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Welcome to the Oral Apothecary Podcast, authentic chat about medicines,
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pharmacy and healthcare in the UK.
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Pharmacists Jamie, Gimo and STC take on topical and controversial
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stories but keep it edgy yet light-hearted.
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Podcasts share their career-defining drug, song and book and also
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share their joyful patient stories.
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Welcome to the Oral Apothecary Podcast. It's Series 9. My
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name is Jamie Hayes. For this episode, we're joined by Dr.
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Caroline Copeland. Caroline is a senior lecturer in pharmacology at
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King's College London. Her work focuses on drug-related deaths across
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the UK. We'll welcome Caroline in a moment as she
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shares a drug for our formerie, her career anthem, and
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recommends a book for the Oral Apothecary Library. Our micro-discussion
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this week will be informed by a paper from the
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International Journal of Drug Policy looking at the data on
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opiate-related deaths in England and Wales. But first, let me
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welcome my two fellow apothecaries. STC is in Bournemouth and
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Gimmo is in Cardiff.
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Welcome both. Welcome, evening.
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Yep.
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Series 9.
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Here we are. Very happy to be back for Series 9, yeah.
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We're never quite sure when we finish the previous series
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whether we're going to make it to another one, but
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we have, so well done us.
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Great series lined up.
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It is.
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Lots of guests already pre-booked. The listener might be interested
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to know, but we're not going to tell you who
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they are.
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It's a surprise.
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Wait and see. What have you been up to over
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the summer?
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It's been warm, hasn't it?
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Super hot, yeah.
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So for context, if some people are listening in the future,
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it was a hot summer, record breaker, it's a heat wave,
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and the world's going to end because of AI. So
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AI was a little baby when we started this podcast,
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and we've charted this journey, and we may well find
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ourselves doing the last series when the world's ended because
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of it. But I suppose my main news, Harry, my son,
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graduated with a first in law, so that's That's big
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news for us. So congratulations, Harry.
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Congratulations, Harry.
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Very good. I don't have any students anymore in my family.
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But going back to your AI point, Gimo. Yes, I've
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been trying to be my curious pragmatist self. And I've
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been trying to follow and use some large language models
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where I can. But can't help but being dragged back to, hmm,
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we do need to use the guardrails here, don't we?
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And what came out this week, which was the National
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Commission into AI Regulation in Healthcare. And in fact, one
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of the authors, Professor Henrietta Hughes, who's also the Commissioner
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for Patient Safety, is one of the guests at the
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Royal College of Pharmacy conference, which we are attending, are
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we not? So that will be good. And I thought
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that it's good. And what I really liked, actually, was
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that the new president of the Royal College of Pharmacy
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actually had a good quote. And it said, for pharmacy
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and medicines, it is essential that AI supports rather than
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replaces professional judgment with patients at the center of how
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it is used. We look forward to working with our
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members and partners to ensure AI is adopted safely, effectively,
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responsibly across pharmacy and healthcare. And I obviously agree with that,
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but it was slightly contrary to the overall commission's vision on,
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I think it's page eight of the document, and it
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looks at safe, fast, and trusted, but fast comes at
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the top, And therefore, to my mind, looks like it's
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saying that it's more important than safe and trusted. But
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that might just be the way I'm reading it. But anyway,
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keeping my watch on AI anyway. James?
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Public workshops continue through the summer, which was great. As
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Gimo said, it was a scorcher. And so I think
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some of the workshops went ahead when they perhaps shouldn't, actually.
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It was probably a patient safety incident. asking a load
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of over 50s and over 60s to congregate in a
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local village hall or a rugby club, but they went well.
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And just as we finished Series 8, I gave the
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keynote at the 10-year celebration of realistic medicine in Glasgow.
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So that was a great conference. And the first half
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of the conference in particular was all about culture and
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the arts and the role that they have in improving healthcare.
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And it was a great day.
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And so that was.
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That was that. Okay, let's move on. Our great pleasure
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to welcome Dr. Caroline Copeland to the Oral Apothecary. Caroline
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is a senior lecturer in pharmacology and toxicology at King's
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College London and director of the National Programme on Substance
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Use Mortality. Her research sits at the intersection of pharmacology,
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toxicology and public health, exploring what real-world patterns of drug
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use can tell us about medicine safety and emerging harms.
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Using mortality and toxicological data, she investigates everything from prescription
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and over-the-counter medicines, to novel psychoactive substances and illicit drugs,
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including the often overlooked interactions between them. She also works
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closely with national and international drug policy and surveillance organisations
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to help translate evidence from drug-related deaths into practice and policy.
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Welcome to the podcast, Caroline.
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Thanks very much.
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So.
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If we bumped into you in a pub, a coffee
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shop or indeed a conference in Oxford, what would that
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conversation look like? Tell us about what was the title
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of your session at Oxford? First of all, Caroline, can
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you remember?
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Oh, goodness.
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No.
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Now you're asking me. I submitted something that I hoped
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would be picked. And it was.
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It was eye-catching. I think it was something along the
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lines of learning from death.
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I think, yes, it definitely mentioned death because I think
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we started calling.
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You the death cop.
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It was learning from the dead.
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Learning from the dead. There we are. You're absolutely right.
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We've just got our title.
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Yeah.
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Learning from the dead. So Steve and I bumped into you.
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We were fascinated by, this was before you did your
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talk as well, Caroline, I think we just bumped into you.
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And so tell us about your work, the National Programme
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on Substance Use Mortality and what you get involved in.
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Yeah, so, uh, it's, well, it's been a bit of
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an interesting story to ending up at that conference in Oxford, really. So, uh,
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I'm actually originally a basic pharmacologist, laboratory scientist who did, um,
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all sorts of different experimental techniques. And, uh, it was
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during my first lectureship at St George's medical school that
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I had a new job. It was my first lecture,
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lecturing position. I was very excited. And this woman came
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into my office and said, you're not Colin. To which
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I had to say, no, I'm not Colin.
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Not from accounts either. You weren't from accounts either.
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No, I had to tell her that I had Colin's
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job from Colin's office because he'd left quite quickly for
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another university. And she said, oh, sometimes I have lunch
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with him. And then she went, well, you knew, so
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you won't have anyone to have lunch with. So let's
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have lunch. I couldn't really argue with this chain of thoughts.
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So I said, right, yeah, cool. Let's have lunch. And
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she told me in this conversation that she was the
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point two FT admin assistant essentially left working on this
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drug deaths database. The chap who had founded it died
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suddenly five or six years prior and nobody had taken
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it on and it was going to close. And the
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more I learned about it and heard her speak, I
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was like, this can't shut. Like this is too much
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of a shame. And so I pivoted entirely from neuronal
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network sensory pharmacology to the pharmaco-epidemiology of drug deaths. And
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here we are, however many years it is later, I
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started doing this in, I think that was 2018. So yeah,
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so coming up for eight years now, rescuing this database,
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promoting it, using the data and learning.
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From the dead.
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So what was it about the database that struck you
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as important?
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So the database was started in 1997. So even by 2017,
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there was 20 years worth of drug death data that
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was being routinely reported by coroners. And it wasn't digitised.
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It was all paper-based records in a filing cabinet. And
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I just thought that it would be a massive shame
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for all this data that could be used to evidence
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better drug policy and prevent future deaths from happening and
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I just thought it was a massive shame that it
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would otherwise just go to waste and drugs are interesting
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you know drugs are cool as well so you know
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you have that aspect of it that I was interested
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in getting into and yeah it's such an amazing resource
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and I think another aspect of it is that if
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you meet me at a conference in Oxford dressed quite nicely,
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you'll see a fairly well-spoken white woman who I like
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to think of myself as well-dressed, but it really depends
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upon the day, I suppose. But actually, both of my
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parents grew up on council estates. Neither of them went
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to university. And they worked really, really hard to make
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sure that me and my brother weren't exposed to the
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childhoods that they had, essentially. And I know that I
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am just one generation away from living in a deprived
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area of the UK and exposed to social housing and
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all the problems that come with that. And reading about
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all these people that did live those lives and weren't
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offered the opportunities that me and my brother were, that's
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part of my motivation for working on this as well,
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is to try and afford better opportunities to those that
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weren't as lucky.
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As I was.
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Thanks Grant.
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Just for the listener, it sounds as though, what is
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the name of your two-year-old who's making his debut on podcast?
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Oh, sorry. Yes, it's little Eugene, just Gene we call him.
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He is in the room next door having a bath.
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So if you can hear some splashing like a washing machine.
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I apologise for that.
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I can hear laughing, he's loving it by the sounds
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of it.
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Yeah, bath time with Daddy, so yeah, always chaos.
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So Carly, you mentioned the database. For the lay listener,
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very simply, what is the database? How does it work
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and what's it involved in?
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So any death... uh, due to psychoactive drug use. So
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that's drugs that act on the brain, uh, gets reported
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to us by the coroner that presided over the inquest of,
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of that person's life and death. Uh, so that the
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deaths that happen can be due to illicit drug use.
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So things like heroin or MDMA or ecstasy, uh, but
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also licensed medicines. So things like fentanyl and, uh, pregabalin
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people might have heard of, diazepam, which is marketed as Valium.
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So any deaths due to those substances. And so there's
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a huge range of things that we can do with
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that data. So broadly, the aim of the work that
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we do is to try and evaluate current drug policy
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and suggest how we can make it better and propose
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new drug policy. We can... survey the illicit drug market
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for emerging substances and new substances that haven't appeared yet,
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usually quite dangerous substances as well. So that's one of
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the things that we do and we report those new
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notifications to national and international agencies that might not have
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come across them before. We also work with public health
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teams about potentially new innovative things that could be done.
