours as a lecturer/teacher, what approaches can you take to ameliorate your students anxiety? I don't think taking measures to prevent prescribed medications would count.

steddyeddy

Dingle_berry wrote: »

How do you know that the students just 'don't like presentations' or are only 'feeling nervous during presentations' and not experiencing genuine pathological anxiety? Excessive anxiety is a recognised pathology.

And if it's a concern of yours as a lecturer/teacher, what approaches can you take to ameliorate your students anxiety? I don't think taking measures to prevent prescribed medications would count.

Hey, I'm glad she's taking them IMHO opinion. It's none of my business what she takes but they definitely help her. It's the smart drugs I don't like. I originally thought they were being prescribed but they're not.

steddyeddy

I think this is similar to the phenomenon of the pushy patient demanding antibiotics and the passive doctor supplying them IMHO. It's a lot worse in the case of antibiotics IMHO but there seems to be an increase towards pushy patients making demands.

Taco Chips

This is obviously anecdotal so YMMV but I think the stereotype of the passive doctor writing a script for just about anything is grossly over exaggerated. In my time on placement in hospitals anyway I've seen nothing but total vigilance over drug prescription. More docs leaning on the side of super caution (as it should be) than anything. And antibiotic stewardship is taken very seriously with medical microbiology having close input to nearly every inpatient case I've seen. I've heard rumours etc.. about students being on study enhancing medication but never seen any real evidence of it, and the rumours themselves tend to come from North Americans where that kind of thing may be a bit more common. I'm open to correction on this if anyone has stats for the situation in Ireland but from my experience docs are highly attentive about all prescriptions here nearly all of the time.

Kurtosis

OP what would you consider inappropriate prescribing to be? I think any discussion like this needs to be framed with what inappropriateness constitutes. I would think of it as either:

- prescribing a medicine to someone who does not have an evidence-based/licensed indication for it or
- prescribing a medicine where the harms outweigh the benefits or there is an alternative option with a better risk/benefit ratio.

With regard to beta blockers for anxiety, it is a licensed indication as has been mentioned and they certainly would be safer than pharmacological alternatives like benzodiazepines. So if a person does suffer from presentation anxiety and their GP is confident of this, I think it would be appropriate to prescribe a beta blocker. Of course there are going to be situations where a person may be deceptive to try and obtain a drug but if we are talking about the general case I can't see any problem. (This is from a non-doctor perspective)

Taco Chips

Taco Chips wrote: »

This is obviously anecdotal so YMMV but I think the stereotype of the passive doctor writing a script for just about anything is grossly over exaggerated. In my time on placement in hospitals anyway I've seen nothing but total vigilance over drug prescription. More docs leaning on the side of super caution (as it should be) than anything. And antibiotic stewardship is taken very seriously with medical microbiology having close input to nearly every inpatient case I've seen. I've heard rumours etc.. about students being on study enhancing medication but never seen any real evidence of it, and the rumours themselves tend to come from North Americans where that kind of thing may be a bit more common. I'm open to correction on this if anyone has stats for the situation in Ireland but from my experience docs are highly attentive about all prescriptions here nearly all of the time.

What was the meropenem use like? Micro seen everybody?

Xeyn

To be fair I don't see any recreational benefit for beta blockers [i am willing to be corrected on that] Ritalin or benzodiazepines on the other hand - yes, so not sure why anyone would purposefully be deceptive to obtain them.

RobFowl

Xeyn wrote: »

To be fair I don't see any recreational benefit for beta blockers [i am willing to be corrected on that] Ritalin or benzodiazepines on the other hand - yes, so not sure why anyone would purposefully be deceptive to obtain them.

You haven't lived ....

echo beach

Xeyn wrote: »

To be fair I don't see any recreational benefit for beta blockers [i am willing to be corrected on that]

Depends what recreations you indulge in. They may improve your performance at any activity that requires a steady hand, e.g. snooker, darts or clay pigeon shooting.

Xeyn

Cheers lads, that's my weekend sorted then!

BetterThanThou

I have no experience in pharmacology at all, bar some small research I've done on my own time, but I'd always assumed beta blockers were simply to treat tachycardia, never heard of them used to concentrate or for any other reason, though I may be wrong. As far as ritalin is concerned, mental health is something quite easy to lie about, and no doctor can really distinguish lies from the truth in that area, it's simply a case of having to take what the patient says as fact. There's always going to be people abusing drugs like this, and you can't really deny it to them without denying it to people who actually need it.

partyatmygaff

Though they can be used for tachycardia, i'd have thought their most common use would be in treating heart failure, dysrhythmias and hypertension.

They're not approved for treating anxiety but they're occasionally used off-label for treating some symptoms of anxiety such as tremor, increased heart rate and so on. The more lipophilic beta blockers like propranolol cross the BBB (to the point that they may cause unusual dreams or nightmares) so there may be some possible reduction in psychological symptoms of anxiety with long-term use. This is a bit old but it and its related articles may be a good read: http://www.ncbi.nlm.nih.gov/pubmed/2905981

Ethically, contraindications aside, it's much less risky than going down the road of benzos. I'd have no issue dispensing a script for beta-blockers for anxiety providing it's suitable for the patient.

steddyeddy

Taco Chips wrote: »

This is obviously anecdotal so YMMV but I think the stereotype of the passive doctor writing a script for just about anything is grossly over exaggerated. In my time on placement in hospitals anyway I've seen nothing but total vigilance over drug prescription. More docs leaning on the side of super caution (as it should be) than anything. And antibiotic stewardship is taken very seriously with medical microbiology having close input to nearly every inpatient case I've seen. I've heard rumours etc.. about students being on study enhancing medication but never seen any real evidence of it, and the rumours themselves tend to come from North Americans where that kind of thing may be a bit more common. I'm open to correction on this if anyone has stats for the situation in Ireland but from my experience docs are highly attentive about all prescriptions here nearly all of the time.

