Wednesday, March 21, 2007

Medicines: The Good, The Bad, & The Ugly


So we started this line with Why I Still Prescribe Seroquel (see post below with it's 58 heated comments), ClinkShrink continued it with her Max & Me post which drew in my dog, and it got me thinking about a discussion on medications in general. I started with Life Is Full of Risks as the set up for this, so if you're still along for the ride, thanks for listening. And if you've seen Roy...it seems he Quit his Day Job then disappeared. I'm hoping I don't have to have those floor boards pulled up again.

I work in Free Society -- a term I learned from ClinkShrink who works in the jails. My patients are all adults and with few exceptions, they seek my help of their own accord. Often they come with a request for medications, sometimes a request for a specific medication--something that's helped them in the past, something that's helped a friend.

So humor me while I talk a little about medicines.

The Good
Medications are prescribed by doctors to target symptoms, to target abnormal laboratory or radiologic findings, or to prevent the development of disease in at-risk populations. Symptoms are things like pain, insomnia, hallucinations, cough, angina, heartburn. The goal of medication is to relieve the symptoms. Abnormal laboratory values are things like elevated glucose levels in diabetics, low red blood cell counts (anemia), elevated cholesterol. Examples of medication given to healthy people might include aspirin to prevent heart attacks, or the ill-fated Hormone Replacement Therapies that were given to women in the hopes of preventing heart disease and
osteoporosis, Lithium for bipolar disorder that is continued between symptomatic episodes. I didn't get it all-- fit chemotherapy for cancers, anti-hypertensives, and a slew of other medications where you will. At any rate, the point of the medicine is to get rid of something bad or to prevent something worse from happening, or both: anti-hypertensives normalize blood
pressure and prevent end-organ damage --end organs for high blood pressure are the retina, the kidneys, the coronary arteries, and the cerebral arteries-- so the goal of them medicines is to normalize the numbers and prevent strokes, blindness, and renal failure.

So the good: medications sometimes work. In some people, some of the time, they make the bad things go away and they allow people to live healthier lives longer.

The Bad:
The bad thing about some medications is that they have Side Effects. Side Effects are results of the medications that are nearly always unwanted, kind of the weeds in the garden. Symptoms in their own right, they happen, with some regularity, and sometimes we even use medications for their side effects rather than their primary purpose. So trazodone is an antidepressant, but it makes a lot of people sleepy, so it's used in sub-therapeutic (for depression) doses to help with insomnia. Mostly, though, side effects are bad-- they are uncomfortable for the patient and are often a reason people will stop medications. It's great if that medicine strengthens my bones so I won't break them later, but not if it gives me intolerable Side Effect X now. Side Effects are uncomfortable, they aren't fatal, and they are reversible, they go away when the medication is stopped, and for certain medications, certain side effects are fairly common-- if Ibuprofen upsets your stomach, you're not alone.

What's interesting about side effects is that few of them happen to everyone. So a lot of people will have sexual side effects from SSRI's, but certainly not everyone. Some people will have a tremor from lithium, some will get tired on thorazine. Certain cancer chemo therapies cause everyone to lose their hair, and dry mouth on therapeutic doses of tricyclic antidepressants (at least in my personal observation) seems to be par for the course, but many side effects seem to be fairly random. Many psychotropic medications are known to cause weight gain, and that has been a topic of concern in the comments on Shrink Rap, but I've certainly seen plenty of people take medications that are associated with weight gain who never gain weight. We don't know who will have side effects, kind of like we don't know who any given medication will work for, and because of this, it really becomes impossible to tell patients anything more than a list of the more frequent side effects with this implicit understanding that other side effects may also occur. Pharmacies provide lists, but it's hard to be comprehensive. From the doctor standpoint, there is no guarenteed free ride: when you swallow a pill the possibility of a side effects are there and largely unknown. For the patient who is struggling with a condition that's impeding his life, as many psychiatric patients are, it may be worth taking the risk of any given side effect because that side effect may simply not happen. Since weight gain is a hot topic, I will say that I've seen patients have good responses to Lithium, Clozapine, and Zyprexa (all notorious for causing weight gain) who've not gained an ounce. Other's have inflated like balloons-- the only good news here is that the weight goes on a pound at a time and the medicine can be stopped if the weight starts going on. The problem, of course, is what to do when the patient has a good response to the medicine but also has side effects: unfortunately this scenario leaves the patient with difficult choices.

The Ugly:
Side effects are unpleasant, but often anticipated, and reversible. Many medications have really rare and really ugly effects-- these aren't side effects but Adverse Reactions. They can be awful, and they can be fatal and they can be irreversible. So Stevens-Johnson Syndrome, fulminate liver failure, and agranulocytosis are not side effects, they are life-threatening adverse reactions. Tardive Dyskinesia is an Adverse Reaction, though one that takes time to develop. Adverse reactions are the stuff of Black Box Warnings. The usual response to the Ugly is to stop the medication ASAP.

So what do I tell patients?
Mostly, I tell patients the more common side effects and of any black box warnings. I don't know, off hand, every side effect of every medication. If a patient asks in more detail, I open a PDR and read from the list of side effects. I offer reassurance that the medication can be stopped if side effects develop. I can offer no real guarantees about the possibility of catastrophic reactions-- though generally these are less then the risk of getting into one's car and usually I'm left to say "I've never seen that." A friend recently had a patient experience a life-threatening really rare reaction to a medication (one not listed in the PDR) and for a while after I told any patient I started on that medication about this patient's reaction--- no one refused the medication even after hearing the story. My friend says she will never again be able to prescribe that medication. Rational? No, but our own experiences are sometimes more powerful than statistics. In the case of side effects, ultimately the patient is left to decide if the cure is worse than the disease. In the case of an adverse reaction, I stop the medication and don't restart it.

Sometimes, in some patients, the medications simply relieve the symptoms without any ill effects. It's nice when that happens.