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We're currently working on a project of delivering naloxone, which
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is an antidote for opioid overdose by drone, because the
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modelling suggests that the drone will get to a lot
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of these overdoses much more quickly than an ambulance would. So, yeah,
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so some interesting public health interventions. And then the policy
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thing as well. And, yeah, drug policy is a difficult
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fish to fry.
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Caroline, in preparation for the podcast, we I think we've
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all listened to the BBC Inside Health, Can We Reverse
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Rising Drug Deaths? And really going back to your original
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point about your motivation to get involved, it was a
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fascinating conversation, including a GP who had previously been an
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addict on that Inside Health document. And so as you
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kind of alluded to in talking about the social and
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economic deprivation and the stigma attached to addicts, And maybe
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we'll come on to this. But like you say, if
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we don't shine a light on the numbers and the severity,
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then that potentially stops further investment, doesn't it, in relation
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to public health and things. And it was just such
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a fascinating episode, I think, in relation to, and I
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remember this, the GP, who previously was an addict, saying that,
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you know, it's hard for health professionals to sometimes to
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show compassion to addicts, but that actually on a human level,
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you know, each death needs to be considered, doesn't it?
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And so I suppose, again, that partly drives on what
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you're trying to do there is shining a light on
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these things.
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I think for a lot of people who haven't ever
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used drugs themselves or know someone close to them who
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uses drugs, that for those people who are using drugs dependently,
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they have to use those drugs. It's not a choice.
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It's not A recreational, oh, let's have fun tonight, you know,
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pop a tab whilst we're dancing in Ministry of Sound
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or whatever. And it's that dependent drug use, which is
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the problematic drug use. And those are the people that
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need the most help. Often they've started using drugs to
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escape some horrible reality or traumatic experience. And it's then
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just become more entrenched since then. And in terms of
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stopping drug use in the UK and anywhere, I think
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we have to realise that there are some people that
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will take drugs because they like them and that's just
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going to happen anyway. I am an absolute lover of coffee.
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That's a drug that's psychoactive. It keeps me awake. It
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just happens to be a legal one. But it's the
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drug use that affects people negatively. their relationships, their ability
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to work, their ability to function that need the most help.
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And unfortunately, that population of people aren't a particularly attractive
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bunch for taxpayers to see their money being spent on.
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Yeah.
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I mean, the other thing that I did was I
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decided to read Matthew Perry's autobiography that was recommended by
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a previous guest, Sally Neith, episode 6.3, if you're catching up.
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And like you said, his story is incredible. If you've
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never read a story about somebody who openly says that
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they're an addict, it is incredible. Like it's totally, you know,
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I've been a health professional for 35 years. Of course,
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I've dealt with addicts. But actually, I've never in any
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great depth listened to or read, in this case, just
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all the things that he did to feed his addiction.
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And going back to the GP who was on the
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inside health He said that they are addicts, they are
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at dis-ease. And he was saying you need to treat
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it like a disease because they are at dis-ease. And
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it was incredible, the Matthew Perry story about how you
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might know this, that he ended up after a jet
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ski accident, he ended up on Vicodin, which is an
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American version of essentially paracetamol and a type of opiate
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that we don't have in this country called hydrocodone. but
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he constantly talks about that. At times he was taking, well,
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he says he was taking 55 tablets a day. Well,
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I worked that out and that's 16 and a half
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grams of paracetamol a day. So I'm not sure whether
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he really was on 55, but maybe he lost count
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after a certain time. But the point was, and he
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was also on at times 14 milligrams of lorazepam, otherwise
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known as Ativan, which is equivalent to 140 milligrams of diazepam.
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And he was making Friends, you know, the episodes of Friends.
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It was incredible that he was still going and all
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the things that he did to hoodwink genuine health professionals,
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not people he had on speed dial who were dodgy
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and could get him things, but actual genuine health professionals
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and how he hoodwinked them into saying he was in
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much more pain. That was a real, real window for
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me in relation to the life of an addict.
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Well, I mean, the doses that you're describing there, I
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would agree with you that I would question his liver
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function at that point with that much paracetamol on a
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daily basis. But in terms of things like that level
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of diazepam, oh gosh, I can hear the bath has
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just ended. In terms of that much diazepam, there are
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certain drugs that when you take them regularly, what he
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gets used to them a bit like alcohol for some
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people and so in order to achieve the same effect
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you have to take more and more and more and
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next time it's then even more that you're taking so
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you know i'm not surprised that he was able to
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you know tolerate and function at that such high levels
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of flurazepam.
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Thing is is you hear about matthew perry don't you
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because he's he's famous and and was it was it
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ketamine he he overdosed on in the end and and
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i think So you hear those stories, don't you? But
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looking at your research, Caroline, it's a common cause of death,
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isn't it? You know, once you strip out natural causes,
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it must be up there with one of the sort
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of highest sort of.
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Yeah, so I don't think we've quite got there in
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the UK. I don't think we particularly want to get there.
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But I believe that drug overdose a few years ago
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surpassed suicide as the biggest killer of under 40s in
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the USA. the number of accidental drug overdoses that are happening.
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When you're defining drug overdose, you're meaning taking too much
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of a drug as opposed to deliberately taking a drug
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to take your own life, isn't it? That's what happens.
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So we do, so the database that I work on,
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we do take any death following drug use, irrespective of intent.
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So we do and have done and are doing some
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work in terms of suicide prevention, but we treat, you know,
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accidental overdoses as unintentional deaths.
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Can you join some dots for me then, Caroline? Somebody dies,
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where does the corona preventing future death reports fit into that?
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And then I think it's a colleague of yours and
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it's the preventable deaths tracker. Where does all that sort
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of fit together in our world?
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So when somebody dies, if their death is deemed to
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be unnatural or unexpected, that's when they're referred to a coroner.
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So I think if you've seen a healthcare professional within
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two weeks of your death and you've been fairly unwell,
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your death can be treated as expected and you're not
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going to be referred up. Then a coroner, if you
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get to the coroner's desk, will make an assessment as
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to whether or not they will need to proceed with
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an inquest. A post-mortem will be ordered depending upon the
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circumstances of the death. Toxicology will be taken, but not
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all deaths have toxicology. taken. And then the toxicology is
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tested for. In terms of which drugs are tested for,
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there's a common library of drugs which deaths are screened for,
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but the the novel drugs, I think you've mentioned some
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of the nitizines, which are these synthetic opioids, synthetic cannabinoids
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we have as well, now you're finding counterfeit vapes. And
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they aren't tested for in every death. They're only tested
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for usually if they're suspected that the person might have
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been using those drugs. And it's at that point that
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then the toxicologist feeds back any detections and interpretations to
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the pathologist who did the post-mortem. And then the pathologist
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sends their diagnosis anatomical findings report together with the tox
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report to the coroner. The coroner then, depending again upon
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the circumstance of death, will have things like a police report,
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maybe recent contact with healthcare, maybe some social care support
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if that was involved. And they will hold an inquest
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and determine the cause of death that happened. And it's
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at that point that if a drug was involved, a
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psychoactive drug, they will report to us a bundle of
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notes about that death, which we then collate and analyse
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together with all the others that we receive. But the
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deaths only have what's known as a prevention of future
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deaths report written if the coroner feels that that death
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could have been prevented if certain action had been taken.
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And the idea of a PFD, is there no prevention
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of future death report, is for the coroner to write
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specifically to the organisations that they feel need to action
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in order for those such deaths to be prevented from
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happening in the future and what my colleague Georgia does
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is she collects all these PFDs together so I think
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PFDs about a third of them are related to drug
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use but a good two-thirds are due to other things
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such as the um One famous case, which you probably
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will remember, is there was a young girl who ate
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a baguette at Pret that was freshly prepared on site.
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And there was a rule at the time that freshly
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prepared food, you didn't have to list the ingredients on them.
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And she had a nut allergy or a sesame allergy,
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and she had an anaphylactic reaction and died. So PFD
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was written about that anaphylaxis case, you know, maternal death cases,
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things like that, all had PFDs written as well.
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I guess we might come back to the coroner's bit
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when we do the micro discussion, but I don't think
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we can let you go before we move on to
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ask you to explain to our listeners about nitazines. And again,
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00:22:35.089 --> 00:22:37.710
we'll put the link in the show notes, the other
400
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podcast that we listen to called The Drug Detectives. But again, fascinating.
401
00:22:41.650 --> 00:22:44.869
Would you want to just explain to the listener nitazines,
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what they are and why they're such a problem?
403
00:22:48.170 --> 00:22:51.380
I will try and give you a quick rundown of them.
404
00:22:51.440 --> 00:22:57.559
So nitazines are a type of synthetic opioid that appeared.
405
00:22:59.069 --> 00:23:03.259
More widely on the illicit drug market particularly as adulterants
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to heroin and also counterfeit valium tablets in large numbers
407
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in summer 2023 and this was in response we think
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to the drug gangs in europe not being quite sure
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where they were going to get their heroin from so
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in 2021.
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00:23:22.190 --> 00:23:24.509
This was after the afghanistan war yeah is that right
412
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sorry so.
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When yeah so when um the Taliban returned to power
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in Afghanistan. One of the first things that they did
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was to ban opium poppy planting and harvesting. And Europe
416
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and the UK got most of its heroin from Afghanistan.
