Root of confidence
Better benzodiazepines
Dangerous alien

Root of confidence

There used to be an assumption that people who performed special functions in society, and incidentally got paid for their services, were expected to be both competent and conscientious in the actions they performed. It is often impossible today to track down the individual who is responsible for dealing with a complaint, for restoring your access to an essential service such as water, electricity or telephone, for repairing your road, or arranging your admission to hospital within a reasonable time when you need medical or surgical attention. It is next to impossible to persuade your elected representative in local or regional government to take up your case when you are aggrieved. Needs get lost in a maze of jettisoned responsibility and computerised communications.

In fact this is no new problem, although it may have become more acute with the relentless spread of bureaucracy. In 1914, in his book 'Chance', Joseph Conrad wrote that "no ship navigated and sailed in the happy-go-lucky manner people conduct their business on shore would ever arrive in port". His point was that, although in the safety of dry land it is possible to shelve responsibility and pretend to a competence which you do not possess, in a situation of critical isolation where your life depends on your competence, you really have to know what you are about. And not only know, but act accordingly. We are sometimes sorely tempted to take the hopeless advice of Psalm 146: "Put not your trust in princes nor in any child of man; for there is no help in them." This is a counsel of despair.

Pharmacists, like other providers of special services to the public, are coming under criticism from consumer groups for what are alleged to be their shortcomings. Most criticisms are of the discretion exercised by a pharmacist in situations where he or she is in the position of being able to assess whether or not a customer should be provided with a certain medicine, taking into account the hazards and the advantages.

Being open to such criticism depends upon two aspects of the professional approach which are not based upon legal considerations, factors which must always exercise a truly professional mind. The first is scientific and technical competence, the second social competence, the ability to meet a patient face to face and offer any appropriate advice, and if necessary to refuse to comply with a request that is judged flawed. These two aspects form the backbone of any truly professional approach to a social function that is justified by specialised knowledge.

We are well aware of the need to keep our scientific knowledge up to date, and undergo postgraduate education to ensure that this happens. So far we have been less willing to undergo training in the person-to-person commerce of a professional career, in which we have, without indulging in personal criticism or demonstrating lack of sympathy, to make soundly based decisions that are disciplined as well as kindly. The computer mentality makes it more difficult to deal with people as individuals while preserving the milk of human kindness and the desirable degree of warmth. We are, after all, health carers, not medication robots.

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Better benzodiazepines

In Chemistry in Britain for February there is a note on research which promises the advent of better benzodiazepine anxiolytic drugs than those we have already encountered. The author is Ruth McKernan of the research laboratories of Merck Sharp & Dohme.

It is pointed out that benzodiazepines, although clinically useful, have a sorry history in some respects. Triazolam was withdrawn from the United Kingdom market on account of multiple side effects. Temazepam abuse was associated with thrombotic episodes when gels were injected intravenously. Flunitrazepam became notorious because it was used in criminal circles to spike alcoholic drinks and incapacitate intended victims. Diazepam has been so widely prescribed that there have been problems of withdrawal when therapy was continued too long, some patients claiming to be unable to do without it. Despite the unwanted effects of sedation, abuse potential, interaction with alcoholic beverages, memory impairment and dependence, prescriptions for benzodiazepines amounted to 18 million in the UK last year. Pharmaceutical manufacturers have therefore pursued the design of better compounds able to achieve the same results.

Benzodiazepines rapidly enter the brain and bind to receptors concerned with anxiety, memory, sedation and co-ordination. These receptors are activated by gamma-aminobutyric acid (GABA), whose activity is enhanced by benzodiazepines. There are more than 20 types of GABA receptors in the brain, to some 15 of which these drugs bind. Four main subtypes are distinguished, called alpha-l, alpha-2, alpha-3 and alpha-5. Six different aminoacids contribute to their chemical reactions, one of the most crucial being histidine. If this is replaced by arginine sedation is much reduced. In transgenic mice it has been found that the alpha-1 receptor is the target for sedation, the alpha-2 for anxiolysis, and the alpha-5 for some memory impairment. The subtypes concerned with ethanol interaction, dependence and withdrawal symptoms are being studied. Synthesis of compounds in which the desired clinical activity can be achieved and limited to one effect, for instance anxiolysis, will be followed with interest.

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Dangerous alien

The habit of importing alien plants or animals to gratify the desire for novelty has always been suspect. Today we face the results of adopting yet another foreign weed, reminiscent of the notorious Japanese knotweed, cultivated in the gardens of our forebears for generations, and now presenting a tricky problem as it invades water-courses and damp corners and resolutely refuses to give up its struggle for continued existence.

The latest menace to the wildlife of our ponds is Myriophyllum aquaticum, the parrot's feather weed. This is an import from the New World, introduced into Britain in the 1960s and still available from garden centres as an ornamental pond plant. It is particularly prevalent in the south-west of England, where the climate is mild and severe frosts rare. In an ancient millpond at Hayle, in western Cornwall, a major operation has had to be carried out to deal with an enormous mass of the weed which has endangered the natural flora and fauna, and called for the rescue of more than 3,000 perch, gudgeon, roach and rudd and the removal of about 1.5m of mud by mechanical excavator. The solidity of the mat formed by the weed is set to strangle the native wildlife. Mechanical removal of the entire mass has been necessary, and it is unknown how much herbicidal treatment may be necessary to prevent a recurrence.

The Myriophyllum aquaticum at Hayle is thought to have originated in a local garden ornamental pond. The Environmental Agency has offered to advise people on what plant species to avoid, and on how best to dispose of unwanted aliens without risking environmental catastrophes. There is much to be said for insisting upon gardeners limiting their purchases to native plants and avoiding aliens. Ideally there should be an effort on the part of proprietors of garden centres to avoid any introduction of exotics, however attractive, unless their capability to do harm to the natural environment has been fully evaluated.

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