This is also a feature of the national scale, not just at local hospital level, although some of the other British countries have deliberately focused on achieving better national cooperation in some domains. For example, Wales has a nationwide obs chart and drugs chart - some trusts in the UK don’t even have this at different hospitals within the same trust. There may be some role for the networks here but there is significant difficulty faced by the imposition of external factors; money being the obvious one, but also externally imposed targets. Indeed, this silo working has such visible adverse effects on care, and yet seems so hard to combat. People can be working very hard and diligently towards a goal, but without the collaborative thinking on the right scale, the outcome might not be the sum of its parts. This problem is not just in medicine, and ‘The noble purpose paradox’ summarises it quite nicely - “the more compelling the mission, the more tricky it can be to get the best collaborative behaviours”. Essentially, a part of collaborating in a group involves a degree of sacrifice of the members, and yet the benefits reaped should more than make up for this. GPICS V2, just released that morning may be a great opportunity for this - time will tell.
The next talk of the morning was from Dr Craig Mckenzie (@itsdrmac), director of the Forensic Drug Research Group. He gave a fascinating presentation on novel psychoactive substances (NPSs) and an eye-opening lowdown on the current illicit drug scene. This is a fast moving area with new substances constantly evolving and significant factors outside the pharmacology itself. These drugs are taken as a cocktail and in an illicit market environment, and so they should be studied and understood that way - a bit of a change from our usual pharmacological approach. In addition, there is also a lot of misuse of prescription drugs now, with certain classes being used in very big doses to ‘get high’. These are completely different from our usual encounters with these drugs, sometimes with dose increases of 10s of times.
The NPSs are a very topical problem. The issue is that a lot of the information around these substances is widely available through the internet, for example through drug patents. These can be easily accessed and the drugs then synthesised by amateur chemists around the world. Current trends in this field are towards a rapid expansion of the synthetic opioids, with the previous trend for novel synthetic cannabinoids decreasing in number (mainly because producers have worked out the good ones and these are being reproduced rather than new ones developed). However, the non-pharmacological factors are still continually evolving with some synthetic cannabinoids having even made it into e-cig liquids, and methods for getting drugs into prisons under constant innovation.
From a clinical perspective, opioids and benzodiazepines are the big killers. Gabapentinoids are also getting involved and it is the interacting effects of the polypharmacy that contribute towards the lethality. A further clinical component is the impact of the illicit market. There is essentially no quality control on the dosing, or even what the actual drug is due to the variable tablet labelling and appearance. Indeed, changes in batches (whilst still appearing the same) have led to epidemics of adverse reactions, including clusters of deaths. Their use really is such a Russian Roulette, and it is likely these patients that we are most likely to encounter in our critical care practice. The specific trends appears to continue to vary; opioids are causing huge numbers of deaths in the US, whilst spice has been the drug of choice in certain UK groups. As such, keeping up to date with trends is useful, and Craig directed us to a number of useful resources:
NEPTUNE - a clinical resource
UNODC world drug report
European drug report
Devastating Brain Injury
Links & References
- ANWICU. http://www.anwicu.org/
- FICM. GPICS V2. https://www.ficm.ac.uk/news-events-education/news/guidelines-provision-intensive-care-services-gpics-%E2%80%93-second-edition
- PICS. Quality standards for the care of critically ill children. https://picsociety.uk/about-pics/pics-standards/
- Anaesthesia. https://onlinelibrary.wiley.com/journal/13652044
- NEPTUNE. http://neptune-clinical-guidance.co.uk/
- UNODC. https://www.unodc.org/unodc/index.html?ref=menutop
- European Drug Report. http://www.emcdda.europa.eu/edr2019