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And some listeners might be thinking, well, hang on a
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second for the previous 20 years, who was in charge
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in Afghanistan and let poppy planting happen? Anyway, that's a
420
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different topic for a different time. But when the Taliban
421
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came back, they said no more poppy. And the drug
422
00:24:00.079 --> 00:24:02.440
gangs in Europe were probably going, Christ, what are we
423
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going to do? We've got lots of customer base and
424
00:24:04.279 --> 00:24:07.259
we like making money. And you might think, well, why
425
00:24:07.279 --> 00:24:10.279
haven't we got fentanyl then? And they probably thought the
426
00:24:10.319 --> 00:24:14.269
same thing. But a lot of the illicitly produced fentanyl
427
00:24:14.309 --> 00:24:18.950
and fentanyl precursors go to the US via Mexico. And
428
00:24:19.150 --> 00:24:23.049
the Mexican cartels essentially have a monopoly on fentanyl. fentanyl
429
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and its precursors. And I think the European drug gangs
430
00:24:25.910 --> 00:24:29.420
realized that going into business competition with the Sinaloa cartel
431
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was probably a very good way of not being alive
432
00:24:32.039 --> 00:24:35.460
for very long. So they looked for some alternatives. And
433
00:24:35.519 --> 00:24:38.619
the nitizines were actually synthesized in the late 50s and
434
00:24:38.660 --> 00:24:45.509
early 60s alongside fentanyl and its analogs for potential use
435
00:24:45.569 --> 00:24:49.700
in humans clinically. But it became quite apparent very quickly
436
00:24:49.839 --> 00:24:52.690
that they were far too potent to be useful. Their
437
00:24:53.049 --> 00:24:57.950
therapeutic range massively overlapped with their fatal range and so
438
00:24:58.029 --> 00:25:01.109
being able to titrate a safe dose is just not possible.
439
00:25:01.690 --> 00:25:05.700
So clinical development stopped and they were essentially forgotten about
440
00:25:05.859 --> 00:25:09.819
until 2021 when there were some drug gangs looking for
441
00:25:09.859 --> 00:25:14.319
some alternatives and I think that's probably how we've ended
442
00:25:14.380 --> 00:25:17.089
up with them on our streets and they're incredibly potent.
443
00:25:17.109 --> 00:25:21.019
They are as potent as fentanyl, some of them, and
444
00:25:21.299 --> 00:25:25.180
they're like the weakest ones. And I say weakest there,
445
00:25:25.220 --> 00:25:28.799
but very, very strong still. And then some of them
446
00:25:29.140 --> 00:25:33.009
are 50, 100 times more potent than fentanyl. And so
447
00:25:33.029 --> 00:25:36.769
these are not safe for human use. I think some
448
00:25:36.789 --> 00:25:39.769
of the reported potential uses for them have been the
449
00:25:41.150 --> 00:25:45.650
inclusion in darts for wild animals like rhinos and hippos.
450
00:25:46.349 --> 00:25:50.099
And I think a colleague recently found a proposed use
451
00:25:50.140 --> 00:25:55.289
for them to euthanise beached whales. So they are incredibly
452
00:25:55.329 --> 00:25:58.769
potent and they're incredibly dangerous as a result. I think
453
00:25:58.950 --> 00:26:04.990
for the BBC documentary I prepared three vials of just
454
00:26:05.009 --> 00:26:08.119
table salt for them and in one vial I had
455
00:26:08.460 --> 00:26:11.859
what is a pretty standard accepted lethal dose of heroin
456
00:26:12.480 --> 00:26:15.140
which is half a teaspoon or something in the bottom
457
00:26:15.160 --> 00:26:19.119
of the vial. The amount that a fatal dose of fentanyl,
458
00:26:19.180 --> 00:26:21.859
which is a tenth of a teaspoon, and then a
459
00:26:22.220 --> 00:26:25.019
fatal dose of one of these nitosines. And to do that,
460
00:26:25.299 --> 00:26:29.180
my PhD student at the time was going through some
461
00:26:29.220 --> 00:26:31.720
grains of table salt and he was picking out the
462
00:26:31.769 --> 00:26:35.670
smallest one and putting it on the scale and going, no,
463
00:26:35.710 --> 00:26:38.390
that one's too heavy. I need to find a smaller
464
00:26:38.509 --> 00:26:42.990
one to then plonk it in this vial. That's how
465
00:26:43.029 --> 00:26:45.549
potent these things are. If they were to aerosolize me,
466
00:26:45.589 --> 00:26:48.529
you could overdose just breathing them in which is why
467
00:26:48.670 --> 00:26:53.970
when police and emergency services come across a scene which
468
00:26:54.049 --> 00:26:57.390
involves potential synthetic opioids they have to put on PPE
469
00:26:57.430 --> 00:27:00.809
because they have to be trying to protect themselves in
470
00:27:00.869 --> 00:27:01.930
that scenario as well.
471
00:27:02.109 --> 00:27:06.750
Wow that's a great visual for the listener that's a
472
00:27:06.789 --> 00:27:09.289
great way of describing just how potent they are and
473
00:27:09.670 --> 00:27:12.829
again in that podcast the sad cases of people who
474
00:27:13.309 --> 00:27:17.210
You know, we're forever telling people don't buy drugs online
475
00:27:17.609 --> 00:27:19.589
from somewhere that you don't know where it's come from.
476
00:27:19.630 --> 00:27:22.950
And there were cases, weren't there, where people have bought oxycodone,
477
00:27:22.990 --> 00:27:26.329
for example, because they couldn't get it. And even these
478
00:27:26.349 --> 00:27:29.109
are people who weren't necessarily addicts. They were saying they
479
00:27:29.130 --> 00:27:30.849
couldn't get hold of their, they were short over a
480
00:27:30.869 --> 00:27:33.710
weekend or something, bought it online and it was laced
481
00:27:33.759 --> 00:27:34.880
with nitrazine and they died.
482
00:27:35.710 --> 00:27:39.279
Well, if you've got any listeners out there with some
483
00:27:39.299 --> 00:27:40.740
kids that they want to learn how to say no
484
00:27:40.759 --> 00:27:42.119
to drugs, just send them to me for a week
485
00:27:42.240 --> 00:27:45.329
or two and to redo some of the deaths and
486
00:27:45.910 --> 00:27:49.930
it acts as a pretty good contraceptive in that regard.
487
00:27:49.950 --> 00:27:52.930
And it makes you think that those drug gangs must
488
00:27:52.950 --> 00:27:57.289
have had some pharmacy input or pharmacology input, mustn't it?
489
00:27:57.299 --> 00:27:59.599
There's a couple of pharmacologists waiting for those drug gangs,
490
00:27:59.640 --> 00:28:00.039
isn't there?
491
00:28:00.740 --> 00:28:07.240
Oh, completely. So prior to the Psychoactive Substances Act, there
492
00:28:07.259 --> 00:28:09.000
were things that were called, you might have heard the
493
00:28:09.019 --> 00:28:12.950
term legal highs or designer drugs and And the term
494
00:28:12.990 --> 00:28:14.890
legal high came from because they were at that point
495
00:28:15.150 --> 00:28:17.049
technically legal because they weren't.
496
00:28:17.089 --> 00:28:18.630
Controlled by our drug laws.
497
00:28:19.069 --> 00:28:21.630
That was one of them. But the other term that
498
00:28:21.670 --> 00:28:24.519
was used was design a drug. And that's not because
499
00:28:24.559 --> 00:28:27.299
they had, I don't know, the Louis Vuitton logo on
500
00:28:27.339 --> 00:28:30.380
the pill or something. It was because they were specifically
501
00:28:30.420 --> 00:28:34.819
being designed chemically to circumvent the drug laws. So the
502
00:28:34.839 --> 00:28:37.339
way drug laws are written in banning or controlling a
503
00:28:37.400 --> 00:28:43.519
substance is that the actual structure is described. And these
504
00:28:43.559 --> 00:28:47.440
gangs have medicinal chemists that can interpret this and say, aha, well,
505
00:28:47.480 --> 00:28:53.400
if we do an alkyl substitution instead of a carbonyl substitution,
506
00:28:53.490 --> 00:28:55.589
that will circumvent the law.
507
00:28:55.630 --> 00:28:56.829
Gimmo loves a bit of chemistry.
508
00:28:57.690 --> 00:29:01.150
And we can design our way out of control.
