From the Archives: Have Americans Become Afraid of Their Doctors?

Noncompliance and the paranoid style.

[Originally published June 27, 2007]

Note: In the everlasting battle between consumers and Big Pharma, amid a string of recent exposes concerning whose doctor took what payment under which table, I am republishing an essay I wrote several years ago, in which I attempt to view the doctor/Pharma/patient interaction from a different angle.


Once upon a time, Americans went to their doctors to get pills. Doctors complained that patients believed competent medical care consisted of being handed a prescription. In the absence of that piece of paper with the unintelligible signature, a patient was apt to claim that the doctor’s visit had been a waste of time. What was the point of seeing a doctor if the doctor didn’t give you anything that would cure what ailed you?

That was then. Patients now demand that doctors and pill makers come clean about the safety of the products they offer (long overdue), and that the pills themselves be absolutely benign in their effects (utterly impossible). In ever-greater numbers, Americans are coming to fear prescription drugs. This condition, in extremis, is a phobia with a recognized set of diagnostic criteria: pharmacophobia—an abnormal fear of medicine.

Today, Americans go to their doctors to be healthy and “drug-free.” If they are taking prescription medications, their goal is to get off them. Yesterday, patients demanded pills for conditions they didn’t have, or for which pills were ineffective. Today, patients are routinely filing lawsuits, demanding to know why their doctor gave them pills. Ironically, one of the major hindrances to health care, from a doctor’s point of view, is “patient non-compliance”—sick people often don’t take their pills properly. (This may be a good place to note that I do not work for, or with, or against Big Pharma, as the drug companies are now called. I don’t work for anybody.)

The drug industry, one of the most tightly regulated industries in America, is the kind of corporate villain Americans understand. What particularly rankles many critics is that the drug companies advertise. They market.

“Presumably,” Joseph Davis concedes in his jeremiad against drug advertising in the journal Hedgehog Review, “some percentage of those who identify their face and their feelings with those signified in the ads actually suffer from a debilitating condition. So much to the good.”

But of little significance, it seems. The central issue for Davis is: What if people who don’t need those pills are exposed to those ads? Normal people might think they need those pills—and they don’t! And very soon, as you can easily see, you’ve got trouble in River City. In the same issue of Hedgehog Review, biomedical ethics professor Leigh Turner professes similar shock, recounting with indignation “a world where a host of marketing strategies are used to package tidy, authoritative, and often profoundly misleading claims” about the safety and effectiveness of products. You can imagine how I felt when I learned that commercial advertisers were capable of doing that.

For lack of a better term, we will have to settle for calling it the real world, where soap, life insurance, housing, cars, psychiatric care, and legal advice are all marketed in misleading ways, to people who don’t always need them. And so it is with pills. However, where once patients desired this, they now resent the offer. Writing in the May 2007 issue of Harper’s, Gary Greenberg declares that “Under the agreement we’ve made—that they are doctors, that I am sick, that I must turn myself over to them so they can cure me—the medicine must be treated with the reverence due a communion wafer.”

Previously, patients wanted their communion wafers, and doctors were often accused of withholding them. Now, as Greenberg makes clear, patients fear doctors will drag them to the altar and force the holy wafers down their throats. One cannot help wondering what manner of pact Greenberg would like to arrive at with his treating physicians. His approach does not seem like a particularly promising step forward in doctor-patient relations.

Interestingly, Americans have shown little interest in a thorough examination of the adverse side effects of non-pharmaceutical approaches to health. Talk therapists and holistic practitioners of every stripe operate in a virtually regulation-free environment. Where, for example, can one find a list of common side effects associated with the practice of various forms of psychotherapy, from post-Freudian talk therapy to, say, the increasingly popular varieties of cognitive therapy? Where, I would like to know, is the list of unwanted side effects that can occur as the result of an on-air encounter with that manipulative bruiser, Dr. Phil?

Science writer Sharon Begley, in a June 18 Time column entitled “Get Shrunk at Your Own Risk,” declares: “What few patients seeking psychotherapy know is that talking can be dangerous, too—and therapists have not exactly rushed to tell them so.”

