‘Self-Medication’: A term almost always referencing choices, illegal or frowned upon by many or some within society, often accompanied by a strong preference towards advice to do less of whatever you shouldn't be doing (woeful knowledge of addiction, for starters), rather than a serious effort to examine reasons. To me, these are some significant failures in British medicine: Historical, environmental, psychosocial contexts, all fundamentally relevant to health and behaviours, yet largely unexplored. Organs and biological mechanisms continually impact one another. Investigating and viewing them independently makes no scientific or logical sense. Conveyor belts of people given treatments with effects likely to result in another health problem, isn't effective treatment. It's medically-approved deterioration! With personal experience of pharmaceutically-induced issues plus how brutal withdrawal from prescription drugs usually is, my views on medication are likely to differ from someone with no significantly bad experiences. I'd consider accessing cancer treatments, but very reluctantly, given my previous encounters with oncology have been overwhelmingly damaging to at least my mental health. Though certainly not the only example of this therapeutic breakdown, I will never, ever forget my distress and frustration at not being heard when I was trying to explain that ‘gold standard’ treatment or not, an operation resulting clinical menopause was something I wasn't comfortable with at all, given that with the neurological condition, I have many unpleasant symptoms already. With my tumour markers low I was prepared to gamble it was benign this time. I wasn't heard when I said the pressure to go this route, and clerical mistakes and miscommunication had, alongside other issues, driven me to my deepest depression for years. Only when I was shouting and crying on a ward, despite all the antidepressants I was now on, was I finally heard, and treated like a person and not a body part. Unfortunately the pharmaceutical, domino model I described earlier leaves me with no reason to doubt my experience would be different in another department. Another department's problem is no consolation to the patient, the person you gambled with.
I've long believed it misguided for cannabis to be placed in the hands of ‘medicine’. It can't be measured in the same way as pharmaceuticals, yet we collectively lack imagination to accept this and approach it differently. Lavender, chamomile, and many spices like turmeric have known therapeutic, medicinal properties. But they've not been embraced by health care, private or publicly funded, and their regulation isn't constantly meddled with. I'd largely assume that's because they don't get you high, because successive governments seem to think that with the inequality and unrest in Britain, that's the biggest problem. Give your head a shake, elected folks! You don't honestly believe that reefer madness nonsense, do you? I assure you, my life is still not that exciting! Discrimination against cannabis means that even where it can be, to a reasonable degree measured like for like with pharmaceutical alternatives, it very obviously is treated more unfavourably. Though far higher with synthetic cannabinoids, risk of death, even indirectly, seems exceptionally low [1] compared to many prescribed drugs, and indeed, alcohol. If medicalisation guaranteed treatment irrespective of wealth, that would be a strong argument, but it isn't! So, Self-Medication as a tool of blame and shame in a clinical context surely raises the questions ‘are doctors our ethical and legal guardians or caregivers? What connotations does that have for patient care?’. I'll examine some reasons I feel this conflicts with effective patient care and therapeutic relationships. I've said before and will again, I've encountered loads of excellent clinicians and professionals of various disciplines, I still do, but this article is about the systemic damage, intentional or not, that conflicting roles and priorities might inflict and an individual right to choose.
Reason 1.
Why is it assumed we only make bad decisions?
The gateway drug argument: People selling ‘hard’ drugs and cannabis (which not all cannabis suppliers do, of course) will make the former easier to obtain, and numerous reasons might lead people to try other substances, but by the same token, why would I want to move from cannabis to something that works in different ways and will do different things? I have severely disabling symptoms that reduce my functioning immensely. Why would I want to make that worse? People might be taking cannabis to mask voices rather than causing them, and I'll grant you that insight is often absent in people experiencing psychotic breaks, but that doesn't mean they're always wrong or that they shouldn't be listened to. Or those taking speed to improve their concentration, cocaine to increase confidence (none of these are in any way recommendations, by the way). Social and healthcare departments might actually know how much therapy and work many of us have done, if there was a co-operative, interactive system with regards to communication. This would be offset to a degree by the misinformation/ misinterpretations within those notes, by those whose preconceptions made them unable to accurately convey what was said or not said.
