27 March 2007

Journamalism and drugs

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.

Summary:
An abscess in her buttock related to injections of a unnamed drug.
Multiple drugs which have sedating effects:

  • Chloral Hydrate (in toxic concentrations)
  • Ativan
  • Valium
  • Klonopin
  • Oxazepam
  • Benadryl
  • Methadone
  • Soma
  • Robaxin
Note: the list varies between the autopsy report and that in today's Seattle Times. Maybe someone can explain the discrepancy for me. Either way, it's a buttload of drugs. (Sorry for a truly awful though unintended pun.) The conclusion seems entirely reasonable -- accidental overdose. All of these drugs individually can cause respiratory depression and in combination, especially in a patient acutely ill with a bacterial infection, I can see respiratory arrest as a logical consequence.

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.

12 comments:

  1. I just gave a lecture on benzo overdoses, using Nicole Smith as a casy study. I hope that's not some kind of violation!

    By the way, the 911 call which you can easily hear online, is very strange:

    Caller: "She's not breathing and she's not responsive. It's... acutally Anna Nicole Smith"

    Dispatch: "Oh, okay."

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  2. I am someone who has gone to the ER on more than one occasion a couple of years ago after running out of klonopin because I took more than prescribed. In those cases, I admitted that I had taken extra. I know this puts doctors in a bind, and it must be incredibly irritating when people don't just confess what the are there for, but I think you might not be recognizing the deep sense of shame that many people feel in these situations. In fact, I went to the ER on one occasion despite having a doctor I could call who would help me because I was so concerned that my doctor would look down on me, and I didn't want to destroy an ongoing doctor-patient relationship.

    On a separate note--your post does a good job of noting the risks of benzodiazapene withdrawal, which many doctors don't seem to believe is real, but I think you still fail to recognize how serious it is, and in particular how long it lasts. There is just no way that someone who has been regularly prescribed benzodiazapenes for more than a short period of time will be detoxed after a few days--indeed, that is when some of the more serious symptoms will start to present. I do acknowledge your frustrations, but if you are concerned about the risks of withdrawal, you need to recognize how long it lasts. (Incidentally, the Ashton Manual, which you can find by googling it, is probably the best resource on benzo withdrawal available anywhere--I have had psychiatrists thank me for pointing them to it.)

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  3. Anon --

    Just FYI, coming to the ER for a refill probably might do more to damage your relationship with your PCP -- because I often call the PCP to get the inside scoop, and then he'll be even more irritated, thinking you're trying to pull a fast one. If it's an infrequent thing, I strongly urge folks to 'fess up and stick with the doc who knows them.

    Having said that, you are right that BZD w/d can last quite a while. It's a real pain.

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  4. I think shame is quite a barrier in the doctor-patient relationship. I don't know if it is so much with the attorney-client relationship. Maybe it is.

    I know that if my weight is up, I really dread going to the doctor, and have in fact allowed HBP prescriptions to lapse in part because of this reluctance.

    It is not like I consciously say, "I'm not going to get my prescription renewed because I don't want to hear about how fat I am," but I do dread the visit and can "lose" track of easier as a result.

    I have no idea about what the solution is. Doctors need to tell people to stop doing things that are shortening their lives. I'm just pointing out that the problem is probably not limited to drug addicts and teenagers with VD.

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  5. As a doc who does a great deal of addiction work, let me introduce my 5 favorite letters: DD DWI as in Daily Dispensed, Daily witnessed injestion.
    Benzodiazipne withdrawl is a serious situation and requires medical management. (Interestingly alcohol withdrawl is still probably the most lethal and common for of withdrawl seen in any setting)

    So here are some tips that can help out in a bind...for benzo dependant folks presenting as drug seeking:

    Offer them medically supervised detox if available.

    If they refuse then offer them a prescription for daily dispensed, daily witnessed injestion of a long acting benzo (many people like Valium, I prefer to use Clonazepam).

    Prescribe a rational dose, and only one dose per day. The goal here is to avoid withdrawl mediated seziure, that is it.

