A bad week for mediparactors wishing to prescribe.

August 13, 2010
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Picturefg1 Things have been so bad with the BCA/GCC alliance  lately, I may have lost sight of the bigger picture and why I would always choose a skilled adjustment before drugs and certainly drugs prescribed by a medipractor. Thanks to  the comment by “le saucisson chocolat” for getting me back on track.

 Skeptic Andy Lewis refers to this  tactic as a “quack trick” called  “whataboutery”. Apparently we use this to divert attention from chiropractic, I have offered to take any challenge the skeptics care to put in front of me and after a year they have failed to produce anything.

Revealed: NHS fails to curb lethal painkiller errors

guardian.co.uk, Thursday 12 August 2010

Exclusive: 1,300 dosage mistakes leave three dead as research finds patient safety directives not being met

Study finds higher asthma risk among adolescents taking paracetamol

Taking a common over-the-counter painkiller may increase the risk of asthma and related conditions in young people, reports a new study. Researchers found that 13- and 14-year-olds who took paracetamol as little as once a month were 2.5 times more likely to have asthma symptoms than those who didn’t take it.

Common Painkillers Raise Heart Death Risk

Ibuprofen Increases Stroke Risk; Diclofenac as Risky as Vioxx, Study Finds

By Daniel J. DeNoon
WebMD Health News

June 8, 2010 — High doses of common painkillers raise the risk of heart death in healthy people, a huge Danish study finds.

It’s the first evidence that so-called NSAID (nonsteroidal anti-inflammatory drug) pain relievers — including some sold over the counter — increase the risk of heart disease and death in people without underlying health conditions.

The risks are dose related and are mostly associated with high doses of the drug. However, for most of the drugs, the deaths occurred in people who had been taking the drugs for only two weeks.

"We found that most NSAIDs are associated with increased cardiovascular mortality and morbidity," says researcher Emil Loldrup Fosbol, MD, of Gentofte University Hospital in Hellerup, Denmark.

The study’s most disturbing finding: Diclofenac (brand names include Cataflam, Voltaren) is as risky as the now-banned Vioxx. Both diclofenac and Vioxx nearly doubled the risk of death from heart disease among healthy people in the Fosbol study.

Although diclofenac is available in the U.S. only by prescription, it’s sold over the counter in many nations.

Ibuprofen Heart Risk

Perhaps of concern to more Americans is the finding that ibuprofen (brand names include Advil and Motrin) increased risk of stroke by about 30% in the Fosbol study.

Although low doses of ibuprofen seemed to lower the risk of heart attack, the study found a trend toward increased heart attack risk with high doses (more than 1,200 milligrams per day or more than two 200 milligram pills three times daily).

Based on other evidence, an American Heart Association panel in 2007 warned that treating chronic pain with NSAIDs other than aspirin increases a person’s risk of heart attack and stroke. The lead author of that AHA statement, Elliot M. Antman of Harvard Medical School and Brigham and Women’s Hospital, says the Fosbol findings underscore the importance of those recommendations.

"Doses examined in this new study were very similar to doses that patients are likely to encounter both at the over-the-counter level and the prescription level," Antman says in a news release.

The silver lining to the Fosbol study is that naproxen (brand names include Aleve and Naprosyn) does not appear to carry any risk of heart disease or stroke.

However, all NSAIDS, including naproxen, increase the risk of potentially fatal bleeding.

Previous studies of NSAID risk examined people with underlying health conditions. The Fosbol study differs. Because detailed medical records are available for everyone in Denmark, the researchers were able to study NSAID risk in more than a million healthy people from 1997 to 2005.

Although NSAIDs increased the risk of death from heart disease, the risk was small. Among the 1,028,437 people who took NSAIDs, there were 769 deaths from heart disease and stroke

Even so, the finding that NSAIDs increase heart risk in relatively healthy people is important, says Howard S. Weintraub, MD, clinical director of the NYU Langone Center for the Prevention of Cardiovascular Disease.

