Wednesday, 30 June 2010

Grannies and druggies.

If you look at the title you might think what the hell are we at ND Central thinking of?

Well at first sight the link is not evident but if you bear with us it may become apparent.

The link is drugs. Now because your first thought will be grannies and druggies no way man. But stick with us for it is very yes, way man.

Let us go back a few decades when a group of drugs called benzodiazepines (or benzos in current street speak) were marketed.

These were prescribed as sleeping tablets or “anxiolytics” to relieve anxiety but rapidly became recognized as being “addictive”.

Some of the team recall how they as junior doctors were told to prescribe Temazepam as a sleeping drug and Paracetamol as a painkiller for all inpatients to avoid being called up at 02.00 because a patient could not sleep or had a headache.

The bible of UK prescribing, the British National Formulary (BNF), back a quarter of a century ago said these were addictive and advised short term prescribing only.

Sleep deprivation is a powerful tool and after a couple of nights without sleep and being told prescribe or else you won’t sleep most junior grunts succumb to the sleep deprivation avoidance method of prescribing the above drugs to every patient they admitted.

Remember our seniors, tucked up in bed, told us only prescribe for the condition required not in advance for that is bad medicine. Right.

Not a problem until the patient was discharged and the doctor doing the discharge wrote automatically, without checking preadmission drugs, why the drug had been prescribed in the first place and was it still required post discharge?

Again sleep deprivation led these doctors to ignore these basic checks. If a patient on no previous pre admission drugs had come in and been prescribed these drugs on discharge it was house officer induced not necessarily therapeutically indicated.

As a result some people may have become addicted to benzos as a result of a short stay in hospitals. A larger number we suspect as a result of GP ignorance and incompetence over several decades. These patients are often now pensioners who have been on these drugs for years and are resistant to any change especially stopping them.

Even if you as a GP do try and stop these drugs it is very time consuming and you will encounter a lot of opposition from these older druggies. Often the approach is to let nature and time eventually eliminate the problem passively although this is not good prescribing.

A case a few years ago highlighted this and how quickly a drug, which should at the time it was initially prescribed only have been used short term, became used long term.

So let any GP without any patients on benzos be the first to cast a stone at our assertions above.

Things have got worse due to the explosion in opiate misuse.

There is a cascade of what drug addicts will use to avoid heroin withdrawal.

The gold standard for a heroin misuser is heroin which is an opiate. If you can’t get this then other less strong opiates will do for example Dihydrocodeine (DF 118) as a stop gap which can sometimes be bought off old grannies to top up their pensions as they pay not for their prescriptions especially if they have alleged chronic back pain. They can just re order if they do have back pain they are less suspect.

If that does not work then benzos can help addicts sleep when they are withdrawing but hey they need huge doses. So an elderly aunt on long term benzos loses the odd prescription and almost every request for a lost prescription is for a drug of abuse.

One of the strengths of general practice is that staff come to know family relationships. So if a granny Wilma starts losing benzo prescriptions this could be forgetfulness but if grandson Wayne is a known user then this can be nipped in the bud.

The lost prescription ploy usually goes along the lines of (but there are many sub variations):

I put the Crown Jewels and the whole of the Bank of England’s gold reserves into a locked box in an armed convoy on my way to my holiday at Aberystwyth and despite no interruptions when I arrived the Crown Jewels and the whole of the Bank of England’s gold reserves were there but my month’s prescription of benzos were not.

Can I have another a prescription?

All that security and teleportation too? Have we missed something here? Why do we never get requests to replace the paracetamol tablets that were prescribed at the same time and were in the same locked box as the benzos?

Benzos are also currency in that they can be converted into cash but selling them onto other addicts which can then be used to buy harder drugs. So an addict who gets a months worth of benzos, from a dodgy GP say 120 tablets worth £2 a shot on the street, could get a little Brucie benzo bonus of £240 a prescription and then if they “lose” it and blag another prescription, another £240 + benefit.

Which brings us to the Z-drugs (Zopiclone being the principle one). Once again alleged non addictive drugs are now currency and are frequently lost more often than the Crown Jewels despite their users air tight security systems detailed above.

This may sound a bit funny but in general practice these prescriptions and their loss creates a large amount of hassle. For we are basically dealing with liars and drug addicts at both ends of the age spectrum who feel that society owes them something for nothing.

While the younger addicts are using benzos and Z-drugs for different reasons the behaviour we see from both groups to get these drugs is the same. Both groups lie, cheat and deceive and, although the older ones do not usually resort to physical threats and violence that the younger misusers do, they are both as bad as each other.

A medical commentator a while back said something along the lines of what would happen if they bought a plasma TV and Blue ray recorder in the morning and went home with their “gear” and then “lost” their purchases?

If they went back in the afternoon to the shop and said they had put it in their car and they had disappeared by the time they got home could they, at no expense to themselves, get a replacement for their loss?

What do you think? Can you see the link between druggies and grannies now?

Praise be to the Party for the NHS and “free” drugs for those who abuse them. Unless you work and have to pay for your goods you do not realize how much free prescriptions for some cost those who work in general practice.

The costs to the rest of society are merely criminal.


Anonymous said...

'the Party' caused benzodiazepine addiction and irresponsible prescribing? All the relevant patients got free prescriptions? a 10 quid per item prescription charge would make selling the drug not worthwhile?

A New Kind of GP said...
This post reminds me of the film "Twin Town" set in Swansea, and a great scene set in a car on derelict land under a flyover, with two grannies in the back trying to trade their Temazepams for magic mushrooms.....

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Paddlemaster said...

Thanks for this post. My mother is one of the granny addicts and I've been banging my head against the wall trying to convince some one there may be a problem. Her neighbour is possibly a 60+ pusher. I glad I'm not alone anymore!

Please keep fighting!