Clopidogrel and rationing in the NHS

Photo:Trounce/Wikimedia Commons

Last year I was at a clinical update day for GPs and one of the topics covered was the current guidance for anti-platelet treatment. Clopidogrel has now replaced aspirin in several areas. For instance, it is now the anti-platelet of choice after stroke. The king is dead, long live the king.

I’ve no problem with that – but I was a little shocked to discover that the evidence for its superiority has been known since 1996. Seventeen years? I know it takes a while but this seems a little beyond even the usual delay from research into practice. The key factor that has now changed is that clopidogrel is out of license – so it is a darn sight cheaper than it was. It was purely a cost-effectiveness decision to keep aspirin. Actually, even in terms of pure effectiveness, the difference between clopidogrel and aspirin is quite small – and the confidence intervals cross so it may not be real in any case. But clopidogrel does appear to have the edge and hence the recent change.

(Just as an aside. Do you say CLOPPY-DOG-rel or CLOH-pidogrel? I’m fairly sure the latter is ‘right’ but the first always sounds more fun and less Pharma.)

It is clear that this was a case of rationing. I don’t have a problem with that either – it’s hard to envisage a sustainable health service that doesn’t ration in some form, at some point. However, the public health approach can jar at the individual level. For instance, and this is just a little thought, if you had a bit of spare money would you have been prepared to spend it on clopidogrel rather than aspirin? An upgrade if you like. If I’d had a stroke I’d be pretty enthusiastic about doing what I can to reduce my chance of another. Should people have the option? Or perhaps it’s the price we have to pay for the NHS – we won’t always get access to the absolutely leading edge of healthcare but all of us, without exception, will receive something that is pretty darn good. It’s a deeply political argument and you can apply it to all areas of medicine. Heck, you can have the same debate about schooling.

We shouldn’t be under any illusions though, the NHS doesn’t provide perfect treatment every time. It never could. The clear downside of allowing any sort of ‘top-up care’ is that it will worsen health inequalities and encourage a two-tier system. That is, in my view, highly undesirable and I’d pick the NHS above other healthcare systems because I value the total inclusion it provides. Yet, when sat with a patient it’s awkward as we’ve withheld information from people who’ve had strokes about the best possible treatment. The real differences may not have been great but it still feels a little uncomfortable.

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Heavy alcohol use and the treatment gap

SMMGP Blog: Heavy alcohol use and the treatment gap

I wrote the blogpost (link above) after putting together the last SMMGP Clinical Update. I’m sure we’re going to see a lot more of these harm reduction medications targeting alcohol use coming through in the next few years.

You can read the Aug-Sep 2013 Clinical Update here. I’m busy writing another one – due out next week.

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Quincy, M.E. – a homage

This is a re-written version of a blogpost that I put up on back in 2008. The death of Jack Klugman seems an appropriate time to post a small tribute.

Kick back and enjoy the classic opening theme for a minute. It’s a proper little earworm – I’ll be humming it for days now. Doo doo-doodoo doo dooo!

One of my resolutions when teaching medical students is to stop making cultural references that are likely to be met with blank looks.  Partly because it baffles the students – most of them were not born when Quincy was in his pomp – but mainly because it is mildly depressing for me.

Quincy, M.E. is the reason I am a doctor.

With no doctors in my family, and in the pre-internet universe (how did we cope?), my view of the medical profession was limited to 1980s television. That really didn’t extend much beyond Quincy, early Casualty and that programme, Doctors to Be, that followed some St Mary’s medical students through their course. That really was it. Exposure to Quincy at such an impressionable age meant that I initially assumed I would go on to be a forensic pathologist. The postmortem scenes may look tepid by today’s maggot-ridden standards but at the time they were thrillingly morbid. However, when I arrived at medical school in 1992 I was very quickly disillusioned after about 5 minutes into our first histology lesson. Squinting down microscopes at pinkish-purplish blobs with my defective colour vision meant pathology quickly lost any glamorous associations with Quincy.

Klugman was magnificent as the character and Quincy remains a great, albeit fictional, role model. He was phenomenally tenacious with exemplary clinical skills. Most importantly, he had a moral compass second to none. All of this was allied to an ability to sniff out a corporate murder from the other side of the county. He was also a bit of a one for the ladies and he enjoyed a good rant at stifling bureaucracy. What a legend.