"This could have far-reaching implications, as many individuals rely on these drugs for pain relief," Weintraub says in a news release. "It is likely that sporadic, non-sustained use of NSAIDs in low doses for pain relief will remain safe, while more chronic use of higher doses may have to be questioned."

What about people already taking NSAIDs for chronic pain?

"For patients regularly taking an NSAID now — whether it’s prescription or OTC — it is advisable to discuss with your physician why it was originally recommended or prescribed, whether you need to continue taking it, and at what dose," Antman says.

The Fosbol study appears in the June 8 online edition of the AHA journal Circulation: Cardiovascular Quality and Outcomes.

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Related posts:

  1. Increased risk of heart attack posed by use of NSAIDS
  2. British Chiropractic Association asks the General Chiropractic Council to seek prescribing rights for its members

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  • http://www.chiropractorswarwick.co.uk Stefaan Vossen

    Hi Eugene,
    Your statements make a lot of sense to me, in particular about easing the burden on GP’s. That would also tally well with the GP’s relative dislike for orthopaedic conditions. I also think chiropractors are very well equipped to become something along the lines of “biomechanical GP’s”, or a centre for all things moving and hurting in the neuro-musculo-skeletal framework. I, for example, have developed great interest for gait and occlusal mechanics because I see their relevance to chiropractic practice to be significant.
    I do think however that we are debating this point (prescription rights) because of variations in practice experiences and successes, rather than belief systems. The point being that the variation you seem to be reflecting here is slightly removed from what most chiropractors here are primarily concerned with in their day-to-day. Of course these day-to-day practice concerns are reflections of our belief systems, so therefore you do have a valid point, in my view.
    So, let’s assume we accept that we all practice in slightly different ways because of the varying beliefs we all have. We have differing beliefs about success, about clinical context, about purpose, about who we are and what we are meant to be as chiropractors. Professions naturally embrace such variations around a common theme. A theme with which they define the core values of their identity. One of the core values of chiropractic is that it does not use drugs or surgery to help patients. Rightly or wrongly, this is one of the core values of chiropractic, recognised nationally and internationally. Is that good enough reason to just accept it as blind faith? Of courtse not, and this is why I think that it is a very important discussion to have.
    But why is it a core value of chiropractic not to use drugs or surgery? i.e. is this core value actually coherent with the theme? And vice-versa. And what is the theme?
    Many people I have encountered over the years, particularly in the what I would call “nutty” section of the profession (every profession has one so don’t get excited, sceptics) felt that it was a tenet or value that reflected chiropractic’s “dislike” for conventional medicine, represented by drugs and surgery. Medicine is “evil”, “what the doctors don’t tell you”, and “Big Pharma”.
    It was no longer about trying to do the job by enabling your own ability to heal. It was no longer about finding and disabling root cause of what caused you inborn ability to heal to not be able to do the job. It became economical, it became political.
    Because, you see, by saying ” I do things without drugs or surgery”, I always took that to mean “I only treat people who can get better without drugs or surgery”. Those who can’t, I don’t. It never was about rejecting conventional therapies, just adding to teh spectrum. To me, it always meant “knowing my limitations, my realm”. It meant finding the reason for being unable to heal, it meant being strict and disciplined about causation and limits. It meant knowing when to refer to peple who had tools to deal with the problems these people were faced with. That is what I took to be the chiropractic “theme”. The subluxation concept is just another “core value” to the theme. I never took it to be a restricted motion segment, but rather any cause of abnormal posture and functional movement pattern. Hence why my interest in gait and occlusion along with manipulative therapies.
    Cortisone injection and pain meds are great, no one is argueing that… But thing is; cortisone and pain meds do not align with the chiropractic theme. They seek to by-pass a clinical reality by disengaging pain and inflammatory protocols that have evolved over the eons of natural selection. Not that this is a problem, just an observation.
    You use the word “belief” and possibly my fault, I read some sense of condescendence in that choice of words. A “belief” would be appropriate if there wasn’t an overwhelming amount of evidence to support the notion of getting to cause to treat symptom.
    But you’re not really talking about the “belief”, you’re talking about “wouldn’t it be nice if we could”.

