6.3a The red flags of disease: a review
Throughout the study of the various diseases considered so far, the red flags of disease have been systematically introduced. In this section the rationale for describing certain clusters of symptoms and signs as red flags is clarified. The section continues with some guidance on how to prioritize 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 can be found in Appendix III.
The red flags of disease
Red flags are those symptoms and signs which, if elicited by an acupuncturist, merit referral to a conventional doctor. Referral is indicated because the presence of red flags indicates the possibility of a condition that either may not respond fully to non-medical treatment or may benefit further from conventional diagnosis, advice or treatment.
Referral may be considered for the following four broad reasons:
•to enable the patient to have access to treatment that will benefit their medical condition
•for investigations to exclude the possibility of serious disease
•for investigations to confirm a diagnosis and help guide treatment
•for access to advice on the management of a complex condition.
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. Not all of the red flag conditions listed in this text indicate that the patient will need medical treatment. In some cases referral is advised so that the patient can have tests to exclude an unlikely but important treatable condition (e.g. a mole that might have features of skin cancer), or to obtain a medical diagnosis to guide in the future management of the condition (e.g. ascertaining the severity and cause of suspected anemia). In other situations it may be important to refer so that the patient can have access to detailed medical advice (e.g. on the complexity of assessing coronary risk and how this impacts on subsequent choice of medical treatment).
Use of acupuncture and red flags
There are very few examples of when acupuncture would not be beneficial to someone who is also receiving conventional investigation or treatment for a condition. Therefore, referral in response to a patient with red flag symptoms or signs does not mean that acupuncture need be discontinued, as long as the therapist is sure that the patient has given informed consent to this treatment.
The red flags as guides to referral
Red flags are guides to referral and 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 two hours in a child. In reality, of course, disease falls somewhere along a spectrum that bridges the state of being of little concern and one of being of serious concern (see Figure 6.3a-I). 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.
Figure 6.3a-I This illustrates the fact that red flags have to fall at a fixed point along the spectrum of symptoms of mild to serious disease
Bearing in mind the potential flexibility of interpretation of red flag syndromes, there may well be situations in which the clinical opinion of the acupuncturist 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 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 clinical situation.
Prioritization of the red flags
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. These categories are:
* Non-urgent: A non-urgent referral means that the patient can be encouraged to make a routine appointment with a medical practitioner, and this ideally will take place within seven days at the most.
** High priority: A high priority referral means that a medical practitioner assesses the patient within the same day.
*** Urgent: The urgent category is for those situations when the patient requires immediate medical attention, and this may mean summoning an on-call doctor or calling paramedics to the scene.
The summaries of red flags that can be found in Appendix III indicate by means of the symbols * or ** or *** which category of urgency best fits each red flag. Again, this categorization is simply a guide to the degree of urgency rather than a fixed directive on the appropriate response in a particular clinical situation.
For many of the listed red flags, the labeling 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.
How to respond to the red flags
The response to a red flag in a clinical situation depends very much on what degree of urgency the response merits. The practicalities of this are described in Section 6.3c.
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 is actually present. An example of this is the patient who has features of anemia, including pallor, breathlessness and palpitations on exertion. Anemia can have serious underlying causes, for example, chronic gastrointestinal bleeding or pernicious anemia, some of which cannot be expected to respond fully to non-medical therapies. In a case of anemia, the patient obviously requires further investigation and may possibly require medical treatment according to the outcome of the investigations. However, if the symptoms have been developing over the course of weeks to months, the patient does not need to be seen by the doctor on the same day.
Another example of a non-urgent red flag is the well 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 prioritized as of non-urgent priority. This is because such features have usually taken weeks to develop, and one or two days’ delay is not critical in the course of most cancers. For example, in the UK, the National Health Service (NHS) referral system is structured so that the patient demonstrating red flag signs of cancer is seen by a hospital specialist within two weeks of referral by their GP. Therefore the acupuncturist ideally needs to ensure that their patient with a red flag of cancer is seen by a GP within a maximum of a few days of referral in order to minimize the total wait, but there would usually be no need for an urgent response to finding the red flags. Of course, there will be some situations in which it would be appropriate 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 categorized as non-urgent will require non-urgent referral. 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 passing on the essential information verbally. If a letter is needed, it can either be taken to the doctor by the patient (the most reliable approach) or can be sent by post to the practice (more likely to be delayed or to go astray). A guide to writing letters of referral to general practitioners (GPs) can be found in Section 6.3c.
