Content Selection


The BMJ Editor's Choice

  • Treat addictions with evidence, not ideology


    发布:Fiona Godlee, editor in chief,The BMJ


    The war on drugs is failing. This was the conclusion The BMJ reached at the end of last year, leading us to call for reform of drug policy (doi:10.1136/bmj.i6067). Evidence now supports decriminalisation of non-violent drug use, as do a growing number of health and human rights organisations. And the debate is moving cautiously towards support for legalised but heavily regulated drug markets.

    Adding their voices to calls for drug legalisation are parents of young people who have died as a result of taking drugs. As Richard Hurley reports (doi:10.1136/bmj.j1876), an international campaign group called Anyone’s Child aims to show the human cost of prohibition, which it says stigmatises people who use drugs, stops them getting information on what they are taking, and limits access to treatment for drug dependency. They envisage legalisation and regulation of the supply and use of drugs, with clear age limits and quality control. This would not mean a free for all, they say: “Our current laws already achieved that.”

    Our editorial last year prompted an early day motion in parliament and some supportive and well argued rapid responses (www.bmj.com/content/355/bmj.i6067/rapid-responses). Chris Ford and Sebastian Saville from International Doctors for Healthier Drug Policies called on doctors to be at the forefront of change, highlighting the poorer health outcomes from punitive rather than health related approaches. GP Richard Byng wrote of the effects of the wide range of available addictive substances that “dominate the lives of our patients”: tobacco, alcohol, and prescribed and street drugs, making consultations “feel like being at the epicentre of contradictory policies and powerful marketing.” He wants to see an overarching, coherent, and evidence based policy on all addictive or psychoactive substances, with more liberal laws for illegal drugs but tighter legislative control over tobacco and alcohol—“a compromise between the libertarian free market (still dominant with respect to alcohol) and paternalistic authoritarianism (still dominant with respect to heroin).”

    He might have added problem gambling to the list. As Henrietta Bowden-Jones writes (doi:10.1136/bmj.j1593), this “hidden addiction” is clearly linked to increased crime and violence, mental illness, and family breakdown. She argues for problem gambling to be recognised as an illness, on an equal footing with other mental and physical illnesses. Psychological and drug treatments are supported by evidence, she says, and should be available on the NHS.

    People need compassionate, non-judgmental treatment of their addiction, whatever the cause. And society needs to act to protect vulnerable people from harm, not through ideologically driven prohibition, which has never worked, but through evidence based, pragmatic policies that promote health and human rights: decriminalisation definitely; legalisation and tight regulation probably.

    BMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j1925 (Published 20 April 2017)
    Cite this as: BMJ 2017;357:j1925


  • Our commitment is to patient partnership


    发布:Fiona Godlee, editor in chief, The BMJ


    Evidence that leads to changes practice is rarer than we might hope. In partnership with the MAGIC non-profit research and innovation programme (http://magicproject.org), we are now on the lookout for such practice changing evidence on which to base our “Rapid Recommendations” series. So far we have published one on whether patients with severe symptomatic aortic stenosis who are at low to intermediate surgical risk should have transcatheter or surgical valve replacement (doi:10.1136/bmj.i5085). We will soon be looking at knee arthroscopy and then drug treatments to reduce maternal transmission of HIV to the fetus.

    This week we focus on low intensity pulsed ultrasound (LIPUS), a form of bone stimulation intended to promote healing. As recounted by Rudolf Poolman and colleagues (doi:10.1136/bmj.j576), LIPUS was approved in the United States in 1994 for fracture healing and in 2000 for treatment of non-union. In 2010 the National Institute for Care and Health Excellence approved it for similar indications in the United Kingdom. LIPUS is now widely used in the developed world. But does it work?

