The summaries of red flags that make up Appendix III indicate which category(ies) of urgency best fits each red flag. Again, this categorisation is simply a guide to the degree of urgency rather than a fixed directive on the appropriate response in a particular clinical situation.

How to respond to red flags

The response to a red flag in a clinical situation depends very much on what degree of urgency the response merits. In this part of the chapter, the advice given relates to the practicalities of referral to a GP or emergency hospital department within the UK National Health Service (NHS).

Non-urgent red flags

Some red flags are indicators of possible serious disease, and yet the patient does not require urgent treatment, even if the disease actually is present. An example of this is a patient who has features of anaemia, including pallor, breathlessness and palpitations on exertion. Anaemia can have serious underlying causes (e.g. chronic gastrointestinal bleeding, pernicious anaemia), some of which cannot be expected to respond fully to complementary medicine. In a case of anaemia, the patient obviously requires further investigation and, depending on the outcome of those investigations, may require medical treatment. However, if the symptoms have been developing over the course of weeks to months, the patient does not need to be seen by a doctor on the same day.

Another example of a non-urgent red flag is the child who has symptoms that indicate occasional bouts of mild asthma. In this case referral is recommended more for confirmation of diagnosis, and so that the patient can have access to medical advice about how to manage a potentially serious condition, rather than simply for treatment. It will be obvious that in such a situation the child does not need to be seen urgently.

Most of the red flags of cancer have been prioritised as of non-urgent priority. This is because such features usually have taken weeks to develop, and a delay of 1 or 2 days is not critical in the course of most cancers. In the UK, the NHS referral system is structured so that the patient demonstrating red flags of cancer is seen by a hospital specialist within 2 weeks of referral by their GP, so to be seen by the GP within only a few days of referral would be ideal in order to minimise the total wait. Of course, there will be some situations in which you will wish to make a high-priority referral for patients showing features of cancer, either because of rapidity of progression of symptoms, or in order to allay anxiety for the patient.

Those red flags that have been categorised as non-urgent will require non-urgent referral. What this means is that, in these situations, it can be suggested to the patient to make a non-urgent appointment with their GP. This means that the patient will be seen within the next few days. In this situation a letter of referral can be prepared, although this may not be necessary if the patient is capable of communicating the essential information. A letter can either be taken to the doctor by the patient (the most reliable route) or can be sent by post to the practice (more likely to be delayed or go astray). A guide to writing letters of referral to doctors is to be found in Chapter 6.3c.

High-priority red flags

Some of the red flags are indicators of serious disease, and these merit seeking a medical opinion on the same day. This is because there is a possibility that the condition of the patient might deteriorate rapidly without treatment. An example of a high-priority case is the situation of haemoptysis (coughing up blood) in a man who has lost 2 stone in weight over the past few months (strong indicators of lung cancer or tuberculosis). In this case, the potential for serious blood loss or the possibility of contagiousness makes the referral a high priority.

In high-priority situations it may be best practice to speak to the patient’s medical doctor. It is appropriate in such cases to telephone the patient’s practice to confirm a time in that day when you can talk to one of the doctors. After discussion, if the doctor agrees with your assessment of urgency, a same-day appointment for the patient can be made. Alternatively, it may be more appropriate that the patient makes this referral themselves, and they can be advised to request a same-day appointment with their doctor.

In such situations it is good practice to give the patient a letter describing the clinical findings and concerns to take to their doctor before they leave your clinic. In a high-priority case, a hand-written referral letter on headed notepaper is acceptable (see Chapter 6.3c).

Urgent red flags

In some cases red flags indicate that the patient requires urgent medical assessment. If you are absolutely sure that the patient needs this, it is appropriate to dial 999 (911 in the USA) to request an ambulance to take the patient to hospital. A less dramatic option is to ring the patient’s practice and ask to speak to a doctor urgently in order to get his or her advice about referral to hospital. If there is some uncertainty, the doctor may choose to visit the patient first, or ask for them to come to the practice to be seen before an ambulance is called.

In those urgent cases in which you are unlikely to meet with the examining doctor, it is good practice to hand write the reason for referral in a letter that is either taken with the patient to the hospital or given to the patient’s doctor when he or she arrives (see Chapter 6.3c).

The summary of red flags of disease: Appendix III

The red flags of disease are summarised in Appendix III. In the first part of this appendix (Section A), the tables of red flags are presented according to physiological system. Each red flag is labelled according to priority of referral:

_*	non-urgent referral
_**	high-priority referral
_***	urgent referral

For many of the red flags listed, the labelling indicates a range of degrees of priority (e.g. */**). For these red flags the precise level of priority depends on other characteristics of the individual case, which should become clear according to the particular clinical situation.

Section B in Appendix III presents the red flags according to symptom keywords to enable easy reference in a clinical situation.

Section C in Appendix III summarises the high-priority and urgent situations in which first-aid management is indicated, and gives some guidance on first-aid treatments. This guidance is intended to supplement the periodic updates of first-aid training that it is advisable for all complementary medical practitioners to undergo.

Chapter 6.3b Withdrawing from conventional medication

Learning points

At the end of this chapter you will be able to:

• describe the ways in which the body might respond to the withdrawal of a long-term medication

• categorise a drug according to the ease with which it can be withdrawn

• guide a patient through the process of drug withdrawal using an approach that is both safe and respectful of the prescribing doctor.

Estimated time for chapter: 90 minutes.

A review of the action of drugs on the body

This first section of this chapter on withdrawal from conventional medication reviews the physical and energetic effects that drugs are understood to have on the body. These effects were first described in Chapters 1.2c and 1.3b.

The physical effects of drugs on the body

The range of physical effects that drugs can have on the body were introduced in Chapter 1.2c, and are summarised in Table 6.3b-I.