High priority red flags
Some of the listed red flags are indicators of serious disease, and these merit seeking a medical opinion on the same day, because there is a possibility that the patient’s condition might deteriorate rapidly without treatment. An example of a high priority case is hemoptysis (coughing up blood) in a patient who has lost two stone in weight over the past few months (strong indicators of lung cancer or tuberculosis). In this case, the potential of serious blood loss or the possibility of contagiousness makes the referral high priority.
In high priority situations, it may help with the referral for the acupuncturist to speak to the patient’s medical doctor by telephone to explain the clinical situation. After discussion, if the GP agrees with the assessment of urgency, an appropriate appointment for the patient can be made.
Alternatively, it may be more appropriate that patients make these referrals themselves, and they should request a same-day appointment with their GP.
In such situations it is good practice to give the patient a letter describing the clinical findings and concerns to take to their GP before they leave the clinic (see also Section 6.3c).
Urgent red flags
In some cases the red flags indicate that the patient requires urgent medical assessment. In these cases it may be appropriate to request an emergency ambulance to take the patient to hospital. A less dramatic option is to telephone the patient’s practice to ask to speak to a GP urgently in order to get their advice about referral to hospital. If there is some uncertainty, the GP may choose to visit the patient first, or ask for them to come to the practice to be seen before the paramedics are called.
In those urgent cases in which it is unlikely that the acupuncturist will meet the examining doctor, it will be helpful to produce a brief clinical summary letter to be taken with the patient to the hospital or to be given to the GP when they arrive (see also Section 6.3c).
Summaries of the red flags of disease
The red flags of disease are summarized in a format designed for easy access in Appendix III. Throughout the text, red flags have been systematically presented according to the physiological system of the body in which the disease they indicate might have become manifest. If the red flags are to be incorporated into a structured teaching clinical medicine program, this structure enables the red flags to be taught in a systematic way.
However, in the clinic situation, symptoms do not arise in a systematic way. Rather, in the clinic the question “Is this symptom/sign serious?” is more likely to be asked than “I wonder if there are any serious symptoms arising from this patient’s digestive system?” For this reason, Appendix III presents the red flags according to symptom keywords to enable easy reference in a clinical situation.
6.3b Withdrawing from conventional medication
A review of the action of drugs on the body
This first section reviews the physical and energetic effects that drugs are understood to have on the body. These effects were first described in Sections 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 was introduced in Section 1.2c, and are summarized in Table 6.3b-I below.
Mode of action of drug
Examples of drugs
Replaces a deficient substance that is normally obtained from the diet
Iron (ferrous sulfate) in iron-deficiency anemia
Kills or suppresses the growth of infectious agents (microbes and other life forms that cause infection)
Benzylpenicillin sodium in meningitis
Toxic to rapidly dividing human cells, in particular, cancer cells
Vincristine in cancer chemotherapy
Replaces a substance that is normally produced by the body
Insulin in diabetes mellitus
Specifically stimulates the immune response by the introduction of an antigen
Other drugs that artificially stimulate natural bodily functions
Clomifene to stimulate ovulation
Suppresses natural bodily functions
Corticosteroids used to suppress the immune response in autoimmune disease
Counteracts the damage caused by toxins
Acetylcysteine in paracetamol overdose
The energetic effects of drugs on the body
It was explained in Section 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 eight 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.
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.
