Secundum Artem

Albuterol and Political Correctness

2009-01-14T18:08:00.002-05:00

Nobody get all prescriptive versus descriptive linguistics on me, but I'm noting a bizarre thing lately. It may not be new, but there's this odd tendency for people to call decisions or acts that they disagree with that they think are clearly done to please somebody not them "politically correct."

There's a fair deal of politics in this post, but I swear it's about a pharmacy-related issue.

Political correctness, PC-ness or PC-ism is a term mostly associated with liberals and liberal thinking. The basic gist of PC-ness is the idea that you shouldn't offend people, but it extends beyond that; you shouldn't do things that might offend people. Furthermore, everything you do is potentially offensive to someone, no matter how mundane it seems to you. Taken to its extreme, PC-ness is "left-wing censorship." It is frequently assumed within the context of PC that white males are not really offended by anything, but that women, racial minorities, and religious minority groups are "sensitive" to "careless speech." Women in particular are used as an example, partly because some feminist groups really do go way too far, insisting that the word "human" is offensive because it contains the word "man" and that alternative terminology needs to be developed.

The idea of what is and is not offensive is highly affected by cultural and subcultural norms, so I'm not even going to go into that. You could write a book on the subject. I'm sure someone has.

What I'm going to take issue with is the use of the phrase PC being grossly misapplied and my understanding of why it happens. The most recent example of this that I've seen was when I, out of morbid curiosity, clicked a link to "saveCFCinhalers.org" (I'm not going to link them because I don't want to boost their google ranking).

Summary: CFCs, or chlorofluorocarbons, are compounds that have been used as aerosol propellants and refrigerants for roughly the past century. CFCs react with ozone in the upper atmosphere and catalyze its destruction. Because CFCs are a catalyst, they are not used up in the reaction, so a single CFC molecule may destroy a number of ozone molecules, converting them to oxygen. Ozone blocks ultraviolet radiation, specifically UVB rays. It is well-established that CFCs deplete ozone and that this will increase the amount of UVB rays that reach the earth's surface. CFCs were phased out of aerosol paints and other products during the last decade. 2008 was the last year that CFCs could be included in metered-dose inhalers (MDIs, or "puffers").

MDIs containing a different, non-CFC propellant (HFA inhalers) have been on the market since 1996. As of December 31st, 2008, CFC inhalers may no longer be sold and supplies have basically been exhausted anyway since nobody has been making them for a while. The most commonly used MDIs are albuterol "rescue inhalers" that expand the passageways in the lungs. This is a big deal drug--if you want to know what it's like to have an asthma attack, go get a straw. Put it in your mouth. Breathe only through the straw without opening your mouth wider or using your nose.

Anyway, the old inhalers have been replaced with environmentally-friendly versions. Same drug, same dose, same efficacy. Some people are throwing a fit about this.

There are a few big complaints.

1. The HFA inhalers cost a little more. The old albuterol generic was about $25, less if insurance picked up part of the tab. The new inhalers are about $35-40 and insurance pays less since they're generally "brand name" products now. The whole insurance payment thing might change soon if enough people complain about it.

2. The HFA inhalers don't "feel" the same when sprayed--they're a bit less "forceful," which leads people to think that they don't work.

3. The propellant contains a very tiny amount of ethanol, which might leave a bad taste in the user's mouth. It is not enough to get you drunk by any stretch of the imagination.

The websites railing against HFA inhalers are full of comments that basically tell the same story. My inhaler doesn't work anymore. My daughter changed to an HFA inhaler and she died of an asthma attack a few months later. I changed to an HFA inhaler and now I have a huge long list of health problems I didn't have before. The government and the FDA are ripping us off and lying about the safety and efficacy of HFA inhalers. Here's a list of doctors that don't believe the HFA inhalers work as well. The American Lung Association is full of shit. Etc. I actually got into an "argument" of sorts with a coworker over this one day--not someone that works in the pharmacy. He was convinced that albuterol had been taken off the market completely and that you simply couldn't get it anymore, and when I informed him otherwise he seemed incredulous--but I didn't get an opportunity to talk to him about it further.

The comment that piqued my interest (and inspired this entry) was the complaint that CFCs had been removed from inhalers to "be politically correct."

I don't know exactly what train of thought the commentor used to get to that point, but here's how I see it. Before anyone accuses me of straw-manning anybody, I'm quoting statements made by my incensed coworker. While his thoughts may not be echoed by everyone who opposes this particular bit of regulation, this is the only dialogue I've had with someone who had a problem with the banning of CFCs on principle rather than because of some specific complaint (such as the new inhalers costing more).

1. Some people ("environmentalists") think that CFCs damage the ozone layer.
2. People who want to be "environmentally-friendly" by using CFC-free products should have the right to buy them; let the market decide.
3. I'm not convinced that CFCs damage the ozone layer.
4. Not letting me choose which product to buy is an unfair limitation of my personal freedom.
5. Therefore, a CFC ban limits my personal freedom.

This train of thought hinges on one particular premise, which, again, lest you think I'm constructing a straw man, was basically the crux of my coworker's entire argument: I'm not convinced that CFCs damage the ozone layer.

Let's go with the "free market" approach. In order to make an informed decision about which product is best, you have to understand several things. First, you have to know what the ozone layer is. Second, you have to know that CFCs damage the ozone layer. Third, you have to know the consequences of damaging the ozone layer. Once you have all of that information, you can make a choice: Do I care whether or not the ozone layer is damaged by the products that I use?

Here's the problem. This isn't a personal choice that's (primarily) going to affect only you, like what color to paint your shutters or whether or not to snort cocaine. Your decision is going to affect everyone living on the Earth for at least the next 50 years, which is how long an individual CFC molecule can remain in the atmosphere destroying ozone molecules. You are contributing to an increase in UVB radiation reaching the planet's surface during your lifetime, much of your children's lifetime, and at least part of their children's lifetime. You are increasing the risk of skin cancer for everyone alive now and everyone who will be born over the next several decades.

Frankly, I don't think you should be allowed to make that decision any more than you should be allowed to shoot me and take my wallet or dump sewage on my property, and the fact that you're too short-sighted to see the consequences of your actions shouldn't affect my personal health. I have rights too, you know.

(Incidentally, to preempt the slippery slope, I don't favor smoking bans because if second-hand smoke bothers you, don't go where people are smoking. If the owner of a particular piece of property opts to ban smoking for the comfort of their non-smoking patrons, that's their call, but nobody should be able to tell you you can't smoke outside or in your own car--though exposing your kids to second-hand smoke is certainly irresponsible and I have mixed feelings about it.)

What does any of this have to do with PC-ness?

Well, PC-ness is about not offending people. One of the things that I've heard said several times, more by conservatives than by liberals, is that "you don't have a right to never be offended," and I agree. Sometimes, people are going to do or say offensive things, and unless they're hurting you or there's a specific rule against whatever they're doing (sexual harassment at work, for example), you just have to get over it and move on. That doesn't mean you have to like it, and you can certainly say you don't like it, because criticism is not the same thing as censorship. Plus, some things are just socially unacceptable within a specific culture because enough people have decided that they don't like thing X that doing or saying thing X will get you publically ostracized (being openly racist in many circles in the US is a good example).

At this point, environmentalists become a minority group identified by a set of opinions or beliefs. If you don't accept the whole CFC-ozone layer thing, you might call it an "environmentalist belief," which puts it on par with any other faith-based assumption that you don't share. At that point, the government banning CFCs does seem like a "PC thing." They're doing it to appease some minority's feelings.

Which means that you're treating the CFC-ozone "belief" kind of like the beliefs of religious groups that are not your own. It's like if the government banned pork products because Muslims consider them unclean. You don't care what Muslims believe if you aren't one. Why should the "belief" of a minority group infringe upon the rights of the majority? Stupid political correctness!

This is why calling something PC in this context is just an empty smear--we're not talking about offending people here. We're talking about reducing the risk of skin cancer for human beings all over the world. There is a concrete reason for banning CFCs that has nothing to do with anyone's feelings. The EPA, NASA, National Weather Service and National Oceanic and Atmospheric Administration all concur. So do independent researchers at Manchester Metropolitan University in the UK and scientists from Germany, Belgium, Denmark, Norway, Spain, Switzerland, Finland, Canada, and Greece. Some very compelling evidence would be necessary to invalidate current theories.

Here's the part of all this that I don't entirely comprehend. Conservatives are generally very black-and-white--things are true, or they aren't. They pride themselves on being practical thinkers and denounce liberals as naïve idealists. The reason I think that this is funny is because calling evidence-based environmentally-friendly legislature "PC" is essentially invoking a kind of relativism. "You and I believe different things. Neither one of us can produce proof that will convince the other, so let's just agree to disagree." Except that you can't do that, because whether or not CFCs affect the ozone layer (for example) isn't a matter of opinion. It's either true or it isn't. And if we're talking about laws, something is either a law or it isn't; we have to decide. To "agree to disagree" in that context is to suggest shutting down dialogue on the subject--therefore, nothing is changed and the conservative viewpoint "wins" by default.

Inappropriate use of relativism regarding what is valid knowledge--which I see on both the far left and far right--is actually an interesting enough topic to warrant its own post, and I might have to make one later.

So. Here's the tl;dr summary: You can't criticize someone for being "PC" when what they're doing is not about avoiding offending people but about responding to objective, measurable conditions. This is true even if you think that the thing being done is intended to appeal to a "minority group" because you don't care about the issue at hand. Using the phrase PC doesn't make a damned bit of sense--but as with all language, you're free to use the phrase to mean whatever you want. You just shouldn't expect your listener to interpret what you're saying properly.

Thank You Michael Crichton

2008-12-15T16:22:00.003-05:00

First, I would like to point out that whoever scheduled a total of ten different examinations over the course of a three-week period needs to be informed that cruel and unusual punishment is prohibited by the Bill of Rights. I suspect that by the end of this week I will have lost what little sanity I have left.

But that's not what I'm posting to say--complaining about examinations may be part of student life, but there are more entertaining remarks that I can make. So here are a couple funny highlights from recent work shifts.

A girl calling me for a refill on her oral contraceptive pills expressed sincere belief when I told her that we didn't have the item in stock and that it would not come in until Thursday. The particular product recently went generic and there are still a few holdovers (despite the fact that they're made by the same company), but either way supplies of the brand name are not as numerous as they once were on our shelves.

I believe her exact phrasing was "wow, you guys can run out of drugs?" No, silly me, let me go open up the extradimensional pharmaceutical holding chamber where we keep the infinite supply.

But why reference Michael Crichton?

Those of you who have seen the movie Jurassic Park may recall a particular scene in which the power is out and most of the main cast is sealed in one of the bunkers, hiding from the rampaging dinosaurs. Attempting to formulate a plan, game warden Robert Muldoon brings up "the lysine contingency," a totally ridiculous safeguard thereafter explained by Samuel L. Jackson's computer programmer character:

"The lysine contingency - it's intended to prevent the spread of the animals is case they ever got off the island. Dr. Wu inserted a gene that makes a single faulty enzyme in protein metabolism. The animals can't manufacture the amino acid lysine. Unless they're continually supplied with lysine by us, they'll slip into a coma and die."

Of course, this makes absolutely no sense. Lysine is an essential amino acid, meaning that it cannot be synthesized by the human body--it must be consumed in the diet. In fact, no animals "manufacture" lysine. And as it is common enough--contained in many plants and all meat products--the "lysine contingency" isn't much of a plan at all.

I mostly mention this because I had trouble refraining from laughing the other day when a woman was desperately searching for L-lysine supplements. I should've asked her if she needed it to keep her pet dinosaur alive.

Happy Thanksgiving!

2008-11-27T12:51:00.001-05:00

It's been a busy few weeks around my small corner of the world, but there's no way I'd miss the opportunity to take two minutes to wish those of you in the blogosphere a happy Thanksgiving.

May you surround yourself with good company on the outside and fill yourself with excellent food on the inside!

Stop RFK Jr.

2008-11-07T10:34:00.003-05:00

Robert F. Kennedy, Jr. is on the current list of potential appointees for President-elect Obama's cabinet. While RFK Jr. has had a very successful political career, the positions for which he's being considered are the EPA or the Department of the Interior.

This cannot be permitted to happen. Why? Because he's a total crank when it comes to science. He believes the vaccine/autism link is plausible and has praised antivaccination movement leader Dan Olmsted--who has continually pushed junk science disproven years ago. He blamed Katrina on global warming (errr) and has opposed the building of wind turbines near Martha's Vineyard on because "it would damage the view" despite the project having support from many other environmentalists. He's got a track record of politicizing science to serve his own needs--and that's bad for reasons that should be obvious.

You can contact the Obama transition team and let them know how you feel about this. Not sure what to say? Consider Mark Hoofnagle's letter as an example:

RFK Jr. must NOT be appointed as head of the EPA. He is NOT a scientist. He does NOT understand science. He does NOT respect science. He is, in fact, a crank, who believes in pseudoscientific nonsense like vaccines causing autism. And when people are cranky and unscientific in one area of belief, it is never restricted to just that area. It reflects a fundamental misunderstanding of science and an incompetence in evaluating the quality of data and scientific information. This is not remotely a partisan letter, this is a plea for your administration not to make a horrible error.

This is a BAD choice. Do not do this or you will alienate scientists from your campaign very early on, not to mention doctors and especially pediatricians. This man is a crackpot, and I simply can not condone his presence anywhere in government.

Congraturation!

2008-11-05T14:18:00.003-05:00

Congratulations, Barack Obama, on becoming the 44th President of the United States in what will probably be remembered as one of the most significant elections of my generation. And I have no doubt that I will remember it despite all the champagne I consumed last night in celebration.

It's going to be a long road, but this is a step toward fixing a lot of the problems that have sprung up over the past decade.

A Tenuous "Alli"ance

2008-10-28T12:55:00.004-04:00

It appears that GlaxoSmithKline has recieved approval to market Alli overseas to our European cousins.

This means the product will now be proposed for final approval by the European Commission and marketing authorisation could be granted in the coming months. On licence grant, orlistat 60 mg would be the first licensed weight loss aid available without prescription throughout Europe.

You hear that? An FDA-approved weight-loss supplement! It's a miracle!

Alli was actually released to US markets last summer as one of the more unusual Rx-to-OTC product conversions that we've seen recently. Popular once prescription-only Zyrtec I expected, but Alli was really out of left field. I actually meant to blog about Alli when it was released, but somehow it got away from me. Now I can do so to commemorate its release across the pond.

What is Alli? Alli contains the same active ingredient as a prescription drug that was developed by the Swiss company Roche Pharmaceuticals--the generic name for it is orlistat. It is the first over-the-counter drug approved as a weight loss aid by the FDA, mostly because there's good clinical data that it's actually effective when used properly.

OTC "diet pills" generally contain high doses of stimulants/caffeine, claim to suppress appetite, or somehow purport to "melt fat" or "block calories." Some stimulant weight-loss supplements contain as much caffeine per capsule as three cups of coffee and have "serving sizes" of two or three caps at a time! Clever wording is usually employed to conceal the simplistic nature of these products--Zantrex-3 refers to its caffeine content as "a proprietary xanthine-based stimulant." Caffeine is part of a chemical family called methylxanthines. Other times numerous herbal ingredients or Latin names for botanicals obscure the true content of the supplements except to the most attentive consumers.

Alli, true to its claims, is different. How does it work?

First, a bit of basic biochemistry. There are three major "macronutrients" required for human nutrition--carbohydrates (sugars), lipids (fats), and proteins. All of these are absorbed through the intestine whenever you eat. Macronutrients are then delivered to the liver or various cells of the body that can use them. Carbohydrates are easy; the body breaks them down into smaller units and uses them to produce ATP, a small molecule that is the primary source of energy for the body at the cellular level.

Proteins and fats cannot be used directly by most cells. Instead, the liver processes them into more readily useful forms. Some proteins can be converted into glucose, the most basic (and preferred) form of fuel for body systems, especially neurons. Fat metabolism is more complicated and involves many steps that ultimately culminate in the release of free fatty acids; these are also usable as fuel by many body systems.

If you eat too much of anything, be it proteins, carbohydrates, or fats, the body is remarkably efficient at storing the excess energy produced. The most energy-dense form of stored energy is fat; fats produce the most energy (in calories) per gram. This fat winds up getting stored throughout the body as a reserve for times when food sources are scarce. Each pound of fat on your body represents a total stored reserve of 3,500 calories. Yum!

I've heard it mistakenly stated that you "can't get fat" eating a high-protein diet because "carbs make you fat" or, more obviously, "fat makes you fat," but this is completely false. Your body can (and will) make fat out of anything the liver can get its...um...lobes on.

What does this have to do with Alli?

Alli is not actually absorbed into the bloodstream. Instead, it floats around in the intestines and binds to fat molecules, preventing those from being absorbed. If your body doesn't absorb the fat molecules, it can't process them--in a sense, it's like you never ate them in the first place. Alli binds an average of 25% of consumed dietary fats, potentially reducing caloric intake from a fatty meal significantly.

Problem: Alli is not magic. It cannot break the laws of physics and destroy matter (and I suspect converting fats to energy in your intestine would have odd effects, were it possible). If you don't absorb the fats, they still have to go somewhere. Since they're already 3/4 of the way through your digestive tract, and getting the whole system to flow in reverse is both very unpleasant and very difficult, I'll let you think about it on your own for a second.

A funny aside: The makers of Alli recommend that you not wear light-colored pants while taking it.

I personally like to think of Alli as "negative reinforcement." Operant conditioning is basic psychology. Continuously eat fatty meals on Alli and you're going to suffer chronically oily stools. You're either going to learn to control your dietary fat intake or you're going to throw away your Alli.

This isn't to say that Alli is bad. As part of a comprehensive diet and exercise plan, it will help you lose more weight, even if it's only a few extra pounds. But the reason Alli can get FDA approval, aside from the fact that it's been subjected to more rigorous clinical trials, is that Alli doesn't claim to be magic. "Eat all you want and still lose weight!" "Melt fat away while you sleep!" Due to loose regulations, dietary supplement manufacturers make these kinds of claims all the time. But the makers of Alli had to be realistic about the potential benefits of their drug to get it approved. This isn't a bad thing. It's what we should expect from all drug and supplement manufacturers--indeed, it's what should be legally required.

Anyway. Now Europeans can experience the thrill of Alli without a doctor's prescription!

...just remember to wear dark pants.

Tagged, I'm "It"

2008-10-27T20:02:00.003-04:00

It would appear that I have been tagged with some infectious, self-propagating idea by Abel Pharmboy.

Well, I've only got five exams this week. Why not take a few minutes to answer some simple questions?

Here are the rules for the game.

1. Link to the person who tagged you.
2. Post the rules on your blog.
3. Write six random things about yourself.
4. Tag six people at the end of your post and link to them.
5. Let each person know they've been tagged and leave a comment on their blog.
6. Let the tagger know when your entry is up.

One and two are done. Six random things? You'll have to settle for six pseudorandom things since I don't feel like making a list of personal traits with more than six elements and generating random numbers to determine which things to include. Yes, settle for pseudorandomness. Settle...and suffer!

1. If you ever need to bribe me with something, I suggest a Japanese dinner. I can't get enough salmon sushi, ever, and will continue to eat the stuff until I explode. Please stop me before then so that the restaurant staff doesn't have to clean up N.B. bits.

2. My university was not my first choice school; my actual first choice was Duke University, which, in retrospect, would've been a terrible idea. Duke has no pharmacy program, so I would've needed to transfer after two years. My reasons for wanting attend Duke despite its lack of a pharmacy program? Like so many other messes guys get into, it was because of a girl. Not the most rational motivation.

3. Over the past four years I have transformed from passionately foofy-doctrineless liberal Christian to skeptic and atheist. My conversion to skepticism is actually a result of my studies of alternative medicine. I was first exposed to altmed two years ago when I inadvertently wound up at the Quackwatch website while doing a research project. Thorough investigation of the subject really improved me as a scientist; I would say that before poking into the innards of altmed that I wasn't thinking like a scientist.

Of course, skepticism in medicine led to me applying skepticism to other areas, and when I was exposed to atheism as "skepticism of religious claims" instead of "disbelief in god--as much a matter of faith as any religion" it hit me that there was no other choice than to turn the skeptical eye in the direction of my religious beliefs. They were predictably destroyed once suitably scrutinized.

4. I own a cat. True to family tradition, I didn't get the cat at a pet store, nor did I adopt her from an animal shelter; I simply picked her up off the street as a kitten (roughly 6-8 months old, by the vet's estimation). After pulling onto my street and nearly hitting the poor thing with my car I stepped out of the driver's side door and there was a tuxedo-print cat mewing at me. I did what any soft-hearted but clueless animal-lover would do and took her inside for a saucer of milk (and, when that seemed insufficient, a can of solid white albacore tuna)--all this despite the fact that my lease specifically prohibited pets. I spent the next two hours thinking "what do I do with this animal now?" until I picked my girlfriend up from the airport and informed her that we needed to stop for cat food. She'd owned cats; I hadn't.

5. I used to live in Dayton, Ohio, the so-called "birthplace of aviation" as it is home to the Wright Brothers.

6. I was a Boy Scout as a teen, but I never achieved a rank higher than First Class. I was the first member of my troop to earn a climbing merit badge; I didn't care about promotions or decorations, I just wanted to go camping. I still can't reliably tie any knots.

Tag six, you're it! Go to!

Cobalt at Secher Nbiw
James McGrath at Exploring Our Matrix
Bad of the Bad Idea Blog
The Bronze Dog of The Bronze Blog
Dana of En Tequila es Verdad
and Greta Christina of the aptly-named Greta Christina's Blog!

But Think of the CHILDREN!

2008-10-21T12:55:00.003-04:00

You ought to recognize that line as a classic refrain of those in a state of "moral panic."

According to a recently released study, 3% of all children and adolescents in the United States go without health insurance at some point in a given year:

That translates into almost 3 million U.S. children with no medical care at all and no access to prescription drugs over a full year. Slightly more than half of that number qualify for public coverage but aren't enrolled.

Overall, more than 9 million U.S. children are uninsured; some 18 million have a coverage gap at one time or another, according to the study.

But, surprisingly, this includes kids whose parents have coverage:

The authors of the first study looked at data from 2002 to 2005 on children and adolescents under the age of 19 living with at least one parent. The study included more than 39,000 participants.

Their analysis found that 3.3 percent of children and adolescents were uninsured, even though they had at least one insured parent. (emphasis mine)

What about demographic information?

Uninsured children and adolescents were 58 percent more likely to be Hispanic than white non-Hispanic; had double the odds of being from a low-income versus a high-income family; were 48 percent more likely to be from a middle-income rather than high-income family; and twice as likely to come from a single-parent home than a home with two married parents.

...children whose parents had less than a high school education were 44 percent more likely to be uninsured; they were also 64 percent less likely to be insured if their parents had public coverage rather than being privately insured.

None of this should be a surprise. Poor kids don't have adequate health care coverage. Middle-class kids are less likely to be insured than kids from richer families; kids whose parents make between $38k and $72k a year are just as likely to be uninsured as their poorer counterparts. Kids with parents who have limited education are less likely to be insured, probably because the parents are less likely to have jobs that offer comprehensive family healthcare plans.

Why haven't we passed legislature to provide all children with health care coverage? Remember, the people who typically vote against candidates daring to propose universal health care are also the people who are most opposed to family planning.

"But N.B.," say some members of the audience, "the article says that over half the kids involved qualify for public assistance but aren't signed up. That's the fault of parents, not the government."

You're right. But not providing health care for children is sheer negligence, and we punish people for child neglect already. The definition of child neglect is "any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation." It is considered neglect to fail to provide for a child's basic needs, and medical care is included among them.

