Category Archives: Drug therapy

103. The Optimism Crash.

I spent all morning trying to set up Mesh wifi (fail) and all afternoon trying to mirror my phone onto the TV (epic fail). Yesterday I spent an afternoon editing a pdf document to help someone apply for a UK pension (pass, barely). 

And then my HP printer had a seizure of some kind and went into a gobbledygook printing frenzy. HP detected this and immediately sent me an email to say they are really pleased I am having fun with my printer and look forward to more printing in the future, possibly a golden age of print. It’s 1476 all over again.

This is all fine, first world problems, but it’s not quite the future we expected when Tomorrow’s World was on TV. After the moon landings, Velcro and Pot Noodles we looked forward to free energy and a working week of 1 hour when we went in to feed the robots.

Finding that people tend to be optimistic is one of the most important and far reaching discoveries in Psychology. It explains why people keep on buying lottery tickets, electing pathological liars to Downing Street and hitting 3 woods out of fairway bunkers.

People are more optimistic than they really should be.The human spirit is seemingly hard-wired to be indomitable. 

Though it must be said, a lot of optimism research was carried out in the USA, often using samples of college students and arguably during a more optimistic period of history.

During that era, post war, the cultural vibe was an expectation of progress, that each generation would become more prosperous and happy than the one preceding. According to historians* ‘the belief that things are going to get better was already connected to a figurative America even before European settlers set out for the New World’. 

The American Dream preceded D:ream and their song ‘things can only get better’ by 3 centuries at least. 

A word of caution about the American Dream, regarding nomenclature. Call me a pedant, but we need to separate out the differences between Dreams, Daydreaming and Wishful Thinking. People who like to think wishfully fall into the ‘two biscuits later’ category, instead of the ‘one biscuit now’ group who end up in prison. Wishful thinking overlaps to an extent with positive thinking, which can be helpful to the positive thinker, if detrimental to everyone around that person.

The new wishful thinking in politics is to bring back an imaginary world where the map was mainly coloured pink, ambulances arrived within 2 minutes and your GP had a housekeeper called Janet who could mainly solve your problem herself with a shilling’s worth of homespun wisdom. Otherwise a GP would visit before the kettle had even boiled.

Such imagery was perfected by John Major who put it thus: ‘long shadows on county cricket grounds, warm beer, invincible green suburbs, dog lovers and – as George Orwell said (he didn’t) – old maids bicycling to Holy Communion through the morning mist’ (He said ‘hiking’ not ‘bicycling’; call me a pedant again).

Choosing to embrace nostalgia instead of optimism led to Major’s Conservatives being eclipsed by Labour in 1997, who deployed the above mentioned anthem ‘Things can only get better’, by D:ream. Featuring TV scientist and Professor Brian Cox, D:ream were probably the only band ever to use a colon in their name, a device that artfully referenced the computer language underpinning electro-pop.

Dreams, daydreams, nightmares, flashbacks, are all different mental experiences. But they are quite interchangeable in the context of popular music. We are not expecting artists to use psychological terms accurately, (especially as most psychiatrists use them inaccurately too).

Daydream is a Mariah Carey album from 1995, featuring the singles ‘Fantasy’ and ‘One Sweet Dream’. Daydreaming, unlike Mariah Carey herself, is only of limited interest to psychiatrists, since it is a normal mental experience. Daydreaming is a normal mental event, ditto Fantasy and having One Sweet Dream. Or so we thought, until the concept ‘maladaptive daydreaming’ was invented in 2002 by Eli Somer, by which time Mariah Carey had moved on to her ninth album, ‘Charmbracelet’. 

The diagnosis of maladaptive daydreaming was never accepted mainstream. There’s always a backlash against attempts to medicalise aspects of normal life, though anyone could see that daydreaming might be a problem, say, for a fighter pilot or the person who inserts pins on a grenade assembly line. 

Daydreaming is more usually counted as a positive and constructive mental experience, where ideas can flourish. Nevertheless, Somer thought that daydreaming could be problematic if it became excessive or morbid in content. 