Table 6.3b-II Energetic interpretations of the therapeutic effects of drugs according to the modes of drug action
Mode of action of drug
Replaces a deficient substance that is normally obtained from the diet
Usually returns the body to a state of more balance: energetic cure
However, if given without attention to a deeper underlying cause of deficiency: suppression
Kills or suppresses the growth of infectious agents (microbes and other life forms that cause infection)
In infections that are a manifestation of strong Evil (Xie Qi) Pathogenic Factor (in Chinese medicine terms) in a healthy individual, the drug may enable full clearance of the bacteria that are causing the manifestation of the infection, and so will enable the restoration of balance as the healthy body can then easily recover naturally: energetic cure
In infections that have occurred as a result of an underlying imbalance in the individual, the treatment does not target the root cause, and so tends to be suppressive, even with full clearance of the bacterial overgrowth: suppression
In some cases the end result is one of Residual Pathogenic Factor, and this means that symptoms will continue to present at a deeper energetic level: suppression
Toxic to rapidly dividing human cells
These treatments always target the manifestation (a tumor) of a deep underlying imbalance: suppression
They also are very toxic to a wide range of healthy bodily tissues and are characterized by: marked drug-induced disease
In cases in which the body will never be able to produce the essential substance ever again: energetic cure
In cases when the body is under-producing an essential substance as a result of an ongoing deeper disease process: suppression
Specifically stimulates the immune response by introduction of an antigen
Other drugs that stimulate natural bodily functions
If stimulants mask the symptoms of an imbalance then this is: suppression
When used when there is no medical disease: drug-induced disease
Suppresses natural bodily functions
The suppression of a natural bodily function is not targeting the root cause of the problem: suppression
Counteracts the damage caused by toxins
These treatments reverse the damage that would have been caused by an external toxic substance: energetic cure
Withdrawal from suppressive medication
In Section 1.3b it is proposed 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 asthma attack. 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 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 treated. 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 patient who becomes wheezy once they have 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 either 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 may therefore 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 take note that 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 consistent with the conventional medical understanding of physiology.
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, it has to be described as curative in nature.
To summarize, 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 that they are prescribed to treat. For example, inhaled salbutamol has a range of short-term side effects, including tremor, palpitations and tachycardia. These 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. They are an example of drug-induced disease, and 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.
However, there is one particular aspect of drug-induced disease that may lead to persistent problems for the patient, and this is the development of drug dependence.
It is recognized 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 that, 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.
In reality, the distinction is not that clear-cut. Withdrawal from drugs of dependence will usually lead to a constellation of physical and psychological symptoms.
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 behavior 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.
The mechanism of drug 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 of the 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, 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 recognized 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 endorphins to stimulate the increased numbers of receptors in the body, and the complex syndrome of opiate withdrawal is experienced.
Tolerance is 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.
The time for recovery from the physiological imbalances induced in drug dependence depends very much on the drug concerned. For example, it is generally accepted that physical recovery in acute withdrawal from alcohol and opiates occurs in a relatively short timescale of about two weeks, whereas recovery from a long-term prescription of a minor tranquillizer such as diazepam may take many more weeks. The timescale of the prescription is another important factor to take into consideration. The longer the body has been exposed to a drug, the more it will have adapted to accommodate that drug. This is why it is safe for a patient to withdraw suddenly from a short course of corticosteroids (less than one week), but if the course has lasted for weeks to months, the withdrawal must be extremely gradual.
Social reasons for drug dependence
So far drug dependence has been described in terms of the physiological adaptation to the chemical of the drug. However, in many cases of drug dependence there are some far more complex factors in the equation. In particular, cultural and social factors play a profound role in dependence on recreational drugs. This role is, by its very nature, difficult to explore or quantify. Although a heroin addict can withdraw physically from the habit over a period of a few days, an extreme vulnerability to returning to the habit remains for much longer, and sometimes for life. This suggests that the addict is left with a lasting belief that the drug has something to offer, and particularly so in certain settings. Animal experiments have suggested that a brief exposure to certain recreational drugs can lead to a lasting state of depletion of certain neurotransmitters in the brain. This physical phenomenon might explain, at least in part, the persistent state of vulnerability experienced by some drug users following withdrawal from a drug of addiction.
Drug rehabilitation programs aim to work at reducing this vulnerability. Such programs take place in a setting that separates the former addict from the factors that might increase their tendency to return to using the drug. A rehabilitation program often begins with a short period of medical support during the time of physical withdrawal from the drug, followed by weeks to months in which the former addict is encouraged to find a way of living that avoids those triggers that might lead to a return to the habit.
