Preeya Alexander: I know you love to talk about your ailments, Norman…
Norman Swan: Yeah, well, let’s take a couple of yours first.
Preeya Alexander: Well, I was going to ask whether or not you’ve experienced low back pain, and I’ll share my story if you share yours.
Norman Swan: Well, like most people, the answer is yes. I actually had one period where it went for nine months and I had referred pain down my leg. Luckily I went to see a very sensible orthopaedic surgeon who said, ‘This will pass, don’t get it operated on.’ And it did pass.
Preeya Alexander: And it did pass. I actually had low back pain after a long-haul flight, I remember telling you about it, and it really scared me, because I do pilates, I’m very active, and when I had this low back pain, it was debilitating, and it can be really problematic for some people, impact sleep, their ability to work. But often the solutions, Norman, are really not what people think. It’s about movement, activity. And today we’re going to cover some research which shows that cognitive functional therapy with physiotherapists is really critical.
Norman Swan: That’s coming up on the Health Report. I’m Norman Swan on Gadigal land.
Preeya Alexander: And I’m Preeya Alexander on Wurundjeri land.
Also on the show, there may be other options on the table for women when it comes to reducing the risk of ovarian cancer, but many health professionals and patients have never even heard about it.
Norman Swan: Yeah, it could reduce the risk of ovarian cancer by more than 25% some people think, without an extra operation. Also coming up, we’re endlessly talking about the microbiome, and there’s really fascinating research into the microbiome and insomnia. It’s complicated, but it starts to explain why we’ve got the microbiome we have, and not just insomnia but in other issues as well.
Preeya Alexander: But first in the news, in Victoria, Norman, the overdoses report has come out, and it’s really put the spotlight on pregabalin.
Norman Swan: We try not to use brand names, but I think most people listening go by brand names, it’s called Lyrica, used for lots of different things. What’s it used for?
Preeya Alexander: It can be used for different types of nerve pain. So if you get postherpetic neuralgia after shingles, it can be quite helpful. Some people use it for sciatica; you just mentioned that before with your back pain. Trigeminal neuralgia, which is when you get pain in the face. It’s a medication that has been really well marketed, is what I would say. I’ve certainly seen a lot of marketing around this medication, and it basically acts on the calcium transporters on nerves and modulates how the nerve signals get sent down.
Norman Swan: But, boy, does it have side effects.
Preeya Alexander: Well, that’s what this report is really suggesting. It’s stressing that pregabalin was involved in 92 out of 584 deaths resulting from combined drug toxicity.
Norman Swan: And we should just explain here, we’ve done this before in the Health Report, is when you look at drug deaths and overdoses, it’s usually not a single drug, it’s usually a combination of drugs. It could be diazepam with heroin, or alcohol with heroin, or ice and heroin and other drugs, so it’s a combination. So that’s what we’re talking about here.
Preeya Alexander: So the coroner’s report essentially says exactly what you’ve said, Norman, which is it’s not really just the pregabalin, it’s the interactions with other things, like opioids for pain relief, benzodiazepines for sleep. But this is a drug which does have potential significant side effects, and I don’t use a lot of it, honestly, because it can cause dizziness, sedation, and in older people it can contribute to falls risk.
Norman Swan: Depression, anxiety, you feel crap on it. And a lot of doctors prescribe it because they think, well, it’s not an opiate, therefore it’s safe.
Preeya Alexander: That’s right. I think that’s some of the clever marketing that has been done. If you look at the number needed to treat, so how many people do you need to treat with a particular drug to see a response in one person, for pregabalin, depending on what you look at, it’s between four to 11, it really depends on the type of pain. There are actually medications like amitriptyline, which is a tricyclic antidepressant, which at really low doses can be good for chronic neuropathic pain, and it’s actually quite well tolerated, it’s cheap as chips, and the number needed to treat for that is two to three. So it’s a much more effective drug, but a lot of people do use pregabalin.
Norman Swan: So, there’s a lot of it around, and therefore, inadvertently, you can think, ‘This is a safe drug and I’m okay to have a drink,’ or, if you use illicit drugs, ‘I’m okay to have an illicit drug.’
Preeya Alexander: That’s right. And so the Coroner’s Court has come out and said that substantial education effort is needed for doctors to safely prescribe the drug, that they need to be aware of interactions. But I think for people listening, if you’re on this medication, you just need to be careful, chat to your pharmacist, your health professional, about what else you’re on and the potential interactions.
Norman Swan: And it also has abuse potential. It is increasingly being used as a recreational drug, and some researchers suggest it’s relatively safe as a recreational drug, well, this would give the lie to that, that as a recreational drug, if you’re using other recreational drugs, it may well not be safe at all.