509
00:29:02.309 --> 00:29:05.579
We mentioned at the beginning... and you know it, don't you,
510
00:29:05.640 --> 00:29:08.380
is Dr. Amira Ghegheiros, who we had on, I think,
511
00:29:08.420 --> 00:29:12.839
our second guest, second episode. And the book she recommended51200:29:12.880 --> 00:29:16.759
was Narconomics. And just a reminder, if anyone hasn't read it,51300:29:16.779 --> 00:29:18.619
it's a really good book, but it's essentially about how51400:29:19.339 --> 00:29:22.339
the drug business, the illegal drug business, is a business51500:29:22.380 --> 00:29:25.880
like any other big business. And you've just described it51600:29:25.920 --> 00:29:29.279
perfectly there. Their supply lines have run up, they've run out,51700:29:29.299 --> 00:29:31.900
they've come up with an alternative, they've created a new51800:29:31.960 --> 00:29:35.349
product for the market. um you know they've tested it51900:29:35.369 --> 00:29:37.450
and they put it put it out to market it's52000:29:37.700 --> 00:29:41.980
it's it's frighteningly business like what you're describing isn't.52100:29:41.759 --> 00:29:43.740
It i give you breaking bad.52200:29:45.940 --> 00:29:51.140
Completely and um before um the so the netizens were52300:29:51.160 --> 00:29:55.490
brought under control in the uk beginning of last year52400:29:55.509 --> 00:29:58.589
and they were controlled in china in summer last year52500:29:59.630 --> 00:30:05.009
And prior to a lot of these novel psychoactives come52600:30:05.089 --> 00:30:09.509
out of illicit labs in China. And prior to their52700:30:09.569 --> 00:30:14.450
control in those two jurisdictions, the nitizines we were seeing52800:30:15.089 --> 00:30:17.250
most of were the ones that were actually the lesser52900:30:17.309 --> 00:30:20.359
potent ones. And that's because we think the market sort53000:30:20.410 --> 00:30:23.460
of settled on the users not wanting to take something53100:30:23.500 --> 00:30:25.930
that would kill them. and the dealers not wanting to53200:30:25.970 --> 00:30:28.529
deal something that was killing their customers, because that's bad53300:30:28.569 --> 00:30:30.730
for business. If you're shrinking your pool, you're not going53400:30:30.750 --> 00:30:36.529
to make money. But post-control, what we've seen is those53500:30:36.569 --> 00:30:38.789
principles have now gone out the window, and the drug53600:30:38.809 --> 00:30:42.950
gangs are now prioritising not being caught. And so we're53700:30:43.019 --> 00:30:46.279
now seeing the more potent nitizines that we didn't actually53800:30:46.319 --> 00:30:50.079
see before appearing. And that's because if you need to53900:30:50.500 --> 00:30:52.670
smuggle drugs and you don't want to get caught, If54000:30:52.690 --> 00:30:55.069
you can smuggle the smallest amount, it's probably not going54100:30:55.109 --> 00:30:58.569
to get intercepted. And it can be diluted at destination54200:30:58.609 --> 00:31:02.170
into many, many, many more doses. And so they've moved54300:31:02.230 --> 00:31:05.650
away from let's not kill our customers to a, well,54400:31:05.670 --> 00:31:07.849
we still want to make money. And so we're now54500:31:08.650 --> 00:31:12.289
being pushed towards a more potent product, which is even54600:31:12.329 --> 00:31:16.569
more dangerous. And this isn't, unfortunately, a new phenomenon either.54700:31:16.609 --> 00:31:20.210
There was something coined as the potency paradox, I think,54800:31:20.259 --> 00:31:27.079
in the late 90s, by some drug policy experts that54900:31:27.150 --> 00:31:30.720
had noticed then that you control something and what next55000:31:30.779 --> 00:31:33.559
appears is this even more potent hydro.55100:31:34.339 --> 00:31:36.799
Well, let's try and lighten the mood slightly and move55200:31:36.819 --> 00:31:38.380
on to your... No, no, no, no, it's fine. We55300:31:38.500 --> 00:31:40.799
asked you and you told us, and I think our55400:31:40.839 --> 00:31:43.740
listeners will find it very interesting, which is why when55500:31:43.769 --> 00:31:46.430
we heard you at Oxford, Jamie and I looked at55600:31:46.450 --> 00:31:48.069
each other and said, we've got to get her on55700:31:48.109 --> 00:31:50.759
the podcast. So one of the pleasures of coming on55800:31:50.799 --> 00:31:53.220
the podcast, and I know that you know this, is55900:31:53.259 --> 00:31:56.420
to give us your three prescription item for the oral56000:31:56.440 --> 00:31:59.740
apothecary prescription. And the first one always starts with a56100:32:00.009 --> 00:32:03.450
desert island drug. So this is a drug or medicine56200:32:04.369 --> 00:32:08.450
that evokes a powerful memory for you. So what would56300:32:08.470 --> 00:32:10.150
you like to choose and why?56400:32:10.170 --> 00:32:15.160
So I am going to choose the very recent and56500:32:15.200 --> 00:32:17.819
much talked about GLP-1 agonists.56600:32:18.279 --> 00:32:18.599
Okay.56700:32:18.950 --> 00:32:19.890
Any one in particular?56800:32:20.690 --> 00:32:24.210
Well, I'm not actually going to name one because the56900:32:24.250 --> 00:32:28.230
memory that evokes is at the time, I don't think57000:32:28.269 --> 00:32:30.750
I knew the name of any of the drugs. So57100:32:30.990 --> 00:32:38.119
back when I was an undergraduate in 2000, mid-2000s, I57200:32:38.160 --> 00:32:43.700
can't remember if I was in second or third year,57300:32:44.000 --> 00:32:49.569
I did pharmacology undergraduate at UCL. And we had a57400:32:50.049 --> 00:32:53.170
chap from pharmaceutical industry come and give us a talk.57500:32:54.009 --> 00:32:56.190
And it was at a time when we were likely57600:32:56.230 --> 00:32:59.190
to be going to industry, you know, big pharma startup,57700:32:59.210 --> 00:33:01.619
to be staying in academia. And it was meant to57800:33:01.630 --> 00:33:05.880
be a careers talk for us. And what he was57900:33:05.920 --> 00:33:10.359
talking about was trying to show us the process of58000:33:10.920 --> 00:33:14.339
big pharma. And he asked us, what is the best drug?58100:33:14.730 --> 00:33:16.390
that you can think of, you know, chat to your58200:33:16.410 --> 00:33:18.470
partner for five minutes and see what you can come58300:33:18.529 --> 00:33:21.710
up with. And when he brought everyone back, you know,58400:33:21.750 --> 00:33:24.160
we had things like, you know, a cure for HIV,58500:33:24.220 --> 00:33:27.720
a cure for tuberculosis. And he sort of went, yeah,58600:33:27.799 --> 00:33:31.859
that all seems very good. But in terms of a58700:33:31.960 --> 00:33:35.700
large market of wealthy people that can make a profit,58800:33:36.569 --> 00:33:41.019
not really the best one. And he then proposed to us,58900:33:42.140 --> 00:33:44.519
anti-obesity drugs. He said, you know, it's a problem of59000:33:44.559 --> 00:33:47.859
the West. The West has lots of money. And these59100:33:47.900 --> 00:33:50.240
are people that have a problem that can be solved59200:33:50.339 --> 00:33:54.000
by purchasing these drugs. And that's what a pharmaceutical company59300:33:54.099 --> 00:33:58.160
is interested in, is the revenue. And I remember, and59400:33:58.220 --> 00:34:00.660
it's a crystallising moment for me in my career, I59500:34:00.660 --> 00:34:04.079
remember sitting in that lecture theatre and just thinking, I59600:34:05.380 --> 00:34:08.880
don't want to be doing science just to make money.59700:34:09.659 --> 00:34:12.630
I want to be doing my science to make a59800:34:12.659 --> 00:34:16.489
difference and it was at that point that I decided59900:34:16.570 --> 00:34:19.309
I did not ever want to go into industry and60000:34:19.349 --> 00:34:23.349
wanted to stay within the academic research field which is60100:34:23.369 --> 00:34:26.070
why I can't tell you a particular one because okay60200:34:26.420 --> 00:34:28.980
back in the mid-2000s they were more of a concept60300:34:29.000 --> 00:34:32.500
than a Zenpig or a Wee Govie or whatever the60400:34:32.539 --> 00:34:33.599
newest one is at the moment.60500:34:33.659 --> 00:34:36.079
But there is a link though isn't there because basically60600:34:36.239 --> 00:34:38.139
a lot of these people are addicted to sugar right?60700:34:39.039 --> 00:34:43.159
Um oh gosh goodness me maybe we shouldn't get on60800:34:43.260 --> 00:34:47.920
to i am a career fat person here and so60900:34:48.059 --> 00:34:51.320
um yeah i i'm um yeah i just have to61000:34:51.360 --> 00:34:53.679
look at a jelly baby and i put on three61100:34:53.719 --> 00:34:57.659
kilos um whereas my darling husband can drink three liters61200:34:57.719 --> 00:35:00.320
of full fat coke an entire packet of haribo and61300:35:00.340 --> 00:35:02.500
still have room for a chocolate orange and be shaped61400:35:02.519 --> 00:35:07.119
like a triangle and run triathlons so um I don't61500:35:07.280 --> 00:35:09.460
think it's just down to how much you eat, unfortunately.61600:35:09.519 --> 00:35:11.360
And the sad thing is there's probably going to be61700:35:11.389 --> 00:35:13.269
a connection in the future with your current work, because61800:35:13.309 --> 00:35:17.130