Somer was a daydream believer but we are left with the philosophical question first raised by The Monkees: Oh, what can it mean? 

Daydreams are what we do when boring people are giving long speeches. If they are maladaptive they can equally be adaptive. Some of my best thinking, such as planning the list of plumbing parts I will need for a new drain, has taken place as my mind drifted during a long sermon (sorry Father Chris).

The American Dream, which never was really a Dream, somewhere in recent history, seemed to reverse its mood polarity. As Billy Joel put it in the song ‘Allentown’, ‘every child had a pretty good shot / to get at least as far as their old man got’. The lyrics go on to say that, ‘something happened on the way to that place / they threw an American flag in our face’. The song marks roughly the time when the optimism curve started to trend downward.

(That time was emphatically not 1982, which was the year I got married. Allentown was written a few years before that, but yes it was released in 1982. Apologies to Mrs EP).

The life expectancy curve took longer to start declining, but by 2020 most countries, other than New Zealand, Taiwan and Norway, (the smug countries) were predicting reduced average lifetimes. 

Something has gone a bit wrong, but who can we blame? In ‘Allentown’ the problem was the decline of the steel industry, or more accurately its export to Asian countries.

The obvious suspect is the onward march of so-called neo-liberal economics and its fellow apocalyptic horsemen: war, climate change, plague and library closure.

Social division has increased and people are more unhappy in countries with higher levels of wealth inequality. Commentators have linked neoliberal economics to general dissatisfaction and anxiety and to a huge increase in the prescribing and consumption of antidepressants. 

Children in the UK, especially girls, were particularly unhappy compared with other European countries, according to a 2015 study, being made to feel inadequate in one way or another.

Schools continued to overload both students and teachers with assignments and assessment despite the finding that during the plague year, when schools were closed for months on end, the students got better exam results than they ever had when the schools were open.

Social media companies are helping to fuel the fires of envy and self loathing. They are essentially advertising agencies, though more artfully targeted than billboards and posters.  

The targeting still seems erratic, which is why I keep getting adverts from HomeStoreandMore for Patchwork Posie Kitchen Textiles. Or, today, ‘how to make it look like you have abs in every photo’. Instagram is trying to ab-shame me now. And that’s right on top of being cholesterol-shamed at the health centre.

The internet has a lot to answer for and is routinely blamed for every type of disruption. The internet wasn’t a thing in 1982 when Allentown was released, and it wasn’t a thing during most of the 20th century’s wars and genocides. But one has a feeling that the IT revolution exaggerates every social trend, from redefining the ideal female eyebrow to closing small shops and is probably making wars even more deadly than they ever were.

Despite very difficult times ahead, as we collect our thermal pyjamas and hazmat suits from HomeStoreandMore, can we rely on people to stay cheerful? 

Hard-wired optimism is one reason why all of us are not depressed all of the time. Is this resilience being gradually overwhelmed by a tide of damaging online experiences? Yes, clearly, for some, such as adolescents who use Instagram and have been presented with ‘the bleakest of worlds’**.

There is evidence to suggest that Optimism Bias, though basically an incorrect prediction, leads to better outcomes than seeing the future realistically:  

‘that the mind has evolved learning mechanisms to mis-predict future occurrences, as in some cases they lead to better outcomes than do unbiased beliefs’***

This raises a problem for therapists, at least those whose system is based on countering cognitive distortions. This probably explains the recent trend of therapy morphing into Coaching. Check out your therapist’s footwear next time around. If the Clarke’s cornish-pasty loafers have been replaced by Air Max, you may be predicting a ‘better version’ of yourself in the world to come. New Balance might be better. 

According to Wikipedia, Billy Joel is still only 73, so ideally placed for a future presidential run.

*‘Things are going to get better: the American dream in contemporary young adult chicano literature’ Marlene Roider and Stefan Brandt, Graz, 2017.

**Now we know that big tech peddles despair, we must protect ourselves; Zoe Williams, Guardian, 7 Oct 2022

***Sharot, 2011, https://www.sciencedirect.com/science/article/pii/S0960982211011912

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98. Monstrous carbuncles revisited.

