Saturday, December 29, 2007

One More Reason I'm Not Voting for Ron Paul

Orac has the whole story.

Aside from rejecting evolution and being racist and anti-Semetic, Paul supports the DSHEA, opposes mandatory vaccinations, and is pushing the Health Freedom Protection Act. The HFPA, as presented by Paul, is full of ridiculous statements:

"For example, the FDA prohibited consumers from learning how folic acid reduces the risk of neural tube defects for four years after the Centers for Disease Control and Prevention recommended every woman of childbearing age take folic acid supplements to reduce neural tube defects. This FDA action contributed to an estimated 10,000 cases of preventable neutral tube defects!

The FDA also continues to prohibit consumers from learning about the scientific evidence that glucosamine and chondroitin sulfate are effective in the treatment of osteoarthritis; that omega-3 fatty acids may reduce the risk of sudden death heart attack; and that calcium may reduce the risk of bone fractures."

Uh, right. The FDA is evil and doesn't want people to get better. Nevermind that "health claims" well-established scientific evidence like "vitamin C prevents scurvy" have been allowed to be on dietary supplements since the conception of the DSHEA because there is well-documented evidence that it is true. No sane doctor or pharmacist is going to deny that calcium is a required element for bone health. Conversely, only a small percentage are going to outright recommend various herbal products for which the evidence is considerably weaker.

I don't need to tear apart the quacks and the promoters of quackery here; that has already been done for me by Orac and others, time and time again. But get the word out. Not only is Ron Paul a psycho racist, he wants to give the modern snake oil peddlers of the United States license to scam you in the name of a free-market economy.

Oh, yeah. Paul is pushing all this "Health Freedom" nonsense, but he's pro-life. WHAT? How inconsistent can you possibly be!?

And here's a more complete record of Paul's voting records, courtesy of blogger Orcinus and commenter Calton Bolick on Orac's blog.

Extra, Extra: College Student Endorses Alcohol Use

The astute may have noticed that many medications warn that they should not be taken with alcohol. The "can I drink while I'm taking this medication?" question is one that I get a lot when I'm working. There are a lot of misconceptions about the effect of alcohol when combined with different drugs; this can be largely attributed to the fact that there are rarely degrees of severity described on "no alcohol" warning labels.

Let's put this another way. I'm an inquisitive youth and always have been, and I'm in my early 20's, the only decade where rebellion is anywhere near as likely as in the teens. I always thought warnings or prohibitions without explanations were patently stupid. You can't just tell me "don't do it." I have to know why I can't do it so that I can decide for myself whether the rule is worth following.

Let me also remind you that you should always follow any precautions listed on medications and consult your doctor or pharmacist instead of taking advice from an anonymous blogger. If I'm your only source of medical information, you should seriously reconsider your actions.

From a counseling perspective, there are two ways to handle the alcohol question. You can assume that all people are good little boys and girls and tell them that should a drop of whisky pass their lips while they're on amoxicillin that they will suffer terrible consequences (this is clearly an exaggeration). Or you can be realistic. Amusingly, most patients are very careful about how they phrase their "can I drink" question. Anecdotally, the most common phrasing is "is it okay if I have a glass of wine with dinner?" Nobody wants to sound like a booze hound who can't put down the liquor when they're sick. I think the lone exception I've seen so far in practice was the fellow who wanted to know if he could keep up his six-beer-a-day habit. That's ten-foot-pole category stuff, there. So many things are wrong that you have no idea where to start and you pray silently to the cosmos that someone else with more time on his hands will refer this man for a different flavor of counseling.

Alcohol is a drug. There are two different categories of drug interactions; pharmacodynamic and pharmacokinetic interactions. P-dyamics is essentially what the drug does to the body, whereas p-kinetics is what the body does to the drug. P-kinetics has four components, absorption, distribution, metabolism, and excretion, often abbreviated ADME. Here's a simplified look at both sides of the equation for alcohol:

P-Dynamics: Alcohol is central nervous system depressant.
P-Kinetics: Alcohol is absorbed through the small intestine, distributed into the blood and other fluid portions of the body, metabolized by liver enzymes into other compounds and excreted in sweat, urine, and saliva.

When we're talking about drug interactions, we have to know if the interactions are dynamic or kinetic. For example:

P-Dynamics: Some antihistamines cause drowsiness. Antidepressants can cause drowsiness. Combining the two produces more drowsiness.
P-Kinetics: Lipitor and other statins are broken down by liver enzymes. Grapefruit juice reduces the action of these enzymes. Combining the two prevents the breakdown of Lipitor, increasing Lipitor levels in the body.

A lot of common drug interactions with alcohol are p-dynamic in nature. Alcohol causes drowsiness, so combining it with other drugs that may cause drowsiness will result in the patient experiencing potentially unexpected levels of sedation. In the case of moderate drinking, most interactions with antihistamines, antidepressants, and anti-anxiety drugs and alcohol fall into this category. You're not going to die if you have a couple beers. But you're going to feel a lot sleepier than you would otherwise.

Painkillers are a slightly different story. Acetaminophen and alcohol are both toxic to the liver, and that toxicity is amplified when the two are used in conjunction. NSAIDs are more likely to cause stomach bleeding when taken with alcohol, which can also damage the lining of the gut. And combining opioids like Vicodin or Oxycontin with alcohol can lead to fatal respiratory depression. Don't do it! It's dangerous!

Most antibiotics do not significantly interact with alcohol, but you aren't doing yourself any favors by drinking while sick. The dehydration caused by alcohol does your body no good in fighting an infection and might also worsen some symptoms of illness. There are a few noteworthy exceptions, however; perhaps the most notorious of these is metronidazole, otherwise known as Flagyl. This is a classic p-kinetic interaction. Metronidazole inhibits aldehyde dehydrogenase, a key enzyme in alcohol metabolism. Without this enzyme, toxic levels of acetaldehyde, a by-product of ethanol breakdown, build up in the body and cause nausea and vomiting, among other potentially more serious symptoms of acetaldehyde toxicity. The reaction in question is often referred to as a disulfiram reaction. If your pharmacist tells you absolutely no drinking while taking an antibiotic, he or she is probably trying to warn you of a potential disulfiram reaction.

