I Still Prescribe Seroquel But I Don't Get Paid To Do It.

Chapter 10 remains up at Double Billing. Thanks to those who've commented!

And don't forget to check out the ClinkShrink fiction venture at Double Celling!



From today's New York Times : PSYCHIATRISTS TOP LIST IN DRUG MAKER GIFTS. Great.

How this money may be influencing psychiatrists and other doctors has
become one of the most contentious issues in health care. For instance, the more
psychiatrists have earned from drug makers, the more they have prescribed a new class of powerful medicines known as atypical antipsychotics to children, for
whom the drugs are especially risky and mostly unapproved.

Vermont officials disclosed Tuesday that drug company payments to psychiatrists in the state more than doubled last year, to an average of $45,692 each from $20,835 in 2005. Antipsychotic medicines are among the largest expenses for the state’s Medicaid program.

Wow! Or maybe Oy! That's a lot of money, they don't say How Many Vermont psychiatrists see that kind of moola. One, two, ninety percent of those maple-syrup, Birkenstock-wearing Shrinks, or all of them?



So, for the record, last year I earned $0.00 from pharmaceutical companies. Funny, it was the same amount that I earned the year before and the year before that and the year before that. What am I doing wrong? Where's my 45 grand?



Full disclosure: I work in two different settings that serve indigent, often uninsured, patients. Some of the people I see in private practice have no health insurance. Atypical antipsychotics cost a lot of money. If you don't have health insurance, they remain pretty much inaccessible to many many people. So I'm nice to the drug reps, I chat for a few minutes, I sign for samples, sometimes I even call and request samples, I use their pens, and if you show up needing an antipsychotic agent, you get the one that's in the closet. I used to run a clinic, and part of that work entailed educational programs for the staff and boosting morale: go straight for the stomach. Sometimes I asked the pharmaceutical reps to provide lunch and they'd bring a tray of sandwiches. This went over well with the staff.



Do the pens and sandwiches influence what I prescribe? I can't say no for sure, but it feels like they all come, so what's to say which I use more? Really, boils down to my anecdotal evidence more than anything else: if the first time I try a med, the patient returns saying it helped, I'm more likely to use it. If I have to slowly titrate up and it takes a lot of time and a lot of appointments, I'm less likely to use it. Sorry, Effexor. If the first patient who tries it comes back ranting it was horrible, I get a bit colored. I talk to my shrinky-friends: are they having the same experience? If not, I'll reassess and try again. Even if I don't use the drug myself, I still smile at the reps, sign on the dotted line, and throw the samples in the closet for whoever else wants it.



So why aren't they paying me? Really, that post I wrote on Why I Still Prescribe Seroquel, shouldn't that be worth a few bucks? Look, I'm cheap, never mind the 45 grand, I'd have done it for a mere $20,000.



Finally, I need to say a few words about media sensationalism. Villainizing psychotropics seems to be the thing to do, and hell, get those docs who prescribe them while you're at it. I really wish that atypical antipsychotic medications didn't cause weight gain, diabetes, and metabolic problems. And now that I know this, I tell people. Many people don't develop these side effects-- I've become more diligent about checking labs and warning people of the risks. Though I really wish I could say that it's rare for people to develop diabetes either on or off these meds-- the truth is it's a really common illness and a lot of my patients have it before they see me, a lot get it during the course of treatment, and some get it during the course of treatment with atypical antipsychotic medications. If there was something else I could prescribe, I would and often I do. From my perspective of the doc-in-the-office, there sometimes is just no option but to use these medications, they're what we've got. This isn't to defend the drug companies, I believe their goal is simple: to make money. Kind of like your health insurer runs ads with soft music telling how they care, but really they just want to make money. What surprises me is that anyone expects anything else from them. No answers, sorry.



My last word about media sensationalism: It's hard to get Medicaid, you have to be sick. An episode of depression treated with Prozac doesn't do it. To get Medicaid, at least in Maryland, you have to be chronically ill (and even that isn't always enough), so a bad psychiatric illness, chronically, probably one that you need a chronic, expensive, antipsychotic medication to get. No wonder antipsychotics are a high percent of the Medicaid budget.

