Matters of Substance

Roger Jones

doi:10.3399/bjgp16X683017

The landscape of substance misuse in the UK is depressingly familiar to most clinicians. It includes high levels of alcohol misuse, particularly binge drinking by younger people and steady heavy drinking among the affluent retired. Almost 300 000 people use heroin and crack cocaine, and a heavy health burden of morbidity and premature mortality is associated with drugs, alcohol, and tobacco. The struggles to get to grips with these last two are highlighted in articles in this month’s BJGP. Jamie Brown and colleagues found that smokers in England who reported visiting their GP appeared more likely to receive advice on their smoking than those drinking excessively were to be advised about their alcohol consumption: 50% of smokers recalled receiving a brief intervention on smoking whereas less than 10% of those drinking excessively recalled having received a brief intervention on alcohol. The 2012 revision to the Quality and Outcomes Framework (QOF) seems to have increased the amount of smoking cessation support given by GPs, although this has not been paralleled by an increase in the prescription of smoking cessation medications. Szatkowski and Aveyard, whose analysis of the revised QOF was based on data from the electronic records of 3.3 million patients aged >16 years, registered each month in The Health Improvement Network, speculate that the availability of over-the-counter products, prescribing by non-clinicians, and the increased use of e-cigarettes may have been influential.

These familiar threats to the public health have now been joined by some new pests, which will be unfamiliar to many. How would you respond to a patient who was having problems after using ‘Charly Sheen’ or ‘Magic Dragon’? Are you up to speed on empathogens and psychonauts? Comfortable talking about the use of crystal meth and GHB to enhance sex between men? Two substance misuse scenarios that will be new to most of us are the use of novel psychoactive substances to produce legal highs, and ‘chemsex’, where potent narcotics are used, often in combination, to increase sexual pleasure. Our editorials this month help to demystify these phenomena, and provide helpful links to sources of information and advice.

Brain function comes in for further attention in other articles this month. Alice Theadom and colleagues found that 12 months after a mild traumatic brain injury (concussion) almost half of patients reported experiencing four or more post-concussion symptoms, and 10.9% of participants revealed very low cognitive functioning, with 10.4% experiencing poor global functioning. Interestingly, no increases in levels of anxiety or depression or reduced quality of life were observed in this study. There are implications for management in primary care, which complement another paper on trauma, from Nottingham. Denise Kendrick’s group has shown that, following discharge from hospital, about half of trauma patients have persistent physical and psychological difficulties, which could be more effectively managed, and perhaps prevented, by the implementation of an injury care pathway.

Finally, brain as metaphor. John Goldie’s Debate & Analysis article considers how the well-recognised lateralisation of brain function serves as both an explanatory model and a metaphor for the task of the general practitioner. Goldie describes how the right hemisphere’s broad, vigilant attention sees things as a whole and in context, and is the site of relational, empathic skills. The left hemisphere, with its narrow, focused attention, ‘allows us to step outside the flow of experience … through its capacity for denotative language and serial analysis, “re-presents” the world as explicit, abstracted, compartmentalised, fragmented, disembodied … It is the locus of conceptualised knowledge, whereas the right hemisphere embodies intuitive perception.’ So, in many consultations, there will be tensions between the priorities of the individual patient and the wider responsibilities to, for example, public health, compliance with clinical guidelines, and the use of resources, and between confidentiality or disclosure of privileged information.

And if, after the festivities, you feel that your own brain needs a bit of a workout, our book reviews in Out of Hours offer an eclectic selection of reading — including Tom Wolfe, Iain Bamforth, John Gray, Mary Midgley — that should contain something for everyone.