The disulfiram reaction can actually be used therapeutically. Ever heard of Antabuse? It's the drug for which the disulfiram reaction was named. When administered to alcoholics, it causes them to become violently ill after consuming alcohol--a form of aversion therapy. Cute, huh?

I don't like seeing patients who are afraid of their medications or who feel that being committed to a particular therapy is going to significantly affect their quality of life. Many people enjoy the occasional drink, and for the vast majority of them, being on medication is no reason to give up that pleasure. Other health complications might be a reason to avoid alcohol, but I've spoken to way too many otherwise healthy people on antidepressants or mood stabilizers that almost pathologically avoided drinking not because they feared it would interfere with their therapy from a mental health perspective but because they were certain that combining alcohol with their medications would be irreversibly harmful or even fatal. With a little time and explanation as to the "whys" behind drug and alcohol interactions, patients can be reassured that they don't have to change their lives to revolve around their medications. And if your doctor or pharmacist hasn't told you why there's a particular warning on your medication, don't hesitate to ask! The more informed you are, the better, especially if you're going to be putting these medications into your body for years to come.

Don't forget that all of this applies primarily to occasional, responsible alcohol use. If you're drinking four or five alcoholic beverages a day, some of your body's metabolic machinery operates under different rules. But don't feel like you have to give up your New Year's bubbly just because you've been prescribed a Z-Pak.

Thursday, December 27, 2007

Just in Time for New Year's

Somebody linked this comprehensive dissection of the Left Behind "rapture novels" of the late 20th century. I've been reading, engrossed, since last night. There's a lot of interesting stuff here, most of which makes me glad I never read the books.

Tuesday, December 25, 2007

Quote of the Day

"This is a tool. Like a hammer or a shovel, only a lot more complicated. Just because you don't understand something at first...doesn't mean that it's the magic of the gods." ~Daniel Jackson, Stargate SG-1

Man, science fiction is wonderful.

Happy Holidays from SA!

Today is Christmas, but whether you celebrate Hanukkah, Kwanzaa, Yule, Dewali, HumanLight or just Boxing Day, may all go well for you and your loved ones.

Sunday, December 23, 2007


This is the dumbest thing ever.

Fentanyl is an opioid analgesic, like morphine or codeine. Unlike everyone's favorite analgesics, Tylenol #3 and Vicodin, fentanyl is most commonly administered via a transdermal patch that is worn on the skin. Oral forms are available, but considerably less common (notably orally-disintegrating tablets and even a narcotic sucker). Fentanyl is very potent, and must be used in small doses--25 micrograms (or 0.025 mg) of fentanyl per hour over a 24-hour period is recommended for patients taking between 60 and 134 milligrams of oral morphine per day. Fentanyl should not even be initiated in patients taking less than this--for comparison's sake, 60 mg of morphine is equivalent to 30 mg of oxycodone. Your standard Percocet tablet has 5 mg of oxycodone per tablet.

I may be belaboring the point. In any case, fentanyl is potent stuff. It takes very little fentanyl to match an equivalent dose of some other opioid painkiller.

Prescribing fentanyl for patients with anything less than chronic pain due to cancer or long-term injuries is irresponsible. The package insert itself says that using fentanyl patches for short-term pain is a mistake. Physicians prescribing the patches for patients with headaches are only part of the problem; there are no statistics available, as far as I can tell, but I'm willing to bet that much of the problem not misprescribing of fentanyl. The problem is misuse. Not in the sense of drug abuse, but rather in the sense of improper administration of the patches. Heating pads are a popular means of relieving chronic pain. But putting a heating pad over a fentanyl patch will dramatically increase the rate of transfer from the patch into the patient's bloodstream, potentially resulting in death when the patient's central nervous system stops triggering the breathing reflex. Patients who slap on a patch and then get into a hot tub may not get out.

An interesting issue is that transdermal patches must contain much more active ingredient than is to be delivered to the patient because the rate of transfer from the patch to the bloodstream is dependent on the difference between drug in the skin and drug in the patch. In short, a patch that only delivers 0.025 mg per hour may have to contain 3 mg of total drug to keep the flow moving. This means that a "used" patch still contains a lot of drug, and improper disposal of the patch can result in children or animals getting ahold of a lot of "leftover" fentanyl--easily fatal, should the patch be chewed or torn.

These deaths are so preventable it's ridiculous. A little patient education about the proper use and disposal of fentanyl would have saved nearly everyone involved. This is the task set before pharmacists. This is the value of proper patient counseling. Like all drugs, fentanyl has risks. But the risks can be minimized if patients are properly informed. Counseling for such drugs should be legally mandated--and furthermore, drugstores should be required to give pharmacists the time and staffing to perform the task adequately. These deaths aren't the fault of pharma. They're due to ignorance and irresponsibility. Pharmacists need to educate their patients--and patients need to pay attention instead of quacking away on cellphones while they sign the pick-up log for their fentanyl patches.

If in two weeks I have to read another article about fentanyl patches for the fourth month in a row I'm going to go crazy.

The War on Ignorance

P.Z. Myers has an interesting take on the efficacy of ridicule in getting people to back down on the creationism in schools front.

His point interests me mostly because I'm glad to see some progress, but let's face it. This is the worst possible way to make progress ever. It's depressing, in fact, that the only way for reason to win is for it to make the irrational look stupid until they shut up, relying on the hope that reasonable people are indeed the majority.

Call me an idealist, but wouldn't it be a billion times better if we could get the irrational to think rationally instead? Is that even possible, at least, on the scale we're hoping for? My belief that people are all fundamentally rational has been shaken a lot recently, and this really doesn't help.

Oops, I Diverged Into Politics

This is a rarity, but today's Facebook political debate is encouraging.