Although social factors might play a less significant role in the withdrawal from most prescribed medication, it is worth considering that they may be important in some cases. The use of a prescribed drug may, in some cases, bring rewards that are additional to the relief from symptoms. The possibility of an additional, less obvious benefit resulting from a treatment in this way is conventionally referred to as secondary gain. Reinforcement in the sick role and feelings of protection are two examples of the additional rewards, or secondary gain, that a prescription might bring.
When to consider withdrawal from medications
The possible negative consequences of drug withdrawal just discussed can be seen to result from two distinct processes. The first is the recurrence of symptoms. In the case of curative treatment, the recurrence of symptoms reflects the fact that cure has not taken place and the drug has been withdrawn too early. In the case of suppressive treatment, it is suppressed symptoms that reappear. In some situations these symptoms may be tolerable and responsive to positive lifestyle change, but in others they may be so severe as to overwhelm the patient.
The second process is the appearance of new symptoms as a consequence of a particular form of drug-induced disease known as drug dependence. In this case the symptoms of drug withdrawal can be profound, and in some cases, life-threatening.
It will be clear from this summary that withdrawal from medication is a process that needs to be managed with care. There are indeed many situations in which withdrawal is a perfectly safe prospect. However, an acupuncturist needs to be familiar with those situations in which it may not be reasonable to consider withdrawal from medication at all, and with those situations in which close medical supervision would be advisable. The remainder of this section is concerned with the practicalities of recognizing those situations when it is safe to withdraw from medication and, if it is recognized to be safe, supporting a patient through the process of withdrawal.
Withdrawing from prescribed medication: a practical approach
The basic principles
When considering withdrawal from long-term medication it is important to consider some basic principles:
•If the treatment is curative in nature, do not consider withdrawal.
•Withdrawal from suppressive medication is very likely to result in recurrence of the symptoms of the original condition, unless the patient has been able to make positive changes in lifestyle or emotions.
•Long-term adaptation of the body to the drug may give rise to an unpleasant withdrawal syndrome.
•In some cases, either the recurrence of the original symptoms or the withdrawal syndrome carries serious health consequences.
Categorization of drugs for withdrawal
Bearing the above-listed principles in mind, the various types of drugs can be categorized according to the main effects that can be expected on their long-term withdrawal. The categories are:
i.The underlying condition is not serious. Recurrence of symptoms is likely; there is no withdrawal syndrome.
ii.The underlying condition is not serious. Recurrence of symptoms is likely; the withdrawal syndrome is unpleasant, but does not seriously threaten health.
iii.Withdrawal may have serious physical or mental health consequences, either because the underlying condition is serious, or because the withdrawal syndrome is dangerous.
iv.Replacement therapy. Withdrawal will result in serious ill health or even death.
This categorization of the individual classes of drugs (ordered by the chapter in which they appear in the British National Formulary (BNF)66) is given in Appendix IV. This is designed to be a reference aid for use in clinical practice.
Practical aspects of withdrawing from medication
Now that the principles that underlie an approach to drug withdrawal have been clarified, the practical aspects of helping patients to withdraw from medication can be explored.
KNOWING WHEN NOT TO WITHDRAW FROM MEDICATION
When considering withdrawal from conventional medication, a fundamental question to ask is: “How much will the patient benefit from withdrawal from medication at the current time?” It may be that the answer to this question leads the practitioner to the conclusion that this is not the time to consider such a change.
Even for category (i) medications, withdrawal will necessarily result in some physical change in the body. Symptoms of the original condition are likely to recur, and will need to be dealt with. The patient needs to be prepared for this change, and willing to make the necessary changes to their lifestyle that will prevent recurrence of the original condition. If the drug is suppressive in nature, any residual symptoms that remain before withdrawal is initiated can only be expected to worsen on withdrawal, even if only temporarily. Therefore, ideally, it needs to be clear that the patient has been making good progress on the treatment before a reduction in medication is contemplated. If not, it may be wise to defer withdrawal until residual symptoms have subsided.
This consideration is even more important for category (ii) and (iii) drugs. Withdrawal from these medications will result in additional distressing symptoms, as well as recurrence of the original symptoms. The patient needs to be in a good state to prepare for the inevitable period of physical and emotional imbalance that will occur on withdrawal.