And we’ve got an update on that story we’ve been following for a month or two, the Monash IVF story. Just remind us what that story was about, Preeya.
Preeya Alexander: So, earlier this year, Monash IVF admitted to several mistakes. So in Queensland the wrong embryo had been implanted into a patient, and they’d given birth to a baby not genetically linked to them. And in another patient in Victoria, in Clayton, they were meant to have their partner’s genetic material implanted but ended up having their own implanted. And so people will likely recall from a previous show that at that time the CEO of Monash IVF stepped down, and they launched an investigation, so Senior Counsel Fiona McLeod was brought in.
Norman Swan: And it should be said that this is not an independent investigation, this is an internal investigation with an outside independent person.
Preeya Alexander: That’s correct, and that review has been published or laid out but it’s not public, and so all we really know is that human error was at the heart of both the problems in Queensland and in Victoria. But we don’t know much more than that, and there’s a lot of people, IVF advocates, even Mark Butler, the Minister for Health, who are really demanding to see the results of this review so that there’s transparency. Because as you can imagine, a lot of people have lost trust.
Norman Swan: And the regulator is actually part of the industry through the Fertility Society of Australia and New Zealand, but even they have been concerned about the release of this information, but say it was because it had to be released to the market because it’s a publicly listed company.
Preeya Alexander: Yes, and I think it’s always a problem when you’ve got the peak body who’s also self-regulating. So there really needs to be an overhaul of the system.
Norman Swan: We don’t know what’s happening in the rest of the system.
Preeya Alexander: That’s right.
Norman Swan: There are also issues there. And it should be said that there’s no such thing really in medicine as human error. If there’s human error, it’s that the systems allowed the error to take place. I think we were talking about it on last week’s show, the Swiss cheese model, where you’re supposed to design systems where somebody makes a mistake, the assumption is that humans make mistakes, no matter what industry they’re in, and that that mistake…the system should be designed so that that mistake goes no further, somebody doesn’t get killed, somebody doesn’t get harmed, or an embryo doesn’t get put into the wrong woman. If there was a human error, there’s something wrong with the system, there was not an individual to blame.
Preeya Alexander: And it should be noted that in terms of the mix-up in Victoria in Clayton, the review has found that there might have been some limitations in the IT system as well. So human error and IT. But I think the thing is, Norman, people want to know what recommendations have been already put in place, what needs to change? Why did these failures occur? Because there are a lot of people who are quite anxious having heard about all of these developments this year. And as you said, it’s not just limited to Monash IVF, it’s postulated that this is a much wider industry problem.
Norman Swan: And this happens in the year when the Healthscope group of hospitals were put into receivership and put on the block for sale, largely because of the financial structuring of the business, where the hospitals were burdened with the debt created by the private equity company that bought Healthscope. So they were they bought it with debt, and the debt was put on the hospitals, so the hospitals, in addition to running their business, had to pay off debt as well, leaving a lot of patients in doubt. Also in the light of Ramsay closing its psychology services.
We’ve covered the issues in relation to private investment in certain areas, such as pathology, such as infertility services and so on. And a very significant proportion of infertility services, and indeed pathology services, are owned by either private equity, private investors, or they’re publicly listed companies. And the question is, who are they running these companies for? Are they patients, or are they the investors themselves? And of course if you’re a publicly listed company, the temptation is to say you’re running it for the investors, even though that’s not necessarily the case.
And what’s interesting here is the regulation of private equity, in other words companies that buy up companies and then often turn them over, make them more profitable, then on-sell them or list them on the stock exchange, and Massachusetts has just introduced this year…and there’s an article in this week’s New England Journal of Medicine, if they want to find it, on how Massachusetts has just introduced the most far-reaching state legislation in the United States, which is trying to curtail the influence of private equity in healthcare that follows the collapse of a very large healthcare system called the Steward Health Care system. I think there were eight major hospitals in Massachusetts belonging to that system, and that was owned by a private equity firm and a real estate trust. And there was a whole series of issues around failure to disclose losses, how it was financially structured, how debt was financially structured. And without going into a lot of detail, Massachusetts introduced a whole series of regulations around transparency, about debt ratios, about how you’re funding the purchase of the organisation, how you might surreptitiously increase the monopoly you have by buying up other practices without necessarily declaring them. And the question really for Australia is should we have a serious root-and-branch examination of private equity, other investment and the impact of publicly listing companies that the public believe are there to serve them, and often funded by the taxpayer through Medicare.
Preeya Alexander: I think given everything that’s happened this year with Healthscope and others, the answer is, we probably need to have a good look at it, don’t we?
Norman Swan: We do.