    I could,… but I don’t want to.

    Because the risks it poses to my identity (as perceived and understood by the public and myself) are too grave and the losses incurred are too significant.
    Unless you are able to guarantee that prescribing is no threat to the chiropractic theme I will vote against. Because I care more about the chiropractic theme and what it will bring to society once fully understood than I care about those who wish to be all to all men.

    Kidn regards,
    Stefaan

  • Eugene Pearce

    Thanks Rod, you are of course wrong to disagree with me :)

    Honestly I gave up on subluxation theory. I dont really know what Subluxation is meant to be. Nothing in my training or clinical experience has convinced me that localised lack or abberent motion in the spine affects homeostasis (innate) casuing dis-ease. Dis-ease what is that meant to mean any way. Discomfort, pain, disease? its all so abiguous. I accept “it” causes pain and discomfort both locally and away from the site.

    Look at the research:

    Poor interexaminer reliabilty with motion palpation (unless patient gives feedback then its better) cant be bothered to google studies but you can check or trust me if you like.

    Stuart McGill demonstrated both osteopaths and chiropractors had a 1 in 5 chance of hitting the right level when the adjusting lumbar spine, and that when we adjust the spine cavitates from the bottom up or the top down.

    So we have poor interexminer reliabilty finding “it” and pure chance if we correct “it”, unless we are deliberately less specific and adjust multiple levels. Perhaps “it” doesnt exist and the procedure of spinal manupulation has an intrinsic effect on a joint that reduces pain. Bu**%^red if I know. I am easily swayed by more plausible explanations.

    Patients dont care how manipulation works, just that they are in less pain and are less stiff afterwards. How many of your paitients have asked you how exactly did the Ibuprofen work?

    As far as respecting boundaries are concerned chiropractors have treated “medical” complaints for years, it hasnt bothered us before! I am talking about easing the burden on GP’s for relatively trivial (for a GP) minor short term prescribing for pain releif.

    As far as I need to check up to what I signed up to, I checked Chiropractic is not a religeon, so we should not be based on belief its disengenuous to our patients. Personally, I signed up to a young healthcare profession that appeared to be rather good at back pain. If we stick to our definition we will never change. Imagine if medicine had not changed…. yes leaches still work all hail the leaches. If hypothetically subluxation is conclusively disproved (pretty bloody unlikely because we keep changing its meaning) does that mean you will all retire?

  • rod macmillan

    Hi all

    Thanks to Eugene for his contributions, I do not agree with him, he is however one of the few that uses his own name.

  • http://www.chiropractorswarwick.co.uk Stefaan Vossen

    Respecting inter-professional boundaries… Accepting your own playing field.

    Eugene, could I have some thoughts on what you understand subluxation theory to be?
    Stefaan

  • Paul

    No supporting evidence for the subluxation after 115 years – sorry Eugene you are showing both bias and ignorance here.

    I would have expected this from a skepdick not from a chiropractor.

    Why not ask the SCA what papers the GCC were shown that changed their minds?

    Why would you want to change a whole profession and its ethos so you can prescribe drugs to your two or three patients a month?

    Many patients ask me about OTC drugs and my reply is respectful telling them to ask their pharmacist.

    I don’t mean to be rude but you have again undercut your argument with informing us of how little one has to do to gain prescribing rights (limited as they might be) and it sounds untrained and unprofessional.

  • Eugene Pearce

    Firstly in answer to Paul I am not trying to denegrate the Chiropractic profession. But if what I signed up to is to have an unquestioning belief in Subluxation for which after 115 years we have no supporting evidence, and that is the only model I can use because I am a chiropractor, it is stupid. And would I really hire a Doctor or Nurse pratitioner for the 1 or 2 patients an month that might benefit from prescribing / cortisone injection.

