Too much medicine?
BMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7342.859 (Published 13 April 2002) Cite this as: BMJ 2002;324:859
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
A large number of drugs, including antibiotics, aspirin, NSAIDS,
antidepressants, statins, cannabis, amphetamines, cocaine, heroin,
morphine, and antidepressants may impair mitochondrial oxidative
phosphorylation (1-14). It is very likely that the effects of many of
theses substances are additive when administered together, the most
serious damage likely to be inflicted not only by individual substances
taken in abnormally large amounts but also by the mixing of different
substances taken in normal amounts (15). Different doses have different
effects. In the case of alcohol, the most extensively studied, a binge may
induce massive mitochondrial damage (16). Chronic consumption in moderate
amounts, on the other hand, may increase the efficiency of oxidative
phosphorylation (17) and abstinence may reverse the mitochondrial damage
done (18).
An impairment of mitochondrial oxidative phosphorylation appears to
be the cause of most organ dysfunctions and failures in the acutely ill
(19,20) and probably in the chronically ill (21-28). It is very likely,
therefore, that many of the medications that are being administered for
the management of chronic illnesses and taken for recreational purposes
increase the risk of developing organ dysfunctions and failures in acute
illnesses and the risk of developing chronic illnesses such as
neurodegenerative disorders and chronic heart failure.
1. Fosslien E. Mitochondrial medicine--molecular pathology of
defective oxidative phosphorylation. Ann Clin Lab Sci. 2001 Jan;31(1):25-
67. Review
2. Yamanouchi H, Imataka G. Mitochondrial diseases due to drug toxicity
Nippon Rinsho. 2002 Apr;60 Suppl 4:473-7. Review.
3. Szewczyk A, Wojtczak L. Mitochondria as a pharmacological target.
Pharmacol Rev. 2002 Mar;54(1):101-27. Review.
4. Cormier A, Morin C, Zini R, Tillement JP, Lagrue G. In vitro effects of
nicotine on mitochondrial respiration and superoxide anion generation.
Brain Res. 2001 May 4;900(1):72-9.
5. Berson A, Fau D, Fornacciari R, Degove-Goddard P, Sutton A, Descatoire
V, Haouzi D, Letteron P, Moreau A, Feldmann G, Pessayre D. Mechanisms for
experimental buprenorphine hepatotoxicity: major role of mitochondrial
dysfunction versus metabolic activation. J Hepatol. 2001 Feb;34(2):261-9.
6. Boess F, Ndikum-Moffor FM, Boelsterli UA, Roberts SM. Effects of
cocaine and its oxidative metabolites on mitochondrial respiration and
generation of reactive oxygen species. Biochem Pharmacol. 2000 Sep
1;60(5):615-23.
7. Muscari C, Bastagli L, Ventura C, Bernardi P, Caldarera CM. Reduction
of the rate of mitochondrial respiration in the rat heart perfused with
opioids and naloxone Cardiologia. 1988 Apr;33(4):353-7.
8. Das NP, Ratty AK. Studies on the effects of the narcotic alkaloids,
cocaine, morphine, and codeine on nonenzymatic lipid peroxidation in rat
brain mitochondria. Biochem Med Metab Biol. 1987 Apr;37(2):258-64.
9. Chari-Briton A. Proceedings: Swelling of rat liver mitochondria
induced by delta1-tetrahydrocannabinol. Isr J Med Sci. 1975
Nov;11(11):1189.
10. Bailey SM, Cunningham CC. Contribution of mitochondria to oxidative
stress associated with alcoholic liver disease. Free Radic Biol Med. 2002
Jan 1;32(1):11-6. Review.
11. Cunningham CC, Bailey SM. Ethanol consumption and liver mitochondria
function.
Biol Signals Recept. 2001 May-Aug;10(3-4):271-82. Review
12. Goodlett CR, Horn KH. Mechanisms of alcohol-induced damage to the
developing nervous system.
Alcohol Res Health. 2001;25(3):175-84. Review.
13. Burrows KB, Gudelsky G, Yamamoto BK. Rapid and transient inhibition
of mitochondrial function following methamphetamine or 3,4-
methylenedioxymethamphetamine administration. Eur J Pharmacol. 2000 Jun
9;398(1):11-8.
