Friday, September 25, 2009

Sister Morphine

This weeks BMJ has the Rolling Stones song reviewed as its "Medical Classic", in a slot generally reserved for worthy tomes like "The Conquest of Pain" or medical novels like "The Citadel". I'm a bit miffed, because I'd already decided on it for the title of this follow on post from the earlier post on heroin. Not actually miffed enough to change it though you'll notice.

The thing is it rather fits what I've got to tell you. Not so much the song as the title to be honest. You see Mick and the boys were rather reinforcing what I had to say last time with their plaintive song about addiction, but this time I want to point out the undoubted therapeutic value of this much maligned drug.

For years Morphine has been a "back of the cupboard" "painkiller of last resort" "fit only for the dying" sort of a drug. True there has been increasing use of morphine drips for post operative pain in recent years (these days even administered at a rate determined by-- of all people-- the poor soul who has the pain). And as suggested, Sister M and her bigger beefier cousin Diamorph' have been the mainstay of end of life pain relief since Hippocrates was in short chitons. Anyone with any involvement in such care will recognize the beatific change in countenance that comes when a pain ravaged patient finally achieves symptom control through their tender mercies.

There's a lot of guff talked about the "Doctrine of Double Effect" that implies it's o.k. to administer potentially lethal doses of opiate to relieve pain. Given methods of administration widely available for at least three decades this has never been a part of my reality or that of my patients. Used correctly opiate analgesics kill one thing and one thing only. Pain. Abuse and overdose are not and have never been therapy and should not be allowed to confuse the issue.

Once every eight to ten years we are sold a new "miracle" non-opiate pain killer. They tend to be derived from some species of anti-inflammatory, are heralded with a vast fanfare, tried with enthusiasm by many of us, and within twelve to eighteen months turn out to be no better than, more expensive than and often more toxic that all non-opiate analgesics that have gone before them. Then they disappear or dwindle to a background, occasional, niche painkiller for when everything else (except morphine) have been tried.

Recently we have had to appreciate that a whole class of painkillers-- the non-steroidal anti-inflamatories, can do bad things to aging kidneys, making them hard to use in severe arthritis (which is precisely where you might want to be able to use them). So the poor punters are left with paracetamol plus or minus a bit of codeine. This seldom works, but it's rare that a patient will welcome the offer of a tiny dose of morphine to help give back their pain control.

Which is a shame.

Tuesday, September 22, 2009

A day in the life....

The BMA are keen for us to invite MPs into our surgeries at the moment. must be something to do with the looming election. I'd invite ours, but a nearby practice has beaten us to it, and after my recent run-in with Alan I'm not sure how keen they would be anyhow. So instead I'll open the doors to all of you, my loyal readers for a little snapshot of an average day at the Ambridge Surgery.

8.00-- Surgery opens. Dr Neighbour (an insomniac workaholic) starts consulting-- he will consult until 10.30, break for admin and for coffee at Coffee Time (c) The Ambridge Surgery 2000. He will then consult again from 11.30-12.00. Mean while the Duty Doc from yesterday afternoon (your humble interlocutor) will turn on the Surgery Mobile-- the contact for all urgencies from 8.00 to 8.45 when the surgery switchboard will swing into operation. The ringtone and the wallpaper on said phone he will not immediately recognize as they have been reprogrammed by his offspring. Thus every mornig urgent calls can become a little whimsical voyage of discovery-- it's odds on the poor supplicant caller will be heralded by "The Macarena" or the latest Motorolla Death Metal ringtone. The Duty Doc is powerless to prevent or alter this.

9.00 Dr J begins consulting after an idyllic drive through the Borsetshire lanes, accompanied by the plangent strains of the Macarena, punctuated by updates on "Our Wayne's" vomiting. Our Wayne (aged 22 and still living with Mum) is invited to attend mid-morning for an examination.