    Secondly dear Stefaan acute severe spasms, and neurogenic pain patients will travel with these conditions and they dont respond to Ibuprofen. As for the economics not stacking up, if you choose not to prescribe there is no increase in insurace, then it is not your problem but why take away my choice? As for the training for Chiro’s who prescribe there would proably be increased CPD hours for those who choose to prescribe, which will put most off but some would like the option. As for the training I am talking about tailoring the existing pharmacology segment of the course to something actually clinically useful, and recognised. You will be surprised to hear for limited independent prescribing the addtional training required by the DOH is only a matter of weeks!

    Of course if a patient is non responsive I may have underestimated matters, but if you have been in practice more than a few months you will realise some conditions dont respond predictably to manual therapy, shoulder impingement, adhesive capsulitis are 2 prime examples. I advise patients of this. I also tell them Cortisone may be useful if it fails to respond and the side effects of a cortisone injection. If I can then povide the injection, rather than the GP and then the follow up therapy why should you care. You dont have to do it.

    So it is the case if you can buy it in the health food shop it is “Chiropractically OK” but if its prescribed I am destroying the profession.

  • http://www.chiropractorswarwick.co.uk Stefaan Vossen

    @Eugene
    “to ignore the use of pain meds is absolute stupidity, suggested by stupid people who would rather their patients suffered because of their own beliefs”
    I would say I am taking exception to your comment, but I am not… as no-one here even remotely suggested that pain meds should be ignored. You do however seem to mix up issues here as “ignoring pain meds” is not part of the “belief”-system that is being protected here. Proper chiropractic is not about denying the use of pain meds or any pharmacopoeia for that matter. It is about critically assessing what you, as a chiropractor by choice, have signed up to be, and thoughtfully recognise your place in the clinical landscape of the patient. The other thing I hear in the comments made on this site is a call to recognise the risk/effort vs gain-balance. You seem (and please do correct me if I am misunderstanding your proposal) to suggest further education in pharmacology, increasing academic and cpd hours, increasing insurance costs and risks (what are the risks associated to NSAIDS again?)to the patient, in order to help the occasional patient flying in from the outer Hebrides/ And not just any patient! Only those patients who are flying in from the outer Hebrides AND don’t have ibuprofen in their handbag…
    I think you’re seeing where I am going with this. It may be true, dear Eugene, that it would be nice for the occasional patient for us to have access to certain drugs, but quite frankly the economy of your suggestion does not seem to stack up in my clinical experience.
    If a patient were to come in and have some inflammation on say an SI joint or discal tear,… and the TESCO 24hrs around the corner is closed why not offer some of your receptionist’s private stash?
    As a last suggestion: if it’s really that bad that the patient can’t travel,… how do they get into your office? And if the patient is non-responsive then it will be because you missed something or underestimated matters. No shame in that, it happens to us all. But then,… your patient becomes someone else’s…
    Kind regards,
    Stefaan

  • Paul

    Eugene – smoke and mirrors.

    Limitation of scope comes with specialist training otherwise why not train the students in architecture in case they need to design and build their own clinic?

    No one is saying that patients shouldn’t be able to avail of medication but this isn’t your job. What you need to be is a real chiropractor to your community and as a practice manager realising the needs of you community hiring a nurse practitioner, or better still a doctor.

    There are two professions presently under the umbrella title of chiropractor in the UK you are right, but to describe both as chiropractic is a disingenuous misnomer which you then use to denigrate the chiropractic profession.

    I would suggest you consider retraining or undertaking medical training (as is your choice) to add as you wish to your arsenal treating pain instead of destroying the nature of a profession which has much to add to the world without drugs.

    What you’ll be asking for next is the right to do minor surgery (and incorporate it into the day to day practice of chiropractic) since you’re up there and no one else is around – what twaddle.