14. Fiddian-Green RG. Concerns about prescribing antidepressants
bmj.com/cgi/eletters/325/7366/701#25874, 28 Sep 2002
15. Fiddian-Green RG. The real danger is in the mixing?
bmj.com/cgi/eletters/325/7367/736/c#26113, 7 Oct 2002
16. Mansouri A, Gaou I, De Kerguenec C, Amsellem S, Haouzi D, Berson A,
Moreau A, Feldmann G, Letteron P, Pessayre D, Fromenty B. An alcoholic
binge causes massive degradation of hepatic mitochondrial DNA in mice.
Gastroenterology. 1999 Jul;117(1):181-90.
17. Piquet MA, Nogueira V, Devin A, Sibille B, Filippi C, Fontaine E,
Roulet M, Rigoulet M, Leverve XM. Chronic ethanol ingestion increases
efficiency of oxidative phosphorylation in rat liver mitochondria. FEBS
Lett. 2000 Feb 25;468(2-3):239-42.
18. Addolorato G, Capristo E, Greco AV, Caputo F, Stefanini GF,
Gasbarrini G. Three months of abstinence from alcohol normalizes energy
expenditure and substrate oxidation in alcoholics: a longitudinal study.
Am J Gastroenterol. 1998 Dec;93(12):2476-81.
19. Fiddian-Green RG. Gastric intramucosal pH, tissue oxygenation and
acid-base balance. Br J Anaesth. 1995 May;74(5):591-606. Review.
20. Fiddian-Green RG. Monitoring of tissue pH: the critical measurement.
Chest. 1999 Dec;116(6):1839-41.
21. Fiddian-Green RG. Haemodynamic and/or tonometric monitoring in
cardiac surgery.
Br J Anaesth. 2000 Jan;84(1):128.
22. Iatrogenic diseases with a common cause?
Richard G Fiddian-Green
bmj.com/cgi/eletters/325/7370/913#26512, 25 Oct 2002
23. Depression: a metabolic perspective.
Richard G Fiddian-Green
bmj.com/cgi/eletters/325/7370/934#26529, 26 Oct 2002
24. Beta blockers and the risk of neurodegenerative disorders
Richard G Fiddian-Green
bmj.com/cgi/eletters/325/7369/873#26451, 22 Oct 2002
25. Coenzyme Q vs levodopa for Parkinson's
Richard G Fiddian-Green
bmj.com/cgi/eletters/325/7369/851#26420, 21 Oct 2002
26. Headaches and cerebral tissue oxygenation
Richard G Fiddian-Green
bmj.com/cgi/eletters/325/7369/881#26368, 18 Oct 2002
27. Might statins cause Parkinsons?
Richard G Fiddian-Green
bmj.com/cgi/eletters/325/7369/851#26356, 18 Oct 2002
28. Fiddian-Green RG. Iatrogenic diseases with a common cause?
bmj.com, 25 Oct 2002
Competing interests:
None declared
Competing interests: No competing interests
Sir
Surely the more drugs available the better....newer drugs, drugs with
fewer side effects, drugs for fatness, drugs for thinness, drugs for
appetite, drugs for sleep, drugs for energy, drugs for conception, drugs
for contraception, uppers, downers, drugs that cause dependence, drugs to
treat dependence, drugs for constipation, drugs for diarrhoea, where would
we be without them, a pill for every ill?
Perhaps the most unfortunate outcome of our 'drug culture' is that
children can no longer tell the difference between 'good' drugs and 'bad'
drugs, especially when the massively successful 'corporations' -
distributing coffee, chocolate, cola, tobacco, pharmaceuticals, heroin,
cocaine are self-evidently drug-based - show one the road to riches.
What did we do before the institutionalisation of drugs?
Regards
John H.
Competing interests: No competing interests
The earth too is being over-drugged.
In India this is particularly sad since we still have large pools of
native wisdom that tell us how to live in creative equilibrium with the
environment.
Our health policies are fuelling the devastation of the earth and
people alike.
I have documented this in my book, Health Care, Earth Care,
published by Earthcare Books, Mumbai and Kolkatta.
The two major sections are Drugging the Body and Drugging the Earth.
My submission is that we err seriously when we fail to consider
ourselves as an extension of the environment we occupy. This alienation is
the basis of our Conquer-the Earth, Conquer-Disease outlook.
Competing interests: No competing interests
EDITOR- to me the anus is one part of our body where
"medicine's power to harm individual patients and whole
populations"( 1 ) is evident. There is a lot of money to be
made from telling people "haemorrhoids and their symptoms
are on of the most common afflictions in the Western
world".( 2 ) Unfortunately and tragically, patientes
suffering from any symptoms related to the lower bowel and
anus assume all too frequently and often incorrectly that
their symptoms are due to haemorrhoids.
