Secundum Artem

What Hath Science Wrought?

2008-05-14T20:23:00.002-04:00

I'll tell you what, or rather, Decrepit Old Fool will.

Just one more kick in the head to people like Ben Stein who want to throw us all back into the good old Stone Age--without giving up the perks of modernity that they find personally convenient, like cell phones, cars, or antibiotics.

The Price of Potency

2008-05-12T20:23:00.002-04:00

Male readers, would you risk your life for an erection?

It seems like a bizarre (and personal) question, but there are patients that are more than willing to do it. They are so willing, in fact, that they will lie to both doctors and pharmacists to get their hands on little blue pills when it's the little white ones that are keeping their heart supplied with oxygen.

Viagra, Cialis, and Levitra belong to a class of drugs called PDE-5 inhibitors. PDE-5, otherwise known as phosphodiesterase isoform 5, is an enzyme indirectly responsible for maintaining the amount of free nitric oxide, or NO, in certain parts of the body. PDE-5's claim to fame is that it decreases the amount of NO in the vasculature of the penis in an area called the corpus cavernosum. NO causes blood vessels to expand, which in turn causes an erection. By blocking PDE-5, the overall concentration of NO goes up, making it easier to achieve erection--but not in the absence of sexual stimulus (typically, anyway). If you want some good anatomical diagrams, try this link, which coincidentally explains more or less exactly how these drugs work in more detail.

Nitroglycerin and other nitrates work on the NO system, too. All of these drugs either directly degrade into NO or indirectly release NO via metabolism in the bloodstream. Angina pectoris (chest pain) is caused by the heart receiving insufficient oxygen. In the treatment of angina, NO causing expansion of blood vessels allows more blood to flow to the heart. It also decreases the pressure in other vessels, making it easier for the heart to pump blood; because the heart is not working as hard, it needs less oxygen. The result is a reduction in angina symptoms.

Both of these drugs increase NO levels. NO dilates blood vessels. Can you see where this is going?

Yes, combining nitrates with PDE-5 inhibitors can result in so much dilation of blood vessels that blood pressure drops to dangerous levels. If pressure drops too low, vital organs (such as the brain) can become starved of blood--which means that they are also starved of oxygen.

This drug combination is therefore contraindicated, i.e., a totally bad idea--and the kind of thing that a doctor (or more likely a pharmacist) could get sued for prescribing/dispensing. Giving a patient on nitrates a drug for ED is putting the patient at serious risk. But I've encountered patients who were willing to lie to everyone within a five-mile radius--doctors, nurses, technicians, pharmacists--to get their hands on the blue pills (or yellow ones, depending on their preferred drug).

The whole scenario raises some interesting questions. Why are male patients willing to lie to their healthcare providers? Perhaps they don't really understand the risk. Perhaps they think they understand the risk, but they don't care. Perhaps they're being fed all kinds of mass-marketing and commercial nonsense about how they'll never be able to satisfy their lovers without Big Pharma's magic erection pills. ED is a serious quality of life issue for a lot of patients--those with diabetes are among the most commonly affected. But when we as a society are putting pressure on men to the point where they are willing to risk their lives to get a hard-on, something is wrong. And this pressure isn't new--the search for aphrodisiacs has been on ever since the start of recorded history. A biological imperative? A product of culture? Who can say for sure?

The Future of Automotive Engineering

2008-05-08T20:26:00.002-04:00

I couldn't resist sharing this comic I found:

Alternative mechanics ahoy?

Advertising in Bizarro World

2008-05-06T16:22:00.004-04:00

The other day I picked up a new copy of everyone's favorite pharmacy publication, DrugTopics. I generally like DrugTopics, except when they're running Zicam ads or otherwise uncritically promoting unproven treatments because the manufacturers were willing to pay for a page. The Zicam ads are annoying because they attempt to lend legitimacy to a product that has done everything conceivable to skirt FDA regulation--like calling itself homeopathic when in fact it contains measurable amounts of zinc. At a "1X" and "2X" dilution, a "recommended daily dose" of oral Zicam "cold remedy" tablets contains 80 mg of zinc. That's nearly eight times the typical dietary intake, and your average multivitamin contains about 10 mg as well. In essence, Zicam is about as homeopathic as Prozac, except that Prozac required FDA approval and Zicam didn't. Way to go, guys.

But this post isn't about Zicam. No, another advertisement caught my eye this time around--it was an ad for Luvox CR.

Luvox CR is a new formulation of fluvoxamine, a drug used to treat depression and obsessive-compulsive disorder. It's in the same general family as all the other SSRIs--Prozac, Zoloft, Paxil, Lexapro, et cetera. Granted, there are subtle differences between all of these drugs, but it's fair to say that fluxovamine (more or less) doesn't do anything spectacular by comparison; it is, in fact, one of the oldest SSRIs on the market.

Luvox CR, like many other drugs, is a follow-on drug intended to extend the patent life of a drug entity. Of course, follow-on drugs typically tend to come out a few years before a patent expires as opposed to a decade later, so Luvox CR is kinda missing the boat, but they're trying. All of this is acceptable, if shady, given the tendency of drug reps to push follow-on drugs like they're the greatest thing since sliced bread (and, of course, are totally worth paying $5 a dose for as opposed to the 50 cents the generic version of the old drug might cost).

Here's why I'm making the bizarro world reference. The advertisement's tagline was, and I quote: "NEW LUVOX CR: AN ANTIDEPRESSANT WITH NO GENERIC EQUIVALENT!"

I blinked in curiosity after reading these words. Was this supposed to be a good thing? Are reps supposed to approach psychiatrists, talk them up about the wonders of their new product, and wow them at the end with a concluding "best of all, this drug is going to cost your patients a fortune?" Who is this supposed to impress? I'm pretty sure the only people who think that "no generic equivalent" is a merit are the drug companies.

Or maybe these sorts of advertisements aren't ads at all--they're a warning to uppity pharmacists not to try doing stuff like "saving patients money" by "requesting lower-cost alternatives" and "cutting into pharma's profits."

Did I publish that where it was publicly viewable? Oooops.

Seriously. This is my biggest gripe about the pharmaceutical companies and their method of advertising. I can deal with them buying filet mignon for doctors. I can tolerate the magazine ads and even the occasional television spot, even if I think direct-to-consumer advertising does a lot more harm than good (no statistics, just impressions). What I can't stand is pharma advertising flaws as merits. "Our product costs ten times as much as our competitor's!" is something you would never hear touted as a positive in any other industry.

But hey, I'd much rather pharma play fast and loose with patent laws to try to squeeze a few more good years out of drugs that the FDA has thoroughly reviewed than "big woo" (sometimes the same companies, for that matter) play the get-out-of-jail-free "it's alternative medicine" card. After all, big woo has to slap the quack Miranda warning on all their products.

It's a strange day and age when "costs more!" and "isn't proven to work!" are somehow twisted to be signs of a good product.

