Progenitorivox

Enough is enough! Stop the me-too drug explosion now.

Ask your doctor.

Did Danny Carlat write this song?

Gotta get me some of this.

Are Drug Reps Going to the Dogs?

Is it unethical for my dog to accept treats from a pharmaceutical representative? 

Reps can't influence my prescribing with free pens and sticky notes, or by taking me out to lunch, but where there's a will there's a way. Last week a drug rep brought treats for my dog who always comes to the office with me. (Even if they were FDA approved, I'm sure this is an off-label use.) At least the drug name doesn't appear on the treats.

Now every time I write a prescription for the rep's drug my dog rolls over, and when I write for a competing drug he growls!

Pharmacists Gone Wild

(Facts altered to disguise cases.)

• A patient relates that her pharmacist told her if the increased dose of her medication failed to produce improvement in her symptoms after 21 days at the higher dose, she should revert back to the original dose.
• A pharmacist faxes me to ask the diagnosis of a patient, even though the patient pays cash for the prescription, and there is not insurance company involvement.
• A pharmacist tells a patient that a drug I frequently prescribe can be very sedating, when in fact most patients complain that it does not sedate them enough.

Everyone seems to want to play doctor these days, but how much do we want pharmacists to get into that role? There is something to be said for having each of every patient's diagnoses accessible from the pharmacy data bank. For example, it might prevent an asthmatic patient from using a potentially fatal beta blocker. But can we trust them with psychiatric or substance use disorder diagnoses? My patients already complain about pharmacists talking about such diagnoses where other customers can hear.

The first item above appears to clearly involve exceeding the boundaries of a pharmacist's competence and authority. This probably has happened as long as their have been pharmacists, but does the current climate encourage non-physicians to take liberties, possibly to the detriment of patients?

Benzodiazepine Backlash

In the July/August, 2009 issue of the Bulletin of the King County (Washington) Medical Society psychiatrist August Piper, MD asks, “Has the Time Come to Cease Thinking of Benzodiazepines as Routinely Addictive Drugs?” My response appears in the September/October issue and below with minor modification:

Regardless of the answer to Dr. Piper's question I would like to present some arguments against prescribing benzodiazepines routinely.

Benzodiazepines are not bad drugs and have many indications. Many patients do take them without becoming addicted to them. We use them for anesthesia and to manage withdrawal from alcohol, opiates, and other central nervous system depressants, including benzodiazepines. We use them to treat epilepsy and to manage status epilepticus. They are safer than the drugs they replaced: acetylcarbromal, chloral hydrate, chlormethiazole, Doriden, ethchlorvynol, ethinamate, Equanil, glutethimide, meprobamate, methaqualone, methyprylon, Miltown, Noctec, Noludar, paraldehyde, Paxarel, Placidyl, Quaalude, Sopor, thalidomide, Thalomid, Valmid, mostly names we do not hear any more, and others.

The risk of addiction to benzodiazepines is very real. Patients addicted to them and other drugs seek them from physicians and will lie to obtain them. Use of benzodiazepines can produce a “high” or euphoric effect. Other risks include dangerous interactions with drugs like buprenorphine, alcohol, and other central nervous system depressants. Use of these drugs can lead to disinhibition, impaired judgment, and amnesia. Impairment of motor coordination may not be accompanied by awareness of impairment.

Benzodiazepines can help build a thriving practice. Most patients like to take them and do not like to skip a dose. What I do not like about this is that eventually I am unable to determine whether the patient continues to take them because they really need them or because they like them.

For treatment of insomnia and anxiety many other classes of drug offer substantial advantages, but both conditions often respond to behavioral intervention alone. Most antidepressants effectively treat anxiety and gabapentin and pregabalin may offer advantages as well.

Grand mal seizures can result from abrupt discontinuation of benzodiazepines. Dr. Piper argues that abrupt discontinuation of other “drugs” not usually considered addictive can produce symptoms, but none of these drugs or classes is typically used to get high or can be purchased on the street (except that the class “anticonvulsant” includes barbiturates and benzodiazepines), and in my experience patients almost always find discontinuation of benzodiazepines more unpleasant. To say discontinuation of insulin can lead to symptoms is like saying discontinuation of oxygen can lead to symptoms.

Whether we should consider benzodiazepines “routinely addictive” (whatever that means) or not, Dr. Piper has failed to convince me to prescribe them for anxiety or insomnia.