Psychiatric drug critic Joanna Moncrieff and biomedical model champion Dr Trevor Turner were talking on the Today programme this morning.  The bone of contention is Moncrieff’s assertion, that we should not consider psychiatric drugs to be correcting an inherent ‘chemical imbalance’  and thus correcting a physiological abnormality, but rather to be drugs that alter brain states sometimes in a useful way.  I quite like this approach, it seems more humble and moves away from a ‘disease and correction’ model toward a more pragmatic symptom based model, which may be more compatible with non-pharmaceutical intervention.

Today discussion – 15 July 2009

Moncrieff’s paper – How do psychiatric drugs work?

Co-incidentally, I’ve volunteered to oppose the motion ‘this house believes that our lunch should continue to be funded by the pharmaceutical industry’ at a meeting today.  The ‘no free lunch’ debate is an ongoing one arising from concerns that pharma’s influence on doctors leads to a medical model biased towards ever increasing prescribing, a situation which is better for the pharmaceutical companies than for our patients or wider society.

Here is it, as ever I’d like to know what you think, unfortunately unless you comment in the next 30 minutes I’ll be unable to change the text!

”

I wish to oppose the motion “this house believes that our lunch should continue to be funded by the pharmaceutical industry”.  This is important for both our independence as doctors and is in the interests of our patients.  I will outline here why we should be wary of the pharmaceutical industry and why we should not accept their hospitality;

First a bit of history.  Before the 1930s doctors were pretty useless.  We had insulin, morphine and had worked out the benefits of conducting operations in sterile conditions, but that was about it.  Then miraculously an era of advancement between 1930-1970 produced an impressive array of medical cures such as antibiotics, transplants, ITUs, dialysis and during this time pharmaceutical companies grew big by producing and promoting innovative medicines for major diseases.

However of recent years it has become ever more difficult and expensive for these companies to repeat such successes and the number of genuinely innovative new products being released by them has significantly reduced.  I would argue that the continuing benefits of prior triumphs have led us to view pharmaceutical companies in the positive light of their past achievements, and we do not sufficiently scrutinize their current practice.

Today’s situation is that faced with maintaining their profits without the support of truly innovative products, pharmaceutical companies have engaged in refashioning and repackaging old products as ‘innovations’ and, worse, identifying and promoting new diseases for their medicines.  Many of the truly innovative treatments that have emerged in recent years have come from the funding of public bodies, whilst pharmaceutical firms have concentrated on ‘me-too’ drugs which aim simply to gain footholds in established and lucrative markets.

Psychiatry is particularly vulnerable to drug company tactics.  Our sketchily defined diseases provide opportunities for increasing product sales as they allow scope for expanding definitions of sickness, for instance depression, social phobia, female sexual dysfunction, to include more and more areas of social and personal difficulty not previously within the medical realm and thereby sell more medication.  Overall this has been  a very successful tactic and antidepressant prescribing increased 173% from 1991 to 2001.  The UK’s overall drug spending has increased from 3.9% GDP in 1960 to 7.7% GDP in 2002.

There are other concerns too.  The industry’s heavy involvement in the organisation of research into psychiatric drugs and the dissemination of research findings raises questions about the scientific objectivity of this research and the extent to which the industry is able to shape the research agenda. They also seek to gain advantage by political lobbying and funding drug-friendly patient support groups.  There has been disquiet about the burying of negative trials and over the exaggeration of drug benefits as newer expensive treatments such as SSRIs and atypical antipsychotics have not proved more effective than older and cheaper alternatives.

Pharmaceutical companies have thus sold us a reductionist biomedical model of the world.  They haven’t done this on their own of course, as it suits the purposes of many to live in a world where there are simple problems requiring simple solutions, but they have done their best to make sure that their voice is heard above any of those that might provide an alternate, non pharmaceutical vision.  For human beings can survive without endless drugs to cure every possible ill, but the companies that prescribe them cannot.  Pharmaceutical companies are primarily commercial concerns, and their major motivation is maximizing their profits.
But does this knowledge necessarily stop us accepting a free lunch from the dark side?  After all it saves us from buying our own thus allowing us to conserve funds in these uncertain times.  Can we not use our contact with pharmaceutical company representatives to evaluate what they tell us and learn about their products?

I argue no and for one simple reason: because we are weak.

Ask yourself this question: why would a commercial company, to whom profits are key, spend money on buying us lunch if they felt it would make no difference to our behaviour?  The answer is that they wouldn’t.  They know that by their engagement with us they can persuade us to use their products despite any other reservations we might previously have had.  They know that they can influence us to choose the treatment that is best for them, and not necessarily best for the patients we seek to treat.

