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Rapid responses are electronic letters to the editor. They enable our users to debate issues raised in articles published on thebmj.com. Although a selection of rapid responses will be included online and in print as readers' letters, their first appearance online means that they are published articles. If you need the url (web address) of an individual response, perhaps for citation purposes, simply click on the response headline and copy the url from the browser window. Letters are indexed in PubMed.

Re: Substance misuse in older people Rahul Rao, Ann Roche. 358:doi 10.1136/bmj.j3885

Rao and Roche [1] note the number of people aged over 50 using substances problematically is increasing across a range of settings globally [2, 3]. We wish to extend their editorial by pointing out that the proportion of older people who inject drugs (PWID) also appears to be increasing, at least in the developed world [4]. Many PWID commenced their injecting careers in the drug epidemics of the 1980s and 1990s and continue to use substances (including injecting) through to today. Research on the health needs of older PWID, particularly those who continue to use opioids in North America, [5-7] and the United Kingdom [8-10] shows how little we understand of the life trajectories of ageing and drug use. This cohort has already established lifestyle and health trajectories which will carry them into their old age over the next two decades, the management of which has emerged as an increasingly important public health problem [11-14].
For example, some symptoms such as changes in blood pressure, changes in moods or memory impairment may only manifest in older age and the lives of older PWID are likely to be characterised by considerable levels of morbidity [15] not experienced by other older people without a drug injecting history. A range of barriers to accessing health care for PWID have been identified for PWID, including stigma and discrimination [16, 17], health workers’ lack of confidentiality [18], service models that are unacceptable or inaccessible [19, 20], cultural differences in approaches to managing health problems [21] economic disadvantage and competing priorities [22]. Recent research has also highlighted that PWID often do not seek health care or delay accessing it [23].
Australian surveillance data suggest there is a large, ageing cohort of (predominantly) opioid injectors in Australia [24]. Similarly, national opiate substitution treatment (OST) data show that, of the over 48,500 people receiving OST, 22 per cent were aged over 50 [25]. It is also largely unknown what impact continuing to inject has on the life course of older people.
Issues of stigma mean that relatively few older adults with injecting histories seek on-going primary health care, this is despite many having regular contact with pharmacies and alcohol and other drug specialists [26]. Primary care and other health-care services may provide a valuable opportunity to screen for any potential health problems associated with either opioid use or ageing the burden of which may be due to issues directly related to on-going injecting drug use.
There is a need to understand and design services for this population the key features of which are likely to be low-threshold and client centred. There is still much to understand in relation to the impact of OST on people who have been using it for decades especially in relation to cardiovascular disease, especially given the high rates of smoking in this population. As PWID get older their presentations to primary care for a broad range of chronic health problems will likely increase the sooner we can address these the less likely they are to end up in tertiary health settings.