Morning Surgery I

In no particular order we see and try to help;

two survivors of severe trauma (one abused by a relative from age 7-- over 40 years ago, but still grappling with the fallout, one still being abused by an ex patrner who is about to receive an injuction in the hopes that this will make him stop),

one wheezy babe in arms who is otherwise quite well, though mum takes some convincing of this,

a patient with a chest so bad they require night time ventilation but remain desperate to be able to get back to work,

a patient made psychotic by amphetamines,

a man in an Aircast Boot (imagine Robocop in pale blue plastic) after ankle surgery who just needs a note for work-- and something for the pain,

an expectant mum six weeks off delivery for a check up and a chat about some mechanical chest pains she's been getting because of the pregnancy -- she's not an Ambridge native and has no family within 300 miles so she's also feeling a little isolated and apprehensive which makes her worry more about her chest pains,

Our Wayne, looking a bit green around the gills and in the grip of a touch of food poisoning after a dodgy curry (and around a gallon of Lager) last night,

a couple of "Flu" victims who felt iller on tamiflu than with "flu"-- so probably not then,

a man in need of gluten free bread who's in a rush to get home again before his demented wife (not our patient-- she has kept to her old surgery for the past 40 years and he sees no reason to change her registration) takes it into her mind to wander or to try to set the house on fire.

11.00 Coffee Time (c) The Ambridge Surgery 2000. Half an hour set aside for all the docs and the management team to meet and chat. Sometimes we actually get around to chatting about the punters-- more often movies, kids and knockabout comedy one liners...

11.30-12.20 Morning surgery II

6 more punters with a random assortment of ailments. One requiring urgent hospital admission for a possible embolism which puts the rest around 15 min's behind.

12.20 (but really 12.35) Driving License Renewal Medical.
HGV and PCV (that's lorries and busses to you and me) drivers need a five yearly license medical. 20 minute exam and form filling exercise. Passes without incident.

13.00 Home visits. Two today that will take us to 14.00 and lunch. On the way one lady with nasty pain after shingles last month. We had hoped Zovirax would have headed this off, but no such luck, so now we will need top notch pain relief, probably for a few months-- drat. T'other had come over "all unnecessary" this morning and in the end turns out to have cystitis-- a powerful confuser of little old ladies (and indeed little old men, though less often for reasons too boring for here and now). At least she should be better after 3 days on antibiotics.

14.00 Lunch. Life being too short to make sandwiches, Mr Sainsbury is called upon to provide and does so admirably, which takes us to 14.15 and...

14.15 Phone calls (5) of which three count as "worried well" and two relate to consultations a few days back and effects of the pills therefrom. Then repeat prescriptions 25 to sign and 10 or so to be updated and reprinted for signature.

Now, when I was a lad repeat prescriptions usually ran to a blood pressure pill or two and the odd painkiller. Nowadays most repeats are for 4 or 5 items, which for the over 50s will more than likely include a statin, aspirin, at least 2 blood pressure lowering agents, something for heartburn, and one or two items to overcome the side effects of the other meds, so they warrant a bit of scrutiny, even when they look routine.

15.00 Afternoon Surgery
3 straight hours consulting. We don't break for Tea, so the machine on the desk supplies a steady stream of Java straight to the Jesterly mug-- well from the jug on the hotplate at least...
The surgery will be pretty much a reprise of the morning, or will, once a week, be an all comers "Duty Surgery" for really urgent sore throats and ingrowing toenails-- o.k. I may be exaggerating, but the definition of urgent is mutable depending on which side of the desk you're sitting. To be fair last duty surgery saw me admit three patients urgently to hospital where often I can go months without admitting anybody-- in the words of the song "it goes to show you never can tell".

18.00 Notional end of afternoon surgery, often overtaken by events so average end of surgery closer to 18.20 (worst this year so far closer to 19.05).

18.20-? catch up on calls, write up home visits, stare blankly at the walls waiting for the caffeine buzz to wear off enough to be safe to drive home.

Scattered through the day will be emails (professional and personal) and on any given day, laughter, tears, births, marriages and deaths, blood, sweat and tears. In short about as much fun as you can have with your clothes on and staying within the law.

Not quite the two surgeries and an afternoon on the golf course in between of yester-year that everybody still assumes to be the norm.

Still I wouldn't want it any other way now would I.

Wednesday, September 16, 2009

Drugs 'r bad, M'kay!*

Except when they're good. Some can be both. I've recently been asked by a friend for a response to the suggestion that we import Swiss style "Shooting Galleries" to the U.K. for injecting heroin users. I have to start by admitting absolutely no expertise in this area, but some experience in caring for drug users working towards withdrawal trough the substitution of methadone or subutex for their heroin. I'm also a big fan of it personally** for its proven role in pain control.