A Brief Personal Update: Plus, Insulin By Mouth? (Kinda)

2008-05-05T20:06:00.004-04:00

After several panic-filled weeks of last-minute cramming for final exams, N.B. is finally "free" for the summer (aside from all those lick-and-stick hours at the local pharmacy where he earns his keep). The goal at this point is to finally find things I enjoy doing--like blogging--instead of shoving medicinal chemistry into my head so that I can pass the semester-end exam.

It also gives me time to do less academic (but arguably no less cerebral) things to do, like finally beating Metal Gear Solid 2 on the "extreme" difficulty. Preferably without using hundreds of continues. No, I haven't done it yet, but it's a by-end-of-summer goal.

In any case.

This particular story apparently isn't breaking news--and if you've been following it, it's a saga that has dragged on for several years, reportedly with the intervention of Big Pharma trying to shut down Little Biotech, or at least buy them out. But here's the exciting news for patients and investors alike. An oral insulin spray is still in development and has apparently performed well in trials. The medication is approved for use in Ecuador and India, and it is currently undergoing phase III trials in the U.S., suggesting that we may see some sort of release in the states in the next one or two years.

Buccal administration is a complicated-sounding way of giving medicine by having it absorb through the cheek. The cheeks and area underneath the tongue have a rich blood supply and fairly thin barriers between the bloodstream and the outside world, permitting specially-formulated drugs to cross easily. While a lot of buccal drugs are used for their local effect (like anesthetics), some are intended to effect the whole body, like the opioid pain-reliever fentanyl, which is available as what amounts to a sucker.

Another major advantage of buccal administration is that it bypasses both the stomach and the liver, preventing the drug from being broken down before it enters the bloodstream (in the case of the liver, this is called first-pass metabolism). Protein drugs, such as insulin, cannot normally be taken by mouth because the stomach and intestine will digest them like any other protein, rendering them inactive. To prevent insulin from being reduced to useless amino acid bits, it must normally be given by injection.

The reason inhalation was considered as a route of administration for insulin was because it, too, bypasses the breakdown that takes place in the stomach. Theoretically, the rectal route partially bypasses first-pass metabolism (it actually depends how far up you insert the suppository), but I can't imagine rectal insulin would be very popular, and there are other complications.

For the pharmacologists in the audience, now I'm trying to imagine what sort of formulation barriers might exist to insulin suppositories. Base incompatibility? Temperature/storage problems? I've never even heard of a protein drug being given by that route. But I digress.

The product that the article I linked is talking about is a spray--think something like breath spray--that is applied to the inside of the cheek. The spray would be metered to provide a precise dose, but fine-tuning might be difficult unless the spray can be "dialed" to spray different amounts of insulin. The details are still fuzzy, but the research is still very exciting.

Patient compliance--the ability and willingness of a patient to properly use his or her medications--is a huge obstacle for patients with diabetes. Anything that makes administration of insulin easier for adults and children alike is definitely a good idea, assuming of course that there are no long-term drawbacks and that the system is practical (inhaled insulin turned out not to be). I'm looking forward to seeing where this research goes.

An Idea

2008-04-17T21:24:00.001-04:00

A group of endocrinologists should start a metal band called Thyroid Storm.

Just Pissing It Away

2008-04-17T10:57:00.002-04:00

It's been quiet in my corner of the blogosphere, but I lay the blame squarely on the fact that my latest round of exams has kept me extremely busy. Ths plus side of all this is that I get to come back to lots of news, all ripe for comment!

Like this article published today analyzing a couple studies from early 2000 about certain drugs prescribed for high blood pressure being potentially tied to bone loss, particularly in older men.

Most of the time, our sound bite-focused media doesn't get the whole story out there. This article is no exception.

Diuretics are commonly called "water pills," particularly by older people. I really, really hate that term. It isn't even remotely appropriate for describing how diuretics function. I suppose that the analogy comes from the idea that drinking more water causes increased urination, and taking diuretics causes increased urination; hence, diuretics are "water in pill form," except that that totally fails to explain how they work to lower blood pressure. Normally I don't think it's necessary for patients to know the mechanisms of action for the drugs they take--such details are excessively complicated. But we strive to explain things in the simplest way we can without sacrificing accuracy. Antidepressants, for example, are said to "balance or correct problems in brain chemistry." This is simple, but true at the base level.

Diuretics don't add anything to your body, and they certainly don't hydrate you. They have varying mechanisms of action, but what they really do is increase the body's excretion of certain elements that float around in the body in ion form. Sodium, potassium, and calcium are three good examples--they are commonly called "electrolytes," especially if you like reading the labels on your sports drinks. Generally, sodium loss is desirable in patients with high blood pressure. All of these ions must be present in proper concentrations for the body's various functions to work properly. Too much and too little are both bad. Diuretics are a convenient way to get rid of excess electrolytes.

The diuretic the article is talking about is furosemide, though there are other diuretics in the same family that have the same effect. Furosemide flushes out sodium, potassium, and calcium by preventing the kidneys from re-absorbing it at a specific point (the loop of Henle, if you're curious). Many patients on furosemide are also prescribed potassium supplements to counter the potassium loss. The calcium loss is not as frequently addressed, but it really should be; then again, most people don't get enough calcium anyway.

But saying diuretics in general are responsible for worsening bone loss is not only alarmist, it's false. Hydrochlorothiazide, or HCTZ, actually results in calcium retention. Sometimes this is a problem, as it can cause calcium levels in the blood to get too high. But for some patients with high blood pressure who are also at risk for osteoporosis, HCTZ is a great drug; it helps them retain extra calcium, improving bone density! This doesn't mean that everyone at risk for osteoporosis should be on HCTZ; increasing dietary calcium and vitamin D are a much better idea. But when treating patients with high blood pressure, it is often best to use drugs that "kill two birds with one stone." Likewise, it doesn't mean that patients at risk for bone loss shouldn't get furosemide. This is what trained physicians and pharmacists are for--evaluating the complicated mess of risks, benefits, and drug interactions that make modern medical therapy so difficult to manage.

And that's the bottom line--medicine is complicated. One 200-word article in a newspaper is never going to explain all the ins and outs of any particular treatment or drug; that's why scholarly journal articles are long, detailed, and extensively referenced. So consider very carefully where you get your information; chances are that if it was packaged for the general public and sold at the newsstand, you're not getting the whole story.

Really Delayed Ambulance Chasing

2008-04-11T16:07:00.003-04:00

A few months ago I was in a minor vehicular accident when traffic ahead of me slowed to a complete stop on the highway. A pickup truck swerved across three lanes and cut in front of me; my eye still on the truck, I failed to notice that the cars ahead had stopped, so I wound up rear-ending a fellow motorist at about five miles per hour as I failed to come to a complete stop. The total damage done was a slight scratch on my front bumper and a tiny imprint the shape of my car in the poor guy's fender. Neither party was injured, so the police didn't even file a full report, just a non-investigated accident form for the both of us as a way of formally exchanging information.

Fast-forward to today, nearly four months later.

When I got home from class, I was told that someone had called about my insurance. Since the other driver had (about a month after the accident) apparently smelled money and tried to claim an injury, I figured that this was about the resolution to that case.

Nope. It was a chiropractor's office.