About half of U.S. children without health insurance had to go without medical care or prescription medications while they were uninsured, said researchers from the University of Rochester Medical Center. Even more children went without preventive care, including receiving necessary vaccinations.

If you don't see why this is a problem, you're part of it. And if you don't see why there need to be laws mandating health coverage for children (and adequate government assistance for those who need it), you're still part of the problem. Until there are laws mandating health care coverage for all children, we're losing a battle. There are kids out there who don't get treatment for the most basic illnesses because they lack health care coverage. Maybe one of them is yours.

"Children are like flowers," they say. "You can never have too many."

If you aren't watering your garden and your flowers are dying, maybe you should rethink that assertion.

So...please! Think of the children!

Five "Myths" about Socialized Health Care

2008-10-10T13:19:00.002-04:00

A friend of mine and I were having a discussion about "socialized medicine" the other night. After a lot of verbal parrying and thrusting we concluded at about 3:30 AM. When I woke up, I found that he had left me a message--a link to an article called "five myths about socialized health care." Here's the article. It's written by a "John Goodman."

Here's what I think about each of Goodman's "myths" and his ultimate conclusion.

Myth: "Socialized medicine gives you a right to health care."

Goodman argues that socialized medicine does not REALLY give you a right to care. In Canada, he claims, you don't have a right to heart surgery. You don't even have a right to a place in line.

In a sense, Goodman is correct. Just because the government provides single-payor insurance doese not mean that all people have the right to care automatically. That's why single-payor insurance/health care coverage is necessary but not sufficient. We need both single-payor health care AND a government declaration or law stating that citizens have a right to health care.

This argument is fallacious because it has inverted cause and effect. People aren't saying they want socialized medicine because it gives them a right to care. People are simply asserting that they have a right to care. People don't have a right to care under the current "free market" system, either.

Goodman claims that the market provides a means for people who need care more to get it--by paying more for it. He asserts that patients "waiting for care" in socialized systems are suffering. This is completely ridiculous. Hospitals in single-payor systems rank patients based on priority. The patients who are in most urgent need of care get it first. Care costs money; what Goodman is saying is that someone who really, really needs to get to "the front of the line" will magically produce as much money as it takes to get there. Where does this model account for people who really, really need to get to the front of the line but have no money for care?

Furthermore, many people are already sitting around and suffering because they can't afford medical care. Right now we are rationing care based on people's ability to pay rather than the severity of their illness. From a medical perspective, this makes absolutely no sense. You should treat the sickest patients first, not the wealthiest patients.

Myth: "Socialized medicine gives people higher-quality care."

Goodman claims that patients in Canada and the UK get worse care based on the number of patients in chronic renal failure who get dialysis or the number of patients who get coronary artery bypass surgeries. He also asserts that British doctors spend less time with their patients than American doctors.

In one study done in America (Ohio to be precise) physicians spent an average of 17.5 minutes with each patient. And it's true that physicians in Britain spent, on average, just under 10 minutes. But Goodman is exaggerating when he says that the physician barely has time to take the patient's temperature. Routine examination tasks like checking temperature and blood pressure are now relegated to nurses; doctors almost never do these things themselves.

If a patient is complaining of "coughing up yellow gunk" and "sinus congestion" and similar symptoms it generally takes about five minutes for the physician to listen to the patient's lungs and diagnose the problem appropriately because he's seen the same presentation of symptoms ten thousand times. The mean visitation time is likely skewed downward by the fact that some illnesses honestly don't take that much time to diagnose. Medical professionals report a prevalence of 62 million cases per year for the common cold; you can't really expect them to spend 20 minutes explaining proper treatment for that sort of thing.

Dialysis and coronary bypasses are strange endpoints. Dialysis is only actually medically necessary when kidney function declines to about 10%. 485,000 patients in America are estimated to have end-stage kidney disease requring dialysis or transplant; in 2005, 341,000 patients recieved dialysis, or 70% of patients with ESRD. 17,429 kidney transplants were performed, so 3.5% of patients recieved a new kidney instead (which is better).

In 2005 there were 32,375 Canadians requiring renal replacement therapy. Of these, 19,721 recieved dialysis, or 61%. It's true; this number is lower. But 12,654 patients recieved a functioning kidney transplant. So 33% of Canadians who needed a new kidney got one. That's TEN TIMES more people who recieved a new kidney, which is infinitely better than dialysis as far as patient quality of life and outcomes.

Also, we shouldn't brag about how many coronary artery bypass surgeries we're doing. The fact that people need bypasses means that preventative measures have failed. Ideally we'd do fewer bypasses because fewer people would need them because we provided better preventative care.

Myth: "Socialized medicine gives people more per dollar in terms of care."

Goodman claims that Americans don't get more care despite spending more money. He asserts that life expectancy is the primary measure used to judge "health care quality."

The WHO created a scale to assess health care quality in different countries based on five criteria:

-Overall level of population health
-Health inequalities (or disparities) within the population
-Overall level of health system responsiveness (a combination of patient satisfaction and how well the system acts)
-Distribution of responsiveness within the population (how well people of varying economic status find that they are served by the health system)
-Distribution of the health system's financial burden within the population (who pays the costs)

So no, no one is claiming that life expectancy is the primary criterion for evaluating health care quality.

Goodman also claims that more people who get breast cancer or prostate cancer in the US survive than those who develop these conditions in other countries.

See page 4 of this document.

It is true that the US outranks Canada and England in terms of breast cancer survival rates (in fact, it is 14% higher). But the survival rates for colorectal cancer are better in the UK and Canada. Childhood leukemia survival rates are better in Canada than the US. So are kidney transplant rates, as I already pointed out. So are liver transplant rates (about 20% higher, in fact).

Cherry-picking breast and prostate cancer is dishonest. Disease survival rates, incidences, and other statistics vary from country to country. Choosing two examples where the US outperforms other countries does not prove anything in the grand scheme of things.

Myth: "Socialized medicine gives people equal access to health care."

Goodman claims that care in countries with socialized medical programs does not really offer equal access because minorities still get less care. That's a terrible thing, but it doesn't really help his point. It isn't damning that socialized medicine isn't perfect.

Goodman then cites a survey of the elderly. According to the results, the elderly think that it is easier to get care in America, that they have shorter wait times, and that services are better.

This survey doesn't prove jack the way he's citing it. It's terribly misleading because as the author is presenting it he's basically saying "more elderly people think health care is good in America, so it is!"

I found the actual study cited--"The Elderly's Experiences with Health care in Five Nations" by Cathy Schoen et al., published May 2000. Let's see what it says.

12% of polled US elderly said it was "very difficult" to get care. 15% said the same in the UK; not a huge difference, and potentially attributable to randomness. 13% of Canadians said it was very difficult to get care--again, not terribly significant. Only 6% of Australians and 9% of New Zealanders thought it was very difficult to get care.

7% of those polled in the US said they had to wait five weeks or more for nonemergency surgery compared to 51% in the UK. So? That's the point--it's "nonemergency surgery." There's less rush to get it done. Having to wait to get an appointment to remove a mole or get a vasectomy is not a serious problem.

32% of those polled in the US rated their health care as "excellent." It is true that only 25% of those in the UK did the same, but New Zealanders had the highest rate at 39%. And again, 40% of US respondants reported "excellent care from their doctors," whereas 51% of New Zealanders did.

27% of respondants in the US described their most recent hospital stay as "excellent" compared to 39% in New Zealand.

9% of US respondants complained that their hospital stay was "too short." What in the world is this about? I think a team of medical professionals is in a better position to judge when you're well enough to go home than you are, especially since the longer you have to stay in the hospital the more it costs (both you and them).

I'm not going to go into the part of the study about prescription drugs because this study was released before Medicare Part D, and I'm sure that things have changed significantly.

As far as "younger patients preferentially getting care," which makes more sense--a liver transplant for a 30-year-old or a liver transplant for an 80-year-old? Who will ultimately benefit more?

In short, the US is somewhere in the middle of the pack. We do better than the UK and Canada on some issues but are vastly outperformed in most categories by New Zealand and Australia (and they have socialized medicine there, too). All this means is that if we institute universal health coverage we should learn from the flaws of the UK and Canadian system and emulate the good parts of systems from countries like New Zealand.

Myth: "National health insurance is an efficient way to deliver care."

Goodman says that the US health system is more efficient than other systems. He first asserts that this is true because the US has shorter hospital stays than anyone else. But he just cited a study where respondants complained that their hospital stays were "too short!"

What he says is true, to a point:

A 2006 survey says that in England the average length of stay was 6.3 days whereas in America it was 4.8 days (average of all diagnoses). One day's difference, really. That's not terribly significant in the long run. And hospital length of stay is not really an appropriate sole measure of the efficiency of health care systems.

Goodman continually uses the UK as an example of a poorly-run socialized health care system. What he fails to take into account is that the UK is not the only country with socialized medicine, and it does not have the best system by any stretch of the imagination. Saying that Britain's health care system is socialized but not as good as ours in terms of efficiency does not prove socialized health care is bad, it proves that Britain's health care system is less efficient. We would have to compare America to more than one country. Furthermore, if the British model is bad, we can choose to do things differently than they do, taking examples from what works in other countries and throwing out whatever doesn't.

Goodman also asserts that when you incorporate the cost to hospitals and doctors that Medicare and Medicaid are inefficient, but he doesn't provide numbers to back his assertion.

Cato: "Capitalism will fix the problem."

No it won't.

The free market won't fix health care because as far as the "free market" is concerned there is no problem. People who can't pay for goods and services in a free market economy don't get them. Ability to pay is the primary rationing mechanism. This means that it's okay if people don't get medical care if they can't pay for it because you only deserve things you can pay for.

What medical insurance does is not provide you with health care--it protects you against the astronomical cost of health care. Insurance works by spreading out the risk of illness over many people. This is why it's cheaper to insure a whole company, where the risk is distributed over a larger group, than it is to buy private insurance. Health care is not going to get cheaper. As we develop more advanced technology it requires more specialized knowledge to be a doctor or nurse. This means doctors and nurses require more expertise and education. This translates into increased costs.

To quote someone else's words on the subject:

For most Americans, providing health care ought to be different from selling soap; they won't tolerate doctors acting like commissioned salesmen and investment bankers. And if that means having less market competition and more regulation in the health care system, it seems to be a trade-off they're willing to make.

The free market is fantastic for regulating the price of most goods. Grecian urns? They're worth whatever someone is willing to pay. Luxury cars? Caviar? Designer clothing? Pepsi versus Coke? Price is a good rationing factor for all of these things. If people won't buy Pepsi because it costs more than Coke, Pepsi can lower their prices and see if people change their minds.

If you have a heart attack you don't have time to comparison shop. There is no incentive for hospitals to charge less. If you need a drug and there are no other drugs on the market that are just as good because the only drug that treats your illness is too expensive for you to afford, why should drug companies lower their prices to accomodate you? Medicine isn't a luxury, it's a basic human need. It cannot be subjected to the whims of the market. It cannot be treated like "just another service." There is no other industry where "buy" or "don't buy" is literally a decision between life or death.

Seriously. Every choice you make regarding health care directly impacts your chance of survival. We as a society, if we value the lives of our members, cannot afford to permit people to make the wrong choices. This doesn't mean people should be treated against their will. It means that people who want care should be provided with the best care available.

Patients often have no idea how to choose which care is best--that's why they go to doctors. If you develop an infection, do you know which antibiotic to use to treat it? In a true "free market" scenario drug companies would advertise their antibiotics directly to consumers and let them choose which one to use. This would be an absolute disaster; patients would wind up choosing antibiotics based on who connected with them through advertising rather than which antibiotic would actually treat the infection. If you have trouble believing this, consider the fact that 75% of consumers purchase brand-name drugs when buying over-the-counter medications despite the fact that on average generics cost about 2/3 as much and are equivalent products. They choose the more expensive product even though it is no better than the cheaper product. They do this because of brand recognition, faith in companies that produce brand name drugs, misconceptions about generic drugs, and many other reasons.

I have a hard time with the idea that patients who won't buy generic acetaminophen because they like Tylenol better will choose the right therapy for complicated illnesses. Which insulin should a diabetic use? Which ACE inhibitors have the best data to prevent strokes and heart attacks? What chemotherapy regimen is best? Giving patients full control over these choices is a mistake because they typically do not have the information necessary to make them--and most people overestimate their ability to make the right choice. If I had a dollar for every time a patient told me they should be able to get antibiotics whenever they wanted (and pick the ones they should get) because "I know when I'm sick" I would be a millionaire.

And that's what I think.

One More Thing to Write your Congressman About

2008-10-08T00:27:00.004-04:00

PalMD has pointed out yet another area of healthcare that is clearly lacking and potentially in need of intervention.

In order to know how much short-acting insulin to take, a diabetic has to insert a test strip into their glucometer, prick their finger with a small needle, and touch the drop of blood to the test strip. This is usually done (at least) on waking, before every meal, and at bedtime---at least four times per day. Thankfully, blood glucose monitors are quite inexpensive and last a long time. Test strips, however, are expensive and disposable. How expensive? Depending on the brand of meter being used, and how many times you need to test, $30-$200 per month. These strips are usually not covered by insurance.

To give a comparison, good medical treatment for coronary heart disease, which usually requires about four medications, costs around $16/month. Older forms of insulin are also rather inexpensive (but the newer ones are costly). Without insulin, diabetics die---fast. Without test strips, diabetics don't know how much insulin to use.

He's absolutely right--and this is an absurd situation. Why don't insurance companies generally pay for something that is at least as necessary as insulin itself?

So...do something about it! Write, using this link. Or perhaps this one. Do both. The first is for the House and the second the Senate.

Don't know what to say? Try starting with what Pal suggested:

Diabetes is a serious disease affecting more than 20 million Americans. Part of the treatment of diabetes is the regular testing of blood glucose levels. In order to do this, diabetics must purchase glucometer test strips, which cost around a dollar a piece, and are usually not covered by insurance. For diabetics, especially those who have financial difficulties, the cost of test strips, which can be up to hundreds of dollars per month, makes diabetic treatment impossible.

I respectfully request that you look into potential solutions for this very serious problem, and bring this to the attention of your colleagues.

Sincerely...

Selected Conversation of the Evening

2008-10-07T22:07:00.004-04:00

From tonight's work shift. This phone call left me thinking.

"Hello, thank you for calling CorpoPharmacy, this is N.B., how can I help you?"

[shrill old woman's voice] "What's the name of that disease that's going around, it's killing lots of people and everyone is getting it?"

"Um...I'm...what?"

"You know! It's that disease, everyone has it..."

"Do you...er..."

"Why can't you just tell me what it is!?"

"Ma'am, you're being very vague. I don't actually know what you're asking."

"Everyone's getting it!"

"...do you have some idea as to what causes it?"

"NO! Nobody knows what causes it!"

"Er, no, I meant...how does it spread? Animal bites..."

[she cuts me off] "NO! You get it, it's spreading, it affects your brain, and you forget things!"

"...Alzheimer's?"

"YES!" *click*

Generics and Allergies Redux

2008-10-06T14:51:00.002-04:00

I've covered generic drugs and their supposed inferiority to brand-name drugs before. But something came up at work the other day that made me want to take a second look at the topic.

Scenario: Male patient, age I forget, military (so he has Tricare insurance, which pays for everything except for the things that it doesn't). A middle-aged woman is driving him around and apparently in charge of his care (wife? mother? again, I forget the guy's age).

Four new prescriptions. Metoprolol XL (beta-blocker), raniditine (antacid), warfarin (Coumadin, anticoagulant/"blood thinner"), furosemide (diuretic/fluid mobilizer). All new meds for him. I guessed post-heart attack or maybe heart failure, but didn't actually ask what was wrong.

Doctor signed the Coumadin script dispense as written. Tricare won't pay for brand-name Coumadin for this patient. Other three drugs come back $0. Zero, zip, nothing, free. Coumadin comes back $55. The patient has two options: Wait for someone to call the doc tomorrow and get authorization to dispense generic or pay for the brand. For $55, I'll tell you what I'd do. He didn't; he paid the $55. Why?

"His doctor is very particular, and he has a lot of allergies, so he's going to go with the brand name. He might be allergic to one of the fillers in the generic, you know."

To the credit of the woman managing his care, she was actually pretty smart. She asked a lot of good questions and knew a thing or two about the medicines she and some of her family members were on. Best kind of patient. But here was an example of what she knew getting her in trouble, and she wouldn't be talked out of it. I had previously explained to her that it didn't matter whether he went brand or generic as long as he stuck with his choice (warfarin is a fickle mistress, and you want to be consistent).

I'd heard this line of reasoning before--once from a patient and once from a tech I used to work with. "I might be allergic to the fillers in the generic."

News flash. You might be allergic to the fillers (excipients) in the brand, too. There are probably only about two dozen different ingredients that you can put into tablets and have them still do what they're supposed to do. The brand and the generic probably differ by only one or two excipients. If you've never taken either one, you are just as likely to be allergic to a component of the brand as the generic. Generic drugs are not made with ingredients that are somehow more likely to be immunogenic.

So. Unless you know you're allergic to something (a dye, for example) and you know the brand or generic version of a particular drug contains that something there's no reason to assume you are "less likely" to be allergic to something in the brand name drug.

Another day, another victory. Generics are still the way to go, 99.999% of the time.

Retail Pharmacy: Bringing Home the Bacon

2008-10-06T11:02:00.007-04:00

I'm afraid that I must both simultaneously agree and disagree with a recent post by The Angry Pharmacist about an issue that hits fairly close to home.

Pharmacy professors wield the term "patient care" to their students like its what brings home the bacon every pay-period. Hate to break it to you kiddies, but they are full of shit.

You know what makes the store money? Filling prescriptions. Like it or leave it, filling an Rx fills your paycheck. This precious 'patient care' where you go out front and waste your time consult Mrs Smith on how to take her atenolol for the 4th time this month ends up costing the store money in the long run because you are not filling prescriptions. Spending hours with patients may make you feel warm and fuzzy, but getting off your ass and filling Rx's is what keeps your paychecks from bouncing.

As one of those ignorant pharmacy students, I'm sure my opinion is worthless, but I think that this sort of thinking is both immensely practical and startlingly backwards.

When I settled on pharmacy as a career I was 16. No one in my family was a pharmacist. No one in my family was a healthcare professional of any sort, for that matter. What initially appealed to me was medicinal chemistry. I wanted to research the next generation of drugs, develop treatments or cures for man's most devastating illnesses, and spend most of my life in a lab surrounded by bubbling beakers.

Once I actually got into heavy lab science (analytical chemistry) I decided I hated it. I made some phone calls and arranged for a summer job at a pharmacy in my hometown. After about three weeks of working there I was solid enough on all the mundanities of the job (register duty, cleaning and organization, data entry, etc.) that I was able to start dedicating my "brain time" at work to learning about drugs.

I started learning drugs in the most disorganized fashion possible, which is probably good because my mind wraps itself around trivia and traps it forever. I asked questions of the pharmacists on duty. I pulled package inserts off bottles while I worked and read eagerly. I was lucky to have preceptors that were willing to take the time to answer my inquiries and who encouraged me to continue trying to soak up as much knowledge as I could. The "big secret" that helped everything fall into place was the pharmacist who told me that drugs in the same class have similar names (like all ACE inhibitors ending in "-pril"). Suddenly I realized that I could generalize my knowledge about some specific drugs.

What was the point of that long story?

I started out thinking I wanted absolutely nothing to do with patients because I hated dealing with people and loved chemistry. Loving chemistry translated into loving drugs. I started studying drugs in a vacuum, practically absent of other knowledge about the human body. I learned about the functions of the body based on the activity of drugs, not the other way around. This is probably the most detached-from-reality way to go about the process. The people involved were irrelevant. The drugs were cool. They weren't.

Four years later I live for patient care. Not because I necessarily like patients more, although I did discover that I'm not as misanthropic as I thought. No, I live for patient care because patient care is when I'm getting the most out of the effort I've put into learning things. Not being able to do patient care would be like telling a carpenter that he needed six years of school to get licensed but that on the job all he'd be allowed to do is hold the toolbox and make sure that the boss was using the right tools.

But N.B., you're thinking, TAP didn't say patient care was unimportant or bad. He said it wasn't profitable. "Patient care" doesn't pay the bills. Dispensing prescriptions does.

I agree that somebody does need to be paying attention to whether or not a business is making money. I don't ever want to be that person. That's why I would never start my own pharmacy, although I considered it at one point (it's also business suicide in today's climate, but whatever). I want to take care of patients without being worried about whether or not I'm filling enough scripts per week to pay my overhead, and if that makes me an empty-headed pharmacy student, so be it. Because if script volume is the most important indicator of whether or not I'm doing a good job then I am not a clinician, I'm a salesman.

Modern big-box stores and corner pharmacies are taking a loss on operating their pharmacy departments. It's the honest truth. The money is made elsewhere. How else could the big-boxes justify giving away generics at $4 or select antibiotics for free? They know the pharmacy doesn't make money; the pharmacy attracts customers. The pharmacy is not making money no matter what. What you are doing by filling more scripts is not making money, it is losing less money.

TAP's opinion on this subject is that the solution is to target the PBMs, or pharmacy benefits managers, that screw pharmacists over by reimbursing them considerably less than what they deserve. A business cannot operate by selling its product at a loss, but the PBMs essentially say something like this: "Well, you collected the patient's $10 copay and you charge uninsured patients $150 for the drug? It costs you $120 to order the drug? Yeah, we'll give you $90 + $3.50 for the dispensing fee, take it or leave it." Fix the industry regulations that let the PBMs get away with robbery and we're all good.

Because I'm young and naïve, I'm too stupid to know my ideas are bad. So here's mine. Pitch out the idea that pharmacy is a business altogether. Fuck pharmacy entrepreneurship. Stop assuming that pharmacies should operate as "drug sellers" and start thinking of them as "drug providers." The old business model doesn't work anymore. No longer does Joe the Pharmacist open his own shoppe on the corner and grind powders with a mortar and pestle all day so that he can punch capsules or roll pills. Nobody sells patent medicines anymore (unless you count the altmed scammers). Pharmacy is now ruled by giants, not Joes.

We should turn pharmacy over to the ultimate giant--the Feds. No more corpo-pharma. Pharmacists become government-salaried employees. Prescription drugs (not OTCs), patient care, whatever, they all become services funded by your tax dollars, free or practically free depending on your income level. Pharmacists already counsel for free. They're already giving away their services without collecting a dime--because it's viewed as a professional responsibility. The only thing stopping them from giving away the drugs is the perception that it's necessary to make a profit because no one will keep you afloat otherwise. Currently, that's true. But it doesn't have to be.

Laugh if you want, call me a socialist (the ultimate bad word), whatever, but at least have the courtesy to tell me why you think it wouldn't work. Spain has a system sort of like this. Germany has its own version. A lot of European countries have variations on this model; even if the pharmacies aren't government-owned, public healthcare provisions cover the cost of patient care. Clearly the government is not expecting pharmacies to "operate at a loss." If it did, the pharmacies would go out of business and there would be be no more pharmacies, which is a rather self-defeating model if the purpose of having universal health coverage is to make sure people have access to care.

I know I'm committing the error of "is versus ought" here, saying all this. But that's okay. The current fight in pharmacy is trying to keep pharmacy a working "business" under the present model. We'll never win. Pharmacy is too big now for Joe pharmacist to contain its girth. The business end of pharmacy needs to be abandoned altogther in favor of a patient-focused model.