Withdrawal from category (iv) medication should not, in general, be contemplated. This is absolutely the case if the replacement therapy is a substance that is normally produced by an organ whose function has failed totally. An example of this is insulin replacement therapy in type 1 diabetes mellitus. In the case of patients who are taking replacement therapy to support a failing organ, there is a possibility that complementary medical treatment can enable them to reduce the dose of medication. An example of this is the prescription of thyroxine in autoimmune hypothyroidism. However, in general, in such cases it is not usually necessary to be proactive in the reduction of medication. The dose of medication is balanced against the bodily requirements as measured by medical tests. If the body no longer requires such a high dose, the tests will indicate this, and the doctor will reduce the dose accordingly.
WITHDRAWAL FROM MEDICATION: PREPARATORY STAGES
In all cases of withdrawal from medication it is important to check that the patient is clear about the reasons for withdrawal, and is keen for the process to occur. To make a good decision the patient needs to be equipped with information about the advantages and disadvantages of medication, from both an alternative and a conventional medicine point of view.
If the patient is clear about the pros and cons relating to taking medication and definitely wants to come off the medication, the next stage is to ensure that the patient has the support of their doctor in this process. Most doctors are also keen to reduce medication, and are only reluctant not to if they believe there will be a worsening in the patient’s condition as a result. In many cases, it is appropriate simply for the patient to meet with their doctor to explain that they wish to cut down on their medication. Acupuncturists may also wish to give the patient a supporting letter to take to the doctor, although in most cases of withdrawal from category (i) and (ii) medication this should not be necessary.
Most doctors, if they can see that the patient’s symptoms have improved and that the patient is positive about making the change, will give the patient advice about how to set about the withdrawal process. For the acupuncturist this is the ideal situation; the patient can be supported through the process by means of acupuncture treatment, but the professional responsibility for withdrawal rests with the doctor who initiated the prescription.
It is unwise to set about withdrawal from category (iii) medication without the patient having the support of their doctor. Table IV-3 in Appendix IV indicates that medical supervision is deemed to be essential for the withdrawal of all classes of drug in this category. In such cases it will be appropriate for the acupuncturist to write to the patient’s doctor to demonstrate awareness of the health consequences of withdrawal, and to indicate a commitment to monitor and support the patient through the withdrawal process. Guidance on how to write a letter on this topic is given in Section 6.3c.
SPEED OF WITHDRAWAL
Some drugs can be withdrawn abruptly, as long as the patient is in robust health and is prepared for the consequences of withdrawal. Drugs that can be withdrawn abruptly are those that are given for non-serious conditions and that do not induce a state of physical or emotional dependence. A return of the original symptoms is the main problem for the patient withdrawing from drugs that fit this description. These drugs fall exclusively into categories (i) and (ii), and are indicated by a single asterisk (*) in Tables IV-1 and IV-2 in Appendix IV.
Other drugs need to be withdrawn more slowly. Slow withdrawal will allow the return of the original symptoms to be more gradual, and the symptoms of any withdrawal syndrome to appear less abruptly. Slow withdrawal is very important in situations in which the previous condition has serious emotional or physical features. In general, it is also prudent that drugs that induce a state of dependence are withdrawn gradually.
However, not all drugs that induce dependence should be withdrawn slowly. For example, current medical advice is that people who are addicted to alcohol should withdraw abruptly, and then weather the storm of the inevitable withdrawal period with the aid of alternative physical and emotional support. For some drugs that are highly addictive, gradual withdrawal is less effective than abrupt withdrawal, probably because the drug’s continued presence during the withdrawal process can stimulate an easy return to the original dose.
Slow withdrawal of most of the category (i) and (ii) drugs (indicated in Tables IV-1 and IV-2 in Appendix IV by a double asterisk (**)) can take place over the course of two to four weeks. In slow withdrawal it is advisable not to cut down the dose initially by more than one-third at a time, and to reduce by less if this is possible. The next step down should be made only when the patient has adjusted to the reduced dose, and when withdrawal symptoms have abated. For those drugs indicated by a treble asterisk (***) in the tables in Appendix IV, for example, long-term hypnotics or opiates, the reduction should be even more gradual, with a longer time interval between dose reductions. Full withdrawal may require a few months in some cases.
