Personal View: The ivory towers are as resilient as ever
Authors: Martin Vaughan
Journal: BMJ (2005)

I have a patient called Betty. Betty is 75 and is weighed down by more than her share of troubles. She has had severe rheumatoid arthritis for as long as I have known her—which is approaching 30 years. Her pains, which are still severe despite hip and knee replacements, have been augmented by the recent death of her husband. Now she faces a further hurdle: the painkiller that is most effective for her is about to be withdrawn.


The profits on co-proxamol are tiny, so which drug company is going to do serious studies to promote it?


Over the years Betty has tried all the second line agents, as well as most of the non-steroidal anti-inflammatory drugs and every combination of analgesics from paracetamol up to morphine. However, every time we have a change of painkillers she always comes back to co-proxamol as being the one that helps her most.

I know this flies in the face of all the “evidence,” but do I ignore the evidence of what this woman tells me? “There, there, Betty. I know you think you have less pain now, but my scientific friends all tell me you must be wrong—they have done studies.”

What about studies of one of one? What about listening to our patients? Besides, the patent has long since expired, and the profits on co-proxamol are tiny, so which drug company is going to do serious studies to promote it? Where is any new evidence going to come from?


How do we control the flow of unrealistic rules, guidelines, and diktats concerning what is “good practice”?


Perhaps I am getting cynical in my old age, but it struck me that co-proxamol has lain quietly in the shadows for decades—people acknowledging its dangers but using it because it is useful, in patients like Betty, in a way that other drugs may not be. Then suddenly there seems to be a political target to reduce the number of suicides, and co-proxamol is dragged into the limelight and its sins held up for all to behold.

When I heard about the consultation exercise I wrote to the Medicines and Healthcare Products Regulatory Agency (MHRA) to tell them how useful co-proxamol was for Betty and a few other patients like her. I urged them to look at ways that it could be kept available, perhaps just making it available for people past their 30s, when impulsiveness has declined somewhat.

I received news of the MHRA's decision in the newspapers. I went to its website to get more information on how it had reached its decision. It seems that it had received 52 responses to its wide ranging consultations (of which eight gave “no comment”). The respondents divided into two broad groups. In one corner were the royal colleges and the prescribing advisers; in the other were the GPs, rheumatologists, palliative care and pain specialists, and patients. Guess which group said to ban the drug and which group wanted it kept? The ivory towers still stand firm despite all the rhetoric about patients being involved in decision making.

Perhaps if my daughter had died after taking an overdose of co-proxamol I might see it differently. Yes I might, but then a rheumatologist who had a patient who died after taking methotrexate and who then refused to prescribe it or acknowledge it as a useful drug would be accused of getting things out of perspective. And if my daughter had died in a car crash would I be calling for the abolition of all motor vehicles?

In years gone by I assumed that the people who sat on the Committee on Safety of Medicines must be doctors of great knowledge and wisdom. Then one day I received a small card telling me what I was supposed to explain to all my patients before I put them on oral steroids. When I got as far as the cardiomyopathy I decided enough was enough. How many GPs sit on these committees? I wrote to find out. No, they hadn't actually discussed this document with any GPs before it had been circulated to all 30 000 of us. The exercise was totally unrealistic—but totally revealing. These doctors may have great knowledge, but their wisdom can be suspect and their knowledge of general practice seems to be extremely limited.

How do we control the flow of unrealistic rules, guidelines, and diktats concerning what is “good practice” (a euphemism for “what we think you should do”)? Unless some way is found to inject a large dose of realism into their edicts, all these august bodies, set up with the best of intentions, will fall into disrepute among GPs.