They were trying to convince me to schedule an appointment in the event that I was having "headaches, backaches, or other pain problems" as a result of the "accident." "It can take several weeks or months for problems to develop," noted the woman on the phone. "This is because at the time of the accident your body is full of all kinds of chemicals."

Right. It still is, as a matter of fact, and I bet I know more about them than she did. Moving on.

I was polite to her; there was no reason to be otherwise, and I declined her offer to make me an appointment for a chiropractic evaluation.

This is all just a story--an anecdote. But I've never seen any other "doctors" having to resort to cold-calling patients from accident records to solicit them as patients. Chiropractors have more in common with ambulance-chasing lawyers than with physicians; the only way most of them are going to get any business is with colorful advertising or by dubious phone-farming.

In retrospect, it might've been somewhat humorous to suggest that I had developed allergies or diabetes since the accident. I wonder what the representative on the phone would've told me if I asked what they could do about it at the office?

Alarmist Media Soundbites Annoy Pharmacy Student

2008-04-07T13:42:00.004-04:00

Let it be known that there are few ideas that cannot be expressed in a more entertaining way by using AP-style headlines.

There's been a lot of talk about how common medication errors or overdoses occur in hospital settings, particularly in children. A good bit of this can be attributed to the recent heparin mix-up involving Dennis Quaid's children. This particular error, fortunately, caused no deaths, unlike some previous errors in Indiana a year or two ago. The Quaids have every right to be upset--and they have every right to campaign to make the issue more visible. Medication errors are serious business, and hospitals should do everything in their power to prevent them from happening.

That said, the issue is being way over-hyped by the media.

According to the first link, one in fifteen children admitted to a hospital--about 7.3%, or 540,000 children across the United States each year--is harmed by a medication error. These are the figures that are being pitched around by the media in multiple places.

But these figures are misleading and alarmist. What a shock! Here's the study they're citing.

Part of the issue is the definition of an adverse drug effect. According to the Washington Post:

More than half of the problems cited involved overdoses or allergic reactions to painkillers.

The "or" in that sentence complicates the issue, but here's a simple statistic. The two biggest classes of pain medication are NSAIDs like ibuprofen and opioids like morphine or codeine.

True opioid allergy is exceedingly rare. In fact, less than 1% of the population is estimated to be allergic to opioids. Likewise, only about 1% of the population is estimated to be allergic to NSAIDs (though NSAIDs may precipitate problems in some patients with asthma).

This means that if the numbers reported are accurate and 11 out of 100 children hospitalized experience an adverse effect, only one of those is truly allergic to the drug in question--and there's nothing that can be done about that, short of avoiding the drug. Unfortunately, patients without a history of an allergic reaction are not going to discover the allergy without being exposed to the drug. This seems largely unavoidable. So what about the other ten kids? If the Post is correct, all of them recieved some kind of overdose.

Let's take a look at the actual study:

Twenty-two percent of all adverse drug events were deemed preventable...ninety-seven percent of the identified adverse drug events resulted in mild, temporary harm. [emphasis mine]

Mild, temporary harm? What kind of harm?

The most common adverse drug events identified were pruritis [itching] and nausea, the most common medication classes causing adverse drug events were opioid analgesics and antibiotics

Huh.

Even patients not truly allergic to opioids may react with what is called a pseudoallergy. Where a true allergic reaction is a result of inappropriate overactivity of the immune system, pseudoallergy reactions are a result of sudden histamine release, causing flushing, itching, sweating, or hives. This is a well-documented side-effect of opioids. Is it totally preventable? Sure--by not giving opioids! Of course, this is why using the lowest effective dose of a drug is always a good idea--unlike true allergies, opioid pseudoallergies are dose-dependent, so higher doses increase the probability of a reaction. The good news is that antihistamines can be used to reverse the majority of these symptoms.

Antibiotics, conversely, wipe out friendly bacteria in the digestive tract, which is commonly accepted to be a cause of antibiotic-induced nausea and diarrhea. Other factors include the direct effect of the drug on the digestive tract, but decimating gut flora isn't doing anyone any favors. Some antibiotics are worse than others, but nausea is extremely common with antibiotic therapy--and, again, there's basically nothing that can be done about it.

At this point, the question should not be "how many children suffer adverse drug reactions?" This statistic is too simple to have any predictive power, especially when including mild or easily reversed side-effects that are extremely common (and predictable) or associated with the use of particular drugs. We should be more concerned with medication errors than minor adverse reactions. A patient getting a thousand-fold overdose of heparin is serious. A child getting a stomachache as a side-effect of antibiotics is not. So let's turn the statistics around--only 3% of adverse reactions were serious. A full 97% were mild and/or reversible. That sounds like good news to me!

I've come to expect that the media is going to spin everything they report to make it sound infinitely worse than it actually is--bad news sells. But the last thing we need is parents panicking about medication errors and being afraid to take their children to the hospital. Vigilance on the part of both parents and healthcare providers is good. Panic--and subsequent distrust--is not. Distrust of medical professionals is one of the main factors that turns patients to supporting woo.

And since I can't resist plugging my own profession, let's not forget that well-trained pharmacists are crucial players in reducing medication errors.

At Least He Didn't Need any Narcan

2008-04-07T13:29:00.003-04:00

This is what happens when I get too busy to catch up on blogs for a few days--I miss gems like this post on the Bad Idea Blog.

Zero Tolerance has struck again: eight-year-old Eathan Harris was recently suspended for the dastardly crime of realizing that Sharpie markers smelled sort of neat.

"Zero tolerance" policies in schools have always been taken to positively baffling conclusions. However, they certainly fulfill their function--allowing school teachers and administrators to resolve every problem that might come up via knee-jerk reactions without having to think or reason. Some of the policies occasionally make sense at the most fundamental level, but they inevitably get stretched way beyond reasonable limits:

Student expelled for bringing a butter knife to school.
Another student expelled for possessing Tylenol. Tylenol!
Boy expelled for having two soft pellet guns in his car. What were "school authorities" doing searching his car in the first place?

It's no wonder schools have so much trouble imparting the merits of critical thinking to their students--their administrators don't seem to get it, either.

A Total Waste

2008-04-07T11:22:00.004-04:00

According to a recently released report, lack of health insurance results in higher death rates.

A report issued Friday by Families USA, the national organization for health care consumers, concludes that nearly three people die each day in North Carolina because they don’t have health insurance.

The Families USA report says people without health insurance are more likely to delay seeking care because of the high bills, which means disease such as cancer are diagnosed at a later, more deadly stage.

Really?

I believe that this sort of thing speaks for itself. The cost of healthcare is astronomical--and it is quite simply unaffordable for the uninsured. By contrast, the insured in this country have an exceedingly poor grasp of the real cost of medical treatment, simply because they've been insulated from it by copays and percentages. Most people have some tenuous grasp on the idea that treatment for life-threatening illnesses is costly--treatments for cancer, for example, or any major surgery. But if outpatient pharmacy is any indication, most patients think that $50 is a "really expensive" drug product and they start complaining about how their insurance clearly didn't cover anything.