Here's the bottom line. If you operate a pharmacy (or a doctor's office, for that matter) like a business, profit must trump patients. This is contradictory to every code of medical ethics in existence. It's true, you might take some patients at a loss in "real" practice. But there still exists a conflict of interests; as long as pharmacists are concerned about keeping a roof over their heads and worried about "the bottom line" they will never be giving 100% to the patients they serve. Healthcare is a service field. It is lucrative for many people. But ideally the point of being a doctor or pharmacist is not to get rich. It is to help people--and be sufficiently compensated so that one can live comfortably during his "off hours."

Don't recoil reflexively when someone says "socialist" or "government-subsidized." Abandon the idea that individualism--i.e., capitalism--is the best solution. You can't even start your own pharmacy anymore and have it survive; claiming that starting a pharmacy is a sound business idea at this point is utterly foolish. Quit thinking about you and how you want to run your own business which is the American dream. Stop being a selfish prick and put your patients first!

And if that's not why you went into healthcare, leave. Because we don't want you here.

Thought Experiment

2008-10-03T10:07:00.001-04:00

What if more things worked like health insurance?

INT. A FIREHOUSE AT NIGHT.

DISPATCHER sits over a bank of computer terminals, nervously adjusting his headset. He reaches for a volume dial. CHIEF sits at a table in the background behind Dispatcher, nursing a cup of coffee.

DISPATCHER: Chief, we're getting a call. It's the Taylor house on 38th.

CHIEF: Mmm. That's too bad. Nice place. How's their coverage?

DISPATCHER: They don't have any, sir. Their policy was cancelled two months ago when Mr. Taylor was laid off.

CHIEF: What!? They didn't bother to get private coverage? How irresponsible can Mr. Taylor be?

DISPATCHER: Well, they said they couldn't afford the premiums. And Mr. Taylor is a smoker. You know what that does to rates. Besides, with the deductibles on the private plans, they'd have to burn down two houses before we picked up anything.

CHIEF: Yeah, you're probably right. Well, that settles it. We can't afford to respond. The risk of not receiving payment is too high. We can't operate a business like that.

DISPATCHER: Too true, sir. Actuaries are in full agreement. And the initial assessment is sound. The house is too far away from neighboring property for the fire to be contagious. It'll burn itself out without any trouble.

CHIEF: Oh, good. No worries about liability. I'll take the call. (dispatcher presses a button on the console) Mrs. Taylor? I'm sorry, but we're just going to have to let your house burn down.

MRS. TAYLOR's voice breaks in over the intercom.

MRS. TAYLOR: (clearly distressed) But...my baby is in there! You have to save my baby!

CHIEF: I'm sorry, ma'am, but we just can't help you. Why don't you call the emergency fire department? They're required by law to come help, even if you don't have coverage.

MRS. TAYLOR: But everyone's calling the emergency fire department lately! It could take them hours to get here!

CHIEF: Well, Mrs. Taylor, I'm sorry to say this, but we wouldn't have that problem if people would just be responsible and make sure they always had fire insurance. This is America, and people have to be willing to be accountable for their own bad decisions. We can't make the taxpayers bear the burden of a few careless people whose houses catch on fire. (he coughs) Especially smokers like your husband. It's just a disaster waiting to happen.

Mrs. Taylor continues to weep in the background. The Dispatcher and Chief exchange glances, shrug, and terminate the connection.

DISPATCHER: I really think that the free market has done wonders for the firefighting industry. We spend so much less time answering unnecessary calls.

CHIEF: It's like my father always said. There's nothing that can't be improved by privatization. Who wants the government interfering with our lives?

DISPATCHER: Yep. Besides, there's no "right to firefighter services" listed anywhere in the Constitution. America really has become a nation of whiners.

CHIEF: You said it. You want a cup of coffee?

DISPATCHER: Cream and two sugars, please.

Student Finds Classical Reporting on "Holistic" Medicine Still Lacking Critical Rigor

2008-10-01T09:16:00.005-04:00

The rise of "alternative medicine," if you can claim that it has risen at all, has mostly been due to word of mouth and unwarranted exposure by an uncritical press. Seeing as how CAM itself never actually changes, it should be no surprise to anyone that neither does reporting on it. We hear the same fallacies, the same appeals to authority and tradition, and the same overweighting of anecdotal evidence over and over again.

So I wasn't even a little shocked at this typical article on the common cold.

ABCNews.com asked four holistically minded doctors what they do when they feel under the weather. Their prevention and treatment advice might help you dodge or short-circuit the next bug that comes your way.

I'm not even entirely sure where to begin. "Holistically-minded doctors?" What does that even mean? Proponents are going to spout some gibberish about doctors that "treat the whole person, not just their symptoms," but let's see what these doctors recommend to "treat the whole person."

Let's start with Dr. David Rakel, MD.

There's no firm evidence that any medication or herb will prevent the common cold, said Rakel.

Hey, cool, he's actually concerned with whether or not there's evidence for the stuff he suggests!

At the first sign of symptoms, the goal is to attack the virus early because it replicates the most within the first 48 hours, pointed out Rakel. He might drink more green tea, which appears to have antiviral and antibacterial properties. And he would also drink three big glasses of orange juice to get more vitamin C...

...besides consuming more liquids, Rakel might take 20 to 30 milligrams of zinc acetate lozenges twice a day to improve his immunity. He takes zinc only for the first two or three days of a cold, when he feels it's most effective. He might add andrographis, an herb that's sometimes called "Indian echinacea." He would take 400 milligrams of this immune-stimulating herb three times a day.

That's why when it comes to his own health he takes a shotgun approach and tries everything that has ever been suggested for treating the common cold. Vitamin C, zinc, green tea (antioxidants), and "Indian echinacea," which must be better than "Western echinacea."

At least Dr. Rakel gets an annual flu shot, but he bemoans the presence of thimerosal in flu shots. I guess the fact that thimerosal-free flu shots is not important to him, or maybe he just thinks the CDC has it all wrong.

Strike one, MD's out. Who's next? Lynne Shinto, ND. You can probably guess where this is going.

She says she thinks that too much sugar can weaken immunity...when she gets a cold, her philosophy is to let it run its course. She'll turn to the usual suspects: bed rest, more fluids and chicken soup -- or because she's Japanese-American -- miso soup with shiitake mushrooms, fungi known for their immune-strengthening compounds.

Go Lynne! You strengthen that immune system! Is that the humoral or cellularly-mediated immune system? What do you mean you don't know? You're just sure it works? Well, as long as you're treating the real cause of disease instead of just addressing symptoms, like a good holistic doctor.

These approaches may make the symptoms feel better, she admits, but they likely won't make a cold go away faster.

Oops. I guess not. So you fail at both science and pseudoscience.

If Shinto's sinuses are congested, she turns to an "old naturopathic therapy" thought to stimulate the immune system. Called hydrotherapy, she might stick her bare feet in hot water for three minutes then in ice-cold water for 30 seconds, and she repeats this hot-cold sequence three times.

This is a fantastically plausible treatment for nasal congestion. Maybe the alternating peripheral vasoconstriction and vasodilation...no, this really is so implausible as to not warrant investigation.

What about another MD's perspective? Surely a second opinion is worthwhile. Dr. Kevin Barrows?

He's a big believer in meditation and has found this mind-body approach helps increase his awareness of subtle body shifts, a tip-off that he may be getting sick. For him, a sore throat is his early warning sign of a cold, his cue to start taking echinacea.

That's great, doc. I'm glad that you can recognize one of the most common symptoms of the common cold as...indicative of the common cold. But he didn't learn that in medical school. No, he figured it out through meditation! Once he determines that his chakras--er, his throat hurts--he knows it's time to start taking echinacea, the herb that a Cochrane review states "shows inconsistent benefit."

Sixteen trials including a total of 22 comparisons of Echinacea preparations and a control group (19 placebo, 2 no treatment, 1 another herbal preparation) met the inclusion criteria. All trials except one were double-blinded. The majority had reasonable to good methodological quality. Three comparisons investigated prevention; 19 comparisons investigated treatment of colds. A variety of different Echinacea preparations were used...

...there is some evidence that preparations based on the aerial parts of E. purpurea might be effective for the early treatment of colds in adults but the results are not fully consistent.

I know that whenever I have a problem, I'm willing to rush out and spend money on things that "might work."

Outside of a mental health context, I know that if I ever had a doctor who suggested "meditation" as a serious method for identifying or treating any illness I'd pull up my pants and walk out the door. Three doctors I'd never want to visit--assuming that their beliefs are being accurately portrayed in this article. Well, what about Dr. David Leopold, our fourth contestant?

At the first sign of a cold, Leopold treats his symptoms extremely aggressively. His goal is to support his immune system so that it helps clear the virus and slows down the spread of symptoms.

He takes zinc gluconate lozenges, drinks plenty of herbal tea and also uses a liquid tincture of echinacea. Despite research that questioned the herbs' benefits, "I'm convinced that most of the well-done studies of echinacea suggest it seems to be effective for reducing the severity and duration of a cold."

Just what I need, a doctor who flunked both statistics and immunology. No thanks.

The thing is, I'm not entirely sure that the blame is entirely on the doctors being quoted here. Now, granted, I don't think that their words (or positions) are being fabricated; I'm sure that, when interviewed about their "holistic medicine" use, all of these doctors (and the naturopath) volunteered honest information.

But here's the problem. This "sound-bite medicine" doesn't actually leave room for--or invite--serious discussion of anything beyond "some doctor said you should try this." And, in the interest of "unbiased journalism," the reporter behind this story didn't bother to fact-check any of the claims made by the doctors. After all, they're just harmless claims; the article isn't about "what is good medicine" but rather opts to provide some opinions by licensed medical practitioners.

Unfortunately, this approach is seriously misguided. Most people think of physicians of all stripes as having a good, solid understanding of medicine, and this implicit trust that doctors know what they're talking about is crucial. If patients think doctors are idiots, why would they ever solicit one for an opinion? The drawback to this is that off-the-cuff "opinions" about vitamin C, echinacea, or other various treatments that don't stand up as effective under serious scrutiny reinforce the misconception that these treatments actually work. Just try telling a patient whose doctor takes vitamin C that vitamin C doesn't treat or prevent colds. "If it doesn't work, why does my doctor do it?" What surprised me about this article is that it didn't even contain the "token skeptic" interview, but then, the article is subtitled "what alternative medicine experts do when they get sick."

Physicians who succumb to non-evidence-based thinking do more than harm themselves. They drag down patients with them, even patients they'll never meet, because their endorsement of unproven remedies assures that these treatments will never die out despite the immense evidence against their efficacy. As long as there are doctors promoting these remedies, no amount of double-blinded, well-controlled, properly randomized research is going to convince the public that they aren't effective--because their doctors, expected to be the gatekeepers of knowledge, are ignoring it.

But Doctor, I NEED Antibiotics!

2008-09-26T11:51:00.002-04:00

How often do you go to the doctor? What prompts you to seek care?

For many people, the answer to that question is "at least once a year" and the reason is upper respiratory tract infection (URTI). Because of the amount of time and effort involved in isolating precisely what is causing an upper respiratory tract infection, doctors quite frequently prescribe unneeded antibiotics:

Various bacterial respiratory infections were diagnosed during 6.5% of physician office visits in 1999. One or more antibiotics were prescribed during 51.0% of those visits. The probabilities of resistance to the most frequently prescribed antibiotics varied from 20% to 40% and showed a weak positive correlation with the frequencies of antibiotic prescriptions.

It is a well-established fact that a huge percentage of antibiotic prescriptions are dispensed for conditions where they will have no effect, such as the common cold, simply because doctors feel that they have some obligation to write patients a prescription--or because the patients pressure the doctor and insist that they need an antibiotic.

But statistics released in this month's Pharmacist's Letter make the issue very clear. Overtreating with antibiotics does more harm than good.

There's only a 1 in 4000 chance that an antibiotic will help most acute upper respiratory infections.

But there's a 1 in 4 chance of diarrhea...a 1 in 50 chance of a skin reaction...and a 1 in 1000 chance it'll cause an ER visit.

...antibiotics [overuse] can also lead to more resistant infections that are harder to treat.

Now, as always, I encourage readers who believe that they might be suffering from any illness to consult their physicians. But think about those numbers for a second. There's only a 0.025% chance that it's going to do you any good to beg your doctor for an antibiotic prescription. The odds that you will wind up in the ER because of a bad antibiotic reaction are higher than the odds that the antibiotic is going to do you any good.

This does not mean that you should avoid antibiotics at all costs, believing that the risks always outweigh the benefits, because that is patently untrue. Keep in mind that these numbers only pertain to (generally non life-threatening) respiratory infections. What this really mean is that you should ask your doctor to be straight with you, especially if you are going to the doctor because you're coughing up phlegm or have a stuffy head. "Do you really think I need an antibiotic?" Make it very clear that you will take no for an answer if it is that physician's professional opinion that you don't need one. They didn't go to school for nothing.

Adding to the Growing List

2008-09-23T10:28:00.001-04:00

Epididymal Superinfection needs to be the name of a band.

Like Decaf Coffee, but More Dishonesty

2008-09-22T10:13:00.004-04:00

I got a kick out of this article about a "new" dietary supplement that supposedly contains the FDA-banned stimulant ephedra while still being legal through various loopholes:

Garza, a bodybuilder who nearly won the Mr. USA competition in 2004, said XP2G is manufactured for his store by a private lab.

He said his pills are made from the same plants used to make traditional ephedra products but lack the ephedrine alkaloid chemicals named in the bans.

Garza said because XP2G lacks those particular chemicals, it does not present the same risk of side effects as traditional ephedra products, and it is not in violation of the bans.

Hmm. So it contains "ephedra" but it doesn't contain ephedra. Do you follow?

Ephedra is actually the name for a genus of plants. Extracts from the Ephedra sinica plant, known in Chinese medicine as ma huang, contain the stimulants ephedrine and pseudoephedrine (yes, the same stuff that's in Sudafed). The popularity of ephedra stems from its so-called "thermogenic" properties--it increases heart rate and blood pressure and raises blood sugar by stimulating the sympathetic nervous system. Most people know the sympathetic nervous system as the system responsible for the "fight-or-flight" response. Essentially, ephedrine acts on the same cellular receptors that epinephrine does. Epinephrine, if you aren't aware, is the same thing as adrenaline; they're just different names for the same chemical.

So what Garza is claiming that his proprietary formula contains parts from ephedra--the plant--but not the alkaloid stimulants that make ephedra "worth" adding to diet pills in the first place.

Why would you do this? Well, because, as I've previously stated, most people don't read anything beyond the front of the bottle when they're buying drugs or supplements. By being able to put "new and improved! Totally contains ephedra!" on the packaging, Garza will sell more product, especially to consumers who liked the old ephedra products that are now subject to FDA ban. What those consumers probably won't realize is that they're being scammed even worse than they were before; the manufacturer is using some loophole to claim the formulation contains ephedra when it doesn't contain the chemicals that make ephedra desirable. It's a bit like selling "coffee" to caffine junkies on the basis that your product "contains real coffee extracts!" without letting on that your product is actually decaf.

More troubling is the fact that Garza may, as they say in France, be totally full of merde:

University of Maryland professor Dr. Fermin Barrueto said legal ephedra is only a marketing gimmick. He said the only way to remove banned chemicals from ephedra is through a complicated extraction process that manufacturers are unlikely to perform.

Which means one of two things: The manufacturer is lying about including ephedra (and not including it, but listing it on the label anyway), or the manufacturer is lying about lying about including ephedra (including it despite it containing the banned alkaloids).

As they said in Smash TV: Big money! Big prizes! I love it!

It's Ozone Action Day: Don't Use Your Inhaler

2008-09-22T09:48:00.003-04:00

Do you remember the CFC reduction efforts that went into effect in the latter half of the 20th century? CFCs, or chlorofluorocarbons, are a class of compounds that were traditionally used as refrigerants, solvents, or propellants in aerosol spray cans. When scientists determined that CFCs were contributing to the hole in the ozone layer. CFCs participate in a reaction with ozone where they act as a catalyst--i.e., they are not used up--that breaks ozone down into oxygen gas. Because individual CFC molecules are not used up in the reaction, a single CFC molecule may continue to break down thousands of ozone molecules over its lifetime.

What does this have to do with inhalers? By the end of 2008, CFC-containing inhalers will no longer be sold.

Traditional inhalers used to treat respiratory diseases like asthma used CFC-based propellants to deliver an aerosolized spray of medication directly to the lungs. But the time has come to phase out the old inhalers and replace them with new, more environmentally-friendly alternatives. The replacements, HFA inhalers, are just as effective as the old standbys without causing damage to the ozone layer or contributing to greenhouse gas production. The switch is a good thing, on the whole.

For once, Pharma is releasing a bunch of variations on their old products that aren't just a scam to extend their patents. They're actually doing something to help the environment. Y'know, aside from the fact that they're doing so because of Federal mandate.

There are a few minor issues that must be addressed. The new inhalers are just as good as the old ones, but FDA regulations consider them to be different, non-equivalent drug formulations. This means that you can't simply switch back and forth from CFC to HFA--in most states, the physician who writes the prescription must specify that the inhaler to be dispensed is an HFA inhaler. HFA inhalers are also going to cost slightly more--about $50 versus $30 for the old inhalers. But many manufacturers are distributing coupons that might help reduce costs for patients making the switch.

So if you use an inhaler, be prepared--you're going to have to switch, and soon. But the sooner the better, really. With every puff you're taking on an HFA inhaler instead of a CFC inhaler, you're contributing to the efforts to repair the ozone layer. That's like saving the world, one inhalation at at time.

New and Improved! Now With Even MORE Sodium!

2008-09-21T22:56:00.003-04:00

Er, wait a minute, I'm not advertising Grandma Georgia's Lard-o-hardtack, I'm throwing Mike the Mad Biologist another set of major props.

There's just no way I could've said it better myself. Mike is nailing this healthcare thing lately.

...the key point is this: people don't want exciting 'health insurance products', they want adequate care when they are sick. Also, how are we supposed to choose the 'right' healthcare...

...none of us have any way to evaluate if the insurance we have picked will provide the healthcare we need if something disastrous (or even mildly annoying) strikes. I have no idea if something bad happens (and there are many kinds of 'somethings bad') whether my plan will provide the healthcare I need. Would I have access to the specialists I might require? Which treatments would be covered, and for how long?

Tonight, I raise my scotch glass to you, Mike, for a succinct and elegant explanation of everything that's wrong with McCain's vision of healthcare.

Also, Chuck Dupree, a commentor on Paul Krugman's blog, has hit the nail on the head and driven it through the board with one swift stroke:

Add me to the list of those who can’t figure out why we’re talking about insurance. I don’t want insurance. I want health care, and I don’t see why insurance companies should be involved.

Analogy!

2008-09-21T21:27:00.002-04:00

St. John's wort is to pharmacists what garlic is to vampires. It is the most evil herb ever conceived.

I swear that if you hung a sprig of the plant somewhere you could probably repel all the pharmacists within fifty feet. Keep this in mind if for some reason you ever need to keep pharmacists from approaching you.

Caveat Emptor: Drugs and the Free Market

2008-09-19T11:42:00.006-04:00

First reported (within my circle of sources and reading material) by PalMD of denialism blog, the FDA is cracking down on the sale of many unapproved "cancer cures" being sold online and elsewhere. This, in itself, is excellent.

It is also a fantastic example why trusting the free market to solve all problems is a completely bogus idea.

I always come back to healthcare whenever I want to talk about the free market. This is partly because healthcare is what I know; I am much more capable of talking about the prices of drugs (in particular) and medical services than I am talking about the prices of various other products because I'm surrounded by them. But, more importantly, the healthcare "market" is a spectacular example of an area where "natural market forces" are completely insufficient regulation.

The short answer for why this is is that the costs of healthcare services are not always clear up front, so there's no way to "comparison shop." You usually get treated and worry about how much it will cost later, especially in an emergency situation. The capitalist model of self-regulation requires consumers to be able to discern the cost of services in order for it to make any sense. How can you be an informed consumer if you can't evaluate the cost or the utility (worth) of goods?

Sure, this is true on some massive scale when we talk about hospital stays and surgeries, but the problem with those is that the only consumers who actually know what they cost are already bankrupt because of them (everyone else is insulated from the scary truth of the real costs thanks to insurance companies). But those are the big-ticket items of the healthcare world. And you might argue that in some cases that they're often essential to the point where price is no object, because most people would rather pay any amount of money than die. (They might regret this decision later when they're being suffocated by hospital bills, but few rational people are going to say "nah, let me die, saving my life will cost too much.")

So let's talk about small out-of-pocket expenses of non-urgent matters.

Buying drugs is, in many cases, like buying any other good. There exists genuine competition in the market, especially when we're talking about non-prescription items. Should I buy Alavert or Claritin? Benadryl or the "store brand?" Which pain reliever do I choose? The fact of the matter is that 99.9% of the time all of these goods are equal. It doesn't matter, from a medical perspective, whether you buy Claritin or Alavert. They're the same drug. The only reason consumers might prefer one over the other is because of advertising and brand recognition--this is a "Coke or Pepsi" scenario.

Most consumers know that Coke and Pepsi are equivalent products (more or less). Sure, they might have a preference for one over the other, and that preference might even stand up to blind taste-tests. But how many consumers really know that the "store brand" is as good as the brand name when it comes to drugs?

If marketing research is any indication, the answer is not many. In 2005, generic versions of OTC drugs made up only 23.4% of the market share. Conversely, generic prescription drugs made up over 75% of the market share. Hmm. Why might this be?

When filling a prescription, most pharmacies will automatically substitute the generic if one is available as long as the physician has indicated that such a substitution is acceptable. Some states (Massachusetts, for example) actually mandate substitution unless the physician indicates otherwise. It's easy to see why generic prescription drugs predominate the market. Many commonly prescribed drugs are more or less only available as generics; the brand names are no longer made or no longer carried by pharmacies (how many people really care about getting brand name Amoxil?). I think it is safe to say that one major reason generic drugs predominate in the prescription drug market is that patients are not actively involved in the brand versus generic decision. They are leaving the decision to someone who is more educated about the product they are buying. The doctor and the pharmacist both know (and will reassure the patient if necessary) that the generic is just as good as the brand for a fraction of the cost.

Letting your pharmacist substitute a generic to save you money is kind of like getting insider information on stocks or letting your broker decide where to invest your money. You're not stupid for consulting your broker. You're smart. You're using your broker's expertise to your advantage. He probably knows a lot more about the stock market than you do, and you will make more money if you let him help you.

There's also the fact that the price difference between brand and generic in the prescription drug market is pretty large. Consider lisinopril, a drug used to lower blood pressure, prevent recurrent strokes, and protect the kidneys of diabetics. Generic lisinopril costs about 50 cents a tablet. The branded product costs twice as much. Cholesterol-lowering simvastatin's (Zocor) generic is about $2 per dose. The brand is about $5. Does it really make sense to pay twice as much for something if you don't have to? Of course not. Consumers aren't stupid.

The short story is that about 75% of consumers, given what amounts to "expert advice," will pick the cheaper prescription drug product. So why do only 25% of consumers pick the cheaper generic when making an OTC drug purchase?

The same reasons why they would choose a branded drug if there weren't a pharmacist between them and their prescriptions.

Brand reputation. Perception of generics as inferior products--misconceptions about quality, purity, and efficacy. Prior "bad experiences" with a generic drug. Inability to pronounce the generic drug's name (yes, I'm serious). And people are suspicious about the origins of "store brand" drugs. I'm not sure where people think they come from--they're made in the same factories and held to the same manufacturing standards as the brands.