At the time of posting, 65% of respondants say that a candidates' religious belief should have no role in decision-making. 39,000 people have taken this position, many of them presumably old enough to vote (though Facebook isn't just for college students anymore, it tends to attract a somewhat older demographic than other networking sites due to its roots). 11% of those polled say that faith should have a "strong role" and 24% say that the role of faith should be "balanced with other considerations." As they say, two out of three ain't bad. Approximately 60,000 people have responded. The question is poorly worded if we want to get picky and technical, but I think most readers are going to interpret the question as being about religious faith--belief in the supernatural or divine. Given the predominance of Christianity in America, when most Americans speak of "faith" they're really talking about the Christian faith. The "postmodernist Christian" defense has commonly been to say that science is a form of faith, too, but this is a misguided straw man that shows little to no understanding of the principles of the scientific method. Anyway.

Separation of church and state issues aside, I personally think that faith should play no role whatsoever in decision-making on behalf of other people.

The major problem with using "faith" as a decision-making tool is that it is the ultimate defense. It can be used to justify any action. To question an action that another person has taken because of "faith" is a personal attack; it is impossible to separate the logic used to support the action from the person because ultimately the only reason that the person took the action is because "they felt it was right." Any debator knows immediately that this is an absurdly weak justification and cannot be used to support a position.

This has, historically, been a very bad justification. Americans spread from sea to shining sea because they believed God wanted them to do so. The Bible has been used to condone slavery (Ephesians 6:5-9; do note that that's the NEW Testament). Islamic terrorists, too, have faith that they are doing the will of God. The people behind Global Orgasm are convinced that it's going to heal the world's problems if we all just find time to make love, not war, at the same time (at least this isn't going to hurt anybody, as long as all involved partners are willing). The "yuck reaction," an appeal to emotion sometimes referred to as "the wisdom of repugnance," suggests that anything we feel is icky or wrong must be inherently distasteful, perhaps even against the personified will of the universe. But the yuck reaction has classically been a thin justification for oppression, used by racists, homophobes, and opponents of potentially valuable scientific progress (stem cell research and animal testing come to mind).

As a society, we are taught in America that faith is a personal matter, and it is wrong to belittle others because their faith differs from our own. What this means is that faith is the infalliable trump card for decision-makers in positions of power. It was the will of God, they say. It was manifest destiny. Kings throughout the ages have secured their seats of power by proclaiming themselves to be emissaries or manifestations of the divine. Surely they rule because it is the will of the greatest of deities, and their falls can be attributed to the loss of favor with the same. How can anyone not see the fallacious thinking here? If a man told you he invested in a particular stock because his horse told him to do so, you'd assume he was schizophrenic. Why can a government's leaders use an equally sound defense and get away with it?

If you're in a position of power, you had better be able to back up all of your major decisions with research and strong evidence. It is inexcusable to ignore evidence in favor of "gut feelings." To let faith affect decisions that will impact other people is sloppy and irresponsible; it should not be tolerated.

We have never had an openly atheist President in the United States. An atheist President would not be infallible. Indeed, he or she would be susceptible to the same kinds of potential mistakes that any leader is capable of making. It isn't important to me that our leader be an atheist. What I want is a leader who is a scientist, someone who bases his or her decisions on the hardest evidence available and on verifiable data instead of ethereal whispers and tomes so far removed from context as to be nearly useless for governing modern societies.

I'm willing to give the 24% who say faith and "other things" should be considered equally the benefit of the doubt because there are quite a few people who don't seem to realize that your personal feelings can be divorced from available evidence when making decisions. When you are governing a million people, sometimes the best decision for the masses is not the one you personally like the most. We don't have a direct democracy in America; we live in a republic. We elect our representatives to make decisions regarding what is best for all of us. Can't they have the maturity to set aside their personal feelings when drafting bills or voting on movements? Why are so few people able to divorce ideas from their sources and consider the ideas without letting the source bias their reasoning?

Friday, December 21, 2007

The Appropriateness of Chronic Self-care

A lot of over-the-counter products, many of them derived from herbal sources and others as specially-formulated multivitamin supplements, are advertised to treat (or help treat) various chronic disease states. AmealBP is a new product for patients with high blood pressure. Saw palmetto shows great promise in relieving symptoms of benign prostatic hyperplasia, or BPH (non-cancerous enlargement of the prostate), and it may have similar efficacy to finasteride, a prescription drug used for the same purpose--but with fewer reported side-effects (though that doesn't necessarily mean it actually has fewer side-effects). And though trials have generally shown that it is ineffective for the purpose, black cohosh has gotten a lot of press for reducing symptoms of menopause, namely hot flashes.

Let's momentarily ignore the issue of efficacy for all of these products and assume that they work as advertised with minimal risks or side-effects. Would that make them good products?

There are many pros to self-care, or therapy with over-the-counter products without the intervention of a physician. Self-care helps reduce healthcare costs, largely because physician's office visits are expensive. The convenience and ease of access to self-care promotes the seeking of treatment by patients who might otherwise do nothing. And symptomatic relief of common ailments, such as colds, helps reduce the number of sick days taken by employees, increasing workplace productivity. Some do-it-yourselfers love the idea of treating all their ailments via Google diagnosis and OTC purchases.

The question is whether or not these are really illnesses that should be self-treated. Is BPH really an illness that should be self-diagnosed and self-treated? The major symptoms of BPH are related to urination. But there are many problems that might cause difficulty urinating or "leakage" in men, including the anticholinergic effects of many medications, especially since BPH is a problem of old age and older people are more susceptable to these side-effects. And while BPH is a "wait and see" illness, not typically requiring a biopsy, BPH may not be BPH--it may be cancer. Which means that these medications are likely best used under the supervision of a doctor, significantly reducing the monetary savings of self-treatment.

Mevacor, otherwise known as lovastatin, has been considered as an over-the-counter or perhaps a "behind-the-counter" drug. Lovastatin is a "statin," used to lower cholesterol and a member of a class of drugs that is estimated to have saved 83,000 lives since the '80s. Like low-dose aspirin, statins are clearly a life-saving therapy for patients at risk for cardiovascular disease. Wouldn't improving patient access to statins--by making them over-the-counter, or perhaps behind-the-counter--save lives as well? Maybe. Maybe not. Statins are effective, but must be used judiciously. And because statins can cause both liver damage and rhabdomyolysis, or breakdown of muscle tissue, patients on statins need to have regular lab tests and monitoring. So OTC statins don't save patients from regular doctor visits--one at the initiation of therapy to establish a baseline for liver enzymes and follow-up monitoring every three to six months depending on the patient, not to mention lipid panels to confirm that the therapy is actually working. The drug may be more accessible if moved out of the pharmacy, but will it really be any more convenient? And how many patients are going to cut corners, putting off lab tests and appointments they don't think they need in order to save time and money? I really don't think OTC statins are a terribly good idea.

