Tuesday, November 15, 2005

Heinous, deplorable, contemptible NYT article

Strong words from Shrinkette, no? Here...partake of this (go ahead, register). Count the ways in which this article is unambiguously wrong and bad. Not just a little bad...I mean, a breathtaking level of badness. Bad, as in dangerous.

Start with the title. "Playing pharmacist." These patients are playing doctor. And they're doing an execrably bad job at it. They say they're dictating treatments to doctors, lying to doctors, conning and manipulating doctors. They're sharing meds, selling meds, prescribing meds, and donating meds...things they've "prescribed," based on their own "research" and personal experience. What do they think these pills are? A doctor with intensive training can have trouble with these meds...and these patients are going to do better on their own? Think mega-side-effects. Think addiction and withdrawal. Think drug interactions. Think organ damage.

"They are as careful with themselves, they say, as any doctor would be with a patient." No doubt, that's true...if their doctor is an incompetent criminal. Pardon me, but these patients are unequivocally endangering themselves...and others.

"Unlikely to be prosecuted" for illegal use of controlled substances? That is absolutely, unequivocally untrue. Did the journalist even try to talk to anyone who's been prosecuted for this behavior? Did she talk to any psychiatrists whose patients have been prosecuted for misusing controlled substances? I can't find a single quote from a psychiatrist (although there are plenty of derogatory quotes about psychiatists). What are the actual diagnoses of the patients who were interviewed? Might not this behavior be part of their pathology? Was there any attempt to find out?

Let the comments begin. Rants welcome.


Anonymous Anonymous said...

As a patient using the collaborative care model, I winced just as much as you did when I read this. The type of person outlined in the article put my credibility, and all those who rely on the trust of their physicians, at risk.

Being vulnerable, in need and distrusted, is like double victimization.

10:33 AM  
Anonymous Anonymous said...

A poorly researched article, and a disturbing development. I blame direct-to-patient advertising, which puts prescription meds into the same part of the consciousness as Coca-Cola and Pepsi. The television convinces them they need X med, and the only way to get X med is to share a friend's or lie to a doctor. Their confidence stems from their good health and naivete to the true spectrum of illness. (I'm reminded of the 16 year-old I saw last night who was indignant that she waited an hour for me to check what turned out to be a large pimple, when I had just finished intubating an asthmatic.) But I have mixed feelings--if only they could just go to the store and buy the drugs and risk their lives without lying and manipulating and taking up my time, then that would be fine. The problem is, I think this drug sharing has the exact opposite effect. They will come MORE frequently, for their side effects, for more drugs, for their perceived needs.

11:51 AM  
Anonymous Anonymous said...

Why not call it what it is, drug abuse.
The rationalization may be done in a different language, but that is all.

11:52 AM  
Anonymous Anonymous said...

This is Liz from I Speak of Dreams.

I thought your readers might be interested in an article published today in the San Jose Mercury News, by Lisa Krieger:

Psychotherapy for Drugs has fallen out of Fashion
"Prescription drugs are replacing, rather than complementing, ``talk therapy'' in the treatment of depressed children and adolescents, according to a major new study by Stanford doctors.

The trend runs counter to guidelines that call for psychotherapy, which teaches problem-solving and examines negative thought patterns, as the first line of treatment for depressed youth. The American Academy of Child and Adolescent Psychiatry advises medication only for the most serious forms of mental illness -- and then only in combination with psychotherapy...."

"Until now, there has been little data about how depression was being treated in young people. To learn more, Jun Ma and Randall Stafford of the Stanford Prevention Research Center studied two large national databases that tracked visits and treatments by youths to hospitals and doctors' offices from 1995 to 2002, the most recent year for which data was available.

The use of psychotherapy dropped from 83 percent of the visits in 1995 to 68 percent in 2002. During the same time, the use of medication rose from 47 percent to 52 percent.

Although the percentage change in children receiving medication was relatively small, the increasing diagnosis of depression in children means that the number of kids using anti-depressants has more than doubled, Stafford said. Moreover, the researchers found that 42 to 52 percent of the visits associated with medication didn't include counseling."

Randall Stafford's web page

Press release from Stanford on the study

So the kids are getting more drugs, but less counselling -- no wonder they are self-medicating.

I agree though that the NYT piece is a prime example of the fallacy of "balance" and "fairness" in reporting.

I would suggest that you send your criticisms to the Times in the form of a letter to the editor.

I've been doing that on articles that mis-report dyslexia information, and there is some gratification in doing so.

12:05 PM  
Blogger ukexpat said...

This is not just drug abuse, it's drug trafficking...

12:54 PM  
Anonymous Anonymous said...

Doctors gave one of my relatives the drugs duloxetine (sold as an incontinence drug in Europe) and metoclopramide (infamous for wild and wooly side effects). He developed urinary retention (can't pee) and tardive dyskinesia (unintentional muscle activity). The doctors, nurses, nursing home attendants, and so forth were collectively mystified. Their solution was a urostomy! That's permanent, total incontinence by surgical means, for you patients reading along. Maybe his sphincter really was kaput—I have doubts.

How did he come to be taking duloxetine, you ask? Another doctor told him his damaged mitral valve would kill him in months, and he was even less likely to survive replacement. Hence depression, and hence the antidepressant duloxetine. Months later this cardiologist suddenly vanished from practice, and the new cardiologist found that his heart was old and battered but in no immediate danger. The best medicine he got out of this fiasco was hearing "Maybe in ten years we'll think about doing a valve replacement. Don't bother coming back unless your heart does something funny."