Okay, send the check, I'll be waiting

Your Doctor Is Making Jokes About You

And Other Things You Don't Want to Know About Medicine

You deserve to know the truth. The truth is, your doctor may be telling jokes about you. Well OK, not necessarily about you, personally. But about medicine. About the experience of treating patients with common conditions in common circumstances. Stories about patients with unreasonable demands or unreasonable behaviors who come back repeatedly for repair after refusing to change the very things causing them problems. With regard to psychiatry, doctors who have been assaulted by a patient in seclusion may use humor to relieve the fear and anxiety associated with caring for a potentially violent person. In situations like this it's better to make a joke than to scream, throw up your hands and walk away.

Sometimes in psychiatry you work with patients who aren't very nice to you. They may be angry and they may say things that are hurtful. As professionals it is our responsibility to take this dispassionately and allow the patient to be honest about their feelings. We cannot snap back or be retributive or let this influence our judgement. Psychiatrists must be dispassionate, supportive, sensitive and empathic.

Frankly, that's hard work.

Humor is one way of dealing with this. People who read this blog know that we use humor a lot. We tell jokes about medications, about diseases, about the pitfalls of psychiatric practice and about each other. (Well OK, usually about Dinah but that's just because she leaves herself so gosh-darn open to it. And because she takes it so well. Believe me, she can give it as well as she takes it.) According to our readers' comments one of the things people like about this blog is that it gives them a behind-the-scenes glimpse of the human side of psychiatry. That may be disturbing to folks who don't want to think about their psychiatrists in that way.

Every physician at some point in time has used humor to mediate stress and vent frustration. Heck, even an entire television series was based on this premise. The legendary Hawkeye Pierce used humor and practical jokes to highlight the idiocy of military (and medical) bureacracy all the while giving terrific patient care. I imagine my opthalmologist, my dentist, my primary care doc and even my gynecologist have their own brand of behind-the-scenes humor that I as a patient have never heard. (I have to admit I've come up with a few thoughts on my own while straddling the stirrups. And here's an informal survey: how many of you have gynecologists who post cartoons on the ceiling above the exam table?)

Personally, if it keeps my dentist sane and available for me and helps him be more tolerant of me as a patient I'm all for it.

I'll bet he's laughing at how I walk.

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Warning: This blog features graphic scenes of psychiatric humor that may be disturbing to some readers. Reader discretion is advised.

Why I Still Prescribe Seroquel

In my post below, Things I Wish I Knew, I talked about how I'm uncomfortable with uncertainty, in particular when I'm the one to make decisions for other people and don't really have any way to know the full consequences of the decisions I make for them.

I mentioned a number of things I wish I knew, most didn't draw much attention, but two topics did: The consequences of allowing children to watch video games, and the issue of prescribing novel antipsychotic medications off-label, as opposed to Xanax.

Enough about VideoKid--Spring sports have begun and he'll have gobs of homework as the school year ends, he's looking for a job, thinking about college, learning to drive, it's soon to be a moot point. We're doing our best here and it's an imperfect world, what can I say.

Instead, I'll tell you why I'm more comfortable prescribing a very low dose of a second generation anti-psychotic (usually either 25mg of seroquel or 2.5 my of zyprexa) off label when someone is subjectively distressed---let me call it agitated, it's hard for me to say because I'm not inside their skin. Often these are folks who have bipolar disorder or have an agitated major depression, and the dose of the antipsychotic is given on an as needed basis (determined by the patient) until something else kicks in. I don't think I've ever given this as the sole agent unless the patient has simply refused other medications.

To put it simply, I give these medications instead of Xanax because they are easy to stop. No one gets stuck on them, no one makes me uncomfortable by demanding that I continue to prescribe something that is no longer needed. People take them When Needed (usually a handful of times, or a few times a week). Xanax helps, and people take it a few times a day, maybe it helps so much they take it a few times every day, maybe it helps so much they take it a more than I suggested, and they don't want to stop, and if I refuse to continue to write for it they become demanding, or call repeatedly in distress insisting I MUST give them something, and I'm faced with the issue of refusing to write for it and risking that they'll withdraw and possibly seize, or writing for a medication on on-going basis that I'm not comfortable with, sometimes after it's been escalated to doses where I wonder if the FDA will hunt me down. This just doesn't happen with low-dose anti-psychotics.