References

1. Rao, R. and A. Roche, Substance misuse in older people. BMJ, 2017. 358.
2. Han, B.H., et al., Demographic trends among older cannabis users in the United States, 2006–13. Addiction, 2017. 112(3): p. 516-525.
3. Lintzeris, N., et al., Substance use, health status and service utilisation of older clients attending specialist drug and alcohol services. Drug and Alcohol Review, 2016. 35(2): p. 223-231.
4. Madden, A. and P. Parkes, Coming of Age - Issues for older opiod injectors. Drug and Alcohol Review, 2010. 29(Supp 1): p. 47.
5. Rosenburg, H., The Elderly and the Use of Illicit Drugs: Sociological and Epidemiological Considerations. Substance Use & Misuse, 1995. 30(13-14): p. 1925-1951.
6. Tuchman, E., Methadone and Menopause: Midlife Women in Drug Treatment Journal of Social Work Practice in the Addictions, 2003. 3(2): p. 43-55.
7. Anderson, T.L. and J.A. Levy, Marginality among older injectors in today's illicit drug culture: assessing the impact of ageing. Addiction, 2003. 98(6): p. 761-770.
8. Beynon, C., G. Stimson, and E. Lawson, Illegal drug use in the age of ageing. Br J Gen Pract, 2010. 60(576): p. 481-2.
9. Beynon, C.M., et al., Self reported health status, and health service contact, of illicit drug users aged 50 and over: a qualitative interview study in Merseyside, United Kingdom. BMC Geriatr, 2009. 9: p. 45.
10. Beynon, C.M., Drug use and ageing: older people do take drugs Age and Ageing, 2009. 38(1): p. 8-10.
11. Degenhardt, L., M. Lynskey, and W. Hall, Cohort trends in the age of initiation of drug use in Australia. Australian and New Zealand Journal of Public Health, 2000. 24(4): p. 421 - 426.
12. Dietze, P. and J. Fitzgerald, Interpreting changes in heroin supply in Melbourne: droughts, gluts or cycles? Drug Alcohol Rev, 2002. 21(3): p. 295-303.
13. European Monitoring Centre for Drugs and Drug Addiction, Treatment and care for older drug users. 2010, EMCDDA: Spain.
14. Boeri, M.W., C.E. Sterk, and K.W. Elifson, Baby Boomer Drug Users: Career Phases, Social Control, and Social Learning Theory*. Sociological Inquiry, 2006. 76(2): p. 264-291.
15. Beynon, C.M., J.I.M. McVeigh, and B. Roe, Problematic drug use, ageing and older people: trends in the age of drug users in northwest England. Ageing & Society, 2007. 27(6): p. 799-810.
16. Radcliffe, P. and A. Stevens, Are drug treatment services only for 'thieving junkie scumbags'? Drug users and the management of stigmatised identities. Social Science & Medicine, 2008. 67(7): p. 1065-1073.
17. Stoove, M.A., S.M. Gifford, and G.J. Dore, The impact of injecting drug use status on hepatitis C related referral and treatment. Drug Alcohol Depend, 2005. 77(1): p. 81-6.
18. Ho, H. and L. Maher, Co Vay Co Tra: Vulnerability to blood-borne viral infection among ethnic Vietnamese IDUs. Drug Alcohol Rev, 2008. 27(4): p. 420-428.
19. Coupland, H., et al., Promoting equitable access to hepatitis C treatment for Indo-Chinese injecting drug users. Health Promot J Austr, 2009. 20(3): p. 234-40.
20. Winter, R., et al., Integrating enhanced Hepatitis C testing and counselling in research. International Journal of Drug Policy, 2008. 19(1): p. 66-70.
21. Higgs, P., et al., Heroin-gel capsule cocktails and groin injecting practices among ethnic Vietnamese in Melbourne, Australia. Int J Drug Policy, 2009. 20(4): p. 340-346.
22. McCoy, C.B., et al., Drug use and barriers to use of health care services. Subst Use Misuse, 2001. 36(6-7): p. 789-806.
23. Morgan, K., J. Lee, and B. Sebar, Community health workers: A bridge to healthcare for people who inject drugs. International Journal of Drug Policy, 2015. 26(4): p. 380-387.
24. Stafford, J., Breen, C., Australian Drug Trends 2016. Findings from the Illicit Drug Reporting System (IDRS), in Australian Drug Trend Series. No. 163. . 2017, National Drug and Alcohol Research Centre, UNSW Australia: Sydney.
25. Australian Institute of Health and Welfare, National opioid pharmacotherapy statistics. 2015, AIHW: Canberra
26. Higgs, P., J. Kelsall, and P. Dietze, Understanding the health needs of older opiate users. Drug Alcohol Rev, 2011. 30(Supp 1): p. 39-40.

Competing interests: PH has received funding from Gilead Sciences and AbbVie for work unrelated to this letter. PD is supported by an ARC Future Fellowship and has received funding from Gilead Sciences and Reckitt Benckiser for work unrelated to this letter.

25 September 2017
Peter Higgs
Senior Lecturer
Professor Paul Dietze
Department of Public Health, La Trobe University
Bundoora Campus 3083
Re: Psychotropic prescribing in people with intellectual disability and challenging behaviour Angela Hassiotis, et al. 358:doi 10.1136/bmj.j3896

Intellectual disability is a great field for integrated work, if specialists, GP, social workers, families and institutions, can closely work toghether and can support the person, basing on personal needs and avoiding induced needs. When intellectual disabled persons are supported in the daily life and in the own milieu, they can better express and avoid, as far as possible, behavioural and social emergencies. Educational support is needed to involve families and patients, to improve relationship and to promove person in working and living in the possible way, respecting personal possibilities and abilities. Educational support is also needed to help from school time person to know and avoid anti-social behaviours. The outcomes are always linked to investiments, as more disability is supported and persons are helped to have a correct personal and social expression, as less they can need psychotropic medicaments. Further, if intellectual disabled person and familiy are supported to have a correct expression and relation, can be reduced also the need of sheltered facilities, and coercion to care.

