Submission on PE01651: Prescribed drug dependence and withdrawal Made by Dr Peter J Gordon Date of submission: 3rd June 2017. Submission made in a personal capacity.
I am writing in support of this petition. I am an NHS Consultant Psychiatrist who has worked in this specialty in Scotland for almost 25 years now. My wife has worked as a General Practitioner in Scotland over the same period. I have an interest in ethics, human rights and the medical humanities generally. One of the areas I have taken much interest in is informed consent.
I would argue that this backdrop may mean that I can add some thoughts and reflections that might help the Committee in the consideration of this particular petition.
I should make it clear that as an NHS psychiatrist I do prescribe antidepressants and other psychotropic medications. I try to do so following the best available evidence as considered as relevant or not to my professional understanding of each unique patient and their life circumstances.
I wish to keep this summary short as I am aware that the Committee receives a great deal of evidence. So I offer a few points of evidence that I would be willing at a future date to expand upon if that were felt to be helpful:
• Antidepressant prescribing In Scotland (ISD figures) has been rising year-on-year in Scotland for at least the last ten years (this is also true of all other prescribed psychotropic medications). It is estimated that 1 in 7 Scots are now taking antidepressants and many of these in the long-term.
• At a recent Parliamentary Cross Party Meeting on Mental Health and older adults an invited speaker stated that: “depression is under-recognised across all age groups” and that “maintenance treatment has a good risk-benefit ratio.”
• A key opinion leader and Government advisor has previously argued that prescribing of antidepressants in Scotland is “conservative” and “appropriate”.
• Many of the key opinion leaders “educating” doctors prescribing antidepressants in Scotland appear to have significant financial interests with the makers of these medications. Across the UK, £340 million was paid by the pharmaceutical industry in the last recorded year to healthcare workers and academics for such “promotional activities”.
• “Informed Consent” will not be possible if the information that doctors base prescribing on follows such promotion rather than independent, and more objective, continuing medical education. This issue is now at the fore of the Mesh Inquiry.
A few questions that need to be considered:
- When patients are prescribed antidepressants are they informed that as many as 1 in 2 will be taking antidepressants long-term?
- Are patients informed that there may be a significant risk of pharmacological dependence on antidepressants?
- Do patients know that their experience of antidepressants may be considered less valid than the experts (who may have been paid by the pharmaceutical industry) who educate other doctors (who may be unaware of this potential financial bias)?
My view is that antidepressants are over-prescribed in Scotland.
My view is that patients have not been properly informed of benefits and risks.
My view is that appropriate prescribing has not been realised due to a number of factors: the lack of access to psychological therapies or other meaningful supports; the wide promotion of antidepressants where marketing is routinely conflated with education; and a culture of increasing medicalisation generally.
I would suggest that this petition might be considered in light of the Chief Medical Officer’s Realistic Medicine campaign. It is time for balance to be re-established between “medical paternalism” and the valued, vital and real-world experiences of patients who are taking medications like antidepressants. I am particularly disappointed in my own College, the Royal College of Psychiatrists for not making greater effort to facilitate such balance. Without such, I fear more harm will result from inappropriate and costly prescribing in NHS Scotland.
Finally, due to widespread “off-label” promotion of antidepressants in Scotland, patients may experience withdrawal syndromes which can be most severe and precipitate mental states far more serious than the mental state for which they may have originally been prescribed.
I would urge the committee to consider this petition most carefully and to seek balance in their appreciation of where expertise rests.
Submission on PE1517 on Polypropylene Mesh Medical Devices Made by Dr Peter J Gordon Date of submission: 17th May 2017 Submission made in a personal capacity.
The Agenda for the Public Petitions Committee meeting of the 18th May 2017 includes a most helpful summary “Note by the Clerk” on PE1517: Polypropylene Mesh Medical Devices (Document PPC/S5/17/10/1). Having read this carefully, and in accordance with the first suggested “Action” (point 45, page 8), I would like to offer evidence. Before doing so I have listed below the most relevant sections of PPC/S5/17/10/1 in relation to the points of evidence that I wish to make.
In Annexe B of PPC/S5/17/10/1 the Interim and Final Conclusions of the Independent Review are listed side-by-side.
Conclusion 1, both Interim and Final, was that “Robust clinical governance must surround treatment”
Conclusion 3, both Interim and Final, was that “Informed consent is a fundamental principle underlying all healthcare”
In Annexe C: Parliamentary Action (page 21 of PPC/S5/17/10/1) the Cabinet Minister for Health, Shona Robison answered question S5W-07749 by Neil Findlay, MSP on the 17 March 2017, by stating:
“Informed consent and shared decision making are expected prior to any procedure being carried out. The Chief Medical Officer goes into this in more detail in her Realistic Medicine report.”
