Thursday, October 01, 2009

Pain, Addiction, Anxiety, Flu, Malpractice, Meds and More

Prescription drug use is rampant, and complexities abound. Ishabaka, M.D. shares some experiences from the real world of medicine.

Correspondent Ishabaka, M.D. recently shared some of his experience and knowledge about prescription drugs and pain management. Our tort-liability system seeks to pin a percentage of "blame" on various parties, and with the "rewards" (settlements and legal fees in the millions of dollars) and the dangers (of addiction, side-effects and even death) both high, then there is a mad rush for "clarity" and a "solution."

Unfortunately, there are no easy answers when it comes to assessing the safety of various powerful medications, or when they should be prescribed or consumed.

Absurdly high costs for meds is only one issue; the other is that extremely powerful drugs are prescribed in tremendous quantities (and sometimes in response to patients demanding prescriptions for drugs they've seen in Big Pharma advertisements).

So the pharmaceutical industry is "the bad guy," right? It's not always that easy.

Since my father, who passed away this May, suffered from severe pain due to multiple myeloma and osteoporosis, I have seen the relief provided by very addictive narcotics. When you're in the last years of your life and you're in severe pain, addiction is the least of your concerns.

As the doctor notes, I address pain here from time to time based on my own experiences. Since I am still active at 55, I am (after a lifetime of physical toil and injury) often in some low-level (or occasionally worse) pain. There is a big difference between this sort of "I lifted too much stuff" pain and the kind suffered by people with cancer or migraines. Pain is part of life, so the doctor's comments will be of interest to us all.

Here are Doctor Ishabaka's commentaries. the first is on pain management, and the second on drugs, cancer vaccines, lawsuits and much more. The good doctor has a wide variety of experience-- he's worked in emergency rooms and also serves in a free clinic--so his report is from "the front lines" of medicine in the U.S. Many of his views may be controversial in some circles, but he's speaking from experience, so it behooves us to listen carefully.

Something that you comment on frequently, and an issue that intrigues and vexes me is our society's attitude towards pain.

Although they overlap considerably, I'd divide the topic into psychic and somatic pain. Psychic first. You tend to rail against the widespread use of pyschotropic drugs, here are a few things to think about:

- first, imagine a drug was invented that made regular people just feel a little "better", maybe the way you feel after a week's nice vacation. Not "smiley faced automatons" - things would still make people upset/angry/sad, but just a little better. It would definitely be unnatural, but would it be a bad thing? Things such as child and spousal abuse would probably go down. Productivity would probably rise. People would probably be more civil towards each other. Something to ponder, isn't it?

- I doubt you have any reservations against treating severely mentally ill patients (this illustrations in this letter are from my book, so please don't publish them verbatim). For example, I had a man in his 50's who shot himself in the chest with a .38 caliber revolver right in front of the E.R. doors in a suicide attempt - he just missed his heart, and survived. I can't imagine you objecting to giving him antidepressant drugs. You see, it's a question of degree - where do we draw the line between normal life experiences, and pathological conditions?

- depression, and it's counterpart anxiety seem to have been around since the dawn of mankind (and even earlier, I've had pet dogs and parrots suffer from depression and anxiety at times). More gun deaths are in the U.S. are due to suicide than all other forms of gun violence combined. In fact, one of the most important questions to ask a patient when assessing the potential for suicide is "do you have a gun in your home?".

- the first formal medical treatment for depression/anxiety was Freudian pyschoanalysis/psychoanalytic therapy, which is now regarded almost with contempt - "everything is chemical". I think the baby has been thrown out with the bathwater in this case, I imagine we can all recall episodes in our lives where talking about problems with someone with a sympathetic ear helped greatly.

- the next, which again is now regarded with contempt, again; I think, erroneously, was electroshock therapy. There is nothing, I repeat, nothing, that has such a rapid, beneficial effect on depression as electroshock therapy. The drawback is it causes short term memory loss (it's hard to remember things that happened in the two to three months leading up to the shock(s) - I often wonder if this is part of the reason why the therapy works).

I will give you one example. We had a woman in he forties admitted to the pyschiatric ward for depression. She would not eat, and barely slept. Whenever any attempt was made to talk with her, she cried uncontrollably - so talk therapy was useless. We started her on antidepressants and pushed the doses higher and higher - up to and beyond the maximum recomended. After six weeks on the psych ward she had not improved one iota, and was starving - possibly to death. The decision was made to try electroshock therapy. Unlike the therapy depicted in the movie "One Flew Over the Cuckoo's Nest", shock therapy is administered under general anesthesia. After ONE SHOCK the woman was talking, participating in group therapy, and eating. I will never forget it, it was miraculous.

