Pharmaceutical Representative Lunch

I was feeling pretty good driving to work this morning, till I turned on CBC radio.  I sometimes feel like a crack addict must feel at the moment I press the FM 88.1 button and leave the safety and serenity of classical or inspirational music.
Anna Marie Tremonte in that screechingly judgemental supercilious, out of touch with reality, voice she can adopt was talking to a group of angry men making a living off of attacking doctors. 
This weeks condemnation of my profession took the twist that we were unduly influenced by pharmaceutical representatives. 
Some doctors, very few, extremely few indeed, apparently make as much as $500,000 working as speakers for pharmaceutical industry. I was once paid $100 to talk to a group of doctors about a drug  I was using with patietns and knew to be extremely beneficial so was happy to tell my colleagues. I was not going to do this if someone didn't pay me as I'd rather sit at home and read a good book but when offered a meal in a fine restaurant, time to be with colleagues, I took the $100 and ate the meal and told the family physicians why I, a specialist, recommended this drug.
Because Anna Marie Tremonte doesn't live on this planet but is a bubble girl , she doesn't know that there is somebody doing just this sort of thing in every industry in the world.  It's called 'education' and it's done by those who are most knowledgeable. 
I listened to a presentation on RV's by an RV owner on which RV's they recommend. I listened to a fellow talk about motorcycles. I know nurses get paid lunches to listen to different representatives discuss uniform clothing materials.
The greatest corruption in hospitals, if they are anything like the military, happens in supplies. CBC did mention that since buying doctors lunch was out the pharmaceutical industry had shifted to buying lunches for the beaurocrats who decide which drugs appear on the hospital pharmacy lists. Pharmacists, we learned last year, were getting 'kickbacks' from industry to the tune of millions of dollars.
So I normally don't have lunch. I'm too busy. As a doctor I am tasked to do 90 minutes of activities in every 15 minutes of time spent with a patient, and I'm only paid for by my time. Even if I do all this right, and am the most perfect doctor, I can lose my license because I'm 'unpopular'.  I don't even have kill or maim people, I just have to be politically incorrect.  So, like most doctors, who on average work 80 hours (the equivalent of two government jobs, and maybe 3 CBC jobs - senior management in CBC do make half million in perks and benefits at least, don't they? I'm not sure what rock star reporters make but I do know that every band is approached by someone in industry hawking their amps and guitars). 
So this person offers to buy me lunch and tell me about the latest product from their company whose products I already use, Eli Lilly, for instance, (think Mother Earth Magazine, Danier Leather, Ford Cars, IBM, Apple, Angelina Jolie).  That's what I think when I think Merk, Eli Lilly and such folk because their products have saved the lives of my patients.  I've been up in the middle of the night and some scientific wizard in some amazing lab has created a product that has stopped my patient dying in the wee dark hours of the morning and I look and see Hoffman Laroche has made this godsend that has just saved a life.  I am a front line worker. 
When I listen to Anna Marie Tremonte I think she's somewhere safe dressed in white silk and sitting on a soft sedan looking at her painted nails and berkenstocks sometimes soundly pleasantly sane other times sounding seriously daft.  Think of me as a crack addict with CBC, a love hate relationship. 
So yes, I'm influenced by someone offering to take me for lunch, or coffee even.  It's the lever to get me out of the office.  Now when this person makes their pitch, I'm influenced just like I was influenced when I heard this one guy, a motorcycle mechanic, talk about the pros of and cons of synthetic versus natural oils.  I ask questions and I reason and I eat lunch.  I have noticed that the people that the pharmaceutical industry sends around are bright attractive people.  They're in sales.
Only government funded agencies like CBC, sometimes called Communist Broadcasting Corporation, knock sales routinely. Salesmen and sales are not dirty.  I 'sell' life. I try to convince my patients daily to give up killing themselves. I'm not laying life out there like an 'option'. I'm not miles from reality in a radio studio talking about it in the abstract. I'm selling my soul out to keep an adolescent girl from killing herself because she's overwhelmed.  I love 'sales'. I love 'salesmen'.  Sales to me is like any communication system.  Hitler was a brilliant media person but used that media for ill. 