The Clerk, in point 7, (page 2 of PPC/S5/17/10/1) confirms that:
“The Scottish Government does not have the power to regulate what medical devices are licensed for use in the UK. The Medicines and Healthcare products Regulatory Agency (MHRA) regulates medical devices in the UK”
The Clerk, in point 12 (page 3 of PPC/S5/17/10/1) includes quotations from the Preface of the Review’s Independent Report:
“We found some concerning features about how new techniques are introduced into routine practice” and that
“We are aware that some of our conclusions have wider implications and see the need to embed this in patient Safety and Clinical Governance strands of the NHS”
Points of Evidence by Dr Peter J Gordon (GMC number 3468861) • HDL62: the Scottish Government has acknowledged that this Guidance is not being followed by NHS Boards • There have been media reports that NHS professionals working in Scotland, who are involved in educating NHS staff about Mesh procedures, have been paid by commercial sectors who have financial interest in Mesh products. • PE1493, A Sunshine Act for Scotland, was closed in February 2016 • A Public Consultation on PE1493 was undertaken by the Scottish Health Council. The Scottish public, in majority, were of the view that it should be mandatory for all financial payments made to healthcare workers and academics to be declared in a publically accessible form • No meaningful update has been provided by the Scottish Government since this Public Consultation was published more than a year ago. • I fully support the Chief Medical Officer’s “Realistic Medicine” initiative and I have suggested that Sunshine legislation should be considered an essential part of this development • I agree with the Independent Review that “robust clinical governance must surround treatment”. I am concerned that if the current situation continues, where “education” of health professionals may be significantly based on marketing, further examples of iatrogenic harm may occur in NHS Scotland. • The Independent Review concluded that “informed consent is a fundamental principle underlying all healthcare”. If the advice given to patients is based on marketing, either partially or wholly, then informed consent may be denied patients. Further examples of Iatrogenic harm may then unfortunately occur and healthcare in Scotland may risk being considered as unrealistic rather than “realistic”.
Update, 22 May 2017:
Public Petitions Committee – Scottish Parliament: 18 May 2017 (click on image below to watch the full meeting)
The official report of the Public Petitions Committee of 18 May 2017
Sunday Post, 21 May 2017: ‘Probe to examine possible conflicts of interest in troubled mesh implant inquiry’
Petition PE1493 advocating that Scotland introduce a Sunshine Act was presented to the Public Petition Committee of the Scottish Government on 12th Novemeber 2013:
Evidence presented here: http://www.scottish.parliament.uk/parliamentarybusiness/28862.aspx?r=8630&mode=pdf
Film of evidence presented on PE1493: https://vimeo.com/79379949
The Association of the British Pharmaceutical Industry (ABPI) wrote to the Petition Committee of the Scottish Government two weeks in advance of the petition’s presentation (I gather this is unusual). The ABPI letter of the 29 Oct 2013 was written by Andrew Powrie-Smith, Director ABPI Scotland: http://www.scottish.parliament.uk/S4_PublicPetitionsCommittee/General%20Documents/PE1493_A_ABPI_29.10.13.pdf
My response to ABPI Scotland, by e-mail, is below.
Meantime, it might be worth considering the reasons why the lancet withdrew its support of the ABPI Guidance in February of this year.
From: Gordon Peter (NHS FORTH VALLEY)
Sent: 01 November 2013 07:30
Subject: Public Petition PE01493
1 November 2013.
Andrew Howlett, Assistant Clerk, Public Petitions Committee forwarded to me the letter of the 29th October 2013 sent by Andrew Powrie-Smith regarding the above petition lodged by myself.
This was a most helpful letter.
I would be interested to meet up and to learn more of the EFPIA Code and the Disclosure Code. It would be most helpful to know how such would be practically implemented in Scotland. I can also appraise ABPI on what the FOI returns have evidenced to be happening in NHS Scotland. There is also the issue of non-NHS academics who are key-opinion leaders and researchers, often affiliated to Universities where currently very little, if anything is recorded in terms of conflicts of interest.
My view is that the GMC should have a role in developing an open, searchable database and that such could fit in within a statutory Act like a Sunshine Act. You will understand then that I am looking at this matter from both sides: where the medical profession has equal responsibility to that of the Pharmaceutical Industry.
I would also be interested, if it is possible, to attend the multi-stakeholder event planned for this autumn.