Competing interests: No competing interests

24 September 2017
t. damiani tiberio damiani
psychiatrist
mental health department Area vasta 5 Ascoli Piceno, Asur Marche,
mental health department, via degli iris , 63100 Ascoli Piceno, Italy
Re: Margaret McCartney: Nuclear weapons do harm, even if never used Margaret McCartney. 358:doi 10.1136/bmj.j3978

Sir,
The escalating crisis between the USA and North Korea illustrates the major problem with MAD (mutually assured destruction) as a strategy: it depends on a rational assessment of the terrible risks for the world of the use of nuclear weapons. This assessment should then lead to diplomacy, behaviours and decisions calculated to avoid such a catastrophic event. There is little sign at present of such a rational assessment, which is deeply worrying for all of us.

If nuclear weapons are used, the consequences fall mainly on non-combatants. In this sense, nuclear weapons are similar to biological and chemical weapons, which are banned under international law. Our recent letter led by Dr Michael Orgel of MEDACT Scotland and co-signed by Nobel Laureate for Physics Professor Peter Higgs, sets out these arguments and the huge risks to human and planetary health of even a small nuclear exchange. This is likely to affect both hemispheres, not just the immediate area affected by radiation (1).

I would probably accept that the strategy of dependence on MAD may have helped to avoid global, although certainly not regional, conflict since World War 2. However, it is now time for a re-assessment. It is quite clear that the risks of nuclear weapons are growing, and are now much greater than any deterrent benefit. The UK has an opportunity for global and planetary leadership. It could sign the comprehensive treaty banning nuclear weapons agreed by 122 nations and adopted on 7th July 2017 at the UN.

Yours

Professor John CM Gillies OBE

1. UK must take the lead in de-escalating threat of nuclear war. Guardian letters. 31st August 2017 https://www.theguardian.com/world/2017/aug/31/uk-must-take-lead-role-in-...

Competing interests: No competing interests

24 September 2017
John C M Gillies
Medical doctor
University of Edinburgh
Teviot Place Edinburgh EH1 2QZ
Re: Training for children with chronic fatigue works better than medical care alone, finds study Nigel Hawkes. 358:doi 10.1136/bmj.j4372

People with ME/CFS need disease-modifying treatments with proven efficacy, not motivational techniques tested in flawed clinical trials.

It is well established in medicine that self-reported improvement in health can be highly misleading. This clinical trial is unblinded and does not adequately control for nonspecific effects. Participants in the Lightning Process are instructed to deny their illness to themselves and others which introduces the kind of bias into the study that can make ineffective treatments appear effective. It makes no sense to evaluate the efficacy of therapies that aim to manipulate participants illness perceptions and symptom reporting behaviour with self-reported health, even if this is the claimed mechanism by which they work. Fortunately there ways to objectively assess relevant measures of health, such as daily activity levels measured with an accelerometer or standardized cardiopulmonary exercise testing that could be used as primary outcomes in clinical trials with this design.

There are other important problems in this clinical trial but the above is a recurrent problem in the ME/CFS field. Most studies of cognitive behaviour therapy and graded exercise therapy suffer from this flaw.

Competing interests: No competing interests

24 September 2017
Anton Mayer
Patient
-
Re: Mapping the drivers of overdiagnosis to potential solutions Thanya Pathirana, Justin Clark, Ray Moynihan. 358:doi 10.1136/bmj.j3879

