Colin's Blog

The drugs don't work
The number of people on antidepressants is soaring – we may be more miserable, but let's swap the pills for support and care
Ed Halliwell
guardian.co.uk, Monday 29 June 2009
http://www.guardian.co.uk/commentisfree/2009/jun/29/antidepressants-drugs

It may have been the happiest day of the year on 19 June, but we are already into the hangover. Figures obtained by the Liberal Democrats reveal that antidepressant prescription numbers are going through the roof – 36m scripts were handed out to patients in England last year, a rise of 2.1m on 2007. That's almost one for every adult. Lib Dem health spokesman Norman Lamb is right to describe the figures as "deeply disturbing".

Lamb has demanded improved help for people whose problems are recession-related. It's true that financial woes create more distress, but we shouldn't use the economy as a smokescreen for what is a longer-term malaise. Antidepressant use has been going up for years – prescriptions have more than tripled since the early 1990s. We have not become a Prozac nation overnight.

So what is going on? Are we genuinely becoming more miserable? That's part of the story – according to official statistics, the percentage of people with a "common mental disorder" increased from 15.5% in 1993 to 17.6% in 2007 (that's a million extra unhappy people across the UK). Some of these inevitably wind up at the GP surgery, seeking relief.

But perhaps more instructive is what happens next. Most GPs respond to mental health problems by reaching for the prescription pad, even though guidelines from the National Institute For Clinical Excellence generally recommend psychological therapies. To some extent, doctors do this because they have little choice – more than three-quarters have prescribed medication despite thinking an alternative would be more appropriate. Most do so because there are no other options available – decent psychotherapy services are still few and far between, and often have long waiting lists.

However, medics also prescribe drugs because that's what they are trained to do – pills have long been their (and our) default response to depression. The dominant view of psychiatric illness is that chemical imbalances in the brain are mostly to blame, and that they can be controlled with pharmaceuticals. This line has been peddled hard by drug companies, and for a long time it was accepted almost without question — the reception which greeted the arrival of Prozac and the other SSRI antidepressants (which were supposed to counter the "imbalances") was nothing short of hysterical. Reality has been more prosaic: a recent review found the SSRIs barely more effective than a placebo pill. Still, the NHS bill for prescribing them runs into hundreds of millions of pounds a year.

It's a crazy situation, and the tide may be turning. The dubious tricks used by drug companies to make their products seem more effective are becoming widely known (thanks in part to vocal critics from inside medicine, such as this paper's Ben Goldacre), while the government is beginning to invest in proven non-drug alternatives, such as psychotherapy. Research into the biological bases of mental ill-health is floundering – a study just released casts serious doubt on the existence of a previously heralded "depression risk gene". Meanwhile, there is a growing evidence base for simple, socially based steps everyone can take to improve their wellbeing. These include building good relationships, lifelong learning, being kind to others and exercise – not rocket science, but somehow we seem to have forgotten them.

And this week, renowned clinical psychologist Richard Bentall publishes Doctoring The Mind: Why Psychiatric Treatments Fail. In meticulously referenced detail, Bentall documents the shocking failures of biological psychiatry and the drug-based mental health system it perpetuates, and calls for an evidence-based alternative that offers patients support, care and respect. The book effects a courageous, comprehensive demolition of the status quo, and offers a radical vision of a more humane future for services – it should be required reading for everyone with a hand in mental health policy.

It won't be easy to make such radical changes in the way we approach wellbeing. It means giving up hope of medical "quick fixes", at least until they are as good as their makers claim, and turning instead towards methods that are far less financially profitable, and which require hard work on the part of professionals, patients, government and the rest of us. As well as an overhaul of services, it means tackling social fragmentation, greed-based economics and the stress created by a speedy, sensationalist culture. And it means starting a mature debate based on understanding rather than fear of the mind, promoting the ways we can look after our psychological as well as our physical health. That may sound like a tall order, but until we make a start, the queue of glum-looking folk at the chemist will just keep on getting longer.

See a psychiatrist? Are you mad?
Salley Vickers applauds a brave work that argues that mind-altering drugs do more harm than good to the mentally ill
The Observer, Sunday 21 June 2009
Salley Vickers

Richard Bentall, a clinical psychologist, is a controversial figure in the field of mental health. An example of the hostility that his conclusions provoke among those practising conventional (that is, drug-based) psychiatry is given in the preface to this book, which raises serious questions about the treatment of mental illness. Bentall describes an encounter with an amiable-seeming psychiatrist who responds to a talk he has given as follows: "Professor Bentall has told us he is a scientist. But he is not! Nothing that Professor Bentall has said - not one single word - is true."

The unlikelihood of a professor of psychology delivering, in the sober environment of an NHS conference, a talk in which every word is fictitious and every opinion fallacious gives a flavour of the threat that Bentall's theories pose. The response, as reported, sounds deranged and it is interesting to observe how debate among professionals over the causes of mental illness appears to induce its own version of madness, as if the topic itself were contagious. One sign of sanity, both in the individual and society, is the ability to deal with dissent.

In an earlier book, Madness Explained, Bentall was at pains to distinguish his approach from other anti-psychiatrists - for example, RD Laing, whose radical views were discredited because of his flamboyant lack of rigour and attendant inability to accept criticism. Bentall, as this book attests, is a different kettle of fish. With patient persistence and without recourse to rancorous diatribes, he has appraised the scientific evidence for the success of contemporary psychiatric treatments and come up with a dismal report. It is probably the very balance of his approach that drives his opponents crazy.

Doctoring the Mind is an attempt to clarify the dense array of evidence offered in Bentall's earlier work. The result is a much easier read. It is also, for that reason, more disturbing. Other recent books (Lisa Appignanesi's Mad, Bad and Sad, for example) have also traced the dark strains of misperception, mismanagement and downright cruelty in psychiatry's chequered history, but Bentall's achievement is to focus on contemporary psychiatric practices, especially those dedicated to treating serious psychoses (his own area of expertise).

Bentall's thesis is that, for all the apparent advances in understanding psychiatric disorders, psychiatric treatment has done little to improve human welfare, because the scientific research which has led to the favouring of mind-altering drugs is, as he puts it, "fatally flawed". He cites some startling evidence from the World Health Organisation that suggests patients suffering psychotic episodes in developing countries recover "better" than those from the industrialised world and the aim of the book is broadly to suggest why this might be so.

The first part describes the historical evolution of different kinds of treatment, moving on to dismantle some myths about the nature of severe mental illness. On the way, Bentall addresses the problem of diagnostic categories, suggesting that what are conventionally called psychiatric "symptoms" are more accurately termed "complaints". A particular focus of his critique is the notion of heritability, the theory that mental illness has a genetic basis. According to Bentall, there exist grave flaws in the research methods adopted and the stigma of an inescapable genetic stamp baselessly fuels discrimination against those suffering mental disarray. In addition, the dangers of long-term exposure to many psychotropic drugs appears to outweigh their usefulness.

Here it is important to explain something that is not always understood, which is that mental "illness" is not strictly comparable with physical illness. There are several reasons for this, one being that the aetiology (causation) of so-called mental disease is not yet identifiable in the way that, say, measles is. The precise causal relationship between or mind and body remains misty, but that strong emotional states have an impact on physical states is recognisable in everyday life. We do not feel fear because we have paled or experience anxiety because we sweat. We blush or, if we have penises, have erections because strong emotions trigger these normal physical responses.

The question then becomes this: are distressing mental states the result of impaired brain chemistry or is it the other way round? Does trauma, whether singular or chronic, as in the long misery of an abandoned child or the recurring anxiety of an assaulted one, alter the subtle chemistry of the brain to affect subsequent states of mind? This debate, as Bentall demonstrates, is not only still on, but is heated.