In my proctological
clinic various types of anal dermatitis were found more
frequently than haemorrhoids in patients examined for rectal
bleeding.( 3 ) Additionally doctor's advice for anal
cleansing like "Keep the area clean by washing after every
bowel action and night and morning"( 4 ) or "If you are away
from home or good toilet facilities when you have to pass a
motion ase medicated wipes such as Wet Ones or Baby Wipes"(
4 ) is causing harm to thousands of individual patiens
according to what I see at my proctologic clinic.( 5 ) But
much more important, this advice has never been tested by
randomised controlled trials. Anal dermatitis heals if
patients stop with anal cleansing, and avoid showers,
baths,swims, moist tissue, Sitz baths until healing.( 5 )
Competing interests: No competing interests
Is there really too much medicine? [1] It certainly seems to be a
convenient 'get out' for an overburdened medical service. But who gets to
lose out if services are 'reoriented' (withdrawn)? The 'effort' of medical
care does not only arise from providing the care itself but also from
providing it equitably. Surely there is a fine line between 'resisting the
categorisation of life's problems as medical' [1] and ignoring increased
morbidity in those who are more burdened by life's problems? So if you are
rich you shouldn't be depressed and your depression gets treated. If you
are poor (or old), your depression is a product of your disadvantage - and
of course it would be completely inappropriate to 'medicalise' poverty or
'understandable' unhappiness.
1. Moynihan R, Smith R. Too much medicine? BMJ 2002;324:859-60.
Competing interests: No competing interests
Editor,
At the heart of the current government reforms of the NHS is the
belief that the main problems to be addressed are chronic underfunding and
inconsistent quality of care(i). As society has become more consumerist
and less satisfied by a paternalistic approach, policies of evidence based
medicine, clinical governance, risk management and revalidation of doctors
have been implemented to regain the public’s trust. These reforms however
do not address many of the wider issues regarding the role of medicine in
society discussed in Moynihan and Smith’s editorial in the BMJ(ii).
The danger is that the present political climate is stoking
unattainable public expectations of the ongoing reforms. The general
public needs to be told that medicine has limitations even with proper
funding and a well-trained professional workforce. Many rationing
decisions ultimately rest on difficult ethical debates that the general
population must become fully engaged in. Clinical evidence can help inform
the decision-making process in some cases but has a number of limitations
inherent within it. For example, the structure of trials means it is
difficult to provide conclusive evidence on interventions that are complex
or heterogeneous such as many complementary therapies and some forms of
psychotherapy. With the medicalisation of life, medicine is being drawn
into areas it does not have a right or capacity to adjudicate over.
The present health reforms heavily promote the authority of medicine
as a science that can always provide answers. Whereas in the 16th century
Copernicus’ heliocentric view of astronomy was attacked for being
blasphemous, we now accuse schoolteachers who advocate creationist
theories of being unscientific(iii). To promote medicine as king is to
avoid recognising its limitations. Society needs to face its fear of
mortality and discuss the importance of rights, responsibilities and
equity in the modern NHS.
i Check against delivery [Prime Minister's speech on the NHS]. 2001
Dec 6. Available from: URL: http://www.number-
10.gov.uk/news.asp?NewsId=3233&SectionId=32
ii Moynihan R, Smith R. Too much medicine? BMJ 2002; 324: 859-860
iii McKie R. Bishop warns Blair over danger of creationism. Observer 2002
Apr 7.
Competing interests: No competing interests
26th April 2002
Dear Editor,
I read with interest the editorial ‘Too much medicine?’1, with which
I agree wholeheartedly. However, I believe there is a further dimension to
the problem, and hence to the solution. Another way of looking at it is
that we are trying to make our existence perfect. Indeed any kind of
imperfection – e.g. illness, baldness, infertility, ageing and even death
– is looked upon with embarrassment or disdain. While no-one is prepared
for the unexpected, we have the ability to reflect, seek help
appropriately and then adapt. Unfortunately, post-modern medicine has
strayed from its noble humanitarian origins into the commercial arena of
demand and supply. The medical and pharmaceutical establishments, lay
people and academics all shoulder a part of the blame for perpetuating the
myths of the ‘magic bullet’. No biological system is perfect, and even
less so the current social, commercial or information networks.