In many cases medication is given in tablets of fixed dose at prescribed times of the day. When the dose is reduced, the frequency must not be reduced. Instead, the amount given at each time interval needs to be gradually cut down. For example, if the dose is 400mg three times daily, a possible first reduction might be to 300mg three times daily.
Sometimes gradual dose reduction is limited by a tablet of a fixed size. If lower-dose tablets are available, the doctor might be willing to prescribe these. If not, most tablets can be cut in half and then into quarters to aid the gradual reduction process. Even better is for the patient to switch to a liquid preparation of the medication so that doses can be measured using a dosing syringe. Reducing the dose can become confusing for a patient who is used to a certain routine of taking tablets, so it is good practice to prepare a written schedule for the patient, which contains clear instructions about how the dose should be reduced.
ORDER OF WITHDRAWAL OF MEDICATION
Many people are concurrently taking a number of prescribed drugs. It is always safest to focus on withdrawing only one medication at a time so that if any withdrawal symptoms appear, it is clear exactly what has caused them.
WITHDRAWAL FROM CATEGORY (I) MEDICATION
Category (i) medication is prescribed to suppress unpleasant symptoms. It does not induce a significant state of drug dependence. Table IV-1 in Appendix IV indicates that all category (i) medications can either be withdrawn abruptly (*) or gradually over a relatively short period of time (**).
When discussing the withdrawal of a category (i) medication with a patient, it is important to ascertain the previous symptoms of the underlying condition. The patient needs to be advised that the symptoms may well recur after withdrawal, and may even be more severe for some time during the withdrawal process. The return of symptoms is less likely to be as severe if the patient has been making good progress on the treatment and has attended to those lifestyle factors that have been identified as contributing to the root cause of the condition.
Drugs marked with a single asterisk (*) can be withdrawn abruptly. Drugs marked with a double asterisk (**) should be withdrawn gradually (see above, “Speed of withdrawal”). Ideally, the patient is encouraged to inform the prescribing doctor of their decision to stop taking their medication.
WITHDRAWAL FROM CATEGORY (II) MEDICATION
Withdrawal from category (ii) medication is characterized not only by a return of the symptoms of the original condition, but also by the features of a withdrawal syndrome. With drugs that induce a state of physical dependence (see Table IV-2 in Appendix IV), the withdrawal syndrome may manifest in the form of a reappearance of the original symptoms. For example, withdrawal from a stimulant laxative may result in a period of constipation, which temporarily may be even more severe than the original condition. Withdrawal from a drug that induces psychological dependence will result in the appearance of symptoms of emotional imbalance, including anxiety, irritability and sleeplessness. Cravings for the drug may be very strong.
The withdrawal of a category (ii) medication should follow the same stages as described above for category (i) medication. However, acupuncture in the withdrawal period may be needed to address the symptoms of a withdrawal syndrome. It may be helpful for the patient to have prepared in advance some strategies for coping with these additional symptoms. For example, withdrawal from a stimulant laxative may require an intermediate period of taking another form of laxative. Emotional symptoms might be countered by approaches similar to those advised for people who give up smoking. Strategies such as taking up a program of gentle exercise, planning a range of activities to distract from cravings, and use of herbal substitutes might all be considered.
WITHDRAWAL FROM CATEGORY (III) MEDICATION
Withdrawal from category (iii) medication (see Table IV-3 in Appendix IV) again follows the same principles as described for category (i) medication. However, category (iii) medication has either been prescribed for a serious medical condition or may result in a dangerous withdrawal syndrome. For these reasons withdrawal from such medications should always be undertaken with the oversight of the patient’s doctor.
In some cases the doctor may be reluctant to help the patient to withdraw from the drug. If this is the case, it may help if the acupuncturist writes a letter to the doctor, giving their professional viewpoint (see Section 6.3c). If the doctor can be assured in this way that treatment has brought about a positive change in the patient’s condition, and that the patient has the ongoing support of their practitioner, they may agree to start reducing the medication.
There are some drugs in this category that are unlikely to be ever withdrawn by a doctor without very marked improvement in symptoms. This is because the threat to physical and mental health from withdrawal would be considered too severe to take the risk of withdrawal. These drugs are indicated with a quadruple asterisk (****).
