But Think of the CHILDREN!

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

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.

Thought Experiment

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.

Doing One's Duty

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.

Yes, We Have No Tobacco

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.

Doing the Minimum

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?

Advertising in Bizarro World

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.

Really Delayed Ambulance Chasing

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?

A Total Waste

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.

A Remarkable Lack of Self-awareness

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.

Filling the Void

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.

Please Understand Me--and Shut Up

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.

Lose Weight--Naturally!

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?

A (Sterile) Needle in a Haystack

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

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.

Questionable Diagnosis, FDA-Endorsed Treatment

The New York Times ran an interesting article the other day about the use of Lyrica for fibromyalgia. Lyrica was recently approved by the FDA to treat the condition in addition to existing approvals for nerve pain and seizure disorders.

The question on the minds of a lot of medical professionals is whether or not we now have an approved treatment for a disease that may not exist.

Fibromyalgia is kind of weird. My clinical assessment professor, an emergency department doctor specializing in internal medicine, expressed the opinion that fibromyalgia was essentially a BS diagnosis that drug-seeking patients rode as far as they could to get their hands on painkillers to abuse. He seems to have overlooked the fact that most fibromyalgia sufferers say they don't get relief from opiates. In any case, I wouldn't go that far, myself, but as I understand it, the literature on fibromyalgia is iffy.

Most theories suggest that fibromyalgia is a chronic pain disorder characterized by abnormalities in nervous conduction that result in a lower pain threshold in affected patients. However, fibromyalgia has also been used as a "blanket diagnosis" of sorts for patients with non-specific aches and pains, fatigue, or other symptoms that are difficult to pin to a particular disorder.

Fibromyalgia might be a real disease with a clear cause. It might not. I don't have data on hand to form an opinion one way or the other. But I would be willing to bet very large amounts of money that only a fraction of patients "diagnosed" with fibromyalgia are actually ill in any medically identifiable way. Fibromyalgia, like "chronic fatigue syndrome," is essentially a diagnosis that your poor, stressed doctor can make when he's at the end of his rope and ready to give up.

I say this because no MD in his right mind is going to jump to fibromyalgia as a first diagnosis. For example, acute trauma, infection, and diabetes are all going to be considered first as sources of weakness, tiredness, or pain. All of these can be screened for or quickly ruled out by physical exam. Psychogenic illness--in essence, the idea that faulty brain chemistry is responsible for your problem--will probably be proposed at some point. Sufferers of depression, for example, frequently present with fatigue or difficult-to-explain aches and pains. You will try SSRIs, tricyclics, Wellbutrin, SNRIs, lithium, and electroconvulsive therapy before you get tired of treatments that aren't helping.

A dozen lab tests, MRIs, and lumbar punctures later, your poor doctor will conclude that it's not Lupus and be forced to diagnose you with fibromyalgia for lack of any better ideas.

In any case, studies demonstrated that patients diagnosed with fibromyalgia improved more when given Lyrica than when given a placebo. So you could make a case that Lyrica isn't a sham treatment; it's not like using homeopathy for fibro, but I'm sure people have tried it--and felt better afterward.

So it all comes back to placebophilia. What's worse, giving patients with non-specific symptoms of a questionable disease a drug with potentially inconvenient side effects or the same patients treating themselves with fake medicine? Ethically, I'm opposed to "therapeutic placebo usage," but the question is still there. We don't want to give patients medication that they don't really need. Are we doing that here?

Only time and research will tell. Maybe someday we'll get a handle on fibromyalgia. Maybe not.

Old News: Still Sucks

Laws like these have been getting pitched around a lot lately, mostly in the wake of the Plan B "controversy" perpetuated by people who think they have more right to control what goes on in a woman's uterus than individual women do. And if they can't pass laws making contraception, abortions, or premarital sex illegal, then by God, they're at least going to try to shame everyone on the face of the earth into submission.

And by "everyone on the face of the earth" I mean Americans. Who else is there? I suppose there are those outside-the-box thinkers that are willing to look at the problems of Africa.

Here's what bothers me. It's not that the bill is being discussed, because that's old news. It's not the reality-blind moral paternalism that's associated with these issues. It's the fact that the Indiana Pharmacist's Association is supporting the bill. The priorities of the IPA are clear. They really are the Indiana Pharmacist's Association, because they definitely don't represent patients.

This whole issue hinges on the idea that a pharmacist's sense of moral culpability is going to cause emotional damage to a pharmacist forced to dispense "objectionable products" against their will. That's totally more important than the emotional and financial culpability of an unwanted child. That's what you get for fooling around, I suppose. There's your lesson. There are people--and more frighteningly, health care professionals--who think you deserve to be punished for having sex.

Incoming ad hominem: I am not one bit hesitant to say that those people are inhuman monsters. I suppose it's not really an ad hominem. I'm not saying they're wrong because they're monsters. I'm saying they're monsters after the fact. Move along, no logical fallacies here.

You know, type II diabetes is typically caused by insulin precipitated by obesity. Obesity is commonly caused by overeating, and gluttony is a sin. I think I'm going to stop dispensing metformin, glipizide, Actos, Januvia, Byetta, and every other medication used to treat type II diabetes, because clearly, type II diabetics did it to themselves. They know the risks of unhealthy diets and lack of exercise. They're to blame if they didn't listen. I'll still dispense insulin, though, but only to type I diabetics who can provide the results of lab testing proving that their condition is genetic or autoimmune. Those people are being challenged in the strength of their faith by god, which is why they were created with terrible birth defects.