For some reason, telling them that the real cost of the medication is $250 doesn't change their tune.

What more can I say? I live in one of the richest countries in the world, but we have the poorest health outcomes per dollar spent. Despite the fact that America is the "first-world," people die from treatable illnesses because they can't afford to seek medical care until it's too late.

How to Torture a Pharmacist

2008-04-03T12:46:00.002-04:00

Get him or her to optimize your medication regimen when you have multiple diseases, one of them is a seizure disorder, and you absolutely need to take phenytoin.

This just in: Phenytoin sucks.

I don't mean in the sense that it is a bad drug. It is quite effective. It's just really, really, really, really annoying.

An Open Letter to my Pharmacy School

2008-04-03T11:53:00.003-04:00

Please quit sending me emails about the veterinary therapeutics course. Last I checked, it was illegal for non-vets to prescribe medications for non-human animals. What, exactly, is the point of studying how to treat diseases in animals when animals are considered to be outside both our scope of practice and the scope of practices of physicians we work with? In my state, at the bare minimum, pharmacists aren't even allowed to sub brand-generic on vet prescriptions. What's the point?

I will note that I get a lot of calls from a local vet's office when I'm at work, but most of the time the questions being asked are about drug product availability; sometimes pet meds come in dosages or concentrations that human meds don't, and it can be difficult to approximate the doses. My cat's bladder infection was treated with what amounted to an Augmentin 50 mg/5 mL suspension; the least concentrated form available for humans is 200 mg/5 mL, so trying to dose the cat would've been practically impossible considering that she was getting about one milliliter of the stuff anyway. And I feel really bad for the family at our pharmacy who apparently splits the tiny-ass 2.5 mg Norvasc tablets in half.

Actually, the most confusing veterinary puzzle is the cat who uses an albuterol inhaler. If I ever see the owner at the store I'm going to ask how in the world that works.

Flagellating a Long-deceased Equine

2008-04-02T11:27:00.003-04:00

How much more of this are we going to have to take?

Vaccines do: Prevent potentially fatal or crippling diseases.

Vaccines don't: Cause autism.

Seriously. Only in a wealthy, priviledged country like America do people have the time and resources to blame medical care for ruining the lives of their children. People in third-world countries will quite frequently do anything to get medicine, vitamins, or vaccinations to prevent or treat polio, rickets, malaria, or any number of other diseases that have been effectively eradicated in the first-world--eradicated thanks to medical science, not ambulance-chasing lawyers seeking thimerosal settlements.

Let me restate that. People are spending hundreds of court-hours and millions of dollars in legal fees trying to prove that a medical intervention that people across the globe are dying to get their hands on harmed their children.

Is this really about protecting children? Or is it about reaching into corporate America's deep pockets and snagging a piece of the autism settlement pie with your sticky fingers?

Abused Vocabulary #2: Chemicals? In My Child's Hair?

2008-03-31T14:16:00.002-04:00

I cringed today during one of my lectures.

The instructor was discussing pediculosis, otherwise known as lice infestation. Lice are a recurring nightmare for public places where children gather in large numbers--daycares and schools come to mind. I have vivid memories of the school faculty lining us up in the hallways outside the nurse's office for occasional lice inspections.

She went on to mention--but not necessarily recommend--"natural" treatments for head lice. Apparently, olive oil, tea tree oil, and mayonnaise, and various other products are occasionally used as alternatives to "chemical pesticides."

What threw me was the professor's specific quote: "Well, some parents are going to use these because they don't want to put chemicals on their children."

Huh. I don't know. I would be terribly concerned about rubbing oleic acid, palmitic acid, stearic acid, and lineoleic acid into my child's scalp, wouldn't you? I mean, they're acids. Acids are corrosive, dangerous substances that can dissolve rocks and metals!

Except that they're fatty acids. There's a big difference between hydrofluoric acid and oleic acid, especially considering that the latter is the major component of olive oil.

The point is that anything can sound scary if you describe it the right way--consider the dihydrogen monoxide issue. (For those who don't immediately get the joke, dihydrogen monoxide is water). And it drives me nuts when people who are supposed to be scientists--or worse, educators--haphazardly use the word "chemicals," apparently validating the public's irrational fear of the very word, a word associated with harmful, "unnatural" things like benzene and turpentine instead of water, salt, and sugar.

Of course, the joke is on them. The active ingredient in RID is made from crysanthemums.

A Remarkable Lack of Self-awareness

2008-03-28T11:10:00.002-04:00

A tragic story released today by the Chicago Tribune really makes you wonder about people's abilities to critically examine their own point of view--even when lives are on the line.

Police are investigating an 11-year-old girl's death from an undiagnosed, treatable form of diabetes after her parents chose to pray for her rather than take her to a doctor...

...the girl's mother, Leilani Neumann, said that she and her family believe in the Bible and that healing comes from God, but that they do not belong to an organized religion or faith, are not fanatics and have nothing against doctors. [emphasis mine]

Are you sure about that?

According to the article, the girl had not been to a doctor since she was three (at least she got routine immunizations). Relatives, including an aunt, called the authorities to report that the little girl's life was in danger because her parents were refusing to take her to a hospital and were instead trying to heal her with prayer.

The interesting thing about the case is that, like so many others in the same vein, the legal route of investigation is whether or not the parents were negligent in caring for their daughter. The authorities (and most sensible people) will most likely conclude that not taking a comatose girl to a hospital qualifies as negligence.

The parents, on the other hand, are going to argue that "they did everything they could." They wanted their little girl to live; this was not negligence in the sense that they were unconcerned whether she lived or died. The father attempted to perform CPR. If the family's statements are to be believed, they did not want to see her die.

If the parents truly believe that they did everything they could, one of two things is the case. They were incompetent or they were brainwashed.

I'll leave which one up to the reader to decide.

Abused Vocabulary #1: "Sensitive"

2008-03-24T21:26:00.005-04:00

Sometimes, people gratuitously misuse or overuse words in the context of medicine or pharmacy that drive me up the wall. Inspired by The Bronze Blog's doggerel section, I bring you a new feature for S.A.: Abused vocabulary. In these entries, we will explore words that tend to get flung around in such a way as to make them completely meaningless.

Today's word is sensitive.

Dictionary definitions are a poor basis for an argument. The purpose of a dictionary is to catalogue how people use words, not prescribe their meanings. I may have lifted that phrasing from Overcoming Bias, and if so, hat tip to them. Anyway, I'm not going to quote the dictionary at you. What I am going to tell you is how the word is commonly used in a medical context.

One of the classic examples of an adverse drug reaction is a hypersensitivity reaction. There are two major classes of hypersensitivity; immune and non-immune. Immune hypersensitivity includes anaphylaxis. In essence, immune hypersensitivity involves some part of the immune system "overreacting" to the presence of a foreign drug product. Immune hypersensitivity is generally dramatic and hard to overlook, depending on its severity. If your throat swells to the point where you're suffocating when you take penicillin, it's pretty clear that you should avoid penicillin in the future. Immunogenic hypersensitivity is highly unambiguous.