6.3c Communicating with conventional medical practitioners
It is good for both patient care and interprofessional relationships that acupuncturists maintain contact with the conventional medical practitioners who are involved in the ongoing healthcare of their patients. The reasons for communicating include referral of red flags of serious disease, discussions about changes in treatment and acknowledgement of referrals from conventional medical practitioners. Moreover, if the communication is made in a way that is both valid in terms of patient care and respectful of the professional to whom it is directed, it can only serve to improve the ongoing relationship between complementary and conventional medical practitioners. In this way it can promote the ideal of integrated healthcare.
Choice of method of communication
There are three methods by which an acupuncturist might choose to communicate with a conventional medical doctor about a patient. In most cases the most appropriate and convenient method is to allow the patient to do the communicating by meeting with their doctor. Alternatively, the practitioner can telephone the practice or hospital to speak to the patient’s healthcare professional in person. The most formal approach is to write a letter. These three approaches are considered below in turn.
Using the patient as the communicator
The identification of a non-urgent red flag of disease is a common situation in which it might help for the acupuncture patient to communicate with their doctor. For example, an elderly patient has mentioned that they have been more thirsty than usual for the past three months, and have been passing large amounts of urine (a red flag of type 2 diabetes).
In this situation the patient can be advised to make an appointment with their doctor so that the possibility of serious disease can be excluded or confirmed. At the appointment the patient can then explain to the doctor that their acupuncturist is concerned about their symptoms and that there is, for example, a possibility of diabetes. In many such situations a letter is not necessary.
Patients may also be the communicators when they have decided they want to withdraw from category (i) or (ii) medication. A confident patient can simply go to their doctor and say, for example, “I would like to see how I cope without my beclometasone inhaler as I have no symptoms now. How do you advise that I set about stopping it?”
Speaking to the doctor in person
Speaking to the patient’s doctor in person is the preferred mode of communication either if the patient needs to be referred urgently or if there is a matter of some complexity that needs to be discussed. Most doctors would be prepared to discuss a problem concerning a patient over the telephone (e.g. “Mrs Jones, who lives alone, seems to have been getting progressively more confused. Are you aware of this?”). Whenever possible, it is important to ensure that the patient is told in advance what is going to be said, to ensure that there is no breach of confidentiality.
It is normal in most medical practices that there is a system whereby doctors will take telephone consultations on request, often at a particular time of the day. Moreover, in a situation of high urgency the duty doctor may be contacted straight away. If the call is made after office hours, in the UK it will be transferred to an on-call doctor when the general practice telephone number is called. It is important to bear in mind that the doctor who is contacted may not know the patient, although in office hours they should have access to the patient’s records.
Communicating by letter or email
A written communication, ideally by letter, is often an appropriate method of referring patients with complex circumstances and also of explaining clinical information about a patient in a non-urgent situation. In the UK emails are not currently favored for the purposes of relaying detailed patient information as patient confidentiality cannot be guaranteed by this route; a written letter is still preferred, and will be attached to the patient’s records. A letter is not appropriate if a reply is required from the doctor, as the process of writing a reply is inconvenient for a busy doctor and delays may be incurred if the letter is typed. If a problem needs to be discussed, such as Mrs Jones’ confusion in the example above, the telephone is the best medium. If a brief message needs to be relayed, or a question asked, an email might be more suitable. If this is the case, best practice is to use anonymized patient information.
A letter is most useful when it either precedes or accompanies a patient who has made an appointment with the doctor. The letter can then communicate the additional information that it may be important to impart. Letters are also an accepted means of communication for indicating that a referral from a doctor has been accepted by the acupuncturist, and also to inform the doctor about the progress of a patient who has been treated following a referral.
The structure and content of the communication
Whenever a referral is made, after first ensuring that a letter will be handled in confidence, clear and succinct information needs to be imparted to the medical practitioner. Whether by spoken word or by letter, this is best done in a structured way, and with the information offered in an order that is familiar to the doctor. If it is necessary to communicate by telephone, it is worthwhile for the acupuncturist to prepare the order of the information to be imparted before making contact. The list of the categories of information summarized below can be a useful aide-mémoire to ensure that no important details are omitted from a telephone call or letter. Reference to this list will also help ensure that all the necessary information is given in a logical order. General practitioners (GPs) and hospital doctors tend to be overburdened with work and constrained for time, so it is important that telephone calls and referral letters offer information in a brief and accessible format. It helps to organize the information into short statements, and to keep a letter to less than one page in length.