Okay, in reality, I never use Xanax, so this has only been an issue when seeing patients that other docs have started and maintained someone on (up to 8mg a day, chronically, ouch!). But if the same patient as above shows up and there is no reason not to, I may use Ativan (lorezepam) or Klonopin (clonazepam) in the same way. I agree, if they can be used in the short term, and if someone doesn't become addicted to them or physically dependent or tolerant, the risks are less. So, I weigh it in my head: Is there a history of addiction? (yes-- no benzos). Is there a history of or current alcohol abuse (punt). Does the patient get distressed when I tell them they can't drink on this medicine? If there is no history of alcohol or benzodiazepine abuse or dependence (they are cross reactive), if the patient has been on a benzodiazepine before and had no trouble coming off, if they drink sometimes but have no history of alcohol abuse, then I feel comfortable prescribing a benzodiazapine. I give a small amount, and I tell them it's a crisis medication, not for regular use. I warn that it can be sedating, that it can be addicting. Most people worry about that: it's a good sign. It's the person who assures me that he won't get addicted that I worry about.

When I use a novel anti-psychotic, I tell the patient that it is a low dose and that the medication is associated with precipitating/fast-forwarding the onset of diabetes, lipid dysregulation, and weight gain. I suggest they take it only when needed and that they stop as soon as possible (there is no withdrawal to low doses). One of our commenters said that even low doses cause difficulties, even "kill" (I assume this means weight gain, diabetes, dyslipidemia)-- this may be, but in my personal experience, I have not seen problems with periodic low dose medication. Maybe I've simply been lucky to date.

I don't insist that anyone take any medication they don't want to take. Nor do I recruit patients, I'm an outpatient doc, people come to me, often asking for medication. I have never said to a patient "If you won't take this medication, I won't treat you." I tell them what the studies show, I tell them what I think they should do, if they don't want meds and they still feel helped by coming to see me, I see them.

We live in a society that values the right to make choices, even bad choices. We allow people to smoke and to drink alcohol, despite the fact that the risks they expose themselves (and others) to are both huge and certain, the cost to society exorbitant. It is unfortunate, perhaps even tragic, that we don't have medications with no side effects or ugly adverse effects and I wish that weren't so, it would make my job so much easier. But given the options we have, when I see someone in distress, I'm faced with what I know-- and that is full of uncertainty . Will this medicine make you sick? Will you have a recurrence of your illness without it? Will you have a recurrence anyway AND get sick if you take it? Given that there is no free ride, the other option is to refuse to prescribe, and that carries with it lots of other risks, the denial of something that often helps, and the message of there is no hope if you can't be patient-- and honestly, therapy alone, even great therapy, doesn't always do it. Mostly, I'm left to share what I know with the patient-- including statistics if I have them and if it's appropriate-- but ultimately the decision belongs to the patient, and when they leave it to me, I cross my fingers and do my best.

So no one wanted to comment on the rise in teenage suicide following the black box warning?

FDA Drugs: November 2006

2007: Mar | Feb | Jan . . . 2006: Dec | Nov | Oct | Sep

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Just a quick list of psychiatry-relevant FDA and related notices...

• More Ambien (zolpidem) generics (and here) get tentative approval. Sanofi's patent expired on Oct 21, 2006, but they triggered an automatic 6-month extension by applying for pediatric use. We should start hearing about generic Ambien around April or May. The first approved generic manufacturer gets an automatic 6-month exclusivity before the flood gates open up, and other manufacturers can get into the game. There are about a dozen manufacturers all lined up for tentative approval.


• Phase I results promising for NGX426. NGX424 gets coverted in the body to tezampanel, an AMPA/kainate receptor antagonist, which makes it a non-narcotic pain medicine. The company, TorreyPines, seems to be looking at indications for migraines and neuropathic pain, though this class of drug may be useful on epilepsy and anxiety, as well.


