The recent lidocaine (Versatis) patch debate seemed, on the surface, to be just another healthcare resource allocation decided by the media in the face of Health Service Executive (HSE) intransigence, and a disregard of the pain and suffering of ordinary people.

Or was it just General Practitioners (GPs) overzealously prescribing a product because they had one too many visits from a charming drug rep? Perhaps it was a combination of all three, but a certain anomaly struck me, and troubled me the more I thought about it. Why are there more patients using it in Ireland than the entire United Kingdom (UK)? Some 25,000 patients in fact, according to 2016 HSE figures.² This is curious phenomena, since the indication for its use is limited mainly to postherpetic neuralgia (PHN) nor is it the first-line treatment either.

More interestingly, data from the UK would suggest that its effect is little more than placebo in most cases.³ But since a placebo can be elicited in up to 60 per cent of subjects, this effect is not to be dismissed readily.

This number, however, is dwarfed by the almost 500,000 patients on either an anti­depressant or an anxiolytic, figures extrapolated from a special report by Catherine Shanahan in the Irish Examiner in 2015.⁷ Of more concern in the data obtained from the HSE is that up to 23 per cent of General Medical Services (GMS) patients in Cork were on these medications. Why so much use of these psychotropics, and what exactly are we medicating?

To explore some possible answers, I will digress for a while — but stay with me.

The rat trap of epigenetics
In the early 90s, a molecular biologist and geneticist Moshe Szyf and neurobiologist Michael Meaney at McGill University in Montréal looked at anxiety traits in rats and subsequently humans, showing that traits are passed from generation to generation via epigenetic mechanisms i.e. the environment’s impact on gene expression.
Their work suggested that foetal and early postnatal life experiences greatly determined the anxiety levels in several generations of rats — not just the traumatised generation.⁵ They have written 24 papers on this subject.

Further evidence for intergenerational epigenetic effects comes from studies looking at offspring from those who were third trimester foetuses in the winter of 1944 in Holland (known as the Dutch Hunger Winter Study) when food scarcity produced a temporary starvation period — this exposure produced ‘thrifty metabolisms’ in that generation, and in several generations thereafter, resulting in a 20-fold increase in the background rates of obesity and metabolic disorders.¹²

These studies, including Dr David Barker’s FOAD (foetal origins of adult disease research) ⁹ would seem to indicate that trauma of many sorts, if sufficient and sustained, has lasting, intergenerational effects on gene expression via epigenetic phenomena.

If we add this evidence to the findings of the Adverse Childhood Experiences (ACEs) study carried out on behalf of Kaiser Permanente by Drs Vincent Felitti and Robert Anda in the 1980s we begin to see the real progenitors of adult disease. The ACE study showed a dose response correlation between the number of ACEs e.g. physical, sexual or emotional abuse, having a parent with mental illness, a parent in prison or parental separation and subsequent development of alcohol-related problems, depression, suicide, cardiovascular disease and diabetes.⁸ And this was in a population of white middle-class Americans where confounding factors were taken into consideration leaving only ACEs as the principle causative agents.

Irish context
So we have studies showing maternal antenatal stresses and postnatal stresses in the child leading to poorer adult health outcomes. Couple this with data from socioeconomic status and health^12,7 and we begin to wonder how, in an Irish context, this information may be used to formulate a possible explanation for our abnormally high use of these medications.

A situation where those in pain have no language to describe their problems other than to ape a simplistic medico babble and their doctors have nothing to decipher the meaning of their patient’s distress, so they resort to sticking a plaster on it. How metaphorically appropriate.

Drs Gabor Mate and Robert Sapolsky, in separate books^10,11 discuss in detail the priming of the hypothalamic-pituitary-adrenal axis (HPA axis) by high levels of circulating glucocorticoids in various stages of our lives.

This stress response appears to have dramatic effects from very early in life, as shown by Meaney and Szyf in rats and as seen in the frontal lobe development of children from low socioeconomic status (SES) groups. The higher the level of stress the greater the effects on brain development.