    Do not negotiate on dose, doses per day, mode of dispensing, or anything else. Remember this is not a negotiation, it is an offer to prevent possible seziure.

    At the end of the conversation reinforce 'In my medical opinion you are dependant and perhaps addicted to these medications. You need to go to detox, and then probably a drug treatment program. I am providing you with this prescription to prevent seziure. You need to get help with this problem'

    If the patient walks away or refuses the script, let them go. Patients have a right to refuse our advice. Offer the most appropriate treatment and let the patient decide. Don't get caught up in a rescue fantasy.

    Anyways, that's what I do, and it's been helpful to me as a strategy. Hopefully it can be helpful to someone else too.

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  6. I don't take benzo or any other drug that was on Anna Nicole's list and tend to be an addictive null unless we're talking Pepsi, but I did want to say, I drop my pill bottles ALL the time. Although I don't go to the ER for refills b/c I don't lose all the meds and I can wait a day to get a refill from my regular doc. But I just thought I'd say there are people like me out there who do have pill dropsy.

    And I don't have palsy or anything, I'm just clumsy as hell. One of those special people who can trip on air and break and ankle.

    Although, knock-on-wood, I haven't dropped any of late.

    I've probably just jinxed myself now!

    M

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  7. An addict wouldn't care if their pills dropped to the ground on a pile of crap. They would pick them up and use them. It is just the story that they give.

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  8. Ha! Then I guess I'm addicted to protonix and singulair because you should see me scrabble after those pills a)because I've got to get to them before the dogs do and b) the HMO won't refill before 30 days.

    Yep, I take pills off the floor. :)

    M

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  9. Dr. J,

    Can I really write a prescription for DDDWI from the ER? Who is going to witness it, the pharmacist? Seriously, I want to know.

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  10. mumqsvShazam (great name by the way!), Of course you can write DD DWI on a script from the ER. In Canada at least, the pharmacist is pretty much obligated to follow your dispensing orders. In some jurisdictions the pharmacy may charge the patient a daily dispensing fee, but that is just part of the medication cost as far as I am concerned (although I realize it is expensive).
    In general I have cultivated relationships with pharmacists close to where I work, and send the patient to that pharmacy and fax the Rx, when I want something specific like this to happen.
    It's an expensive stratagy, in terms of dispensing costs, but often useful, not only for narcotics but also phych meds, ARV's, TB meds etc.....)

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  11. Oops, forgot to add.....Yes the pharmacist witnesses it the injestion.....

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  12. If anyone comes into the ER with a complaint of Benzodiazipene withdrawal and then refuses or makes a fuss when you give them less than what they were asking for (eg Valium instead of Xanax), despite you having explained to them that it will stop the withdrawal, then I would be extremely suspicious that they were lying about their condition.

    I was addicted to Xanax for almost 10 years (thankfully completely detoxed off it now). One time, very stupidly I must admit, I decided not to get my script refilled but instead to attempt to cold turkey off an average dosage of 8 mgs daily, yes not exactly a wise move. Apart from an incredible amount of physical pain I spent the first night hallucinating and in a delusional state, believing I was telepathically relaying messages from the fish in our aquarium to their "brothers and sisters" in the ocean and by the second night I collapsed and suffered a Grand Mal seizure. I presented to the ER disoriented, hallucinating, vomiting and barely able to standup let alone walk. The Doctor on duty gave me a few Temazpam to stop the withdrawal and hold me until I could get to my own Doctor and believe me I almost wanted to get down on the ground and kiss his feet I was so grateful to be given anything that was going to halt the withdrawal.

    btw just as a point of interest, I have also been addicted to and withdrawn cold turkey off heroin in the past. Compared to Benzodiazipene withdrawal coming off of Heroin is a cake walk. The withdrawal from Benzo's is just absolutely horrendous. I don't think anyone can really appreciate just how bad it is until they have been through it themselves, a situation I would not wish on my worse enemy.

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