Evidence based research tells us that there are harmful consequences of an approach where the Pharmaceutical industry spends twice as much on marketing as on innovation and development. There are so many examples, over generations that one could cite: Reboxetine, Seroxat, Vioxx etc etc. Stephen Whitehead has kept assuring that such “is all in the past”. For balance, I would argue that ABPI’s Director, Andrew Powrie-Smith should have mentioned the repeated and well-established evidence of harm associated with marketing in the first part of paragraph two of his letter of 29 October 2013. Collectively we have an ethical duty of “primum non plus nocere quam succurrere” (first do no net harm).
My secretary can be contacted below and best days for tend to be Friday afternoons.
This is an exact transcript of a submission made 23rd August 2013 to the Public Petitions Committee of the Scottish Parliament: http://www.scottish.parliament.uk/parliamentarybusiness/CurrentCommittees/29869.aspx
1. Name of petitioner:
Dr Peter J. Gordon
2. Petition title
A Sunshine Act for Scotland: payments (including payments in kind) to NHS Scotland healthcare workers from Industry and Commerce
3. Petition text
Calling on the Scottish Parliament to urge the Scottish Government to implement a SUNSHINE ACT that will make it mandatory that all payments, gifts and hospitality from the manufacturers of drugs, nutritional supplements, medical devices and healthcare technology to NHS Scotland healthcare workers are reported, logged and kept on a publicly-open database.
This database should also include all sponsored education of healthcare workers and managers and should quantify the sums of money (or cash equivalent of payments in kind) involved.
The Scottish Government could lead the way in the UK on this issue.
4. Action taken to resolve issues of concern before submitting the petition
Concerns about the over-prescribing of antipsychotic drugs in the elderly led me to consider possible explanations for this behaviour by doctors. I was also aware of a powerful marketing campaign including a series of national meetings led by key opinion leaders promoting the use of another drug, Memantine, for the management of behavioural and psychological issues in dementia. This led me to examine the current systems in place to make clear any potential conflicts of interest.
Two years of enquiry with my local NHS regarding any register of outside interests were eventually answered to reveal that no such register had ever existed.
This led me to write to all 22 of Scotland’s NHS Boards under Freedom of Information legislation and the results show that many of the Boards have no policy in place and in those that do the information recorded is very patchy and generally not available to the public.
The FOI returns can be viewed at: https://www.whatdotheyknow.com/user/peter_j_gordon/requests
I have prepared a summary database: due to the heterogeneity of the returns this is a rough guide at best: https://docs.google.com/spreadsheet/ccc?key=0ApF86-MCSbZzdGlVd2ZPYWhyN1ZUbkliNlFpTGxtMFE#gid=0
5. Petition background information
In January 2013 I wrote to the Scottish Government seeking clarification of regulations in this area. I received a reply which directed me to A Common Understanding 2012 – Working Together For patients: Guidance on Joint-Working between NHS-Scotland and the Pharmaceutical Industry. This document specifically excludes research, procurement and sponsorship. The reader is directed to NHS Circular MEL (1994) 48 Standards of Business Conduct For NHS Staff (which is now nearly 20 years old and written before devolution) and to the ABPI Code of Practice for the Pharmaceutical Industry: http://www.abpi.org.uk/our-work/library/guidelines/Pages/code-2012.aspx
The ABPI Code has been roundly criticised: Guidance on collaboration with drug industry offers little in the way of ethics or transparency. BMJ2012;344:e2910 http://www.bmj.com/content/344/bmj.e2910
Lancet withdraws its support of document on collaboration between doctors and drug industry. BMJ2013;346:f770 http://www.bmj.com/content/346/bmj.f770
The technique of pharmaceutical companies using Key Opinion Leaders (KOL) is well recognised: Drug marketing: Key opinion leaders: independent experts or drug representatives in disguise? BMJ2008;336:1402 http://www.bmj.com/content/336/7658/1402
Guidelines have become an integral part of medical practice but it is not always clear what influences might lie behind their formation: Three quarters of guideline panellists have ties to the drug industry. BMJ2013;347:f4998 http://www.bmj.com/content/347/bmj.f499
The United States of America have just enacted a Sunshine Act: http://www.ama-assn.org/ama/pub/advocacy/topics/sunshine-act-and-physician-financial-transparency-reports.page
As I understand it both Australia and France are in the process of developing a Sunshine Act.
6. Do you wish your petition to be hosted on the Parliament’s website as an e-petition?
7. Closing date for e-petition
8. Comments to stimulate on-line discussion
Conflicts of interests feature daily in the news and in many different fields. Healthcare should not believe itself immune from these.
Date …23rd August 2013
Completed forms should be returned to—
The Clerk to the Public Petitions Committee
The Scottish Parliament
Edinburgh, EH99 1SP