There's limited standardization in naming generic OTC drugs. Because drug chains can't rely on brand recognition the same way ("Claritin is for allergies, I saw it on TV") most generic OTCs have very...generic...names. "Non-drowsy allergy relief." "Non-aspirin pain reliever." "Stomach acid relief." I kid you not when I say that there are probably half a dozen products on a given pharmacy shelf that have some variation on the phrase "cold symptom relief" as their only name, leaving the consumer to decide which product to purchase.

If the consumer does not first consult an "expert" (the pharmacist), they is left using the same reasoning tools that affect their decision about brand-name drugs. Anecdotally, I would say that most consumers don't know the active ingredients in their preferred OTC cocktails. They know the color of the box. They know what the product is called. And, most important to the consumer, they know what worked last time they were sick. They want that again, whatever it was, even if it's the wrong drug for the symptoms they have this time.

(Walgreens is brilliant in this regard by shoving the "Wal-" prefix in front of all their generic names. I get a lot of people who ask me for Wal-itin. I don't work for Walgreens. Our Claritin generic is obviously called something else. Many of them don't even seem to realize that Wal-itin is Walgreen's name for their Claritin generic--they think Wal-itin is its own unique drug, brewed in some secret Walgreens facility.)

The price difference between brand and generic OTC drugs seems smaller, which is another major factor. A box of 50 Tylenol costs $6.50 at Walgreens. A box of the generic costs $4.50, $2 less. Normally, when someone offers you the same product at a lower price, you take it. The generic market should be totally destroying Tylenol sales, but McNeil Consumer Healthcare still sold $129 million worth of their flagship product, "extra-strength Tylenol tablets," in 2003. That doesn't include sales of the popular Tylenol PM, Tylenol Cold, or liquid Children's Tylenol. The sum for all these product lines from 2003 is about $242 million.

Think about that for a second. Consumers spent an average of $2 more per purchase to buy products with the Tylenol brand name so frequently that McNeil made $242 million dollars. And they did it for the reasons I've already mentioned above--or perhaps others. Marketing experts spend their whole careers trying to understand and capitalize on this stuff; my understanding of it is very basic.

This isn't like buying generic foods, where you might get something you don't like as much as the brand product. The generic drug industry is tightly-regulated by the FDA. You can't sell generic drugs that are inferior to the brand names, unless your definition of "inferior" is different from the FDA's. The drugs have to work just as well.

You could argue that consumers might be buying the brands over the generics because of factors other than how well they work as drugs. Sometimes brand name drug tablets have coatings or flavorings that make them taste better than their generic counterparts. Maybe the packaging is easier to open. Some people are legitimately allergic to certain dyes or additives that might be present in the generic that aren't in the brand (but this is extremely rare). But this probably wouldn't account for 75% of consumers choosing brands over generics.

No, the short answer to why consumers choose branded products when buying OTC drugs is that they don't actually have all the knowledge necessary to make an informed purchase.

Man, that was long-winded. Let's come back to the original point of the entry.

If consumers aren't making informed decisions about whether to buy brands or generics when making OTC purchases, who the hell thinks that consumers will be able to make informed decisions about how to treat their own cancer?

I'm not talking about violating patient autonomy here. Patients should never be forced to accept treatments against their will. Patients should talk with their physicians and discuss treatment options, then choose whatever they feel is most acceptable. But it is up to the doctor--who has many more years of education on the subject--to lay out the options. If the patient believes that there is an option that the physician has not mentioned, he or she should certainly bring it up.

But when physicians say "no, I don't think that's a good idea," the answer is not to go ahead and do it anyway. By all means, ask for a second opinion. You're entitled to one. But do not decide that somehow you are more qualified than a trained oncologist to choose your own cancer treatment. You are not. Ignoring the advice of experts to pursue the beat of a different drum to your own detriment isn't individuality. It's idiocy.

This is why holding up "freedom of choice" when talking about unproven (and often highly suspect) treatments for cancer or any other disease is a bullshit move intended to distract from the real issue at hand. Your doctor telling you that herbal tea will not cure your cancer is not oppression. Shutting down salesmen who commit fraud isn't oppression, either.

But in the worldview of the champions of truly deregulated free-market medicine, the consumer is granted a delicious variety false empowerment. You have the right to choose any treatment you want--even those that don't work. And if you choose treatments that don't work instead of those that do, well, caveat emptor. May the buyer beware. All sales are final and non-refundable. The only person you have to blame for getting scammed is yourself. And this is disgusting.

So go ahead. Fight for your freedom to get ripped off. The primary characteristic of the free-market is that it's self-correcting, right? Frauds will eventually be exposed and people will stop buying their products.

But how many people should be allowed to die before we say "enough is enough?"

Abortion Issue Major Deciding Factor for Catholic Voters

2008-09-19T11:42:00.001-04:00

I realize that this is probably kind of like saying "water issue major deciding factor for fish voters," but:

Many "small-town Catholics" are opting to support McCain on the abortion issue alone. Or so they say. That can't be the whole picture:

One parishioner ruled out voting for Mr. Obama explicitly because he is black. “Are they going to make it the Black House?” Ray McCormick asked, to embarrassed hushing from a half dozen others gathered around the rectory kitchen. (Five of the six, all lifelong Democrats who supported Mrs. Clinton in the primary, said they now lean toward Mr. McCain.)

Man, you can still say things like that in public without being ostracized for being a terrible human being? We sure have made progress in America these past 50 years or so.

Many parishes distributed a voter guide, produced by an outside conservative Catholic group called Catholic Answers, which identified five “nonnegotiable” issues for faithful voters: abortion, embryonic stem-cell research, human cloning, euthanasia and same-sex marriage.

I think that's pretty stellar. It's totally acceptable to re-elect a member of a political party whose flawed policies have sent our economy down the tubes. We should definitely consider with seriousness a candidate whose health care plan is no health care plan at all. We should get behind a man who doesn't seem to realize that "clean coal" technology doesn't fix the fossil fuel reliance problem.

We should do all of these things because we care more about blastocysts than ambulatory human beings and the idea of gays having proper civil rights is just terrifying.

America the beautiful.

(H/t Mike the Mad Biologist).

Doing One's Duty

2008-09-17T11:21:00.002-04:00

Most people have heard of the Hippocratic oath. Physicians traditionally took the oath upon graduation. Some parts of the oath are less applicable today; I think a lot of people would object to swearing in the name of a bunch of Greek gods. And while some doctors may not want to perform abortions, I think that it's unlikely that anyone is going to prescribe insertion of a silicone ring as a method of doing so. You get the idea.

But did you know that there's a pharmacist's oath? And a written code of ethics?

The oath is pretty brief. But that's good. It's concise. Here's what it comes down to: You, as a pharmacist, have obligated yourself to serve people. You're going to do this by knowing lots of stuff about drugs.

Likewise, the code of ethics is pretty to the point. You're going to serve patients, and you're going to do your best to be fair about it. You're going to respect and utilize the knowledge of other professionals. And you're going to respect your patients' autonomy.

So why do so many pharmacists think that it's somehow acceptable to refuse to dispense contraceptives?

Now, what I think this guy (Koelzer) is doing is stupid. But in one sense, he's doing this the right way. He's started his own pharmacy. He is not asking businesses that he does not own to make a special exception for his religious beliefs. If people want to patronize a pharmacy that refuses to stock contraceptives, it deserves to stay open as much as a pizza parlor that won't stock non-Kosher toppings. It would be an unfair imposition to tell Koelzer that he has to shut down his pharmacy, because he has the right to run whatever kind of business he wants. It would be wrong.

Koelzer might be a good business owner. But is Koelzer a good pharmacist?

I don't think so, because he's violating the pharmacist's code of ethics. He's violating his oath. He swore to make patient care his first priority--and he isn't. Guaranteeing women control over their own reproduction is patient care. It's not some kind of luxury. Koelzer might say that if women want to control their reproduction that they should refuse sex. But that's not respecting his patient's autonomy, either. His patients in search of contraceptives have clearly decided that they would like to have sex. A lot of people who use contraceptives are married, so this isn't just about sinful, blasphemous fornicators.

So if you want contraceptives, you won't go to his pharmacy. He owns his own business. It's his right not to offer them, and it's your right to shop somewhere else.

But he's still a bad pharmacist.

ScienceDebate '08

2008-09-15T19:13:00.006-04:00

McCain responds to ScienceDebate 2008. Obama answered the questions a while ago; you can also read a side-by-side comparison.

I've decided to summarize each question and the candidate's responses in addition to providing my own thoughts on their responses.

1: Innovation. How will each candidate encourage innovation in science and technology?

Obama: Service scholarship program intended to pay the costs of college for students committed to teaching in high-need areas after graduation. Increase National Science Foundation graduate fellowships. Provide all Americans with broadband internet. Make R&D tax credits for businesses permanent.

McCain: Increase capital by lowering taxes, ideally broadening the infrastructure for technological development. Appoint a Science and Technology advisor to the White House to increase scientific integrity of policies. Eliminate earmarks and allocate some of the money to sci-tech investments, including funds for emerging fields (biotech, nanotech, etc). Reform science and math education. Create employment in rural areas with technology. Meet with academics and business leaders to develop a global agenda.

Pretty much what you would expect from party politics. Obama is focused on getting individuals educated and encouraging them to become teachers; McCain is primarily concerned with businesses and big R&D firms.

2. Climate change. What do you think about existing measures to address global climate change; what other policies would you support?

Obama: Anthropogenic global warming is happening; US needs to decrease greenhouse gas emissions. Market-based cap-and-trade system with the goal of reducing emissions by 80% of 1990's levels by 2050. All "pollution credits" must be auctioned by the Federal government. Cooperate with UN and other countries to reduce emissions. Create Technology Transfer Program dedicated to developing green technologies.

McCain: Notes that greenhouse gas emissions threaten to alter climate. Proposes a cap-and-trade system. Goal is reduction of greenhouse gas levels to 60% of 1990's levels by 2050. Wants to increase penalties for violating minimum gas mileage standards by auto manufacturers. Tax credit of 10% of R&D funds to green entrepreneurs and 2 billion USD/year for the next 15 years will be spent on clean coal research. The first company to develop an emission-free automobile will recieve a $5000 tax credit per vehicle sold. Suggests offering a $300 million prize for the development of a battery that will fully supply an electric car.

McCain's cap-and-trade system has a huge hole--he wants to give away "pollution credits" instead of auctioning them, which defeats the purpose of cap-and-trade. The whole point of C-a-T is to create artificial scarcity by inventing an imaginary resource.

Consider a physical resource like oil. There is a limited amount of oil, and oil costs money, so companies want to use as little oil as they can get away with because being wasteful cuts into profits. Conversely, there is no limit to how much pollution a company can put into the air (short of some point where air quality decreases to where people start dying). What incentive is there for companies to reduce emissions, especially if it will cost them more money to do so? C-a-T creates scarcity by turning "amount of pollution you're allowed to produce" into a commodity--like oil. If you have more "pollution credits" than you need, you can sell them to other companies, much like you could sell any other commodity you accidentally bought too much of.

Suppose the government auctions off 80% of available pollution credits. How do you decide who gets the rest? If the government is going to just give them away, who gets them? Short answer: Whoever lobbies the hardest. True, you have to pay lobbyists to lobby, but the system rapidly becomes crooked. Instead of giving pollution credits to whoever is willing to pay the most, you're giving credits to whoever is most influential with congress. Since the whole point of the system is to give companies an incentive to "stay green" because they have to pay for the pollution they put into the atmosphere it should be pretty easy to see why being able to lobby for more credits destroys the purpose of C-a-T.

Obama's Technology Transfer Program is supposed to encourage the export and trade of green technologies (see page 10-11). The technologies will be ideally traded freely between developing countries to reduce global emissions. Sounds pretty good, but lacking in specific details. Then again, I'm not sure how specific you can get in an 11 page "fact sheet." I think that the idea is to provide green tech to countries like China in exchange for whatever they're able to give us in return--if nothing else, it's a gesture that says "the US cares about reducing emissions." It's pretty hard to convince developing countries to do that when we aren't.

I have mixed feelings about research prizes. They make sense from one perspective; offering a "bounty" on a particular tech development may spur people to think about the problem who previously hadn't. Sometimes research prizes even create entirely new fields. The problem is that research prizes mean that a lot of people who want to research the problem but don't have the money to start researching can't do anything, even if they have good ideas. It also punishes researchers for every failed attempt; the cost of prototypes and whatnot is ultimately subtracted from the prize money. This means that research prizes are biased in favor of preexisting entities that can afford a greater initial investment to win the prize. If a start-up business gunning for a research prize ultimately spends more money than the prize is worth getting to the desired solution, the company is going to flop and everyone who invested in it suffers a huge financial loss. If a big company spends more money than the prize is worth they can probably afford to abandon the "competition" and focus on other projects. The drug companies do this all the time, in a sense--every drug that doesn't get approved is a huge loss, but they eat it and move on, whereas a start-up that tried to do the same thing would go out of business.

Another issue is that you can't measure the value of all scientific research on whether or not it solves a problem outright. Many times science is a stepwise process; assuming that only one arbitrary endpoint is valuable is a mistake. Also, prizes for specific projects creates an artificial demand that will skew private research budgets toward solving problems that someone (i.e., the Federal government) has decided need solved. Doesn't this go against promoting innovation by "setting an agenda" instead of letting individual firms decide what to research?

3. Energy. What are your thoughts on developing economically and environmentally sustainable energy solutions?

Obama: More federal research dollars for alternative energy ($150 billion over the next ten years). Research dollars should go toward alternative fuels, energy-efficient designs, advanced energy transmission and storage tech, greenhouse gas-sequestering tech, and nuclear power. Increase fuel economy standards 4% per year. Provide loans to automotive industry to build fuel-efficient cars domestically. Increase building efficiency by (50% new buildings, 25% existing buildings). Require 10% of American energy to be derived from renewable resources by 2012 and 25% by 2025. Expand mass transit.

McCain: Reform energy economy "over time." Build 45 new nuclear reactors by 2030. Reform tax credits in favor of renewable power; existing tax credits have been "patchwork" without solving the problem. The market can decide which ideas will move us toward clean energy. Commit federal government to "green tech" agenda. Reduce greenhouse gas emissions (see point 2).

I have to give this one to Obama. His plans are more concrete by a longshot. He wants to set hard limits intended to improve efficiency and renewable energy use; McCain seems to think that the market will solve the problem. The market hasn't solved the problem; people are going to use fossil fuels freely as long as they believe the supply is large enough and they can afford them. Investment in alternative energy over the past several years has gone up, but the oil industry is still the biggest energy industry in America. We can't afford for the end of oil to be in sight before we solve the problem of what we're going to do when we run out--we have to be prepared well in advance.

Increasing nuclear power is a great idea, but there's a lot of resistance to it by people who are ultimately too stupid to realize that nuclear power is both safe and clean. Liberals are to blame for this one; NIMBY and other organizations that keep yelling "CHERNOBYL!" every time somebody mentions nuclear power have so maligned nuclear plants that nobody wants them built anywhere nearby--or at least, they don't want to know about it.

People occasionally accuse Obama of being "an empty suit," but he's thrown out some very specific suggestions for the energy problem.

As an aside, McCain claimed in one of his ads that he would support renewable energy, but at the time of airing, his energy plan didn't even mention wind, solar, or hydroelectric power. Most of his energy policies are focused on developing "clean coal" technologies--which is nice, but coal is not a renewable resource. His website now has a blurb about wind, solar, and hydro power at the end of the segment on alternative energy.

4. Education. The US is behind in math and science scores. What do we do?

Obama: We need more science/math education, even for people not in STEM careers, because an educated populace is good. Supports developing new STEM instructional materials and methods. Federal and state grants and organization will be necessary to make this work. The teaching profession needs to be elevated; too many teachers are underqualified and too many good teachers are underpaid. Need to focus on developing reading skills in children 0-5 years old. Higher education (college) should be more affordable; proposes a $4000 tax credit to pay for the cost of college.

McCain: We need to train new students, but we also need to offer re-training for displaced workers. Supported grants for digital and wireless tech for community colleges. We need more science students ("we must fill the pipeline"). Private corporations should be encouraged to sponsor math and science students. Teachers need better training; 35% of Title II funding should go to training. The other 60% of Title II funding should go to teachers who excel as bonuses to encourage good teachers. Supports a $250 million grant to expand online learning opportunities. Continues to support national organizations (NSF, NOAA, DOE, NASA).

Call me biased if you want, but I think having a science-educated populace is a good thing, and Obama apparently agrees.

I've liked the education tax credit ever since I first heard it mentioned. It makes a great deal more sense to give tax breaks to people for doing things that benefit society than it does to give them tax breaks for other things. Giving tax breaks to people for having children makes sense because children are expensive, but nobody gets a tax break for going to college. People bitch about "the welfare state," but giving tax credits for having kids doesn't solve the problem. Giving people tax breaks for getting an education (which helps reduce the overall cost of said education) helps people land higher-paying careers and actually has a chance of fixing the problem instead of patching over it. I'm not saying people shouldn't get tax breaks for having to raise dependents; I'm saying that if you're going to "reward" someone with a tax break, it makes more sense to reward people for pursuing a degree than popping out kids that they ultimately won't be able to support.

The only thing I don't like is the fact that a tax credit doesn't do jack for many students (who aren't working and therefore not paying taxes). An increased stipend or grant would ultimately make more sense.

I like McCain's idea about providing financial perks to good teachers and for teachers willing to teach math and science. I'm not sure how they would ultimately be distributed; my concern is that perks would be handed out based on student improvement of standardized test scores, which is a bad, bad, bad idea.

No matter what we do, we need to find a way to encourage more people to become teachers and a way to increase the quality of teachers in our school systems.

5. National security. Technology is a big part of national security. How should we best use it?

Obama: The space race pushed science education forward in America; bioterrorism and nuclear weapon threats should do the same. We need research for the sake of homeland security. Would like to double the Department of Defense's applied research funding and renew DARPA. The Department of Homeland Security needs to shore up defenses against bioterrorism and cyberterrorism. Reduction of our petroleum dependence (foreign oil reliance) will improve security. We must eliminate erosion of the US manufacturing base and keep defense production domestic.

McCain: We need to adequately fund the military to make sure that our homeland is secure. We need to make sure the American military retains its technological edge, so we need to advance R&D funding.

Er. McCain is always talking about how he was in the military and people are always saying that McCain's national defense plan will more or less be automatically superior to Obama's because of McCain's military record. But all he has to say on the subject of science as it relates to national security is "we need to make sure America remains awesome."
Conversely, Obama points to specific threats (cyberterrorism, biological warfare) and has some specific plans (double DoD research funding, renew DARPA). Keeping defense production domestic seems like a no-brainer; how secure can you be when someone else is building all your weapons?

6. Pandemics and biosecurity. Avian flu (for example) could be a serious threat. What should we do about this?

Obama: Bioterror is a serious threat; wants to invest $5 billion over 3 years in a Shared Security Partnership to form an international intelligence organization against terrorism. Suggests expanding US bioforensics program. Wants to invest in vaccines against potential bioterror agents and technology to trace bioweapons to their origins. Hospitals need to form collaborative networks to respond to any major health crisis. Expand local and state funding for disaster response programs. Stresses funding for drug development and distribution systems--ideally, this will create high-wage pharmaceutical industry jobs.

McCain: We don't know if H5N1 (avian flu) will cause a pandemic, but we need to address threats of bioterrorism. Favors implementation of strategies intended to contain pandemics and alleviate any crisis while still maintaining a functioning economy and community. We need to develop better analytical tools to detect and identify bioterror agents. We must also fund R&D of drugs and vaccines and make sure that we have adequate stockpiles and a response plan if an outbreak occurs.

I really wish the question hadn't been about avian flu just because there's limited evidence that H5N1 is likely to become a pandemic in humans. Oh well. Solid answers from both sides, really.

7. Genetics research. What is the right policy balance between benefits of genetic advances and their potential risks?

Obama: Genetics has raised numerous legal and ethical questions; supports Genetic Non-discrimination Act and introduced the Genomics and Personalized Medicine Act of 2007, which is intended to ensure safety and accuracy of genetic testing. Modifying plants and organisms to improve agriculture is fine as long as we make sure they won't have negative impacts on the environment. Using recombinant DNA (rDNA) to produce protein drugs or replace faulty genes is awesome, but we have to make sure it's safe and proceed cautiously.

McCain: The genetic privacy of all people is incredibly important because of the potential ethical problems involved in storing genetic information. Genetic research can help increase the productivity of agriculture; we should focus on developing higher-yielding crops and improved farming infrastructure.

I think people are panicking about the potential for genetic information way too much. I blame Hollywood. Thanks, GATTACA. The Genetic Non-Discrimination Act is a good idea, though, because the potential for "abuse of genetic information" is still there.

I'm impressed that Obama mentioned rDNA technology because that's some cutting-edge biotech. He probably has some good science advisors.

8. Stem cells. What is your position on government regulation and funding of stem cell research?

Obama: Stem cell research might find cures for several serious diseases. The federal ban on embryonic stem cell research is restricting our ability to find cures for these diseases. Hundreds of thousands of human embryos are stored in fertilization clinics that will ultimately be destroyed anyway; why shouldn't we use these embryos for research instead? Adult stem cell research is good, but embryonic stem cell research should still be pursued because of potential advantages. The National Research Council must be responsible for overseeing embryonic stem cell research to make sure it is being conducted ethically.

McCain: We should fund embryonic stem cell research with federal dollars, but we must not sacrifice our values for the sake of science. Supports adult stem cell research and amniotic fluid cell research. Opposes creation of human embryos for research purposes and voted to make use of fetal tissue created for research purposes a federal crime.

This issue annoys me because it attracts the creation of a horrible straw man: "We shouldn't fund embryonic stem cell research (ESCR) because it hasn't actually produced any cures for any diseases." Aaaaargh! Yes, it is true that no approved medical treatments have been derived from ESCR. It's true that there is no "ban" on embryonic stem cell research, so that's not the problem. There are a fair number of existing embryonic stem cell lines available for research, though not as many as scientific organizations would like.

The real problem people have with ESCR is not that it hasn't produced approved treatments--the real problem is that it violates their personal morals. Even if it had produced viable treatments, these same people would still oppose it. The statement that it hasn't somehow validates their belief. It's essentially saying "not only is ESCR immoral, it's useless, so we don't need to do it." But there's no way to know that ESCR won't eventually produce useful treatments unless we try, and there's no shortage of available embryos. In 2001 it was estimated that 110,000 frozen embryos were stored in the US; the number has only increased. Nobody has to create embryos purely for research; couples utilizing in vitro fertilization have already supplied researchers with a huge number of embryos, and many of them have explicitly wished to donate their surplus embryos for research purposes! Is it really more moral to throw them away than to use them for potentially life-saving medical research?

Saying that ESCR shouldn't be pursued because it hasn't produced viable treatments is a self-fulfilling prophecy. Handicapping researchers of embryonic stem cells is obviously going to reduce the number of ESCR-related breakthroughs.

Enough said; you can probably tell from my position on ESCR that I'm in agreement with Obama on this issue.

9. Ocean health. Scientists estimate that 75% of the world's fisheries are in decline and coral reefs are threatened. What should we do?

Obama: Oceans are important; global climate change could have negative effects on ocean ecosystems, so we should reduce greenhouse gas emission (see item 2). We should expand research on the effect of climate change on marine life. Supports US ratification of the Law of the Sea Convention, an international treaty regarding use of ocean resources. Obama likes long walks on the beach.

McCain: Oceans are awesome; state, local, and federal coordination is needed to reduce issues like invasive aquatic species and agricultural runoff. It is difficult to manage ocean ecology because so many other factors affect oceans without obviously being ocean-related. We need to research the ocean's impact on the carbon cycle, the melting of polar ice, and coastal storms. I was in the Navy, so I love oceans.

