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Press releases Saturday 28 April 2007

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(1) Over the counter drugs can be highly addictive, warn doctors

(2) Is it worth having surgery to remove your tonsils?

(3) Should the UK adopt Dutch rules on euthanasia in newborn babies?

(4) Major change needed to achieve dignified care for older people

(5) Should menstrual suppression be a lifestyle choice?

(1) Over the counter drugs can be highly addictive, warn doctors
(Letter: Over the counter drugs can be highly addictive)
http://www.bmj.com/cgi/content/full/334/7600/917

Over the counter (OTC) drugs can be highly addictive, warn two doctors in this week±s BMJ.

The development of dependency on OTC drugs is often forgotten, write Drs Chris Ford and Beth Good. Yet, in the past three months, they describe seeing three patients with addictions to Nurofen plus (ibuprofen and codeine phosphate).

All three had started using the product for its approved indications, but their use had escalated as they became tolerant to the codeine element. Each patient presented with side effects related to ibuprofen.

Codeine phosphate is now only available on prescription but has been available over the counter in combination with aspirin, paracetamol, or ibuprofen for many years.

The authors searched the scientific literature, but could find no research into addiction to OTC drugs in the UK. Numerous websites are, however, documenting cases of addiction and offering support to those people trying to withdraw from these drugs, they say.

One website illustrates the most common addiction is to Solpadeine (paracetamol and codeine) and suggest more than 4000 people registered there currently have this problem.

There are no official statistics documenting the extent of dependence on legal non-prescription drugs, say the authors. They call for large scale research to assess and monitor the extent of the problem.

Contact:
Chris Ford, General Practitioner, Lonsdale Medical Centre, London, UK
Email: chrishelen.ford@virgin.net

(2) Is it worth having surgery to remove your tonsils?
(Tonsillectomy versus watchful waiting in recurrent streptococcal pharyngitis in adults: randomised controlled trial)
http://www.bmj.com/cgi/content/full/334/7600/939
(Editorial: Recurrent pharyngo-tonsillitis)
http://www.bmj.com/cgi/content/full/334/7600/909

Adults with recurrent sore throats may benefit from having a tonsillectomy in the short term, but the overall longer term benefit is still unclear, and any benefits have to be balanced against the side effects of the operation, according to this week±s BMJ.

A small study of adults from Finland, published on bmj.com last month, showed that tonsillectomy significantly reduced the likelihood of further infection after 90 days, compared with watchful waiting.

But despite these promising results, an editorial in this week±s journal warns that, until we have more evidence about the longer term benefits of surgery, it is difficult for doctors to provide firm advice to patients.

The main problem with the trial is that the follow-up period was relatively short, and people in the watchful waiting group reported improvement during the trial period, says Paul Little, Professor of Primary Care Research at the University of Southampton. This begs the question of whether the benefit of immediate tonsillectomy would be reduced if the follow-up was longer.

Other factors are the small size of the trial and insufficient data on the severity of infections.

Any benefits of the operation must be balanced against potential disadvantages, he writes. The major disadvantage documented in the trial is the 13 days of sore throat after tonsillectomy, which can be severe in many patients. Other disadvantages include the risks associated with an anaesthetic, earache, dehydration, and dental injures, and a risk of life threatening complications, such as major haemorrhage or sepsis.

Until the longer term outcomes in people who do not have surgery are available, and we have more precise estimates of the benefit in terms of the severity of the episodes prevented by surgery, it is difficult to provide firm evidence to patients, he says.

Until such evidence is available, he would advise patients who have had four episodes of tonsillitis in one year or three in six months that they are likely to have on average two and a half days of sore throat in the next six months if they decide not to have the operation; if they decide to have the operation they are likely to have about 13 days of severe pain immediately after surgery, and then on average half a day of sore throat in the next six months.

He would also make them aware that they might have minor postoperative complications and very rarely life threatening complications.

Contact:
Paul Little, Professor of Primary care Research, University of Southampton, UK
Email: p.little@soton.ac.uk

(3) Should the UK adopt Dutch rules on euthanasia in newborn babies?
(Editorial: Euthanasia in neonates)
http://www.bmj.com/cgi/content/full/334/7600/912

Euthanasia for newborn babies with lethal and disabling conditions is illegal worldwide, but in reality, its acceptance and practice vary between different countries.

An editorial in this week±s BMJ asks should it be available?

In the Netherlands, about 200,000 live births occur annually; of these, 10-20 babies ± mostly with severe congenital malformations ± are thought to be actively killed. Yet between 1997 and 2004 only 22 such deaths were reported to the authorities, writes Kate Costeloe, Professor of Paediatrics at the University of London.

To regulate neonatal euthanasia, clinicians in the Netherlands have argued that all cases should be reported and they have developed guidance which defines criteria that must be fulfilled before euthanasia can be considered. Doctors who follow this guidance are not guaranteed freedom from prosecution, but to date no paediatrician in the Netherlands has been prosecuted.

In UK law, the fetus becomes a legal entity only at the moment of birth. Because of this, the Royal College of Obstetricians and Gynaecologists can recommend that late termination of pregnancy for fetal anomaly should be preceded by feticide, but any clinician who injected a similar severely malformed newborn baby with potassium chloride moments after birth would be guilty of murder.