And no more cholesterol-lowering drugs, either. We all know that diets high in cholesterol are unhealthy, and the most prominent sources of cholesterol in the diet are animal products. The use of animals for food is unethical. If everyone were vegan, we wouldn't need Lipitor. The patients who die of heart attacks due to atherosclerotic occlusions are totally responsible for their own undoing.

I would say something about antidepressants in mockery of Scientology, but that ship has sailed, and they launched it themselves. I hope they didn't waste good champagne.

Come on, people. We've been through the Jehovah's witness scenario a dozen times. Is a JW physician allowed to refuse to give blood transfusions because he believes he's endangering the patient's immortal soul? Don't become a medical professional if you aren't willing to do your job.

Fair and Balanced Reporting

The real problem with taking on quacks and misinformation in popular media is that if I spent all my time doing it I wouldn't have time to go to class, eat, sleep, or breathe. I've come to expect depressing amounts of credulity from the media. Honestly, I'm less bothered by the idea that reporters aren't doing proper fact-checking (because that's an eternal issue) and more annoyed by the fact that stories like this one legitimize fraud as actual medicine.

Ann Arough at the Little Rock Wellness Center, she listens carefully and mulls over their conversation before suggesting a remedy. Some of the things Arough, a naturopath, might suggest are herbal supplements, diet or lifestyle change, a visit to a medical doctor or with her husband, Mark, who specializes in acupuncture and Chinese medicine. Or she might suggest that they try a homeopathic remedy.

This article follows a lot of similar articles on the subject of questionable medical practices, especially those run by local newspapers desperate for stories. They always contain a certain set of specific elements:

1: Introduce the practice (homeopathy, acupuncture, ear candling, whatever is on sale at Whole Foods this week) with a brief overview of its history.
2: Touching personal story about a patient who used method X and "achieved miraculous results."
3: Quotes from an "alternative" practitioner who supports method X.
4: Short sound bite from a "skeptic" that gets turned into a variation of "X is unconventional...but...some patients say it works, so good for them."

The "skeptic" quotes are what bug me the most. The writers of these articles are trying to give the illusion that they're giving you "both sides" of a "complicated issue" by interviewing or quoting a mainstream medical professional, but what they're really doing is trying to lend an air of legitimacy to their story by getting an implicit endorsement of the s-CAM of the week.

Allopathic doctors, the physicians most people visit, tend not to understand the diluted remedies, says Dr. Stephen Hathcock, a general practice physician at the Center for Integrative Medicine in Little Rock. “I don’t know that anyone understands the science of it and Western medicine doesn’t function in that realm,” he says.

He goes on to say some silly stuff about how "energy medicine is cutting edge" and what have you. No. No no no. There is nothing cutting edge about misunderstanding quantum physics. Biotechnology, immunology, and biochemistry are the fields driving medical advancement. Not poor interpretations of electron entanglement.

I get really tired of reading these because it's like watching a bad horror movie. You know how you want to scream at the screen when the protagonists are doing something so stupid that there's no possible way they aren't doing it on purpose, unless we assume that horror movie characters have never seen a horror movie themselves? I get the same way about these sorts of statements about homeopathy. Maybe you "don't understand the science of homeopathy" because homeopathy is magic. There is nothing vaguely scientific about it unless we're talking shifting from physics and chemistry into the realm of psychology. At that point, it becomes easy to understand how homeopathy, like many CAM treatments, can be effective: Ye olde placeboe effecte.

Of course, as I've said before, patients like placebos. I recall hearing a story about a patient who wanted his doctor to sign a contract saying that his doctor would try to maximize the placebo effect whenever possible, essentially giving the physician license to "fool him" if it would help with his symptoms. The doctor, on totally reasonable ethical grounds, refused. But the story illustrates my point well. Patients don't typically care how they get better; they just want to do it. And if homeopathy, megadoses of vitamins, or acupunture make them feel better, or give them a sense of empowerment regarding their illnesses, they're going to go for it. But they wouldn't have tried those methods in the first place if someone hadn't recommended them, directly or indirectly. And the lack of willingness of many medical professionals to condemn outright CAM for fear of alienating their patients--or worsening their treatment outcomes--creates a nasty ethical quagmire.

Sometimes you get item 5, which is "alternative medicine practitioner really, really wishes they would license practitioners of X in their home state to ensure quality of care."

She and her husband returned home to Arkansas about two years ago, and she intends to lobby for licensure legislation here, which would allow her and others to practice medicine according to her training, and, she says it would create standards that would ultimately protect patients.

Yeah. I'd much rather see a witch doctor with a degree from Harvard than a witch doctor who picked up his trade from correspondence courses online.

I may write the editor of NWAnews. I may not. I have a feeling my words will fall on deaf ears. Personally, I think this represents the ultimate failure of the media; its tendency to portray and even create controversy where there is none. The scientific consensus--which is the only one that matters, when we're talking about science--is that homeopathy is nothing more than a ritualized placebo. Science isn't like politics. You can't put reality to a vote if you don't like it, and there are such things as absolute truths. "Fair and balanced" reporting implies that both sides of a "controversy" have equal weight. In this case, they do not.

Why can't we bury this issue once and for all?

Oops, I Diverged Into Politics

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

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

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

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

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

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

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

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

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

Drug Use, Paternalism, and Freedom

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

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

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

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

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

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

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

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

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