As a GP concerned to limit the growth of medicalisation and ‘healthism’(1), I welcome Pathirana et al’s account of some of the ways this might be achieved. But I take issue with two points in their opening paragraph. First, while ‘a growing body of evidence’ indicates that diagnosis and treatment can both cause harm, no amount of evidence can tell us how much is ‘too much’ medicine  this is a value judgement. Second, any intervention offered to a person who feels well at present relates to a health problem that may ‘never cause them harm’. Screening tests particularly often involve ‘“the detection of abnormalities that are not destined to ever bother” most of us. Implying that any individual can be ‘overdiagnosed’ makes no sense without a crystal ball. In the thyroid cancer example presented, what we need to know is how many lives were lengthened for every 100,000 people diagnosed and treated. Once available, this information will inform a value judgement about the number of people who should suffer diagnosis and treatment in return for one life lengthened. This value judgement can be made by health economists who calculate which interventions are cost effective, or by individuals who evaluate the pros and cons of an intervention they are offered. The challenge for clinicians is to help people do this evaluating in the consulting room.
While accepting Pathirana et al’s recommendation that campaigns should challenge the public’s current beliefs about how much medicine is just right, I should like the overdiagnosis conversation to accept that it is not doctors’ job to specify this ‘right’ amount. Also, the assumption that the public believe ‘more is better’ is open to challenge. My own research (2) suggests that in accounting for their everyday decisions about preventive medication, patients negotiate the tension between ‘medical progress’ and ‘medicalisation’. I see less evidence that the biomedical community has yet engaged with this tension, but am encouraged that a forthcoming RCGP meeting focuses on both over- and under-treatment. Such engagement is urgently needed as genetic screening begins to generate an enormous number of new ‘at risk’ labels, a juggernaut that needs to be guided by people who simultaneously fear medicalisation and welcome medical progress.

1. Crawford R. Healthism and the medicalization of everyday life. International Journal of Health Services. 1980;10(3):365-8.
2. Polak L. What is wrong with ‘being a pill-taker’? The special case of statins. Sociology of Health and Illness. 2017;39(4):599–613.

Competing interests: No competing interests

24 September 2017
Louisa Polak
GP and PhD student
London School of Hygiene and Tropical Medicine
Colchester
Re: Corticosteroids for sore throat: a clinical practice guideline Geertruida E Bekkering, Arnaud Merglen, Mieke van Driel, Mieke Vermandere, et al. 358:doi 10.1136/bmj.j4090

The authors state "The treatment is inexpensive and likely to be offered in the context of a consultation that would have taken place anyway". They are mistaken. Like many others, I have been educating patients about the natural course of sore throats and self-management. Over thirty plus years in general practice, I have seen a huge decline in presentations for the condition and the time has been filled by dealing with more complex and serious conditions. Attendances for sore throat these days are usually for children and even those are few. The recommendation to consider dexamethasone for a tiny gain (one day shorter duration of illness) has the potential to create new consultations for what is (most of the time) a minor and self-limiting part of life. The cost of dexamethasone may be low but the cost of GP or nurse time which is in short supply is not. The authors have been diligent in using a respected tool for guideline development, namely GRADE. However, the outcome reveals a shortcoming in GRADE: opportunity costs (the benefits to the whole system or other patients from not making this choice) are ignored with potentially serious consequences for us all.

Competing interests: No competing interests

24 September 2017
Kevork Hopayian
General Practitioner
Suffolk, England
Re: Beating type 2 diabetes into remission Naveed Sattar, Mike E J Lean, et al. 358:doi 10.1136/bmj.j4030

That is an ongoing article around the risk of obesity.
The risk not only Diabetes 2 but also hypertension, cardio-vascular diseases, gastro - intestinal and gall bladder diseases in addition to musclo-skeletal system . The subject of nutrition with regard to body requirement for the quality and quantity of food is unknown in the education in schools or university.
We need in UK and all over the world a new educated generation to adjust the food and drink intake.
Even within the health professionals doctors and nurses obesity is alarming.
By combating obesity this can have a huge impact on NHS budget, the economy of the country
and the whole world in addition to improving health and quality of life.
M E Tageldin

Competing interests: No competing interests

24 September 2017
Mohamed Tageldin
Retired orthopaedic surgeon , BMA member
London
Re: Junior doctor is suspended for dishonesty over annual leave Clare Dyer. 358:doi 10.1136/bmj.j4055

I understand that this article is meant to illustrate the importance of honesty in patient care.[1] This article also brought up another important issue: the problem in junior doctors' rota and leaves. It illustrates the difficulty in asking for days off, even if one has given an adequate notice to use his entitled annual leaves. In a recent BMJ issue, we learn how a junior doctor is told to find locum coverage himself despite having a serious illness.[2]

Isn't it ironic that it is junior doctors' rather than rota coordinators' responsibility to arrange for work coverage? The trust expects us to find a co-worker to cover for our leaves, and this co-worker is expected to have superhuman ability to carry the work of two people in a stretched setting. Similarly, when our co-workers call in sick, hospitals do not always have an adequate back-up measure to fill the rota gap. Although that is possibly the norm in many NHS hospitals, it should not be justified as a safe approach to patient care.

