NICE guidance on drug abuse

The National Institute for Health and Clinical Excellence (NICE) has issued new national standards calling for anyone who works with young people to identify those who are vulnerable to drug problems, and intervene at the earliest opportunity - before they start using drugs at all or before they get into worse problems if they are already misusing drugs.

The guidance gives advice on stepping in and helping young people access the right support and services, and outlines effective individual, family and group-based support which can improve motivation, family interaction and parenting skills.

Vulnerable young people such as those excluded from school, those who have been in care, those whose parents misuse drugs and serious or frequent offenders are on average five times more likely to use illegal drugs than their peers, and there are currently over 70,000 problematic drug users in England between the ages of 15 and 24.

In England and Wales in 2003/04 class A drug use was estimated to cost around 15.4 billion in economic and social terms (Gordon et at. 2006)

The British Crime Survey 2005/06 estimates 526,000 people aged 16-24 years (8.4%) have used a Class A drug (cocaine, ecstasy, lysergic acid diethylamide (LSD), mushrooms, heroin, methadone) in the last year and 1,338,000 people aged 16-24 years (21.4%) have used cannabis in the last year.

The National Treatment Agency estimates there are currently 72,791 problematic drug users (opiate and/or crack cocaine users) in England between the ages of 15-24

In England 24% of vulnerable young people reported using illicit drugs frequently in the last year, compared with 5% of their less vulnerable peers (Becker and Roe 2005)

Screening tools include the Common Assessment Framework http://www.everychildmatters.gov.uk/deliveringservices/caf/ and those available from the National Treatment Agency http://www.nta.nhs.uk/.

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The Change Page

The BMJ has started a new feature, the change page, which describes a medical intervention, for which the evidence has recently changed, or which is known to be frequently misinterpreted.

The most recent of these states that some patients with paroxysmal atrial fibrillation should carry flecainide or propafenone to self treat

Atrial fibrillation affects up to 1.5% of the population in the United Kingdom, about 200 000 of whom have recurrent episodes. Although such episodes often resolve spontaneously and within 48 hours, patients may be distressed by symptoms of palpitations, dizziness, fatigue, or chest pain.

Such attacks generally respond to antiarrhythmic agents (such as a single intravenous dose of propafenone or flecainide), which are usually administered under monitoring in hospital.

It is proposed that patients could self treat with oral propafenone or flecainide, using a "pill in the pocket" approach (thereby not needing to go to hospital), as suggested in recent National Institute for Health and Clinical Excellence and international guidelines.

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Urinary tract infection in primary care

A recent prospective cohort study by McNulty and colleagues in the Journal of Antimicrobial Chemotherapy reports on 448 women with symptoms of uncomplicated urinary tract infection who were treated with trimethoprim in primary care. The aim was to see whether women with infections resistant to trimethoprim had worse clinical outcomes. While the answer might seem intuitive, some of the findings were interesting.

Pure bacterial culture was found in 317 women and the rate of resistance to trimethoprim was lower than expected from local laboratory resistance data derived from routinely collected specimens. Predictably, antibiotic resistance was associated with longer median duration of symptoms (7 v 4 days), higher frequency of subsequent prescription of antibiotics (36% v 4% in the first week), and higher rates of reconsultation for treatment failure (39% v 6%). While this sixfold relative difference in treatment failure rates is impressive, what is interesting from a primary care perspective is the low absolute reconsultation rate in the subsequent week in the resistant group (39%). In other words 61% of women with resistant organisms did not reconsult in the subsequent week because of treatment failure.

The treatment of uncomplicated urinary tract infection in primary care is usually empirical. The decision about which antibiotic to use may be influenced by both the practitioner's and the patient's previous experience, available data on antibiotic sensitivities, guidelines, and drug marketing. General practitioners face two sometimes competing imperatives—the first to choose an effective treatment for the individual and the second to minimise resistance in the population by using antibiotics responsibly.

There is a lot of overestimation of resistance rates in women with symptoms of uncomplicated urinary tract infections. The findings in this UK study concur with this—13.9% of patients in the study were resistant to trimethroprim compared with 24.5-27% in routinely collected specimens.

Ultimately, it is relief of symptoms that matters to patients, not microbiological eradication. We therefore need to use data on resistance with care when making decisions and developing guidelines for prescribing in primary care.

The authors claim that their data support trimethoprim as an appropriate first line agent for uncomplicated urinary tract infection in their region. It is clinically effective, relatively safe, and inexpensive. Trimethoprim is alone in its class, which reduces the likelihood of resistance selection to other, newer antibiotics, and it is rarely, if ever, used for more serious infections.

The decision to switch to a second antibiotic should be made on clinical grounds rather than on microbiological grounds—that is, failure of symptoms to resolve after four days of treatment. General practitioners can confidently tell patients that most women's symptoms will resolve quickly, and that they should return if symptoms are not improving by four days.

Ironically, rigid prescribing guidelines for first line treatment may be less effective.  We do not know why some people with symptoms respond to antibiotics faster than to placebo when they do not have infection by any accepted definition, while others with sensitive organisms fail to respond to antibiotics.

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