On bad things

Bandolier this month is all about bad things happening: the bad things that happen when you smoke cigarettes, when you take "recreational" drugs and drive, to your bowel when you take NSAIDs, and bad things possibly related to acne treatment. Bad things happen a lot. While in the long run we are all dead, we still strive valiantly to avoid bad things, so we might do more to understand them.

One thing often forgotten about adverse events, particularly but not only with drugs, is that they are usually related to dose. The more you take the worse the event or the more likely it is to occur. Not a new thought, this. “ All drugs are poisons, the benefit depends on the dosage ” (Philippus Theophrastrus Bombast of Aureolus Paracelsus), which is why “ the best doctor gives the least medicines ” (Benjamin Franklin). Cigarette smoking and driving on drugs provide two nice examples, and good reasons for eschewing both.

Another oft forgotten truism for adverse events is that the more you look, the more you find. Aspirin and NSAIDs have been with us for decades. We thought we knew them. Yet come along with proper modern studies and we find what we chose to ignore previously. As well as causing havoc in the stomach and duodenum, much of the rest of the bowel is at risk of damage as well. Rates of damage are high, and what might protect in the stomach does not work further down.

However hard you look, though, for some very rare adverse events you find nothing substantive, only ephemera. Conclusive links between acne treatments and suicide have not been found. But the evidence we have is that where there is history, personal or family, of mental problems, acne treatments can be dangerous. Not what treatment, but who to treat.

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