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Gp Prescribing Ethics
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Our 21 year old daughter is a second year midwifery student at a Scottish university. For some time, she's suffered heavy periods which have been a puzzle to diagnose by her GP and hospital consultants. She's also suffered from virtually constant abdominal pain during her periods. She's tried The Pill but it hasn't helped.
The consultant advised fitting a Mirena coil to try to solve the problem. This was done by general surgery under full anaesthetic about a month ago. It hasn't helped and the pain is now virtually constant.
She recently saw her GP and was in tears in the consulting room at the time. She pointed out that she's not keen on taking the consultant prescribed codeine due to its potential addictive properties. The GP has failed to bring the 6 week follow-up appointment forward. He also seems to have ruled out IBS as the cause of the pain.
The GP prescribed Amitryptyline 10mg at night for her without explaining his decision. On getting home, our daughter hit the roof as the patient information leaflet states that the drug is only used to treat depression. My internet searches show that it's also used for something called neuropathic pain but our daughter feels her pain was not taken seriously by the GP because of his choice of drug.
I've tried to reassure her and told her to give the Amitryptyline a chance but can anyone provide any further advice. Thank you.
The consultant advised fitting a Mirena coil to try to solve the problem. This was done by general surgery under full anaesthetic about a month ago. It hasn't helped and the pain is now virtually constant.
She recently saw her GP and was in tears in the consulting room at the time. She pointed out that she's not keen on taking the consultant prescribed codeine due to its potential addictive properties. The GP has failed to bring the 6 week follow-up appointment forward. He also seems to have ruled out IBS as the cause of the pain.
The GP prescribed Amitryptyline 10mg at night for her without explaining his decision. On getting home, our daughter hit the roof as the patient information leaflet states that the drug is only used to treat depression. My internet searches show that it's also used for something called neuropathic pain but our daughter feels her pain was not taken seriously by the GP because of his choice of drug.
I've tried to reassure her and told her to give the Amitryptyline a chance but can anyone provide any further advice. Thank you.
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That is the dose used for pain - not for depression. If she's not happy to take a weak opiod like codiene in case she get's addicted to it, i'm not sure what else she expects the GP to do.
if she isn't happy to take either the consultant or GP's advice i can't really see there is a benefit in seeing them
if she isn't happy to take either the consultant or GP's advice i can't really see there is a benefit in seeing them
ps, most drugs have a dual use - eg codiene is sometimes used in chronic GVHD to help with diarroeah, or to help people with a chronic cough, but i bet the Cons didn't tell your daughter that (as there was no need to) just like there was no need for the GP to tell your daughter about the other uses of Amitryptiline as he wasn't prescribing it for the other reasons, but for reasons of pain
I'm no expert on ladies problems but what I have read in your post describes exactly what my daughter has been going through ... more than 10 years.
She has had everything you describe and more. She has eventually been seen by every GP in the surgery. Been referred for counselling and undergone exploratory surgery on two occasions. All of this for her imaginary pains according to the Doctors.
Her 1st surgery revealed nothing and she was referred back to our GP.
Another round of drugs followed and the pain got worse over the coming months. Then our local GP suggested counselling.
One day she was in so much pain she staggered into the surgery where she eventually seen a locom GP. She called an ambulance. Soon after her visit to A&E she was in hospital again for another exploratory.
She explained the whole story to the consultant who found it unbelievable that the NHS had treated her in such a way. The consultant said she was sorry and if there was a problem she will find it.
2 hours later the surgery was complete.
The consultant said the problem had been found and she didn't understand why it hadn't be seen in the first place. That gives you faith, doesn't it.
Endemetriosis was and still is the problem. She has since changed her diet dramatically and is" living with it".
Thought I should share that because I know what agony her problem has caused her and the family over the years. Now we can put a name on it the search over, it is just a case of getting on with it and trying to live a normal life... Good Luck !
She has had everything you describe and more. She has eventually been seen by every GP in the surgery. Been referred for counselling and undergone exploratory surgery on two occasions. All of this for her imaginary pains according to the Doctors.
Her 1st surgery revealed nothing and she was referred back to our GP.
Another round of drugs followed and the pain got worse over the coming months. Then our local GP suggested counselling.