I wouldn't be surprised if they start appearing on PFDs61900:35:17.289 --> 00:35:20.130
or coroner's reports at some point in the future, given62000:35:20.510 --> 00:35:21.429
how much they used.62100:35:22.389 --> 00:35:25.380
So I had a call from a coroner. Gosh, I62200:35:25.400 --> 00:35:27.480
think it was a couple of years ago now. They62300:35:27.519 --> 00:35:30.199
had a lady who had died of an overdose of62400:35:30.500 --> 00:35:34.530
the antidepressant medication she was prescribed. And the coroner's question62500:35:34.590 --> 00:35:38.010
to me was that she had had a few years62600:35:38.070 --> 00:35:42.809
prior bariatric surgery. I can't remember if it was a62700:35:43.889 --> 00:35:48.110
sleeve or a staple or a bypass. I can't remember exactly.62800:35:48.550 --> 00:35:51.929
But his question was that if you have changed how62900:35:51.969 --> 00:35:54.389
a drug is absorbed and how much of that drug63000:35:54.409 --> 00:35:57.989
can be absorbed, is it possible that she was taking63100:35:58.030 --> 00:36:03.750
her drug as prescribed, but actually the altered physiology anatomy63200:36:03.809 --> 00:36:08.150
had led to the overdose and we published a paper63300:36:08.170 --> 00:36:10.710
about a year ago I think we found it was63400:36:10.730 --> 00:36:13.170
only a handful I think it was about 15 people63500:36:13.670 --> 00:36:17.010
who had a history of bariatric surgery and then had63600:36:17.070 --> 00:36:20.710
died of a drug overdose but I think all of63700:36:20.769 --> 00:36:26.150
them had died following use of their prescribed medicines and63800:36:26.170 --> 00:36:30.030
it wasn't clear from them if they had been not63900:36:30.190 --> 00:36:33.510
using them as directed or using them as they should have,64000:36:33.559 --> 00:36:37.639
but then their altered physiology had caused the problems. And64100:36:37.719 --> 00:36:41.960
the same goes for these GLP-1 agonists. Part of their64200:36:42.019 --> 00:36:47.159
design is that they slow down stomach transit time. So64300:36:47.199 --> 00:36:50.550
the food stays in your stomach for longer to make64400:36:50.590 --> 00:36:53.849
you feel fuller for longer and more quickly. But if64500:36:53.869 --> 00:36:58.170
that happens with your oral medication, and your oral medication64600:36:58.230 --> 00:37:00.309
stays in your stomach for longer than it should do,64700:37:00.889 --> 00:37:03.969
and doesn't get transited into your intestine, which has a64800:37:03.989 --> 00:37:06.289
different pH, which means that it's not going to be64900:37:06.309 --> 00:37:08.670
absorbed as well, are we going to end up with65000:37:08.750 --> 00:37:13.110
either overall under-absorption, so overdose or lack of therapy in65100:37:13.150 --> 00:37:15.449
people taking these GLP-1s? And I don't think we know65200:37:15.469 --> 00:37:16.329
the answer to that yet.65300:37:16.449 --> 00:37:19.329
Very good. Well, I don't think anybody's had a GLP-1 before,65400:37:19.369 --> 00:37:22.360
so I think that's the first into the oral apothecary formulary.65500:37:22.840 --> 00:37:25.599
So well done on that. Okay, the second thing then,65600:37:26.429 --> 00:37:29.889
is a life or career anthem, a piece of music65700:37:29.949 --> 00:37:33.460
to go into the Oral Apothecary Spotify playlist. And yes,65800:37:33.559 --> 00:37:35.880
it really is on Spotify. So what would you like65900:37:35.900 --> 00:37:36.679
to give us and why?66000:37:37.159 --> 00:37:41.400
This was actually really, really tough for me. And not66100:37:41.440 --> 00:37:43.019
for the reasons that you'll think of, like, oh, I66200:37:43.039 --> 00:37:47.199
don't know which one to choose. But I genuinely don't66300:37:47.300 --> 00:37:51.389
listen to music. Oh, wow. I'm one of those people66400:37:51.409 --> 00:37:56.010
that can drive for two hours in pure silence. because66500:37:56.030 --> 00:37:58.150
I think it's just that I have such a busy66600:37:58.230 --> 00:38:01.340
brain that is going 100 miles an hour all the time.66700:38:01.760 --> 00:38:05.480
I think I am my own entertainment. And I just66800:38:05.599 --> 00:38:07.880
don't listen to music. So what I'm going to suggest66900:38:07.900 --> 00:38:11.719
to you instead is I do actually play music in67000:38:12.110 --> 00:38:15.829
a brass band. And so I'm going to suggest a67100:38:15.909 --> 00:38:24.150
classic brass banding tune for you, which is Knights Templar. uh,67200:38:24.230 --> 00:38:30.369
by George Allen. And, uh, this particular brass banding piece, uh,67300:38:30.510 --> 00:38:35.360
holds the particular, um, part of my heart because there's67400:38:35.380 --> 00:38:37.340
something called, I don't know if you ever heard of67500:38:37.400 --> 00:38:41.280
the whip Friday marches at all up in Saddleworth.67600:38:42.139 --> 00:38:42.579
Ah, right.67700:38:42.960 --> 00:38:47.590
This is right up your street. So, um, every whip Friday.67800:38:47.610 --> 00:38:51.219
So however many weeks after Easter that is, um, around67900:38:51.219 --> 00:38:54.130
100 bands mostly from the uk but we get people68000:38:54.170 --> 00:38:56.889
from canada and norway new zealand all over the show68100:38:57.429 --> 00:39:01.409
descend on the villages of saddleworth and they all pile68200:39:01.510 --> 00:39:04.269
on to coaches and they drive around and you have68300:39:04.289 --> 00:39:08.170
to each the villages as a competition and you have68400:39:08.210 --> 00:39:12.510
to announce your arrival by marching down the road playing68500:39:12.530 --> 00:39:15.809
a particular tune we in recent years have gone for68600:39:16.440 --> 00:39:19.500
pop songs like Backstreet Boys or I think we did68700:39:19.559 --> 00:39:22.090
Under the Sea by Little Mermaid one year. And then68800:39:22.110 --> 00:39:25.269
you get to the, I'll say arena, but it tends68900:39:25.289 --> 00:39:27.369
to just be a patch of grass, where you then69000:39:27.429 --> 00:39:30.420
have to play your contest piece and be marked. by69100:39:30.440 --> 00:39:34.159
an adjudicator. But a lot of these brass bands have69200:39:34.400 --> 00:39:38.230
very fancy uniforms. And if the adjudicator could see them,69300:39:38.289 --> 00:39:41.269
they would know which band it was just from the69400:39:41.289 --> 00:39:43.130
colour of the jacket or the lapels or something. We69500:39:43.190 --> 00:39:45.329
all look like sea captains when we're wearing these things.69600:39:46.570 --> 00:39:49.460
And so they have to be hidden from view. So69700:39:49.500 --> 00:39:54.480
in some villages, the adjudicator is in a caravan with69800:39:54.500 --> 00:39:57.460
the window open. There's one village where they're in the69900:39:57.500 --> 00:40:00.460
first floor of a pub, just over the way from70000:40:00.480 --> 00:40:02.599
where we play, with the window open. I think my70100:40:02.639 --> 00:40:04.980
favourite one, there was a chap one year who was70200:40:05.019 --> 00:40:07.889
in the back of a lorry that just had the70300:40:07.929 --> 00:40:10.510
back of it just cracked open at the bottom. And70400:40:10.829 --> 00:40:12.869
I could see his shoes, and he was very well70500:40:12.909 --> 00:40:14.769
dressed back there, from what I could tell from the70600:40:14.809 --> 00:40:18.269
shoes and the trousers. But it's this absolutely crazy, mad...70700:40:19.429 --> 00:40:24.349
of all these brass bands playing to adjudicators that can't70800:40:24.389 --> 00:40:28.050
see them. And it goes on until 11 o'clock midnight.70900:40:28.170 --> 00:40:32.849
So Knights Templar, I have probably played as much as71000:40:32.929 --> 00:40:35.329
I have drunkenly sung with a beer in one hand71100:40:35.389 --> 00:40:38.730
and a pork pie in the other, whilst the band71200:40:38.789 --> 00:40:40.510
before us have done it.71300:40:40.809 --> 00:40:42.550
How have I never heard of that? That's fantastic.71400:40:42.610 --> 00:40:43.659
Oh, it's brilliant.71500:40:44.070 --> 00:40:46.239
Let's go. Let's all have an AAA trip.71600:40:46.260 --> 00:40:48.519
Didn't that feature in the film Brassed Off?71700:40:48.969 --> 00:40:50.400
Oh, I think so, probably.71800:40:50.579 --> 00:40:51.760
Oh, I've seen that.71900:40:52.000 --> 00:40:53.699
Yeah, similar. That's what I thought.72000:40:53.820 --> 00:40:57.019
Yeah, we call it band Christmas. It's our favourite day72100:40:57.039 --> 00:40:57.519
of the year.72200:40:57.900 --> 00:41:00.300
Very good. I think that's also a first. I don't72300:41:00.360 --> 00:41:04.210
think we've had any brass band music. So you're doing72400:41:04.269 --> 00:41:06.849
very well. So you've got two. And may I just72500:41:06.889 --> 00:41:10.989
say that you are the 94th guest on the Oral72600:41:11.030 --> 00:41:14.929
Apothecary and you've had two firsts. So why don't you72700:41:14.969 --> 00:41:17.699
fill your boots and go for your third of a72800:41:17.840 --> 00:41:20.210
book for the Oral Apothecary Library?72900:41:20.469 --> 00:41:25.130
So, I was torn with this one because being an73000:41:25.250 --> 00:41:28.719
academic new mum who moved house earlier this year, I73100:41:28.760 --> 00:41:32.480