If lovastatin shouldn't be OTC, why should saw palmetto or AmealBP? All three are intended to be used to treat chronic conditions that require monitoring by a primary care physician. The only reason the latter two escape scrutiny is the DSHEA. Putting aside questions of efficacy--and even safety, at least in the sense of drug side-effects--is it really a good idea for patients to be treating these conditions without the intervention of a professional? And don't even get me started on the notion of these products as "complementary" therapies; saw palmetto is theorized to work via the same mechanism as finasteride, which is the blockade of enzymatic conversion of testosterone to the more potent dihydrotestosterone. No sane physician would prescribe finasteride and dutasteride simultaneously, as they have the same mechanism of action. Why take saw palmetto alongside finasteride? Patients may unknowingly do so, especially if they do not discuss the herbal supplements that they use with their physician.

I apologize in advance to the do-it-yourselfers, but some things just aren't conducive to that kind of attitude, and healthcare is frequently one of them.

Wednesday, December 19, 2007

Drug Use, Paternalism, and Freedom

N.B. has been such a bad blogger lately. That's okay. Unlike many well-established bloggers who provide handy reposts of old material for their readers, I, being a much newer member of the blogosphere, have no such easy out. In any case, I'm hoping I can make it up to you eventually.

I have an unusual position among those in my profession when it comes to the subject of recreational drug use. A lot of pharmacists have a strongly negative knee-jerk reaction to the idea, probably because they're concerned they'll potentially be held responsible for problems created by socially dysfunctional addicts. There are plenty of reasons for them to be upset; drug-seekers are frequently very abusive toward pharmacists who stand between them and the drugs they want. Many pharmacists I've worked with, knowing that their licenses are potentially on the line, weigh heavily on the side of strictness when it comes to dealing with these "patients." It's easy to see where the reaction comes from.

Personally, I'm a big proponent of harm-reduction principles. Give needles away freely. Legalize marijuana. The drugs that have been made illegal in the US are illegal because of politics and paternalism, not because they are necessarily more dangerous--or even physically addictive--than other recreational drugs that are completely legal.

Unfortunately, I do not think I will live to see the day when the government opts to loosen its grip on the recreational use of mind-altering substances. This is at least partly because of multiple political issues and a certain flavor of moral panic, but I think there might be yet another reason. As something of a libertarian, at least in the social sense, I don't think the government has a right to tell me what I can and cannot do with my own body. I think it's wrong for the government not to trust adults to take care of themselves.

The problem, as it often is, is that people are idiots.

Ever heard of "Lean?" It's the street name for a commonly-prescribed cough syrup containing codeine and promethazine. Intended to control coughs, dry out nasal secretions, and reduce nausea, "Lean" has enjoyed success in the club scene as, of all things, a mixer for alcoholic beverages, an idea that has been popularized by hip-hop music, especially in the southern US. Mixing opiates and alcohol is bad enough from a health risk standpoint, but the thing that really terrifies me about this business is that the people who are doing it have no idea what they are doing. Only click that link if you feel like wading through some really bad internet-speak explanations as to how to make "the purple drank [sic]."

A remarkable number of people posting do not know what they are taking to get high. Some of them think the promethazine is responsible for the "high" (not hardly) and suggest acquiring promethazine suppositories while others think that the trip can be attributed to dextromethorphan (which isn't even in the formulation). Everyone has their own recipe, some of which have nothing to do with cough syrup (crushing up Xanax and methadone, for example). Others swap advice for how to get prescriptions written by physicians. Perhaps the scariest of all, though, is one poster suggesting that the best way to get "Lean" is not to pay the outrageous street prices but to "straight rob the muthaf$^@in' pharmacy." Let me tell you, this is the kind of thing that keeps pharmacists awake at night--the idea that someday someone is going to hold them at gunpoint for Vicodin, Oxycontin, or, apparently, codeine-containing cough syrup.

This is the reason that most people, including those running our government, assumes that recreational drug use will turn you into an addled, violent menace to society. I've known smart people who occasionally used drugs as a social outlet, much the same way that many people drink socially, and most of them have not "become addicted" or become socially dysfunctional as a result. But it's clear that many people do not have this sort of self-control. What's worse, many recreational drug users are stupid enough to put pharmaceuticals into their bodies without knowing what they are or how they work! This sort of behavior is incredibly foolish.

I'd like to think that people can be trusted to make their own decisions and take care of themselves without interference from paternalistic governments. But sometimes it really feels that the evidence is against me. What do you think?

Saturday, December 8, 2007

Intergalactic Conquest

As any student in the 21st century knows, the proper way to celebrate finishing a huge research paper during finals week is to procrastinate regarding the rest of your work. In my case, that means it's time to binge on a brilliant 4X strategy game.

Hopefully finals won't produce another week-long posting hiatus, but we'll see what happens!

Friday, December 7, 2007

Vatican Declares Creationism = Paganism

Holy fundie-repellant Bat-spray, Robin! Ker-POW! Wham! BIFF!

Take that, ID!

Infant Cough and Cold Product Recall

If you're not feeling the pain of the finals week crunch right about now, it's because you're not a student. Lucky you!

The whole infant cough and cold drug recall isn't really new news; it's been going on for a few months now. And the lawsuit filed by Dimitria Alvarez of Illinois is still pending, as far as I'm aware.

For those unaware of the essential background, many retailers and manufacturers voluntarily recalled many drug combination products marketed for the treatment of cough and cold symptoms in children under 2. The move has generally been well-received by physicians; Pharma has responded to allegations regarding product safety that all of the products on the market have been deemed to be safe when used as directed.

