Sarah’s Health Notes: Beyond Pills Campaign
This article first appeared in The Telegraph
Medicines do people a lot of good but they can also cause harm, according to the recent National Overprescribing Review, which found that 10% of drugs are unnecessary, inappropriate or may be harmful, as I found to my cost.
In autumn 2002 a serious riding accident led to my being prescribed a heavyweight painkiller called tramadol. My horse had bolted under a tree and, trying to shield my face, my left arm was smashed to pieces. I went through two long operations and was given morphine. As one visitor said, I was high as a kite and very jolly.
Back at home I took tramadol, not knowing that one of the contra indications to tramadol - described by the NHS as a ‘strong painkiller from a group of medicines called opiates or narcotics’ - is an addiction to alcohol or recreational drugs. As a 60s flower child living with a rock band, I’d taken anything and everything although I‘d given up long before the accident. Doctors didn't ask me about any previous problems and I didn't think to say. But I shouldn't have been prescribed that drug.
Repeat prescriptions were given whenever I asked so I took tramadol for about four months. When I stopped, withdrawal symptoms overwhelmed me for almost a year. I had panic attacks, felt intensely depressed, lost my sense of identity and self- confidence – and had weird psycho-physical sensations. In a car, I sometimes felt as if I was paralysed with the car and the outside world separate entities moving past me. Ordinary life felt as if it had spun away from me, on some crazy trajectory I couldn't control. I often felt suicidal.
I told the hospital consultant in pain management what was happening. He told me not to worry and not to be put off taking the pills in future if I needed them. He gave me no advice about managing withdrawal.
I came out the other side after about a year with the help of a GP who understood the ‘murk’, as he called it, a herbalist who helped with my crippling insomnia, a psychotherapist and a reflexologist. One of the most important things they did was to listen to me.
Over the years, I’ve met many people who have suffered from problems with prescription drugs. Let me make it clear I am not against medication. Some pills are vital: one family member needs daily medication to control seizures, for instance. But the recent National Overprescribing Review, commissioned by the Department of Health and Social Care, found that 10% of drugs prescribed in primary care – that’s some 110 million items – are unnecessary, inappropriate or may cause harm.
Tackling overprescribing could improve the health of millions, achieving benefits ‘comparable to a new blockbuster medicine’, according to the Review’s author, Dr Keith Ridge CBE, former Chief Pharmaceutical Officer for England.
It was reading that Review which led directly to the launch today of the College of Medicine Beyond Pills Campaign, which I’ve been involved with from the start, together with senior politicians who have a longtime involvement with health, including Sir Norman Lamb, Stephen Dorrell, Heidi Alexander, Lord Crisp and Sir Oliver Letwin.
One solution that Dr Ridge, who supports the Campaign, recommended is social prescribing. Although it’s part of NHS England mainstream policy the majority of people don’t know what it is, partly because it’s so wide-ranging. The context is that at least 20% of patients who come into a GP surgery – often many more, according to doctors – do not need medical treatment. As Dr Ridge says, ‘People’s health is influenced by a range of social, economic and environmental factors such as housing, economic resources, pollution, health behaviours and diet. Often, medicines only deal with symptoms, and do not tackle the underlying causes of illness or effect a cure.’
Expanding the provision and awareness of social prescribing is a key aim of the Beyond Pills Campaign. As Sir Norman Lamb says, ‘Social prescribing gives GPs something else of value to offer but only in the practices where it is up and running. Sadly, there are not enough of these. It should not be a postcode lottery. People across the country, in every community, should be able to benefit from social prescribing.’
Social prescribing usually involves the patient being referred to a link worker, a non-clinical professional who takes time with the patient – usually three to six 45-minute sessions - to work out together a strategy for their particular concerns. One woman I met had experienced such serious mental health problems she feared she couldn’t look after her two young children. Medication and talking therapy made no lasting difference whereas the companionship and joy she found singing in a local community choir and practicing yoga transformed her life.
Social prescriptions range widely from encouragement to exercise (particularly in nature) or improve nutrition, to joining an arts group, gardening or practicing mindfulness to advice on welfare benefits, housing or occupational choices. Support is principally provided by voluntary community organisations.
Link worker Diane Girling, senior social prescriber at the Heart of Bath Medical Partnership, starts by asking patients ‘what’s at the top of their list of concerns, which could be anything from loneliness, overweight, debt or bereavement to their pet dying. We allow them to explore what they might like to change and how. Lots of people don’t know what they like doing because they’re so consumed by problems that take up their lives. We may not be able to change their situation but we can help them learn to manage it better.’
One criticism is that there is insufficient evidence that social prescribing works. But according to GP Dr Michael Dixon, Chair of the College of Medicine, the problem is that social prescriptions don’t fit the current model of evidence-based medicine dictated by NICE guidelines. The GP Quality and Outcomes Framework (QOF), which accounts for 25% of GP pay, awards practices points (and points mean pounds) on the basis of numbers of patients diagnosed with common chronic illnesses or the risk of them, then treated with extensively trialled drugs. ‘For instance, we have to offer prescriptions to everyone with a 10% risk of heart attack or stroke, which means just about every male over 65 should be on statins,’ says Dr Dixon.
‘You can’t do these types of large scale trials on, say, singing, gardening or mindfulness so there is a big focus on medicines,’ says GP Dr Laura Marshall-Andrews. ‘The only bodies that can afford the costly trials are the pharmaceutical companies, which has conspired to lead to evidence-based protocols around disease treatment that are almost entirely reliant on medication.’
That is a key factor in the huge increase in drug prescriptions. In 1996 dispensing in primary care doubled from 10 prescription items per head per year to 20 in 2016. ‘It’s easier for busy GPs to reach for the prescription pad than hope the patient will take exercise, eat better and lose weight,’ says Dr Dixon.
A big concern is polypharmacy. ‘As people get older, they tend to suffer from more than one disease so they are prescribed a set of drugs for each,’ explains Dr Ridge. ‘At least 15% of the population – 8.4 million people - take more than five separate medicines daily, often using one drug to treat the side effects of another.’
While drugs may work well on their own – which is how they are trialled - they may cause disturbing effects in combination. ‘One in five in patient hospital admissions in over 65s is due to an adverse drug reaction,’ says Dr Ridge.
He believes, as do many health professionals, that the current biomedical model does not benefit patients or doctors. ‘A core finding from the nearly 100 patient interviews for the National Overprescribing Review is that they want to feel listened to. It’s vital that patients are confident to discuss with their doctor whether they need a medicine, the benefits and risks, and whether there’s an alternative such as social prescribing.’
Let me finish with Debs Teale, who was prescribed a cocktail of drugs for her mental health issues from the age of eight for some three decades. The spark that ignited her recovery was going to art classes. Debs told her story at the launch of the Beyond Pills Campaign. ‘Recovery for me means a life worth living. My plan was to take my own life but that didn't work and these days I love being alive, and it’s thanks to social prescribing. I see people like me feeling hopeless and helpless and I want to shine a light for them and say, look, that’s where I was and look at me now.’