The report of the Nuffield Council of Bioethics, published after widespread consultation in November 2006, ±unreservedly± rejected the possibility of neonatal euthanasia in the context of UK practice even when life is intolerable.

One of the reasons the UK is resistant to adopting the Dutch recommendations is that active killing as a therapeutic option is seen as a ±slippery slope± towards its wider use, she says, although some reject this argument.

Another reason is the fear that active killing may have a negative impact on the psychology of professional staff, and that parents may feel pressured to accept the option of euthanasia so that they do not become a burden on medical and social services.

Acts by neonatologists in the UK undertaken with the purpose of ending life seem to be rare, and guidance provided by the Royal College of Paediatrics and Child Health around end of life decisions has provided a framework within which UK neonatologists feel comfortable.

The availability of active euthanasia as a therapeutic option would undermine this progress and be a step backwards, she says.

However, we must look at how to provide for babies who might be candidates for euthanasia elsewhere in the world. Sadly, too often, parents have to battle for essential services that ensure the best outcome for their disabled child, and that also make their own lives more tolerable, she concludes.

Contact:
Kate Costeloe, Professor of Paediatrics, Barts and the London, Queen Mary±s School of Medicine and Dentistry, University of London, UK
Email: k.l.costeloe@qmul.ac.uk

(4) Major change needed to achieve dignified care for older people
(Editorial: Health and welfare of older people in care)
http://www.bmj.com/cgi/content/full/334/7600/913

A radical change in culture and practice is needed to achieve dignified care for older people, says an editorial in this week±s BMJ.

The welfare of older people who live in care homes has raised concern for decades in many countries, write Marion McMurdo and Miles Witham at the University of Dundee.

Of course, both illness and dependency pose threats to dignity, but people of all ages have a fundamental right to be respected. So why is dignified respectful care for older people still lacking, and what might restore it, they ask?

Legislation, regulation and standard setting are widespread in the health and care home sectors, and more of the same seems unlikely to alter attitudes and prejudices. There is a current vogue to appoint champions and commissioners for older people, but what is needed, they say, are not just individual advocates but rather a long overdue and major change in culture and practice to reflect the central position of older people in systems of care.

How might this be achieved in care homes?

Firstly, we need to stop blaming individual practitioners and care homes, they say. A whole systems approach is much more likely to succeed; for example, changing infrastructure, procedures, management techniques, and staff training. Frontline care staff should not be made scapegoats; instead, their dignity should also be assured, they write.

Secondly, access to good quality medical care should be readily available. They believe that primary care teams need to be supported by secondary care specialists and should be given time, money, incentives, and training in comprehensive geriatric assessment.

Older people have an important part to play too. When older people become politically organised they are a large and formidable force that has real power to campaign for change.

They suggest that older people need to demand that carers are paid a decent wage and are well trained, that managers are responsive to their needs, that buildings are fit for purpose, and that vulnerable older people are not denied the expert health care that they are entitled to.

All of this costs money, and those of us in affluent countries need to pay more to ensure that care for older people is of a standard that we ourselves would be happy to receive, they conclude.

Contact:
Miles Witham, Clinical Lecturer, Ageing and Health, Division of Medicine and Therapeutics, Ninewells Hospital and Medical School, University of Dundee, Scotland
Email: m.witham@dundee.ac.uk

Menstrual suppression has been recommended for medical conditions such as endometriosis, but it is also being proposed as a lifestyle choice for women who dislike menstruation or find it inconvenient.

But is menstrual suppression safe and is it a reasonable lifestyle choice, asks Paula Derry, a Health Psychologist in this week±s BMJ?

Birth control options that reduce or eliminate periods are being developed, she writes. The oral contraceptive Seasonale, for example, combines 84 days of active pills with seven days of placebo, reducing the number of pill-induced periods from 13 to four annually.

Seasonale has been approved by the US Food and Drug Administration, but long term research was not required for approval and the long term safety of menstrual suppression remains uncertain, she warns.

Some proponents have argued that menstrual suppression is safe, even beneficial, because monthly menstruation is unnecessary, even unhealthy. They believe that monthly menstruation throughout adulthood is a modern development and is at odds with what female bodies were designed to do.

But if it is more common today to have monthly menstrual cycles throughout adult life, this does not in itself mean that monthly menstruation is unnatural, much less that it is a medical problem, argues Derry. In this case, as in so many others, a wide range of situations may be ±normal.±

Further, why women menstruate is unknown. We do know that a menstruating woman is a healthy, probably fertile, woman, while unhealthy, malnourished, or massively stressed women are more likely to skip periods.

Even if prolonged monthly menstruation were unnatural and unhealthy, this would not prove that suppressing menstruation is better, she adds. Menstrual suppression itself is unnatural; a drug chronically overrides the physiological changes associated with the menstrual cycle, thereby creating an underlying hormonal environment that is not found in nature.

The argument that menstruation is obsolete is illogical and unscientific, she says.

The important questions are these: is there evidence that medications are safe and effective? what are the known benefits and risks, and what uncertainties exist with regard to future benefit and harm? who should be using such medications? are women provided with accurate information to make informed choices?

Contact:
Paula Derry, Health Psychologist, Baltimore, Maryland, USA
Email: pderry@bcpl.net

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