The basic needs of food, shelter, clothing (and love) are unchanged,
but are no longer sufficient for happiness and contentment. With affluence
has come greater expectations, with the most well-off seemingly the most
ill, and the poorest people rating their health the highest2. We have
developed ourselves mentally, physically – and some would add morally, too
– but have forgotten our spiritual dimension. We have forgotten how to be
‘mere mortals’, and little can be said about the virtues of self-control,
altruism and humility. While denying responsibility for our health, we
abhor the concept of fate, and have become ungrateful for small mercies.
We have even begun to think that the whole universe revolves around us: in
fact, we are but a lowly life-form, on a speck of dust in the vastness of
the Cosmos.
The authors refer to the works of Illich from the last century as
having clinched the diagnosis. The cure, however, might lie in the wisdom
from religious texts of the last millennium, or earlier. Life’s not fair,
but what will happen after death. There is definitely life after death:
about 6 billion lives, actually, after your death … and what can they look
forward to if you squander precious resources on ‘non-diseases’ ?
Feroz Dinah Specialist Registrar in Orthopaedics
Royal Victoria Hospital, Belfast BT12 6BA
feroz72@hotmail.com
Competing interests: None.
References
1. Moynihan R, Smith R. Too much medicine? BMJ 2002; 324: 859-60 (13
April).
2. Sen A. Health: perception versus observation. BMJ 2002; 324: 860-1 (13
April).
Competing interests: No competing interests
Each issue of BMJ could contain an Illich section wherein
stories, proposals, and other evidences of the theme
qualities championed by Mr. Illich. Your editorial so
lightly passes over the challenges and their meanings it
would be easy to move slightly in one's chair and turn to
the next page.
Nonetheless your direct exposure of the Illich principles
for consideration indicates to me you know and do not turn
away from their biting illuminations. For physicians to hear
time and again reasonable discussion unmasking the
unnecessarily shallow or profoundly unwise aspects of their
everyday activities is to restore a fundamental integrity
within the healthcare dialogue.
Competing interests: No competing interests
Sir,
For those who read French, what humankind is at risk of (at least its
"developed" part) has been perfectly described by Jules Romain in its
wonderful play "Docteur Knock".
Any activity in his rural village progressively becomes second to health
care.
Any medical student should be given a copy of this book on his or her
very first day in a Medical School.
Sincerely
François Mennerat
Competing interests: No competing interests
Re: Too much medicine?
Is there any interest in a patient's point of view? These
medications are more serious to patients than to doctors.
Ten years after single bypass surgery, working with a fourth
different doctor, and on a third different medication for high blood
pressure, my left leg was swollen and covered with a rash once again. The
Home Blood Pressure Monitor showed 90/57. I weaned myself off the calcium
channel blocker without a by-your-leave. BP elevated to 116/64 and
stayed.
A lifelong smoker, absent tests of any kind, my wheezing prompted a
diagnosis of COPD and I was prescribed Flovent, Serevent and Nasonex.
Bone density tests showed osteopoenia prompting a prescription for
Fosamax. And I remained on the daily aspirin.
I was offered Evista. Internet research showed a possible side
effect of deep-seated thrombosis. My mother died of strokes at age 52. I
refused the Evista and decided to carefully research all the
prescriptions. And I found mention of "weakened immune system".
That research led me to a variety of internet sites on nutrition most
of which seem to be based on the writings of Weston A. Price, DDS, who
advocated the Paleolithic Diet after his worldwide research. Suffice it
to say, that over the last six months I've made my own choices among the
suggestions of these doctors and nutritionists, basically giving up most
sugar and grains, eating organic whole fat dairy and eggs and grass-fed
beef. With all the fertilizers and pesticides prevalent in agri-industry
in the United States, fresh fruits and vegetables are questionable and
sparsely eaten. My theory is that frozen fruits and vegetables at least
are not sprayed to remove the enzymes that preserve their fresh look and
destroy all their value. I drink steam-distilled water and ingest
absolutely no transfatty acids.
I've added a variety of vitamins and supplements but avoid herbs
because of my own ignorance.
I have given up all my prescriptions and all the wheezing. I read
also that aspirin promotes wheezing. In fact, research showed that each
prescription I was taking prompted a condition that required a new
prescription. My blood pressure now averages 120/70. A wide variety of
scar tissue begins to fade.
What shall I say to the doctor when I see her next week? It was she
who told me: "You are responsible for your own health. I am just the
consultant."
But what of the worldwide economic uproar if the entire medical
profession relied on the intelligence and common sense of the patients?
Competing interests:
None declared
Competing interests: No competing interests