• Drugs to turn on specific genes. This is one of the new holy grails. As described in the linked PNAS article, using RNA interference techniques, you make a little piece of double-stranded RNA (dsRNA) that is designed to bind to a specific gene, say, the gene that contains the instructions for making amyloid precursor protein (APP), which is involved in causing Alzheimer's dementia, or maybe the gene that codes for a particular variant of the CETP protein, which has been associated with increased longevity. According the article, sometimes this technique will silence a gene, and sometimes it will crank up the volume. Drugs of the future would be used to selectively turn on, off, up, down genes, like fiddling with 100,000 dials on a huge mixing board, trying to get just the right mix. A fascinating, but scary, proposition.


• Mirapex (pramipexole) approved (label .pdf) for Restless Legs Syndrome. This is old news now, thanks to the marketing blitz on this indication.


• Generic Zyprexa (olanzapine) gets tentative approval. There are now 5 companies with approved versions of generic Zyprexa, waiting to launch when either Lilly's patent expires (2011) or someone successfully challenges their patent application (now in process).


• Rimonabant (brands Acomplia or Zimulti) approved in Mexico. The sexy new diet drug is already approved in Europe, and is now on our shores. Rimonabant is a CB1 cannibinoid receptor antagonist, so it will also block the munchies from smoking marijuana. Sanofi Aventis has already submitted a new drug application to the U.S. FDA, followed by a resubmission in October.


• Seroquel marketing warning letter. AstraZeneca received an FDA letter warning that they violated the rules by underemphasizing the risk of diabetes with Seroquel in a piece of marketing material. They also failed to note some other risks.


• Warning: Tamiflu side effects - delirium, self-injury. Roche and FDA sent out notification letters warning of reports about self-injury and delirium occurring in people, especially children, who have the flu and take Tamiflu. They note that these reactions may also occur from the flu itself.


• Warning: Methadone side effects - cardiac, breathing, death. FDA put out a public health advisory warning of "reports of death and life-threatening adverse events such as respiratory depression and cardiac arrhythmias in patients receiving methadone. These adverse events are the possible result of unintentional methadone overdoses, drug interactions, and methadone's cardiac toxicities (QT prolongation and Torsades de Pointes)."

Search the FDA's "Orange Book" for more drug data.

technorati tags:ambien, NGX426, FDA, iRNA, insomnia, mirapex, pramipexole, zolpidem, RLS, zyprexa, olanzapine, rimonabant, acomplia, zimulti, seroquel, quetiapine, tamiflu, methadone, methadon, psychiatry, psychology, medications

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FDA Drugs: October 2006

2007: Mar | Feb | Jan . . . 2006: Dec | Nov | Oct | Sep

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Just a quick list of relevant FDA and related notices...

Europe approves Chantix: FDA approved this drug in May, but I have yet to see ONE patient on it. This is a unique, anti-smoking drug, so I figure it would be going like gang-busters by now. What's up with that?

Generic Zyprexa: Generic-maker Roxane has received "tentative approval" to make generic olanzapine. This Lilly drug is usually one of the top 3 most costly line-items in each state Medicaid pharmacy budget. The problem with "tentative" approvals is that there remain many hoops for Roxane to jump through, including patent battles, before they can get this to market. Lilly's patent expires in 2011, so it may be a long battle.

Johnson&Johnson has received an approvable letter for their new schizophrenia drug, paliperidone. Unfortunately, it's not much of a new drug. Risperdal (risperidone) get converted to paliperidone in the liver, so the new drug is pretty much the same as the old one. But since Risperdal comes off patent soon, this new drug provides more shelf-life on this product. I figure most will stick with the older, cheaper drug. For more on this, and a great blog I just discovered, go to David E. Williams' Health Business Blog.

First Autism Drug: Janssen (a J&J subsidiary) received a new indication for "irritability associated with autistic disorder" for Risperdal (there are some concerns). That's two firsts. First drug for autism. First drug for "irritability". This really opens up a whole new horizon. It will now be a race to get a drug approved for "agitation associated with dementia". This would be a block-buster!

Severe Alzheimer's Dementia indication approved for Eisai's Aricept (donepezil). It used to be just mild to moderate dementia.

Seroquel for Bipolar Depression: AstraZeneca has received a new indication for "treatment of major depressive episodes associated with bipolar disorder." I think Lamictal is the only other one with this indication (correct me if not).