- finally, antidepressant pills were invented. The first, and most widely used were the tricyclic antidepressants. They worked pretty well, but had two big problems. First, they had a lot of side effects. Not dangerous, but very unpleasant for patients (blurred vision, dry mouth, tremor, constipation, difficulty urinating, sedation, and others). The real problem was, they caused horrendous, life threatening problems in overdose - and it didn't take more than ten or twelve pills to cause a bad overdose. I recall numerous episodes of fighting to keep these folks alive in the E.R., and death by overdose of tricyclics was not uncommon. Therefore they were used sparingly.

- then, Prozac, the first of the SSRI's (subacute serotonin reuptake inhibitors) was invented. Prozac was a real step forward. Side effects were minimal, and it's almost impossible to kill yourself with Prozac - you can take a jarful, and you'll feel kind of ill for 24 hours, but you won't die. At this point, prescriptions for antidepressants exploded. The question is - where do you draw the line? This involves some deep philosophical and ethical problems, such as - is suffering good for your soul? - if so, how much? As this (long email) will tend to illustrate, I believe the pendulum tends to swing back and forth, and at this moment in time, Americans tend to believe, on the whole, that suffering of any degree is intolerable, and should be banished.

- one more thing before I finish with antidepressants - it's a popular missconception, and just plain wrong, that they are addictive - they aren't.

Let's move on to anxiety. Anxiety is a normal, and sometimes beneficial response experienced by virtually all higher life forms. Once again, the question is: where to draw the line? Some people are anxious all the time, for no discernable reason - in psychiatry this is called "free floating anxiety".

- undoubtedly the first drug discovered for the treatment of anxiety was alcohol. It works - but I wouldn't recommend it for daily treatment.

- the next were the barbiturates - they worked, but had tremendous addictive potential, and were extremely lethal in overdose (Marilyn Monroe was an addict, and died of an overdose).

- at this time, the benzodiazepines are the drugs of choice. They too have tremendous addictive potential - especially the shorter acting ones (as a general rule, the shorter the action of an addictive drug, the more addictive it is - this is why cigarrettes are so addictive - the effect comes on within an minute, and is gone in 15 - 20 minutes. Same reason why crack cocaine is more addictive than powder cocaine). The advantage is, in pure overdose they are virtually innocuous. You can take a jumbo bottle of Valium, and you'll probably sleep for three days - but that's it. Xanax (alprazolam) is the fastest acting benzodiazepine that can be taken by mouth, and it has the major market share - and addiction problems are rampant. "Addictive personality" is probably at least part a genetic traiy. It's interesting that the first President Bush became addicted to Xanax while President (eventually his physician made him stop taking it), and his niece, the daughter of ex-Florida Governor Jeb Bush has been in and out of jail many times for Xanax addiction, and forging prescriptions.

- the newest form of psychotropic medications, which again, are gaining huge market share, are the so-called "mood stabilizers", such as Lamictal (lamotrigine), and Seroquel. Unlike the antidepressant and antianxiety agents, these drugs don't banish emotions - they make them less intense. In this way, they are EXACTLY like the most despised psychiatric treatment of all (and again, one which I think should still be used in certain very limited cases - you'll have to read my book to read a description of one) - the pre-frontal leukotomy, popularly known as the "lobotomy". People who have had this surgery feel emotions - they just don't feel them as powerfully. There are no other significant effects (contrary to popular belief, the surgery does not affect intelligence or judgement). So essentially, THE up and coming pyschiatric treatment of the day is a "chemical lobotomy". Incidentally, use of these drugs is more dangerous (some serious/life threatening side effects), and far more expensive than the old operation.

Finally - somatic pain. During my career, I've seen the pendulum swing from way to far to one side, to way too far the other. When I started medical school, the concept that even patients dying of terminal disease should have only limited access to narcotics due to the dangers of addiction was still the general belief. As a third year medical student, I treated a young man dying of multiple myeloma - a cancer of blood cells that invades the bones all over the body, causing excruciating pain. I "took care" of him for three months, and his pain was never adequately relieved. Reasonable relief for all pain can be effected with adequate doses of narcotics. Is pain good for the soul? My wife is Filipina, and every Easter dozens of Filipinos have themselves crucified and paraded through the streets - this felt to be an extremely pious, honorable thing to do.

- at this point in time, medicine, and American society, tend to believe that any physical pain is intolerable. I read an article about pain last night saying that "the patient is always right" when it comes to complaints of pain, and doctors MUST give pain medication until the patient feels their pain is relieved. At the same time, abuse of prescription drugs (mostly narcotics) has become the number one drug abuse problem - not only in the U.S. - but in the entire WORLD (per Health Minister of the United Nations last year). I've had two friends - a surgeon and a nurse - die of prescription narcotic addiction. "Pain Clinics" have sprung up everywhere - some of them well-meaning, others simply money for scripts joints - legalized drug pushing.