  • Eugene Pearce

    No one has to prescribe. The idea is to have a medically recognised level of training in pharmacology, (and we ahould also have this for radiology radiography), that would be generally accepted by the medical professions. Our training in pharmacology is to a totally arbitrary level. We need to have the recognised authority to suggest to GP a statin may be causing weakness or pain. Also if a patient is in absolute agony offer them short term releif from their pain. Is it humane no to have someone in agony have to drive, park, and walk to a pharmacy to get OTC meds. I am in the far north of Scotland today I have patient flying in from the outerhebrides. If she is exceptionally acute too sore to get on off bench it would be great to be able to offer something onsite, in conjunction with treatment. Also if treatment isnt helping cortisone can be useful. We should be striving to help our patients however we can, not striving to limit our scope, and its so sad when I see a student trying to limit their scope before even being in practice. We deal with pain every day to ignore the use of pain meds is absolute stupidity, suggested by stupid people who would rather their patients suffered because of their own beliefs. We can only go with the best evidence at any given time. I had a patient able to go on holiday with an arthritic hip because of NSAID’s maybe she should have stayed here and been seen 3 times a week, I would have been a little better off, and her hip and back would have been a bit more comfortable for a while…true humanity. Would you take your car to a mechanic who only used hammers? And I do agree we very much have 2 professions on our hands. Traditional Chiropractors, and Chiropractic Physicians might be less contentious than medical manipulators, but if chiropractic continues to be a prescientific dinosaur medical manipulator is fine too.

    Kind regards

    Eugene

  • Amit Patel

    When are the results for the Vote of No Confidence being released….? Anyone know? My local MP is very intrested in the outcome……….

  • http://spinaljoint.com Richard Lanigan

    I am sure they know, I could list all the “chiropractic activists” I have contacted in recent years who say they are behind me, (so far behind me you can not see them for miles) but whats the point antagagonising them as well. I have asked to join the UCA so I could be part of this new alliance??

    I have no agenda, I just want people to be honest and treat my colleagues fairly.

  • Paul

    “Richard Brown has some position in the ECU where they are recommending the GCC code of practice be implemented in all ECU member states…. I was wondering what the Spanish association has to say about these developments.”

    My guess is that they don’t know.

  • http://spinaljoint.com Richard Lanigan

    Richard Brown has some position in the ECU where they are recommending the GCC code of practice be implemented in all ECU member states. I asked the ECU president three time to comment on the WFC position paper on prescribing and the the fact the Swiss were prescribing and the BCA and some unnamed associations would follow their example.

    If chiropractors continue to allow these people, to decide their future they get what they deserve. I was wondering what the Spanish association has to say about these developments.

  • Paul

    The Swiss Association should be turfed out of the ECU. They are no longer chiropractors but medical manipulators, with little or no difference between physios bar their manipulative skills.

    Will The BCA ever have the balls to come and ask for their members approve their new name?

    British Medical Manipulation Association and include physios and doctors who use or prescribe medical manipulation?

    Come on Richard Brown show some courage instead of being a second rate predicitable political shambles.

  • http://spinaljoint.com Richard Lanigan

    The people who run the profession are preparing the ground for prescriping. I have communicated with the president of the ECU and he wont be drawn on prescribing which Swiss chiropractors have been doing for 15 years http://www.chiroaccess.com/News/Swiss-Chiropractors-Favor-Prescription-Rights.aspx?id=0000178

    Bottom line is that it is wrong for GCC to pretend that all chiropractors practice in the same manner, this pretence undermines the whole concept of “consent to treatment”. There are two seperate and distinct professions of chiropractic and the sooner chiropractors come out and explain the difference the better for everyone

  • Notthereyet

    As a student I have to keep my head down. But I feel prescribing rights for chiropractors is a seriously bad move. Just because Physios have the prescribing rights does not mean we need the same to compete.

    And, if we are planning on competing directly with physiotherapy, I fear that will be the end of chiropractic in the uk. 2000 or so chiros will get swallowed up and subsumed by the 20,000 physios.

    Just because someone else has all the new toys does not mean they actually need them or that they actually benefit the patient.

    This is certainly not what I signed up for and am still working my bits off to achieve. I could have gone to Nottingham Physio school, been paid a bursary and been done and finished training by now.

    How tough is that Australian Board exam?

  • http://www.chiropractorswarwick.co.uk Stefaan Vossen

    Man on a mission! I don’t know, but I have the feeling that something is hanging in the air…
    Kind regards,
    Stefaan

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