So, all that said, what about these shooting galleries then?

The answer I'm afraid, is complicated. Taking it one step back for a moment what about injecting users then? What do we know, and what have we been taught to believe?

We know it's bad. It must be, after all it's against the law and has been like forever hasn't it? Well not quite, only really from about 1920, and only a "Controlled Drug" in Blighty from around 1971.

Well O.K. it must be really bad for your mental helath yes? Well perhaps, though probably a lot less so than amphetamines and later "mood enhancers". All the punters I've seen with drug induced psychoses have been using amphetamines.

But it kills people! Well yes, no arguing with that, but because of prohibition we have only the sketchiest guesstimates of how many heroin users there are, so we can't say how many as a percentage, though instinct suggests its likely fewer than either alcohol or nicotine do. Overdoses are dangerous, but speak more to the despair and lack of hope that many users experience, of which their drug use if but one symptom. Inadvertent overdoses have happened when uncut drugs have been supplied, so that instead of a 90% talc (or worse) 10% heroin dose users have ended up taking 100% pure junk. Every avoidable death is a tragedy so arguments over relative risk seem specious in that context, but it probably remains the case that of all the drugs we chose for "recreation" heroin is a long way off being the most harmful.

The reality is that prohibition has created a lot of the problems we face right now. Heroin is addicting. To feed a habit costs money, but to have a lifestyle acomodating heroin is likely to imply a level of chaos that precludes a high or regular income. Hence to feed the habit users either deal or steal. Then we catch them and lock them up with dozens (or hundreds) of other dealers and stealers, so they learn how to do it "better". To keep them sweet we turn a blind eye to their continued use in stir-- after all at least they're off the streets, and heroin won't make you violent...

Then there's the "once a user always a user" myth. We have a number of users who have successfully quit not just injecting, but all illicit drug use. The trick is to "normalize" their care so they can be seen in the surgery without all and sundry knowing what they are here for. With a good rapport, a clear prescribing policy, and a willingness to accept change we can make opiate use so boring that clients will glady turn their backs on it, sometimes just for a time, but sometimes for good. Attending our surgery and not a "drug service" is a door back into the mainstream for some and it's this as much as the methadone substitution that gives them the push to move on with their lives and break out of the loop.

So, shooting galeries then?

Well on the plus side we get controlled dosing, reliable and affordable supply, sterile technique to avoid the harm of unsafe injecting and even perhaps a way in to accessing services for may users who are at present excluded precisely because they are "choosing" to continue to inject which will rule them out of admission to the vast majority of rehab systems.

On the minus side we get state sponsored addiction, less pressure to end a demonstrably harmful habit and a system likely to be too rigid to allow the chaos that is the lot of many current injecting users.

Were it to be made to work it could do a lot of good. The U.K is not the C.H. any more than it is the U.S.A. and any attempt to import techniques from another culture needs a lot of thought, but it appears on balance to be an import worthy of consideration.

* time to revive the tradition of the Virtual Chocolate Hob Nob for the first correct attribution.

** but not "personally" obviously.

Tuesday, September 15, 2009

Four More Years?

Looking back it appears I've been at this lark for four years now. I'm the first to admit things have been a bit patchy lately, and at present rate of progress will do well to see out the month, let alone another glorious year, and looking around the "'sphere" I'm beginning to feel a bit nervous. Seems four years in, blogs can start to get a bit time expired and dwindle away to nothing. This simply wont do. I've barely got enough material here for a chapter, let alone a sidesplitting Herriot style memoir or two to see me right in my dotage.

At this rate I'll need to start recycling material rather like a certain teller of Tales of Boy Wizards to see out the time to retirement, only I'm not allowed to go bumping off characters just to revive interest in the franchise now am I?

So if any of you dear, fantastically loyal, vastly talented readers have any amusing GP related anecdotes you're happy for me to shamelessly plagiarize, you know what to do.

Seriously though, four years in, although it's a bit neglected, this old place is still home. I do intend to keep going at whatever rate time, inspiration and real life will allow. After all it's been my safety valve when things get me all hot under the collar, it's introduced me to a fine bunch of people, some nearly as mad as I, and it's done wonders for the old ego, just to know a few of you out there actually want to stop by and read this stuff.

So here's to another fun packed year ahead, and god bless us every one!