Sorry I meant to reply to this earlier but had a mad week. Taco chips I personally think GPs are at fault over the doling out of antibiotics not hospital clinicians.

gctest50

steddyeddy wrote: »

..........Taco chips I personally think GPs are at fault over the doling out of antibiotics............

their customers/patients are at fault

if they don't dole them out - some/most*** will just "get a few" from their mate that had some left over

then they will harp on "that GP is no good" (ie didn't horse out what they wanted)




***(they of that belief that there is a tablet for anything and everything )

steddyeddy

gctest50 wrote: »

their customers/patients are at fault

if they don't dole them out - some/most*** will just "get a few" from their mate that had some left over

then they will harp on "that GP is no good" (ie didn't horse out what they wanted)




***(they of that belief that there is a tablet for anything and everything )

I realise that A GP's patients often puts them under pressure but at the end of the day they're professionals and shouldn't be compromising the health of the nation because of pressure placed on them.

gctest50

steddyeddy wrote: »

I realise that A GP's patients often puts them under pressure but at the end of the day they're professionals and shouldn't be compromising the health of the nation because of pressure placed on them.

It's very hard to win with crazy though

any ideas on how to beat it though ?

more placebos packaged up as "the real deal" ?

disulfiram or something in almost every tablet ? ( package them all as "NEW !!!! IMPROVED !!!")

steddyeddy

gctest50 wrote: »

It's very hard to win with crazy though

any ideas on how to beat it though ?

more placebos packaged up as "the real deal" ?

disulfiram or something in almost every tablet ? ( package them all as "NEW !!!! IMPROVED !!!")

My friend's a GP and it sounds like he has to deal with loons TBH. I have a lot of sympathy for the GPs in this regard. I don't think calling the patients customers helps TBH.

El_Dangeroso

If a patient comes in putting pressure on a GP to prescribe 'something' then it's 100% the GP's responsibility to not prescribe 'something' that is leading us into an antibiotic-less future.

It's a total waste of money to have these public awareness campaigns when all that needs to be done is to not prescribe incorrectly.

If I wanted liquid morphine how much 'pressure' would I need to apply to get it?

_Tombstone_

Agricultural use is the major problem in relation to resistance. Constant low dose use of the last resort of Antibiotics, because of cramped conditions or to speed up weight gain. 80% of all use by some estimates, massive.

FDA has given "guidance" to stop. :pac::pac::pac: LOL, it's depressing me the way Industry runs everything these days.

Doctors aren't blameless, vast majority of them around my way pawn off patients/customers with an Antibiotic....to justify the fee I guess....but when people are dumb enough to go in with a runny nose then why not.

My sister has over a Dozen of AntiB Courses gone into her young fella in the last few years, a sneeze and she's popping them into him. Fupping Disgrace.

So of the 20% left over from above, over half of that is wasted aswell.

But the running out of an Antibiotic should never have been a thing anyway, I see they've finally got off their backsides and "found" a new one that "may" be unresistable, though it's gram positive or negative only, I forget which.

http://news.sciencemag.org/biology/2015/01/microbe-found-grassy-field-contains-powerful-antibiotic

http://consumerist.com/2014/09/18/white-house-acknowledges-over-use-of-antibiotics-in-farm-animals-shrugs/

Links^^.

steddyeddy

_Tombstone_ wrote: »

Agricultural use is the major problem in relation to resistance. Constant low dose use of the last resort of Antibiotics, because of cramped conditions or to speed up weight gain. 80% of all use by some estimates, massive.

FDA has given "guidance" to stop. :pac::pac::pac: LOL, it's depressing me the way Industry runs everything these days.

Doctors aren't blameless, vast majority of them around my way pawn off patients/customers with an Antibiotic....to justify the fee I guess....but when people are dumb enough to go in with a runny nose then why not.

My sister has over a Dozen of AntiB Courses gone into her young fella in the last few years, a sneeze and she's popping them into him. Fupping Disgrace.

So of the 20% left over from above, over half of that is wasted aswell.

But the running out of an Antibiotic should never have been a thing anyway, I see they've finally got off their backsides and "found" a new one that "may" be unresistable, though it's gram positive or negative only, I forget which.

http://news.sciencemag.org/biology/2015/01/microbe-found-grassy-field-contains-powerful-antibiotic

http://consumerist.com/2014/09/18/white-house-acknowledges-over-use-of-antibiotics-in-farm-animals-shrugs/

Links^^.

Running out of antibiotics is very much a thing. The newly discovered antibiotic was followed by several decades of no new antibiotics being discovered.

_Tombstone_

steddyeddy wrote: »

Running out of antibiotics is very much a thing. The newly discovered antibiotic was followed by several decades of no new antibiotics being discovered.

Was anyone actually looking?

steddyeddy

_Tombstone_ wrote: »

Was anyone actually looking?

Yes there were thousands of scientists looking. It got so bad that many people involved in antibiotic discovery couldn't get funding because they weren't getting results. Someone is always looking.

his_dudeness

_Tombstone_ wrote: »

Was anyone actually looking?

Anecdotally, there is not as much antibiotic research ongoing, as ultimately they will only be taken for a short period of time, until the infection clears, therefore not providing the best return on the pharmaceutical companies investment. Part of the reason that most pharma research is directed towards chronic disease and cancer management