The second reason for distinguishing between physical and mental illness is that diagnostic concepts defining "mental disease" are, in Bentall's words, "invented, not discovered". They arise out of a collective decision, rather than scientific discovery (you can't test for schizophrenia in the way you can for diabetes). Schizophrenia and bipolar disease (once called "manic depression") are merely the names given to a loose collection of "symptoms" and the decision to plump for one diagnosis over another will be influenced by the doctor's interpretation of the current psychiatric scoreboard.

Perhaps significantly, psychiatrists in the US and Russia are more likely to diagnose schizophrenia than their warier European colleagues. I was amused to find that, according to one of the quoted tests, I would be labelled psychotic, while no test (at least in my current state of health) could show that I have, for example, TB. In this context, it is relevant that, in the old USSR, dissidents were commonly labelled "schizophrenic". It would have been simpler to be rid of them by calling them "lepers", but leprosy can be disproved through laboratory testing, while schizophrenia cannot. That physical and mental illness are incommensurate is significant, as it has a profound bearing on treatment. While advances in the realm of physical illness have been spectacular, in the shadowy province of mental health the news is at best disappointing.

And some of it is dire. Bentall is not the first to call attention to a drugs industry whose success is based on the efficacy of its marketing techniques rather than of its medications. But it is useful to be reminded of the massive financial forces behind the enthusiasm for drugs. It has become standard practice among psychiatrists to medicate for life those diagnosed with serious psychoses when, demonstrably, more is not better, either in dosage or time scale. In the US, children are being prescribed anti-psychotic drugs for "disruptive" behaviour. Grief, disappointment and old age are nowadays routinely met with serotonin-reuptake inhibitors.

In the course of his inquiry, Bentall is at pains not to fling out the baby with the bath water. He makes an all-important distinction between being "anti-psychiatrist" and "anti-psychiatry", a common category error, and is careful to say that "most people drawn to work in psychiatry are kind and caring". He recognises that there are occasions where drugs are necessary and some when nothing else will do. He is not in favour of half-baked "alternative" remedies.
 
He believes that it is true that some behavioural disorders are the result of a complex malfunctioning of neural chemistry, and also - not at all the same thing - that states of emotional anguish will have a somatic counterpart that can be eased by medication. In other words, he is open-minded about drug therapy, provided it is not used as a panacea or a substitute for treatments that may produce happier outcomes.
 
What's to be done? Abandoning his distinctive note of moderation, Bentall finally becomes passionate. The first answer, he suggests, is a greater regard for the role of adverse circumstances in provoking mental illness. If bad things happen to people, this is registered in their bodies' chemistry ("a troubled brain cannot be considered in isolation from the social universe"). The second answer is a concomitant respect for the power of interpersonal relationships to ameliorate these effects. One of the concluding chapters, entitled "The Virtue of Kindness" (the subject of the psychoanalyst Adam Phillips' latest book), asks if psychotherapy can help. The short answer is yes, because a person, unlike a drug, can learn to listen to another's story.

Psychoanalysis was popularly called the talking cure, but a better name is the listening one, because to be listened to properly inspires, or can inspire, hope. As Bentall starkly says: "Without hope, the struggle for survival seems pointless." At a time when dialogue in the presence of other human beings is becoming less and less available, this brave book gives a sense of why this could be disastrous.

• Salley Vickers is a novelist and former psychotherapist. Her latest book, Dancing Backwards, will be published next week by Fourth Estate

 

The Penny Still Hasn't Dropped
 
What do Marilyn Monroe, Judy Garland, Jimi Hendrix, Elvis Presley, Paula Yates, Heath Ledger and Michael Jackson have in common? All seven were taking prescribed mind-altering drugs (often tranquillisers) at the time of their deaths.
 
And yet, we must so love and respect the medical practitioners responsible for prescribing these drugs that we are prepared to forgive and exonerate them. Not once, as far as I can recall, has a prescribing doctor been brought to justice. It seems a licence to practise medicine is also a licence to kill with impunity.
 
And spare a thought for the not so rich and famous. Countless millions have been wiped out, incapacitated and crippled by doctors in the fifty years since benzodiazepines were first introduced. Their plight rarely even gets a mention.
Ray Nimmo
 

From The Times
June 27, 2009

Drug mix Michael Jackson took is key
Dr Martyn Lobley

http://entertainment.timesonline.co.uk/tol/arts_and_entertainment/music/article6585279.ece

The list of prescription drugs that Michael Jackson was reported to have taken includes drugs from three main chemical classes. Those most frequently referred to are the anti-depressant sertraline, known as Zoloft in the US and Lustral in Britain, the Valium-like tranquilliser alprazolam (Xanax) and the morphine-like painkiller pethidine (Demerol).

It is reported that Jackson collapsed shortly after an injection of Demerol, presumably administered by a doctor or nurse. The timescale is not clear, but the limited interval between the injection and his collapse suggests that the two may have been linked.

All tranquillisers and morphine-like painkillers are known to affect patients’ breathing patterns, especially if taken in excessive doses. Doctors know that the large single doses of opiates and sedatives given to patients in their final hours to relieve pain could shorten their lives by depressing their respiratory efforts.

When two drugs are given together, especially if they are from different classes, the effects do not simply combine — they multiply. Doctors make use of this when treating high blood pressure where low doses of two drugs given simultaneously are often more effective than high doses of one or the other. But the multiplication principle also holds true for unwanted effects. The death of the actor Heath Ledger last year was attributed to the combination of Xanax with another opiate painkiller, oxycodone

The sedative effect of previous doses of Xanax, combined with an injection of Demerol, could have been responsible for the apparent shallowness of Jackson’s breathing in the minutes that followed. By the time that the 911 call had been logged by the emergency services his breathing had stopped altogether. The sedation resulting from the drug combination may well have removed the desire for him to breathe for himself as surely as if the drugs had been administered by an anaesthetist.

When breathing stops and the heart is deprived of the oxygen required to function a cardiac arrest is inevitable.
 
As soon as a patient collapses the priority is to re-establish some sort of circulation and to provide essential oxygen, usually by administering cardiopulmonary resuscitation (CPR). If the cause of collapse is known it is mandatory to deal with that too. A collapse as a result of a heart attack is often due to a pulse abnormality known as V-fib (ventricular fibrillation) and a couple of shocks from a defibrillator may restore the heart’s normal rhythm.

If the reports are accurate, the short time between the injection and the collapse would mean that the doctor who injected the Demerol would probably have considered administering an opiate antagonist (or antidote) to reverse any respiratory depression.

The effects of the most commonly used antidote, naloxone, are short-acting but the time it buys the emergency response team, allowing them artificially to ventilate a patient, is invaluable.

But even in the best situations, attempts at CPR are not always successful. Jackson was known to be physically frail, reportedly weighing as little as 7st, and to be under great stress. Perhaps it is not surprising that the paramedics and emergency room staff were unable to revive him.

Dr Lobley is a general practitioner in South London

Michael Jackson Drugs

Jackson was allegedly taking painkillers Demerol, Vicodin, Dilaudid, anti-anxiety medications Xanax and Zoloft, muscle relaxant Soma, Prisolec for heartburn and the anti-depressant Paxil.

email 24 June 2009

Colin,
 
The almost obscured elephant in the room of the iatrogenic induced benzodiazapine plague, and the ineffective system of medicines regulation and pharmacovigilance in the UK, which predicated it would happen,...is that had the legal action against Hoffman La Roche and Wyeth, been allowed to proceed, the whole scandal of PHARMA's corporate dominance of health politics would have been exposed for what it mostly is: A money making scam.
 
But then you know that better than me. ie. An alleged quote from a Roche executive illustrates the why of the matter: "We are not in the business of curing people, we are in the business of making money" I have no reason to doubt that was said, and what difference? After all it is the truth.  So are the illicit drug cartels, but of course they don't have their bought medical journals, medical articles, key opinion leaders and political lobbyists, nor do they fund govt. regulators, and I imagine no MP, or minister would make a declaration of interest to parliament that they were also a non-executive member of such an illegal enterprise, which, they do of course where employment by pharmaceutical companies and other corporate entities is involved.
 
