I don’t know the demography of Poldark viewers, but I’m happy to admit that it includes me — and my wife. There is always much to learn from the goings on at Nampara and Trenwith. Captain Ross’s great friend Dr Dwight Enys and the dreadful Dr Choake represent the opposite poles of diagnosis and treatment: the biopsychosocial at the Enys end, and the cupping, purging, and bleeding quackery peddled by Choake at the other. The yin and yang of medicine, which can still easily be traced in the diagnostic and therapeutic dilemmas we face in practice today. Pre-modern medicine was all about diagnosis and prognosis, with most treatments being useless, or dangerous, or both. Modern medicine heralded our triumph over disease, with escalating patient expectations — a pill for every ill, ‘something can be done, surely’. In this postmodern phase, avoiding or reducing drug prescriptions is the dominant theme: recognising the limitations and dangers of antibiotic prescribing, deprescribing for older patients with multimorbidity and polypharmacy, appreciating the serious pitfalls and the slippery slope of anxiolytic, sedative, and analgesic medication, and using the available technologies to support safe drug prescribing and medicines management. These are the themes running through many of the articles in this issue of the BJGP.
Self-harm by young people has become a national concern, affecting as many as one in seven youngsters aged 10–19 years, with a particularly sharp recent rise in incidence among females aged 13–16 years. Those who self-harm are likely to do it again, and are more likely to attempt suicide. Tyrell and colleagues have studied over 40 000 cases of self-harm identified in the Clinical Practice Research Datalink, finding that poisoning with medications is the commonest method used, followed in about 12% by cutting. Paracetamol, alcohol, NSAIDs, and antidepressants are the most commonly used agents. The risk of self-harm is inversely related to socioeconomic status. Families need to know about the substances children are likely to obtain over-the-counter for these purposes, and the quantities of analgesics and antidepressants prescribed for young people should be carefully considered.
Careful prescribing is also required if the potential interactions between prescribed medication and herbal medicines and other supplements are to be avoided. Agbabiaka and colleagues studied patients over the age of 65 years in two practices in southern England and found that about one-third were taking herbal medications and other supplements in addition to their prescribed medication, sometimes taking as many as eight different agents. They calculated that about one third of these patients were at potential risk of drug interactions with their prescribed medication, emphasising the need for clinicians and pharmacists to routinely ask about alternative medicines and supplements.
The important relationship between GPs and pharmacists is the subject of two papers this month. Maskrey and colleagues report encouraging results from a cohort study of specialist pharmacists working in general practice, finding that they are able to free up GP time and capacity and also improve patient and staff morale, while Bradley and colleagues report the increasing involvement of pharmacists in direct patient care activities, but also note some difficulties with support and integration within the practice. Both studies comment on the uncertain funding future for these important, innovative schemes. The NHS England funding scheme for practice pharmacists will come to an end soon. Practices will have to decide whether to continue funding them from their own resources in the absence of robust economic evaluation of their benefits.
It is, of course, helpful to know what doesn’t work, and the systematic review by Benjamin Speich and colleagues from Basel, Switzerland, provides helpful evidence to clinicians wondering what to prescribe for patients with a persistent cough following a respiratory infection. They could find no compelling evidence for the efficacy of any of the usual medications such as salbutamol with ipratropium, budesonide, fluticasone, and montelukast in reducing the duration or severity of cough. Adverse effects were reported in 14% of patients across all the studies included in the review. These data should help in discussions with patients about the natural resolution of subacute cough and the limited role of medication. Perhaps a brisk coastal walk? Definitely no leeches.
- © British Journal of General Practice 2018