Former editor, BMJ
Hospitals are unsafe places, but citizens perceive them as safe. Citizens, at least in Britain, are also unaware of the variations in performance among hospitals. I was at a meeting on quality in health care where the head of a patient organisation described his ideas of quality. He didn’t mention either safety or the quality of clinical care, two features that a senior doctor thought mattered most when talking about quality. Why, asked the senior doctor, didn’t he mention them? Well, the head of the patient organisation answered, I just assumed that all hospitals are safe and offer high quality Are citizens equally ignorant about drugs?
The average Britain takes about 20 prescription drugs a year, a doubling since 1995, and recent data show that many older patients with multiple conditions are taking eight or more prescription drugs long term. In addition, people take many over the counter drugs, and 95% of the English drink alcohol, a quarter smoke tobacco, and almost everybody drinks tea, coffee, and soft drinks containing caffeine. Millions use illegal drugs, particularly cannabis, and 750 000 use “legal highs,” manufactured drugs that are not for human consumption but which are known by young people to “get you high.”
So Britain, like most countries, is awash with drugs. Yet despite the use of drugs being literally an everyday experience, people are ignorant about drugs.
The perception of illegal drugs like heroin is that they are lethal. It comes as a great surprise to most people to learn that eminent doctors have carried on their successful careers for decades while using opioids. It’s the perception of their danger that makes it almost impossible for politicians to be seen to be sympathetic to legalisation of currently illegal drugs.
In contrast, most of those using cannabis, cocaine, and alcohol think of them as relatively harmless. People have recognised the dangers of drinking and driving, and they see “alcoholics” in the parks. Encouraged, however, by both the alcohol industry and politicians, the many people who are actually drinking at harmful levels see themselves as “normal” or “responsible” drinkers.
The perception of over the counter drugs is that they must be safe—“otherwise, they would be on prescription.” People are largely unaware of the dangers of overusing analgesics. Most people don’t know why they are limited in the number of paracetamol tablets they can buy, and there are still people deliberately taking overdoses of them while unaware of their effects on the liver.
Most people—and certainly all older people—know the story of thalidomide, and everybody knows that chemotherapy for cancer can be horrible. Generally, however, I think that people are not good at balancing risks and harms. But then nor are most doctors. The whole climate is one that exaggerates the benefits and downplays the risks of prescription drugs.
Consider antibiotics. Most people in Britain have understood that you don’t need to see the doctor for “coughs and colds” because most are caused by viruses and antibiotics won’t help. Nevertheless, many people with coughs and colds do go to the doctor and are prescribed antibiotics “just to be safe.” People are not very aware of the side effects of antibiotics, thinking that they are “safe” even if they won’t be helpful. And despite blazes of publicity every so often, they do not see a relationship between them taking antibiotics and growing resistance to antibiotics.
I have a regular debate with my wife about taking acyclovir for cold sores. We both get them regularly, but she uses topical acyclovir and I don’t. I tell her that the drug has minimal benefit and that when she gets herpes in her brain she’ll regret that she’s contributed to the resistance of the antibiotics. She thinks I’m nuts.
Vaccines interestingly are perceived wholly differently from antibiotics. Their benefits are not obvious to people because most have never seen diphtheria, polio, tetanus, or even measles. Yet many people worry hugely about the side effects of vaccines. We have several times in Britain seen dramatic drops in vaccination rates because of fears of side effects—autism with MMR and brain damage with whooping cough vaccine. People have little understanding of herd immunity, and, even if they do, are tempted to be what economist call freeriders, enjoying the benefits of herd immunity while not exposing their children to whatever dangers vaccines may have.
Attitudes to long term drugs—like statins, antihypertensives, and antidepressants are complicated. People in Britain don’t like taking drugs long term, and adherence is poor (as it is everywhere). For example, menopausal women in Britain didn’t take hormone replacement therapy in large numbers (compared with, say, American women), but that was less worries about safety of the treatment and more a reluctance to take drugs long term particularly for a natural event.
There was a time in Britain when benzodiazepines were perceived as wholly beneficial and devoid of side effects. Millions of people, particularly women, took them long term, and it was the media rather than doctors who eventually showed how dangerous they could be. There has since been a great deal of publicity about the harms associated with taking these drugs long term, but still many people continue to take them long term.
And antidepressants have taken over from benzodiazepines as the most popular psychoactive drug. In England alone prescriptions for antidepressants have increased from 9 million in 1991through 24.3 million in 2001 to 46.7 million in 2010. We have now reached almost one prescription for every inhabitant in England. People are warned that the drugs can have side effects, but people see them as safe in that they think that the benefits far outweigh the risks. In fact the benefits, particularly for those with mild depression, are small, even non-existent. So probably far too many people in England are taking antidepressants, partly because they think of the drugs as safe.
Statins have also become very common: around 7 million people in Britain are taking them. People think of them as almost entirely safe, and perhaps they are not very wrong. Millions are also taking anti-hypertensives and are perhaps more conscious that they may not be so safe, which may be one of the reasons for low adherence.
As I’ve said, we know that many people in Britain are taking eight or more prescription drugs, and many of those people will be combining the drugs with alcohol, caffeine, and other drugs. People are probably aware that the more drugs they have to take the greater the risk of interactions and harm, which might explain why their taking of the drugs may be haphazard. As a student I encountered an elderly woman who kept all her drugs in one large sweetie jar and didn’t take them regularly but would put her hand in the jar and take a selection of a few when she was not feeling well. I suspect that such practices continue.
My conclusion is that Britain—like most countries—is awash with drugs, and that although Britons are well aware that some drugs can be dangerous they are generally hazy on the ratio of benefits to risks. This means that many people may be exposing themselves to the dangers of drugs when they can expect little or no benefit.