If anyone other than your good-self gets to read this missive, I can imagine the shouts of "foul", "madness",  "must be a scientologist", etc., and in truth the pharmaceutical industry manufacture many good and effective treatments, but in the matter of the so-called psychotropic drugs and the way they have been marketed by the industry, there is often little difference twixt the illegal (recreational) psychoactive drug(s) and the licensed drug(s) or their adverse effects, certainly with regard to their addictive properties, although with the licensed version we have come to be dependant on the drug, not addicted to the drug. What difference?

A small matter: It is called informed consent. Had I chosen too take crack cocaine, cannabis, or any other illicit psychoactive drug, then it could be argued I had used informed consent, and I could be prosecuted under the law, but would contrarily also probably be able to access drug counselling, and even a placement in a drug detox programme at a cost of around seven thousand pounds plus per treatment.
 
The unwilling iatrogenic addict is a different can of worms:

a) There was, and often still is, no informed consent, unless you count the prescribing doctor's.
b) The addiction is not illegal, after all, the state provides the drugs.
c) There are no publicly funded withdrawal programmes, the state will not admit to the problem, but rather prefers to blame the patient for their lack of informed consent.
d) No public body will ever prosecute the suppliers. They are the pillars of society itself.
 
And although in the USA., state attorneys' general are busily engaged in the process of recovering monies from pharmaceutical companies for fraudulent market practises, I don't have much faith that will happen in the UK. A lack of faith reinforced by the debacle of the MHRA's four year investigation into GSK's marketing of the SSRI Seroxat, with the result that although the MHRA did find there was malfeasance, when it came time to prosecute, someone had discovered some arcane legal excuse not to do so. Odd that!.... After a four year investigation.... More odd, was the fact that the investigating officers didn't even question the suspected persons involved in the scam, but then of course GSK had already informed the MHRA that none of their operatives would answer any questions put to them. However, the fact is: When a person is questioned under caution in this country they are given the option of not answering any question asked, but also informed that failure to answer may be used against them in a court of law. As I mentioned, odd that, but little wonder then, that benzo iatrogenically afflicted patients have not been able to get redress through the UK system of law. It may also account for why the so-called yellow card system of adverse event reporting does not work.
 

Stuart Jones, Drug Safety Advocate

Study highlights co-prescribing links to drugs deaths
http://www.eveningtelegraph.co.uk/output/2009/06/22/story13340227t0.shtm

22 June 2009

A 12-year study of addicts in Tayside has highlighted links between drug-related deaths and co-prescribing of methadone with anti-anxiety drugs (writes Steven Bell). Researchers found that almost nine in 10 recovering addicts who eventually died were mixing heroin substitute methadone with benzodiazepines.

The study was led by experts from Ninewells Hospital and Medical School and involved 2378 patients — 8% of whom died during the research period.

Dr Brian Kidd, a member of the Dundee team, said the retrospective study backed the approach to prescribing adopted in Tayside, and identified further areas of study vital to cutting the number of drug-related deaths.

He said, “The findings support local policy such as avoiding benzodiazepine prescribing and add to the understanding of factors affecting premature death in this population.

“They identify key areas of concern, such as mental health, which must be addressed as part of a joined-up approach to combating drug-related death.”

The paper, published by the British Medical Journal, showed that 181 Tayside patients on a methadone prescription died during the 1993-2004 period.

The research was carried out using data from the Health Information Centre — a database which records all medication prescribed by GPs in Tayside.

Clinical data is rendered anonymous and linked to other databases that record hospital admission or deaths so it can be used for research purposes.

As a result, Tayside is the only area where such research of this depth can be cross-referenced and used to study such large numbers of patients.

Strong predictors of death were identified as taking the methadone over a shorter period than the prescribed period, a history of being prescribed benzodiazepines, and a history of psychiatric admission.

Of those people who commit suicide, 40% have substance abuse problems and the study identifies a need to address issues of access to appropriate mental health care and treatment.

Patients who took their methadone in a shorter period than that stated within the prescription had increased risk while those addicts who were assessed and monitored by doctors through urine testing were less likely to die prematurely.

Subjects prescribed benzodiazepines were found to be at increased risk if prescribed, which is an important issue for GPs who may prescribe such drugs for a range of complaints.

Many of the factors identified in the study have already been addressed in a review of prescribing policy in Tayside, researchers said.

     
“Once a person has been announced as an expert, they lose the impetus to use wisdom wisely... The problem with being an expert is that once it's been announced you know it all, it almost ceases to matter what you say - because you're an expert. Some perfectly sane, intelligent people fail to question the questionable, because if a statement is prefixed with "the expert's view is ..." they think it escapes analysis... These people don't let new knowledge in, they don't allow for variables, they don't listen. They don't need to, after all. I wonder at which point experts decide they no longer need to learn, because they already know it all?” Annalisa Barbieri, The Guardian, Saturday February 9, 2008

It is time that medicine and involved politicians valued the solid values of Philippians ;-"Whatsoever things are true, whatsoever things are honest, whatsoever things are just, whatsoever things are pure, whatsoever things are lovely, whatsoever things are of good report; if there be any virtue and if there be any praise, think on these things."

Yesterday (10th June 2009), I received an email which was both surprising and unusual. Although Professor Malcolm Lader said in a radio interview in 1991, "The Medical profession, I think, is fairly ashamed of what has happened...” and Professor CH Ashton said in 2005, “How the dependence potential of the benzodiazepines was overlooked by doctors... is a matter for amazement and casts shame on the medical profession...” in my estimation, there has been little sign of it until I received the email that is. A senior GP was reported as saying:

"Do you know I stopped prescribing benzos when you came to us and I saw the mess you were in?  I only wish you could be sitting in the corner when I get patients from elsewhere begging me for repeat prescriptions. If they could see what benzos do to people, they perhaps wouldn't be so keen."

     This is truth and this is reality but the doctors’ trade union the British Medical Association has never been so frank and maintains the line of it being difficult to change prescribing habits. This may be true and it says a lot about the skill level of prescribers and how seriously patient safety is taken in this country.

     Not only has the medical profession as a group failed to display any public sense of shame for what it has done to patients through gross over-prescribing of tranquillisers, but neither have those supposedly in charge of medical provision, the Medicines and Healthcare products Regulatory Authority, The Department of Health and local health authorities. Patients whose lives have been ruined have been left to pick up what pieces they can. Instead, maintaining the image of the NHS as a caring and scientifically based organisation has been the priority for all groups of providers.

     Instead of offering help to people who have seriously injured lives, the past has been modified in terms of the present. BMA spokesmen will now say they things like this:

Tranquillisers are very good in the short term. But the problem is people want to go on and on and there’s the problem. Tranquillisers are excellent but they’re not designed for long term use. A lot of people can get off them but I’m afraid there’s a significant minority who have problems. Government should come out so that the public at large know it’s not their right to receive tranquilliser prescriptions. It’s not in their interests. It’s like smoking, alcohol and other things which are bad for people and doctors speak out against. And there is a growing problem of the drugs being obtained from the internet.

     The BMA, the Royal College of General Practitioners and the Department of Health not so long ago, used to say things like this:

"There's still a significant continuing problem with benzodiazepines in this country. We would have liked if it was solved 20 years ago, but it still exists. We continue to work as a College with prescribing groups around the country to try and continue to raise awareness of this issue and reduce the prescribing of these drugs to appropriate use, but it is a very long struggle. ...” Dr Jim Kennedy, Royal College of General Practitioners, The Tranquilliser Trap, BBC Panorama, May 13, 2001.

"It is difficult to defend that we have such a huge problem of benzodiazepine prescription and long-term use and therefore dependence. – Professor Louis Appleby, National Director for Mental Health, The Tranquilliser Trap, BBC Panorama, May 13, 2001.