Among many other examples, Begley reminds us of the “recovered memory” therapies that tore families apart and sent innocent people to prison for the alleged sexual abuse of children. And “stress debriefing,” a method of re-experiencing traumatic events in an effort to eliminate Post Traumatic Stress Disorder, sometimes leads to increased stress and higher levels of anxiety, compared to PTSD victims who do not undergo such therapy. I’ll privilege an upset stomach and occasional loose stools from pills over that kind of deep-seated trauma any day.

Begley also cites a 2000 study of professional grief counseling which concluded that four out of ten people grieving for the death of a loved one through formal therapy would have been better off with no therapy at all. Compared to a control group, 40 per cent of mourners in professional therapy experienced increased depression and grief. (In some cases, the most benign contraindication is when the treatment doesn’t do anything at all.)

The side effects associated with talk therapies remain shrouded in mystery. “The number of people undergoing potentially risky therapies reaches into the tens of thousands,” Begley concludes. “Vioxx was yanked from the market for less.”

Pill Head: Book Review

Desperately seeking Vicodin.

Recently, the Office of National Drug Control Policy, home of the nation’s “drug czar,” released a survey of the nation’s drug use, demonstrating that prescription drugs used non-medically have become the nation second most “abused” drug, after marijuana. In addition, the Substance Abuse and Mental Health Services Administration (SAMHSA) chipped in with a cheery report that painkiller drug abuse had increase by a staggering 400% from 1998 to 2008.

 Radio entertainer Rush Limbaugh’s 2006 bust put prescription drug abuse on the public radar. Limbaugh surrendered to authorities on a charge of prescription fraud involving pain pills, the result of a three-year investigation into Limbaugh’s addiction to oxycontin—an addiction that may have cost him his hearing.  (Earlier, in 2001, Winona Ryder was arrested for shoplifting and found to have collected 37 prescriptions for painkillers from a total of 20 different doctors.)

Joshua Lyon, the young author of Pill Head: The Secret Life of a Painkiller Addict, can tell you exactly how people have pulled that off: Steal a prescription pad. “Doctor shop” with a list of hard-to-disprove physical ailments. (Migraine is a favorite.) Impersonate a physician and call a pharmacy if you have his or her Drug Enforcement Agency (DEA) number. Perhaps connect with a corrupt pharmacy employee, or with an organized ring of truck thieves. Another favorite is stealing pills from old people. Or you can suck it up and try buying them in bars or on the street. For a while, Joshua Lyon found a workable shortcut: “I just posted a bulletin on my MySpace page, asking if anyone had any Vicodin they wanted to sell. By the next day I had three different offers.” Users have learned to easily circumvent the time-release formulations by crushing the pills and snorting the powder, like Edie Falco’s Nurse Jackie. Corrupt doctors don’t appear to play a major role in much of this, even though they are a favorite DEA whipping boy.

Lyon’s pain pill odyssey began in 2003 when, as a 27-year-old reporter for Jane magazine, he was assigned a story about the “no prescription needed” Internet pill farms that were stuffing everyone’s email inbox with spam about cheap drugs. The author placed his orders, and in a few days, received Fed Ex boxes containing Xanax, Valium, and Vicodin. In only one case was he required to talk to a prescribing doctor over the phone. The "doctor" briefly asked him why he wanted painkillers, and then simply asked him how many pills he wanted.

No stranger to drug use, and a frequent habitué of the gay club scene in New York City, Lyon quickly discovered that prescription opioids were his drugs of choice. “The media,” he writes, “hadn’t dubbed us ‘Generation Rx’ for nothing.” A DEA official told Lyon: People taking Vicodin or hydrocodone, which is probably the most popular pharmaceutical drug in the United States, get the same rush as they would taking heroin, but you’re taking something that people perceive to be safe.”

There is at least a partial answer to prescription drug abuse: digital prescription databases. Unlike other addictive drugs, opioid medications begin life as legal compounds, licensed and produced under specific federal guidelines. The implementation of an electronic prescription drug reporting system, something several states have already undertaken, is a first step, but is obviously limited by the lack of a federal clearinghouse. And privacy concerns have hampered attempts to systemize the collection of prescription records from different doctors.

A health worker in a Lower East Side naloxone program told Lyon that if he called the ambulance about an OD, “don’t tell them that it’s an overdose. Tell them your friend has stopped breathing. They’ll come faster that way.”