You don’t need to believe me on this one.  Believe the authors of an article in the JAMA, who found that meetings with pharmaceutical representatives were associated with changes in prescribing practice.  And the next time you use your sponsored pen, consider an article in the Am J Bioethics, which concluded that ‘considerable evidence from the social sciences suggests that gifts of negligible value can influence the behavior of the recipient in ways the recipient does not always realize’.

The true situation is that pharmaceutical companies realize that in order for their products to find a market, they must first influence doctors to prescribe them and they spend a lot of money ensuring this takes place.  From early in our careers they win our favour by providing small gifts, and by taking part in medical education seek to inculcate us with their world view.

We should realise our vulnerabilities and not tempt ourselves so.  I’m not saying that drugs have no place in modern medical health care.  What I am saying is that as doctors we have but one duty, and that is toward improving the health of our patients; any action we may take to place ourselves at the risk of being influenced by another competing agenda is unwise and should be avoided.

For these reasons I commend you to join with me and oppose this motion.  Thank you.

”

Further reading:

Jackie Law Big Pharma – a comprehensive guide to this subject

Extract from Richard Bentall’s book Doctoring the Mind

Ben Goldacre on Medicalisation from his book Bad Science

The myth of the chemical cure Joanna Moncrieff BBC Health 15 July 2009
The myth of the chemical cure book on Amazon

Elvis Presley visited President Nixon in 1970 to talk to him about, amongst other things, the evils of the drug culture. The picture of them together is one of the most popular in the national archive.

More up to date and I’ve been listening to Lily Allen – pop princess and queen of myspace – ‘s new album ‘It’s not me it’s you’. With her song ‘Everyone’s at it’ she has strayed into social commentary:

I don’t know much but I know this for curtain
And that is the sun poking its head round the curtain
Now please can we leave?
I’d like to go to bed now
It’s not just the sun that is hurting my head now
I’m not trying to say that I’m smelling of roses
But when will we tire of putting shit up our noses
I don’t like staying up, staying up past the sunlight
It’s meant to be fun and it just doesn’t feel right

(Chorus)
Why can’t we all, all just be honest?
Admit to ourselves that everyone’s on it
From grown politicians to young adolescence
Prescribing themselves anti depressants
Now how can we start to tackle the problem?
If you don’t put your hands up and admit that your on it
Now the kids are in danger, they’re all getting hammered
From what I can see everyone’s at it
Everyone’s at it x 3

I get involved but I’m not advocating
got an opinion, yea your well off the slating
so you’ve got a prescription, yea that makes it legal
finding excuses, is well over whelming with people
you go to the doctor and you need pills for sleeping
if you can convince him then I guess that’s not cheating
see you’re daughters depressed, so get her straight on the Prozac
but little do you know that she already takes crack

(Chorus X2)
Why can’t we all, all just be honest?
Admit to ourselves that everyone’s on it
From grown politicians to young adolescence
Prescribing themselves anti depressants
Now how can we start to tackle the problem?
If you don’t put your hands up and admit that you’re on it
Now the kids are in danger, they’re all getting hammered
From what I can see everyone’s at it
Everyone’s at it x 3

At the risk of spoiling her fun, I’ve read through these lyrics a few times and I’m not sure of the point that Allen is trying to make. It’s undoubtedly a tricky subject; witness the scolding that David Nutt recently received from the Home Secretary. With this in mind, perhaps we should congratulate Allen for attempting to tackle such a difficult subject within the confines of a four minute sugary pop coating. But it’s a shame then that her undoubtedly noble intentions have fallen foul for want of a bit of homework.

By my reading Allen’s essential points are threefold: ‘everyone’ does drugs, we’re not honest about this, there is no real distinction between psychoactive drugs that your doctor might prescribe and those you might get from whichever drug dealing, bmx riding youngster happens to be passing by.

I suspect that in Allen’s circles everyone is probably using drugs and staying up all night, which might account for the obvious world weariness of her first verse. However taking the population as a whole – which crucially includes people who have proper jobs, the best evidence (pg 34 onwards) suggests that around a third of all UK 16-59 year old have used illicit drugs; that’s two thirds short of ‘everyone’. Additionally 2.4% of 16-59 used either crack or cocaine powder in the past year, which means that Allen’s scenario whereby someone might go to their doctor for antidepressants whilst also using crack is a scenario which applies to an even smaller number of people.

