Drugs of the devil

I’m not going to tell you how long ago I was at university, but I will say it was in a different millennium. It doesn’t feel very long ago to me, but then I still think of The X-Files as a new show. Let’s just say I can remember when we used to have pagers when we were on call. And all this used to be fields.

Back when I was a young student, I never dreamed I would be tempted by “the dark side”, but we all know what the road to hell is paved with.

When I was at university, a class of drugs was regarded by the clinicians as so fiendish, so downright evil that their repeated use was regarded with horror and haughty derision by the specialists who no longer worked in general practice. The clinicians would read the histories of referred animals, and lampoon the frequent appearances of these drugs.

It’s been many years since then, and many corticosteroids have passed under my particular bridge. I wish I could say I used them with caution, consideration and care – usually I do, and I always explain the possible side effects to the owners – but sometimes, I admit it, if I’m stuck for ideas on a case, I will give steroids to see if they work…

That’s the problem with steroids, of course. Half the time you try that, they do – and even when they don’t, the fact they don’t gives you some information.

I always felt, however, steroids were unfairly demonised. Yes, they have many, many side effects, but those side effects are generally predictable and mostly reversible (though I’m aware there are quite a lot of diabetic cats out there that may argue with that last point) and they have also relieved more suffering than any other drug I have in my arsenal – with the rather depressing exception of pentobarbitone, of course.

Nevertheless, I have spent many years feeling vaguely guilty whenever I reached for the bottle of Dexadreson on my shelf, so it is with some surprise for me to discover my drug of the devil has been replaced with a new, and deadlier, class of demon.

My wife is very close to completing her certificate in general practice (with a surgical emphasis) and the feedback from her case reports has made it very clear that although university clinicians still aren’t keen to see steroids overused, overprescribing another type of drug is really likely to get them frothing at the mouth (and I don’t mean pilocarpine).

You see, it turns out that all these years, I should have been feeling far more guilty about the next bottle I was going to pick up, that other frequently abused panacea of general practice. I always knew I had to be careful with my antibiotic usage – even in my creaky 20th century university education we were given dire warnings about the risks of antibiotic resistance.

It’s one thing to be aware of the problem. It’s quite another to have President Obama tell you to stop doing it.

These drugs are more worthy of the concern and mockery than steroids, I feel. At least when I overprescribe steroids I am only potentially harming a single patient. When I’m trigger-happy with my antibacterials, I’m contributing towards plunging civilisation into a new medical dark age, which is not really the legacy I hoped I would leave behind.

It’s true that, quick to reach for them as we are, vets are far from the biggest reason antibiotic resistance is becoming a problem: it turns out doctors feel as much pressure from clients as we do to prescribe the things. As well as this, they are still, shamefully, used as “growth promoters” to enable production of cheap meat, as an alternative to, for instance, providing humane living conditions to animals that we raise and kill purely to fill our bellies with something tasty.

In many countries around the world, the older antibiotics are freely sold over the counter without a prescription. And, depressingly, antibiotic-resistant bacteria can be found in soil samples that have never been anywhere near a waiting room or a farm.

Nevertheless, when I’m reaching for them, I am increasingly aware that I am contributing to the problem, and I don’t want to look the next generation in the eye when we finally have run out of ways of combating bacteria with the pretty feeble excuse that “it wasn’t just me”.

I think we can all agree that the Jedi master Yoda has taught us all a great many things. I suspect he was, at least in part, talking about antibiotics when he told us that the dark side wasn’t stronger, but it was quicker, easier, and more seductive.

Seductive they most certainly are: I can’t tell you how many times in my career I have given diarrhoea cases antibiotics “just in case”, and it is a rare feline with cystitis that leaves my consulting room having just been given anti-inflammatories and behavioural advice. Well, I have finally realised that whenever I have made mistakes in my life, it’s almost always because I didn’t listen to what Yoda told me.

I’m standing up to be counted, here and now. My name is Nick, and I have dallied with the devil. I have overprescribed antibiotics.

I am going to try to get better. I am going to use them less.

Who’s with me?