Oceans are good. They cover 72% of our planet.

Obama's concerns about ocean health tie into his concerns about global warming, so his statement is basically that his plans to reduce greenhouse emissions should also improve ocean health. Both candidates think more research is needed regarding ocean ecology; McCain makes the excellent point that things that seem to have nothing to do with the ocean affect oceans. I'd like to know what sort of solutions he has in mind for reducing agricultural runoff, for example.

10. Water. How should we address water shortages and the fact that water is a limited resource?

Obama: Prices and policies should encourage efficient water use and discourage waste. Farmers should be encouraged to shift to more water-efficient practices and potentially receive economic assistance to make the shift possible.

McCain: Water is a valuable resource that must be protected. The Department of the Interior and states should make agreements and implement technology to reduce water demand.

Water: Republicans and Democrats alike agree that we need it.

11. Space. How should we prioritize space exploration/research?

Obama: NASA should not only explore space but be involved in researching climate change, energy independence solutions, and aeronautics technology. Wants to encourage the private sector to support NASA. Believes we should re-establish the National Aeronautics and Space Council to oversee space activities.

McCain: Space activities have driven scientific discovery for the past 50 years. The Cold War is over, and this has left NASA uncertain as to what to do; however, we are heavily dependent upon satellites and other space-based assets for communication. Other countries are exploring space (Japan, India, Russia, China, Europe). The role of manned space flight goes beyond exploration; it encourages national pride. Supports funding for more space exploration and science; sponsored legislation supporting the commercial space industry. Wants to maximize the research potential of the International Space Station, maintain space infrastructure, prevent wasteful earmarks that divert potential money away from space research, and guarantee adequate investments in aeronautics.

McCain is seriously excited about space. Who knew? He's definitely got a point--the "space race" is a big part of what pushed science and engineering in the latter half of the last century, and once we'd "beaten the Russians" and been to the moon several times people seemed to get kind of burnt out on space. What they've forgotten is that NASA's technologies ultimately wound up in everybody's homes, partly because we'd spent so much money developing them. Many packaged food technologies, for example, are a product of the space race.

I'm not sure we could artificially engineer another "space race" to push technological development, but space technology has been seen as a proxy for overall technological advancement for the past fifty years or so. The whole reason we wanted to beat the Russians to the moon was that it would somehow prove American ingenuity was better than Russian ingenuity. Now China and India are launching manned space flights. The point is not to go the moon--we've been there. The point is to get people excited about technology with a big, visible symbol. The space shuttle is an excellent symbol of the modern era for that very reason.

12. Scientific integrity. Many government scientists report politics interfere with their jobs. Is it acceptable for government officials to alter or hold back scientific reports if they don't like the results? How will you balance scientific data with political and personal beliefs?

Obama: Decisions should be made based on the best available scientific evidence, not ideology. Transparency is important. I have a bunch of science advisors, including some Nobel Laureates! Plans to appoint people with strong sci-tech backgrounds and ethical qualifications to positions requiring scientific expertise. Wants to establish a Chief Technology Officer to make sure that government agencies have the right infrastructure and strengthen the role of the President's Council of Advisors on Science and Technology. Would issue an executive order requiring the release of government research publications and wants to guarantee that the results are not distorted by political biases.

McCain: The government spends lots of money on research; the public deserves to see the results. Denying facts will not solve problems; policy should be based on sound science. Wants qualified engineers and scientists to join key technical positions in his administration. Believes integrity is critical to scientific research.

I would like to quote McCain's last line verbatim:

"My own record speaks for integrity and putting the country first, not political agendas."

Um. I don't know about his opinions regarding the integrity of scientific research, but McCain has put his political agenda before his "integrity" (if he's using the word to mean the same thing that I am) on many occasions:

-He accused Obama of voting for "corporate welfare" for oil companies. He actually raised taxes on oil companies.
-He accused Obama of planning to raise taxes on the middle class when in fact tax rates would only increase for families making above $250,000 a year, among other miscellaneous lies about Obama and taxation, like the claim that small businesses would pay more taxes under Obama.
-He also grossly mischaracterized Obama's health care plan.

Politicians are notorious for being dishonest, and Obama has also stretched the truth on several occasions, but I'm not sure why McCain thinks that he can claim that he always puts the country before his political agenda when he...doesn't. He endorsed the Iraq war and reversed his position on torture to curry favor with his party and secure his presidential bid.

Anyway.

13. Research. What priority will you give research in upcoming budgets?

Obama: Federally supported research is essential and must be continued. Laments the decline in federal research dollars for the physical sciences and engineering. Would double basic science, math, and engineering research budgets over the next decade.

McCain: We must maximize the value of our research spending; has supported increases in funding for the NSF and would like to see "top scientists" decide how to utilize funding. Wants to make sure federal research dollars are allocated based on quality, not earmarks.

Obama wants to double federal funding over ten years; the Bush administration requested $137.2 billion for federal R&D funding. $50 billion of that is supposed to go to science education and modernization of research infrastructure. The remaining $86 billion finances R&D tax incentives. The linked report was updated in 2006; at the time, Bush also called for doubling federal R&D funding over the next ten years. In a sense, Obama wants to leave the existing plan intact.

McCain's budget is based on cutting earmarks, which he claims will save $100 billion. But most sources suggest that "cutting earmarks" will save less than $20 billion. If the $137.2 billion figure is accurate for federal R&D grants, that means we're going to need to come up with about $274 billion over the next ten years. Obama doesn't say where that money is going to come from (troubling), but McCain seems to think that cutting earmarks is going to cover it. This seems improbable.

There's also the fact that earmarks direct funds from executive agencies to specific topics--cutting earmarks won't cut government spending, it will just change the way the same dollars get spent. I'm not sure we're going to get sufficient R&D money from "cutting earmarks" much like I'm not convinced McCain can reduce the federal budget by $100 billion "without cutting into federal programs," especially if he plans to increase defense spending.

This might just be me, but I would rather a candidate offer no details (assuming they will come later) as opposed to offering a plan that is verifiably wrong.

14. Health. How do you see science and tech contibuting to improved health and quality of life?

Obama: Medical science has made huge steps in combating disease; he notes, specifically, advances against heart disease, stroke, cancer, AIDS, mental illness, infectious diseases, and surgical techniques that reduce hospital stays and costs. Notes that US health care spending per capita exceeds other countries but low-income groups suffer from reduced access. Believes that America's health care system is more beneficial for pharma and insurance companies than it is for citizens. Wants to increase employer-based coverage benefits, require insurance companies to cover "preventative medicine" and limit charges by insurance companies. Insurance companies would be required to cover preexisting conditions. Wants to provide tax credits to small businesses and individuals to pay for the cost of health insurance and provide coverage for all children. Would like to see the healthcare system become more efficient, continue to support research to treat diseases, and provide healthcare to all citizens.

McCain: Medical science has developed some amazing cures for illnesses. Telemedicine is an opportunity to increase health care access, especially for patients in remote areas. Insurance costs a lot and many Americans are unable to afford it; we should promote R&D and wellness to reduce costs.

I'm in the healthcare field, so I feel very close to these issues. If you forced me to pick one issue to focus on, I would say that improving the American health care system is at the top of the list.

Private insurance costs a fortune; it isn't reasonable to expect people to purchase private insurance because in the long run it doesn't save them money unless they are struck down by dire illness. My girlfriend has a private insurance plan because she doesn't get coverage through her current employer. She pays $70 a month in premiums. She has a $5000 deductible. For those who don't know what that means, it means that until she pays $5000 out of pocket in a given year, her insurance covers nothing. She is responsible for the first $5000 in health expenses. Now, I don't know what your financial situation looks like, but having $5000 in health expenses would bankrupt her right out. In other words, by the time her insurance picks up the cost, it's too little, too late. All of her standard medical needs--doctor visits if sick, annual OB/gyn appointments, prescriptions--have to come out of her own pocket. The average doctor's office visit costs about $60; the average ER visit costs $383. The last time I went to the doctor I paid $125. The national average cost for a hospital stay, depending on what sort of treatment you need, was $6525 in 1999. In 2007, that figure climbed to around $10,000.

If you make minimum wage, going to the doctor represents more than a full day's wages in cost. That's more than enough to discourage low-income families from visiting the doctor if they have to pay out of pocket--and that doesn't include the cost of medications or travel to and from the office or the lost wages from having to take off work (if it is necessary to do so, and it often is). Even if you make more than minimum wage, it's pretty clear that health care is prohibitively expensive. The median household income in the US is just over $50,000. In what universe can people be expected to afford dropping one-fifth of their yearly income on a hospital stay?

McCain's statements on health care here don't even touch the issue. Telemedicine? Being able to have your doctor examine you with a video camera instead of you having to go to his office is not going to matter if you can't afford an exam in the first place.

McCain's website has more details about his health care plans. I wonder why he didn't bother going into any of these details for ScienceDebate--I actually have reservations about critiquing his health care plan as described on his site when what I'm primarily doing is talking about ScienceDebate. But I've already done it, so let's do it. In case you're curious, here's Obama's website on his health care plans.

Anyway, McCain favors a tax credit to offset the cost of insurance; the credit would go directly toward purchasing a chosen plan, and any extra dollars will be deposited directly into a tax-free health savings account. The credit would be $2500 for individuals and $5000 for families.

Obama's health care plan involves a tax credit to small businesses equal to 50% of what those businesses spend on health care premiums for their employees. How much money is that? A report from a 2004 NY Times article states that California businesses paid $6.30 per $100 in employee payroll for employee insurance benefits.

So let's run some numbers. Suppose you run a small business with 30 employees, yourself included. You're extremely charitable and your business is doing well enough that the mean income for your employees is about equal to the national median of $50k per year. No, this doesn't mean the janitor is getting $50k; it means that the average of your employee's annual wages is $50k, which allows for a minimum-wage janitor and a high-paid CEO. The average can still come out the same. Anyway, $50k x 30 employees = $1500k. You spend 6.3% of that on providing healthcare for your employees, which is $94,500 per year. Obama wants to give your company $47,250 in tax relief every year. McCain wants to give you and each of your employees $2500 per year (you're all bachelors for some reason), which is $75,000. So McCain actually wants to give you more money.

But what will the benefits be? Obama wants everyone to be able to have coverage equivalent to the Federal Employees Health Benefits Plan (FEHBP). Here's a table showing plans available nationwide. I could get a Blue Cross/Blue Shield insurance plan for myself for $37.97/month or $90.26/month. This chart shows deductibles; I've chosen the BC/BS standard plan, which is the second row on the table. The total per person deductible is $300 per year. Once I met my deductible, an office visit would cost $15 and a hospital stay no more than $100. I would pay 25% of the cost of prescription drugs as my copay, which isn't too bad. I personally would have to spend about $150 a month on prescription drugs (and I'm only on one medication), so I would pay ~$28/month for drugs.

Let me summarize. Obama wants to give you (private citizens) the ability to purchase benefits comparable to the following:

-Premiums of $90/month for a family of four
-$300 out-of-pocket responsibility per person per year
-A copay structure where office visits cost as little as $15-20 and hospital stays run between $100-400
-A prescription drug plan where generics cost as little as $5 and even the most expensive drugs only cost you 50% of their retail value

McCain wants to give your hypothetical family of four $5000 to purchase health care. I don't think he realizes that private insurance for families cost an average of $9950 per year in 2004 and that that price is continually increasing.

I don't think I can stress that enough. If you don't get insurance through your employer and have to buy private insurance, McCain wants to give you half what your annual health insurance costs will be in the form of a tax credit. $5000 sounds fantastic until you realize that the average family will have to pay another $5000 just to get coverage. And that's just premiums. Deductibles are not included--and for privately insured patients, deductibles could easily add up to another $5000. In short, McCain's plan involves families spending as much as $10,000 per year before their health insurance pays a dime.

I've said enough on this subject.

That concludes my analysis of ScienceDebate '08. Hopefully you found it informative. We report, you decide!

A Semi-random Thought

2008-09-14T00:41:00.002-04:00

I wonder if Orac of Respectful Insolence(TM) knows that he shares his name with a commonly cited assay used by woo-meisters to promote the health benefits of their products?

Oxygen Radical Absorbance Capacity (ORAC) is a method of measuring antioxidant capacities of different foods...correlation between the high antioxidant capacity of fruits and vegetables, and the positive impact of diets high in fruits and vegetables, is believed to play an important role in the free-radical theory of aging.

Yes, We Have No Tobacco

2008-09-13T23:32:00.006-04:00

There's an old joke of sorts that goes something like this:

Why do sick people have to walk all the way to the back of the pharmacy to buy medicine when healthy people can get cigarettes in the front?

Legislature passed in San Francisco in July might make this joke completely unintelligible to the next generation. But drugstore giant Walgreens is throwing a fit.

The ban, which is scheduled to take effect Oct. 1, doesn't extend to grocery stores or big-box stores that also have pharmacies. That's why the company wants the plan stopped, said Walgreens spokeswoman Tiffani Bruce.

In short, Walgreens thinks it's unfair for Meijer, Wal-Mart, Target, and various other grocery store chains that have tacked pharmacies onto their business in recent years to continue selling cigarettes if they can't.

The reasoning here gets kind of weird. Walgreens is claiming that somehow it's more appropriate for cigarettes to be sold at pharmacies than at grocery stores because pharmacies offer a greater opportunity for patient contact with pharmacists. Pharmacists, as they continually remind us in school, are as responsible for public health as any other health care professional. The logic is apparently that a patient buying cigs at Walgreens, Rite-Aid, or CVS is more likely to have an encounter with their pharmacist during the same trip. During this encounter, the pharmacist is expected to "do the right thing" and encourage the patient to quit if given the opportunity.

Huge logical flaw: I would wager that only a small percentage of customers at my workplace who are buying cigarettes are also there to talk to a pharmacist. It's true that sometimes customers come in to pick up both meds and smokes, but the items are sold at different check-out counters, which means that a great number of cigarette purchasers never speak to a pharmacist. And even buying your smokes at the pharmacy check-out doesn't guarantee you're going to talk to a pharmacist. He or she is probably too busy making sure Mrs. Johnson isn't going to inadvertently get a lethal dose of digoxin or calling some doctor who forgot to write an actual dosage on Mr. Smith's prescription.

In other words, your chances that a pharmacist is going to swoop in like Superman and rescue you from yourself are very slim. So much for the idea that it's somehow healthier to have cigarettes in pharmacies than in grocery stores.

I don't know what message Walgreens' lawyers are trying to send, but here's how I read it: We all know cigarettes are unsafe, but if you're going to buy them, you should at least buy them somewhere where someone might try to talk you out of it. So they carry cigarettes in hopes that you will encouraged to quit buying cigarettes. What? Do they really expect us to believe that?

I think the ban sends precisely the right message. Why? It's all about public perception.

Most customers at your typical big-box store will never use its pharmacy component. The pharmacy is an afterthought; the stores were not built to be pharmacies, they simply contain pharmacies, much the way that they occasionally contain lawn and garden sections or automotive departments. The pharmacy is there to complete the one-stop-shop set. Business moves like Wal-Mart's $4 generic initiative make it pretty clear that the big-boxes don't actually expect to make a lot of money running pharmacies. The pharmacy is a way to get you to do your other shopping at their store. It is a lure, like the dangling light of an angler fish.

There's nothing inherently altruistic about today's corner drugstore, but I'd wager that there's a reason the big-boxes have had to resort to bargain-basement prices to get people to use their pharmacy services--the corner drugstore just "feels" better to the consumer. They're smaller and feel more focused. The message from the corner drugstore is that pharmacy is the purpose of their existence. The drink case, the cigarettes, and the greeting cards are for your convenience. It's more like the store is attached to the pharmacy than the pharmacy is attached to the store. (This isn't exactly true, given the history of corner drugstores in America, but we're talking about consumer perceptions, not truth.)

So if you take the cigarettes out of grocery stores, people are going to throw a bloody fit. They'll spew all kinds of vitriol about the nanny state and freedom of choice. And, to some degree or another, they'd be right. No, you don't have an inherent "right" to buy cigarettes, but cigarettes are sold, and a broad ban on cigarette sales would provoke a lot of rage. Even most non-smokers would say that the government had gone too far.

Conversely, if you take cigarettes out of drugstores, a few people are going to complain about the inconvenience--smokers, of course--but everyone else is likely to congratulate you for reinforcing the notion that the drugstore is a place where medicine and health care are the number one priorities. Can you imagine a doctor's office with a cigarette vending machine in the lobby? Nevermind the fact that cigarette vending machines have gone the way of the dinosaurs--most people would find the notion appalling these days. (This is, of course, a product of changing culture. It wasn't long ago that doctors had no problem endorsing their favorite brands, and pharmacists were no less guilty of "promoting" smoking.)

The corner drugstore isn't what it used to be. Gone are the days of pharmacists doing double duty as soda jerks. The modern pharmacy is trying to become an arm of the healthcare system, not just "a store"--and eliminating cigarette sales goes a long way toward reinforcing that idea.

Nationwide Pen Shortage Imminent

2008-09-12T11:04:00.002-04:00

As any doctor or pharmacist knows, drug reps are a great source for office supplies. I have to question how much information about their products that they disseminate, and I've mentioned in the past that occasionally reps get way, way too enthusiastic about pushing products that are honestly mediocre attempts to extend the patent life on drugs no one is using anyway. I suppose that's their job, so I can't fault them for it...too much.

But there won't be any more free stuff for listening to their sales pitches.

Starting in January, drug detailers will have a lighter load to carry when they visit physician offices. That is when new industry guidelines take effect that bar them from leaving behind drugmaker-branded pens, notepads, coffee mugs and other reminder items.

Here's the interesting bit--this is voluntary. The major drug company association, PhRMA, is adopting these new standards in hopes that they'll avoid legislation actually banning the practice. In essence, they're surendering before the battle even begins because they know that the legislature will not be kind to their pen-pushing ilk. Various bills are already in circulation, so it's probably just a matter of time; voluntary actions on the part of Pharma are unlikely to impress legislators at this rate.

Educational items are still okay, as long as the total value is less than $100. So reps can still hand out literature, books, subscriptions, patient education materials, whatever. Just no more pens and pads. I'm not sure what we're going to write on at my pharmacy now. We have a stockpile of post-its from various pharmaceutical companies, but the supply will eventually run dry. I guess we'll have to settle for store-using real post-it pads.

I think that the best part of this whole story is a statistic cited by Pharmacist's Letter. Only 16% of physicians think that drug rep gifts influence their prescribing. But 61% of physicians think that other doctors are influenced by rep gifts. Hah!

Today is an Anniversary

2008-09-11T16:00:00.003-04:00

There is simply nothing I can post today that will compare to what PalMD has already said on the subject. That noted, today is September 11th, whatever that means for you. This does not affect me particularly strongly; I think it is a good sign that people have, as a whole, moved past the tragedy. The wounds are no longer as fresh as they once were. While I don't think we should forget the WTC attacks, I think that it would be a terrible mistake to dwell on them; I prefer to look forward, not back, whenever possible.

For those who lost loved ones seven years ago, you have my sympathy. There is simply nothing else I have to say.

Bizarro Health Savings Account

2008-09-07T18:24:00.002-04:00

So the company I work for automatically lists items as "FSA eligible" if they are commonly covered by a flexible spending account for health purchases, sometimes known as an HSA. An HSA, if you're not familiar with the concept, is essentially a "bank" of money that you pay into (often with each paycheck). This money is tax-free, but you can only use it to pay for your medical expenses. Some plans allow your unspent dollars to roll-over at the end of the year, whereas others do not, leading to a last-minute spending frenzy. Most HSA plans allow you to spend the dollars you have on any health-related purchase, but there are always exceptions. As a general rule, it's safe to assume that standard over-the-counter products are probably covered, so those last-minute spending frenzies usually turn into people buying more aspirin and bandages than they are ever going to use just so that the money doesn't disappear unspent.

Anyway, at my store, both the register and the customer's receipt specifically note items that are eligible purchases; the customer can keep the receipt in the event that there is a dispute with the insurance company. This also allows the customer to just swipe their HSA card and have eligible items paid for while ineligible items remain unpaid. This saves the cashier from having to ring the items up separately if the customer wants to pay for some items that are eligible and some that are not.

There used to be an occasional problem where ineligible items would get rung up with an HSA debit card by mistake. Ultimately the consumer would get an audit from their insurance company bitching at them about trying to use their HSA to pay for bread and greeting cards. A recent update to the system actually prevents the register from accepting an HSA card for items that the register does not recognize as eligible; the cashier will get an error message saying that the customer needs to use a different form of payment.

So imagine my surprise today when Mucinex and Benadryl didn't ring up as FSA-eligible items. That was odd, and potentially noteworthy, but not that strange. It was conceivable that recent policies had changed to prohibit consumers from buying OTC items without a prescription.

Then Oscillococcinum rang up as FSA-eligible and I stared at the register screen in disbelief.

To make a long story short, "Oscillo" is a homeopathically-prepared dilution of the organs of a muscovy duck. It is a "200C" dilution, which is impressive even by homeopathic standards; the original formula has been successively diluted in a 1/100 ratio 200 times, meaning that the ultimate concentration of duck organ solution is 1 with 400 zeroes following it. This is four times the estimated number of molecules in the known universe, so the probability that the resulting solution contains any of the original "duck molecules" is basically nil unless somehow we have an entire universe filled with "Oscillo." Not that that's a problem for devoted believers in homeopathy. The preparation is touted by its manufacturer as a remedy for "the flu." You know, an illness that actually kills people from time to time.

So let's get this straight. According to the computer system at work, your insurance company is more likely to let you spend your tax-free savings on fake medicine than real medicine. In fact, the register would not let me charge a box of Benadryl to this guy's HSA because it considered the drug "an ineligible purchase."

See why I used the word "bizarro" in the post title?

Two Birds, One Stone

2008-09-05T16:19:00.005-04:00

Jack Davis, Democratic congressional candidate from New York, has some amazingly unique ideas about how to solve his city's problems:

“We have a huge unemployment problem with black youth in our cities,” Davis told the Tonawanda News recently. “Put them on buses, take them out there [to the farms] and pay them a decent wage; they will work.”

That's just BRILLIANT! Let's buy this man a Guinness! It gets better.

“If we take away the magnet of good-paying jobs from illegals, they’ll go home,” Davis said in an interview with The Buffalo News this week. “If they can’t make a good living here, they’ll go home.”

So wait. The average hourly wage of an illegal immigrant is $5.45. Oh, man! If we just stop illegals from working for less-than-minimum-wage by giving those jobs to black youth they will give up and go home! Especially if they came all the way to New York. I wonder if he can get federal money to start some cotton plantations?

Even if you agree with him on other issues, you have to wonder what planet he's living on when he starts proposing these kinds of plans.

(In case you're curious about his stance on other issues: He's not sure which presidential candidate has a better health care plan, thinks global warming is due to solar irradiation increases [I am really tired of hearing this argument], and is pro-drilling in Alaska.)

Thank You, Orac, or: A Little Knowledge

2008-09-05T13:56:00.003-04:00

This is what happens when people who know absolutely nothing about how to do science get their hands on a little bit of scientific data. An excerpt from Orac's post:

According to Mrs. Janak, less than one milligram of histidine is going to cause nausea, vomiting, and irritable bowel syndrome. Mrs. Janak needs to learn some units before she embarrasses herself by posting such burning stupid to the web. But she's just getting warmed up. She fixates on an observation that histidine is involved in the regulation of of trace minerals and concludes that getting all that histidine (remember, 0.78 mg worth, to be precise!) must somehow mess up the body's metabolism of heavy metals and cause heavy metal poisoning.