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People had been working on measures of social deprivation for decades before Donald Trump invented the shithole scale.

Sadly, the Donald didn’t colour in the broad canvas between Haiti on one end and Norway on  the other. Africa and El Salvador were reported somewhere in between, but where for instance would he place Mexborough? 

In the UK people love to write satirical articles slagging off their towns, including architecture, town planning, the appearance of the inhabitants and their behaviour. There are a few reasons for this, beyond what Jeremy Corbyn might call ‘english irony’.

The project ‘Crap Towns’ was an attempt to say something about urban deprivation in the UK. Crap towns featured in a series of publications associated with The Idler.

Most of the crap towns identified  would also rate as deprived on scales of social deprivation such as Townsend or Jarman, but Crap Towns is more subjective and much more fun. 

People nominate their towns and surveys are carried out. The process has not been tightened up or ‘operationalised’ as much as social scientists might like. As a result the essential notion of the crap town has been far-fetched to include entities like London, York and Chipping Norton. These places are not face-valid as crap, even though some of their inhabitants know better. There are plenty of aspects to criticise, even in affluent towns. Try walking past the Grafton Centre, Cambridge late on a Friday evening, where the cast of Mad Max has reassembled.

In another survey  conducted by iLivehere.com, Peterborough came out as the worst town. Runners up to Peterborough include traditional favourites like Halifax, Doncaster, Rochdale and Rotherham. ILiveHere self-identifies as satirical but its findings seem broadly valid. In most of those towns over a quarter of general practice patients are depressed and taking cheap generic fluoxetine.

Most of the Crap towns voted Leave in the referendum, and in general the Leave vote was closely correlated with the CQ (crap quotient). Crap towns are all about self-flagellation.

I lived in crap towns, including Peterborough, most of my life and I enjoyed them greatly. I have to say Peterborough is not a proper crap town. It has a John Lewis store which may reopen one day and a fine cathedral, not to mention an excellent road system. It does not have a branch of Boyes (the nearest one is in March) though it does have three B & M stores. There is a large suburb called Eastern Industry, telling it like it is. 

For me, in a proper crap town the shops will include Boyes, B and M, Superdrug (not a proper Superdrug, but its poor relation, Savers) and at least 5 charity shops. The charity shops will have hundreds of DVDs and Jack Reacher books. There will always be a CD copy of Misplaced Childhood, by Marillion. There may be a branch of Heron Foods, which is a portal to a Waitrose in a parallel universe.

Greenwood menswear, Weigh and Save and Bargain Booze are now boarded up, having teetered off the top end of the CQ scale. 

There are often shops that specialise in outdated food items. You don’t have to be a food scientist to know that cream sherry will never deteriorate during your lifetime.

The post office has usually been transplanted to the corner of a Spar Shop. People tend to travel by electric scooter. These move silently along the pavements catching unwary people lumbering out of Martin McColl’s scratching lottery cards.

If it’s a particularly cold and windswept day, four TalkTalk reps will be in the market square, trying to make you feel sorry enough for them to engage in light banter. One of them is usually nice looking enough to have attracted the attention of two big girls with prams. There’s a hairdressers that charges £4.99 for a cut and the barber looks like Liberace.

Crap towns should have poor Air Quality. Crap towns to the West have less pollution, with the exception of Port Talbot, which has the worst air in the UK. Crap towns to the east have less rain, but what rain there is gets more acidic. Scunthorpe is an Industrial Garden Town, or so it says on the signpost, telling it like it isn’t. Scunthorpe has the worst air quality in England. It might be worth spraypainting over the word Garden if you’re passing the town sign. 

I don’t go there now, although I can thoroughly recommend the colonoscopy department. I don’t imagine there’s a better colon imaging experience anywhere in the world – I still treasure those intimate photos – which goes to show, there is much more to a town’s amenity than its deteriorated retail area. Many facilities that we used to think we needed are now obsolete, following the harsh judgement of the Covid crisis: 

Pubs – like your living room, but with more infectious particles, and drinks three times the price you pay in Lidl.