One day she was in so much pain she staggered into the surgery where she eventually seen a locom GP. She called an ambulance. Soon after her visit to A&E she was in hospital again for another exploratory.
She explained the whole story to the consultant who found it unbelievable that the NHS had treated her in such a way. The consultant said she was sorry and if there was a problem she will find it.
2 hours later the surgery was complete.
The consultant said the problem had been found and she didn't understand why it hadn't be seen in the first place. That gives you faith, doesn't it.
Endemetriosis was and still is the problem. She has since changed her diet dramatically and is" living with it".
Thought I should share that because I know what agony her problem has caused her and the family over the years. Now we can put a name on it the search over, it is just a case of getting on with it and trying to live a normal life... Good Luck !
A friend of mine had that problem. I remember when she passed out at school with the pain. She suffered really bad pain for sometime and eventually was given a contraceptive implant which prevents periods so she never had any more problems. She was told she produces a lot of prostaglandin which is what causes heavy periods and pain.
bednobs, with due respect, I think you may be missing the point here. Both of us are willing to accept that drug therapy alone may not resolve her problem and as surgery is out of the question in a GP surgery, she's not expecting the GP to work wonders.
Further referral be it to a gynaecologist or some other expert seems inevitable, therefore there continues to be likely benefit albeit in the future.
I would have liked the GP to have spent just a minute or so informing my daughter that the drug was being prescribed for pain and not for depression. He did not do so and undoubtedly none of this issue would have arisen had he done so. Surely, he would have been aware that the Patient Information Leaflet was biased towards the use of the drug for depression? Why cannot the drug manufacturers ensure that this is mentioned on the PIL? Or is it because the use of Amitryptyline in pain is unlicensed? Surely, all the more reason for reassuring the patient over its use?
Further referral be it to a gynaecologist or some other expert seems inevitable, therefore there continues to be likely benefit albeit in the future.
I would have liked the GP to have spent just a minute or so informing my daughter that the drug was being prescribed for pain and not for depression. He did not do so and undoubtedly none of this issue would have arisen had he done so. Surely, he would have been aware that the Patient Information Leaflet was biased towards the use of the drug for depression? Why cannot the drug manufacturers ensure that this is mentioned on the PIL? Or is it because the use of Amitryptyline in pain is unlicensed? Surely, all the more reason for reassuring the patient over its use?
This is indeed a very interesting issue and I entirely agree with the last post made by the OP. The GP should have explained why he was prescribing the drug to the patient in order to mitigate what he should have known might well cause distress to the patient upon reaching home.
This is absolutely nothing to do with dual or multi-purpose usage of drugs. This is down to the GP not thinking ahead and anticipating what someone would think upon reading the PIL. Let’s be honest about this, if I was a 20 year old who had been crying in front of a doctor with a pain that the doctor was mystified about, I know what I would think if I picked up a pack of antidepressants from the pharmacy. That’s it, pure and simple.
This unlicensed use of medicines is both admirable and successful in many cases. However, because the unlicensed use cannot be disclosed on the PIL, it can result in great misunderstanding and anguish as in this case.
Yes anneasquith, I've just checked the PIL online from a number of manufacturers and they only mention its use as an antidepressant, just like all unlicensed drug applications.
bednobs, just to clarify the multi-purpose use of codeine are mentioned in the packaging PIL's.
This is absolutely nothing to do with dual or multi-purpose usage of drugs. This is down to the GP not thinking ahead and anticipating what someone would think upon reading the PIL. Let’s be honest about this, if I was a 20 year old who had been crying in front of a doctor with a pain that the doctor was mystified about, I know what I would think if I picked up a pack of antidepressants from the pharmacy. That’s it, pure and simple.
This unlicensed use of medicines is both admirable and successful in many cases. However, because the unlicensed use cannot be disclosed on the PIL, it can result in great misunderstanding and anguish as in this case.
Yes anneasquith, I've just checked the PIL online from a number of manufacturers and they only mention its use as an antidepressant, just like all unlicensed drug applications.
bednobs, just to clarify the multi-purpose use of codeine are mentioned in the packaging PIL's.
PIL is useful IF it holds complete information and IF prescribers explain things properly. They are good for stuff like side effects, how to take or use meds and so on.