Part of the issue is that there have been very few studies regarding the use of products like dextromethorphan and pseudoephedrine in children, and the new replacement for PSE, phenylephrine, doesn't even have established weight-based dosing guidelines. Many dosages, therefore, are extrapolated from adult doses using various rules of thumb. Clark's rule, for example, suggests dividing the child's body surface area in meters squared by 1.73 (the average BSA for an adult) and multiplying that ratio times the adult dose to get an approximate children's dose. Fried's rule suggests multiplying a child's age in months by the adult dose and dividing the result by 150 when dosing medication for children from 1 to 2 years of age.

These approximations are no substitute for thorough clinical trials. They assume, quite incorrectly, that children are like little adults, and that weight-based dosing is sufficient to guarantee safety. Not only do children have less "body space" in which to distribute a drug dose, increasing its concentration in the blood, but their bodies are less capable of metabolizing and eliminating a given dose. Drug half-life, or time required to eliminate half of the amount of drug in the bloodstream, is typically much greater in children than adults, and not always proportionally so. The half-life of caffeine in healthy adults is 3-4 hours; in newborns, it may be as long as 30 hours. Furthermore, children often respond differently to medications than adults. Antihistamines often produce paradoxical excitement in children whereas they have a sedating effect on older people.

Since many cough and cold products are untested in infants and young children and their efficacy cannot be guaranteed, treating them for cold symptoms is less about treating the child and more about assuaging the concerns of parents. This is particularly true in the case of infants who cannot communicate except by crying; nervous parents will frequently assume that crying is a sign that an infant is uncomfortable and likewise assume that a lack of crying indicates comfort or relief of symptoms. Anecdotally, a pharmacist I work with told me once about a one-year-old who had been prescribed Donnatal elixir. Donnatal is a drug normally used in adults to provide relief of gastrointestinal upset; it contains atropine and other belladonna-derived alkaloids, which slow the movement of the stomach and bowels, as well as phenobarbital, a central nervous system depressant. Donnatal elixir is also about 23% alcohol by volume--it's more alcoholic than many liqueurs, including irish cream! I'm willing to bet that any "therapeutic value" that medication had for a one-year-old primarily manifested itself as "shutting junior up."

I've discussed the popularity of the placebo effect before; since nothing tugs at mom's heartstrings like a crying baby, treatment of illnesses in infants that are not life-threatening is more a matter of making mom feel like she's doing something to help her poor child. As a result, tired physicians or busy pharmacists might be inclined to recommend something just to keep mom happy. From an evidence perspective, pulling these products off the shelves was an excellent move; appropriate non-pharmacologic treatments are frequently available and generally safer. Saline nasal spray is probably a better treatment for nasal congestion in young children overall, and it has the added benefit of soothing dry membranes. The risk versus benefit analysis of cough and cold products, especially in infants, really suggests that they aren't worth using.

If you ask me, the lack of clinical trials in infants and children to support the use of cough and cold products aside from fever-reducing agents (such as acetaminophen and ibuprofen) really nails the issue. It's true that many of the products were used for years before the recall, but the benefits have generally been small--medicating children is frequently done just to make the parents feel better. As such, the recall of these products is no great loss.

If your kid has a cold, think things through; if he's only been sick for a day or two, he's probably going to get better on his own. Nothing you can do is going to make the illness go away faster. Do you really need to do anything but provide the kid with adequate fluids and let things run their course? Is it really worth struggling against the inevitable fact that your child is going to be sick for a few days? I'm hoping that in time parents won't be lamenting the disappearance of these products. They'll adapt to the idea that there are no miracle cures for sale on pharmacy shelves.

Wednesday, December 5, 2007

Pharmacy is Not a Commodity!

Pharmacists and Corpo-Drugstore are intertwined in a sort of Faustian bargain.

There's not a lot of glamour in community/retail pharmacy. CorpoDrug pays pharmacists lots of money to stand behind a counter. The fact that "patient" and "customer" are used interchangeably to refer to patrons of CorpoDrug's pharmacy is very telling; I find it most interesting who chooses to use which word. As an informal observation, most pharmacists prefer patient. Most technicians and store managers use customer. Sapir and Whorf may be onto something here. Patient sounds a lot more "medical." Calling patients customers reinforces the idea that CorpoDrug is a store. I would quip about portraying pharmacy as the equal of the Big Box retail business here if it weren't for the fact that such a comparision is pointless; Wal-Mart, Meijer, Target and CostCo all have their own pharmacy departments.

The problem is not that CorpoDrug is turning pharmacists into glorified store managers who coincidentally have medical degrees. The problem is that pharmacy started that way and that it has failed to break free of those chains. CVS retail outlets originally did not include pharmacies; the "CVS/pharmacy" nomenclature grew out of a need to inform consumers which locations had pharmacies and which did not. Walgreens began as a drug store, but this was back in the era where the drug store was a place to get malted milkshakes and tobacco products. The history of community pharmacy suggests that with the advent of pharmaceutical manufacturing and the downfall of compounding that pharmacists filled no clear niche in the healthcare field. Now, pharmacy is rapidly evolving into a profession of drug information and medication therapy management experts. Pharmacists in hospitals and managed-care facilities have the opportunity to work with other healthcare professionals to optimize patient outcomes by contributing their unique skills and knowledge as drug experts. Physicians can rely on pharmacists as valuable allies.

But CorpoDrug is still living in the stone age of pharmacy, perhaps with fewer mortars and pestles. It is two-faced, talking out of both mouths simultaneously about the value of its pharmacists. Surely it "values" pharmacists in the sense that CorpoDrug is willing to pay them a median salary of $90,000. And the American public, at least, considers pharmacists to be among the most ethical professions, just behind nurses. It is clear that people think that pharmacists are ethical. And if my experience is any indication, they think pharmacists are knowledgeable, too. Pharmacists get asked some pretty crazy questions, like whether or not sodium benzoate is safe or which urinary tract infection test strips are more reliable. This is in addition to the more traditional queries like "can I take these two medications together?" and "how much Tylenol should I give my four-month-old?" A big part of why pharmacists get used so frequently as a source of information, aside from the public's assumption of their ethics, is their accessibility. I can think of few doctors who have time to take phone calls about sodium benzoate, but pharmacies do it all the time.