All of this makes the ready availability of naloxone, the anti-overdose drug, an ethical imperative. See my posts on overdose kits for opioid addicts HERE and HERE.

Graphics Credit: http://blog.makezine.com/

Common Medicines That Can Kill You [Guest Post]

Legal but lethal.

[Today’s post was written by Kat Sanders, who regularly blogs on the topic of pharmacy technician certification. She welcomes your comments and questions at her email address: katsanders25@gmail.com.]

Medicines are supposed to save lives, but as with all things that are not used responsibly, they end up killing people more often than not when they are abused. It’s not just illegal drugs that kill; even the ones that are prescribed have the potential to become dangerous when they are not used as they are supposed to be. While we know that heroin, crack and other illegal substances cause death in the event of an overdose, we are not aware of many others that are relatively unknown, but just as dangerous. The below list is not exhaustive but details just a few of the drugs that could lead to death if abused.

NPF: Non-Pharmaceutical Fentanyl has been responsible for more than 1000 deaths (those that have been reported--there are definitely going to be many more that went unnoticed or unreported) between 2005 and 2007, according to the US Center for Disease Control and Prevention (CDC). NPF is a painkiller, one that is also illegally produced and sold because of its narcotic effects. Since it is much cheaper than heroin, sales are high, as are the deaths that it is responsible for. What people do not realize is that when this drug is produced illegally, it is 30 to 50 times more potent and risky than heroin.

Codeine: We would hardly think that the cough syrups we obtain over the counter could end up killing us, but the codeine they contain is a narcotic that causes hallucinations if taken in large amounts. And when cough syrups are abused, they could end up being potentially dangerous, like the case of Chad Butler, the rapper more popularly known as Pimp C. The singer already suffered from sleep apnea, and large amounts of codeine combined with sleep apnea is apparently enough to cause respiratory problems and cause death.

Acetaminophen (Paracetamol): While paracetamol alone cannot cause death, if you are a habitual drinker, your liver is already weak and damaged. And when you take large doses of paracetamol under such conditions, you may start feeling the symptoms in a day or two; you may experience a stomach ache, vomit, and feel pretty ill. Death, if it occurs, happens after four or five days after the overdose, if you do not take any treatment at all in the interim.

Opioid painkillers and Anti-depressants: This combination was responsible for killing up and coming actor Heath Ledger. The star, who was said to be increasingly despondent and depressed, was on anti-anxiety drugs and painkillers as part of his prescription. An overdose (a combination of six different drugs that included sedatives and painkillers) found him dead, just before the release of the blockbuster movie The Dark Knight, the latest in the Batman series and the one that saw him winning a posthumous Oscar for his devilish portrayal of the Joker.
The CDC reports that accidental drug overdoses are responsible for the death of more than 22,000 Americans every year. In fact, it is the second leading cause of preventable deaths, next to automobile accidents. And this is why we need to be extra careful and exercise caution when handling drugs and medicines.

Photo Credit: Canwest News Service

addiction drugs

John McCain and Ambien

Is he sleep-driving through the campaign?

After the last three weeks of erratic and unpredictable behavior from presidential candidate John McCain, it seems reasonable to revisit an issue first raised in May by ABC News: Is McCain’s use of the drug Ambien as a sleep aide affecting his behavior and judgment?

After the press was allowed a brief look at candidate McCain’s medical records earlier this year, Dr. Peter A. Fotinakes of the St. Joseph Sleep Disorders Center in Orange, California, told ABC News that, while Ambien was generally a safe medication, “Taking more than the recommended dosage of Ambien or combining it with other sedative-hypnotics--for example, alcohol—may result in amnesia, fugue states, and sleep walking.”

Ambien’s official website lists other reported effects: “A variety of abnormal thinking and behavior changes have been reported to occur in association with the use of sedative/hypnotics. Some of these changes may be characterized by decreased inhibition (e.g. aggressiveness and extroversion that seemed out of character)....”

In addition, some users have reported bizarre personality changes such as excessive agitation and depersonalization (a dissociative disorder in which the patients self-perception is disrupted). A very small percentage of patients suffer hallucinations attributed to Ambien.