Orac, know that if I could, I would have your children. You've probably already found someone else to do that by now, assuming you want them, and I lack the essential plumbing, but the offer stands in some sort of metaphysical context.

"Pray for McCain's Death"?

2008-09-05T11:36:00.004-04:00

You know, when I started this blog I specifically told myself I didn't want to get into talking about politics except when necessary. I wanted to talk about pharmacotherapy and pharmacoeconomics and maybe the politics of medicine, but I really can't resist passing this along. Hat tip to Ed Brayton (and also compliments to PZ Myers, who also mentioned this story):

Palin is a Christian, so she ought to get elected president. Here's the "plan":

1. Vote Constitution Party. (I vote my conscience and cannot support McCain even with Palin.)

2. Hope and pray for McCain/Palin to win. (I am an idealist, but also a realist!)

3. Pray for John McCain's salvation and pray specific imprecatory prayers if he fails to pro-actively defend the sanctity of human life. (Google The Forerunner's articles on Impecatory Prayer if you don't understand this.)

You can't make this stuff up, folks. Some people are totally batshit crazy. Even if you believe in the existence of a god or gods, explain to me how it's even remotely moral to pray for someone's death so that you can get the president you want? Aren't these the same people who are always saying that the ends don't justify the means (which is why abortion is terrible, even if it's to save a woman's life)?

I just don't get it.

FYI, for anyone who's going to come along and say, "no one is praying for McCain's death!" I did as the writer suggests and looked up "impecatory prayer," which is actually spelled "imprecatory prayer," but you will get a billion google results for the former because everyone is reposting this story.

Anyway, imprecatory prayer is when you pray for God to help you hurt somebody else or defeat some enemy (because supposedly you are praying for a "righteous" reason, otherwise God won't help you and you're a dirty, dirty sinner. What is "righteous" is presumably up to the individual to decide by reedin' his Biiiiible).

Doing the Minimum

2008-09-03T18:03:00.003-04:00

So I managed to get myself into a dispute with someone in another arena about the minimum wage. He seemed to think that the free market would sort everything out equitably if we eliminated it. (He also provided no data to support this assertion. I have to charitably assume that he thinks this will be the case because he just has that much faith in humanity to "do the right thing.")

I'm not even going to touch that, but someone came along and attempted to defend Mr. Free-market's viewpoint. At the end of his post, he posed a philosophical question of sorts. What is the intent of the minimum wage?

I think that the "intent" of the minimum wage is to make sure that employers aren't paying employees less than they are able to live on. I decided to dig up some information on the subject.

The Economic Policy Institute has an interesting calculator that lets you put in typical family structures and locations to calculate a "basic family budget." The budget only covers the cost of food, shelter, and clothing. It includes "no savings, no restaurant meals, no emergency funds--not even renter's insurance."

I decided to calculate the cost of living based on two parents and one child for Indianapolis, Indiana. I myself live in Indianapolis, so I can tell you exactly how much I pay to live here for comparison. I live with three other roommates and we all pay equal shares, but we also all earn wages and are employed at least part-time (I work about 10-12 hours a week). I am also lucky to have parents that pay some portion of my expenses (I am a full-time student). Unless stated otherwise, I am only listing my share. To estimate the "actual" cost, multiply by four.

My monthly rent is $1000, of which I owe 1/4 (I have roommates) for a total of $250/month.
I spend about $125/month on groceries.
My basic utilities cost me about $150 a month.
I also have phone and internet access that costs me $12/month.
I don't pay my own car insurance, but I decided to estimate it by getting a quote from my insurance company. Basic coverage would cost me $100/month.
Gas to operate that car currently costs me about $45/month.

Total: I spend $632/month for my barest necessities, not factoring in entertainment or savings, which amounts to $8,184 per year. It also doesn't include health insurance, which I have through my family. I suppose I could tack an extra $75/month on for a health care plan that basically doesn't cover anything--that's what my girlfriend has (and a $2500 deductible, to boot). If I had to pay everything myself it would cost $32,736 per year. None of this accounts for my $30,000/year education, which I can only pay for because the government is subsidizing some loans and I have a small scholarship.

The budget calculator suggests the following monthly expenses for a family of two with one child living in my city:

Housing: $726
Food:: $514
Child care: $542
Transportation:: $447
Health care: $286
Other necessities: $298 (I assume they mean toiletries, clothing, etc)
Monthly taxes paid: $377

The monthly total is $3,189 and the annual total is $38,273. I have zero problems believing that this calculator is accurate at estimating the cost of a family of three living in Indianapolis.

Indiana's minimum wage is $6.55/hour as of July 24th, 2008.

$6.55/hour x 40 hours/week x 52 weeks/year means that if you take no unpaid vacation, get no overtime, and work every day you possibly can you make $13,624 per year in Indiana. If you are married or in a domestic partnership and your spouse has the same earning potential you will therefore make $27,248 per year, before taxes.

You are about $10,000 short.

As far as state taxes go, Indiana has the third lowestindividual income tax rate of any state as of 2007. Federal income tax for this family will be filed jointly (let's assume they're married). For reference, here is a tax bracket calculator. They make between $16,050 and $65,100, so they pay 15%, or $4,087. But hey, they get it all back, right?

In short, anyone arguing that the minimum wage is actually sufficient to live on clearly hasn't done any math lately. How is the average American family supposed to live with a $10,000 budget deficit? And that's without any recreational expenses. No movies, no restaurant dinners, no mommy-and-daddy dates, no alcohol or tobacco purchases. The answer is that they borrow it, and that's where we get into trouble.

Here's the thing. You have to be a dreadfully callous human being to say that people who work minimum wage jobs (mostly those who didn't or can't get a college education) don't deserve a living wage. Should people with more education make more money? Of course. But should people with only a high school diploma be paid less than they can afford to live on?

Rumours of My Death...

2008-09-02T13:33:00.003-04:00

...have been greatly exaggerated.

I've been lurking in the blogosphere the whole time, but I haven't been saying much, mostly because I've been busy and I haven't made blogging a priority. But fear not! Loyal readers, assuming I have any at this point, know that I intend to return and get back on some sort of regular posting schedule.

Repetition =/= Truth

2008-09-02T13:31:00.000-04:00

Apparently Tim Pawlenty, governor of Minnesota, was recently questioned about his position on teaching creationism/intelligent design--mostly because it's something that's come up with VP Sarah Palin, who favors "teaching the controversy."

GOV. PAWLENTY: I saw her comments on it yesterday, and I thought they were appropriate, which is, you know, let's -- if there are competing theories, and they are credible, her view of it was, according to the comments in the newspaper, allow them all to be presented or allow them both to be presented so students could be exposed to both or more and have a chance to be exposed to the various theories and make up their own minds.

Emphasis mine.

That's it. Full-stop. If they are credible. They aren't.

Evolution is a scientific theory. So is natural selection. They are supported by data, research, and observation. They don't just explain something, they invite further questions. How do things evolve? What pressures favor which adaptations? What conditions affect the visible "rate" of evolution? Thousands of issues are being explored by biologists using what we know about evolution as a starting point because it's been thoroughly demonstrated that it happens.

Creationism doesn't invite any serious questions that can actually be answered ("so, who is this designer, anyway?"). It doesn't present any hypothesis other than "stuff was designed," and that hypothesis isn't scientifically valid because it isn't testable. It is not a competing theory because it is not science.

It's disgusting that people are offended that their children are learning science in science classes because science apparently offends their theological sensibilities. And the politicians that are using this talking point--"it's a local issue"--are doing the smart thing, politically, and dodging the issue altogether. They're not saying they don't have an opinion. They're saying that they won't voice their opinion because they're afraid of alienating some portion of their constituency. No political candidate who wants to keep his career is going to stand up in front of America's 75% Christian population and tell them that their faith and beliefs are irrelevant when it comes to determining what is and isn't verifiably true.

Even if local school boards don't want their kids exposed to scary ideas like evolution, it's a waste of taxpayer dollars to teach them bullshit instead just so that they can be sheltered from theologically unpalatable truths.

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.

Weekly Factoid: Oral Contraceptives

2008-03-03T20:20:00.002-05:00

Did you know that they make chewable birth control pills?

I don't know about you, but I really have to wonder about whether or not people who can't swallow tablets should be having sex.

Please Understand Me--and Shut Up

2008-02-28T13:52:00.003-05:00

This article has been making the rounds, in one form or another, for the past couple days. Naturally, most people get the beautifully condensed MSNBC version.

Let's go to the article for a quote:

“Patients aren’t sure how ill they really are, and neither is the clinician — sometimes dismissing their symptoms, sometimes overestimating them,” said Dr. Alexander Niculescu, III, a psychiatrist at the Indiana University School of Medicine in Indianapolis, who led the research published Tuesday by the journal Molecular Psychiatry. “Having an objective test for disease state, disease severity, and especially to measure response to treatment, would be a big step forward.”

Absolutely right. Granted, the test that's being discussed isn't actually anywhere near 100% accurate. Rather, it's about 60-70% at best. Plenty of room for false negatives--or false positives, though it would be irresponsible to diagnose an illness based on a single blood test with 60% accuracy.

The problem I have is that instead of cheering that we might finally have a good biomarker for a devastating mental illness, everyone is whining about ethical concerns. Let's think about this. An objective measure of bipolar disorder would not only allow for more accurate diagnosis, but it would give us better treatment benchmarks. It's easy to tell if a drug for hypertension is working; does it lower the patient's blood pressure by a significant amount when compared to a placebo? Evaluating the efficacy of treatments for bipolar disorder essentially comes down to asking patients "so how do you feel?" and hoping they're being totally honest. Is it any wonder why doing research regarding new treatments for the illness is so hard?

But no, nobody seems to be saying "this is amazing!" Instead, they're all complaining about how people with bipolar disorder are going to get discriminated against in hiring or rounded up and thrown into camps.

Let's start from the beginning. In the US, your health information is private. It is protected by federal law. Employers are not allowed to ask questions about any illnesses you may have, nor are health care providers allowed to disclose any information about your health to employers (or anyone else), including what medications you may be taking.

You might be wondering about urine screening for drug use when hiring new employees. Yes, the practice is legal, but laws vary from state to state. You could argue that this provides a foothold for pre-hire blood testing--except for the fact that most of the people whining about the blood testing procedure are saying that it's going to go beyond hiring. They're suggesting that landlords might blood test people before letting them sign leases, or banks might want people to submit blood before they'll hand out loans. You'll notice that none of these entities can legally conduct urine tests. Under current law, even if an employer were able to get a blood sample and test you for illness X or Y, you could sue them if they refused to hire you based on the results of the test--and you'd win.

Being mentally ill is a disability. Discriminating against people with disabilities in the workplace is illegal. It doesn't matter the disability is patently obvious (a person in a wheelchair) or totally invisible (bipolar disorder). As long as you're qualified for the job, that's all that matters--unless the employer wants to risk a huge lawsuit. This isn't likely to change any time soon. The ACLU would throw a fit, for starters.

The ability to definitively diagnose mental illnesses on the basis of a blood test is 99.9% good. Unless all the work of anti-discrimination proponents is suddenly reversed tomorrow, there's no reason to assume that this is going to create a problem. The only reason to think otherwise if you've watched Gattaca in the past week and it's cranked your paranoia setting up to 11.

All About Perspective

2008-02-27T22:16:00.002-05:00

This is an older article, but I was digging through "news" archives tonight and I happened to stumble across this little gem.

On July 12, the cancerous growth imbedded in the brain tissue of Warren Lenders got the news no tumor ever wants to hear: chemotherapy. Facing the prospect of cancer-killing radiation, the six-month-old malignant brain tumor could have cursed the heavens for dealing it such a cruel fate. Instead, it chose to be grateful for the time it has left, viewing each new day as a gift from God.

Total brilliance.

Some Depressing News

2008-02-27T14:46:00.002-05:00

A friend of mine sent me a link to an article yesterday, thinking it might be useful blog fodder. However, I didn't have the actual study in front of me--but thanks to The Frontal Cortex, now I do. If you ask me, Jonah has hit the nail on the head when he pointed out the biggest weakness in this study--all of the trials involved were, at most, eight weeks long.

For those unaware, this study was a meta-analysis. A meta-analysis involves doing no new research trials; instead, the results of a large number of old trials are compiled and analyzed using statistical methods. Results from fourty-seven trials were compiled for the meta-analysis; thirty-three of those were only six weeks long. Short trials are known to be less valuable in testing the efficacy of antidepressants; the longer the studies run, the farther apart the placebo and treatment groups usually get. For example, this study demonstrated that if you give patients escitalopram (an SSRI) for sixteen weeks and then switch half of them to placebo without them knowing about it, the placebo group will do significantly worse in terms of probability of relapse into depression.

It's interesting to see placebos compared to antidepressants. According to the PLoS study, placebos had about 80% of the therapeutic activity of SSRIs in the short term--that is, they were about "80% as good" in the six-to-eight week studies they analyzed. This is not actually all that surprising. For many depressed patients--or those with mental illness in general--the placebo effect is huge. Sometimes, the pro-active nature of seeking treatment is enough to bring depressed patients out of a slump, if only temporarily. Patients who feel as though they're finally doing something to fix themselves are likely to experience an emotional boost. And let's face it--not everyone on SSRIs is experiencing symptoms because they have low serotonin, one of the major neurotransmitters behind depression. Other diseases can cause patients to present with depression-like symptoms if they aren't properly ruled out before initiating treatment. That isn't likely the case with this study; before patients can participate in a drug trial for a new antidepressant, other causes of depressed mood must be ruled out.

The problem is that the mainstream media tends to get ahold of things like this and run amok making claims that "a new study proves antidepressants don't work," which is both incorrect and irresponsible. It's incorrect because all this meta-analysis (like many individual trials on the subject) suggests is that SSRIs must be taken long-term to have benefit, and that short-term reactions are largely attributable to placebo effects. There's a big difference between "antidepressants don't work" and "antidepressants have to be taken for months to see major improvement." The rate of relapse for patients switched abruptly to placebo is higher, even if the authors of the meta-analysis aren't convinced that antidepressants create "enough" improvement in the short term to be clinically significant.

To continue, this style of reporting is irresponsible because the everyman is a lot more likely to read a news article with a catchy headline than he is to seek out the original study and pore over the methods of the researchers, either because he has no idea where to look or because he hasn't taken enough statistics to have any idea what the hell these sciencey people are talking about. Which means that the everyman on antidepressants is going to take the words of some reporter at face value--perhaps higher than the words of his doctor, if enough reporters are all saying the same thing--and they're going to throw away their meds, decrying them as a useless waste of money. I've seen this happen before in clinical practice; many mentally ill patients take meds for a while, decide they don't need them any more (either because they "aren't working" or they "feel better"), pitch them, relapse, and start the whole vicious cycle over again.

Is there a tendency to "cover up" the results of clinical trials with negative outcomes? Sure. That's publication bias. But antidepressants aren't the only medications for which reporting bias is an issue--and just because some negative studies don't get published doesn't mean that the positive ones are automatically worthless. The negative studies don't necessarily get swept under the rug as part of some "grand pharma conspiracy." One negative study doesn't prove a drug is ineffective any more than one positive study proves that it is. If the overwhelming trend is positive or negative, then we can make judgments. But even trends can be misleading; you can connect the dots many different ways, depending on where the dots are and what kind of analysis you're doing. And that's one of the risks of meta-analysis studies. There's just as much room for spin there as anywhere else.

So don't throw out the Prozac. There's no such thing as an "official study" that proclaims antidepressants to be therapeutically useless. And any journalist who tells you otherwise is being sucked in by spin just as badly as the drug reps who are trying to push the products--they're just being spun in the opposite direction.

I Stand Corrected

2008-02-25T13:30:00.003-05:00

I take back my comment in the last post about napping being a source of relaxation and stress relief. If this news article speaks the truth, seniors who fall asleep unexpectedly during the day have a higher risk of stroke, even when patient populations are controlled for diabetes, high blood pressure, and other risk factors.

You know, I fall asleep on my couch after a rough day with fair frequency. I wonder if my risk for stroke is higher as a result? Probably not.

I think (and don't quote me on this) that a much more likely explanation is that seniors who have difficulty maintaining alertness have that particular problem because of declining health in general. Medication side-effects might be part of the reason the patients are nodding off, though if the study controlled for disease states, they likely also controlled for medications likely to cause drowsiness. Either way, it's safe to say that patients who lack energy and fall asleep during the day are probably sicker than those who don't.

And even if falling asleep during the day were a direct cause of stroke risk, what would we do about it? Make daytime television more stimulating? Provide the elderly with free Starbucks?

Seriously. Correlation versus causation. Who funds these studies?

Curiosity Killed...

2008-02-25T12:01:00.004-05:00

This article is hilarious if only because it's a great example of conflating correlation with causation.

Have you ever thought how lucky you are to have your cat with you? According to a controversial study, presented at the American Stroke Association in New Orleans on Thursday, cats reduce the risks for their owners to have a heart attack and protect them from other cardiovascular diseases.

Without the original study in front of me, I can't really analyze the statistics the authors used to conclude that cat ownership reduces the risk of heart attacks. The proposed "mechanism" for this is that cat ownership--a source of affection and companionship--reduces stress levels. Less stress means fewer heart attacks. Well, okay. That might be the case. Maybe. Heart attacks are occasionally triggered during high stress situations or periods of exertion.

However, the idea that having a cat around--and the study says nothing about man's best friend, the dog--will improve your health sounds like shoddy scholarship. I'm sure you could find a similar link between tea, enjoyment of classical music or a love of quiet meditation, or even just a tendency to take naps. Anything that helps you chill out would offer similar benefits, assuming that stress was a primary cause of heart attacks (which is isn't).

Cat ownership is pretty prevalent. You might as well connect having eaten tomato sauce to cancer or driving a car to catching the flu.

Paging William Shatner

2008-02-23T18:32:00.003-05:00

Normally, I don't post work rants, because I feel like that subject has been well-covered in the blogosphere. But today's "pill-counting action," to steal a phrase from the Drugmonkey, concluded with a jaw-dropping exchange that ties into some of the stuff I've been covering lately. Diabetes, that is.

I missed the initial exchange between the woman at the counter and the pharmacist. "Hey, N.B.," he said, "she needs some insulin and some syringes. Can you get her set up?" He went off to do something else. I confirmed the type of insulin in question (Humulin 70/30 mix, which is available without a prescription). I asked how many vials she wanted. "I dunno, how much are they? I'm getting tired of having to go to the pharmacy all the time, maybe I'll get a bunch." About $40. She decided she only wanted one.

"What kind of syringes do you need?" "I dunno," she said. Hmm. Perhaps her doctor sent her here with no patient counseling whatsoever, although he would've at least written her a script. "Alright, how many units do you use?"

She looked confused by this question. "I think 30. Three times a day."

This is an absolutely ridiculous amount of 70/30 for a newly-diagnosed diabetic to be using. I'd estimate she weighed less than 130 pounds; half that amount would've been reasonable. And Humulin 70/30 is an intermediate-acting insulin, so that many doses/day was outrageous. Also, the idea that she would be unsure as to how much insulin to use was mindblowing.

The pharmacist stepped over to me as I was digging around for syringes and suggested (quietly) that we go ahead and give her 40 syringes--no more--because he was convinced she was just going to pitch the insulin and use the syringes for something else. I have commented before on how I don't have a problem with providing syringes and needles to drug users because in my state I'm not liable for what they do when they leave the pharmacy as long as I follow proper sale protocols and the person has a valid photo ID. Alright. 40 syringes.

"Should I get one of these meters?" She was referring to the blood glucose meters, of course. "Yes," I said, "you should have one. How often does your doctor want you to test your blood sugar?"

"I don't know," she said, "this isn't really for me, it's for my boyfriend, he's never done this before." If she was just trying to get syringes, she could've come up with something less elaborate. There was certainly no need to buy a glucometer. I was pretty sure at this point she did, indeed, have a boyfriend with diabetes who needed insulin.

This is bad territory. Now I am not counseling my patient. I am counseling my patient's (slightly loopy) messenger.

"How often should he check his sugar?"

"Well," I told her, "it depends on what your physican wants you to do, but usually at least twice a day, more often if you're trying to monitor changes in blood sugar closely."

This is the part where we entered the Pharmacy Twilight Zone.

"So, how much insulin is he supposed to use?"

I refrained from falling over in shock. "Er. How much did your physician say to use?"

She seemingly ignored this question. "What if he takes his sugar, what should it be? What's high? What's normal?" "Depends on whether he's eaten recently, among other factors. Usually, if he hasn't eaten in a long time, it should be pretty low, like 80-120. Did the doctor tell him what his goals were?"

"So he should check his sugar and if it's above that he should take insulin?"

I was starting to get the impression at this point that this boyfriend of hers had never, in fact, seen a doctor about his diabetes. Or, perhaps, he had seen a doctor once, ignored everything he was told, went home and told his girlfriend that he had diabetes and needed insulin, and set off a bizarre chain reaction that somehow ended with "I can get a random pharmacist to sell me insulin, confirm the diganosis of diabetes, and prescribe an appropriate insulin regimen for a patient he will never see again."

Note to the reader. THIS IS WRONG.

"Yeah," she continued, "he doesn't pay attention to stuff, he can't do this himself, so I'm trying to take care of it. I'm goin' to go to nursing school, I gotta understand this stuff, I know about checking blood sugar. He can't do this stuff himself, you know how boys are."

I just blinked at her. "Uh."

"Well, some of em' anyway."

I'm not sure who to blame for this scenario. Opponents to universal health care? A careless physician? I don't think the blame belongs to a doctor. Her boyfriend came in a couple minutes later. He had no clear idea of what was going on. Apparently he knew he needed insulin--and that was it. He remarked that the insulin and glucometer were expensive. "It'd be cheaper to get the other medicine," he said. "Yeah, well," replied his girlfriend agitatedly, "you're too disorganized to do that, so we have to waste the money like this."

She produced a one-hundred dollar bill to pay her tab, at which point I requested a photo ID for the syringes. She didn't have one. He didn't either.

"We'll just use the syringes we've got at home," she said. They took the insulin and the glucometer and left the store. The pharmacist and I stood and stared at each other in total shock. We were both completely baffled by the exchange. I am moderately concerned that he's going to go home, overdose himself on insulin, and wind up in the ER, convulsing and in shock. If it had been my call, I wouldn't have sold them the insulin, but the pharmacist didn't have a problem with it. This was the most confusing exchange I'd ever had with a "patient." I had a distinct notion that both of these people were like cats without whiskers, perpetually caught behind the refridgerator, and I had just let them leave the store with a bottle of something that could easily result in an unintentional lethal overdose if used improperly.

I kind of hope these people never breed. The cynical part of me thinks that this problem will short itself out in short order when this guy removes himself from the gene pool.

The Heart of the Problem

2008-02-19T12:13:00.003-05:00

Commenter Bunc on Mike the Mad Biologist's ScienceBlog has succinctly put his finger on the real reason why the whole evolution debate is such an issue. If I may paraphrase:

Part of the problem is that this is seen as atheist evolutionists versus theistic creationists. The fundamental issue is not this--it is scientific literacy versus ignorance.

The reason that many popular versions of theistic philosophy in America are "dangerous" is not because theism is a direct threat--the problem is that many prominent theists, namely American Christians, are fundamentally opposed to naturalistic theories that exclude their god from the creation of mankind (and everything else).

The interesting thing, if you ask me, is that there are well-spoken and intelligent Christians out there who don't have any problems with evolution (or science) and in fact actively promote understanding of it. If you're looking for a breath of fresh air on the subject, I recommend James McGrath's Exploring Our Matrix.