A district manager for the retail pharmacy that employs me stopped into our store one day and was conversing with the pharmacist. "We're here to help people," he said, "but pharmacy is a business, too." In the most base sense, this is true. It isn't wrong to want to make money; it's a necessity of living in a capitalist society, and there is nothing immoral about that in itself. From a marketing perspective, prescription drugs are a commodity. The time and advice of a pharmacist is a commodity. These are goods and services for which there is a demand and only a limited supply. But healthcare professionals, the dedicated, honest, ethical ones at least, don't see their services as commodities, not in the same way that businessmen do. Can you imagine a physician offering to push people to the front of his waiting list for appointments if they volunteered to pay higher fees? Would an ethical doctor provide patients with prescriptions for whatever they asked for on-demand as long as the patient was a paying customer? These might be very profitable business moves for a physician. Assuming he evaded prosecution, a physician willing to "sell" prescriptions for drugs of abuse could make a huge fortune. But it would be illegal, and more importantly, unethical.

Pharmacists, like physicians, take an oath. Nowhere in that oath is "I will uphold a committment to the idea that the customer is always right" or "I promise to provide the lowest prices for antibiotics in town." The first point is "I will consider the welfare of humanity and relief of human suffering my primary concerns." Pharmacists are professionals.

The mechanisms that CorpoDrug use to secure customers are insulting. Gift card coupons that encourage patients to bounce back and forth between retail chains whenever they get a new piece of junk mail. My chain is currently offering as much as $50 in gift cards for filling a new or transferred prescription at our chain instead of somebody else's. "Ten minutes or less" guarantees that any reasonable pharmacist will recognize as total bull; if your insurance company is being a pain or your doctor's handwriting is illegible, I'm not going to uphold some fast-food speedy service ideal at the expense of patient safety. Drive-through windows are perhaps the most appalling of all; they suggest that the time and expertise and pharmacists aren't even worth getting out of your car. I'll be amazed when a physician's office puts in a drive-through and volunteers to diagnose patients through the window. Once you've got your diagnosis, you pull up to the second window to pay and get your prescription. Absolutely absurd.

CorpoDrug treats pharmacy like a commodity, and the public has picked up on the idea. Pharmacies, like McDonalds' outlets, are interchangeable. I have dozens of stories about patients who were in my store and thought they were at a different retail chain. All pharmacies have the same drugs, right? Perhaps pharmacists are interchangeable, too, like grill cooks, as long as the product is the same. CorpoDrug uses one mouth to say that pharmacists should take the time to counsel patients and verbally slaps them on the hand for "unacceptable" wait times that cause loss of profit margins with the other. It becomes the job of individual pharmacists to uphold high standards of care--with or without the support from their retail outlets. Many find it impossible to keep up and have simply folded.

A lot of patients on chronic therapies, namely insured patients, will pick one pharmacy and stick with it, giving the pharmacist or pharmacists who work there a greater degree of access to their medication history. Programs to encourage these patients to stick with one pharmacy, or at least one chain, have been largely successful. On the other hand, there are the patients who comparison shop, bouncing back and forth between outlets based on who has the cheapest prices for each particular medication. This spells disaster when the patient winds up on two drugs that should never have been taken together.

Which brings us to universal healthcare. Pharmacy wouldn't have to be a commodity in the face of universal healthcare--we could have universal pharmacies, too. Instead of walking past displays full of toilet paper and office supplies on the way to the pharmacy "department," the whole structure could be dedicated to health. With adequate staffing, patients could make appointments to speak with pharmacists about their medication--a service that is already being promoted for Medicare patients. Imagine if every corner drugstore offered the same service and advertised it as heavily as they do sales on toothpaste! The sort of competition CorpoDrug engages in with PharmaMart is bad for patients, whether they realize it or not; they become sources of revenue rather than sick people, permitting greed and capitalism to steamroll good health practices in the face of profits. CorpoDrug doesn't sell dietary supplements because they help people. They're on the shelves because they add to CorpoDrug's profit margins.

My absolute least-favorite "pharmacy" publication is Drug Store News; sure, they talk about clinical issues from time to time, but a huge portion of Drug Store News is things like "which brand of lip balm sells the best?" and "how can I add proprietary vitamin blends to my inventory to boost earnings?" It's positively revolting. If drug stores were really focused on being healthcare providers, this sort of crap would never propagate. Physicians don't distribute coupons through the mail. That's the shady realm of chiropractors. Would physicians subscribe to publications suggesting that they add in-office plastic surgery or proprietary herbal blends to their services to supplement their incomes? Absolutely not, and most physicians would be offended at the idea. Why do pharmacists put up with it? The short answer is that most of them feel that they don't have a choice. Independent pharmacies really do need to go to extremes to keep from being washed away by the tsunami generated by the chains. And pharmacists employed by those chains are essentially being bribed into silence with high salaries.

Pharmacy is not a commodity. Medical care is not a commodity. Medical care is a necessity, a basic human right. And if pharmacy is going to contribute to overall human health for our communities, it's going to be necessary for pharmacy to distance itself from "business" as much as is humanly possible. Pharmacists need to support themselves and their families, and it's easy to see why a desperate pharmacist, buried in debt and student loans, would sign on with CorpoDrug in order to dig their way out. But if CorpoDrug really had any respect for their pharmacists and their clinical expertise, they wouldn't treat them the way they do.

Corpo-Pharma's assault on pharmacist ethics persists.

Tuesday, December 4, 2007

Only 21 More Shopping Days...

What do you get the scientist, scienceblogger, physicist, chemist, boy scout, or evil genius who has everything?

How about a nice tin of uranium ore? Great for testing Geiger counters, powering death rays, or use as a carcinogenic paperweight.


A discussion thread on one of my favorite blogs included this fascinating link to a story that is just incredible. The article is a little lengthy, but not too bad, and it's definitely worth the read, especially if you have any interest in biology or science. Thanks to Sid Schwab for providing the link.