In the UK there is legislation designed to protect the rights of patients to confidentiality so that sensitive information about them is stored in a safe way. The Data Protection Act (DPA) 199867 requires a practitioner to register if they intend to keep electronic records of sensitive information about patients. This is not necessary if electronic copies of letters are deleted once the letters have been printed out, in which case paper copies can be kept securely for the patient’s records. Whether or not the practitioner is required to register, according to the Act all patients have a right to have their information kept confidential and secure, and also that only the absolute minimum of detail about them is recorded, which might be considered necessary for the delivery of clinical care.
Bearing this in mind, information to include when communicating about a patient to a medical practitioner is as follows:
•Patient identifiers: full name, date of birth and address. All three are required for medical records.
•Brief summary of reason for referral: in one sentence. For example: “I’d be grateful if you could assess this 28-year-old man who tells me he has had three episodes of nocturnal bedwetting.”
•More detailed history of the main complaint: a brief synopsis of the key events in the history of the main complaint, including:
–Signs: describe any findings (including relevant negative findings such as “blood pressure was normal”) from clinical examination.
–Drug history: summarize the medication the patient is currently taking (including contraceptives and non-prescribed medication such as indigestion remedies).
–Social history: list any relevant lifestyle factors (e.g. smoking, alcohol use) and occupational factors that might have impacted on the current condition.
•Summarize what is wanted of the medical practitioner: for example: “I am concerned that this man might be experiencing nocturnal seizures, and would value your opinion on whether he needs further investigations.”
•If appropriate, take the opportunity to describe how you have been treating the patient: a referral is a good opportunity to explain more about what acupuncture involves. It is best not to use too much Chinese medical jargon in a referral, but a couple of sentences on why the patient is having acupuncture and how they are benefiting can do no harm.
IMPORTANT ADDITIONAL POINTS THAT APPLY TO LETTERS
The important points to follow when structuring letters are:
•Headed notepaper: this should include the practitioner’s name, professional title and qualifications, address, telephone and/or mobile phone number, email address and website address.
•Date: the date of the letter is essential.
Choice of language
It will help with all communications if the practitioner aims to match the medical use of professional language as much as possible, and avoid using Chinese medical terminology, which may be misinterpreted or dismissed as meaningless.
Although letters between conventional health professionals are often written and sent without the express permission of the patient, it is advisable whenever possible to ensure that the patient is happy for their acupuncturist to be writing to another professional about them, even if they have been referred to the acupuncturist by that professional. A helpful hint is to always write a letter that health professionals would be prepared for the patient to read. There should be very few situations in which health professionals wish to give information to the doctor without the patient knowing about it.
Sample letter formats
Boxes 6.3c-II to 6.3c-V give sample letter formats as a guide for letter design.
Dear Dr Jackson
Thank you for referring John Smith for treatment of recurrent migraine. I saw him in my clinic today.
Recurrent unilateral headaches felt over the left eye and temple that are associated with blurred vision and nausea.
Headaches worse at weekends.
Frequency of headaches increasing over the last six weeks associated with stress at work. He currently suffers a headache most weekends.
Alcohol: at least 40 units/week (wine).
Overweight (BMI 35).
Full red complexion.
Propranolol 80mg daily.
Sumatriptan and paracetamol during acute attacks.
My diagnosis, based on his history, physical examination and pulse and tongue examination, is that he has features of a syndrome recognized in Traditional Chinese Medicine that is likely to respond to acupuncture treatments and also modifications to his diet and stressful lifestyle. The raised blood pressure is consistent with this diagnosis.
Eight acupuncture treatments at weekly intervals.
I have advised him to reduce alcohol, and also the fatty and spicy food in his diet. He is also likely to benefit from gentle exercise and a less stressful approach to his working day.
I would hope that with treatment he may be able to reduce his need for propranolol, which makes him feel drowsy in the day, and he may discuss this with you in due course, assuming he makes good progress.