Cinemas – like your living room, only someone is sitting behind you crunching popcorn and someone in front of you is staring at a very bright phone screen, scrolling down ebay items. You can’t skip the trailers by pressing a button.

Shops – like  your living room (using Amazon) but you have to drive, park, pay and display and not find the thing you want.

Cafes – like your living room but tea is 200 times as expensive and you need a code for the toilets.

Libraries – like Amazon but without the book you wanted 

Schools – like your living room but without proper IT or chocolate biscuits.

This change toward online living is another reason for shrugging off some of the aesthetic limitations of one’s town centre. Since most retail and many services went online, does it matter any more where you live, providing you have robust lungs, a smartphone and noise cancelling headphones?

For instance, when you’re asleep – does it matter then where you live ? Or when you’re watching TV, does it matter then? Or staring at a computer screen?

What about the neighbourhood, what about crime, what about those yobbos on mopeds? What about those hot hatchbacks parked window to window, exchanging little packets of not very legal substances in the leisure centre car park?

Granted, some areas are a bit too clockwork orange to feel comfortable, but in general, the real risk of violence is far lower than the subjective risk. Even in a crap town, you are far more likely to fall down stairs texting or get hit by a scooter than get knifed in the subway.

There are many more subjective accounts of terrible environments, such as featured in Failed Architecture and the long running Private Eye column Nooks and Corners. Everyone has their own ideas about which towns truly suck. After a while it becomes obvious that none of the towns are as bad as people make out. Writing about crap towns has become a genre. The writers more often love their towns than hate them. Rather than paint the towns ‘warts and all’ this genre just paints the warts. Finally The Telegraph runs an article called ‘Crap towns and why we love them’. Most people get the joke. We learned to live with concrete and steel. Prince Charles never did. That thing he called a monstrous carbuncle was an art gallery extension, something we’d have celebrated if they’d built it in Stirchley.

Which is surprising. Charles came from one of the most privileged families in the world and yet was sent to a prison-like boarding school where the dormitory windows were always kept open and he was systematically bullied. He should have written the definitive textbook on family sabotage, a book called ‘how and why we make rods for our own backs’.  Instead he went on to attack modern buildings, usually ones that were made of concrete, forgetting that they were often very useful, warm and nice inside, like the crap towns they formed. 

97. Snakes and ladders, without the ladders.

 

Physician heal thyself / the tailor is the worst dressed man.

This is for my friends who keep asking what’s happened to EP.  I can’t promise it will be a good read, unless you’re one of those rare people who like to hear about other people’s medical problems without getting paid to do so. But, as ABC put it, excuses had their uses, but now they’re all used up.

From February last year my life changed from being a health care provider to a health care recipient. A service user perhaps, or a patient, or to what non-PC doctors used to call a ‘punter’. Seeking health care is very much taking a gamble.

Think of it as a long overdue field trip through the health services. Every doctor should be made ill and admitted to hospital for a few days. I’d bring it in as a short module in year five of medical school, between ethics and breaking bad news.

Early last year I started to get pain in the neck. It began as what felt like a sprained muscle just to the right of C7. It got worse, I went to the GP, he referred me to physio and ordered a lot of blood tests. He forgot to tell me there was a 3 month waiting list for physio, which had been privatised. He also forgot to tell me it was impossible to make an appointment to see him again, ever. 

The pain got worse again, I went back to another GP who prescribed Cocodamol and Naproxen and ordered an X ray. I spent a lot of time lying on the floor staring at the ceiling. 

The X Ray showed some degenerative changes and possibly a facet joint problem. The word ‘mild’ cropped up a lot, which was reassuring. 

But at the same time, a friend of a friend with neck pain turned out to have a spinal cyst which was not discovered soon enough. He developed multi-system failure following surgery and died tragically. An extremely rare occurrence, I was sure, but my subconscious mind didn’t see it that way.

So, seeking further guidance / reassurance, I got referred to the musculoskeletal service, or ‘MSK’ as it calls itself. MSK, whoever they are, have organised their services based on old kidnap movies. The ransom payer is forced to run between telephone boxes and directed towards a remote venue. MSK make a series of anonymous phone calls and lead you a long way down a symbolically pot-holed road, to an industrial area a long way from where you live, leaving you scanning the skyline for snipers. 