Anna Maria Tremonte and the CBC are too often hack journalists and propagandists rather than unbiased reporters.  Where's the 'balance'.
I'm now feeling guilty about having that lunch.  I spent a third of my life in free time studying to be the best doctor I could be and out of sheer curiosity, all post graduate, and no body was buying me lunch.  I don't have a pension. I think my hourly wage is now about minimum wage but then I started the workforce 12 years after my neighbours who bought a house while I was training and now are retired early and spending their winters in Cancun. 
Yes, there are bad doctors. Yes, there are bad media people, but why the broad brush and why the Watergate Scandal over somebody buying me lunch who wants to tell me about something in my field when this is 'normal' business.  It's 'normal' Anna Maria Tremonte. Somebody in your CBC got a lunch to discuss which microphone you used today. 
And as for free samples, you get them at the cosmetic store.  You can't tell me you never ate a 'free sample' of food at Christmas time walking through the shopping mall.
I take free samples of medications I'm going to prescribe. I take these because I can give this sample to my patient. I do this not to 'push' drugs like heroin industry. I don't even do this like the guys at the car mall who let me drive around the block my Miata Sports Car.  I love my Miata Sports Car. It's been 35 years of 7 day a week work and today I'm able to affor a car that has heated seats that help my back and I don't want to feel guilty because last I looked doctors individually and collectively weren't the really rich people in this country.  Oprah makes 2.6 million dollars. How much does Anna Marie Tremonte make and how many perks is she given.
What's wrong with making money, doing good.   To listen to CBC making money is evil, collectively. (except perhaps if you are an athlete and why did it take CBC so long to catch the government officials in Quebec stealing outright millions of dollars and seeing no wrong in in it. And why did that 'Scandal of the Year', get so little play when the Senate red herring that cost us all only $500, 000)
I ask for samples so I can give my patient a sample so if they get a side effect, most likely in the first week of use, they won't fill the prescription which would cost them $100 and they'd lose the money because you can't take back antibiotics or medications for psychosis, or any medications and we counsell everyone not to use their neighbours medications.  So rather than have a rash and lose $100 I am so thankful the Pharmaceutical Industry, these greats who have extended the lives of my HIV patients by 30 years and saved my Diabetes and allowed my schizophrenic patients to lead relatively normal lives, well I'm thankful they let me save my patients some money. 
My patients usually aren't rich supercilious news casters like Anna Maria Tremonte.  Because they're sick their income has been affected and they appreciate any help the doctor can provide. 
I liked test driving my luxury sports car.  I am by CBC standards a 'dirty capitalist pig' even though I can't remember not working and so much of my activity overlaps with my work and I don't own a house, don't have time to gamble on the stock market and don't have pensions and haven't really given money the thought I've given to 'curing' or 'comforting' the person who has come to me sick and suffering.
And frankly, I'm really thankful for the Pharmaceutical Industry because they've given me the tools that have helped me do my job and I get tired of academics and monday morning quarterbacks hawking their books.
Yes, I know, a department head at a university could be bought for $50,000 and there were those who were unduly influenced just as everyone is in 'big business' and there's a need for accountability.  But somehow Anna Marie Tremonte and the CBC do more 'carping' than reporting.
Influence pedalling happens in every nook and cranny of existence and every item in our day to day lives is a product of sales so please, wake up.  And I will be more impressed if you first tell me whose paying you off and how influence affected which soft seat you sat in and how you refused to let the car company get you to test drive their car and how you really are 'above' it all.  Because you do sound very high and mighty and judgemental in a most obsequious way and I guess I'm returning the same. 
So I'll pray and forgive and hope tomorrow I can resist turning on CBC.   