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The SMMGP Clinical Update – Oct/Nov 2012

This is my 20th Clinical Update – you can access them all here. Or jump to the bottom to learn about SMMGP.

The papers covered this time are:

A record-linkage study of drug-related death and suicide after hospital discharge among drug-treatment clients in Scotland, 1996-2006. Merrall ELC, Bird SM, Hutchinson SJ. Addiction 2012. Published online ahead of print. 

This study showed that there is an increased risk of death in folk who have recently been in hospital and are also registered with substance misuse services in Scotland. Even those who hadn’t stayed overnight showed an increased risk of death.

Opioid dependence during pregnancy: relationships of anxiety and depression symptoms to treatment outcomes. Benningfield MM, Dietrich MS, Jones HE, et al. Addiction 2012;107 Suppl 1:74–82

This was a secondary analysis from the excellent MOTHER study. Women who had just anxiety were more likely to drop out. Women who were just depressed were less likely to leave treatment.

Jones HE, Heil SH, Baewert A, et al. Buprenorphine treatment of opioid-dependent pregnant women: a comprehensive review. Addiction 2012;107 Suppl 1:5–27.

This was a huge review that lays out all the most recent evidence for buprenorphine treatment.

‘Subutex is safe’: Perceptions of risk in using illicit drugs during pregnancy. Leppo A. Int J Drug Policy 2012;23:365–73.

This qualitative study highlights some of the wider issues in women who use during pregnancy: far too often health care professionals get stuck in the ‘biomedical discourse’ without considering other areas.

Heroin users’ experiences of depression: a qualitative study. Cornford CS, Umeh K, Manshani N. Fam Pract 2012;29:586–92.

Another qualitative study from the remarkable Fulcrum Medical Practice in Middlesborough.

Depression and prescription opioid misuse among chronic opioid therapy recipients with no history of substance abuse. Grattan A, Sullivan MD, Saunders KW, et al. Ann Fam Med 2012;10:304–11.

Development of dependence following treatment with opioid analgesics for pain relief: a systematic review. Minozzi S, Amato L, Davoli M. Addiction 2012. Published online ahead of print. 

These two papers look at different aspects around the problems of prescription opioid misuse.

The challenges of reducing tobacco use among prisoners. Richmond RL, Butler TG, Indig D, et al. Drug Alcohol Rev 2012;31:625–30.

‘Do more, smoke less!’ Harm reduction in action for smokers with mental health/substance use problems who cannot or will not quit. Baker AL, Callister R, Kelly PJ, et al. Drug Alcohol Rev 2012;31:714–7.

These two papers draw together papers on smoking cessation in some very challenging groups who have high rates of smoking.

Widening access to treatment for alcohol misuse: description and formative evaluation of an innovative web-based service in one primary care trust. Murray E, Linke S, Harwood E, et al. Alcohol Alcohol 2012;47:697–701.

A web-based service that helps address alcohol may seem like a good wheeze but, in practice, there are many problems and barriers to overcome.

Opiate substitution treatment and HIV transmission in people who inject drugs: systematic review and meta-analysis. MacArthur GJ, Minozzi S, Martin N, et al. BMJ 2012;345:e5945–5.

A solid BMJ systematic review that makes it clear that opiate substitution therapy remains a key intervention to prevent HIV transmission. Yet, globally, only around 6-12% of people who inject drugs will receive it.

Benzodiazepine use and risk of dementia: evidence from the Caerphilly Prospective Study (CaPS). Gallacher J, Elwood P, Pickering J, et al. J Epidemiol Community Health 2012;66:869–73

A UK based cohort that shows that there is a clear association between benzos and dementia. Some aspects of the paper seem to rule out reverse causation but there wasn’t a dose-dependent relationship – so whether benzos are causal is not yet clear.

The SMMGP Clinical Update is a summary of some of the key clinical papers on substance misuse relevant to primary care. Generally, it’s around 3000 words long and I might cover anything from seven to ten papers in that. There is a summary of the methodology and findings of the paper and I make an attempt to put it all into some sort of appropriate context. The team at SMMGP read it through, make helpful comments, and try to filter out any blatant libels. It’s available at under the ‘Resource Library’ heading.

If you’ve any interest in substance misuse in primary care then you should join SMMGP – it’s free.


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