Monday, 3 December 2012

Weighing risk and benefit: audacious or reckless?

Prescribing is all about weighing up risks and benefits. The weighing up may be explicit (helpfully already carried out by the licensing authorities and NICE guidelines etc.) or implicit (carried out by the doctor at the bedside) and everyone makes some sort of judgement when self-medicating. It is half a millenia since Paracelsus said that the only difference between a medicine and a poison is the dose.

However, it does seem that lately this process of weighing up risk and benefit seems to be going a bit squiffy. I see two contributing factors to this. On the part of the presciber we have the loss of the personal, an absence of a holistic view of the patient leading to, or due to, the emphasis of explicit over implicit. On the side of the patient there is a tendency to subjectivism, giving an additional weight to the inconvenience of the illness rather than the reality of the treatment. Reduced inconvenience in the here and now weigh more on the scale of risk and benefit that the long term effects of a medicine. And it is not just the healthcare professionals who have lost their holistic view: patients too are inclined to reduce everything to the biological. I'll take a tablet and it will all be better.

First up: drug cocktails. I do think that evidence-based medicine is a good thing. We should be using medicines to help people have improved health and quality of life and it is important that everyone has access to the benefits of knowledge regardless of location and how switched on your GP is. From this point of view, guidelines, recommendations and national standards are no bad thing. But sometimes the guidelines seem to come before the patient. If you have a heart attack, for example, you will be prescribed 4 different medicines straight off, no questions asked to reduce your chance of having a second. As someone who was, until recently, taking 6 tablets a day I would say that the mere fact of taking a lot of medicine makes you feel ill. Physically I feel no better since we changed everything round a bit so I could take only 2 tablets a day, but psychologically it makes a world of difference. If this person who had a heart attack had nothing else wrong with them, they've just gone from zero to four, but the chances are that if they're an older person they might have diabetes (at least 1 more medicine), moderate pain of some kind (paracetamol, codeine and two laxatives for the constipating side effects), anxiety (brought on or compounded by the amount of medicines they now have to take)...

If the number of tablets taken is our main concern then 'polypills' could be the answer. Instead of taking 4 different pills after your hypothetical heart attack, you would just get one which contained all 4 medicines. Easier to remember, less psychological impact,  might be a good thing. But there are problems... If you need to increase the dose of one of these medcines (because following your hypothetical heart attack, you have started taking your medicines and your cholesterol is now under control but your blood pressure is still going through the roof) what do you do? If you need to stop taking one of them (becuase the aspirin gives you an ulcer) what happens then? In fact, prescribing has moved away from combination painkillers in recent years. I believe Such polypills, with their one-size-fits-all approach, possibly lead us yet further in reducing the patient to the merely biological

From the patient point of view I would like to cite the example of hormonal contraceptives, a supposed panacaea for women's health problems as well as the terrible disease of fertility. Contrary to popular belief these are medicines. The benefit (I don't need to worry about what I do) comes from such a narrow vision of what a person really is that immediately half of the risks are discounted (STDs, and then all the non-biological ones) as is the fact that this "benefit" can easily spill over into other aspects of life: I can do what I like with respect to behviour which might lead to pregnancy swiftly becomes doing what I like with respect to commitment (and no, I am not saying that the pill causes infidelity). And the short-term benefit of not getting pregnant becomes a long-term risk of not getting pregnant: very few people think about the fact that when they finally do decide that they want a family they might find that they can't. We also shouldn't ignore the reports of extremely serious consequences: death and permanent disability.

Acne is one of those conditions where the risk:benefit calculation seems to be working out a bit strangely. Above is the report of a girl who died after taking the pill for acne, likewise Roaccutane (OK, the report is from newsbeat, but BBC3 recently broadcast a documentary) can cause extremely serious problems (incidently I don't know why Roche say there is no link between the drug and depression as their own SPC for Roaccutane says there is...?!). I realise this is not a black and white situation. If you have severe acne (and if you are seeking such drastic measures presumably your acne is severe) then you might well be depressed (or so fed up that you think you are depressed), believe your life is over, etc and I don't want to belittle that in any way. But I can't help thinking that the choice of acne or death, or acne or permanent untreatable depression, is a no-brainer. So on what basis are we making these decisions?

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