- a personal example - I have fairly flat feet. After a busy twelve hour shift in the E.R. (almost all of which have linoleum over concrete floors), my feet hurt bad. Arch supports, orthotic shoes - I've tried 'em all, nothing really works. One day I saw an electrician as a patient. He was about my age, and wanted me to re-certify him as disabled and refill his Percocet prescription. He had been on complete disability for about ten years. His problem, he told me, was that he had flat feet, and standing on the job for long periods of time caused him pain.

- I'd like to point out that all narcotics are extremely addictive (as the horrors of Oxycontin have demonstrated), and all are deadly in overdose.

Day by day, I muddle through, trying to come up with answers to these problems. I think there needs to be a national dialogue about these issues, especially if the general public are going to be paying for treatment. It's often not easy to decide where to draw the line.(Emphasis added: CHS)


The first malpractice trial against Merck regarding their drug Fosamax ended in a misstrial when jurors wound up shouting and throwing chairs at each other (I couldn't make this up).

This is an excellent example of why medications cost so bloody much here. While I have little respect for Big Pharma, it isn't all their fault.

Osteoporosis is one of the most common and serious diseases of our elderly. THIRTY percent of patients who fall and break a hip die within the year - mortality far higher than heart attack or stroke - or even most common cancers.

A couple of years ago Merck came out with a truly revolutionary drug - Fosamax - that seriously slowed, and in some cases reversed osteoporosis. One serious side effect was discovered - if it stayed in the esophagus instead of going into the stomach it could cause serious esophageal burns. Merck publicized this risk widely in ads to docs and patients.

It was a blockbuster seller. I'm not sure when, but it was over a year after the drug was released was is discovered that a very small percentage of woman who took the drug had part or all of their jawbones die. So now there are lawyers advertising on TV that if you took Fosamax and got jaw problems, contact them.

Charles, the jaw problem is so rare that Merck couldn't have found out about it unless they tested millions of women. Furthermore, there is no evidence of a cover-up. As soon as Merck got new of the jaw problems it promptly notified doctors (they sent a letter to my house). Even with the serious jaw problem, the benefit of the drug is so great that I would let my wife take it if she should get osteoporosis.

EVERY drug has side effects - did you know that the class of drugs that kill the most patients year after year after year are the "nonsteroidal anti-inflammatory drugs" - these include Motrin (ibuprofen), Naprosyn (Naproxen) Aspirin, and others?

Cover-ups are wrong. Not releasing side effects found in pre-release studies is wrong. No releasing side effects found in post relief studies is wrong. But someone has to say "the line stops here" when it comes to suing drug makers.

You may or may not remember Bendectin. This was a drug used for vomiting in early pregnancy, which occasionally is so severe it puts the mom in the hospital for IV fluids. Bendectin worked, and was a blockbuster. Some children born to mother who took it had malformations, and the suit-mania against the Bendectin manufacturer (I believe it was Warner-Lambert - this was in the 70's) was on. The manufacturer lost tons and tons of money - it's easy to persuade a jury to give money to a mom with a seriously deformed child.

Then the test results started coming in. A certain percentage of women will have malformed children for reasons unknown. The percent deformed children of mothers who had taken Bendectin was EXACTLY the same as the percent of deformed children whose mothers took no medications during pregnancy.

Did the manufacturer get any money back from the settled lawsuits? No. And they decided they were sick and tired of being sued so they made the decision to not resume making Bendectin, although it had been PROVEN 100% safe. This left doctors and mothers NO medication whatsoever to use for vomiting during early pregnancy, and more women admitted to the hospital for dehydration (which IS proven to increase the risk of fetal malformations).

- one of the greatest drug swindles of our lifetimes was Vioxx. This drug, made by Merck, was released in 1999. Remember I told you the non-steroidal antiinflammatories drugs cause the most deaths every year? There are three reasons why: they irritate the stomach lining, and may cause ulcers or gastritis, which may bleed - more often in the elderly, and sometimes at a catastrophic rate. They are taken by many people, and many of them are available over the counter. For years docs have been searching for ways to give NSAIDS safely. They tried giving them with antacids - didn't work. Tried giving them with misoprotol (a drug which thickens the protective mucus lining of the stomach) - didn't work. Tried giving them with drugs that decrease the secretion of acid by the stomach, such as Zantac or Prilosec - didn't work.

