Pepin’s Pharmaceutical Prattle for 06-21-2004

Quote of the day: 

Never despair, but if you do, work on in despair. Edmund Burke

Good morning ! 

"Why won't my patients take their medicines?"

 Maybe we should ask it differently…

"How do we help people be/stay healthy using medications?"

 We could start by understanding why people take medications then move on to why they don't do what they are told to do.

 The main reason to take medication is to repair, regain, or maintain health. That sounds like the perfect reason to continue to take medications if they are working. What if you don't "feel" any different (no better and no worse)? Would you continue to pay for medications and remember to take them at inconvenient times? Could your psyche stand the constant reminder that you are not perfect?  Now throw in a few unpleasant side effects.. nausea, vomiting, diarrhea, impotence, drowsiness, etc….. Plenty to get in the way of taking medications. Add in the fact that you have to see a physician, obtain a prescription, fill it, and remember to refill it and it is not surprising that few people are "compliant".

Assuming that we can do nothing for patients in the way of drug selection. Educating them or making the process more convenient might help patients help themselves.

Medication possession ratio: What percentage of the time do members have enough medication in their possession to "take as directed"? We can't make patients TAKE their medication but maybe we could make sure that they have medication available to take.

 From a mail order facility it may be possible to send refills to members on a “keep fill” type program where the member would get a refill unless they intervene to STOP the medication from being sent. If this is done via the web then an email could go out. The message could vary from “We will send you medications unless we hear from you” to “Reply to this message to activate a refill for this medication”. These messages would have to be “HIPPA-fied”. While this may work for one medication this could quickly get too complicated when messages are sent for multiple drug regimens. (the big PBM's now allow for online reorder of medication at mail now.) This type of system would not be possible in a retail setting due to lack of a common computer system across all retail outlets, The need to reprogram and obtain patient consent may curb their willingness to participate. There may be some legal (I'm not a lawyer or even play one on TV) hurdle in some states that would require that member “order” the medication. There is also potential for member noise if they received medications (and a copay) which they were no longer taking due to physician initiated discontinuation. You could incent member participation in the “keep fill” program by waiving (or reducing) copays.

 The bottom line is that patients will do what they perceive is in their own best interest.  For some, spending money to feel no effect but to experience side effects does not seem in their own best interest. Our job is to educate them about what is “best” after reviewing the scientific evidence for the best therapy. Facilitating the flow of medications to patients may help too. (Don't worry.... the medications save you money over the long run with healthier employees who can avoid more costly treatment)

1) How to increase your suicide risk…

If you are elderly and have certain chronic diseases such as bipolar disease, depression, COPD, …. you are more likely to attempt suicide. The authors link the diseases to suicide. Being a pharmacist, I think more about the drugs used in these diseases as the potential "cause".  Antidepressants "activate" severely depressed patients who wanted to commit suicide but could not muster the effort. Many drugs used against high blood pressure and heart failure are notorious for causing chemical imbalances that manifest as depression. Drugs used urinary incontinence can cause "atropine psychosis" and other psychiatric symptoms. I'd say it may be more than a coincidence that these people saw a physician within a week of attempting to harm themselves. (but then again I only edit the ppp instead of the Archives of Internal Medicine)  Original paper is Arch Intern Med 2004;164:1171-1172,1179-1184.

http://www.medscape.com/viewarticle/480964?src=mp

 2) Testimony on safety of imports…

Only 1 in 10 packages inspected. Misbranded, mislabeled, and fake drugs found.

http://www.medscape.com/viewarticle/481253?src=mp

 3) Stupak stews about Accutane.

After the death of his son by suicide while taking Accutane the congressman has pursued this issue. This illustrates the difficulty that manufacturers encounter when trying to attribute "side effects" to drugs…. For example: If a patient already had a cancer but never been diagnosed with cancer and, after exposure to a drug subsequently the cancer was diagnosed with cancer then the drug gets blamed.

A single case does not prove the association and is the reason that the FDA insists upon multipatient tests prior to approval and robust post-marketing scrutiny. Accutane (and the generics now available after the 20 year patent expired) already has enhanced warning labels and is under one of the tightest medication controls available. (it is easier to obtain narcotics!). The FDA continues to investigate how to regulate and make this drug safer.

http://www.detnews.com/2004/health/0406/16/politics-185803.htm

 4) National drug trend moderated by generic use.

Release of a study done by a PBM shows a 7.9% increase in per prescription prices. (Last year it was about double that rate). The ethical pharmaceutical companies are feeling the pressure but they knew when their patents would expire when they started manufacturing and selling the brand names. I wonder if they have extracted the cost of development and a little profit along the way…. If they find themselves surprised by patent loss then they had better assign someone in marketing who can read a calendar.

http://www.newswise.com/p/articles/view/505423/

5) If American kids could only act as donors….

Study finds that millions of children throughout the world could be spared death if they had adequate nutrition. All this while many American kids are overweight and destined for diabetes and all its woes. There is a way in which these same American kids could become "donors" of sort… give up a little food and send the money to a world hunger relief agency. (What?!! you though I was going to suggest something akin to organ donation?)

http://reuters.com/newsArticle.jhtml;jsessionid=OQLVPTWIWKQPCCRBAEZSFEY?type=healthNews&storyID=5447031

 6) Diabetes drug may enhance fertility in certain cases.

This study was performed in only 42 women with polycystic ovaries. Because these women are more prone to diabetes and that can affect fertility there is a lot more to be investigated. This is truly EXPERIMENTAL treatment and would fall outside of most benefit plans. Now the bad news: because it is a common drug and not subject scrutiny…  you will never know. (Do not even THINK about putting a prior authorization on this drug… it would be a waste of time and effort and might discourage diabetics from getting needed treatment... that old compliance issue again!)

http://news.yahoo.com/news?tmpl=story&cid=594&u=/nm/20040617/hl_nm/diabetes_ovary_dc&printer=1

 7) New approach to drug study results… on-line access.

Glaxo will soon be posting results from all of its sponsored clinical research. Glaxo is the first to make this available and one other manufacturer sounds interested but the rest of the herd a wary. Phase III and post marketing studies would be what is released. The rest of the early research would continue as is.

 http://biz.yahoo.com/rc/040618/health_gsk_3.html

----