Non-immune sensitivity, on the other hand, is highly ambiguous. Which leads to people claiming "diseases" like multiple chemical sensitivity to be the source of life's ills. MCS is a non-specific diagnosis of a non-existent illness that is more likely a manifestation of a psychiatric problem than a problem with an environmental cause. But I digress. Luckily, few people I encounter on a daily basis claim to have MCS (although one did). But a lot of them do claim "sensitivity" to this or that drug--or just to "drugs."

If you want to annoy your pharmacist, tell them that "there are very few drugs that you can take."

It's true that some patients are more susceptible to particular side-effects due to age, gender, or other preexisting diseases. Drug interactions are another potential culprit. In the field, we call a patient's unwillingness to take a drug due to side-effects (real or imagined) intolerance. Some drugs have noteworthy (and common) side-effects that almost everyone experiences. High doses of niacin, for example, dilate blood vessels and produce a characteristic facial flushing reaction. A huge percentage of patients taking niacin experience flushing--it is an expected reaction, totally predictable based on the drug's pharmacologic profile.

But when patients pull "side-effects" out of seemingly nowhere, claiming that their sleeping pills make them itchy or that they've been jittery and nervous ever since they were switched from brand to generic on their antidepressant--one has to wonder what's going on. Part of the problem is likely "nocebo" effect--the fact that even patients administered an inert tablet containing no drug will report side-effects and associate them with taking the "drug." Sometimes these complaints can be explained by the pharmacology of the drug. Other times they cannot. Frequently reported adverse effects are collected and sent to the FDA for evaluation, and some of them do turn out to be related to the drug in question. But many more are in no way related to the drug, which is why most pharmacists--and doctors, for that matter--don't jump three feet every time a patient complains of "drug side effects." The signal to noise ratio is poor.

When a patient says "I'm very sensitive to drugs," what he or she really means is "I have no tolerance for the same side-effects that everyone else deals with without complaining." The vast majority of the time, the problem is not that these patients are affected by drugs "worse" than other people are. The problem is that the patients are picky. They have unrealistic expectations. They are frequently overly preoccupied with minor aches, pains, or sneezes. These are the patients who call the pharmacy to complain every time they get diarrhea during antibiotic therapy--a common side-effect that is frequently mentioned during patient counseling. They think that they are "informed" patients--that they keep close tabs on their body. They want to know every side-effect that might be caused by their medications. They are the hypervigilant patients of the pharmacy world.

This is all very annoying for your pharmacist. But these people aren't necessarily at fault. What can we do?

For starters, we can make sure to convey realistic expectations to patients. We should do our best to make sure that they receive information about side-effects in context, or they end up like this guy who was convinced he was growing breasts as a side-effect of his antacid. Drugs are not magical cures. They alter the way the body works to achieve a desired outcome, and drugs do not "know" what to alter and what to avoid, which is why most side-effects happen.

Some of these patients are legitimately concerned. But many others frequently seem like they're just seeking attention, hypochondriac-style. Claiming to be "sensitive" to all kinds of things makes them feel special. It's a common altie claim, actually, that they're "sensitive" to "drugs and chemicals," so they avoid them altogether and drink hyperdiluted nux vomica, because natural is safe. Nevermind that most of the world's deadliest poisons are made by plants and animals--not labs.

"Sensitive" doesn't mean anything in a clinical context. Be specific. State the name of the drug you took and what happened when you took it. If your pharmacist or physician seems skeptical that the drug was to blame, it isn't because he or she is an insensitive prick. It's because people are very bad at accurately establishing cause-and-effect, and the drug may not have been responsible at all.

Quote of the Day

2008-03-24T12:02:00.001-04:00

"Medicine used to be simple, ineffective, and relatively safe. Now medicine is complex, effective, and relatively dangerous."

From a lecture I attended today.

Blog Plug: Why We Can't Solve "The Mysteries"

2008-03-23T19:06:00.002-04:00

Overcoming Bias is rapidly becoming one of my favorite blogs. In particular, I'd like to point to a relatively new post:

If you demand magic, magic won't help.

One of the occasional complaints against a rationalist/materialist worldview is that choosing to use empiricism as a standard for beliefs destroys some notion of "wonder" or "imagination." Eliezer Yudkowsky argues that the people who are most drawn to the "wonder" of magic would not, in fact, pursue magic if we lived in a fantasy world like those commonly depicted in literature. If magic were real--more importantly, if magic were commonplace--the people chastising scientists for being too preoccupied with testable reality would be just as disappointed with magic in that hypothetical world simply because of its common nature.

In fact, the people who would study magic and become its most skilled practitioners are likely the people who in this world are scientists; those driven to explore the world through observation and experiment and willing to spend years of their lives studying, especially if magic required any significant amount of work to master.

This, in some sense, can be generalized to medicine, but not in the sense of the end-user. The victims of this "love of fantasy" are the practitioners of faith-based medicine systems.

Let's face it. Medicine is hard. It takes years of rigorous study to become a professional at any level of the trade--nurse practitioner, pharmacist, physician, whatever. By comparison, chiropractic is easy. At the most basic level, a chiropractor only needs to know how to do one thing--crack spines. Being a homeopath is easy because there's no reason to believe that you can make mistakes; the worst thing that will happen is your patients aren't satisfied. No one can accidentally overdose their child on homeopathic teething tablets. Sure, people can die during alternative medicine treatments. Yes, there are risks. But the draw, both for practitioners and for patients, is that alternative medicine is easy. "All diseases can be traced to a nutritional deficiency."

The draw to fantasy, like the draw to alternative medicine, is the fact that it is a shortcut around lots of effort.

The Great Generic "Controversy"

2008-03-19T09:58:00.005-04:00

The short version of this post is that there is no controversy. 99% of generic drugs are safe and effective. Given available data and a long history of positive results, there is simply no reason for your pharmacist (or your doctor) to recommend against use of a generic in 99% of all cases.

Let's start off the post with a list of comments I hear from patients on a fairly regular basis on the subject of generic drugs.

•"I want the 'real thing.'"
•"My doctor told me that generics don't work."
•"I'm allergic to generics."
•"How can the generic be as good if it's cheaper?"
•"No one is willing to guarantee that the generic and the brand are exactly the same, so I want the brand."

For starters, generics are "the real thing." They contain the same drug molecule that is responsible for changing your body's function as the brand. They are not cheap imitations. A technician I once worked with explained that people's objection to generic drugs was frequently because of their experience with generic foods; generic Oreos don't taste like "real" Oreos, after all. But unlike drug laws that mandate generics to be the same as brands, there's no law saying that generic Oreos have to taste just like real Oreos.

You aren't "allergic to generics." You just aren't. It isn't possible. An allergy to some component of a specific drug formulation (a dye, a flavoring, whatever) is totally possible. Saying you are allergic to generics is like saying you are allergic to fruit. The category is too big to be plausible.

If you think your doctor told you never to get generics, your doctor either failed to explain the difference between generic and brand adequately, or you are an idiot. A third possibility is that your doctor is a dermatologist. Some huge percentage of dermatologists advocate marking prescriptions for acne creams and similar products as "brand medically necessary" because they claim there is a huge difference. Hm. I'd think that if there were any product where a little bit of variation wouldn't matter much to my health would be my cosmetic face cream. Who knew?