     Today all three bodies emphasise internet buying and the role of the patient in insisting on prescriptions. People do buy drugs on the internet and patients do misguidedly ask for inappropriate prescriptions but that does not represent the true history of benzodiazepines in this country. The real history is one of pharmaceutical company marketing influence, the unquestioning attitude of prescribers, the political calculations of government and the ruination of large numbers of patients who thought they were taking medicine through informed advice.

     Although benzodiazepines have been over-prescribed in the hundreds of millions to patients for fifty years, no attention has been paid to the real consequences for what the BMA describes as a ‘significant minority’. The BMA has no idea of the size of this ‘minority’, since no provider of medicine has ever thought it worthwhile to find out. The Public Health Minister Dawn Primarolo, who in the 1990s knew that medicine was involved in a scandal, felt no compunction in standing up in Parliament as a government minister recently to declare that the Department of Health had no information on impairment caused by benzodiazepines or the number of addicted patients.

    For years a succession of ministers has been using this response:

“First of all let me say that the Department of Health, the NHS and the various professional groups regard involuntary addiction upon benzodiazepine drugs as a very important issue... As you know, the main focus of the Department of Health's action in this area has been to try and prevent addiction/dependence occurring in the first place by warning GPs and other prescribers of the potential side-effects of prescribed medicines and the dangers of involuntary addiction.”
Rosie Winterton MP, Minister of State, Department of Health, January 11, 2004

     How it is possible to claim that benzodiazepines are an important issue for government when the bones of the issue are denied and ignored in practice, is mystifying. The issue is that government and its regulatory agencies took far too long to believe in the addiction and when they finally did, they did nothing for the thousands already adversely affected and did nothing effective to safeguard those in the future.

     Today, five years after Rosie Winterton’s response, a very telling change has taken place within the DoH, There is a stubborn refusal to continue to admit what was admitted in the past. In the past there was admission that medicine had caused a problem, even though the nature of that problem and its size were not explored. Today, if you write to the department, they will not move from a position where the patient is seen as the cause of his own injuries. There has been a change to viewing the patient in the same way as the drug abuser on the street. You have to wonder why this is and it should serve as a warning to those who may in the future take potentially addictive drugs on the advice of doctors. The fact that benzodiazepines on the street are the same as benzodiazepines in the surgery is a poor excuse for maintaining now that if only patients had only been sensible and controlled their drug-seeking behaviour, the consequences would have been avoided. As Shakespeare said, ‘Though this be madness, yet there is method in ‘t.’

Special report: Prescription medicines
Deaths from prescription drugs more than double in 10 years
Published: 21 October 2007
http://news.independent.co.uk/health/article3081840.ece


Thousands of patients are dying each year as a result of side effects from pills prescribed by GPs and hospital doctors.
And while the number of deaths from suspected adverse reactions to prescription drugs has more than doubled in the past 10 years to 973 last year, medical experts warn that as few as one in 10 deaths and other serious complications are being reported.
Doctors' poor prescribing skills and repeated failures to recognise accurately adverse drug reactions in patients have seen deaths multiply by about two and half times since 1996.

...today's revelations highlight a 155 per cent rise in reported deaths from adverse reactions to prescribed and over-the-counter drugs – a far steeper increase that will shock the both medical profession and patient groups.

An international conference on drug safety which convenes in Bournemouth tomorrow will hear that "too little progress" has been made in the past 15 years in training doctors to use medications more safely.

Professor Saad Shakir, director of the Drug Safety Research Unit at Southampton University, said: "Doctors need to know how to use medications – this is the most important ethical responsibility for us. Surgeons wouldn't conduct an operation they haven't studied and trained for, and these same standards should apply to medications.

"The competence of doctors in understanding medicines, knowing when and how to use them and how to recognise problems is as essential as training a surgeon in how to perform an operation. Using medicine should be a part of medical training and the ongoing monitoring and evaluation of doctors."
"In recent years, there has been less pharmacology taught in medical schools, but if you consider the growing number of drugs available and the trend towards combination therapies, then this does seem to go against the grain."

A failure by doctors to make the difficult distinction between adverse reactions and disease symptoms can prove potentially fatal, as patients may be given drugs that are more harmful than helpful. According to patient groups, doctors and other health professionals do not always take the suspicions of patients and relatives sufficiently seriously.

Penny Bunn was prescribed anti-depressants by a psychiatrist in 1998 when she was a slim 30-year-old broadcast assistant at the BBC. Five years later, she was in hospital with kidney and liver damage, weighing 20 stone. Eventually she was diagnosed as suffering adverse reactions to her prescribed drugs.
As well as serious weight gain, she experienced blurred vision, vomiting, jaundice, irregular periods, agitation and difficulty passing urine. But because none of these symptoms was recognised as adverse drug reactions, Ms Bunn was prescribed more and more medication, eventually leaving her close to death.
She said: "We now know that I am allergic to all anti-depressants. However, rather than even consider this as an option at the time, the consultant psychiatrist continued to blunder blindly on, misdiagnosing all the reactions I was having as being evidence of further psychiatric disorders.

"No medical personnel ever mentioned anything about side effects or interactions, yet I now know some of the medications I was given are not meant to be used together. How the psychiatrist managed to sit there, as I changed before his eyes, and never cotton on to the fact that there was something horribly wrong with what he was doing, I do not know."


Sedatives and sleeping pills raise suicide risk in the elderly FOUR fold, researchers warn
By Cher Thornhill
Last updated at 2:00 PM on 04th June 2009
http://www.dailymail.co.uk/health/article-1190802/Sedatives-sleeping-pills-raise-suicide-risk-elderly-FOUR-fold-researchers-warn.html

Vulnerable elderly people prescribed sedatives or sleeping pills may be more likely to take their own life, a study suggests.
The drugs, which are prescribed to ease depression, anxiety and problems with sleep, raise the risk of suicide among the elderly four fold , the Swedish researchers found.

‘Clinicians need to be aware of this as these drugs are widely prescribed to the elderly,’ the researchers warn.

The team reviewed figures for the Swedish city of Gothenburg along with two nearby counties and found that older people taking antidepressants, antipsychotics, sedatives or hypnotics were all more likely than others to commit suicide.

While research has linked use of these drugs to suicides among younger people, there had also been evidence the pills may reduce the risk in the elderly, Anders Carlsten and Margda Waern of Gothenburg University reported in the journal BMC Geriatrics.

To find out, they compared the records of 85 men and women older than 65 who had committed suicide with those of 135 elderly people from the general population who had not.

Psychiatrists interviewed people close to the patients about mental problems over the past month and the volunteers were also interviewed in person.
After taking account of the diagnosed psychiatric conditions, the team found that patients who took sedatives and hypnotics for sleeping problems were four times more likely to commit suicide.

According to the World Health Organisation, some 877,000 people worldwide kill themselves each year.

For every suicide death, anywhere from 10 to 40 attempts are made, the U.N. agency estimates

Scientists have linked sleep disturbances to an increased risk of suicide in people with psychiatric disorders and in adolescents but it is unclear whether the association also exists in the general population.

‘A careful evaluation of the suicide risk should be carried out when an elderly person presents with symptoms of anxiety and sleep disturbance,’ the researchers said.

While they do not know exactly why, Carlsten and Waern suggested that the drugs somehow trigger aggressive or impulsive behaviour or provide the means for people to take an overdose.

However, disabilities or sleep problems may make people more likely to commit suicide, they added.

‘[People] with these problems might be more likely to seek health care and perhaps more likely to receive prescriptions for psychotropic drugs,’ they said.

Sophie Corlett, External Relations Director at mental health charity Mind said: 'Any research that links a drug treatment with increased risk of suicide is alarming, and further research is needed to clarify the role that sedatives might play.
 
'We know that older people can be routinely over-prescribed or given inappropriate medication for the sake of convenience, and health professionals must act responsibly and be alert to the damage some medications can cause.'