Perhaps, a hidden lesson here is this: when being declined to use our entitled leaves, we should ask the British Medical Association for help rather than trying to resolve the problems ourselves.

References
1. Dyer C. Junior doctor is suspended for dishonesty over annual leave. BMJ. 2017;358.
2. Clarke R. Cheap, undervalued, expendable: junior doctors in 2017? BMJ. 2017;358.

Competing interests: No competing interests

24 September 2017
Eugene Y.H. Yeung
Doctor
Royal Lancaster Infirmary
Ashton Road, Lancaster, LA1 4RP, UK
Re: Shared medical appointments Benedict Hayhoe, Anju Verma, Sonia Kumar. 358:doi 10.1136/bmj.j4034

The editorial by Hayhoe et al successfully highlights the potential and challenges of the shared medical appointment (SMA) as a solution to capacity issues in contemporary practice. We would like to take this opportunity to share our real life experience of employing this approach in the management of gestational diabetes (GDM), in south west Essex.
Over the years, the palpable despair and sense of isolation displayed by many pregnant women following a diagnosis of GDM, captured our attention. However, things only really came to a head in February 2015 when NICE updated its’ pregnancy guidance to stipulate a new requirement for specialist clinic review within 7 days of a new diagnosis of GDM. At a time of unprecedented increases in the prevalence of gestational diabetes and limited NHS resources, meeting this obligation was predictably challenging. Our rate of achieving this standard gradually deteriorated and rather disappointingly, by February 2016 this standard was being achieved in only 31% of our GDM patients.
In March 2016 this led to a transformation of our weekly conventional first contact clinic to a multidisciplinary group clinic called EGGS (Educating Gestational diabetics Group Sessions), resulting in a four-fold increase in our weekly capacity, at no additional cost. The outcomes have been quite stark and indeed we too soon realised the additional virtue of enabling the professions, patients and partners to learn with, from and about each other. By optimising exchange of experience and expertise, this interactive partnership with service users results in simultaneous co-reflection, with all participants comparing perceptions, values, roles and responsibilities while pulling in the same direction. We now see this as the most critical component of our progression and 16 months after implementation, 94% (Monthly range: 88- 100%) of new GDM patients are being seen within 7 days. Furthermore, over 97% of 338 service user respondents acknowledged that all educational objectives, including adequate psychological adjustment to the new diagnosis, were achieved.
For us this has been a truly exciting development, recently culminating in our winning of the 2017 Health Enterprise East NHS Innovation Award (Diabetes category).
Whilst we recognize the stated challenges and concerns about shared medical appointments, our service journey proves these barriers are not unsurmountable, understandably influencing our perceptions and motivating our full endorsement of SMAs in this domain of care.

Competing interests: No competing interests

23 September 2017
Amaju A Ikomi
Consultant Obstetrician & Gynaecologist
Joanne Hoare, Shaheen Mannan
Basildon and Thurrock University Hospitals NHS Foundation Trust
Nether Mayne, Basildon, Essex SS16 5NF
Re: Consider corticosteroids for acute sore throat, says BMJ review Gareth Iacobucci. 358:doi 10.1136/bmj.j4333

The strange knocking sound you can hear is GPs everywhere banging their heads on the table in frustration. By the authors’ own admission the recommendation is weak due to the minor evidence of benefit, and the suggestion that costs will be small because corticosteroids are cheap completely disregards the costs of providing a GP consultation.
GPs have spent years advising patients that normal sore throats are a minor price to pay for the joy of being alive, and should not require professional help. The suggestion that the consultations will take place anyway is indefensible as the perception that there is a prescription-only treatment available will encourage attendance, and within a system like the NHS that will inevitably deny consultations to patients with genuine needs.
We live in an era of over-diagnosis, over-treatment, and over-reliance on doctors, and the conclusions in the paper will, if enacted, do nothing to improve the physical or indeed mental health of the population, which surely should be medicine’s ultimate aim.

Competing interests: No competing interests

23 September 2017
Andrew Green
GP, Clinical and Prescribing Policy Lead, GP Committee, BMA
The Hedon Group Practice
The Hedon Group Practice, Market Hill House, Hedon, East Yorkshire

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