The FDA has already answered the cost question. I won't answer it again.

Pharmacy colleague Abel Pharmboy has already elaborated on the basics of generic drugs. Patients are often confused by the 80-125% rule, so I rarely bring it up in clinical practice, but what it boils down to is this. It has nothing to do with the amount of drug in the tablet. It has nothing to do with the potency of the drug. Generics are equal to the brands in this respect. What differs between brands and generics, in most cases, are the "inert" fillers and binders that hold a tablet together or comprise the granules contained inside a capsule.

You rarely get the full dose of a drug. If you put a 100 mg tablet of drug X in your mouth and swallow it, there is a good chance that only a small percentage of drug X is absorbed (anywhere from 5% to 95%, depending on the drug). The big, technical word for this is bioavailability.

Suppose taking 100 mg of drug X means you have blood levels of 10 nanograms (ng) per deciliter (dL). What the 80-125% rule means is that if you take 100 mg of generic drug X your blood levels could be anywhere from 8 to 12.5 ng/dL and the drug would still be considered acceptable by FDA standards.

And that's the thing. For most drugs, it doesn't matter where you are in that range as long as you're above some minimum and below some toxic maximum, both of which are typically pretty far from the ideal range. Generic ibuprofen versus brands? Not gonna matter. Antibiotics? You're more likely to get sub-therapeutic blood levels because the patient isn't taking the drug properly than you are some bioavailability issue. Blood pressure meds? Your goal BP is based on averages, so it's all going to even out over time. Going generic is not going to cause your blood pressure to fluctuate wildly.

The whole thing only becomes an issue if this is not the first time a patient has taken a drug. If you have never taken a particular drug before, your blood level of that drug is obviously zero. You will start taking the drug, and after a set period of time, your blood level of the drug will reach a "steady" concentration as long as you continue taking your medication appropriately. It is only if you are suddenly switched from brand to generic that you might see a change--and you'd have the same issue if you started on generic and then switched to the brand.

For most drugs, as I mentioned above, there's no difference between our hypothetical 8 and 12 ng/dL. For others--those said to have a narrow therapeutic index--8 ng/dL may mean "no effect" and 12 ng/dL might mean "liver failure."

Of course, with drugs like this, patients must be closely monitored--using blood tests, in many cases--to make sure that they're getting just the right amount of drug. But that doesn't mean that the brand is superior. It means that the patient's therapy should be consistent. If the patient starts on the brand, they should stay on the brand, and if they start on the generic, they should stay on the generic, with no flip-flopping back and forth between the two. Most pharmacists are loathe to switch people back and forth repeatedly on drugs like Synthroid, Dilantin, or Lanoxin. And some states explicitly forbid it in their pharmacy law codes. Seizures in particular are all-or-nothing, so I totally agree with these sentiments.

Some people want to extend this no-substitution issue to all psychoactive drugs. Antidepressants are the big one; some patients really, really want the branded Paxil over the generic (generic brands just don't know how to act), for example (nevermind that brand name Paxil has not been on the market for a few years now).

It's easy to see why this might happen, drug efficacy aside. More expensive medicine makes patients feel better. I'm not saying antidepressants are placebos; the jury is still out on that one, though most evidence favors efficacy, even if it is slight (the drugs would never have been approved otherwise). But paying more for a drug--or a placebo--results in a better outcome for most patients. Perhaps paying more for the drug raises their expectations and subtly influences their mood. With largely subjective disorders like depression, subjective improvements are real improvements.

The case of the Wellbutrin scenario is somewhat unique in that we are talking about an extended-release product.

The process of making a tablet can be extremely simple or extremely complex. It is possible to make aspirin tablets by compressing crystalline aspirin with corn starch and water. At the other end of the spectrum are tablets that are designed with microscopic pores designed to release their contents at a constant (and precise) rate as the tablet passes through the intestinal tract, with the empty tablet shell being excreted with the next bowel movement. Extended-release formulations are generally on the complicated end of the scale, and the design process for these tablets is a great deal more involved. Many drug companies even patent their own extended-release mechanisms, like the OROS mechanism.

Because a generic manufacturer cannot simply use the same extended-release mechanism as the brand-name manufacturer (remember, these mechanisms are often patented), they must design their own tablet designed to release the drug at a similar rate. According to the ConsumerLabs data, the generic buproprion XL tablets released their drug more rapidly than Wellbutrin XL tablets. But the same amount of drug did get released, and the full dose was delivered.

Honestly, this doesn't surprise me in the least. The question is whether or not the increased rate of release is significant. For that, I'm going to have to go to Lexi-Comp's Drug Information Handbook, online edition. This could get a bit technical, but don't worry, I'll sum it up at the end.

The half-life of bupropion is greatly dependent on the person's liver function, ranging from 12 to 30 hours with an average of 21 hours. Bupropion's metabolites, i.e. the by-products of breakdown by the liver, are also active drugs, though they are less potent than bupropion (20-50% potency). These metabolites have half-lives similar to or longer than the primary drug, one of them having a half-life of anywhere from 30 to 40 hours.

What all these numbers ultimately mean is that bupropion hangs around in the body for a long time, and generic tablets releasing the drug over 2 and 1/2 hours instead of 5 hours is not going to significantly effect the "lower bound"--the lowest blood level measured in the peaks and valleys produced by daily administration. Remember that blood levels of a drug look kind of like a normal distribution curve, only flatter or shifted up, depending on the drug. To continue the math analogy, what the more rapid release is going to do is increase the slope of the curve.

This is not going to effect treatment of depression if the benchmark we're looking at is "is the patient maintaining minimum drug levels?" The more likely outcome is that the patient is going to experience a slight increase in side-effects compared to the brand name (if they've been switched from generic to brand recently) due to the fact that their blood levels are climbing more rapidly after administration. Whether or not this is going to be a problem depends on the patient. Last I checked, however, no one was complaining that patients switched to generic Wellbutrin XL were having seizures (which would be extremely unlikely unless the patient had an existing seizure disorder, which is a NO-NO when it comes to prescribing this drug). The specific issue probably never would have come up if it weren't for ConsumerLabs doing a bunch of assays.

Like with most brand-generic issues, the complaint from patients was most likely that the drug "wasn't working" or that they "just didn't feel right." These are the same complaints that come up all the time. That doesn't mean that they shouldn't be investigated; it just means that it's hard for heathcare professionals to filter things out given the poor signal to noise ratio.

I'm still not convinced that the differences between brand and generic Wellbutrin XL are clinically significant, but then, I'm just a pharmacy student. What's troubling is that this information didn't come out sooner, and, as Abel mentioned, the fact that it was kept under wraps until an independent lab started poking around seriously undermines both the generic drug companies and the FDA's trustworthiness in the eyes of the public. That's the true tragedy here; patients are going to think that this failure to disclose information is indicative of serious problems with the generic drug industry when in fact the complete opposite is true. The generic drug industry has a long record of producing safe and effective drugs. Most community pharmacies dispense generic alternatives for over 90% of the prescriptions they fill without any hitches--I know mine does.