Doctor accused over death of 12 elderly patients who were 'over-sedated and left in comas'
By Daily Mail Reporter
9th June 2009
http://www.dailymail.co.uk/news/article-1191587/Doctor-accused-death-12-elderly-patients-sedated-left-comas.html

Twelve elderly patients died after being over-prescribed painkillers and sedatives by the same doctor, a disciplinary hearing was told yesterday.

Dr Jane Barton prescribed strong opiates in 'excessive' doses, leaving the men and women in 'drug-induced comas', the hearing was told.
 
Many died within days of coming under her care on two wards at the Gosport War Memorial Hospital, Hampshire, between 1996 and 1999

Opening the General Medical Council hearing, Tom Kark, for the GMC, said the elderly patients expected to be rehabilitated and sent home. But the two wards concerned, Dryad and Daedalus, became known as 'the end of the line'.
 
Many of the patients had never been given opiates before, but Dr Barton wrote prescriptions for drugs, including diamorphine, which allowed nursing staff to increase dosage massively if they saw fit.

Police carried out three separate probes into 92 suspicious deaths at the hospital in the late 1990s, referring ten cases to the Crown Prosecution Service, but no charges were brought.

Dr Barton, who graduated in medicine from Oxford University and still works as a GP, took charge of the two wards in 1988.

She would do two hospital rounds during the morning and then attend to her other GP work, leaving nurses with much of her authority.
 
In many cases, as soon as a patient was admitted - even ones previously described as 'well and happy' - she wrote on their notes: 'I'm happy for nurses to confirm death.'

Mr Kark told the hearing: 'Many of the patients you're going to hear about... had not been given opiates as a form of pain relief nor apparently required them. None of the patients were appropriately prescribed opiates by Dr Barton.
'There was, we say, a series of failures which led to patients being overmedicated and unnecessarily anaesthetised.'

The 12 who died were: Leslie Pittock, 82, Elsie Lavender, 83, Eva Page, 87, Alice Wilkie, 81, Gladys Richards, 91, Ruby Lake, 84, Arthur Cunningham, 79, Robert Wilson, 74, Enid Spurgin, 92, Geoffrey Packman, 68, Elsie Devine, 88, and Jean Stevens, whose age was not given. Mrs Lake was admitted to the Dryad ward on August 18, 1998, after a hip operation and was described as mobile, lucid, well and happy.

However Dr Barton prescribed sedatives diamorphine and midazolam, to be administered by an automatic syringe. Three days later Mrs Lake was dead.
 
Mr Kark said: 'It is likely that this patient died not from illness but as a result of the combined effects of the drugs in her system.'
Barton admits that the dosage prescribed for 11 of the 12 patients was 'potentially hazardous', that for 11 a situation where excessive drugs could be administered had been created, while for ten the dose range was too wide.

She also admits she failed to keep clear, accurate and contemporaneous notes in relation to some or all of her patients.

She denies serious professional misconduct.
The hearing continues.

This study from last year illustrates an aspect of the great unknown areas in benzodiazepine research.

Biswarup Saha
Ananda Mukherjee
Chitta Ranjan Santra
Atiskumar Chattopadhyay
Amar Nath Ghosh
Utpal Choudhuri
Parimal Karmakar

Journal of Biomolecular Structure &
Dynamics, ISSN 0739-1102
Volume 26, Issue Number 4, (2009) July 30, 2008

...Thus,our observations suggest the strong interaction of Alp with DNA, which may raise serious questions about the random uses of Alprazolam.

...In this study in vitro interaction between DNA and BDZs group of drugs, Alprazolam is evaluated. Several lines of evidence suggest that, this group of drugs is toxic (8, 9) and considered as a non-DNA interactive carcinogen (7). However, no efforts have
been made to determine its DNA binding abilities in vitro. So, we undertook this project to evaluate the DNA binding ability of Alprazolam. Here, we have provided evidences to show that Alp binds strongly with DNA in vitro.

...The reports about the toxic effects of BDZs are controversial. No evidence of carcinogenic potential wasobserved for the BDZs during two years of bioassay studies in rats at doses up to 30mg/kg/day (210 times the maximum recommended daily human dose of 10 mg/70kg/day) and in mice at doses up to 10 mg/kg/day (70 times the maximum recommended daily human dose) (4). But on the contrary, it was also reported that some of this group of drugs were teratogenic and also carcinogenic in experimental animals. Oxazepam, a member of the BDZs group of drugs has been shown to be a hepatocarcinogen (5) and induces DNA damage in human myeloid leukemia cells (6) through the production of oxidative stresses. Thus, oxazepam was considered as a non-DNA intercalative mutagen (7). On the other hand, an experiment carried out with 32 BDZs drugs, showed absence of liver DNA damage after oral administration of extremely higher doses of BDZs in rats (8). But no efforts were made to find their interaction with the DNA in vitro.

...Consequently, after entering into cells BDZs can interact with different molecules and modulate their functions of which PBR mediated apoptosis and cell cycle arrest have been already reported (15,16)

...By measuring cytochrome c oxidase, it was shown that Alp induces selective changes in brain oxidative metabolism (18). Alp reduced endothelin-1-stimulated thymidine incorporation into DNA, protein synthesis, and cell growth significantly(19).

...We showed that, Alp interacts with chromosomal and plasmid DNA with an affinity greater than that of ethidium bromide (EtBr). From circular dichroic (CD) spectroscopy and transmission electron microscopy (TEM), it was also shown that Alp induced conformational changes in  DNA. Thus, our present study for the first time demonstrated the in vitro interaction of  DNA with Alp, the drug that is generally considered so far as less harmful.



Pertinent references

5. M. L. Cunningham, R. R. Maronpot, M. Thompson, and J. R. Bucher. Toxicol Appl Pharmacol 124, 31-38 (1994).
8. P. Carlo, R. Finollo, A. Ledda, and G. Brambilla. Fundam Appl Toxicol 12, 34-41 (1989).
9. G. K. Isbister, L. O’Regan, D. Sibbritt, and I. M. Whyte. Br J Clin Pharmacol 58, 88-95 (2004).
15. A. P. Sutter, K. Maaser, B. Barthel, and H. Scherübl. Br J Cancer 89, 564-572 (2003).
16. K. Maaser, A. P. Sutter, A. Krahn, M. Höpfner, and P. Grabowski. Biochem Biophys Res Comm 324, 878-886 (2004).
18. H. Gonzalez-Pardo, N. M. Conejo, and J. L. Arias. Prog Neuropsychopharmacol Biol Psychiatry 30, 1020-1026 (2006).
19. A. Montero, A. Rodriguez-barbero, and J. M. Lopez-novoa. Eur J Pharmacol 243, 235-
240 (1993)

"When the whole rot started in the 1980s we had 700,000. I suspect that's much closer to the real figure than the one we've got now. If you want a recipe for getting people on to IB, we've got it: you get more money and you don't get hassled. You can sit there for the rest of your life. And it's ludicrous that the disability tests are done by people's own GPs - they've got a classic conflict of interest and they're frightened of legal action." David Freud, Investment Banker and Welfare Reform adviser

" Purnell is showing astonishing energy, there is going to be a much more single-minded ferocity." David Freud, Investment Banker and Welfare Reform adviser

"If you're disabled, work is good for you and not working is bad for you.” David Freud, Investment Banker and Welfare Reform adviser

"A life lived without work is not a life fulfilled,"  James Purnell, Work and Pensions Secretary, February 2008

“We know that sickness absence is economically and socially damaging and makes people more likely to drift into social exclusion and poverty. Getting people back into work quicker is good for their health as well as the country's finances.” Health minister Ben Bradshaw, 28 May 2009

“When people demand that the disabled - and I'm talking about the genuinely incapacitated here, not the malingerers - should work, they generally mean that they should do rubbish jobs for rubbish money. Fill the call centres with cripples. Dogsbody jobs for the deaf; boring ones for the blind, they can't see anyway. But where are the decent job offers?” Alice Miles, The Times 23 July 2008

“I know that the withdrawal symptoms can be agonising for some people and can be very difficult indeed." – John Patten, Health Minister, 1984.