As sick and disabled people are likely to be short of money, it seems strange to assume they'd spend on something they didn't believe they needed. Ironically, if my bad choice and reason for poverty was gambling, it's unlikely anyone would have even asked and found out. How surreal it must feel for parents giving their children cannabis oil when they're treated like they're negligent, ignorant, irresponsible, self-medicating by proxy, as it were. It defies logic: An expensive way to be abusive, you'd think. They go to parliament and the papers, for goodness sake. I'd imagine many or most parents of epileptic children have video evidence of cannabis working too. I've seen loads of these myself. I've posted my own. Cannabis was just as effective before I got the respectability, depending on who you talk to, of a prescription. Illicit didn't have testing certificates, but it worked, or at least the right stuff did!
Reason 2
Oversimplification alters reality.
People are complex and unique. We experience different things in entirely individual ways. Yet there seems a natural tendency to reduce everything to something simpler, perhaps so we can interpret it in a way that works for the most thought processes. I'd argue a significant shortcoming in this approach is that by doing so, we reduce everything to generalisations which might fit some reasonably well, but certainly not all, possibly not even many. If that isn't acknowledged, you are surely not able to adequately help those who present differently. I lost interest in statistics after having a Cancer they didn't think it was and developing a rare disease. Medically speaking, I almost certainly fit some generalisations, I'd imagine we all would, but I defy plenty. I also lost patience with having concerns over surgery dismissed as “that's unlikely to happen”. So was what happened already, mate. Everything you see is seen for the first time once. There's also an assumption amongst many people, that they can completely understand or grasp a person's hardship simply by thinking about it albeit often not for long, without any comprehension that that is impossible, because they're only viewing it from their own life perspective.
So: Onto Alcohol. Only a species as bonkers as us would select a depressant as the most consistently legal ‘pleasure-seeking’ drug. It's often said that alcohol destroys lives, but it's consequences of how and when people imbibe it that does that. Alcohol in itself isn't destructive. As we're routinely asked how much we drink in a GP consultation, I've known people disbelieved for saying too little or much, according to the preconceptions of the documenting clinician, so you still can't guarantee what you said is what's written. Are our answers arbitrary then? Where and what and why you're drinking matters. You'll almost certainly be judged if you're drinking too much, perhaps asked why, there are plenty of places where you can get cheap doubles or lower-priced pints. The Tax Office probably won't judge you for going in them either! If you need help, on the other hand, whether there's support in your area and your doctor knows about it is another question again. The ‘Postcode’ Lottery! Do they view it as a health and social issue worthy of help, or a moral failing worthy of disdain? You likely won't be asked how much you drink of the currently more apparently fashionable coffee, despite the fact excess of that could give you palpitations, racing heart and would send my movement disorder berserk. I don't remember my healthy diet being something worthy of much time in these settings, nor congratulations for having always exercised. I do know one person of more advanced years who has been treated like a confused old dear more than once because they couldn't possibly not be on medication by their age.
Reason 3
Is it possible to have a meaningful therapeutic relationship if doctors are presenting themselves as extensions of the judiciary?
Recently passed amendments in relation to abortion [2][3] is a great example: Some women's health and trust was being put at risk by clinicians reporting them for potentially illegal abortions, and it highlights how poor we are at revisiting archaic laws. Where cannabis patients may feel judged, such as whether they are vaporising their script [4], as directed, or smoking it (which they may have done historically, or there may be another reason), this is a patient group that may well have an extensive history of discrimination, including conflicts with the police and judiciary, whether through legal use or not. The person you're meant to be supporting may also have been naive enough to at least expect compassion within a doctor's consultation room. It might sound harsh, but my personal feeling is that given that there will never not be a need for doctors in all areas, perhaps those who approach those they're prescribing with disdain and judgement should consider switching to a patient demographic they do like. Of course I'm not suggesting that in health terms, smoking is the better choice. I'm just saying there are reasons people do it, and threatening patients or using language that might make them feel under threat doesn't seem like a very effective way to address that. Maybe something crazy like support and education? Conversely and perversely, the judicial and policing system certainly don't seem to be reciprocating by playing medic, given that it's still reported that many of the British public still don't understand the legality changes that 2018 brought about [5]. Are the judged illicit consumers being told that they have a legal alternative they may well qualify for? This is only my opinion, of course, but there's a section entitled ‘Treating patients fairly and respecting their rights’ in the General Medical Council ‘Good Medical Guidance’ [6] that judgement faced by patients is in direct defiance of, namely the right not just to dignity but your right to go against advice being respected). It's hard not to smirk a little at someone who's judging your ethics whilst apparently being hazy over their own. A fine parallel would be that of two US politicians, supremely responsible for the ‘War On Drugs’ which would lead to prohibition here. One, John Ehrilchman, ended up in prison [7] for himself breaking the law (later admitting publicly the malicious origins of drug laws [8]). The other, Richard Nixon, avoided it because he was President, but he would instead publicly admit (during a televised interview with David Frost [9]) that he genuinely didn't see it as law breaking because he was President. See what I'm saying about double standards?
