Estimated time for chapter: 60 minutes.
Throughout the study of the various diseases considered so far, the red flags of disease have been systematically introduced. In this chapter the rationale for describing certain clusters of symptoms and signs as red flags is clarified. The chapter continues with some guidance on how to prioritise patients who present with any combination of these warning symptoms and signs, and on how to refer patients to conventional medical practitioners. A summary of the red flags in a format designed for quick reference in clinical practice is given in Appendix III.
The red flags listed in this text have been defined from the perspective of a practitioner of complementary medicine. Red flags are those symptoms and signs that, if elicited by a complementary medical practitioner, merit referral to a conventional doctor. Referral is indicated because the presence of red flags indicates the possibility of a condition that may not respond fully to complementary medical treatment and/or which may benefit from conventional diagnosis, advice or treatment.
It is important to clarify at this stage that the red flags indicate those potentially serious conditions in which the patient would be in need of further tests, advice or treatment. Complementary medical practitioners vary greatly in their opinions about the benefits of medical treatment. For this reason, some readers of this text may not agree that the presence of a particular red flag need be seen as an indication of referral. However, there is a powerful argument that patients are ideally offered the freedom of choice between treatment options. Referral for a medical opinion offers patients the opportunity to learn about the conventional medical perspective of their condition and thus the freedom to make an informed choice about its future management.
There are very few examples of when complementary medicine would not be beneficial to someone who is also receiving conventional investigation or treatment for a condition. Therefore, referral of a patient in response to red flag symptoms or signs does not mean that complementary medical treatment need be discontinued.
Red flags are guides to referral, not absolute indicators. Often, the red flags described in this text specify a fixed, measurable point at which referral should be considered; for example, high fever (especially if over 40°C) not responding to treatment within 2 hours in a child. Of course, in reality, disease falls somewhere along a spectrum that bridges the state of being of little concern and one of being of serious concern. A disease does not suddenly become serious once a fixed point has passed. Moreover, what might constitute a red flag in one individual may be of less concern in someone of a stronger constitution.
Bearing in mind the potential flexibility in the interpretation of red flag syndromes, there may be a case when the conclusion is that referral is unnecessary even though a red flag is present. Conversely, if a nagging uncertainty persists in a clinical situation, even if the patient does not fit the criteria for any of the red flags, it is safest to trust your clinical instincts and refer. The important thing is that there is an awareness of these indicators of possible serious disease, and that in every case time has been taken to consider their relevance for patients in the given clinical situation.
The various red flags merit different responses from the practitioner according to the nature of the underlying condition of which they may be an indication. To aid with decision-making in the clinical situation, the red flags listed in this text are assigned to one or more of three categories of urgency:
• Non-urgent: a non-urgent referral means that the patient can be encouraged to make a routine appointment with the medical practitioner (GP), which would ideally take place within 7 days at the most.
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.
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).
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.
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).
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 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:
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 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.
Estimated time for chapter: 90 minutes.
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.
|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|
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.
|Category||Mode of action of drug||Energetic interpretation of therapeutic effect|
|1||Replaces a deficient substance that is normally obtained from the diet|
|2||Replaces a deficient substance that is normally produced by the body|
|3||Kills or suppresses the growth of infectious agents|
|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|
|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.
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.
Most drugs also have side-effects that are unrelated to the condition which they are prescribed to treat. For example, inhaled salbutamol has a range of short-term side-effects, including tremor, palpitations and tachycardia. These side-effects can be explained in terms of the action of the drug in stimulating the beta receptors in other parts of the body, including the skeletal muscles and the heart muscle. These effects would occur in asthmatics and non-asthmatics alike. These effects are an example of drug-induced disease. They are not manifestations of suppression. If the drug is withdrawn, it would be expected that these less beneficial manifestations of drug-induced disease would, in most cases, subside.
It is recognised that there are some drugs that cause the body to change in such a way that the patient comes to be reliant on the presence of that drug for a ‘balanced existence’. What this means is that, if the drug is withdrawn, the patient will experience a range of symptoms which, at least temporarily, will disturb their normal ability to cope with the stresses of everyday living. This effect is known as ‘drug dependence’.
Drug dependence may manifest primarily in the physical body. For example, withdrawal from certain types of antihypertensive medication can lead to a dangerous rise in blood pressure. It is as if the body has ‘forgotten’ how to control blood pressure within a relatively safe range. This type of dependence is termed ‘physical dependence’.
Other drugs seem to have effects that are more pronounced in the emotional and mental realms. For example, withdrawal from nicotine can lead to a syndrome of psychological symptoms, including cravings for nicotine, irritability, insomnia and anxiety. This aspect of dependence is termed ‘psychological dependence’.
‘Addiction’ is a term that is often used interchangeably with ‘dependence’. Medically speaking, the term ‘addiction’ is used more precisely to mean a state of dependence that leads to ‘drug-seeking behaviour’ on withdrawal of the drug. A person who is addicted to a drug may spend a significant proportion of their time and effort in ensuring that the drug is in steady supply. Drugs of addiction are those that induce a powerful state of psychological dependence.
To understand what is happening to the body in drug dependence it is helpful to consider the chemical changes that might occur in response to a drug. Conventional pharmacology describes the response of the body to a drug in terms of adaptation. Many drugs act by mimicking the action of one or more of the natural chemicals of the body. These natural chemicals include the hormones and neurotransmitters that connect with receptor proteins on the surface of certain cells to effect a physiological change. The drug salbutamol acts in this way, as does cortisone (an artificial corticosteroid hormone).
If a drug is present in the body for some time, in many cases the body adapts to its presence by reducing the production of the natural chemical that the drug is mimicking. For example, in the case of a long-term prescription of cortisone, the adrenal cortex ceases to produce the normal amounts of natural corticosteroids. In fact, the tissue of the adrenal cortex actually becomes wasted in someone who is taking a long-term prescription of cortisone. This adaptation is potentially fatal if the artificial cortisone is withdrawn suddenly. The shrunken adrenal cortex is no longer able to respond rapidly to produce the level of corticosteroids necessary for a healthy response to stress. From an energetic perspective, this bodily change is a clear example of drug-induced disease.
Other drugs stimulate the body to counteract their effects by increasing the number of protein receptors on the cell membranes of the tissues at which the drug is acting. This means that more drug is required to have the same effect as time goes on. This situation, known as ‘tolerance’, is very important to understand from the perspective of drug withdrawal. If tolerance to the drug has developed, then on withdrawal the normal levels of the body chemicals that act at those tissues will be insufficient to effect a healthy response. Opiates (including morphine and heroin) are drugs that are known to induce a state of tolerance. Whether used medicinally for pain relief, or illicitly for their psychological effects, increasing doses of opiates are required over time to generate the same effect. It is well recognised that opiates mimic natural body chemicals, including the endorphins. As tolerance develops, it is believed that the numbers of cellular endorphin (opiate) receptors in the body increase. On withdrawal, the body is simply unable to produce sufficient quantities of natural endorphin to stimulate the increased numbers of receptors in the body, and the complex syndrome of opiate withdrawal is experienced.
Tolerance is, of course, a particular aspect of drug dependence. Once a person has become tolerant to a drug, withdrawal is very likely to lead to unpleasant symptoms. The development of tolerance is another example of drug-induced disease.