This whole issue cloaks itself as a religious debate--but it isn't. It has nothing to do with theism per se. It has everything to do with promoting ignorance over science.

Whisky'd Away

2008-02-15T23:12:00.002-05:00

After a week consisting of five exams over the course of three days, it's the simple things in life that get you back on track.

Like a bottle of Dalmore 12-year single highland malt. If I wanted to take a leaf out of several other blogger's books, I'd do weekly whisky reviews, but good Scotch isn't exactly in the typical college student's weekly budget. Certainly not mine.

Needless to say, it was a good buy--excellent for the price at only $25.

Diabetes Discussed: Part 3

2008-02-12T21:42:00.002-05:00

Thus PalMD and I continue our cross-blogging endeavor to explain what researchers have figured out about diabetes in light of recent proclamations from the mouthpiece of science that type II diabetics may not benefit from dropping blood glucose levels to their minimum levels as much as previously thought.

Treatment of diabetes is multifaceted. As Pal pointed out, insulin is the mainstay of therapy, especially for type I diabetes. In type I, insulin is the only reasonable therapy; right now, nothing else works. They don't make insulin. They need insulin. Simple enough.

Insulin was the first protein drug product developed and widely used--it was originally derived from pigs or cows. Nowadays, we get our insulin from E. coli that have been genetically "reprogrammed" to produce human insulin through bioengineering. And we also have a huge variety of insulin products that are essentially just modifications made to the basic insulin design. Some insulins act more rapidly (like Humalog or Novolog) whereas others are intended to last up to 24 hours to provide an insulin "baseline" (like Lantus or Levemir). Insulin dosing may initially be based on weight, but after that, dosages are recalculated based on trial and error. It is difficult to predict precisely what quantity of insulin will produce the desired result, and there are several different rules and protocols for optimizing insulin dose. In short, insulin doses must be individualized to the patient, requiring a lot of careful monitoring by both the health care provider and the patient (with a home blood glucose monitor).

Treatment of type II diabetes is way, way more complicated.

Because type II diabetics can create insulin, but their cells are less responsive to its effects, the initial treatment of choice is usually metformin. Metformin is amazing. It's the only drug in its pharmaceutical "family" on the market, and nearly every type II diabetic is on it. It works by increasing the sensitivity of cells to insulin and by decreasing the amount of glucose the liver makes--it's that gluconeogenesis process again--which results in an overall decrease in blood sugar. It even causes some patients to lose weight, which is excellent; losing weight generally decreases the severity of type II diabetes.

Pal covered metformin and the other "oral hypoglycemics" already--sulfonylureas, like glipizide, force the pancreas to spit out more insulin. And thiazolidinediones (TZDs for short; that word is quite a mouthful) have multiple body effects, including increasing insulin sensitivity, but by a different mechanism than metformin--which means that they can be combined, and sometimes this produces better results.

I would like to stress at this point that if you or a loved one have diabetes, while this series may be thought-provoking and raise interesting questions, that you should discuss the matter with your primary care physician when it comes to individual treatment recommendations--not here. I'm not a licensed medical practitioner*, just a student of pharmacy with a flair for words and a desire to share his knowledge with the world. And even if I were licensed, reading some article written by an anonymous blogger is not an appropriate substitute for face-to-face medical advice.

With that out of the way. What does recent research tell us? Past research tells us that blood glucose is important. But new research says other things might be just as important--maybe more.

Heart disease is a number one killer of patients with type II diabetes. Kidney failure is more common in type I. They're both considered to be manifestations of the same disease. But they're clearly different in several ways. Pal mentioned ketoacidosis--that's common in type I, but incredibly rare in type II. What explains these differences?

If I wanted to indulge my inner conspiracy theorist I'd blame the drugs used to treat type II diabetes, which is kind of like the absurd claims made by tinfoil-hatwearing HIV denialists that AZT causes AIDS.

Much more likely is the difference in co-morbidities ("other diseases/conditions the same patient has") for both type I and type II patients. Type II patients are typically obese, or at least overweight. The Framingham heart study has demonstrated that being overweight (as defined by medical science, not People magazine) is a risk factor for cardiovascular disease. So is having wonky cholesterol levels--and those are pretty common for type II diabetics, too.

This study is kind of interesting. Essentially, cholesterol deposited on beta-cells--the part of the pancreas that secretes insulin--can induce beta-cell failure. Cholesterol essentially "clogs the pipes." Even more interesting is the fact that this whole problem may be tied to a gene that codes for a protein called ABCA1. ABCA1 is essentially the "conductor" responsible for regulating lipid transport in and out of beta-cells. People whose genes incorrectly code for the ABCA1 transmembrane protein may be more susceptible to lipid-based damage to the pancreas. It is entirely possible that controlling lipids is at least as important as controlling blood sugar in type II diabetes, which means that dietary modifications, exercise, and cholesterol-lowering drug therapy may all play an even greater role in achieving good treatment outcomes than previously thought. This is exciting research!

That study's too neat to just be a throwaway link. I might come back to it later.

I think the point of recent research basically demonstrates that we can't just treat blood sugar. It doesn't mean we're completely mean about how we're treating diabetes. It just gives us a new direction to focus our research. Diabetes may be conceptualized as a problem with glucose metabolism, but that isn't the end of the story. Physicians, pharmacists, and patients have to work together to design treatment regimens that address cholesterol and sugar, among other factors.

*Well, I have a pharmacy intern's license. Which permits me to practice pharmacy, compound medications, and counsel patients under the guidance of a licensed pharmacist. But it's essentially a learner's permit. And you shouldn't be using the internet as your sole source of health advice anyway. It's not a good resource. In pharmacy, we call using a drug by itself that shouldn't be used alone "inappropriate monotherapy." Getting all your medical information online is the same. Go talk to your doctor!

Lose Weight--Naturally!

2008-02-12T18:54:00.001-05:00

I'd like to plug an entertaining (and short, this time) entry by Pharmacy Girl.

In Arizona, naturopathic doctors can legally prescribe any legend drug or controlled substance (except IV medications, chemo drugs, and antipsychotics). The only prescriptions I see from naturopaths are for phentermine and metformin. Usually for the same patient.

This is why licensing naturopaths doesn't help. No, I don't have statistics that this is true, just one pharmacist's observations. I would like to get detailed statistics. And sure, you could argue that without licensing they would be doing something less savory than handing out amphetamines to any yuppie who wants to lose ten pounds before swimsuit season. But you give them legal power to prescribe medications and this is what they do.

This isn't even me saying that naturopaths are irresponsible or incompetent at treating illnesses. There is always the possibility that there are some naturopaths that actually know their anatomy, physiology, and pharmacognosy. What annoys me about this is that they are hypocrites. Aren't proponents of so-called natural medicine always advocating things like diet and exercise instead of drugs? You know, letting the body work itself out "naturally" as opposed to dumping in synthetic compounds that speed up the central nervous system? Wouldn't a real naturopath prefer you get on a treadmill to raise your heart rate than take speed? Hell, prescribe bitter orange or guarana extract. Those, at least, are derived from plants--even if they are just sources of caffeine or ephedra.

There are a lot of physicians with questionable motives and practices out there, too. They aren't blameless by any means. Look at the plastic surgeons who put up phony "board certified" credentials and operate on patients in their offices. But if becoming a naturopath is quantitatively easier in terms of time and money investment, and you can get your naturopathic license and rake in the cash by seeing patients for five minutes and throwing phentermine at them, isn't that a bad system? You simply can't expect me to believe that getting a degree from Bastyr takes the same amount of work and time as going to Johns Hopkins. Why should we give people a short-cut to opening crooked practices?

When Pharmaceuticals Fail, Consider Possession as an Etiology

2008-02-12T14:05:00.000-05:00

Bad of The Bad Idea Blog, one of my favorite sites for silly and skepticism, has posted an excellent article about demonic possession and the rising popularity of exorcisms in Europe. I am not ashamed to admit that I nearly fell out of my chair laughing. I'd quote my favorite sections, but that would spoil the article for you. So go read it! Keep yourself amused somehow while I work on part three of the diabetes series PalMD and I are co-blogging about!

Diabetes Explained: Part 1

2008-02-11T13:06:00.000-05:00

The medical world is abuzz regarding the recent revelation that driving blood sugar to its lowest theoretical level may not be the optimal treatment regimen. PalMD of WhiteCoat Underground has already addressed the issue in a short post, noting wisely that this whole issue just raises more questions about the nature of diabetes and how it should be treated.

But what is diabetes, anyway? There are a lot of misconceptions, perhaps the most popular being that diabetes is a disease you contract as a result of eating too much sugar. My own mother was convinced that a diet proportionally high in carbohydrates was likely to cause diabetes until I made an attempt to explain otherwise. It also gets likened to a sort of food intolerance--the idea that diabetics can't eat sugar because it will cause acute damage. Naturally, the truth is far more complicated; patients with diabetes won't keel over and die in minutes if they eat cake.

Diabetes is often conceptualized as a problem with glucose metabolism. When you or I eat, the body breaks down complex carbohydrates into simple glucose units. Certain amino acids, the building blocks of proteins, are converted into glucose by complex pathways in the liver (the big, scientific word for this is "gluconeogenesis"). Glucose then circulates through the blood and is delivered to various sites; it is the preferred fuel for every cell type in the body, especially neurons. Something like 80% of the glucose in your body is utilized by the brain and nerve tissue.

The issue is that glucose is unable to enter cells unless the drawbridge is down, because glucose molecules are too big to freely pass through cell membranes. In order for glucose to enter cells, special pores on the cell surface need to open. And the trigger that opens those pores is insulin. Without insulin, most of the body's cells have no way to utilize glucose--and therefore, they are unable to fuel themselves efficiently.

It isn't that sugar is somehow toxic to patients with diabetes--the problem is more like having a blocked fuel line in your car. No matter how much gas you put in, your car can't get the gas because of the obstruction. And if you keep filling the tank anyway, you're going to cause it to overflow and spill gas onto the street, harming the environment with damaging emissions.

There are two types of diabetes. Type I diabetics are unable to make insulin; this could be because of a genetic defect, damage to the pancreas by infection or trauma, etc. The net effect is that no matter how much the type I diabetic eats, he is essentially starving, because his body's cells have no way to use glucose. Instead, they rely on far less efficient fuel sources like ketone bodies, which is sort of like putting the lighter fluid-soaked charcoal remnants from last night's bonfire into your car's gas tank and expecting it to operate well. The typical untreated type I diabetic is thin and malnourished. There is tons of glucose floating around in the bloodstream and none of it is accessible, so it gets excreted in the urine.

Type II diabetics make insulin--in fact, they frequently make tons of insulin, especially in the early stages of the disease. The problem is that their cells are less responsive to the effect of insulin, so they use glucose very inefficiently. If type I diabetes is an obstructed fuel line, type II diabetes is a leaky gas tank. Type II diabetics are commonly overweight--having large amounts of fat cells decreases the body's response to insulin. Fat doesn't just sit there; it secretes hormones that regulate glucose usage and appetite, among other things. The bizarre thing is that from a metabolic standpoint, your type II diabetic, despite being overweight, is functionally starving.

If I were stranded on a desert island with nothing to eat, my body's metabolic machinery would switch gears in less than 24 hours. We're starving, it would say, and the pancreas would release a hormone called glucagon to remedy the situation. Glucagon would tell my body to break down my fat stores (the few that I have), cannibalize muscle tissue, and instruct the liver to release its glucose hoard to feed the brain. Eventually, the stores would run out and my brain, cut off from its supply of necessary glucose, would shut down, taking the rest of the body with it. My heart, ever a trooper, would keep on truckin' until the autonomic nervous system crashed, because it is perfectly happy to feed on metabolic scraps.

An untreated diabetic's body is doing this all the time, and the only reason it doesn't kill them is that the brain, kidneys, and nerves don't need insulin to take in glucose. They're the exception to the rule, and if they weren't, diabetes would be fatal a lot more quickly than it actually is.

The reason sugar is harmful to diabetics has less to do with the essential properties of sugar itself and more to do with the effects of wildly fluctuating glucose levels on those three tissues. When glucose levels are high, glucose rushes into the big three--the nerves, the nephrons (the functional units of the kidney), and the retina of the eye. When blood glucose finds its way back down, frequently by being excreted in the urine, there is a huge disparity between the amount of glucose in the nerves and in the blood.

Those of you who remember basic chemistry will recall that such concentration differences are considered unfavorable in accordance with physical law. If we put a tablespoon of sugar in a glass of water, the sugar molecules would slowly spread out throughout the glass (though more slowly than we might like, which is why most people opt to stir the glass). Given enough time, the concentration of the sugar will be uniform throughout the water, and we will have a solution.

But what if we put a barrier in the glass dividing it in half from top to bottom, and the barrier permitted the passage of water, but not sugar? If we put sugar in one partition, the sugar-water on that side will be much more concentrated. Physics doesn't especially like this scenario; equal concentrations on both sides would be preferable. Sugar can't move through the barrier, but water can. As a result, water is going to pass through the no-sugar side to the sugar side in an attempt to equalize the concentrations.

This is the precise scenario that takes place in the human body. Once sugar concentrations in the bloodstream go down, the sugar concentration inside cells (retina, nephron, and neuron) is higher than the sugar concentration outside the cells. Since the sugar can't come out, water goes in. But the cells are limited in size by the boundaries of their membranes. When enough water rushes into the cells, they burst and are destroyed like overfilled water balloons.

So the big problem with sugar and diabetes has less to do with sugar itself being harmful and more to do with osmotic pressure, the situation described above with the barrier that will permit water to cross but not glucose. This is why diabetics with poorly-controlled blood sugar--blood glucose that fluctuates from low to high with great frequency--are more likely to suffer nerve damage, blindness, or kidney failure.

The recent study suggests that type II diabetics (NOT type I diabetics) were just as likely to die from their condition if they maintained low blood glucose levels than if they didn't (this isn't the whole story, so nobody panic). This is a surprise mostly because prior research has fairly conclusively confirmed that controlling blood sugar reduces the risk of those three problems I mentioned earlier in addition to reducing the likelihood of heart attacks, strokes, and other cardiovascular complications.

Why might this be? To understand this issue, we'll need to look at the way diabetes is treated, which will make absolutely no sense without an understanding of what diabetes is. Next post, we'll explore the issue of treatments for diabetes, how they work, and what this new research might mean.

Optimizing Your Caffeine Intake

2008-02-11T12:30:00.000-05:00

This article by Chris Chatham of Scienceblogs' Developing Intelligence is worth a look. It's a fascinating read, and if you're a caffeine enthusiast like I am, it might even be practical knowledge!

I predict my intake of the world's favorite stimulant will increase significantly over the course of the week--with five exams coming up between Tuesday and Thursday, there're going to be a lot of cups of coffee and cans of No Fear finding their way down my gullet.

Why Bioavailability and Drug Delivery Make the "Simple" Complicated

2008-02-08T17:41:00.000-05:00

A co-worker, colleague, and fellow student of mine approached me a long time ago saying she had a story that I absolutely had to hear. While home for the Christmas holidays, she wound up talking with some in-laws and family friends. One of these people turned out to be some sort of naturopathic practitioner. There was some disagreement about the value of statins, as could be expected (apparently someone suggested that everyone on statins should just take high-dose vitamin E instead). But the part that interested me was the fact that my colleague wound up having to explain the dopamine hypothesis of ADHD.

In short, the naturopath didn't understand why hyperactivity was commonly treated with stimulants. This is a reasonable question if you don't understand how amphetamines work. Most ADHD drugs are prescription amphetamines, essentially "Speed" used for a legitimate medical purpose. The same drugs are also sometimes used for narcolepsy. On the surface, it really does seem like a massive contradiction. Why give children who are having trouble focusing because they can't sit still stimulants?

The current hypothesis supposes that ADHD is at least in part caused by an insufficient quantity of the neurotransmitter dopamine in the brain and central nervous system. Dopamine is associated with pleasure and reward; in fact, all addictive drugs, directly or indirectly, have some effect on dopamine pathways in the brain. In ADHD, insufficient dopamine results in "lack of satisfaction," resulting in children and adults with ADHD being unable to focus on tasks. In essence, their brains are not programmed to acknowledge task completion as worthwhile, making it difficult to concentrate; the brain is too busy trying to find something else to do that is worthwhile. Many stimulants, amphetamines included, increase the concentration of dopamine in the brain. Appropriate stimulation of the brain and central nervous system increases "satisfaction" in patients with ADHD and allows them to focus more effectively.

Unfortunately, amphetamines have other side-effects. They speed up the heart, increase blood pressure, and, if the dose is too high, may cause insomnia, jitteriness, and anxiety. So the naturopath's next question was reasonable. "If dopamine is low, why can't you just give kids with ADHD dopamine?"

I don't expect laymen to know the answer to that question. I do expect anyone with an understanding of pharmacology to know. Naturopaths claim they understand the workings of the human body. Clearly, drug bioavailability is beyond their expertise.

There are a whole slew of reasons why you can't just take dopamine tablets. Some of them are specific to dopamine; others are general drug issues. Bioavailability sounds like a tough word, but its meaning is actually fairly simple. Essentially, bioavailability is a measure of how much of a drug the body can use after the drug is given. In order for a drug to have an effect, it has to reach its site of action. An anaesthetic has to diffuse into nerves before it can produce a numbing effect. Drugs designed to lower blood pressure have to be able to access the heart, arteries, and veins.

When you swallow a tablet, it goes to the stomach and is broken down to release its contents. In order to get into the bloodstream, the active drug must cross body membranes; otherwise, it will proceed through the intestines and be expelled unchanged. Luckily, your intestines have a large surface area and are good at absorbing things--otherwise, eating would be rather pointless, because you wouldn't be able to get any of the nutritional value from your food. However, there are limits to what is allowed to cross the intestinal membrane. Some drugs or chemicals can't cross it at all. In fact, some drugs are designed not to cross the membrane; they stay in the intestine and do their work right there. Alli is a good example. It doesn't need to be absorbed into the body. It stays in the intestine and binds fat molecules, preventing them from being absorbed.

Once a drug is across the intestine and in the bloodstream, the first stop is the liver. The liver is responsible for removing poisons from the body; it would be irresponsible for your body to deliver absorbed substances directly to organs like the heart and brain without filtering the contents first!

The liver is responsible for breaking down many drugs introduced to the body, usually by adding or removing a chemical group to inactivate the drug or make it water-soluble so that it can be excreted more readily. The liver does this to substances your body makes naturally, too; when red blood cells die (they only live about 120 days), the liver modifies the remnants, recycles them, and converts the waste products to a form your body can easily get rid of.

There's an enzyme called COMT (or catechol-O-methyl transferase) that's responsible for breaking down neurotransmitters like epinephrine (also called adrenaline, depending on which side of the pond you're on), norepinephrine, and dopamine. If we gave dopamine by mouth, COMT in the liver would rapidly inactivate most of the dose, assuming it were absorbed across the intestinal membrane.

So give a higher dose, you say. Or give it by some other route. You can bypass the liver in a lot of different ways; inhalation, injection, tablets absorbed through the cheek or under the tongue, skin patches or creams...

Let's go for broke and say we inject ADHD patients with dopamine shots like we give insulin to diabetics. What's going to happen?

Increased heart rate, first of all. Dopamine acts directly on the heart. It has different functions in different parts of the body, though dopamine isn't the primary regulator of heart rate (that would be due to the combined efforts of epinephrine and acetylcholine, which is also the neurotransmitter that is responsible for muscle contractions). It will increase blood pressure, too. Same side-effects as amphetamines, more or less. In fact, dopamine is sometimes used in emergency situations to raise patient BP and heart rate (though a synthetic alternative, dobutamine, is actually better for the task). But isn't it a more natural way to deal with dopamine insufficiency in the brain?

Nope. Here's why.

The blood-brain barrier is essentially the brain's defensive perimeter. It is composed of tightly-jammed cells that are designed to keep out miscellaneous poisons and waste products to prevent damage to the central nervous system. In order for a drug to affect the brain, it has to cross the BBB. Lots of drugs do. But dopamine doesn't. The brain would like to keep the dopamine it has...in the brain. The BBB prevents dopamine from escaping or entering.

Let's summarize. Extensive metabolism will break down an oral dose of dopamine very quickly. And even if we bypass the liver, the dopamine will never enter the brain. We'd have to inject the dopamine directly into the brain with a long needle. Try to get your kid to hold still while you do that. Even if we could get dopamine directly into the brain, neurons are good at recycling or re-absorbing stray neurotransmitters. The best case scenario is that we'd get a very brief improvement. The worst case scenario is that we'd go overboard on the dopamine level and the kid would have hallucinations.

Dopamine, in short, is a crappy drug. The solution is to give other substances (amphetamines) that indirectly increase dopamine levels to push the brain in the right direction. And you know what? It works. Sometimes the chemical your body would use to naturally regulate a function isn't something we can easily replace or modify directly.

So that's why we give hyperactive kids uppers to chill them out. It seems counterintuitive at first, but there is a good explanation. And the theory behind the dopamine hypothesis holds up in clinical trials; kids (and adults) treated with amphetamine do get better.

Isn't pharmacology fascinating?

Oops, I Patented Your Natural Product

2008-02-06T14:54:00.000-05:00

What are good ways to lower your cholesterol? You could eat less cholesterol. That helps, but the human liver is great at making cholesterol. In fact, it tends to do so pretty much constantly--but entertainingly enough, the liver works the hardest at producing LDL cholesterol (the "bad" cholesterol) while you're sleeping. No, you shouldn't give up sleep. But what's worth recognizing is that diet isn't the only source of cholesterol, and in fact, the liver probably contributes more bad cholesterol than diet. In fact, removing part of the liver reduced circulating LDL concentrations in animal studies. You could also exercise, drink less alcohol, and give up smoking. All of these things work. But what if they aren't enough?

Statins are a popular target for proponents of "alternative medicine." You don't need statins, they say, you can just take vitamins and eat healthy. Sometimes they promote other unproven supplements or "treatments." Statins are dangerous. Statins are worthless. The lipid hypothesis is false; scientists are lying to you and cholesterol has nothing to do with cardiovascular disease. Here, drink this Kool-aid.

Pigs fed high-cholesterol diets are more likely to develop cardiovascular disease (CVD). And Watanabe rabbits lack a specific gene that prevents them from manufacturing receptors for LDL cholesterol in the liver. Normally, the liver's LDL receptors sense circulating cholesterol levels as a regulatory mechanism; if there's a lot of cholesterol floating around, the liver will react by making less cholesterol. Since the rabbits' livers are unable to compensate for high levels of LDL, they develop arterial plaques with astounding frequency. If fed a high-cholesterol diet, the rate and probability of plaque formation increases. And if animal studies aren't good enough, check out the Framingham heart study, which involves an entire town in Massachusetts that's been followed for three generations to learn more about CVD risk factors. Scientists didn't just pull the lipid hypothesis of atherosclerosis out of thin air. There's a lot of very thorough research and credible data that's been taken into consideration.

All the attempts to "debunk" the lipid hypothesis and the value of statins are crackpottery. Are they miracle drugs or cure-alls? Of course not; no one says they are.

Anyway. "Natural" methods for treating illness are popular with a lot of patients. There's something wholesome-sounding about the word, like your mother would want you to take natural products. Nevermind that natural does not mean safe; botulinum toxin is one of the most dangerous substances in the world, and it's made by bacteria. All-natural! Maybe that's why people are willing to inject it into their faces to get rid of wrinkles.

Here's a secret. Statins are natural.