Generic drugs are a great thing for patients. Let's not let one little slip--a slip of questionable significance from a clinical perspective--ruin that.

All Antibiotics Are Equal

2008-03-17T13:14:00.003-04:00

...but some are more equal than others. Or so patients seem to think.

Here's the bottom line. If you take nothing else away from this post: Antibiotics are not "strong" or "weak." They are targeted.

Patients ask me some questions about antibiotics that sound truly strange if you know anything at all about microbiology and antimicrobial agents. Granted, most patients don't have that background, and it would be unfair for me to expect them to know the difference between Gram-negative and Gram-positive bacteria or to know anything about activity spectra. Probably the most common question, in some form or another, is "is this a good one?"

The answer is not as simple as yes or no. Are the antibiotics on the market effective for treating bacterial infections? Yes. Will this antibiotic be effective against your bacterial infection? I don't know. And, chances are, neither does your doctor, at least, not for certain. Are the risks of taking this antibiotic going to outweigh the benefits? Probably, unless you're taking telithromycin for acute bacterial sinusitis (which is not an acceptable use of the drug).

That bit about telithromycin was a bit of pharmacy dark humor. If you didn't get the joke, forget I mentioned it and move on with your life.

The only way to know if a given antibiotic will be effective in treating a particular infection is to culture the microorganism causing the disease. This means taking a sample from the patient, growing the sample on a petri dish, and then trying to grow the sample in the presence of various antibiotics that are released by little discs inserted into the growth medium. The bacterial growth results are then compared to a table for each antibiotic to determine whether or not the antibiotic sufficiently inhibited bacterial proliferation to say that the antibiotic will be effective against an infection in a living person.

This process takes anywhere from three days to a week to get right. Most patients are not willing to wait that long, and the lab tests are both costly and time-intensive. Most doctor's offices are not equipped to do a lot of lab testing. As a result, most doctor's visits where patients complain of what sounds like an infection result in the patient being sent out the door with a prescription for some antibiotic that the doctor thinks will be appropriate.

You can't blame physicians for not taking the time to culture everything, though I imagine most infectious disease specialists would bite your head off for suggesting that it's acceptable to start throwing around prescriptions without doing a culture. My microbiology professor would have a heart attack if I showed him the script I transcribed from a phone conversation on Saturday; Tamiflu and an antibiotic. Tamiflu kills influenza A viruses, but not bacteria. Antibiotics kill bacteria, but not viruses. You could argue that the physician is just covering his bases and trying to help the patient.

You could also argue that this is a little bit like using a blunderbuss to kill a mosquito.

The point of culturing bacteria is that antibiotics are not like a set of progressively bigger guns. They're specific tools in a toolbox. Using the wrong antibiotic is like using a hammer instead of a screwdriver. The problem is not that the tool isn't "strong" enough, it's that it isn't specific enough. Even healthcare professionals throw around terminology that makes it sound like some antibiotics are explicitly more "powerful" than others, but what they're really talking about is antibiotics that are used as last resorts. There are certain antibiotics that are used after everything else has failed--not because they're better and the others are "weaker," but because bacteria are less likely to resist them.

Which brings me to my second point. Bacterial resistance.

Bacterial resistance is a matter of evolution, i.e., natural selection. Suppose that 99% of all bacteria exposed to genericillin die. The 1% of the population that survives does so because it has randomly developed a means to protect itself from genericillin; perhaps it breaks down genericillin by secreting enzymes before the drug can affect the bacteria. That 1% of the population goes about its life and continues to reproduce, so that 1% of the old population is now billions of bacteria. The population rebuilds itself rapidly (due to lack of competition for resources), so we expose the bacteria to genericillin again. But this time, it doesn't work, because these bacteria are immune to genericillin. They were never susceptible to genericillin. What we have done is selectively bred the organisms most fit to survive in a genericillin-laden environment and killed off all of their competition, permitting their population to explode.

You do not become "immune" to an antibiotic because antibiotics don't do anything to "you" (at least, not ideally). This is probably the biggest misunderstanding of antibiotic resistance that I encounter--patients who think that they have become "immune" to genericillin because they took too much of it.

This is a little like expecting to be immune to bullets because you've shot too many people.

Unfortunately, the situation is much worse than that. You aren't the only one who has to deal with the consequences of resistant bacteria. We all do. And we have no one to blame but ourselves. Every unnecessary antibiotic prescription, every antibiotic that someone stops taking halfway through their therapy or that they "save for later," every "borrowed" medication--all of these contribute to resistant bacteria. The resistant bacteria already exist, for the most part, results of genetic mutations. But we're selectively breeding them by killing off their competition. Curing syphilis today requires eight times the dose that was required in 1960.

I've said it before, and I'll say it again. I would rather see physicians overprescribe narcotics than antibiotics. Drug addiction and substance abuse are bad, from a public health perspective, but breeding "superbugs" is a great deal worse. Addicts are, as a rule, only hurting themselves; overuse of antibiotics hurts everyone.

Filling the Void

2008-03-14T17:14:00.003-04:00

I really, really hate seeing pseudoscience in pharmacist-targeted publications. Granted, I'm sure that physicians and other healthcare professionals feel the same way, as evidenced by Orac's feelings about woo in medical schools.

Let it be known that I just flat-out don't like Drug Store News. Drug Store News is a publication that is at least 50% about stuff I totally don't care about. They have some occasional clinical information, or a little bit here and there about how to improve your outpatient practice (say, how to talk to patients with diabetes). The rest of Drug Store News is about how to sell more lip balm and whether or not your drug store should stock chunky peanut butter. It's not a science-oriented publication; it's a business-oriented publication. Because I have absolutely no interest in the "business end" (har har) of pharmacy, all of this seems like a huge step backward to me. If pharmacists are going to spend all their time fighting to be recognized as clinicians instead of shopkeepers, their right hand clearly doesn't have any idea what the left is doing. The left is still very concerned with keeping profit margins high by knowing which Burt's Bees products that the public prefers.

However, I have reason for my annoyance with the publication above and beyond the fact that they don't focus on things that I care about. They, perhaps in the "printing all the news that's fit to print" vein, have no qualms publishing articles about such ridiculous and unproven woo as homeopathy. They regularly advertise homeopathic products, often with several ads per issue, and announce their introduction to the market with the same fanfare that they give to real medications. And I'm not just talking about "homeopathic" products like zinc lozenges, which are marketed as being homeopathic to avoid FDA regulations despite containing comparably large amounts of zinc.

What stunned me was that a recent column was promoting homeopathy as a substitute for drug therapy in children under two due to the recent OTC cough-and-cold withdrawals. Much to my annoyance, I can't find the column replicated on their web site, preventing me from simply linking it, but the highlights of the column were more or less what you might expect from proponents of homeopathy pushing the products as a replacement for the pulled children's medicines.