I don't want to offend with the next bit but I used to work in the NHS. Its not uncommon for people who are stressed to genuinely believe that something hasn't been explained or discussed when in fact it has, but maybe at that time, they weren't capable of hearing what had been said and maybe also the person saying it hadn't picked up on the fact that their patient was so stressed that they weren't hearing and didn't check what had been heard....it happens....
I don't want to offend with the next bit but I used to work in the NHS. Its not uncommon for people who are stressed to genuinely believe that something hasn't been explained or discussed when in fact it has, but maybe at that time, they weren't capable of hearing what had been said and maybe also the person saying it hadn't picked up on the fact that their patient was so stressed that they weren't hearing and didn't check what had been heard....it happens....
Good post by woofy above^^^
The GP is in a difficult position and only has two options, firstly to say to the patient that the tablets which he prescribes are not mentioned in the PIL for pain.
OR
Do not mention it and hope that she does not read the PIL (which i feel is useless)
In front of you is an intelligent 21year old girl, suffering from painful periods and has been seen by Consultants and GP, various treatments have been prescribed and none successful. She is crying in pain and you have to explain to her that the tablets that you have prescribed contains a PIL which gives mental disorders as an indication and doesn't mention pain.
This is a human situation with a very human explanation to give and whichever way the GP chooses is likely to be the wrong way.
Again, I fail to see the value of PILs.
The GP is in a difficult position and only has two options, firstly to say to the patient that the tablets which he prescribes are not mentioned in the PIL for pain.
OR
Do not mention it and hope that she does not read the PIL (which i feel is useless)
In front of you is an intelligent 21year old girl, suffering from painful periods and has been seen by Consultants and GP, various treatments have been prescribed and none successful. She is crying in pain and you have to explain to her that the tablets that you have prescribed contains a PIL which gives mental disorders as an indication and doesn't mention pain.
This is a human situation with a very human explanation to give and whichever way the GP chooses is likely to be the wrong way.
Again, I fail to see the value of PILs.
Yes, a good post from woofy.
PIL's never contains complete information about the drug. On every PIL you will find a statement saying something along the lines that the PIL does not contain all the information about the medication and goes on to advise the patient to consult their doctor or pharmacist for further information.
PIL's do not contain full information on dosage, side effects etc. They are written in simplistic language aimed to cover the vast majority of the population and certainly do not cover all eventualities in detail.
The people who compile these PIL's may argue that they don't want to complicate the information to patients. However, there is a point where generalistic information can be very dangerous for the patient.
As a student health professional, I would have thought that this young lady is accustomed to listening and taking in the advice and information provided by a GP or other health professional. After all, persistent conditions do tend to focus our attention on all possible solutions to the problem out of desperation if nothing else.
Like Sqad, I consider the value of a PIL as being next to useless despite the fact that it's usually a double sided print on a sheet close to A4 in length if not in width.
Incidentally MrsProf, who is a Professor of Cardiology, tells me that it's common for a consultant to spend quite a few minutes during a follow-up consultation with a patient clarifying the bumf the patient has seen on the PIL.
Finally, as I said earlier unlicensed drug usages are legally not allowed to be mentioned on the PIL. Come on GP's, let's start talking to the patients!
PIL's never contains complete information about the drug. On every PIL you will find a statement saying something along the lines that the PIL does not contain all the information about the medication and goes on to advise the patient to consult their doctor or pharmacist for further information.
PIL's do not contain full information on dosage, side effects etc. They are written in simplistic language aimed to cover the vast majority of the population and certainly do not cover all eventualities in detail.
The people who compile these PIL's may argue that they don't want to complicate the information to patients. However, there is a point where generalistic information can be very dangerous for the patient.
As a student health professional, I would have thought that this young lady is accustomed to listening and taking in the advice and information provided by a GP or other health professional. After all, persistent conditions do tend to focus our attention on all possible solutions to the problem out of desperation if nothing else.
Like Sqad, I consider the value of a PIL as being next to useless despite the fact that it's usually a double sided print on a sheet close to A4 in length if not in width.
Incidentally MrsProf, who is a Professor of Cardiology, tells me that it's common for a consultant to spend quite a few minutes during a follow-up consultation with a patient clarifying the bumf the patient has seen on the PIL.
Finally, as I said earlier unlicensed drug usages are legally not allowed to be mentioned on the PIL. Come on GP's, let's start talking to the patients!
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