“...a lot of these patients are just kept on their medication indefinitely. No real attempt is made to help them come off ... The Government should tackle this problem face on... I think the Government should now acknowledge the problem and set funds aside... Professor Malcolm H Lader, Royal Maudesley Hospital,1991.

"Withdrawal symptoms can last months or years in 15% of long-term users. In some people, chronic use has resulted in long-term, possibly permanent disability." Professor C Heather Ashton DM, FRCP, August 2003.

     In the third age of Blair after the 2005 election, the Conservative opposition and to a lesser extent the Liberal Democrats found a new stick to beat the government with - the issue of a vast number of people receiving sickness benefits (Incapacity Benefit) many of whom it was said were scroungers and should be added to the total of unemployed people. The government it was declared had been keen to keep the jobless total down by allowing the inexorable rise of those declared sick and unable to work.

     In 2001 James Purnell was elected MP for Stalybridge and Hyde. In 2002 he bought a house in the Manchester constituency and claimed it as his main home. In 2004 he sold his London flat which had been his second home for parliamentary expenses purposes. He avoided Capital Gains Tax though by telling HMRC it was his main home for tax purposes. Also in 2004 he rented a flat in Covent Garden and then switched his second home designation to that address, claiming around £20,000 a year in expenses. This was all within parliamentary rules which seem in his case and that of a number of others to be at variance with tax rules that apply to the rest of the population.  Purnell is the Work and Pensions Secretary. Purnell is responsible for catching benefit cheats!

     Purnell rehired an investment banker, David Freud (great grandson of Sigmund) to look at Incapacity Benefit, a man who had also influenced the Conservative welfare reform proposals. It was Blair who originally hired Freud to review the Welfare system in 2006 because of his success in the City it was said but political rows between Blair and Brown ensured nothing was done at the time.

     Freud's great idea was to put out welfare provision to private tender, putting the private sector in charge of the long-term unemployed and paying them to do it. Companies taking part would receive large fees for getting somebody to stay in a job for more than three years and nothing if they were unsuccessful. His belief was that up to two thirds of people claiming Incapacity Benefit were not entitled to do so. Brown had been against the original proposals but in 2008 saw the light and backed the shake-up. In the present recession however, it is worth asking just who is going to provide the jobs for those forced off benefit.

     The fifty years of prescription addiction to tranquillisers leading to thousands being unable to work and being forced onto benefits (many, including myself for decades), is a bigger picture than the one described by Freud, Purnell and others. It is by any definition a scandal but it has never been acknowledged by government. The present harrying of all claimants makes no recognition of the special nature of those living on benefits because of what medicine did to them. This scandal is not just about getting the benzo-affected with unrecognised and invisible symptoms back to work, it is about the fact that these victims were ignored, rejected and left to rot on benefits for decades. Now it suits politicians to look at welfare and so these people who were rejected, ignored and left to wither are to be resurrected and looked at in the same way as everyone else. The fact that they were rejected, ignored and left to rot is not an issue for the DWP which follows the Department of Health line in the few symptoms it recognises. It does not recognise permanent ill health and lost careers. Its doctors prod and poke, take urine samples, blood pressure readings and ask about irrelevancies. Twenty or thirty years of not working because of the effects of medicine is not relevant. Twenty or thirty years of living in poverty is not relevant. The psychological scars are not relevant - I have never heard of the symptoms you claim to have. What is relevant is that you have two working hands and two working legs – you are capable of work. What that work is or even whether it exists is not my concern.

     The situation is this. You have an unquantified by government (but certainly large) number of people who are claiming benefits because of the effects of drugs over-prescribed and wrongly prescribed in their millions over a period of fifty years. These drugs reduced people to the level of supplicants because of the side-effects they caused. No attempt was ever made by government to effectively control this prescribing and no attempt was ever made to discover how many were affected and to offer help to those made dependent. Government went in the other direction, repeatedly saying it took the problem seriously without ever admitting what the problem was while seeking to minimise it. Now that for political reasons it is seen as desirable that the number of Incapacity Benefit claimants is reduced, tranquilliser victims are lumped in with the rest. The recession has intervened but the DWP bureaucrats still follow the intended line and are systematically and methodically calling on all claimants to justify their claims. Suddenly a life on benefits is a life not lived.

"Thousands of people could not possibly invent the bizarre symptoms caused by therapeutic use of benzodiazepines and reactions to their withdrawal. Many users have to cope, not only with a frightening range of symptoms, but also with the disbelief and hostility of their doctors and families. Trickett S, Withdrawal from Benzodiazepines. Journal of the Royal College of General Practitioners 1983; 33: 608.

That has been the situation for fifty years, and to doctors and families we should add the Department of Health and the Department of Work and Pensions.

Labour's 'phoney war on drugs is a costly flop'

By Matthew Hickley
18th May 2009
http://www.dailymail.co.uk/news/article-1183850/Labours-phoney-war-drugs-costly-flop.html

Labour has waged a 'phoney war' on the drug problem by squandering billions on ineffective treatment while presiding over Europe's most liberal drug regime, a damning report claims today.
 
The study highlights rising levels of drug use, fewer prosecutions and a treatment system which has 'trapped' thousands of people on the heroin substitute methadone.

The report, from the Centre for Policy Studies, urges ministers to return to tough enforcement of drug laws, and copy nations such as Sweden and the Netherlands which are widely seen as liberal but in reality take a far firmer line than the UK.

Drugs expert and author of the report Kathy Gyngell says Britain spends £1.5billion a year combating drugs, but enforcement operations are underfunded and costly treatment programmes do not work.

More than £800million a year is spent on treatment projects, the report states, compared with £380million on trying to keep drugs out of the UK.
And while ministers boast of 200,000 addicts in treatment, less than three per cent of them have become 'clean'. Around 147,000 are simply kept on prescribed substitutes, such as methadone, and only 6,700 have undergone residential detox treatment.

Spending on methadone has trebled in the past five years to around £300million a year.

The study is scathing of the Home Office's 'FRANK' online drugs advice service. It says the website 'effectively endorses' drug-taking and 'epitomises the Government's low aspirations' in keeping young people off drugs.

Over the last decade consumption of Class A drugs has risen dramatically.

The Government claims that overall cannabis use is falling but Britain still tops the European league for use among school pupils with 29 per cent admitting to having taken the drug --compared with an EU average of 19 per cent.

In 1998, 3.8 per cent of UK adults admitted having tried cocaine. By 2007 that had risen to 7.7 per cent, more than double the EU average.
The UK suffers 47.5 drug-related deaths per million adults a year compared to 22 in Sweden and 9.6 in the Netherlands.

'The UK drug problem is the worst in Europe,' the report says. 'The UK leads in "recreational" drug use with the highest levels of cocaine, ecstasy and amphetamine consumption.'
 
Miss Gyngell says the Government must focus its efforts on stopping drug use rather than reducing the harm drugs cause.
It should focus treatment on detox and rehabilitation rather than substitute drugs, and draw up 'a tougher, better-funded enforcement programme to reduce the supply of drugs'.

Why is the NHS killing so many with drugs?
By Daniel Martin
20th May 2009
http://www.dailymail.co.uk/news/article-1184591/Why-NHS-killing-drugs.html

An extraordinary rise in the number of patients killed by drugs given out by the Health Service has led to calls for an investigation.
The figure has more than doubled since Labour came to power, rising from 520 in 1998 to 1,299 last year.

Official figures also show that the number of such deaths last year was up by more than a quarter on the figure of 1,030 recorded in 2007.
Investigation: The number of patients killed by drugs given out by the NHS has doubled to 1,299

Liberal Democrat health spokesman Norman Lamb, who obtained the statistics following a parliamentary question, said: 'The Government needs to urgently investigate this extraordinary rise.

