According to William Osler, ‘The desire to take medicine is perhaps the greatest feature which distinguishes man from animals’.
When I was a medical student we were taught about the dangers and evils of barbiturates. But fortunately we now had the safer and non-addictive benzodiazepines. By the time I was a GP I was busy weaning patients off those same benzodiazepines. And then came the ‘Defeat Depression’ (DDC) campaign of the 1990s, which led to a huge increase in antidepressant prescribing. The percentage of the UK population prescribed an antidepressant rose from 8.0% in1995/1996 to 13.4% in 2006/2007.2 We GPs were woefully neglecting our patients by not identifying depression and putting them on the wonderful new SSRI antidepressants. Which were, of course, safe and nonaddictive. And so much quicker than the long waits for the uncertain outcomes and costs of psychological therapies.
And then came the evidence that in mildly or moderately depressed patients (that is, most of those who were seeing their GPs) antidepressants didn’t really work.3–4 But still, they were great for anxiety, unlike those dreadful benzodiazepines.
And GPs were also neglecting veritable legions of patients with chronic pain. Sometimes paracetamol and NSAIDs just don’t do it. But fortunately we have the new pain modulators, which are safe and nonaddictive. And of course the new opioids, which are … OK, you get the picture.
Osler also said that ‘doctors should use new remedies quickly while they are still efficacious’.5 How prophetic! Although perhaps he should have said ‘… before they turn out to be poisons’.
PHARMA SPONSORSHIP
It would be very easy to see such sad tales of magic fixes gone wrong as due to the greed of the pharmaceutical industry. And there are indeed some tales, thinking particularly of the OxyContin debacle. But it takes two to tango, and another to suggest the tune. Should we not have learned by now to be much more exacting in our demands for long-term safety evidence? Shouldn’t we, above all, have built better walls within our own profession between drug discovery (good) and drug marketing (bad)? Or were we all too easily bewitched by our need to have the answers? And, fair enough, our desire to help patients, even when the evidence was doubtful or conflicted? And of course, the DDC was backed by the RCGP and the RCPsych — who were we to argue?
But should we not have questioned the science more? Should we (and I very much include myself here) not have questioned the Pharma sponsorship of the DDC? And of course, Osler’s first remark still held true. In part, we prescribed these magic fixes because our patients wanted them.
OUR CRAFT AS PRESCRIBERS
Medicine has always been both a science and an art, or at least a craft. This month, to supplement the BJGP research papers that look at the science, we have chosen to publish articles in Life & Times where we examine some of the successes and failures of our craft as prescribers, and continue a conversation as to what we might do differently, nodding briefly at a big source of our patients’ social misery.
I suspect that in the future we will be advocating more lifestyle fixes, still more psychological fixes, and fewer drug fixes for anxiety, depression, and chronic pain.
Trust me, I’m a doctor — don’t get fooled again.
- © British Journal of General Practice 2021
