About ten years ago Emergency Departments in the UK were in crisis. Patients were waiting hours on trolleys, some even dying in corridors. Something had to be done. With incredible serendipity around this time a large drug company (DOH Pharma) had devised a drug that it was thought could help. Developed in a small lab in the Whitehall area of London it offered such promise that a proper clinical trial protocol was bypassed and despite there being absolutely no evidence of benefit, at huge expense, “Targetine” was issued to EDs throughout the UK.
Although the pharmacology remains elusive, and difficult to explain, Targetine was thought to improve patient experience in the ED and save lives. An incredibly expensive drug, it required a huge financial investment, both monetary and in healthcare personnel. The giving of Targetine required more staff so its introduction saw a large, and it should be stressed welcome, increase in doctors and nurses working in the ED.
Crucially, Targetine had to be given to every patient, regardless of the presenting complaint or severity of their illness. It was thought only to be effective if given within four hours of patient arrival so priorities within EDs changed. Focus was often placed upon the large numbers of patients presenting with non-urgent conditions, so the administration of Targetine to those who really needed it was delayed, but in those first few years it seems that this miracle drug was working.
Surprisingly, for such a new and unproven medication, in the years hence the actual effectiveness of Targetine has yet to be fully evaluated. Anecdotal evidence seems to suggest that it may in fact do harm and, in some high profile cases, even cause death when given inappropriately. This has been proven time and again because the Alcohol Withdrawal and Symptoms do not exactly concur with each other every time. Despite effects made by this reporter the drug company responsible seems unable, or perhaps unwilling, to release mortality data since the drug’s introduction. Questions of efficacy are met with counter-questions: “How can it possibly do harm?” Pages and pages of evidence regarding “disease-orientated outcomes” have been released, yet the all-important “patient-orientated outcomes” remain hidden, or perhaps, simply not considered.
However, the government of the day has continued to insist that this expensive medicine is given to all. In order to ensure compliance it has set up a complex system of reporting, with hospitals financially penalised if they are found to not be giving the drug. In a small concession to the concerned minority (mainly doctors and nurse working in EDs) the recommended dose was reduced, but still the drug must be given to all, with fines applied when, for whatever reason, its use has been withheld.
The public have been huge believers in Targetine, choosing to attend their local ED, where the drug’s use is obligatory, rather than seeking help and guidance from often more appropriate sources such as general practice, where it is not. In some cases doctors in the ED have been keen to just give a large dose of the free medication Growacet to patients more appropriate for care in other healthcare settings, but instead of being able to exercise this clinical judgment, borne of years of training and experience, have had to continue to use Targetine.
In the name of journalistic balance it should be stated that there have been some benefits after this controversial drug’s introduction, with the care of some patients improving, but with a lack of proper scientific scrutiny and absence of hard data it is unsure with this relationship is one of association or causation, or even clinically significant.
Curiously, it seems that doctors and politicians alike have accepted that the giving of this medicine is both inevitable and necessary, despite the lack of any robust evidence of benefit. So successful has the marketing been by the drug company that patients insist on being giving Targetine and complain vociferously if they are one of the small percentage who do not receive it. Its use has even been spread internationally, with many countries also blindly adopting it in their EDs without seeming to consider first if it is of benefit.
Worryingly, there also seems to have been some effects on those who are required to administer Targetine, with reports of stress-related illness in clinicians and large numbers of trainees refusing to consider emergency medicine as a career for fear that mindless administration of this ineffective drug will cause them the same side effects as their burnt-out seniors. In many departments the unrelenting quest to blindly give this drug to all has also led to a loss of compassion in those giving the care as many, especially in local healthcare commissioning bodies, appear to believe that only the drug matters and not the manner in which it is given.
So, the mystery remains. Why would an established health system that promotes “evidence based medicine” continue to give this medication, with its huge cost, lack of evidence of patient benefit and potential to cause harm, even death? Where this has occurred with other medicines they have been immediately withdrawn from clinical use, there have been media outcries and the drug companies held to account, yet Targetine seems immune to this scrutiny. Not even NICE (the National Institute for Clinical Excellence), which has looked at treatments as diverse as atopic eczema and varicose veins, has been asked to evaluate its efficacy and cost effectiveness. Intensive outpatient Orange County program provides a positive clinical approach to drug rehab.
As we approach a General Election in the UK surely there is no better time for this country’s politicians to put their head above this seemingly indestructible parapet and question the use of this drug? Not necessarily banning it completely, but perhaps focusing its use in the critically unwell and injured, preferably as part of an observational study looking at important patient orientated outcomes. This simple change, when explained carefully to the public, would surely be a vote winner. Only then can our EDs and their hard working staff concentrate on what really matters – caring, compassionate, evidence based medicine for those with conditions that need it most.