"Homeopathy is safe," they assert, first and foremost. A definite reassurance needed in a time of uncertainty. The shifting guidelines and need for further research (which will probably never be done) mean that parents are struggling with the idea that they can no longer simply give their children medicine when they're not feeling well. Homeopathy can fill the void for concerned parents--giving them a way to feel like they're helping, even if they aren't. It's certainly easier to give children homeopathic tablets, which are mostly lactose, than it is to try to use a rubber suction bulb to reduce nasal congestion in an infant. But parents will feel better either way. What a seductive marketing promise.

Treating a teething child with homeopathy isn't exactly child abuse, but it is a waste of money. And providing parents with false alternatives to medical treatment is likely to delay the time until children see a physician. You might think that reasonable parents will take the time to go see a doctor, but I've talked to my share of parents who just want to give their poor babies some medicine and avoid a doctor's visit--or worse, the parents who can't afford to take their children to see a doctor, so they really want you to recommend some liquid Tylenol and send them on their way. Which really means that the decision to include homeopathic products on the shelves preys on the poorest and most desperate of parents, those trying to find a way to comfort their children when all other ready alternatives have been removed from their grasp.

It's easy to see why a "drug store" would market homeopathic products. They make money. But is it ethical to market homeopathic "cures"--especially when the tendency is to place them right next to the "real" medicine, where consumers can't tell the difference? In a world where patients tend to choose products based on what's on the front of the box--instead of the back, where the real information is--current marketing practices are nothing but a cleverly designed deception. And that's why a pharmacy shouldn't be doing it.

I Thoroughly Apologize

2008-03-12T01:08:00.006-04:00

A good deal of scotch and Sapporo later, I've come to the conclusion that it may, in fact, be time to post another work rant, because today officially made absolutely no sense whatsoever. As I've noted before, I don't typically post work rants, just because so many other pharmbloggers do it better than I do, but my egregious lack of content of late has me digging for things to post. I could honestly throw out some words of praise for the Purdue Pharmaceuticals rep I talked to today, or go into a long monologue about antibiotics, but I'll save that for a time when my blood-alcohol content is considerably lower.

The short story is that I dealt with the biggest jerk in the universe today.

The slightly longer story is that today I was "greeted" by a middle-aged man with salt-and-pepper hair, probably in his 50's or early 60's, presenting a prescription for prednisone. Sure. Easy. Prednisone. When do you want to pick this up?

"Right away," he says. "Also, I filled a script here two weeks ago for two weeks' worth of medication. I want it back."

"You want the prescription?" I was somewhat confused. "I want you to transfer it." "That's easy, just have the pharmacy call us." "Great," he said. "Transfer them to Canada."

Yes. Canada. The whole country.

"Er." As you may or may not know, once you fill a prescription, it is no longer yours. It is a legal document retained by the pharmacy, a contract between you, your doctor, and the pharmacist that you have been issued a specific medication for a specific purpose. You cannot get it back. It must be kept, filed, stamped, and otherwise notarized, presumably kept in a box somewhere in someone's pharmacy basement for at least seven years. Furthermore, there is no logical reason to want it back. Any other pharmacy can call for a copy and take your script. Canada, however, is apparently one big pharmacy and it can do whatever it damn well pleases.

At this point, the pharmacist noted that it was a matter of federal law that we had to retain his prescription. He was not happy about this, and the pharmacist suggested that he write his congressman.

There was a lot of shouting. I believe I was called a crook. I was told that I should be ashamed of myself for being part of the American pharmaceutical company's great scam, the price-gouging mafia of American drug stores, and all sorts of other general nastiness. I, apparently, am a terrible human being for charging this guy less than $20 for medications intended to prevent his blood pressure from skyrocketing and causing him to stroke out. Maybe we can blame the prednisone for his mental instability. Other customers joked about how nuts this guy was. The customer threatened to contact a lawyer unless we returned his prescriptions. We later noted, somewhat nervously, that it would have surprised none of us if he had jumped the counter or pulled a gun.

I quipped that should he have done so, a lawyer would've been provided for him, should he have been unable to afford one.

"Do you want THIS prescription filled here--and now? Not in Canada?" I wanted to make damn sure that he wanted his prednisone from an American pharmacy. He did.

The customer left the store, fuming. He came back five minutes later. "It's your lucky day!" he said, handing the pharmacist a slip of paper, a receipt from a Canadian mail-order pharmacy with a phone number and information for him. "Call this pharmacy and transfer my stuff there," he said. So the pharmacist called the number later. He was told to call a different number. He called that number and someone hung up on him. It was then that he noticed a number listed for a "United States Canada Mail-Order Service" at the bottom of the label. He called that number.

He got the patient. Apparently, the patient owns a company that imports and ships medications from Canada. GO FIGURE.

In any event, Canada wound up getting his prescriptions. Some specific Canadian pharmacy, that is, which is apparently legal albeit suspect, in the sense that the FDA has officially ruled that importing medications from Canada is "illegal." The Canadian pharmacy claims they do no billing, so none of us have any idea what the meds cost when imported. No one where I work plans to touch the situation with a ten-foot pole.

As an aside, physicians who read my blog? Don't sign your prescriptions "dispense as written." Just don't. Your patients want the cheaper generic. Your pharmacists want to dispense the cheaper generic. And don't refuse to permit substitution when we call you and tell you the patient wants generic, it's $10 versus $70. And for the love of all that is holy, don't sign antibiotics brand-name only. Do you really think there's that much variation between brand and generic Omnicef?

Nothing I Can Say Will Top This

2008-03-07T11:25:00.003-05:00

Orac's Friday Dose of Woo for the week has left me so jaw-droppingly stupefied that I can say absolutely nothing that will top his post.

Someone claims to have discovered the Philospher's Stone.

Not only that, but it will give you god-like powers. In fact, the only ability you don't get, as far as I can discern, is the ability to turn undead, which would arguably be useless unless somebody discovers a way to create zombies over the weekend. Maybe Big Pharma will unleash the T-virus and we'll all be totally screwed. Who knows.

That makes me wonder. Would "zombies" created by the T-virus actually be affected by turn undead? After all, they're technically living, just infected with a pathogen that alters their physiology, kind of like the zombies in 28 Days Later. This is going to be on my mind for the rest of the day.

I Got Meme'd

2008-03-06T16:17:00.004-05:00

So a few days back PalMD slapped me with a meme--and who am I to defy the will of the blogosphere by resisting the viral transmission of ideas? Of course, I hadn't really planned on getting around to participating until after exams for the week were done, but I found myself getting a bit of a breather.

1. Go to page 123 of the nearest book.
2. Find the 5th sentence.
3. Write down the next 3 sentences.

Note to fellow bloggers. Don't do this when your significant other is in the room, lest she hand you the nearest book.

"And even though the residual soul welcomes the invader, something in it always recognizes the particular soul of which it was once a part. It will choose that soul if there is a battle. And even a bewildered soul can make a powerful attempt to reclaim its mortal frame."

The Tale of the Body Thief, by Anne Rice, book four of the Vampire Chronicles.

Do you really expect me to analyze this? I certainly hope not.

I think I'll have to tag pharmacy colleague Abel Pharmboy and Bad of the Bad Idea Blog.