Essentially, when geneticists mapped out the human genome, they discovered that while only 2% of it was entirely necessary for life, as much as 8% consisted of "junk" DNA believed to have been incorporated due to infections from retroviruses. Retroviruses, for the uninitiated, are viruses capable of permanently altering the DNA of organisms they infect, occasionally causing the changes that they make to the human genetic code to be passed on to offspring. The most notorious retrovirus, of course, is HIV, the virus responsible for causing AIDS. A few innovative geneticists studied these fragments and managed to sequence the genetic code of one of the retroviruses that might've insinuated itself into the genome of more complex organisms tens or hundreds of thousands of years ago.

Using biotechnological methods for creating recombinant DNA, these scientists effectively resurrected an extinct virus. And their creation was capable of infecting mammalian cells.

According to the article, there's evidence that the incorporation of retroviral DNA into our genome influenced our evolution. The formation of the placenta, for example, may have been a result of retroviral infiltration. And retroviral incorporation may explain why monkeys are carriers for HIV but are unaffected by it; there's a huge chunk of retroviral DNA that they have that we don't. So sequencing and experimenting with "extinct" retroviruses gives us more concrete evidence for evolutionary pathways and may have medical applications.

Read the article. It's totally worth it.

Interesting to think that there are "fossils" of extinct organisms in your DNA, no?

Monday, December 3, 2007

Quote of the Now

"Now, of course, if agitation + dilution could produce some sort of powerful effect, then washing machines around the world would be churning out huge quantities of homeopathic socks." ~"Bad" of The Bad Idea Blog

I'm trying to imagine what homeopathic socks could possibly be good for and thinking homeopaths would be more likely to claim that washing machines produce homeopathic sock water. Which, in accordance with the homeopathic principle of similia similibus curentur, would be the ideal cure for smelly feet.

Man, that's a brilliant idea supported by remarkably sound logic! Why doesn't everyone drink from their washers? I'm going to start bottling the stuff and hock it from a roadside stand for $9.95 a bottle.

Pharmacists as Triage

Jim Plagakis is hard-hitting and frequently acerbic, but that's what makes bloggers like P.Z. Myers the moguls that they are. Jim's most recent entry on pharmacists as the ultimate kings and queens of triage is a rather interesting read, and I really couldn't agree with him more.

I don't have a lot of the bitterness Jim does, likely because the system hasn't chewed on me for quite as long. Jim still remembers the days when it was illegal for pharmacists to discuss medication with patients. Nowadays, many physicians are starting to recognize the value of good pharmacists in the healthcare network. Not just the pharmacists that work in their hospitals, mind you, but the pharmacists manning drugstore counters at retail outlets.

The healthcare system is dramatically inefficient; the Buckeye Surgeon recently related a case that was an appalling waste of resources. You can't possibly appreciate the number of people who use their drugstore pharmacist as a first resource for medical advice unless you've worked in a community pharmacy. Pharmacists are accessible, abundant, and best of all from the public's point of view, free. There's no office fee, no receptionist, and no paperwork. Pharmacists are available at all hours. Your pharmacy may not be open 24/7, but in all likelihood there is another pharmacy that is within 20 minutes' driving distance. And distance is arguably irrelevant with the telephone; pharmacies recieve calls at all hours of the night. Getting a phone call at 9:30 from a concerned mother or a constipated senior is a regular part of the job.

But if pharmacists are going go wind up being a major point-of-triage by default, we must ask if they're doing a good job. Most of the pharmacists I've known have been good medical professionals on this point. They know what they can and cannot handle. Being a community pharmacist is really all about knowing what illnesses are self-treatable and being willing to take a thorough history to rule out cases that are inappropriate for self-care. We refer many patients to their physicians or even to the hospital, but we save many more from trips to the ED over upset stomachs. The problem is that from a documentation and communication standpoint, this absolutely sucks. In 99% of cases, the only surviving record of care provided by a pharmacist is in both parties' short-term memory. Patients, then, have to pass on care that a pharmacist has suggested verbally. Many of them will forget to do so, leaving gaps in the patient's medical history.

Granted, it isn't necessary for patient records to be bogged down by entries like "on November 14th I had a headache and the pharmacist recommended Excedrin." But wouldn't it be wonderful if pharmacists had a way to keep accurate records of patient self-treatment? When hospitals perform medication reconciliation for recently admitted patients, they call pharmacies to confirm records. If only there were a mechanism for pharmacists to store more detailed information about a patient's history of illness and attempted therapy! It would be particularly handy for pharmacies to have a record of patients who take supplements or herbal products. A counseling record wouldn't have to be particularly complicated or long to be useful; most records would be the result of about 5 minutes' worth of conversation.

"Patient reported to pharmacy on [date] with [chief complaint]. Reports [symptoms]. Medical history includes [x and y]. Recommended [course of action]. Known action taken by patient includes [z]." These records could be passed on to the patient's primary care physician. This is the 21st century! We have the technology!

Of course, in accordance with privacy laws and to keep everything easily retrievable, computerized data is the way to go. The problem is that this could get ugly; patients new to the particular pharmacy would not have established records, and the process of setting up a patient profile is a time-consuming task for staff. In reality, most pharmacies can collect information for a full patient profile in minutes, but this assumes adequate staffing--and most busy pharmacies are not adequately staffed. "Having time to do thorough and appropriate patient counseling" already feels like a pipe dream for many pharmacists, and adding an additional step to the process would require time that numbers-obsessed retail giants are not willing to spare. And then there are the patients are talking to pharmacists specifically because they want to avoid drawn-out meetings or filling out paperwork. In today's drive-through society, the idea of having to wait for anything just sets some people's pants on fire. Would patients be willing to take an extra 3-5 minutes to improve the quality of their healthcare by getting proper advice and attention from their pharmacist?

An oddity of this whole situation is that patients want more counseling but that they're unwilling to pay for it. Cost is apparently the number one factor in choosing a pharmacy. Hm. But costs being equal, patients prefer pharmacies where they feel that the pharmacist is involved in their health. They want a rapport with their pharmacist. Many patients at my store actually bypass closer retail outlet locations because they like our staff better--and they say so.