Reason 4
An overstretched NHS is struggling to offer GP appointments [10], and waiting lists remain long for many assessments and treatments [11].
Although this has become a greater issue in more recent years, surely, it's particularly harsh to criticise people for trying to self-treat, for good or bad, when you're not providing the service designed to support, advise and reassure them? Oh, and treat them, actually? Are you recommending they remain in mental or physical pain or anguish in the meantime, potentially getting worse through inaction? It's another example of working with what you've got. I see little sense in early intervention medical scans unless you're equipped to provide the treatment you advise is needed. Otherwise it's an identified problem, and source of anxiety you can't control or solve. Helpful! We're told by the government this is changing but recruitment doesn't wave a magic wand and we're yet to see.
Reason 5
Do we really view Personal Autonomy as an infringement?
Do we forfeit our right to personal choice by seeking medical advice? The Assisted death debate for terminally ill patients, now headed for the House of Lords for another reading [12], a plea for autonomy in death at least. I myself support its passing, and it's the furthest such a Bill has got. I recognise some of the arguments and misgivings but given I've written this article about autonomy over one's living body, it appears to me that the argument that withholding it in death is primarily to protect the vulnerable doesn't ring true somehow. Surely less contentious, that people who are suffering should not have their decisions made solely by people who can't comprehend what they have and continue to be experiencing. I know at least two people who have been offered medication recently without explanation as to why it's thought they need it. How is genuine informed consent even achievable without this? Clue: If you're not informed, it isn't!
Conclusion
Whether clinicians or professionals are legally or ethically entitled to approach patient care a certain way, their choices will inevitably impact their relationship with patients, including trust. Existing trust issues from historical abuse or mistreatment, could be made infinitely worse. I'd argue that whatever name you give this, it wouldn't be care. I remember points during my nurse training, one being hearing the word holistic in relation to care, and my enthusiasm that patients should be looked at in their entirety, in the view of our healthcare model. We were even taught Abraham Maslow’s Hierarchy of Needs [13], in recognition of the multiplicity of needs, health being just one, a person requires met in order to function and thrive. It's worth a read to see the clear inspiration in the original intent or purpose, when the British Welfare State [14] and National Health Service was created, soon after its publication. Sadly, the second memory was the stomach churning realisation not long after the first, that ‘the system’ might think that's what it's providing, some individuals certainly try, but in my view, they're kidding themselves by this point. What's being offered has changed, as has the doctor-patient dynamic. Many or most people seeing a different doctor each time, except in private settings, can't not impact the trust within relationships.
A third recollection was perhaps a couple of years after I developed my neuro condition and had become very physically disabled and therefore, unfortunately dependent on state assistance, both financial and personal, having previously worked for decades, so independent, and gladly so. But the more services I began to need, the more I became aware that systemic therapeutic barriers I've discussed in this article apply in almost exactly the same way, unsurprisingly, they're similar models, in terms of their brokenness actually making them a liability, harmful to wellbeing and quality of life, rather than the supportive provisions they profess to be. If you want your people to get better and behave better (hard when the rules are so convoluted, admittedly), treat them better. We're allowed to make bad choices, indeed, we're sold them. Choosing things because they taste good or feel good is hardly the worst thing anyone could be doing, much as you'd think it was! Do Governments and their agencies genuinely have the right to hold citizens to such higher standards than themselves? Moral right or not, is impossible, surely, to see this inequality as therapeutic. If someone is vaporizing cannabis illicitly to try and improve their lung health, is it honestly not relevant that they've been placed in public housing covered with mould? What if someone reliant on a wheelchair like I am, becomes severely depressed and self-treats in some way primarily because the roads and pavements are so neglected they can't physically go anywhere? I worked in Accident and Emergency for a time. I can entirely see how the ‘timewaster’ trope comes about, but it's hardly fair to blame ‘attendees’ because you are short staffed and knackered and stressed. That person may not have deciphered the algorithms of where they are meant to go instead, and additionally given the potential fear induced by an adverse health event, let's try more listening and less telling for a change!
References
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