Have you heard of red yeast rice? It's an interesting product. Monascus purpureus, a fungus that grows on rice, produces a wide variety of chemical compounds, including a group called mevinic acids. Naturally fermented red rice yeast is about 0.4% mevinic acids by weight. Red yeast rice supplements are not always what they claim to be on the label, but there's presumably some statin-equivalent content in there.

How about mevastatin? Mevastatin was isolated from Penicillium citrinum mold. Man, mold is great stuff. We play with mold long enough and we have this interesting tendency to serendipitiously find antibiotics and anti-cancer compounds.

Like penicillin, statins were originally isolated as naturally-occuring substances. The major mevinic acid compound in red yeast rice was named lovastatin. And guess what? It got patented. It's called Mevacor. Huh. I thought the natural medicine folks were always saying that the reason Big Pharma isn't willing to seriously investigate "natural remedies" is because they can't be patented?

That claim, of course, is a load of Penicillium fungus. Sure, you can't patent vitamin C, but you can patent unique compounds that you discover, no matter where they come from. Statins are some of the top money-makers for Pharma today (for better or for worse), and they got their start in yeast and mold colonies. Pharma would have to be incredibly to stupid to ignore nature as a potential source for useful drug compounds. It's true that most of the statins prescribed are synthetic compounds like simvastatin (Zocor). But simvastatin was made by modifying lovastatin to increase its effectiveness. Inspired by nature, proven by science. Saying Zocor is unnatural is like saying cutting trees into two-by-fours to build houses instead of just using felled logs is unnatural. By altering a naturally-occuring substance, we can make it a better drug than it would be otherwise.

If something proves to be useful, medicine will use it, whether it's "natural" or not--a false dichotomy to begin with. And if it isn't, medicine will discard it. Scientific analysis is the only way to tell the difference. And anyone who tries to tell you differently needs to go read about penicillin.

Rx Essentials: Are They Really?

2008-02-06T10:52:00.000-05:00

You may have seen a product line on the shelves recently called RxEssentials. The marketing for these new vitamin supplements is actually pretty slick; Nature Made is a big company, and they do produce some quality products. A lot of their supplements are USP Verified, which means that the United States Pharmacopoeia has verified that what's on the label is what's in the bottle. Always a good thing. I have to commend them for going the extra mile to meet those standards.

RxEssentials, on the other hand, is a clever way to get you to pay more for your vitamins than you would otherwise.

The basic claim behind RxEssentials is that each formulation supplies key nutrients for people taking specific medications. Sometimes this is the case because the drug blocks or reduces nutrient absorption; in other cases, the manufacturers seem to be taking a page out of Pauling's orthomolecular medicine, which posits that nutritional deficiencies (or, for extra woo flavoring, "imbalances") are the root cause of basically every disease ever. There's a little bit of truth to some of this reasoning. Some drugs do reduce absorption of specific vitamins or minerals. Isoniazid, which is used to treat tuberculosis, can reduce vitamin B6 levels to the point where patients may actually suffer neurological problems if they fail to supplement. And methotrexate, an immune system modifying drug, is usually given with folic acid to prevent deficiency--methotrexate actually works by inhibiting the conversion of folic acid to its active form, tetrahydrofolate.

So let's look closely at RxEssentials. What do they offer that your basic multivitamin might not? They cost, on average, about $10 a bottle for 60 tablets, a two-month supply.

The arthritis formula is recommended for anyone taking ibuprofen, naproxen, or aspirin to relieve arthritis pain. It contains vitamin C, vitamin D, and folic acid. Fail. None of these drugs are going to significantly impair absorption of these nutrients, and most of that 500 mg of vitamin C is going to end up excreted in the urine. Vitamin C is abundant in the diet, and vitamin C tablets are dirt cheap ($6 for 250 tablets is pretty common). The most valuable component of the formula might be the vitamin D; most people with arthritis are older, and most older people get insufficient vitamin D. But vitamin D isn't expensive, either. An inexpensive multivitamin a day is going to cover everything.

The cholesterol formula is designed for patients on statin drugs--Lipitor, Zocor, or their close cousins. As expected, it contains CoQ10. Oh, and B-vitamins, but those are in everything, including bread. CoQ10, or coenzyme Q10, is commenly touted as a means of preventing muscle damage due to statin use. Unfortunately, the evidence doesn't hold up. Some studies show benefit; others don't. One study using 200 mg of CoQ10 daily showed no benefit but noted that patients might respond due to the placebo effect. Another showed some benefit with a 100 mg dose. The evidence is inconclusive. CoQ10 is also kind of expensive, as much as $20 for a bottle of 30 softgels containing 100 mg each. RxEssentials might actually be the better buy if you're dying to try CoQ10, but that's not saying much.

I have to admit that I find the depression formula particularly lacking. B-vitamins, folic acid (maybe for pregnant, depressed women?) and vitamin D. Yes, it's the old "depression is caused by vitamin deficiencies" gambit, except that they're telling you to stay on your Zoloft or Prozac and "supplement." More orthomolecular medicine at work. B-vitamins are important cofactors in energy production; the idea is that a lack of B-vitamins results in "decreased energy," which somehow translates into "depressed mood," "sleep disturbances," "loss of pleasure in daily activities," and, my personal favorite, "suicidal ideations." There is no evidence whatsoever that nutrient deficiency is a primary cause of depression; B-vitamin deficiencies can cause neurological problems, but B-vitamins are so prevalent in the diet that hardly anyone has a problem meeting their needs. You're going to get all this stuff in your (much cheaper) multivitamin. Vitamin D is great for bone health, but store brands are generally cheaper. The manufacturers are clearly assuming depressed people don't get enough sun.

I was really hoping that they'd get their heartburn formula right. An acidic environment is important for the absorption of iron, and chronic acid-suppression therapy coupled with low iron intake creates a situation where deficiency is a very real possibility. Except that there's no iron in the supplement! None! Instead, they're pushing B-vitamins again. B-vitamins are a very necessary component of nutrition. They aren't worth paying a lot of money for; they're in everything, including enriched flour, grains, vegetables, bananas, and even beer (although alcoholic beverages are not a good source of nutrients and chronic alcohol consumption, in excess, can cause other problems). Oh, and they throw in some calcium, but only 120 mg per dose. For reference, most people need 1200 to 1500 mg of calcium per day in divided doses (you can only absorb 500 mg "at a time"). It would've been easy to formulate an iron-replacement regimen for patients with acid reflux; I can't believe they blew this one.

Finally, we have the diabetes formula. In case you hadn't guessed by now, their supplement for diabetics includes--yeah, it really should've been obvious--B-vitamins! Oh, and folic acid. We wouldn't want anyone giving birth to babies with neural tube defects. Except that, of course, that's not why the manufacturers chose to include folic acid in the supplement; it's to "maintain energy." Argh! Yes, patients with diabetes have problems with "energy" metabolism; they can't properly utilize glucose to fuel cells because they produce insufficient insulin. But taking extra B-vitamins doesn't help the body utilize glucose any better, unlike oral diabetes medications or insulin injections.

To summarize, RxEssentials gets the big thumbs-down. The manufacturers claim that RxEssentials "provide specially selected nutrients." But as you can see, most of the products contain the same ingredients: B-vitamins and folic acid. At least they're being responsible and telling people that RxEssentials are not a replacement for their prescription drugs.

There are therapeutic precedents for taking specific nutrient supplements for various conditions or with particular medications. I already mentioned a few. But any responsible physician is going to prescribe those nutrients alongside the medication--especially if serious harm will result from not having them. Note that none of these products are for people on methotrexate! Arbitrarily deciding you need to supplement is a waste of time and money.

So what should you do if you think you have a nutritional deficiency? Talk to your doctor. Evaluate your diet with information from appropriate food guides. Nutritional deficiencies have a set of clear diagnostic criteria; less-specific concerns like "I feel tired sometimes" or "I get a lot of colds" are generally not indicative of a problem. Everyone feels tired sometimes. B-vitamins are not effective in reducing the effects of "stress" or a replacement for a good night's sleep. You probably don't need RxEssentials. And even if you did, a cheaper multivitamin would offer the same benefits.

Like most dietary supplements, RxEssentials relies on good marketing to make sales. It's too bad that marketing is all they have.

Alternative Flying

2008-02-02T16:16:00.000-05:00

I'm incredibly amused by this recent offering by Science-based Medicine. Here's a small taste:

Current airplane design is based upon a white male Western European model of what powered flight should look like. Long metal tubes with wings are a phallic design that insults the sensibilities of women, who have an alternative, more natural, emotional, way of understanding airplane design. In the one size fits all design of allopathic airlines, alternative designs are ignored and airplane design utilizing the ideas and esthetics of indigenous peoples and ancient flying traditions are derided as primitive and unscientific, despite centuries of successful use.

I don't think I've laughed so hard in quite a while. Isn't it great how painfully ridiculous the notions of "faith-based treatment" become when applied to any other area?

Skeptico: Extraordinary Claims and Extraordinary Evidence

2008-02-01T13:42:00.000-05:00

Skeptico has posted a brilliant entry about why extraordinary claims require extraordinary proof. It's a common phrase, but Skeptico has done a remarkably good job of explaining its significance.

Link courtesy of PalMD's WhiteCoat Underground, another fantastic skepticism/critical thinking blog with a medical angle.

A (Sterile) Needle in a Haystack

2008-01-30T14:06:00.001-05:00

As much as I hate to flagellate a deceased equine, I really don't think my last entry drove home the point about why we need to provide clean syringes and needles to injectable drug abusers.

There are numerous arguments made by those opposed to selling (or even giving) syringes and needles to drug users. It "doesn't work; addicts will use dirty needles anyway." It "sends the wrong moral message about drug use," which we all know is of primary concern to good, patriotic citizens. And, my personal favorite, it encourages drug abuse by making it "safer."

The first argument can be refuted with science. The second can't be strictly refuted because it relies entirely on subjective opinion; despite what some people seem to think, morals are cultural values, and they vary from person to person instead of being absolute or inherent.

The last argument annoys me more than the others because it blatantly ignores reality. IV drug users may be concerned with their safety, but what constitutes "acceptable risk" for abusers of illegal drugs is not the same as it is for you and I. In clinical practice, we never have patients self-administer IV injections, partly because it is considerably more difficult than giving a subcutaneous or intramuscular injection. Not only is the technique more complicated, but the risks are considerably greater. Forget about dirty needles for a moment; let's look at all the other "safety" issues being bypassed.

1: No way to verify purity of product. You don't know how much heroin you actually have and how much of that product is fillers--many of which do not belong in your veins. Even seemingly innocuous fillers such as talc or cellulose can cause tissue death.

2: Product concentration considerations. Injectable products have to be carefully balanced so that their osmolarity does not disrupt existing tissues. A solute (drug + additives) concentration that is too high will cause cells to shrink as water is sucked out of them to equalize the concentration gradient. A concentration that is too low will result in water rushing into cells and bursting their membranes.

3: Product and injection prep environment sterility. Even if you're using a clean needle, I doubt most IV drug users prepare their doses in a laminar flow hood. When pharmacists or technicians prepare injectable drug products they must meet many standards. You can potentially contaminate your product by touching any one of various critical needle/syringe areas, failing to wipe injection ports with alcohol, cleaning the hood improperly before use, taking your hands out of the sterile environment, leaning too far into the hood...the list goes on.

A "clean" needle is just the first step to sterility. You don't buy heroin in multidose glass vials that meet USP standards for purity and stability, buffered to appropriate pH and preserved with appropriate IV-safe additives. You buy heroin from a shady drug dealer in a back alley somewhere. You have no idea where he got it. There's no one you can complain to about manufacturing standards or product flaws. The fact is that drug users are willing to introduce a substance they bought in a back alley directly into their veins, bypassing all the body's barriers against infection and introducing contaminants or particles that can directly damage blood vessels.

It is so risky to abuse IV drugs that denying addicts access to clean needles is not going to be the straw that breaks the camel's back and turns them away from their dangerous habits forever. It is going to be added to the laundry list of hazards that addicts have already classified as "acceptable risks." And it isn't just addicts; new users aren't really concerned about their safety, either, and if they tell you that they are, they're lying, whether they realize it or not. There's a serious contradiction between "I prioritize being safe" and "I'm willing to inject substances of indeterminate origin and quality directly into my veins."

So we can ignore the reality that hard-core addicts are going to shoot up whether we give them clean needles or not and live in a political fantasyland where people don't do dangerous things. Or we can face the facts.

The fact is that IV drug users don't tend to pay their medical bills when they OD or contract hepatitis. They wind up in the ER, where they cannot be legally denied care, and everyone else absorbs the shock through increased healthcare costs. When addicts end up on Medicaid, you are paying for their AZT. You are paying for their hospital stays when they're suffering from liver failure. Your healthcare costs more when you deny clean syringes to drug users and more of them become seriously ill. I'm not saying you have to approve of their habits. I'm saying that you have to consider the economic ramifications of disease control. More sick people who can't pay their hospital bills means higher hospital fees for everyone so that hospitals can recoup their losses.

The fact is that the moral paternalists who oppose needle programs--and Narcan--don't care about the lives of drug addicts. They cloak their lack of empathy with layers of political doubletalk. But even if you can't bring yourself to have basic human empathy--or honesty--look at the situation from a pragmatic perspective. You are increasing costs for the entire healthcare system every time you deny that syringe sale because Johnny the addict doesn't have an insulin prescription.

Narcan, or: Why You Deserve to OD and Die

2008-01-29T12:17:00.000-05:00

Pharmacy colleague (and I hope he doesn't mind my calling him that) and fellow blogger Abel Pharmboy provides a most excellent summary of the current buzz in the blogosphere about statements made by Dr. Bertha Madras. Dr. Madras, in the event that you were unaware, is a head member of the White House Office on National Drug Control Policy. And Dr. Madras would rather see opioid abusers die than distribute rescue kits that "encourage" opioid use.

I'm sorry, I thought we lived in a country that gave a damn about whether or not its citizens lived or died. Apparently, moral paternalism trumps compassion, which should be no surprise considering the government's track record with the "war on drugs."

This provides me with a handy segue into a topic that bothers me immensely: Pharmacists who refuse to dispense needles and syringes without a prescription, even in states that have laws that protect them from liability. Dispensing syringes without a prescription is clearly legal in 26 states, and most states that permit dispensing without a prescription absolve pharmacists (and technicians) of all responsibility.

The risk of contracting AIDS, hepatitis, or other blood-borne illnesses is not an effective deterrent for IV drug-users. Thinking otherwise is just flat-out delusional. If you believe that denying clean needles to drug users is going to make the give up their habit, you are way off. Drug use, especially injectable drug abuse, is a risky behavior, and it is an all-consuming urge. The fear of withdrawal symptoms is often considerably more powerful than the fear of contracting an illness. Many AIDS or hepatitis patients have no symptoms; they don't even know they carry the disease. They can and will pass that disease to others. It isn't that they don't know that sharing needles is dangerous. Using heroin is dangerous, too. The issue is that the risk is acceptable, given the information that they have. And if you don't know you're a carrier for a disease, you don't have all the information, which means that you're going to incorrectly evaluate the odds.

What denying needles (and Narcan) to addicts does do is send a powerful message. It says "society doesn't care about you, and we're secretly hoping you die so that we don't have to deal with the problem anymore." These are the same people who think you deserve to be punished for unintentionally getting pregnant. They don't care about outcomes. They don't care any more about addicts than they care about single mothers. They can all die, and decrease the surplus population.

They just want you to shut up and pay your taxes.

Seeing the Forest for the Trees

2008-01-29T11:06:00.000-05:00

I have mentioned my aggravation with Forest Pharmaceuticals before in the context of their excessive promotion of Namenda, a drug to "delay the progression" of Alzheimer's disease. While Namenda is effective, the drug reps I've talked to have a tendency to really push it as being significantly better than it actually is, especially since we're looking at doubling the cost per patient and increasing "pill burden" for patients or their caretakers. There's nothing more depressing to me than seeing families spending a fortune on medications for Alzheimer's while watching their loved ones deteriorate despite treatment.

On the other hand, Forest's Lexapro is a follow-on drug that's actually been demonstrated to be better than its parent. So maybe they aren't all bad.

Then they released Bystolic.

Bystolic is a beta-blocker. The market is positively overflowing with beta-blockers. Metaprolol, atenolol, propranolol...a dozen or more drugs. Granted, they have subtle differences, but Bystolic doesn't bring anything new to the table.

Beta-blockers reduce adrenergic (adrenaline-mediated) stimulation of the heart and blood vessels, slowing heart rate and dilating arterioles to decrease blood pressure. B-blockers aren't as good at lowering BP directly as some other drugs, but they are quite useful in preventing further damage to the heart after a myocardial infarction (heart attack) and in treating irregular heartbeats. Intriguingly, propranolol can even be used to prevent migraines, though the precise mechanism of action is not well-understood.

Bystolic is only approved to lower high blood pressure, but Forest is hoping to get it approved for patients with heart failure as well. Unfortunately for Forest, we already have a great cousin drug that has both indications--carvedilol--and it's available generically as of last year.

I realize that sometimes drugs get stuck in the research pipeline and the company gets so far into development that not releasing the drug is a bad financial move even if the drug is not likely to "sell." But Forest has likely spent enough money producing Bystolic that they must find a way to get physicians to prescribe it despite the fact that Bystolic is a "useless" drug. Sure, it works, but no sane clinician is going to prescribe it given a myriad of equally effective alternatives that cost one-fourth as much.

Unless, of course, Forest sends out their reps to promote it. Which means that it's a safe bet that Forest is going to spend a lot of money to advertise a drug that you'd have to be incredibly foolish to prescribe. Drug research and development costs are very high, but pharmaceutical advertising inflates prices beyond what is reasonable. And if given a sufficiently convincing sales pitch, many physicians might prescribe the drug anyway. Many doctors just don't know how much drugs cost. I have personal experience in the matter; I make a lot of phone calls when I'm working to ask physicians to switch to cheaper alternatives or to permit generic substitution when they've signed something "dispense as written" for no good reason (dermatologists, I'm looking at you).

Come on, Forest. You can do better than this. I know I saw your vague, almost viral ads in pharmacy magazines and got a little excited about your "new development in the treatment of hypertension." At least throw us another direct renin inhibitor instead of trying to pass off a totally underwhelming drug as the next big thing.

Introducing...RxWiki!

2008-01-25T00:22:00.000-05:00

I'd like to point you all in the general direction of RxWiki.

RxWiki is a wiki that only licensed pharmacists are permitted to edit; it's being compiled as a resource for anyone, but it's generally being directed at patients. I've been browsing it a bit myself, and I'm very impressed so far. Apparently they have a panel of pharmacists who review everything and approve articles, and they're endorsed by the APhA.

I do take serious issue with their little blurb that's currently on the front page about placebos. The information presented in the articles seems solid, though.

Check it out. I think it might just become my new source for links whenever I cite a drug name.

Feel the Buzz

2008-01-23T12:59:00.000-05:00

A friend of mine specifically asked for my opinion on a novel product. Now, I must say. From a marketing standpoint, this is brilliant and hilarious. It's the kind of thing I might be willing to spend a couple dollars to buy if I saw it on the shelf just because it would increase my geek score by ten points. After being provided with the supplement facts for the product, I began an in-depth analysis.

This product is analogous to 5-hour Energy and similar "energy shot" products, which, if you really want to, you can get at any drugstore, gas station, or supermarket for a couple dollars apiece. The common claim is that products like 5-hour energy provide you with a long-lasting jolt without "jitteriness" associated with caffeine use or "carb crash." Energy shots typically contain little or no carbohydrates, so they won't elevate your blood sugar directly. The caloric content is generally very low. Which means that any energy boost these products provide is all due to the stimulant content--in other words, the caffeine.

Red Bull comes in 8.3 ounce cans. One can has approximately 80 mg of caffeine. A 12-oz Mountain Dew has about 50 mg of caffeine, a Dew Game Fuel has 72 mg, and a can of Coke has about 25 mg. The caffeine of coffee varies depending on preparation, but you're looking at an average of 100 mg per 8 ounce cup. Typical caffeine tablets have 200 mg per tab. For more information on the caffeine content of various products, check out this handy table.

Energy shot products claim to be different from caffeine because they contain B-vitamins, amino acids, and enzymes.

The B-vitamins aren't likely to have toxic side-effects, even at very high doses. They also aren't likely to do anything beneficial, because B-vitamins are water-soluble and you're going to end up dumping all of the excess out in your urine. B-vitamins are important for energy metabolism, but they're also in everything. Most grains are fortified with B-vitamins, including breakfast cereal. Very, very few people have legitimate B-vitamin deficiencies. And they're not something you would miss; insufficient B12, for example, can cause nerve pain and other neurological problems. Extra B-vitamins will not make you more energetic, much like intranasal, sublingual, or injected B12 will not give you a "boost," unless of course you have pernicious anemia, which is best diagnosed by a physician able to test the levels of B12 in your blood.

The "enzyme blend" in the product is presumably being touted as aiding in the metabolism of whatever energy stores you have or whatever food you've eaten. Amylases break down carbs. Cellulases break down indigestable starches (cellulose) found in plants. Lactases break down milk sugar (lactose), lipases break down fat, and proteases break down protein. The claim is that by putting these things into your stomach you will better digest anything that's in there and get more energy. The even more far-fetched claim is that by consuming lipases, for example, that you will break down stored fat in your body.

This is all wrong. Enzymes are proteins. Proteins are rapidly digested and broken down into component amino acids in the human stomach. Those enzymes will suffer the same fate as any hamburger. And they won't do anything in the stomach because enzymes have very specific pH requirements; it is unlikely that they will be active in the acidic environment of the stomach.

There are exceptions to this; it is possible to take lactase capsules to overcome lactose intolerance, for example. But this works because the lactase is protected by a coating to allow it to survive the stomach and reach the intestine. Lactase suspended (not dissolved; proteins are not water-soluble) in some liquid is going to get chewed up by gastric proteases, as are other enzymes thrown into the stomach.

L-taurine is an amino acid that might have some stimulant effects. Glucuronolactone is a by-product of glucose metabolism in the liver; it is touted as a fatigue-fighter, but there's not a lot of evidence to support this. And of course, there's a lot of caffeine. As I said before, the majority of effect of this product will come from the caffeine, which means that it will have the exact same effects--and side-effects--as heavy caffeine use, such as tremors, anxiety, heart palpitations, increased blood pressure, and insomnia. Mana Potion, like 5-hour Energy, is no different from taking a caffeine tab alongside a B-complex vitamin. As far as pharmacologic effect goes, that's a much more economical way to achieve the same outcome as this product. And an ounce or so of fluid is not doing you any favors in the hydration department, so that's not a good reason to prefer liquid shots over solid tablets.

Coffee, without sugar or cream, doesn't contain carbohydrates, fats, or proteins. As such, it is non-caloric. So if you really want a low-cal caffeine fix and you think popping Vivarin makes you a junkie, drink black coffee.

If you don't like coffee and really want a no-cal caffeine fix, and you don't want to pop caffeine tabs, uh...you're out of luck, I guess. You could always switch to...er...diet Mountain Dew?

Or you could shell out for overpriced "energy shots."

Randi 1, Cranks 0

2008-01-21T13:42:00.000-05:00

XKCD is, as usual, short, sweet, and to the point.

Politics + Science = Plug

2008-01-19T17:50:00.000-05:00

The SHARP Network, provided by Scientists and Engineers for America, is a really neat website/database where you can look up your congressional representatives and see how they've voted on various important issues (education, energy, health, grants, stem cell research, etc). These issues are important to everyone, not just scientists, and having handy access to information is always a good thing.