Pharmacists are becoming a bigger part of the healthcare team every day. How can they possibly cope with this increased responsibility or use their knowledge effectively if they neither have access to patient medical records nor have a means to communicate patient information with PCPs? As it stands, pharmacists are huge contributors to patient well-being but are effectively severed from the main body of patient information. They are an island, and messages are neither recieved nor sent, creating a black space where pharmacists are forced to grope around in the dark and hope patients have all the information they need to do their jobs.

I had a man approach me the other day saying he wanted to purchase a particular product. Before simply directing him to the product, I wanted to make sure his decision was sound, so I inquired as to his symptoms and his medical history. He said he was in good health and taking no other medication, so I agreed that the product was a good choice and sold it to him. He came back some three hours later saying he wanted to return the (unopened) product because he had read on the label that it should not be used by patients with thyroid disease--and he apparently had some manner of thyroid disease. Apparently thyroid disease doesn't count as an "existing medical problem." Maybe he was ignoring me, or he could've somehow forgotten. No harm came to the patient, but the case illustrates my point. Universal patient records would've prevented this problem in entirety, and it would also safeguard against more serious ones.

Patients are fallible. Doctors and pharmacists are fallible, too. We would be able to prevent more mistakes and provide a higher standard of care if we could improve communication and implemented a system for pharmacists to keep detailed records of patient counseling sessions. The biggest cost would be in time--in the long run, the prevention of errors and the streamlining of pharmacists as triage agents would ultimately save the medical system a great deal of money. So why aren't we doing it already?

Saturday, December 1, 2007

Take a Deep Breath

The FDA is currently re-evaluating warnings on long-acting beta-agonist drugs used for asthma. This isn't the first time that the subject has come up. It made the news way back in 2003 and was discussed again in 2005. What's the deal?

Beta-agonist drugs stimulate part of the body's autonomic nervous system, or ANS. The ANS is responsible for managing many body functions, some of which are unconscious and others which are conscious. The ANS is further subdivided into the sympathetic and the parasympathetic systems. Put simply, the sympathetic nervous system is associated with the "fight or flight" response; for example, stimulation results in an increase in heart rate. The parasympathetic nervous system is associated with the "rest and digest" response. Among other things, stimulation results in increased movement of the musculature of the stomach and bowels and salivation.

One of the reactions associated with "fight or flight" is the widening of the bronchial tubes, the cartilaginous passageways through the lungs that carry air. Because the sympathetic nervous system receptors on the bronchi are different from those on the heart or the skeletal muscle, it is possibly to stimulate them selectively. These receptors are called "beta-2" receptors, and an agonist is a drug that stimulates a response; therefore, selective beta-2 agonists stimulate only the bronchi, dilating them and making it easier for patients to breathe without simultaneously increasing the heart rate. In asthma, the bronchi become inflamed and constrict, making breathing considerably more difficult, especially during periods of exercise or physical activity.

The most well-known beta-2 agonist is probably albuterol, staple of asthmatics of all ages. If you were ever on a sports team as a kid or even just played outdoors you probably knew at least one person who used an albuterol inhaler. Albuterol is an excellent drug, and it works quickly but its duration of action is relatively short--about six hours. Six hours may sound like a lot, but most people need to breathe all the time. Patients with asthma who find themselves gasping every time their albuterol starts to wear off may find themselves in serious trouble, and shortness of breath can be very scary.

So pharmaceutical chemists developed drugs that work the same way as albuterol, but that would have a longer duration of action. Serevent is one of them. Advair is much more commonly prescribed; it combines salmeterol, the long-acting beta-2 agonist in Serevent, with an inhaled corticosteroid for further bronchodilation and relief of asthma-related inflammation. Before long-acting beta-2 agonists became available, inhaled corticosteroids were the first option for long-term control of asthma symptoms. Salmeterol even has a neat pharmaceutical mechanism; it is structurally similar to albuterol, but has a long chemical "tail" that embeds itself in cell surfaces, resulting in very slow release of the drug to its site of action.

Logically, it seems like salmeterol should be just like albuterol, only better.

A 28-week placebo-controlled study conducted in 1996 in the U.S. (the SMART study) suggested that patients on long-acting beta-2 agonists actually had more asthma related deaths than those on placebos. However, the increase in deaths was not statistically significant in the Caucasian participants in the study--and they made up 71% of the study's population of 25,858 patients. African Americans made up the second-largest group at 17%, and while the number of deaths in African Americans was statistically significant, only 1% of African Americans enrolled in the study suffered an asthma-related death. This could be attributed to the smaller sample size; the study was not designed to provide strong data about possible differences in drug effect between ethnic groups.

So what's going on? Is salmeterol killing people? Is it an ineffective drug? This "salmeterol paradox" is certainly strange. The whole purpose of long-acting beta-2 agonists was to add another option to improve long-term control of asthma. Researchers at Cornell suggest that using long-acting beta-2 agonists may ultimately worsen underlying inflammation and increase "bronchial hyper-responsiveness." Some other data suggests that use of salmeterol causes roughly five deaths per year.

I, of course, really don't know for sure. What I do know is that the statistics here look kind of funny. The FDA has to be conservative in its rulings; some evidence of risk is good enough for them to put a warning on a drug to cover their backs. But in nearly three-quarters of the sample group the number of deaths due to asthma-related causes was not statistically significant. What other factors might cause an increase in asthma-related deaths?

Well, the patients on salmeterol obviously have worse asthma than those who can manage with nothing more than an albuterol inhaler. The SMART study also mentions that deaths were higher in patients taking salmeterol but not taking an inhaled steroid. Er. This doesn't necessarily strike me as a "blame salmeterol" situation. Again, wouldn't patients requiring a steroid in addition to both long and short-acting beta agonists to get control of their asthma obviously be the worst off? The need for salmeterol and other drugs in its class is an indication in itself that the patient's condition is deteriorating.

I'm not convinced by the SMART study or any of the follow-up research that I've seen that long-acting beta-agonists are the cause of asthma-related deaths. More robust studies are going to be required to weed out other possible underlying causes. The real question, then, is whether anyone is going to bother to do them.