Drug Abuse

The concurrent medical forum in LT 2 involved 7 panelists of equally impressive stature, delivering seemingly impromptu presentations on drug abuse. Their findings, as reported by Yee Xian are presented below:

Drug Abuse - The Lowdown

Cardiovascular Disease

The inaugural Students' Medical Forum was conducted in Lecture Theatres 1 and 2, and will be a constant Friday afternoon fixture on the school calendar, 4.30 pm till the speakers' discrection. Owing to the massive number of medical students who yearn to participate, two forums will be held per week, with the obvious implication that one cannot attend both - thus the Student Medical Society Journal has decided to post the lessons and presentations from both forums for the perusal of the student community.

Long live journalism.

These presentations were prepared by Grace, Nik Arsyad, Syarafina, Sit Lee Euan, Sharifah, Ahmad Izwan, Janani, Neela, in no particular order.



An Introduction

Improving Behaviours

Treatments

The Genetic Connection

Symptoms of Cardiovascular Disease

Cardiovascular Disease Surgery

Cardiovascular Disease and Diabetes

Use of Placebos Justifiable?

The first meeting minutes, curiously of the third meeting, of the Students’ Medical Society 05/06, hereafter known as the SMS (copyright royalties owed to the many telecommunications companies and a CERTAIN house in college notwithstanding), well attended by the jungle villagers of Lembah Beringin.

Notes taken by the local town scribe, Kenrick Ng, of PJ birth.

Topic: Is the use of placebos justifiable?

Justifiably, we started off with an esteemed pharmacy-bound student defining placebo. Placebos are generally drugs administered on patients, but have no effect on the patient’s biological system whatsoever. These drugs serve as ‘psychological-healing-substances’; the doctor somewhat deceiving the patient that what he/she has received is medicine. With the mental strength and false belief that the medicine will heal, hopefully, the patient will recover.

Under what circumstances do we use placebos? Why don’t we just give them real medicine?

1. When the patient is not really ill

There are situations where a patient believes: that he/she is ill, but is in fact, not. Some of the more profound opinions from the floor included

- Determining whether the patient is emotionally stable or in a condition of hysteria
If the patient is emotionally stable and appears rational, a doctor should reason to the patient that he/she is actually suffering from some form of self-deception, and is not actually ill. Another member suggested that doctors should sharpen their motivational skills and ways of convincing a patient, rather than merely lying.

If the patient is seen to be hysterical, the doctor is quite justified at giving the patient some form of a placebo (to instill a greater degree of emotional stability) before anything else is done to the patient

- It is also important to realise the consequences of giving ‘fake medicine’ to a patient. Some participants cited cases in the past where doctors were sued by their patients (with respect to this matter) after the patients discovered that they have been cheated. The doctor’s defense? : The placebo is a form of psychological medicine. Valid?

2. When the patient is really ill
Popular examples in this category included influenza and cancer. For the sake of those who know little about biology: Viruses which cause influenza mutate so rapidly that there is hardly any form of effective medication for it.

Members of the floor acknowledged the fact that most patients do not know much about medicine and health, and have a preconceived idea that he/she must have received medication upon exiting a clinic/hospital.

Do doctors charge for the placebos they prescribe? Well, there appears to be no definite answer. Some say doctors prescribe the medicine and the pharmacists sell the medicine/placebo. Others have the opinion that placebos should be given for free, and a ‘trial period’ for the patient allowed. Wouldn’t that affect the credibility of the doctor and the patient’s trust of the doctor’s ability to cure, and reflect that the doctor is indecisive?

A member of the floor shared his experience of not receiving any drugs from the doctor he visited and recovered from constipation after taking note of the doctor’s advice: Proper sleeping hours, diet etc. This individual was an advocate of not prescribing placebos.

The first individual who supported the usage of placebos backed up her argument by mentioning that some articles actually criticise over-prescription of antibiotics to patients, as this act will result in their immune systems being too dependent on medication-in other words, not producing sufficient antibodies. Another suggestion was to only prescribe placebos to waiting patients with the hope that the drug will comfort them, at least during the period of time spent waiting to see the doctor.

The heart of the topic was the role of a doctor and ethics. Some kept on the virtuous path of telling the truth, the truth and nothing but the truth. These members explained that we should return to the basics-that a doctor’s credibility is of utmost importance. A debate of ethics- Is it more important to provide emotional care to patient in the form of placebos and risk having to appear in court; or is it more important to practise the virtues of a doctor by redirecting the patient to a psychiatrist if all else fails?

Many feel that placebos should be used as last resorts, and that a doctor should not risk having to tell lies. Others feel that there is nothing wrong with using placebos-they are not harmful and the patient will probably gather enough emotional strength to free himself/herself from self-deception.

Well, this was an interesting forum, which blended a little knowledge of medicine, a lot about a doctor’s values, ethics etc. A note of thanks to all who attended and participated.

The Biotech and Doctor Tussle

A guest article by Nicholas Pang, self confessed medical journalist

Do you think advances in biotechnology will lessen the role of a doctor?

This, being a less factual topic, will inevitably give rise to more value judgements and sweeping generalisations than other topics - but concurrently, it is also highly thought provoking, allowing the layman to pipe in at a volume as audible as that of the learned professional.