This results in poor concentration, motivation, delayed gratification and impulse control.
It could be argued that we are seeing in these children environmentally induced acquired brain injuries that are being labelled as attention deficit hyperactivity disorder, oppositional defiant disorder (ODD) and addiction.
These authors also go on to suggest that these high levels of stress usually caused by extremely difficult circumstances contribute to the development of mental illness, autoimmune disorders, chronic pain conditions such as irritable bowel syndrome (IBS) and fibromyalgia and may even impair the immune system sufficiently to be a contributing factor in the development of some cancers.
Another author Prof Matthew Walker suggests that the disruption of sleep on a chronic basis by stress may be a causative agent in dementia and cancers also.¹³

Groundbreaking documentaries
How does this all relate to an Irish context? In her groundbreaking documentaries, States of Fear and Behind the Walls, the late Mary
Raftery, journalist and documentary maker, exposed the repressive use of institutions by both the Catholic Church and the Irish State, to incarcerate those who deviated from a very narrow definition of normality.⁴

The documentary makes the point that at one stage, Ireland had more people in institutions per head of population than the former Soviet Union (a figure one has to question as to its veracity given the secret nature of the former USSR, but frightening nonetheless). However, in order to incarcerate that number of people, a society at large would have to collude with the authorities.

What does this do to a people? It is easy to dismiss this conjecture as being of no current relevance, of being part of an Ireland that is all but gone. But as the work of Meaney and Szyf, and as the Dutch Hunger Winter Study show, these effects can last several generations.

When we combine a historically abusive past with the reductionist biomedical model of healthcare delivery, overseen by vested interests that benefit from vast numbers of people prescribed usually totally inappropriate treatments, we reach our current irrational situation.

A situation where those in pain have no language to describe their problems, other than to ape a simplistic medico babble, and their doctors have nothing to decipher the meaning of their patients’ distress, so they resort to sticking a plaster on it. How metaphorically appropriate!

Model criticisms
A practical criticism of the stress, trauma-­induced model is that Irish doctors do not have the resources; they simply have to deal with the immediacy of the problems they are faced with. We deal with endpoints and never really look upstream. I think we do this because there are powerful vested interests for whom the endpoints are big business, and upstreaming is a complex process that involves real multi­disciplinary working not necessarily amenable to the doctor-patient, 10-minute, magic bullet model.
Our current model pays lip service to real issues such as housing, poverty, social isolation, community fragmentation, lack of meaningful jobs and personal identity. Instead, we do little better than telling people to eat like a Mediterranean, run like a Kenyan, meditate like a Zen Buddhist monk, drink like a fish (last time I checked, fish don’t drink alcohol), don’t smoke and get a pet.
Most people understand none but the latter, especially those in lower SES’s, so is it any wonder nobody’s listening.

Closing the gap
This credibility gap cannot be closed by health professionals alone. It would take fundamental changes in how the State addresses the root causes of ill-health. One of those measures could be a guaranteed annual income — also known as a universal basic income — as piloted in Dauphin, Canada in 1973, and more recently in Finland.⁶ , ^14,15 This would improve personal financial security, decrease poverty, and possibly reduce, as in the Canadian study, mental health and GP service use as well as increasing the happiness quotient of Ireland.

How is it paid for? I do not know — ask the Finns they seem to be able to create the most forward-thinking plans for the betterment of their country.

At a doctor-patient level we could utilise the data from the ACE study by screening and thus appropriately directing resources at the most vulnerable in society. Perhaps many of those who are being prescribed lidocaine patches or psychotropic would score highly on an ACEs questionnaire. Who knows, because nobody has yet asked the question?

In summary, our patched up and drugged up society is one in which the pain of several generations is being ignored or mislabelled by a well-intentioned, yet dysfunctional, array of health professionals who for whatever reason cannot or will not see the wood for the trees.

References
1. https://www.hse.ie/eng/service...rsatis-summaryreport
2. http://www.lancsmmg.nhs.uk/wp-...in-PHN-post-LMMG.pdf
3. http://www.awmsg.org/docs/medm...priority+for+funding
4. http://www.thejournal.ie/‘we-branded-people-lunatics-and-locked-them-away’-217965-Sep2011/
5. Nature Neuroscience 12,342-348 (2009)
6. https://en.wikipedia.org/wiki/Mincome
7. https://www.irishexaminer.com/...neration-319128.html
8. https://www.cdc.gov/Adverse Childhood Experiences
9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4608552
10. When the body says no’ Dr Gabor Mate
11. ‘Why zebras don’t get ulcers’ Prof.Robert Sapolsky
12. https://www.PNAS.org Dutch hunger winter and the developmental origins of health and disease
13. Why we sleep’ Prof Matthew Walker
14. https://www.theguardian.com/so...low-wages-fewer-jobs
15. http://www.independent.co.uk/n...nefits-a8082576.html

Original link  >  https://www.imt.ie/features-op...-society-19-04-2018/