surprisingly find that when I need to be reading something,73200:41:32.539 --> 00:41:34.840
unless it's a paper or a bit of my student's work,73300:41:34.900 --> 00:41:39.519
I just have extreme guilt. So, I'd either have to73400:41:39.579 --> 00:41:43.070
pick an adult book that I have read from quite73500:41:43.090 --> 00:41:45.389
a long time ago or I'd One of the books,73600:41:45.429 --> 00:41:47.989
which I've probably read about 100 times just in the73700:41:48.010 --> 00:41:52.730
past month. So you've either got a choice, and I'll73800:41:52.750 --> 00:41:54.010
leave it up to you because one of these might73900:41:54.030 --> 00:41:58.940
be a duplication. It's my absolute favourite book as a74000:41:58.960 --> 00:42:01.420
young adult and even now is The Count of Monte Cristo.74100:42:01.440 --> 00:42:06.139
And it's a huge adventure story, Alexander Dumas. It's got74200:42:06.719 --> 00:42:09.969
a bit of everything in it. It's got injustice, escape,74300:42:10.809 --> 00:42:15.820
this ridiculously elaborate revenge plot. And it's very exciting. And74400:42:15.880 --> 00:42:19.000
so it really grabs my attention whenever I read it.74500:42:20.400 --> 00:42:23.320
You've either got that or you've got Where's Spot?74600:42:23.980 --> 00:42:24.480
The dog?74700:42:25.019 --> 00:42:27.739
The Lift the Flat book. That's one of my son's74800:42:27.960 --> 00:42:32.159
absolute favourite books. And one of the things that I've74900:42:32.239 --> 00:42:35.440
come to realise when reading this with him is that75000:42:36.400 --> 00:42:38.880
Spot has a lot of apex predators living in his house.75100:42:39.800 --> 00:42:44.039
You know, a lion, a bear, Crocodile.75200:42:44.739 --> 00:42:46.579
What was I doing there?75300:42:48.219 --> 00:42:50.449
I think actually either of them would be a first.75400:42:51.349 --> 00:42:58.170
I've read both of them. Any parent can sort of75500:42:58.210 --> 00:43:01.289
align with the idea of a spot or the Gruffalo.75600:43:01.409 --> 00:43:03.369
I like the Count of Monte Cristo. That's a fab book.75700:43:03.510 --> 00:43:05.730
Because I knew we were going down the children's book,75800:43:06.690 --> 00:43:08.730
I thought, wouldn't it be great if you picked a75900:43:08.750 --> 00:43:09.630
squash and a squeeze?76000:43:09.650 --> 00:43:09.719
Yes.76100:43:10.429 --> 00:43:11.110
Oh, yeah.76200:43:11.250 --> 00:43:14.349
And took us all the way back to our polypharmacy76300:43:14.389 --> 00:43:16.170
pain patient of series one.76400:43:16.190 --> 00:43:18.190
I would think Caroline's too young for that.76500:43:18.469 --> 00:43:18.869
Yeah.76600:43:18.889 --> 00:43:21.510
Well, I think we'll go for The Count of Monte Cristo.76700:43:21.639 --> 00:43:23.679
That is a classic. I haven't read it, but my76800:43:23.739 --> 00:43:27.480
dad is 87, and he's always told me that it76900:43:27.519 --> 00:43:30.019
was his favourite book when he was growing up. And77000:43:30.059 --> 00:43:32.480
I recently watched the BBC. No, it wasn't the BBC.77100:43:32.519 --> 00:43:35.500
It was on the BBC, but it was a French dramatisation,77200:43:35.980 --> 00:43:38.880
four parts. Absolutely loved it. Watched it with my wife.77300:43:39.389 --> 00:43:41.599
And did start reading it recently, but I haven't got77400:43:41.619 --> 00:43:42.039
very far.77500:43:42.320 --> 00:43:44.059
So I think it's got to be the Count de77600:43:44.099 --> 00:43:44.699
Monte Cristo.77700:43:44.800 --> 00:43:45.380
Yes.77800:43:45.579 --> 00:43:49.460
Because there is poison in it, isn't it? And opiates77900:43:49.519 --> 00:43:52.099
appear in it and strychnine and things like that.78000:43:52.599 --> 00:43:58.119
A massive poisoning plot. I think that's one of the poisons.78100:43:58.199 --> 00:43:59.420
I don't think.78200:44:01.659 --> 00:44:04.440
This does actually give anything away. But depending upon how78300:44:04.500 --> 00:44:08.119
much you take, it can either be an elixir or78400:44:08.139 --> 00:44:08.980
a deadly poison.78500:44:10.260 --> 00:44:11.840
Oh, the dose maketh the poison.78600:44:11.860 --> 00:44:18.690
Exactly. Paracelvis. It's not the joke for how much you take.78700:44:19.070 --> 00:44:21.530
Exactly. Okay, so we'll go for The Count of Monte78800:44:21.570 --> 00:44:27.210
Cristo by Alexandra Dumas. Excellent. So three firsts, which is78900:44:27.269 --> 00:44:29.130
very impressive as the 94th guest.79000:44:29.349 --> 00:44:33.719
Quick quiz question for you and the listeners. What superhero79100:44:33.860 --> 00:44:35.739
had a dog named Spot?79200:44:36.539 --> 00:44:38.659
Is it a proper superhero or a cartoon?79300:44:38.699 --> 00:44:39.159
Superman.79400:44:39.809 --> 00:44:44.389
Hong Kong phooey. And he actually had stripes, didn't he?79500:44:44.429 --> 00:44:47.130
That was the other thing. Anyway, let's move on. Our79600:44:47.170 --> 00:44:50.949
micro discussion next. We've got the International Journal of Drug Policy.79700:44:50.989 --> 00:44:54.320
It's one of Caroline's that we've gone with. And they've79800:44:54.340 --> 00:44:56.739
done a clever thing here because the title of the79900:44:56.780 --> 00:44:59.480
paper is actually the message of the paper as well,80000:44:59.519 --> 00:45:02.900
isn't it? So comparison of Office for National Statistics and80100:45:02.940 --> 00:45:07.699
National Programme on Substance Use Mortality Data suggests that opioid-related80200:45:07.719 --> 00:45:13.889
deaths in England and Wales have been systemically underestimated discuss caroline.80300:45:13.989 --> 00:45:22.139
Yeah um yeah this is a recent paper and um80400:45:23.039 --> 00:45:29.099
i've started actually not writing long papers um so there's80500:45:29.119 --> 00:45:32.760
a full journal report three and a half four thousand80600:45:32.800 --> 00:45:36.039
words but I've just decided that you can say most80700:45:36.079 --> 00:45:37.719
of what you want within 2,000 words.80800:45:38.559 --> 00:45:42.219
Well, harder to write a short paper than a long paper, Caroline.80900:45:42.340 --> 00:45:44.659
Yes, but who's got time to write and read the81000:45:44.699 --> 00:45:50.210
long ones anyway? So, yes, this was a short report81100:45:50.309 --> 00:45:57.849
that had a really important message to it. And interestingly,81200:45:58.030 --> 00:46:02.239
it startedâ when we had a conversation with the Office81300:46:02.260 --> 00:46:05.659
for National Statistics themselves, and they said, look, we realise81400:46:06.039 --> 00:46:08.909
that this is a big problem, but we just don't81500:46:09.090 --> 00:46:12.909
know how big a problem it is. And, you know,81600:46:12.989 --> 00:46:16.590
can we work together to try and see.81700:46:16.929 --> 00:46:19.809
So what is the problem? Just explain the problem for us.81800:46:20.250 --> 00:46:25.300
So the problem is that if a coroner, when they81900:46:25.360 --> 00:46:28.460
are writing the cause of death of how somebody has82000:46:28.519 --> 00:46:34.039
died down, If they use an ambiguous cause term that82100:46:34.480 --> 00:46:37.579
the ONS, the Office for National Statistics, can't tell what82200:46:37.619 --> 00:46:42.280
the drug is, they can't count it in their deaths82300:46:42.320 --> 00:46:44.780
due to opioid use or deaths due to cocaine use82400:46:44.949 --> 00:46:46.929
because they don't know what they are. And so those82500:46:47.030 --> 00:46:49.550
ambiguous terms, some examples of things like, you know, they82600:46:49.570 --> 00:46:54.929
could just write multidrug toxicity or polydrug overdose. And a82700:46:55.090 --> 00:46:58.429
poly drug, it just means more than one, right? So82800:46:58.449 --> 00:47:04.650
that could be a codeine paracetamol overdose, which could have82900:47:04.690 --> 00:47:10.130
happened due to purchase of over-the-counter cocodamol. Or it could83000:47:10.170 --> 00:47:13.070
have been a death due to heroin and cocaine use.83100:47:13.159 --> 00:47:17.039
They're both poly drug deaths, but very different types of83200:47:17.099 --> 00:47:20.280
deaths in terms of how those drugs were probably purchased83300:47:20.360 --> 00:47:22.920
and used and their motivation and so on and so forth.83400:47:23.710 --> 00:47:28.340
And so what we, so the database that I run,83500:47:29.059 --> 00:47:31.780
in addition to getting the records of inquest, which is83600:47:31.800 --> 00:47:34.679
where the coroner lists their causes of death, we get83700:47:34.739 --> 00:47:38.639
the full toxicology report that ONS don't get. And we83800:47:38.679 --> 00:47:41.570
can see therefore on these deaths that are described as83900:47:41.699 --> 00:47:44.309
poly drug or multi drug, we can actually see which84000:47:44.829 --> 00:47:48.070
of the substances were involved. And so what we did84100:47:48.150 --> 00:47:52.869
was we say, just for ease of interpretation, hopefully, Say84200:47:52.909 --> 00:47:56.929
you had 100 deaths due to tramadol reported to the84300:47:56.969 --> 00:48:01.190
database and 60 of them had tramadol named on the84400:48:01.230 --> 00:48:07.250
death certificate, but then 40 had it ambiguously implicated. We84500:48:07.289 --> 00:48:11.030
