Newsy stuff today. Apropos of earlier discussions, I do feel bad for White House spokesman Tony Snow, who has been diagnosed with metastatic colon cancer. No political snark here.
On another, train-wreck freak-show fascination note, the results of Anna Nicole Smith's autopsy were released today. Kind of amazing, though not particularly surprising.
An abscess in her buttock related to injections of a unnamed drug.
Multiple drugs which have sedating effects:
- Chloral Hydrate (in toxic concentrations)
One wonders how on earth she got these drugs. It's an impressive quantity. I gather she had a few personal physicians who would prescribe for her under a pseudonym. They may now be in trouble, if in fact they knew it was not her real name, and if they knew the amount of medicine she was taking. On the other hand, the sad truth is that patients lie and conceal information from their doctors, especially when drugs are involved. So the docs may have been duped to some degree. And she had been in the Caribbean, where drugs may be much easier to come by, especially if you have money. And of course, internet pharmacies abound. Given the variety of meds, I suspect multiple sources. Even the most unscrupulous pill-pushing docs would tend to consolidate the list a bit -- i.e. ativan or valium, but not both, since they are functionally identical.
Which brings me to reflect on benzodiazepine abuse. I thought, in medical school, that it was a disease of the repressed housewives of the 1960's and was no longer common. Sadly, it is not so -- in the ER, I see use, mis-use, and abuse of benzo's more than any other category of drug save narcotics. I hate it, because it puts me in a bind. The typical presentation is thus:
Patient presents for a somatiform complaint which is clearly affectively mediated. (in the old days this was called hypochondriasis, but I gather that term is politically incorrect these days.)
During the work-up, they ask for something to help them calm down. Shortly before discharge the truth comes out -- they are out of their meds and need a refill. The variety and ingenuity of excuses are legion. Either the pills were stolen or the dog ate the prescription or they opened the cupboard and all the pills just fell into the toilet on accident or, rarely, "I just ate 'em all." And the original prescribing doctor is out of town or is unavailable for appointments or is a jerk and won't do refills or lost his license etc etc etc. So it is my problem and I have to figure out what to do about it.
Problem is that benzo withdrawal is dangerous and can cause potentially lethal seizures (unlike narcotic withdrawal which is miserable but generally harmless). So I have to either give in and refill the Rx, or send them out with a small risk of something very bad happening. There's not much middle ground, though you can punt with a really small prescription for a day or two. If they have been a few days without their meds, they are already detoxed and I can justify refusing to prescribe. But when they are actively withdrawing, or still on the meds, it's a tough situation with no good option.
And the worst thing is that benzos generally cause up-regulation of their receptors in the brain, so over time the patient requires escalating doses of the drug just to stave off crippling anxiety. And coming off the drug is really hard, emotionally. I've seen a lot of people just like the unfortunate Ms Smith in my ER - some just anxious, some withdrawing, some overdosed, and some dead. It's because of people like her, and the mode of her death, that I generally decline to prescribe these meds unless absolutely mandatory.