 'The public needs to know why these adverse reactions are happening more frequently and why the trend appears to be increasing so much.
'Patient safety is being compromised. Ministers must ensure that better information on prescription drugs is available for patients and doctors.'
 
Some experts blamed the increase on failures in the training of hospital doctors and Labour's decision to hand greater prescribing powers to nurses.
 
The figures show that in 2008, a total of 25,424 reports of adverse reactions to drugs - both fatal and non-fatal - were made to the Medicines and Healthcare products Regulatory Agency, the government organisation in charge of drug safety. They were up by 17 per cent on 2007 and by 41 per cent in a decade. Of these patients, 4,487 had to stay in hospital for several days following side effects from medication - around the same as in 2007 but up by more than 50 per cent on 1998.

The figures mainly cover drugs handed out on prescription, but they also relate to over-the-counter and herbal medicines.

Peter Walsh, of pressure group Action Against Medical Accidents, said: 'There are far too many complications resulting in harm or death. These numbers must be reduced, and it must be in the gift of a modern NHS to get them down.

'The true figure will undoubtedly be much higher, because not all incidents are reported [by hospitals and GPs]. And in many cases doctors simply do not know what caused a sudden deterioration or a death - the drugs or another cause.

'Problems with medicines are one of the biggest patient safety issues faced by the NHS.'

Mr Walsh said better reporting of adverse reactions could be the reason behind some of the rise. But there was also the problem of new drugs, and complicated therapies that include combinations of drugs.

These 'cutting-edge' treatments often have unknown side effects.

Adverse reactions can also occur where doctors do not know what other drugs a patient is taking, or about allergic reactions they suffer from.
Errors in identifying patients - with drugs being given to the wrong patient - and in dosages, also cause numerous deaths, he said.

The Daily Mail revealed in January that the number of patients killed by hospital blunders has soared by 60 per cent in only two years.
Official records show that 3,645 died as a result of outbreaks of infections, botched operations and other mistakes in 2007/2008, up from 2,275 two years before.
 
Critics say that the quality of NHS care has suffered as doctors and nurses come under pressure to meet Government waiting time targets.
A spokesman for the MHRA said a number of factors are thought to have played a role in the rise in fatal adverse drug reactions including changes in pharmaceutical companies' reporting of the reactions and increased prescribing of drugs.

'It is not possible to pick out one single factor influencing this trend,' she added.


Relevent Note:   Dr Vivienne Nathanson, said after the report[BMA 2006]:

"Unfortunately too many health professionals are confused about reporting procedures.”

This was confirmed after the MHRA, commissioned the Ipsos MORI poll in 2006. Professor Kent Woods, Chief Executive of the MHRA, said they welcomed the findings and were reassured by the public’s confidence in medicines and medical devices. The poll found among other things that over 90% of doctors seemed oblivious to the fact that suspected adverse drug reactions should be reported to the MHRA. No more than one in five doctors was aware that the MHRA regulates medicines and devices. In spite of that, almost 90% of doctors thought that medicines are adequately regulated in the UK.


 

                                                  


"We are all capable of believing things which we know to be untrue and then, when we are finally proved wrong, impudently twisting the facts so as to show that we were right." George Orwell, In Front of Your Nose 1946

“So, when a politician says "there is no evidence," what he really means is that "yes, it happened, but you cannot prove it." Sir Antony Jay, broadcaster and co-writer of Yes Minister, December 2007

“Standard Reply 1: “Not my responsibility.” Standard Reply 2 is: “Thanks for your letter, but things are getting better: let me tell you about them at length, even though they don't relate to your concern.” I don't know if there is an SR3, but it is becoming increasingly difficult to get any sense out of Whitehall.” Camilla Cavendish, The Times 12 June 2008

“...the fundamental purpose of the British public service is to provide a meal-and-mortgage-ticket for those who work in it, especially at management level. The ostensible purpose of an organisation is rarely its real purpose. I know this from my experience in the Health Service.” Theodore Dalrymple, former prison doctor, The Times, 12 November 2008

Avoiding action on large scale medical injury is surprisingly simple. You start with a politically desirable conclusion – in this case the avoidance of responsibility for the damage done to people through tranquillisers by pharmaceutical companies, regulators and prescribers – and work backwards. You obfuscate the history of the scandal, distort the reality of the addiction, stonewall and finally assert that addicted patients were all drug abusers and misusers. No establishment responsibility for what happened then exists.

In 2004, the then Health minister Rosie Winterton told a group of benzodiazepine campaigners, including Professor Heather Ashton, that she had been misinformed by advisers on the subject of benzodiazepines. I am sure she had been, but in spite of saying that she then produced the stock response. Most of us make the assumption that ministers are in charge of their departments. They are not. Ministers are part of a bureaucratic machine and it is the machine that controls action, truth and access. That is not to excuse ministers such as present minister for Public Health Dawn Primarolo who is well aware of the scale of the benzodiazepine scandal and should in a better system have followed up her knowledge with independent action.

Nearly everyone protects their own. Patients can’t protect themselves against bad medicine - bad regulation, the influence of pharmaceutical companies, the wrong-headed views of partial advisers and the indifference of politicians - but bad medicine can easily protect itself against patients.

No doubt there are some very intelligent advisers in the Department of Health but intelligence is no barrier to stupidity and ignorance. It applies in every field of human activity including medicine.

It is not possible to bring reality to Department of Health politicians, the only reality they experience is that laid before them by advisers not expert in prescribed addiction and those only too well aware of the political/financial consequences of any admission.

Professor David Nutt who is the chief Home Office adviser on drug classification represents an influential view that tranquillisers do not do a great deal of damage and can be prescribed for long periods. Another view is steeped in the illegal drug scene and has somehow managed to persuade the DoH that prescribed tranquilliser addicts brought any disaster on themselves by misusing the drugs, conveniently forgetting that patients thought they were taking medicine on the advice of doctors and received no warnings in advance.

David Nutt wrote this to me not long ago:

"The key issue that I think we will all agree on is that the benzodiazepines help some people with a variety of mental and physical disorders though at the risk of dependence. This latter phenomenon is undoubtedly problematic for a proportion of patients. Why that should be so is not understood and is a very difficult question to answer. It probably reflects a combination of the pharmacological effects of the drugs and the genetic and other make-up of the people who are prescribed them. I believe we should be attempting to understand these issues rather than simply damning the drugs.” Prof David Nutt, email, January 20, 2009

In addressing what Nutt said, Ray Nimmo of benzo.org.uk commented:
 
“I believe Prof Nutt is in a position to address the issues he raises. Topics for research should include:
 
1)  Do Benzodiazepines deplete/destroy GABA/Benzodiazepine receptors?
 
2)  Not everyone starts life with the same concentration of GABA/Benzodiazepine receptors. Is it not true that some have low, average and high concentrations?
 
If the answer is yes to both then it is not difficult to deduce why people suffer from benzodiazepine therapy and why some have more problems than others. Those who start life with low concentrations are most likely never to recover.
 
Prof Nutt needs to get his head round Tolerance and why the "2-4 weeks only" guidelines are not an idle measure designed to thwart his dubious practice of medicine.
 
Though a patient may initially respond positively to benzodiazepine therapy which is doubtless warmly acknowledged by the prescriber, tolerance to the hypnotic and anxiolytic effects develops quite rapidly in everyone. Sooner or later the dose is increased to combat the tolerance withdrawal effects. The patient almost invariably becomes depressed and starts to suffer other side effects. As this phenomenon is not recognised by doctors (thanks to Nutt & Co.) additional psychoactive drugs are prescribed and the luckless patient is in a trap and downward spiral.”