would be able to say that 60% of tramadol deaths84600:48:11.429 --> 00:48:13.969
ONS would be getting, but they'd be missing 40% of them.84700:48:13.989 --> 00:48:17.480
So I should probably point out at this point, we84800:48:17.559 --> 00:48:21.099
don't have 100% of coroners reporting to the NPSUN. We've84900:48:21.139 --> 00:48:23.840
got just over 90% now, but it's not full coverage.85000:48:23.920 --> 00:48:27.539
So ONS get all deaths reported to them, but then85100:48:27.559 --> 00:48:30.760
they're missing the detail. Whereas we get the majority or85200:48:30.800 --> 00:48:34.420
quite a lot of deaths reported to us, but in85300:48:34.539 --> 00:48:36.559
high detail, but we don't get all of them. So85400:48:37.800 --> 00:48:42.300
by triangulating them together, we were able to estimate the85500:48:42.469 --> 00:48:47.809
likely true number of opioid deaths that have happened.85600:48:47.570 --> 00:48:47.989
In the UK.85700:48:48.010 --> 00:48:50.610
I think we did it over a 10 year period85800:48:51.329 --> 00:48:55.860
and it was around I think between 35 and 4085900:48:55.860 --> 00:49:00.159
percent of opioid related deaths have been missed by ONS86000:49:00.739 --> 00:49:03.019
and that's a huge number to be missing.86100:49:03.219 --> 00:49:05.659
And so that matters doesn't it because that's you know86200:49:05.980 --> 00:49:09.960
how much money spent on drug misuse policy you know86300:49:09.960 --> 00:49:14.159
it just means we've massively underestimated the scale of the problem.86400:49:14.159 --> 00:49:16.400
Yeah so if you have a shop that only has86500:49:16.400 --> 00:49:19.860
enough product for 60 of your customers, you're going to86600:49:19.880 --> 00:49:22.820
have to shut early. And for people who use drugs,86700:49:22.860 --> 00:49:24.280
that just means that they aren't going to be able86800:49:24.300 --> 00:49:28.409
to access treatment. But it's not just a scale problem.86900:49:28.449 --> 00:49:31.510
It's not just saying, well, now you need to fund87000:49:31.550 --> 00:49:38.199
drug treatment centres 40% more. Because... scaling is not the87100:49:38.300 --> 00:49:41.639
only solution here. And if I'm teaching a classroom of87200:49:41.639 --> 00:49:44.800
10 students, what I deliver in terms of how that87300:49:44.840 --> 00:49:47.739
teaching is done is very different from how I teach87400:49:47.739 --> 00:49:51.059
50 students. I deliver that in an entirely different way87500:49:51.619 --> 00:49:54.280
and drug services will have to be the same. And87600:49:54.340 --> 00:49:58.030
also we can't assume that the people that ONS aren't87700:49:58.150 --> 00:50:02.050
counting and capturing are demographically the same as the ones87800:50:02.090 --> 00:50:06.769
that they are counting. So, you know, for example, deaths87900:50:07.730 --> 00:50:11.070
by suicide tend to only involve a couple of substances.88000:50:11.130 --> 00:50:13.570
Most people just take a lot of one or maybe88100:50:13.610 --> 00:50:16.730
two things. And so if you've got fewer drugs present88200:50:17.369 --> 00:50:19.309
in a death, the coroner is more likely to write88300:50:19.329 --> 00:50:22.130
them out than they are if there's seven or eight88400:50:22.150 --> 00:50:26.469
different ones that have to be written out. So demographically,88500:50:26.570 --> 00:50:28.949
the deaths that are being missed are also going to88600:50:28.989 --> 00:50:32.489
be different. And so it's not just a scaling issue,88700:50:32.550 --> 00:50:35.909
but a orientation issue as well.88800:50:36.309 --> 00:50:38.369
So just because we mentioned it earlier in the podcast,88900:50:38.409 --> 00:50:42.480
but didn't give numbers. So the ONS data for 202389000:50:42.480 --> 00:50:47.239
says five and a half thousand deaths due to drug poisoning. Granted,89100:50:47.420 --> 00:50:49.940
you're saying that that's not necessarily the full picture. And89200:50:49.980 --> 00:50:53.539
that's about just under 1% of all deaths. That's in89300:50:53.599 --> 00:50:57.119
England and Wales, isn't it? And half of those involved opioids.89400:50:57.360 --> 00:51:02.030
Yeah, so the overall drug death number reported to ONS89500:51:02.179 --> 00:51:06.480
is probably near enough accurate. But it's the proportion of89600:51:06.519 --> 00:51:09.719
those that they're able to attribute to opioids is where89700:51:09.739 --> 00:51:10.760
the problem comes from.89800:51:11.440 --> 00:51:14.059
And I suppose then the final thing, we have on89900:51:14.099 --> 00:51:18.360
this podcast discussed things to do with coroners before. So90000:51:18.730 --> 00:51:20.989
I think it's fair to say that although your paper90100:51:21.070 --> 00:51:25.909
points out politely that sometimes perhaps coroners try to simplify90200:51:25.969 --> 00:51:29.530
for their audience, so particularly for members of the family90300:51:29.590 --> 00:51:31.929
of the deceased, particularly if they took their own life,90400:51:32.739 --> 00:51:35.369
that they had very serious mental health issues, that they90500:51:35.409 --> 00:51:38.469
might not want to go into too much detail. However,90600:51:38.530 --> 00:51:42.409
your conclusion I completely concur with, which is why on90700:51:42.510 --> 00:51:46.449
earth do the coroners not get mandated to use agreed90800:51:46.510 --> 00:51:48.699
criteria and then we would solve the problem, right?90900:51:48.949 --> 00:51:51.619
Indeed, and one of the things that was actioned after91000:51:51.659 --> 00:51:57.179
this paper was that the Office for Health Inequality and Disparity, OBID,91100:51:57.219 --> 00:52:01.880
did write a letter to the chief coroner recommending that91200:52:03.780 --> 00:52:06.260
a letter is written to all coroners in England and91300:52:06.300 --> 00:52:11.059
Wales to better use cause terms that are more transparent.91400:52:11.840 --> 00:52:16.030
I think in the most recent statistics, it's something like91500:52:16.030 --> 00:52:20.710
25% of drug deaths they aren't able to attribute to substances.91600:52:21.230 --> 00:52:24.710
But the coroners in Northern Ireland are actually very good91700:52:24.769 --> 00:52:27.690
at using specific cause terms and only 6% of deaths91800:52:29.230 --> 00:52:34.809
In Northern Ireland, they couldn't attribute to particular substances. But91900:52:34.829 --> 00:52:37.210
that number is even lower in Scotland. Scotland have a92000:52:37.230 --> 00:52:39.610
slightly different system to England, Wales and Northern Ireland. I92100:52:39.630 --> 00:52:42.789
think they were only able to not identify which drugs92200:52:42.809 --> 00:52:45.469
are involved in something like 1% of cases. So it92300:52:45.530 --> 00:52:46.429
is obviously possible.92400:52:46.699 --> 00:52:50.639
Yeah. And unfortunately, Scotland is top of the tables, unfortunately,92500:52:50.679 --> 00:52:53.099
isn't it, in relation to drug deaths?92600:52:54.019 --> 00:52:58.500
Yes, it has the highest number of deaths per capita.92700:52:59.309 --> 00:53:00.590
In Europe, is that?92800:53:00.699 --> 00:53:04.840
In the world, I believe. I think they surpass even92900:53:04.880 --> 00:53:08.639
the US. But it is a proportions and numbers game.93000:53:09.019 --> 00:53:13.719
So Scotland has fewer drug deaths than England and Wales,93100:53:14.199 --> 00:53:16.469
but they have a much smaller population. But if you93200:53:16.489 --> 00:53:21.630
do death per... capita of population, then the number is93300:53:21.650 --> 00:53:22.050
very high.93400:53:22.289 --> 00:53:24.150
So Caroline, two things from me and then I think93500:53:24.170 --> 00:53:26.719
we'll wrap up. We could have gone with your safety93600:53:26.860 --> 00:53:31.340
concerns on fentanyl patches paper, which when I read that,93700:53:32.039 --> 00:53:34.760
so that was safety concern reported by coroners following fentanyl93800:53:34.800 --> 00:53:38.960
patch fatalities in England, Wales, Northern Ireland between 1997 and 2024.93900:53:39.800 --> 00:53:43.960
And that almost mirrors our careers, really, because fentanyl patches94000:53:44.400 --> 00:53:47.019
came about in 94, 95, I think you said, or94100:53:47.059 --> 00:53:48.800
something like that, which was just at the start of94200:53:49.860 --> 00:53:53.849
our careers. And then that safety profile, and then all94300:53:53.869 --> 00:53:55.929
of a sudden you can see that they're starting to94400:53:55.969 --> 00:53:59.469
be implicated. But you mentioned nitizines earlier, just on the94500:53:59.530 --> 00:54:03.269
cause of death bit. We didn't touch on the fact that,94600:54:03.530 --> 00:54:06.460
and so be brief if you can, but that the nitizines,94700:54:07.219 --> 00:54:10.400
has this story changed? That they weren't as detectable as they,94800:54:10.840 --> 00:54:12.579
and that detectability was changing?94900:54:13.260 --> 00:54:14.800
Yeah, yeah, yeah.95000:54:14.840 --> 00:54:19.269
So again, we did a report, I think it was95100:54:19.289 --> 00:54:21.809
published earlier this year. So this was, so I go95200:54:21.829 --> 00:54:24.630
to lots of different conferences and chat to anyone who'll95300:54:24.670 --> 00:54:26.269