    The Rapid Recommendations panel of non-conflicted reviewers has concluded that it doesn’t. Prompted by the TRUST trial, published in The BMJ last year (doi:10.1136/bmj.i5351), they collaborated with others on a systematic review (doi:10.1136/bmj.j656), incorporating 26 randomised trials. The trials at lowest risk of bias consistently found no difference between LIPUS and sham or no ultrasound. On the basis of this evidence, and the costly and cumbersome devices required, the panel makes a strong recommendation, with moderate to high certainty, against using LIPUS for bone healing.

    Crucially, the key outcomes were those that are important to patients. So, instead of simply looking at time to radiographic bone healing, the review focused on time to return to work, time to full weight bearing, and the number of subsequent operations.

    The emphasis on these outcomes is a good sign of progress towards more patient centred research. But there is much still to do. When we ask authors to tell us how patients were involved in their research, the answer is almost always not at all. We now publish statements on patient involvement in every research article to encourage a change in the culture. Other elements of our patient partnership initiative (bmj.com/campaign/patient-partnership) include review by patients of research articles, patient co-creation of educational articles, and patients’ involvement in The BMJ’s events. For the past three years we have been lucky enough to work with our inspirational patient editor, Rosamund Snow. Her death earlier this month is a great blow to us and all who knew her (doi:10.1136/bmj.j850; http://blogs.bmj.com/bmj/2017/02/15/paul-buchanan-on-rosamund-snow). But with the ongoing help of our patient panel we are more determined than ever to continue our advocacy for patient partnership in healthcare.

    BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j939 (Published 23 February 2017)
    Cite this as: BMJ 2017;356:j939

  • Familiarity breeds better outcomes


    发布:Elizabeth Loder, Head of Research, The BMJ


    Let’s be clear: familiarity breeds better outcomes. People who have a usual, continuous source of primary medical care generally do better than those who don’t. We know this, and yet everywhere primary care and general practice are in crisis.

    The United Kingdom is no exception. Its medical schools are “training future doctors for yesterday,” say our editorialists John Oldham and Sam Everington (doi:10.1136/bmj.j294). Only 5.9% of UK medical school professors are GPs. As in the United States, there is prejudice and “institutional discrimination” by medical leaders against generalism. The result is that too few medical graduates pursue training in general practice. Instead, most seek specialty training for careers that are more prestigious and promise a better lifestyle. The proposed solution? Tie accreditation and funding to schools that produce doctors whose career choices are in line with population needs.

    What is it that general doctors do so well? For starters, they can help keep you out of hospital. Barker and colleagues (doi:10.1136/bmj.j84) find that older patients who received more of their care from the same GP were less likely to be admitted to hospital for so called “ambulatory care sensitive conditions.” These are illnesses such as asthma, diabetes, hypertension, or epilepsy that can usually be controlled with careful outpatient management by a doctor who knows patients well and follows them over time. Admissions to hospital for these problems can be an indication of ineffective outpatient care. In a linked editorial, Peter Tammes and Chris Salisbury (doi:10.1136/bmj.j373) say that policies that promote and support continuity of primary care are needed “to improve job satisfaction for GPs and very likely reduce pressure on hospitals.”

    Despite the best efforts of primary care doctors, every year millions of people visit a hospital emergency department. Some are admitted. Most, however, are evaluated, perhaps treated, and then sent home. Of these, a small portion drops dead within the week—0.12% to be exact, finds a study that used US Medicare data (doi:10.1136/bmj.j239).

    Because there are so many emergency department visits, the authors calculate that this small percentage translates into 10 093 deaths a year in the US. The most common cause of such unexpected deaths was atherosclerotic heart disease. More deaths occurred among people sent home from hospitals that had lower rates of admissions through the emergency department, even though the patients in those institutions were healthier overall. Could some of these deaths be prevented? It is tempting to speculate that a lower threshold for hospital admission in borderline cases might make a difference, perhaps by allowing doctors to get to know patients and observe their conditions over time. Sound familiar?

    BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j558 (Published 02 February 2017)
    Cite this as: BMJ 2017;356:j558