Monday, August 11, 2014

Tying a Physician's Hands

Medical research has an incredible history of selfless, hard work and long hours investigating promising leads only to see them go up in smoke during clinical trials. And then the compounds, the elixirs, the pharmaceuticals are relegated to the back cabinets of laboratories and the race begins anew. But sometimes there are discoveries that aren't recognized until years later after the initial results were thought to be worthless. These are the things that make us wonder how much is sitting in the old scribbled notebooks, on the forgotten computer disks or in a freezer in someone's lab. Look at the most recent case of the tobacco plant virus and the serum now being used for Ebola.

LSD, once thought to be the answer the CIA was seeking for use to interrogate people, was seen as a recreational drug as well as a portal to creativity.  Look at some of the famous names who used it and felt it had energized their creative juices. I will leave that part to you.  It was reviled as the opiate of hippies and dropouts.

The CIA researchers, unfortunately, went beyond the bounds of ethics in some of their efforts to try it out and, as a result, college students on a NYC campus were exposed and even persons working for governmental agencies. Now, it is being reviewed as a possible useful drug in the treatment of, among others, PTSD. It may have further medical value as well.  Personally, I've seen the other side, the one we ordinarily think of as the damage done by LSD. A college classmate ended up in a psychiatric hospital never to come back to school. A number of young men became members of a community mental health partial care program, never to return to a productive life outside of it.

Another former favorite of those willing to either venture into another perception of their world or to escape from their current one has seen a new day. I am referring, of course, to marijuana and its medical uses.  We've seen its effects on those with intractable seizure disorders, possibly symptoms of multiple sclerosis, emesis in cancer patients, chronic pain and more to come, I'm sure. Laws, however, don't always mesh well with scientific breakthroughs in drugs with bad reputations.

But it doesn't stop with formerly forbidden "street" drugs. Oh, and BTW, heroin was quite useful in cancer pain in patients (think Brompton's Mixture).  I'm sure it is still useful but it's one of those Schedule 1 drugs on the DEA's list. along with LSD. There are legally imposed restrictions on prescribing some medications simply because any particular state has seen the drug as somehow dangerous and politicians want to protect the people. Drugs in this Schedule V group include Xanax, Soma, Darvon, Darvocet, Valium, Ativan, Talwin, and Ambien. 

The benzodiazepines have been singled out for particularly onerous actions. Drug registries are kept in some states and any prescriber writing a script for one of these meds has to submit it in triplicate form and one goes right into that database. This would seem to be to be a restriction on medical privacy and medical practice, but a sufficient number of physicians subscribe to it and there's been little in the way of challenges. The laws were purportedly intended not to aid patients but to prevent drug diversion to street sales. We see how well some of this good intention has worked. 

The perception, however, is still that certain meds are to be avoided even when they are the only acceptable ones that provide relief to the patient. I see quite vehement statements by physicians about never writing such a script. You can get a script for something that may cause a host of medical illnesses, including diabetes or suicidal ideation, but not for these "forbidden" drugs because they do have abuse potential. But the DEA put them on Schedule IV for a reason. It indicates clearly on their site that they have low potential for abuse and low risk of dependence. Quite a divergence of opinion seems active here. Addictions specialists do not agree with this and "addiction" still appears to be a major concern for all physicians, even those treating cancer or chronic pain patients.

Sleep in the elderly, too, has risen to the top of the list in media outlets because it is such a pervasive problem. Anyone who is involved in sleep medicine will tell you that elderly persons have frequent nighttime awakening and get only sporadic episodes of sleep every night. But, of course, they are to be denied any sleep medication because that's still seen as a no-no. Drowsy, lethargic and cognitive impaired elderly are preferred to those who've had a decent night's sleep. True, some of these sleep meds can cause that too, but isn't a trial of a med sensible to see how it works in an individual patient?

There will, certainly, be those with differing opinions here, but the real concern remains; should politicians be making decisions about medical practice?