have a chat with me. Now I've ended up here.95400:54:26.769 --> 00:54:30.110
And quite a few of the, I think it was95500:54:30.130 --> 00:54:33.210
about three or four different toxicologists that work in the95600:54:33.320 --> 00:54:35.539
UK came to me and were like, Caroline, I'm seeing95700:54:35.619 --> 00:54:39.519
something weird. And there was one chap who was detecting95800:54:39.539 --> 00:54:42.500
mitosine in urine, but not in blood. There was another95900:54:42.539 --> 00:54:45.780
person who detected it in a syringe that was found96000:54:45.840 --> 00:54:48.989
in the deceased person's arm, but couldn't find it in96100:54:49.030 --> 00:54:52.369
the blood. And then there was one person who had96200:54:52.650 --> 00:54:55.369
detected mitosine in a blood sample that was taken on96300:54:55.409 --> 00:54:58.050
the day that the person had died. But then when96400:54:58.070 --> 00:54:59.829
they'd been in the morgue for a week and the96500:54:59.869 --> 00:55:02.550
full post-mortem was done and that blood sample was taken,96600:55:02.650 --> 00:55:05.710
it couldn't be detected then. So we did a controlled96700:55:05.769 --> 00:55:09.889
experiment with some rat studies to see if the nitazines96800:55:09.929 --> 00:55:12.920
were disappearing from the post-mortem blood. And we were able96900:55:12.960 --> 00:55:17.559
to demonstrate that compared to the nitazine present at death97000:55:17.679 --> 00:55:22.000
versus after the body had been stored in the fridge97100:55:22.019 --> 00:55:24.309
for a week, which is often how long it takes97200:55:24.329 --> 00:55:26.929
for a pathologist to get around to doing a post-mortem,97300:55:27.699 --> 00:55:30.070
Not that they're sitting just around doing nothing, they've got other,97400:55:30.329 --> 00:55:32.750
you know, a backlog of cases to get through. And97500:55:32.789 --> 00:55:36.130
then similarly, when they send that sample to the tox labs,97600:55:36.150 --> 00:55:39.570
they've got a backlog of samples to go through. And97700:55:40.230 --> 00:55:42.349
it's not unreasonable, it takes them sometimes a month to97800:55:42.369 --> 00:55:44.909
get to that sample. So after being in the body97900:55:45.250 --> 00:55:47.250
for a week and in the fridge for a month,98000:55:47.869 --> 00:55:52.630
only 14, 1.4% of the nitosine that was detected at98100:55:52.690 --> 00:55:56.340
point of death was left at point of analysis. And98200:55:56.360 --> 00:55:59.159
I've already said how potent these substances are. You don't98300:55:59.219 --> 00:56:03.619
need very much to prove fatal. And now if you98400:56:03.659 --> 00:56:06.510
only have 14% of not very much, that's going to98500:56:06.530 --> 00:56:09.409
be falling below the limits of detection of these toxicology98600:56:09.449 --> 00:56:15.389
machines and come back as a negative result for these nitrosines.98700:56:15.750 --> 00:56:19.320
Once again, don't buy drugs offline.98800:56:19.400 --> 00:56:21.900
That's the message of the show.98900:56:21.940 --> 00:56:25.380
So we're almost... You'll see the headlines. I think we're99000:56:25.420 --> 00:56:28.440
up to over a thousand people have been registered now99100:56:28.480 --> 00:56:35.269
as having died following nitazine use. Vast majority accidentally because99200:56:35.289 --> 00:56:38.590
they didn't know what they were taking. But the modelling99300:56:38.610 --> 00:56:41.489
that we've done suggests that figure might be an underestimate99400:56:41.550 --> 00:56:50.519
by about a third. And on that note... Yeah, essentially99500:56:50.639 --> 00:56:54.610
it's just drugs are really bad and awful and don't99600:56:54.650 --> 00:56:55.070
take them.99700:56:55.369 --> 00:56:58.550
Thank God you didn't throw that book away 15 years ago,99800:56:58.570 --> 00:57:00.889
whatever it was, eh? That's the message here.99900:57:01.409 --> 00:57:04.110
Oh, the file in drug deaths when you took over100000:57:04.150 --> 00:57:07.309
from Colin from accounts. Oh, yeah, well, yeah.100100:57:07.329 --> 00:57:11.719
Yeah, it was, yeah, Christine coming to find me and saying,100200:57:11.760 --> 00:57:14.960
you're not Colin. Yeah, I wouldn't be here if it100300:57:15.000 --> 00:57:17.039
wasn't for her looking for him and.100400:57:17.590 --> 00:57:19.010
And you've recessed the service.100500:57:19.389 --> 00:57:20.190
There we go.100600:57:20.530 --> 00:57:21.550
Yeah, indeed.100700:57:21.730 --> 00:57:24.219
Okay. Thanks all. A big thank you to Caroline for100800:57:24.239 --> 00:57:26.579
joining us on the Oral Apothecary, for sharing her stories,100900:57:26.619 --> 00:57:29.099
her Desert Island drug, her career anthem, and her book101000:57:29.159 --> 00:57:32.599
for the Oral Apothecary Library. Coming up next time, we'll101100:57:32.619 --> 00:57:37.139
be joined by the writer, broadcaster, and Guardian columnist, Adrian Childs.101200:57:37.920 --> 00:57:39.619
Join us next time on the Oral Apothecary. You can101300:57:39.679 --> 00:57:42.360
contact us via X at Oral Apothecary. You can follow101400:57:42.389 --> 00:57:47.610
us on LinkedIn. You can email us at oralapothecarypod at gmail.com.101500:57:47.829 --> 00:57:51.489
The website is there also. Gimo now with a final ingredient.101600:57:51.710 --> 00:57:52.050
Brilliant.101700:57:52.530 --> 00:57:55.269
So on social media, we are trying to make a101800:57:55.289 --> 00:57:57.070
bit more of an effort with LinkedIn. And I think101900:57:57.090 --> 00:58:00.090
we're even going to start posting on Instagram this year.102000:58:00.130 --> 00:58:02.489
So please have a look and make an effort to102100:58:02.530 --> 00:58:05.030
talk to us because we love it when people talk102200:58:05.050 --> 00:58:07.070
to us we might not reply straight away but but102300:58:07.090 --> 00:58:08.949
we do we do like it when people talk so102400:58:09.150 --> 00:58:12.909
um thanks caroline that that was fabulous um steve as102500:58:12.949 --> 00:58:16.289
a clinician can you help me out um so i've102600:58:16.349 --> 00:58:21.230
got sore itchy eyes um it happens after spending too102700:58:21.289 --> 00:58:24.389
long staring at a screen and when i rub them102800:58:24.449 --> 00:58:27.280
they've they've started to turn slightly pink have you got102900:58:27.300 --> 00:58:30.940
any any idea what what i've got conjunctivitis no i103000:58:30.960 --> 00:58:35.800
think i think i've got something called bix bix onomania Bixonomania.103100:58:36.239 --> 00:58:40.320
So it's a condition that's out there, but the problem103200:58:40.380 --> 00:58:45.780
is Bixonomania doesn't exist. And in fact, researchers invented the103300:58:45.820 --> 00:58:50.960
condition and then they planted two deliberately ridiculous papers online.103400:58:52.239 --> 00:58:56.340
In the papers, they mentioned fictional universities, thanked Starfleet Academy103500:58:56.400 --> 00:58:59.000
for their support, and they even admitted in one of103600:58:59.039 --> 00:59:02.880
the papers that the entire study was made up. But actually,103700:59:02.900 --> 00:59:07.590
as reported in a recent Nature feature, major AI chatbots103800:59:07.889 --> 00:59:12.210
began describing Bixonomania as a real illness, complete with symptoms,103900:59:12.389 --> 00:59:16.429
prevalence figures, and medical advice. The fake research was even104000:59:16.510 --> 00:59:20.719
cited in a genuine peer-reviewed paper, which has since been retracted.104100:59:21.880 --> 00:59:24.460
So it's a good reminder on our ongoing theme that104200:59:24.559 --> 00:59:29.309
AI can make mistakes, convincing language for reliable evidence. And104300:59:29.349 --> 00:59:33.690
the polished nonsense is still nonsense. It's a powerful reminder104400:59:33.710 --> 00:59:37.000
of the risks of trusting blindly the answers that AI104500:59:37.059 --> 00:59:39.380
give us. I did do a little follow-up when I104600:59:39.500 --> 00:59:44.039
asked ChatGPT about Bixonomania as a test. It did pass.104700:59:44.400 --> 00:59:46.739
It told me it was a fake condition. But actually,104800:59:46.760 --> 00:59:49.610
a little worryingly, it asked me who told me about it.104900:59:49.860 --> 00:59:52.409
So it was interested, wanted to find out who told me.105000:59:53.510 --> 00:59:55.690
So there we have it. Whether advice comes from a105100:59:55.710 --> 00:59:59.539
chatbot or a peer-reviewed paper, always check. the source.105201:00:00.119 --> 01:00:03.059
You have been listening to a Three Apothecaries production. Sound105301:00:03.119 --> 01:00:07.570
engineer Jimbo Slough, original music Jamie Brewster, artwork by David105401:00:07.619 --> 01:00:09.150
Baker and Jacob Howard.105501:00:09.730 --> 01:00:13.489
Thanks for listening to the Oral Apothecary podcast. For maximum effect,105601:00:14.010 --> 01:00:15.170
install weekly.105701:00:15.730 --> 01:00:20.460
This episode of the Oral Apothecary is sponsored by onelesspill.com,105801:00:20.960 --> 01:00:23.340
a medicines optimization consultancy.105901:00:26.380 --> 01:00:27.280
Thank you.
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