And I do have sympathy for her assertion that there are double standards concerning drug use. Many prominent people are no more honest about their drug use than they are about the extent of their plastic surgery. PM in waiting David Cameron has refused to discuss his own drug past, saying that he is entitled to a ‘private life’ prior to his entering politics. Home secretary Jacqui Smith has admitted smoking cannabis, as have other prominent politicians.

It is true that your doctor can prescribe drugs of abuse, for instance benzodiazepines, and even heroin under much more restrictive circumstances. We can also prescribe psychoactive drugs such as antidepressants. Some people are keener on the idea of this than others. I would draw a distinction between these two circumstances on the basis of intent. A doctor intends to alleviate distress with his/her prescriptions, helping to reduce sleep problems or improve mood. Recreational drugs are just that – an indulgence.

In other psychopop developments, neo cabaret darlings and Frontier Psychiatrist favourites Bourgeois and Maurice have penned a song called Ritalin. I talked to the Maurice Maurice, one half of this duo, about her inspiration for this song, whose origins are apparently when she was working on an American summer camp and seemingly all the children were prescribed it. Listen to it on Myspace

Finally the Government are also talking about banning currently legal substances. The Guardian reports that ‘Spice’, Salvia divinorum, and ‘herbal ecstasy’ and are under threat. Hoover them up whilst you still can kids…

There’s been a fuss in the press and in Parliament this month following a report on ecstasy from the Advisory Council for the Misuse of Drugs (ACMD) and a similarly themed article in Journal of Psychopharmacology by ACMD chairman.

The ACMD’s report made an evidence based recommendation that ecstasy be downgraded to ‘Class B’.  With ‘A’ being the worst, illegal drugs are graded in terms of their harmfulness which informs their illegalness.  The ACMD judged ecstasy not sufficiently harmful either at a personal or societal level to warrant inclusion with the Class A big boys (heroin etc.); alas the UK Home Secretary has chosen to ignore this advice, as she did with similar advice regarding cannabis. 

At almost the same time David Nutt, chairman of AMCD, wrote an article entitled Equasy – An overlooked addiction with implications for the current debate on drug harms.  In it he makes up an addiction, to that of equine sports, which has a similar hazard rate to ecstasy use and draws parallels between attitudes to ecstasy use and those to horse riding. Given the subsequent fallout, it’s as if he engineered the reaction specifically to illustrate his point.

Here’s Professor Nutt:

‘The general public, especially the younger generation, are disillusioned with the lack of balanced political debate about drugs’

And Jacqui Smith

I’m sure most people would simply not accept the link that he makes up in his article between horse riding and illegal drug taking.  For me that makes light of a serious problem, trivialises the dangers of drugs, shows insensitivity to the families of victims of ecstasy and sends the wrong message to young people about the dangers of drugs.

(Smith’s thought process: I find what you say unspeakable, therefore it’s unsayable, therefore you are wrong)

Nutt’s article is sensible and clearly reasoned about the risks we take in our society and how our judgement of them is informed by society’s wider stance on whether they are worthy or not.  In the case of horse riding it’s thumbs up, and ecstasy, thumbs down.  Maybe on balance this is how it should be but Smith’s retort is knee-jerk and lacks nuance or any intellectual flexibility.  A thoughts comes to mind: sometimes, during a particularly exasperating consultation, I say something like ‘look, people come here and ask me what I think.  So I tell them and then it’s up to them to go away and consider what I’ve said and whether they agree with me about the best way forward or not; sometimes they decide to do what I think is a good idea, and sometimes they don’t’.   This, perhaps, is how David Nutt and the Advisory Council for the Misuse of Drugs must feel.

Previous: Cannabis and Jacqui Smith

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Links

Press
Jacqui Smith slaps down drugs adviser for comparing ecstasy to horse riding Guardian February 9 2009
Drugs adviser says sorry over ecstasy article Guardian February 10 2009
Home secretary accused of bullying drugs adviser over comments about ecstasy BMJ February 13 2009

Blogs
Taking ecstasy no more dangerous than riding a horse? - Before you take that pill
(note this statement as an example of relativism: ‘…something creepy about comparing deaths from drug use and horseback riding. I mean horseback riding is a healthy and uplifting activity, while drug usage, even if it doesn’t kill you, drags you down into lower levels of spiritual and mental functioning’
Psychiatrist Says Ecstasy Less Harmful Than Horse Riding, Controversy Ensues - Furious Seasons

Other
Horizon: Britain’s most dangerous drugs