A letter arrived announcing that I will be phoned to discuss an appointment. The phone call happened on time and I was sent to a contracted out service in a contracted out building. The receptionist denied all knowledge of my appointment, but luckily I saw a man who looked like an orthopaedic consultant – by this I mean he was wearing a suit – and this time for once my stereotyping proved accurate. The orthopaedic consultant, who was also contracted out, did a test where he pressed my head downwards into my neck. The pain got worse when he did that and I think I am still an inch shorter than I used to be. 

He requested an MRI scan.  

Same process for the scan – a letter announcing a phone call. The scan is in a portable unit on the same site, sadly there are no toilets. I am phobic of closed spaces but by this time Mrs EP has taught me a lot of Yoga and I yoga breathe my way through the scan trying not to open my eyes or sphincters.

The MRI showed some mild degenerative changes consistent with age, just like the XRay but commenting on different bits of anatomy.  I saw a few different physiotherapists, two NHS, subcontracted, and two private. And I got referred to the outsourced pain services, also subcontracted to some agency you never heard of. I waited for the ransom demand phone call.

 

A short holiday in Scunthorpe 

Then came a huge diversion. At the end of May 2019 I took the prescribed dose of Cocodamol for 2 days which caused a massive abdominal problem, a closed loop bowel obstruction (as it turned out, months later, when my CT scan was reviewed). Cue a very interesting day in a urology ward, which will fuel another article once the PTSD has subsided.

Then a month of abdominal pain and a diet of fish fingers and white bread and very little fibre, surgical and gastroenterology appointments leading up to a colonoscopy and another referral back to the surgeons, thankfully postponed due to Covid.

The abdo pain seemed to dislodge the neck pain. I’m not sure how that works, perhaps there is limited bandwidth in the brain. Maybe pains have a rank order, like suits in Bridge. 

As the abdomen settled down, after about a month, the neck pain came back. 

Cocodamol was firmly off the menu, not to mention Tramadol, which another GP had prescribed over the phone, which Mrs EP observed made me mildly delirious. Luckily Mrs EP hid the tramodol, so I never encountered the biggest snake pit in the pain game, rapid addiction to opiates. So I was left with Ibuprofen and Paracetamol, neither of which made any difference to the pain. By this time I was beginning to realise that Pain doesn’t play by any rules and should be given a capital P.

 

The clinic at the end of the world

The Pain clinic was located at the end of a long cul de sac  along the river, in a former pumping station. Therapeutic nihilism had set in at the pain clinic. There was no sign saying ‘abandon hope all ye who enter’ but that was the vibe.

The Pain clinic does not believe there is much relationship between tissue damage and the experience of pain. They suggested I check out the work of Lorimer Moseley on Youtube, which I did. 

So Pain is mostly an illusion. A distorted and amplified rendering of a routine background noise. A warning of some kind, possibly false news, like the antilock brake light on your Ford Focus. 

Knowing  that Pain is mysterious doesn’t give you much direction. Thinking of Pain as a false warning signal suggests two opposite approaches, which are referred to as ‘recalibration’ or – in technical language – ‘building shit up’ and ‘calming shit down’. The former leads to challenging physical activity and the latter leads to lying down and meditating. It’s vague how you actually go about building and calming shit, but the whole thing is DIY by this time.

Mrs EP, who is the only person who comes out of this well, as a heroine in fact, taught me Pilates as well as Yoga. We went for long runs barefoot on the beach. We did meditation and relaxation exercises. We made rich fruit cake and pizza dough.

I kept a Pain diary for months. I gave the different pains silly names to try and diminish them. The ache to the right of C7 I called Boris. The Pain higher up on both sides I called Colin Blenkinsop. The worst Pain, a crushing sensation that sends you looking for the Tramadol capsules that Mrs EP has hidden, I called Agent X47. If that’s not CBT I don’t know what is!