However, the most baffling side effect of Ambien is so-called “sleep-driving,” in which a person on Ambien drives a car, even though they are not fully awake, and then suffers amnesia about the event afterwards. Combining alcohol and Ambien increases the risks of such amnesiac behaviors, variations of which can include “preparing and eating food, making phone calls, or having sex,” all without conscious awareness, according to the Ambien website.

And there are particular caveats associated with the use of Ambien in elderly patients. “Impaired motor and/or cognitive performance after repeated exposure or unusual sensitivity to sedative/hypnotic drugs is a concern in the treatment of elderly and/or debilitated patients.... These patients should be closely monitored.”

Finally, Ambien users may also experience some of the following central and peripheral nervous system side effects: Confusion, vertigo, euphoria, agitation, difficulty concentrating, emotional lability, and “decreased cognition.” Ambien causes withdrawal symptoms when abruptly discontinued. Moreover, like the benzodiazepines, it can be addictive for some people.

Last year, the U.S. Food and Drug Administration (FDA) tightened labeling regulations on the newer sleep drugs like Ambien to reflect the possibility of these strange behaviors. In 2006, a class action suit was filed against Sanofi-Aventis, the makers of Ambien.

Alcohol and Medicine: When Drugs Interact

Is it okay if I drink with these pills?

We've all seen the warnings; the labels on prescription bottles telling us not to mix the pills with alcohol. The warnings tell us that alcohol may blunt or enhance or nullify the effect of the prescribed drugs.

But what's so bad about mixing alcohol with common medications? What, really, can go wrong? "Nausea and vomiting, headaches, drowsiness, fainting, or loss of coordination," according to the National Institute on Alcohol Abuse and Alcoholism (NIAAA). "It can also put you at risk for internal bleeding, heart problems, and difficulties breathing. In addition to these dangers, alcohol can make a medication less effective or even useless, or it may make the medication harmful or toxic to your body."

The NIAAA reminds consumers that certain medicines, such as cough syrup and laxatives, may contain up to 10 per cent alcohol to begin with. Moreover, older people are at particular risk, since the body breaks down alcohol more slowly with age. Woman are also at high risk for drug/alcohol interactions, since blood--alcohol levels are typically higher in women than in men after consuming the same amount of alcohol.

Finally, the NIAAA advises, "Timing is important. Alcohol and medicines can interact harmfully even if they are not taken at the same time."

Herewith, a partial listing of drug/alcohol reactions to watch out for, taken from the NIAAA's publication, "Harmful Interactions: Mixing Alcohol with Medicines."

Possible reactions with alcohol:

--Angina: Isordil, Nitroglycerin. Rapid heartbeat, dizziness, fainting.

--Anxiety and Epilepsy: Librium, Valium, Xanax, etc. Increased risk of overdose, difficulty breathing, impaired motor control, memory problems.

--Blood clots: Coumadin (Warfarin). Internal bleeding, strokes, heart attacks.

--Depression: Prozac, Zoloft, Lexapro, Wellbutrin, etc. Drowsiness, dizziness, increased risk of overdose.

--Diabetes: Glucophage, Orinase, etc. Abnormally low blood sugar, flushing reaction, nausea, vomiting.

--Arthritis: Celebrex, Naprosyn, Voltaren. Ulcers, stomach bleeding, liver problems.

--High blood pressure: Catapres, Cardura, Lopressor, etc. Dizziness, fainting, arrhythmia.

--High cholesterol: Crestor, Lipitor, Pravachol, etc. Liver damage.

--Infections: Acrodantin, Flagyl, Grisactin, Nizoral, Nydrazid, Seromycin, Tindamax: Rapid heartbeat, stomach pain, vomiting, flushing.

--Severe pain: Demerol, Percocet, Vicodin, etc. Drowsiness, dizziness, increased risk of overdose, difficulty breathing, impaired motor control.

--Sleep problems: Ambien, Lunesta, Sominex, etc. Dizziness, difficulty breathing, impaired motor control, memory problems.

--Enlarged prostate: Cardura, Flomax, etc. Dizziness, fainting.

And don't forget the herbals: Alcohol with Kava Kava may cause liver damage; alcohol with St. John's Wort risks dizziness and overdose. Chamomile, valerian and lavender will increase drowsiness when mixed with alcohol.

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