Table 6.3b-I The categorisation of drugs according to the nine modes of physical action

Category	Mode of action of drug	Example
1	Replaces a deficient substance that is normally obtained from the diet	Iron (ferrous sulfate) in iron-deficiency anaemia
2	Replaces a deficient substance that is normally produced by the body	Insulin in diabetes mellitus
3	Kills or suppresses the growth of infectious agents (microbes and other life-forms that cause infection)	Penicillin in meningitis
4	Counteracts the damage caused by toxins	Acetylcysteine infusion in paracetamol overdose
5	Toxic to rapidly dividing human cells, in particular to cancer cells	Vincristine used in cancer chemotherapy
6	Specifically stimulates the immune response by the introduction of an antigen	Polio vaccine
7	Artificially stimulates natural bodily functions	Clomifene used to stimulate ovulation
8	Suppresses natural bodily functions	Corticosteroids used to suppress the immune response
9	Other drugs that directly counteract the symptoms (manifestation) of a disease process rather than its root cause	Digoxin in heart failure; paracetamol in headache

The energetic effects of drugs on the body

It was explained in Chapter 1.3b that drugs can affect the energetics of the body in one or more of the following ways: cure, suppression, drug-induced disease and placebo. Table 6.3b-II illustrates the predominant energetic effect that may be associated with therapeutic results for each of the nine categories of drugs grouped by physical action in Table 6.3b-I. Table 6.3b-II does not mention the placebo effect, as this is likely to have some positive impact to some degree in all therapeutic prescriptions.

Table 6.3b-II Energetic interpretations of the therapeutic effects of drugs according to the nine modes of drug action

Category	Mode of action of drug	Energetic interpretation of therapeutic effect
1	Replaces a deficient substance that is normally obtained from the diet	Usually cure (when it targets the root cause) Can be suppression Most side-effects are due to drug-induced disease
2	Replaces a deficient substance that is normally produced by the body	Usually cure (when it targets the root cause) Can be suppression
3	Kills or suppresses the growth of infectious agents	Cure, when full clearance of the pathogen occurs in a previously healthy individual Suppression, if the infection is the expression of a Pathogenic Factor already present or when the pathogen is not cleared
4	Counteracts the damage caused by toxins	Cure
5	Toxic to rapidly dividing human cells	Suppression
6	Specifically stimulates the immune response by the introduction of an antigen	Drug-induced disease, and possibly Suppression (of the future expression of a Pathogenic Factor)
7	Other drugs that artificially stimulate natural bodily functions	Drug-induced disease or suppression
8	Suppresses natural bodily functions	Drug-induced disease or suppression
9	Other drugs that directly counteract the symptoms of a disease process	Suppression

The three energetic effects that are most relevant to the withdrawal of prescribed medication are those of cure, suppression and drug-induced disease. When a complementary medical practitioner is faced with a patient who wants to withdraw from conventional medication, it is valuable first to take some time to consider which of these three effects may be most relevant for the patient.

Withdrawal from suppressive medication

Chapter 1.3b proposes that suppressive drugs are those that treat the manifest symptoms of a condition without dealing with the root cause. One drug that is suppressive according to this definition is salbutamol, which when inhaled can be remarkably effective in relieving an attack of asthma. Salbutamol is known to act by means of stimulating the cellular receptors (beta receptors) in the bronchi and bronchioles, which normally respond to the action of the hormones adrenaline and noradrenaline. By acting at a chemical level, this drug induces a bodily change, in this case relaxation of the smooth muscle that encircles the lining of the small airways in the lungs. This is how salbutamol causes relief of symptoms. However, by suppressing the asthma, the stressor that has caused the asthma attack, which may actually be a combination of diverse factors such as environmental triggers and emotional disturbance, has not been removed. With symptomatic treatment such as salbutamol, the stressor is likely to remain, and so may possibly cause more subtle or intransigent symptoms at a later date.

It makes sense then, that when suppressive medication is withdrawn, suppressed symptoms may well return. This can occur almost immediately, as would be the experience of the asthmatic who becomes wheezy once he or she has come to the end of their supply of salbutamol. However, this return of symptoms can be delayed. For example, following the withdrawal of some treatments, such as at the conclusion of cancer treatment, the suppressed symptoms (in this case the cancer) do not return immediately, and may even not return at all. According to the theory of suppression, this is explained by the supposition that the original imbalance is still likely to be present, but is now expressed in a different way in the body, such as in the form of depression, or that the imbalance has been rectified by a different means, such as modification of harmful lifestyle factors. A move towards greater balance, therefore, may be accompanied by a recurrence of the original symptoms at a later date. However, a subsequent move towards balance need not always result in recurrence of the original symptoms.

It is important to acknowledge that this idea of suppression springs from complementary medical theory. In contrast, the conventional medical view is that when a drug causes suppression of symptoms this has no lasting deleterious effect. The idea that an imbalance can be pushed away from the surface only to emerge in a different part of the body is not considered within the conventional medical approach.

From an energetic perspective, replacement therapy is an unusual example of a long-term prescription drug. In the case of some forms of replacement therapy (e.g. insulin in type 1 diabetes), the patient cannot survive without the drug. Although the replacement therapy certainly suppresses symptoms, it has been argued in this text that it cannot be described as energetically suppressive. Because there is no doubt that replacement therapy always returns a patient to a more balanced state, then it has to be described as curative in nature.

To summarise, withdrawal from a suppressive drug might be expected from a holistic perspective to have the following consequences: recurrence of the original symptoms either immediately or at a later date, or persistence of the original imbalance expressed in some way at a deeper level. In some cases there might be no symptoms because of total resolution of the original imbalance, but this would only be expected if the patient had been making some positive emotional and lifestyle changes while taking the drug.