Spot the connections

Addiction Today article
Professor Carlton Erickson

Involuntary Tranquilliser Addiction
Mick Behan

The article by Carlton Erickson is of course relating to use of drugs illegally and it should be read in that context. People made dependent by doctors do not usually warrant such musings unfortunately but there are points here worth considering and of course parallels. What the article says to me is that the indiscriminate long-term overprescribing of tranquillisers stimulates brain disease. The article also highlights the need for dedicated and informed care and compassion - something which those made dependent by doctors universally lack. The reference to neurotransmitters is what particularly struck me in this article. Professor Heather Ashton has said in the past that some people may be more affected by prescribed tranquilliser dependence because the natural level of GABA may vary in individuals and the effect on those individuals given tranquillisers may therefore be more severe. 

To summarise, the first article (even though it is talking about the illegal scene) clearly states that long term addicted people are dependent and are not abusers. They need to be seen differently and need help. The second article emphasises the reality of how the DoH offers no help to patients addicted to tranquillisers by doctors, preferring to assert they are drug abusers.

From the Erickson article: "Dependence is “impaired control” over drug use, probably caused by a dysfunction in the brain's pleasure pathway. This is the disease of addiction, an “I can't stop without help” disease. It requires formal therapy and/or 12 steps and might require anti-craving drug therapy.

The DSM-IV criteria for chemical dependence are:

1)      a maladaptive pattern of drug use, leading to impairment or distress, presenting as three or more of  the following over a 12-month period –
•    tolerance to the drug's actions
•    withdrawal (generally, physical withdrawal)
•    drug is used more than intended
•    there is an inability to control drug use
•    effort is expended to obtain the drug
•    important activities are replaced by drug use, and
•    drug use continues despite negative consequences

2)      two types of dependence can occur  –
•    physiological dependence, including tolerance and withdrawal, and
•    non-physiological dependence, excluding tolerance and withdrawal.

NEUROTRANSMITTERS INVOLVED IN DEPENDENCE.

Dependence is probably due to a functional dysregulation – meaning: they aren't working right! – of one or more neurotransmitter chemicals in the MFB. These include dopamine (which is affected by cocaine, amphetamines or alcohol), serotonin (alcohol or LSD), endorphins (alcohol or opioids such as heroin), gamma-aminobutyric acid (alcohol or benzodiazepines – antianxiety agents), glutamate (alcohol) and acetylcholine (nicotine or alcohol)."

The trouble with Tamiflu
The companies behind the two leading anti-flu drugs are making millions out of the crisis. But just how effective are their products? Sarah Boseley reports

The Guardian Thursday 7 May 2009

http://www.guardian.co.uk/world/2009/may/07/tamiflu-swine-flu-drugs

It was a sight that would have gladdened the heart of Dr Severin Shwan, chief executive of Roche, one of the biggest drug companies in the world. A long line of well-heeled parents assembled on a bank holiday weekend at a British private school, Alleyn's in south London, patiently waiting their turn to receive a packet of Roche's drug Tamiflu from staff. Five pupils had been diagnosed with swine flu and the school had been closed. The pills were intended to stave off infection among the children who had been sent home.

The board of Roche, a Swiss-based company which has globalised the name it inherited from its founder, Fritz Hoffmann-La Roche in 1896, must be laughing. It has a drug which has become a household name and been stockpiled by the millions of boxes all over the world, against a potential pandemic that the World Health Organisation (WHO) warns is almost upon us. Roche has supplied governments with 220m courses worldwide. The UK has stored enough to treat half the population. And yet Tamiflu is of limited use.

There are two drug contenders to reduce the impact of a flu pandemic - Tamiflu (oseltamivir) and the GlaxoSmithKline (GSK) drug Relenza (zanamivir), which is similar but more complicated to use because it must be inhaled - not easy if people have breathing problems. But Relenza, too, is being stockpiled around the world, to the delight of a small Australian company called Biota Holdings - the company that developed Relenza and licensed it to GSK. Biota's share price leapt 16% last week when GSK announced it had sold $46m-worth of the flu drug, giving Biota $32.3m in licensing fees.

Relenza and Tamiflu are known as neuraminidase inhibitors (NIs). Two other, older flu drugs, amantadine and rimantadine, are now of little use because flu viruses have become resistant to them over the years. Nobody claims Tamiflu and Relenza cure flu, but they were licensed after trials that showed they mitigated its severity and reduced the length of the illness by about a day. Unfortunately, you have to take them within 48 hours of symptoms starting.

The government's contingency plan envisages that any of us who start to cough and splutter would ring a flu hotline, where a nurse would give us a diagnosis over the phone and then prescribe the drugs which our nominated "flu buddy" will pick up from the chemist. But the most important element of this arrangement, some will say, is that it keeps the flu sufferer out of the way of the rest of us. Dr Tom Jefferson, of the Cochrane Collaboration in Rome, headed the most authoritative, non drug-company conducted (and therefore without the vested interests) review yet done on the flu drugs. He is appalled that such drugs could be widely used and relied on as the solution to a flu pandemic at the expense of things that really work - like washing your hands dozens of times a day.

The Cochrane review, carried out in 2006 but regularly updated, most recently this year, says the NIs do not stop people becoming infected, although they do decrease the amount of virus sprayed from people's noses when they sneeze all over you in the bus or office. They can also reduce the complications of flu, such as bronchitis and pneumonia. The review concluded that they might be of some help in a pandemic, but strongly recommended they should not be handed out routinely or used for normal winter flu outbreaks.

To Jefferson's horror, however, the WHO has recommended that the drugs should be used against seasonal flu - the usual forms of flu that hit us every winter - so that doctors get used to giving them, and patients to taking them, ahead of a pandemic. "Wide-scale use of antivirals and vaccines during a pandemic will depend on familiarity with their effective application during the inter-pandemic period," it reasons.

"It is more than madness," says Jefferson. "Especially as we don't know what the real reasons for that recommendation are." Doctors who work for the drug companies, carrying out their studies or sometimes simply allowing their name to be attached to the paper, also advise the WHO, he points out.

He argues that there is a very real possibility of resistance developing to the drugs if they are handed out like Smarties. Viruses are clever organisms, and evolve super-fast and efficiently. Treat a virus with drugs and you must hit it hard enough and for long enough to eliminate it. If the dose is not strong enough, or the patient stops taking the drugs mid-course, the virus will evolve into a form that can overcome the drug. It is then a resistant strain. This is a major problem with the Aids virus, HIV, for which many new drugs have had to be developed. Bacteria behave the same way - penicillin, once a wonder drug, is now of little use.

Jefferson points out that although Tamiflu is only eight years old, resistance has already set in. Last year a strain of winter flu was circulating in the US that was found to be resistant to Tamiflu. In the South East Asia bird flu outbreak, there was resistance among 16% of children given the drug and among two out of eight Vietnamese people aged between 8 and 35, according to the Cochrane review.

This resistance is inevitable, says Jefferson, if you believe in the theory of natural selection, in which organisms evolve to overcome threats to their survival. "We know that has already happened with Tamiflu. It has happened with amantadine, which has been around since the 60s." Of course, governments and the public want magic bullets. There is a belief that where there is an illness, there must be a cure. Handing out drugs reduces panic. People are more likely to stay put at home where they cannot infect too many people if they feel they are being treated.

And there is is a role for Tamiflu in severe and complicated cases caught early. But Jefferson balks at the idea of drug hand-outs at schools. "The spread will stop, but only because the children have been sent home," he says.

The most important trial in disease prevention of the last 50 years was carried out in 2005 by a US doctor called Stephen Luby. "For that he should receive a Nobel prize," says Jefferson. Luby carried out a randomised trial in squatter settlements in Karachi, promoting hand-washing in half the families. Children under five who regularly washed their hands had half as many episodes of diarrhoea, impetigo and acute respiratory infection. It saved lives. If the big pandemic hits, washing hands will save more lives than Tamiflu, he predicts.

Meanwhile Tamiflu is sought everywhere. In 2005, Roche asked for help in manufacturing enough of the stuff to satisfy world demand and it got 300 offers from other manufacturers. It has now established 19 partners to produce the drug in 10 locations on three continents. It has also given licences to Indian and Chinese generic companies to make it for the developing world. If only it really was a miracle cure •