Incidentally, I'm the guy who wrote to Shrinkette a while back about my medical oddessy with chronic migraine in the almost total absence of headache. (Yeah, I didn't know it was possible either. The process of reaching the diagnosis was ... torturous. It was an optometrist who finally figured it out when I started seeing flashing lights.)

So what drug is used to prevent migraines? Damned if we know, that's the official medical answer. I've tried two blood pressure drugs, a vitamin, a mineral, three antidepressants, one herb, coenzyme Q-10, several of the OTC "dietary supplements", two anticholinergics, one benzodiazepine, two stimulants, a herd of NSAIDs, one triptan, and two antiepileptics. Three years into this, umpteen drugs under the bridge, and still nothing satisfactory.

In the process I've become a minor league drug expert. Before I take a new drug, I actually read the prescribing information sheets for every prospective migraine drug**. Read, as in sit down and read every bit, looking up anything I don't understand. Then it's off to PubMed to see what the drug really does in practice. In the process, I discovered that doctors have a shocking ignorance about the drugs they prescribe. Take topirimate, an epilepsy drug. It causes metabolic acidosis. Thing is, it's compensated acidosis. The patient doesn't gasp for breath, it sneaks up slowly as the drug builds up in the body. It makes sense from first principles, and the PI sheet spells it out plain as day. Try getting a doctor to believe it, when you're not at your most eloquent or convincing. Good luck.

So I hope you'll pardon me if I'm not a big believer in the "doctor knows best" approach. I'm not going to burn all my skin off with lamotrigine. In fact I'm probably more suspicious of it than the doctor is. It's my skin. I just get the feeling that if I could try drugs on my own schedule I would have found something useful by now, instead of suffering from migraine between suffering from side effects. I can go the the hardware store and buy enough power tools and solvents to kill a brigade, so why is the pharmacy under lock and key? You say adult supervision is needed? No kidding. These people who are whacking themselves out on borrowed Adderall are also tailgating, expanding their beer bellies, and drinking too much. Locking them out of the pharmacy won't have nearly the effect on their life expectancy you seem to think it will.

Ahem. I have to stop writing novels as comments to Shrinkette. But webspace is so cheap, the keyboard so inviting...

*You should see the PI sheet for the Alzheimer's drug memantine. The side effect list is a regular chamber of horrors, even by PI sheet standards. Then you realize they were giving it to 80 year olds who were knocking at death's door, so it ain't so scary.

11:45 PM  
Blogger Internal Medicine Doctor said...

I don't think these kids understand how much we have to contemplate what medication to give someone or if to give any at all. I think that kind of experience only comes after you've seen a few intubations after B-blockers or seizures due to a certain medication.

This article is maybe reporting the truth but, god damn, the truth is scary. People will die. Maybe it will lead to the end of Direct to consumer advertising. I'm pessimistic.

And lying to doctors to get your medication? kids? look what we've come to.

5:50 AM  
Anonymous Anonymous said...

While they are playing with fire, I'm not convinced that the medical establishment is significantly better.

I'd also take issue with saying their doctor is an incompetant criminal. Ask yourself, do you really know? Then go ask a good pharmacist, and then go ask my favorite folks, the FDA. In a majority of cases, its just educated best guesses, and the patient suffers as a result of this big time guessing game.

I'm not advocating self medication, as I know deaths will result. However, deaths are going to result even with the best course of treatment under a physicians care. The only hope is that the probabilities will be less.

2:30 AM  
Blogger aafan said...

If a doctor dished out controlled substances without a physical exam, without a medical history, without a mental status exam, and kept no records, did no follow-up, took no responsibility, did not follow DEA regulations for the documentation and security of controlled substances...that doctor would be violating laws and the standard of care. That doctor would lose her license and would be prosecuted. She would not be a competent criminal. She would be an incompetent criminal.

Hey, check it out: from the Department of Justice website. These are the folks who give us our licenses to prescribe controlled substances. "DEA has launched a toll-free international hotline to report the illegal sale and abuse of pharmaceutical drugs. People now will be able to provide anonymous telephone tips about the diversion of prescription drugs into the illegal market by individuals and suspicious Internet pharmacies. In addition, such information can be reported online through the DEA Webpage.

According to DEA Administrator Karen P. Tandy, “For the first time -- with one simple call -- people in the United States and Mexico have an anonymous, safe, and free way to bring information about suspected illegal pharmaceutical distribution to DEA. This information will greatly assist us in bringing drug dealers to justice and preventing the tragedies that come from prescription drug abuse.”


6:21 AM  
Blogger Greg P said...

I'm sure this has been going on for a long time in the background.
What I saw as most unfortunate was the appearance of this article possibly turning this into a "fad" where more and more people start doing it, just because they can.

There is not so much difference between this and those who take herbal medicines from unreliable sources, where they have no way of knowing what is exactly in the bottle. It's probably some of the same people that would accept or buy a pill from a "friend" as who would take an herbal based on a friend's recommendation.
Surely we know that much of the street traffic in prescription medicines is fraud, usually but not always something relatively benign.

9:32 AM  
Anonymous Anonymous said...

[...We should not be blaming the patients and New York Times for failings of our health system, still stuck with 19th century processes...]

Full comment posted on Hippocrates Blog: Patient Empowerment: Risks, Concerns and Solutions

12:15 AM  
Anonymous Anonymous said...

Sorry, the link is: Patient Empowerment: Risks, Concerns and Solutions

12:20 AM  

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