I apologise if there’s a real person out there called Colin Blenkinsop. Or indeed, Agent X47.

 

The magic bullet fantasy

If I was into CBT, which I’m not, I’d mention an automatic thought that goes as follows: 

‘It’ll probably turn out that there’s a simple problem – mechanical or chemical –  that’s been overlooked.’

I was nearly convinced that the experience of Pain is brain based rather than due to tissue or nerve damage. And I began to feel very sorry for people with problems like fibromyalgia and somatoform Pain disorders.  I began to understand how angry chronic fatigue patients got after being consigned to light exercise and extra-light CBT.

In January this year though, the negative ‘magic bullet’ thought cut in again.  I started to believe the facet joints might be causing the problem. I looked at lots of youtube videos of facet joint injection and radiofrequency denervation. After going through another ‘something must be done’ day I made an appointment at a different Pain clinic. 

Luckily the clinic did not recommend facet joint injections or anything else involving needles or machines that go beep. The worlds of Pain perception and tissue damage are parallel universes. They never really meet, not even through portals in spacetime. 

Pain experience is made of Lego and the body is made of Meccano, the specialist told me. Perhaps not a brilliant metaphor, but one I distinctly remember.

He did however refer me to a colleague to work on my posture, core and neck muscles. No guarantee it would help, but I’d have better posture and muscle strength and my shirts would fit better.  His colleague gave me some very specific exercises. She was positive and reassuring, a welcome change from the doom merchants. Things picked up from there. Co-therapist Mrs EP took over the regime as the lockdown hit and added deep relaxation. We built it up and we calmed it down, without even using the word shit.

 

Pain is an illusion, just like almost everything else.

The world is not what it seems. A lot of the news we receive is distorted or made up. A lot of pain we perceive is distorted or made up. The brain employs a cranky, alarmist and unreliable editor, just like the Mail on Sunday. 

Painkillers don’t really kill Pain. The NHS is not the NHS, it’s been outsourced, sliced and diced and provided by people you cannot ever meet or contact. Symbolically, Pain services are located in the dark places on the edge of town. But – don’t tell anybody – you can also find them in posh looking sports medicine clinics.

 MSK sounds like a terrorist group, and in many ways they do strike terror. Millions of people get addicted to opiates and millions more fall victim to bogus therapies and illicit drugs. Pain patients soon become outsiders to science and society.

Because pain is so common, and evidence based treatments are so few, Pain patients are filtered through a series of rationing devices, including waiting lists. These are really just holding areas for legions of desperate people. Sadly, the delay in assessment allows Pain experience and behaviour to set in, like Japanese Knotweed. 

Earlier this month, NICE issued some controversial draft guidelines for managing chronic primary Pain. 

On Planet Nice, problems are solved with kindness and clear communication. Possibly a little acupuncture, group exercise and a dollop of homespun wisdom aka CBT. None of those nasty tablets. On Planet Nice GPs are like Doctor Finlay or Doc Martin. You don’t have to wait a month before seeing them, you can see the same doctor more than once ever and they may have read your notes. If you see a specialist he won’t be an agency locum. No-one will give you a poor, skewed photocopy of some youtube weblinks and call that bibliotherapy. 

Sadly Planet Nice is an illusion too.

 

95. Acuphase wins by one vote.

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All this talk about plastic in the environment has made me think about our second favourite acetate (after vinegar). Acuphase, more properly known as Zuclopenthixol Acetate, has been widely used in acute mental health settings. For those unfamiliar with it, it is given in the form of an injection and its effect is that of an antipsychotic drug lasting between 2 to 5 days. Typically, the recipient becomes calmer and may sleep for a long period. The duration of its effect is particularly useful when treating acutely disturbed psychotic patients.

The alternatives, if the patient will not accept tablets, are repeated injections of shorter acting medications such as lorazepam or haloperidol, which need to be given at least twice a day.

Acuphase was widely used in the nineties but gradually fell out of favour.