Cymbalta (duloxetine)

Cymbalta (duloxetine) is a new serotonin norepinephrine re uptake inhibitor (SNRI) antidepressant medication developed by Lilly Pharmaceuticals.  After the Tricyclic medications which were the first truly effective antidepressant medications which came out in the early 50's, prozac became available as the first of the Serotonin Specific Reuptake Inhibitors (SSRI's)..  Subsequently antidepressants like Effexor were developped which worked on both the serotonin neurotransmitter pathways and the norepinephrine neurotransmitter pathways.  Cymbalta is not there fore the first SNRI.
What it is however is the first of this class of medications which has FDA approval for pain disorders.  Prior to this amitryptalline, a tricyclic antidepressant was the treatment of choice for fibromyalgia for instance.  However patients commonly complained that they only had limitted benefit and the tricyclics have alot of hard to tolerate side effects.  The side effects in general assocaited with all the new antidepressants are mostly annoying and not particularly dangerous. The tricyclics however could cause heart failure.
Cymbalta in contrast is a major breakthrough and relatively safe with much fewer side effects than those early antidepressants. Already it has given many patients improvement in pain which they did not have from any non narcotic agents. .
Naturally when a new medication is developed the pharmaceutical company would like everyone to switch to this medication. Medications are like cars in this regard.  Commonly family physicians and psychiatrists are given 'free samples' to help start patients on the latest medication.  This is a marketting strategy but it's also a very valuable clinical tool. Commonly in psychiatry a patient may have to try more than one medication before that which is most effective is found. Each time they fill a prescription they are charged the full amount even if they can't tolerate the medication or it's ineffective and they stop it aftera a few weeks. Free samples allow a patient to try a medication without cost to them and if it works without negative side effects then they can fill the prescription.
I have some patients who are still taking the original tricyclic medication prescribed to them 30 or more years ago. It worked then and it works now. Several other patients responded to later SSRI's called Paxil and Zoloft.  They benefited from these medications when they had their first bout of depression, recovered and stopped the medication only to have the depression occur 5 or 10 years later. I tend to try the medication that worked for them before in the hope that they will benefit from this once again. It's not disimiliar to antibiotics in that way.
Roughty 75% of patients with depression or generalized anxiety will respond to whichever antidepressant you choose first time.  Of the 25 % non responders, roughly 75% of them will respond to the second line choice.
When I worked in the states patients without plans would ask for the cheapest medications and I'd be able to know the oldest cheapest antidepressant would do the trick but the side effect profiles were a concern. Not unlike cars, the shocks on the old ones aren't what they are today.  Prozac was a break through in medication as compared to the tricyclics and MAOI inhibitors because it was hard to kill yourself with it.
The newer antidepressants collectively have a safer profile and overall improved side effect profile.  The antidepressants compared to most medications are very safe.
Cymbalta is effective for generalized anxiety disorder and depression.  So normally a specialist, especially a consulting specialist will see the 'non responders'.  There are patients in my practice who have simply not got better with any antidepressant medications and have been sent to me. This is where cymbalta is the 'first line choice of medication. I am truly happy to say that I have already seen Cymbalta work with non responders.
Further, people who had less than complete results with trials of several of the other classes of antidepressant medications have had excellent response to cymbalta.
Also benefitting are those people who have chronic depressions or anxiety disorders and whose medications seems to wear off after a year of two requiring higher dosage with increasing dose related side effects. These people tend to respond immedidately to the lowest dosage of an untried antidepressant medication, like Cymbalta.
What is offensive in psychiatry and why good universities demand that psychiatrists working for drug companies declare their bias is when these 'trend setters' make unreasonable claims for a new medication.  These colleagues get called 'drug company whores'as a result.  For instance they might say some new medications has a 95 % success rate with depression or suggest that patients already responding well to an earlier antidepressant medication should suddenly switch to the newest and more expensive medication.  For this sell out they get a trip to Hawaii or help getting up the academic ladder.
The fact is Cymbalta has something the other medications don't have and for that reason is my first line choice when I'm treating a combination of either a generalized anxiety disorder or depression with a pain disorder. My patients especially the older ones with traumatic athritis and those with fibromyalgia and even a patient with migraines have reported significant improvement in their pain as a result of starting cymbalta.
This happened when I gave wellbutrin, also marketted as zyban, to smokers with depression, a number of them found it easier to quit somking. Hence if I have a patient who wants to quit smoking and has depression I would consider well butrin as a first line treatment.  Wellbutrin is also called buproprion and has been used successfully extensively in addiction psychiatry.
Cymbalta now is the new drug of choice for that mixed state where pain and depression or anxiety prevail.  I love scientific advances in psychopharmacology and this truly is.  My fibromyalgia patients are especially pleased with it's benefit.
The side effect profile is roughly the same as effexor with some nausea and possibly tendency to make one sleepy.  The key is starting the medication at 30 mg and slowly titrating it upwards to the best dose for the patient, which so far in my practice has been in the 60 to 90 mg range though it's likely to be beneficial at double this dosage or it may turn out there's a window between 60 and 120. It's too early to tell but responses are being noted in the early weeks at as low as 30 mg which was what we saw when we started using prozac and 10 mg to 20 mg was sufficient.  Later we learned that obsessive compulsive patients often needed 60 to 80 mg and it's possible there will be a subcategory of patients who need higher dosages of Cymbalta. For now I'm just really thankful to Lilly for providing a product that is such a breakthrough.
Pharmaceutical companies spend millions and millions on research and development something the 'health food industry' is not in the habit of doing.  Consider the making of a new Hollywood movie with all the jobs and all the new ideas and compare that to late night 're runs'. That can be said for alot of 'alternative medicine'. Yes I know their are exceptions but I think people forget that these are 'big business' too and don't appreciate the contributions that are provided by the pharmaceutical industry.
Almost all my patients have tried 'everything' when they get to me.  I am thankful for all the help I can get. Cymbalta is just that kind of help. Lilly is a great pharmaceutical company that has done amazing research and provided great breakthrough in medications. Thank you, Lilly.