First moot point - the borders between biotechnology and medicine are rapidly blurring. Doctors today are firmly grounded in a broad-based biological education in their early years. Concurrent advances in medical technology, especially the advent of DNA recombinant technology, the Human Genome Project and the absolutely essential task of completing the mapping of the human genome to unveil the mystery of many diseases, have turned biotechnology and medicine into increasingly complementary sciences.

Current medical professionals no longer work and conduct research alone. The increasing number of Nobel Prizes won as a team are testament that different hybrid talents do a good medical research effort make. This point, alone, is sufficient to demonstrate that biotechnology will actually INCREASE the role of a doctor, as due to modern research uncovering the many unseen links between previously independent fields of science, there is now more opportunity for research in one field to benefit another.

Thus doctors can prey on the massive output that was previously the exclusive preserve of physics, due to the many biomedical engineers now in operation. Likewise, now that there are so many collaborative efforts and joint degree programmes between different cuts of the same science pie - biochemistry or biogeology, anyone? - biotechnology can answer an increasing number of medical questions - and vice versa.

As in world geography, science has reached its practical threshold where there are no proverbial "vast swathes of wilderness" to foray into, we have to contend ourselves with identifying the various minute rivulets and valleys on the map through GPS positioning technology. How these geological features mutually affect and interact are now the key premise of geography.

Likewise, the frontiers of science have been pushed to their very limits. We are now entering an age where ecumenism (to pinch a religious term), the mutual links and dependency betwen branches of science, and thus biotechnology and medicine, defines the cutting edge of science.

The Real Deal on Placebos

A guest article by Nicholas Pang, self professed medical journalist

A placebo, courtesy of the kind folks at Wikipedia, from the Latin for "I will please", is a medical treatment (operation, therapy, chemical solution, pill, etc.), which is administered as if it were a therapy, but which has no therapeutic value other than the placebo effect.

One may question, how do we get people to literally put their lives on the line for this? Answer: Only people who want so, do so. Current regulations require that the researcher, as well as the test subject, will probably not know if they are receiving an active treatment or placebo. The objective of the study and its design should be clearly explained, especially the inclusion/exclusion criteria, masking procedures, and the use of medication washout, placebo, medication discontinuation and specific interventions.

Arguments For Ethical Use of Placebos

The strongest argument against placebos is such: Their use is unethical when there is a proven effective drug that can combat a disease. The new drug should be measured COMPARED to an existing drug. This is termed an equivalence or a noninferiority trial. The logical reasoning stands as thus: The drug administered to the patient will assist the patient either way; either to a larger (new treatment) or a smaller (existing treatment) magnitude.

Such proponents frequently cite Paragraph 29 of the Declaration of Helsinki which states: “The benefits, risks, burdens and effectiveness of a new method should be tested against those of the best current prophylactic, diagnostic, and therapeutic methods”

Sadly, the drugs unleashed upon the world as a result of equivalence tests may actually be born of a less stringent quality control process.

Equivalence therapy - commonly deemed "proven effective therapy" - often fails to show superiority to placebo. This is not because these drugs are in fact ineffective, but because the trials in question lack assay sensitivity. Assay sensitivity is defined as the ability of a trial to distinguish an effective from an ineffective therapy.

SENSATIONAL PROOF: FDA review documents on 51 clinical trials on nine antidepressants approved between 1985 and 2000 were obtained and indicated that out of 92 active treatment arms (all involving doses that were eventually approved), 47 (51%) failed to demonstrate statistical superiority to a placebo.

Medical research is only justified if there is a reasonable likelihood that the populations in which the research is carried out stand to benefit from the results of the research. To approve ineffective drugs based on flawed science and to let them loose on an unsuspecting public would be more unethical.

This Debate is Not Just about Efficacy

...it is also about harm. Not using a placebo group, it may be impossible to interpret a drug's potential for harm. The famous Vioxx study (United States) showed a five-fold difference in the incidence of myocardial infarction in the rofecoxib (Vioxx) group compared with the naproxen group the US Nonsteroidal anti-inflammatory drugs such as naproxen, however, inhibit platelet function and therefore might have a myocardial protective effect. Thus without the use of a placebo it was impossible to tell whether the changes were attributed to naproxen having a protective effect or rofecoxib having a destructive effect.

In the meantime, rofecoxib was distributed liberally to the public, and four years later, the drug was withdrawn due to an alleged "increased cardiovascular risk". The decision was based on - surprise, surprise - an unpublished Adenomatous Polyp Prevention on Vioxx (APPROVe) study, a placebo-controlled three-year trial of rofecoxib.

In his November 2004 testimony before the United States Senate, David Graham of the FDA provided an estimate of the rate of excess cases of Vioxx-related myocardial infarction and sudden cardiac death. He testified that it was as if, for the five years that Vioxx was on the United States market, “2 to 4 jumbo jetliners were dropping from the sky every week”. Of those cases, he added, 30% to 40% probably died.

If those who believe that “proven therapy” trials are ethically preferable to placebo-controlled trials had had their way, the APPROVe study would have been blocked, and Vioxx would still be on the market today, and we would be left with a heightened body count. It seems ironic that such a stance could be taken in the name of ethics.