- then Vioxx came along. It worked against inflammation and did NOT cause irritation of the stomach lining. It was precribed by the jillions - it's estimated 80 million people took it at one time. Docs (including me), thought it was great. Turned out there was a cover-up - it increased significantly the risk of stroke and heart attack, and it has been proven Merck tried to cover this up.

- so often, it seems the cover-up is what really bugs people. I wonder what would have happened if Pres. Nixon had said "Yes, I authorized the burglary of the Watergate Hotel. It was a very serious mistake. I apologize to all the American people" - instead of covering things up. What if Pres. Clinton had said "Yes, I had sex with that woman. I'm not proud of this, it was wrong, and I apologize to all the American people, and especially to my family."? Merck has lost jillions in Vioxx lawsuits, I wonder what would have happened if they'd said "Hold the phone! We just found out Vioxx can cause strokes and heart attacks!".

An old time malpractice lawyer of mine tells the story of a prominent local pediatrician who needed to operate on a young boy who had kidney cancer. He opened the child up (you do this from the back), and should have found the kidney with a big tumor stuck to it. Instead the kidney was normal. Luckily, he hadn't removed the kidney. He'd operated on the wrong side. He went right out of the operating room and told the parents what he had done. He offered to find another surgeon to complete the operation. The parents said "No, we want you to do it" and never sued the doctor.

- on another subject, one thing that really frosts me is hearing "Oh yeah, the AMA has a cure for _____ but they won't tell anyone about it because they make so much money off it. Charles - pick ANY disease - if it were eliminated, we would still make money because everyone gets sick and dies. The best is "a cure for cancer". There will; in my opinion, never be a cure for cancer because cancer consists of a whole bunch of illnesses with all sorts of causes. What I hope to see is cures found for more and more types of cancer. Of course, we do have a cure for 90% of the #1 cancer killer of Americans, male and female - it's called quitting smoking (lung cancer is the #1 cancer killer of male and female Americans, 10% of lung cancers occur in non-smokers). Asking for a "cure for cancer" is like asking for a "cure for infection".

- Charles - the two greatest revolutions in preventative care are sanitary sewage and vaccines. We don't have thousands of children die every year because we don't get our drinking and cooking water from ditches that other people pour their waste in. We separate our dirty from our clean water, and cleanse the dirty water - although; interestingly enough, not enough for today. There's a fungus called cryptosporidium whose spores are not killed by normal sewage processing. Prior to the late 70's this was not a problem, as it caused no disease in most people, and a little diarrhea in a few. Then came AIDS - cryptosporidium causes severe, life threatening, often bloody diarrhea in a lot of AIDS patients.

- Vaccines have prevented so many cases of serious disease it isn't funny. Smallpox has been ELIMINATED from the human race due to vaccination. Polio is on the verge of being eliminated. Yet, nutjobs come up with every possible reason not to be vaccinated, from the kooks who say thimerosal in vaccines causes autism, to the Taliban, who claimed polio vaccination was "Non-Islamic" because the aid workers in their territory giving the vaccine were not Muslim. Extreme Islamism is the reason polio has not been eliminated yet. Influenza kills thousands of people a year in the U.S., and probably results in the hospitalization of tens of thousands, yet only 40% of people for whom the vaccine is recommended get it.

People have all these "marches or runs against cancer", yet we've come up with a CURE for a common cancer - cancer of the cervix, via a vaccine - Gardasil. Prevents 90% of cancer of the cervix. Supposed to be given to women and girls from age 9 to 26. The religious right claims it will promote pre-marital sex, and campaign against it. Again, less than 30% of females who are candidates for the vaccine get it. The month it came out I paid $340 cash for the three doses you need and gave them to my daughter (she was 10). I didn't even talk about sex, I just said "It's a vaccine that prevents some cancers". That seemed enough for her. Man, I am SURE that if an effective vaccine against HIV was invented, people would find reasons not to take it, and HIV is one of the most miserable ways to die I have seen.

- by the way, a study was recently published about the H1N1 flu outbreak in Mexico last winter. THE #1 most effective preventative was waterless hand sanitizer. I suggest buying a pocket size container to carry all the time, and several big bottles cause if H1N1 gets bad you won't be able to buy any, except for grossly inflated prices on the black market. The #2 most effective method was for people with flu symptoms to JUST STAY HOME. Nothing else worked - face masks, closing schools and other public places, taking preventative antibiotics (antibiotics were effective in treating severe cases in the hospital).

Thank you, Doctor Ishabaka. Your comments are fascinating and instructive. The more we know, the more informed our healtcare decisionmaking will be.

Permanent link: Pain, Addiction, Anxiety, Flu, Malpractice, Meds and More


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