Mood Stabilizers

The first mood stabilizer was Lithium Carbonate. This was the treatment of choice for mood swings and remains the treatment of choice for Bipolar I, manic depressive disorder. The principle concern in use of Lithium is that it can cause kidney disease. To this end one checks Creatine and Glomerular Filtration rate before starting the medication and then again at 3 months and thereafter every 6 to 12 months.  Lithium can also cause thyroid disorder and this also needs to be assess before starting treatment and thereafter at 3 months and then every 6 to 12 months.  Lithium levels are established with safety and efficacy being in the .5 to 1.5 range depending on laboratory normals.  I give these figures here to say that if one is using the lithium predominantly for prevention then the dosage should be established where the lithium level is around .5 however if a person is acutely manic and a risk to self and others the lithium level will be established at around 1.5.  This said Lithium can also be used in the low dose range 300 to 600 mg to augment other mood disorder treatments.
Tegretol or Carbamezapine was the next medication found to be a mood stabilizer. This was used as the second line of choice in Bipolar I, manic depressive disorder.  It's also an antiseizure medication and specific therapy for temporal lobe epilepsy. Clinically I have seen it's benefit with anger management as well.  Bipolar II is a tenuated form of Bipolar I and was previously called 'cyclothymic' or 'dysthymic' disorders.  It can benefit from the use of carbamezapine especially if the 'irritability' component is outright anger.  That said it's use in Asian populations has to be considered in terms of cost/benefit because of the risk for a subset with HLA-B-1502 Allele developing fatal dematitis.  If use is considered in asian population then test for HLA-B-1502 is indicated first.  Aplastic anemia and agranulocytosis blood disorders are a risk so cbc with special attention to wbc is indicated.  The CBC should be taken before starting mediation. There are alot of serious reactions possible including hepatitis, pancreatitis, suicidality, water intoxication and arrythmias.  Therefore CBC, wbc, liver enzymes and EKG are to be considered before starting and when the patient is on the medication especially with increasing dosage.
Valproic Acid was the mood stabilizer most promoted for Bipolar II and so called 'rapid cycling' disorders.  The difficulty with these variants of bipolar is there is a lack of specificity and interrater reliability. Clinically it is also common for mood swings and complaints of them to occur in patients with addiction. When the clinician commonly fails to take an intensive alcohol and drug history or the patient is not forthcoming, the patient is at risk for having liver disease missed. There are been cases of sudden death with valproic in patients with liver disease.  Liver screening is indicated. Adverse reactions noted in Eppocrates include coma, encephalopathy, aplastic anemia in addition to the concerns that can occur with Carbamezapine.  My tendency is to not use valproic acid in the drug and alcohol populations which I treat where liver disease must be considered as most likely. That said I have seen other patients whose lives have been much benefitted from the use of valproic acid.
It should further be considered that the dosages used in psychiatric treatment are often far less than these medications have been used at for seizure disorders for which carbamezapine and valproic acid were first used for.
Gabapentin and Topamax (topiramate) are other mood stabilizers which have benefit in psychiatric disorders.  Topamax must be considered carefully as it can be associated with kidney disease and it can cause reversible with stopping the med unusual localized anaesthesias.  Topamax is often appreciated as it is also associated with weight loss.
Lamotrigine is the latest of the mood stabilizer medications and has been shown to be very beneficial in some cases.  It tends not to be a first choice but has been very robust in its efficacy further it has benefit in augmenting other therapies. It has a side effect profile similiar to valproic acid with sudden death and aseptic meningitis.  I can't say I've heard of any of these complications and my patients have benefitted as greatly from this medication as from the apparently safer carbamezapine, gabapentin and topiramate.
