The MeReC Bulletin1 arrived (Benzodiazepines and and newer hypnotics) and automatically I took down my sackcloth and prepared myself for an evening of penance and self-mortification (what else does a GP do now there is no ‘out of hours?’).
There, as expected, in the summary was the comment about inappropriate prescribing – GPs behaving badly again!
But as I was collecting the ashes from the grate I wondered when I last prescribed inappropriately. How often do we as GPs hand out benzodiazepines on a whim, without dire warnings of addiction, tolerance and side effects? How often when signing repeat prescriptions for the elderly on sleeping tablets do we make a QALY-fied decision to continue? ‘I balanced all, brought all to mind, … In balance with this life, this death’.2 Are patients stupid? Do they take these drugs thoughtlessly or do they crave the extra hour of sleep and escape from the realities they find themselves in? In the consulting room, benzodiazepines are a drug of desperation – of the patient for relief and of the GP to help that person to have some sort of tolerable existence.
Could we do better – obviously. But are we inappropriate – no. Information handed down from august bodies seems to lack connection with reality. Pharmaco-kinetically they are correct. However benzodiazepines are only prescribed psychosocially.
This lack of connection is also shown in the advice about co-proxamol. The intention seems pure – reduce avoidable deaths – no-one would argue with that. But how sensible is the thinking behind it? The MHRA consulted openly about co-proxamol3 – as many as three patients had the temerity to reply – although I suspect that patient views are irrelevant in this situation. The MHRA advise the use of paracetamol as first line4 with the addition of ibuprofen. Both are standard drugs of proven worth. Paracetamol is regarded as effective, but a recent Bandolier article5 finds that, for osteoarthritis, there is no evidence that paracetamol is better than placebo. It is well know that NSAIDs cause renal damage and hypertension, not to mention approximately 2500 deaths per year in the UK6 – in the US NSAIDs caused more deaths than asthma and melanoma put together. Bandolier comments, ‘when you are in a hole, stop digging’.5 It maybe that those patients are not stupid – the desire to have co-proxamol is based on n-of-1 trials that they have tried for themselves, and many are sure that this is a better analgesic than others. The logic of banning co-proxamol is probably less than that of banning NSAIDs, and may relate more to the politics that surround Dr David Kelly's suicide and the lack of pharmaceutical company pressure than anything else.
Prescribing in almost all areas is driven psychosocially – whether it is for benzodiazepines, pain relief, chemotherapy or for hypertension. Bodies that advise GPs need to provide substantial discussion on these aspects, or expect their advice to continue to be ineffectual.
- © British Journal of General Practice, 2005.