Firstly, it is a ‘typical’ or ‘first generation’ antipsychotic. These drugs, for better and worse, were overtaken by second generation drugs such as Olanzapine and Aripiprazole. Olanzapine comes in the form of a ‘velotab’ which melts very quickly in the mouth. Aripiprazole does come in the form of an injection which theoretically lasts a few days, as well as a depot version which lasts a month. However, there are problems with both of these in terms of perceived effectiveness, or ‘street cred’. A substantial number of clinicians don’t believe that Aripiprazole is effective for rapid tranquillisation and the large majority still use lorazepam and haloperidol injections for this purpose.

Secondly, word got round that Acuphase could be a bit dangerous, causing cardiac arrhythmia or even sudden death.

And on a sub-cultural level, the use of Acuphase became associated with certain types of authoritarian ethos units, where the day staff look like nightclub bouncers and the night staff don’t like to have their poker game interrupted.

Last week I met a consultant who had wanted to use Acuphase, only to find that it was not on his hospital formulary and could only be used if approved by a Committee. On this occasion the vote in favour of Acuphase had gone through 4 to 3 in favour, continuing the Brexit – Trump trend of surprises. It’s hard to know which way the pendulum is swinging, especially with some of the older antipsychotics, which may be coming back into fashion.

You may be surprised that an NHS Consultant Psychiatrist doesn’t have the clinical freedom to prescribe a drug that has been widely used for over 30 years, but that’s another story. Some consultants don’t even drive Porsches nowadays.

This particular consultant did not work in Sussex. But if you google the word ‘acuphase’, one of the top results comes up as the Sussex NHS Trust Guidelines.

(If you google Sussex Trust what mainly comes up is headlines like: ‘NHS trust criticised for underestimating risk of patients who killed 10 people’, but that’s another story.)

According to the Sussex Guidelines:

‘Acuphase has often been too widely and possibly inappropriately used, sometimes without full regard being given to the fact that it is a potentially hazardous and toxic preparation with very little published information to support its use.

There are many treatments in use where the evidence is not that strong.

Why pick on Acuphase then? After all, Zuclopenthixol is widely used in the form of Decanoate, where it is called Clopixol Depot Injection, and also in tablet form. Cannot one extrapolate to some extent that the acetate version will act in a similar way to the tablets or depot form? That is exactly what generations of clinicians have done, the distilled wisdom being that Acuphase works well in real life situations.

OK I accept that the distilled wisdom of clinicians can be entirely wrong, yes bleeding and cautery were in vogue for 2000 years, but in general…

The ‘finding no evidence’ game, ostensibly scientific, is highly politicised and has been used to exaggerate or diminish the fortunes of many treatments, from ECT and Lithium to psychotherapy and social treatments like day centres and walking pet dogs through care homes. Remember when our commissioners stopped the Badminton group?

The more you narrow down the focus of your question, the less likely you will find research evidence that exactly addresses the point. And if you refuse to generalise from research to your own situation, you will conclude there is ‘very little evidence to support’ treatment X or Y.

Sticking with Trusts that begin with the letter S, here’s a bit more Guideline, this time from South Staffordshire and Shropshire Trust.

These start a bit more positively than Sussex:

The (2012) Cochrane Review did not find any suggestion that zuclopenthixol acetate is more or less effective in controlling aggressive acute psychosis or in preventing adverse effects than intramuscular haloperidol and did not have a rapid onset of action. The use of zuclopenthixol acetate may result in less numerous coercive injections and low doses of the drug may be as effective as higher doses’.

But the same guidelines quickly go on to say:

Zuclopenthixol Acetate should only be considered appropriate after repeated injections of short acting antipsychotics e.g. haloperidol, olanzapine, aripiprazole.

Would you rather have one injection or several? You might get to choose though. Patient choice trumps even the drugs and therapeutics committee. If you want to have Acuphase if you get very ill, as I would, bearing in mind the alternatives, you can make an advance directive to this effect. Sussex again:

‘If used to good effect and the patient feels that they may benefit from its use in thefuture, then consideration should be given to the preparation of an advance directive’.

Sussex has the only Green Party MP in Britain. But I have checked on this and there is no evidence at all that the acetate from acuphase is affecting marine wildlife.