Oddly Dilantin, another anti seizure medication doesn't appear to have any benefit in treating mood disorders.
Clonazepam, the long acting diazepam (valium)  and lorazepam the short acting anxiety medication are interestingly 'anti seizure medications.  Given this it's not surprising that other anti seizure medications have benefit in anxiety disorder, irritability disorders and the bipolar disorders.
Increasingly atypical antipsychotic medications such as olanzepine, rispiridol, seroquel (quitiapine) and the newer abilify and zeldox have become mainstays of use for 'mood stabilization.'
There is always ongoing conflict with pharmaceutical companies and the regulating bodies around this issue of 'off label' and 'on label' usage. These latter drugs were developed at 'anti schizophrenia' drugs but as schizophrenia commonly has a major anxiety component with some schizophrenias overlapping with mood disorders clinicians naturally use these medications with complex cases and find them beneficial.  Medicine is art and science and psychiatry is very much so. The pharmaceutical companies develop medications that are profoundly beneficial for patients and the government regulatory bodies do their best to regulate their usage to reduce the risk to the population.  The politics of this are often difficult for patients who don't understand that very often a safe and very helpful medication for them specifically is politically and legally suddenly in question because of the means whereby it came to market.  Ironically if a pharmaceutical medication of proven benefit says that its good for anxiety and depression where it's only got 'on label' promotion for depression the company can be sued for millions.  I say ironically because the so called 'health food" "alternative medicines" can make no end of unproven and mostly false claims without any legal consequences.  Further much of the information that is being given to patients by pharmacists is not relevant to them as the doctor chooses a medication and dosage which is specific and considered in the light of their clinical experience.  Because of problems of the courts and the FDA more often than not the side effects given for medications are 'medical disclaimers'.  One case is a million risk is shown beside a one in 100 risk side effect without any explanation given to patients.

The Generic Pharmaceutical Scandal

Too often I've had to bite my tongue as doctors have been scapegoated by government for the costs in medicine. In contrast I've argued frequently that the failure of government to address the costs of 'defensive medicine', what doctors do to protect against lawsuit which really are unwarranted from a strictly clinical basis accounts for the majority of medical costs in the country.

I've been wrong. It turns out that literally billions of health care dollars can be accounted for by what most would call 'graft' in the pharmaceutical industry. The pharmaceutical companies make new drugs. They spend fortunes on research and marketing.

Generic drugs are purportedly 'cheaper' and government has been quick to reduce the 'copyright' of the originators of drugs so that the 'generics' can make 'knock offs' for the benefit of patients.

In Ontario today though the Health Minister has come head to head with the extraordinarily wealthy generic companies because each of these competing with the other generic company has made a sweet deal with each pharmacy only to supply their particular 'generic' 'brand'. The result has been that literally half of the health care budget for medications can be explained by this 'business practices' which had to date not been addressed by government.

Other Ministers of Health are following up on this and the likelihood is that Canadians will collectively benefit.

I only bring this up because frankly I've long been weary with the chronic criticism of doctors by those who like to make themselves taller by 'cutting off the heads of others'.

That said it's the pharmacy business owners and not the lowly pharmacist who works for the pharmacist. This was the same for the hospitals where the 'smart' business practices of administration would get blamed on the doctors.







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