So glad you posted that NEJM study.

Sad but true, placebo response with meds (best possible trial design) is up to 40%.

[Parenthetically, this is why the history of bipolar disorder treatment contians so many “head slam” trends. Like…say….prescribing a med that seems to help - according to peers - and later finding out rigorous clinical trials show it made patients worse - or dead.

I’m looking at you, gabapentin…and Parke-Davis]

Dr. Gary Sachs, director of the Harvard Bipolar Research Program at Massachusetts General Hospital in Boston, helped design and conduct such a study for Parke-Davis. He said on NPR’s “All Things Considered” program: “Yes, patients get better on Neurontin, but they get better at an even more impressive rate if they don’t get Neurontin.” He called the results “shocking,” saying the patients did better with sugar pills than on Neurontin. However, Parke-Davis withheld the results of that study until 2000 – about when the patent on Neurontin ran out.

Parke-Davis was acquired in 2000 when Pfizer, Inc. bought its parent company, Warner-Lambert. Pfizer has consistently declined to comment on the pending litigation except to say that the alleged actions took place before the year 2000, and that Pfizer does not engage in off-label marketing. However, Neurontin continues to be prescribed and sold for mostly unapproved uses such as bipolar disorder – because doctors were told it worked, and have not been told it doesn’t work

Personally, I’ll never forget the (verrry smarty and savvy) psych faculty member when he saw the definitive meta-analysis showing the 40% placebo.

Jolly fellow, thick St. Petersburg accent:

“Kirrrrk – this means 40% of everyting we do is bullshit – and it works!”

nahant
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…. If only all docs had the time to address such needs in writing to these greedy companies! But alas we can only keep wishing for changes needed.

Sadly, the surface economics of clinic practice only measure “consumption” [doing something] and ignore “conservation” [preventing something].

In psych, there are billing codes for all manner of meds and therapy combos. And a few codes for providing info – for which the insurers never pay. [hey, they write the rules].

So the whole structure pushes higher use of services (with a higher risk of side effects) and implicitly discourages prevention.

In salaried public sector positions, the doc doesn’t make any more money for doing more prescriptions. Admin uses negative incentives to penalize time spent on “non-billable” codes, thus pushing clinical activity towards doing something

One example:

I worked with a delightful autistic 31 y/o woman (and her wonderful mom). My patient almost never spoke – we could not any “therapy” I had been trained for.

My patient also had a 42 inch waist and diabetes so out of control her glucose was in the 300’s.

On good days.

Of her prescribed psych meds, two cause lethargy (no exercise), another often causes voracious eating, and two make diabetes worse (if not causing diabetes outright).

The billing codes pay (not much) for psychopharm.

The codes pay more – depending on increasing time up to 90 minutes – for psychopharm with therapy.

But I couldn’t code (bill) for psychotherapy – as an adult shrink, I’ve had no training in non-verbal psychotherapy. I’d none to offer her.

Because of the patient’s wonderful mom, we:

(a) slooowly got rid of the two drugs causing lethargy.

(b) bugged pt’s pvt medical doc about diabetes

(c) fired medical doc and got (great) UC endocrinologist

(d) slowly persuaded mom to allow d/c of psych med most likely to worsen diabetes: expected side effect of d/c being hospitalization for change-over [mom had horrible experience prior psych inpt care w/ daughter]

(e) did get rid of psych med most likely to cause/worsen diabetes. did get hospitalization mom felt ok about. pt more attentive to environment after med change.

(f) blood sugar decreased with endo actually treating patient’s diabetes (vs former pvt doc watching numbers go crazy and doing little to sweet fuck all…)

(g) slowly cross-titrated off mood stabilizer causing huge appetite and on different mood stabilizer.

(h) pt unexpectedly shows increased attention and greatly increased verbalization. Some verbalizations intelligible (and meaningful/congruent).

Speech therapy possibly indicated, but mom will probably provide it herself. Besides, there’s no money for it in “the system”.

we docs (me included) had been drugging her [more] speechless and didn’t even know it

(i) blood sugar now in mid 100’s.

(j) oh: next task slooow taper off remaining antipsychotic (also a third generation with metabolic side effects, damn it).

though i’ve left clinic, but mom is fully educated re this objective. it will happen.

Who cares?

Well, under current billing codes, all the above was psychopharm (medication management).

No extra billing for the huge amount of communication time required to do the above (well, except (j)) in 2.5 yrs.

You see, I wasn’t “doing” anything – like writing prescriptions or looking up your bum or cutting out something or stitching up something.

I was just talking and listening and thinking. Along with competence, this happens to be exactly what patients most want from their GP’s and internists and specialists.

And as far the current payment system works, these activities don’t actually exist.

When we docs do these things, the payment system says “NYAAH NYAAHH NYAAAHH – I can’t see you!” and just tries not to pay for more the barest contact time.

Yet all that “non-billable” time saves huge sums: diabetes out of control in obese patients very often leads to kidney failure, vision loss, amputations, and other miseries.

Very costly miseries.

Even though the clinic is “owned” by the same county that has to pay the (Medi-cal) costs for all those problems…and perhaps provide the hospital, in an emergency…

The clinic “loses” money for all the non-billable time spent managing the meds and side effects and health care system.

This doth not please the admin ilk…

So the point isn’t that I as a doc did a-to (near)-j above – docs do that all the time.

The point is that the reimbursement “system” is so fucked up that even non-profit public care agencies are pushed to minimize the least expensive medical care: sitting and talking and thinking through the problem with the patient.

Payment for that is – relatively speaking – jack shit.

Until that changes, I’m afraid nahant’s wise wish will not come true.

DHS is saying that they WILL be requiring passports for anyone returning to the US …. so I figure that a whole bunch of needy people are going to run out of their meds in a few months

A lot of needy people have been going without meds they need for all types of reasons. And they get into the health care system way too late in a substantial percentage of cases disease by disease–at which time care is considerably more difficult and more expensive.

There are probably many reliable suppliers of meds from Mexico, and some that are not so reliable. But the reasons for the restrictions in bringing back the medications by DHS or anyone else are not pure as the driven snow based on drug safety alone.

The problems of needed meds vs. food, shelter, etc. is a horrible one increasing rapidly.

Hence the occurance of resistant TB and rampant Staph.

There are multiple reasons for Resistant TB, but as to Staph. and many other bugs, far and away the predominant reason is over prescription/high rates of inappropriate Rx of antibiotics, and for years we’ve been seeing ID grand rounds that show drug resistance in smaller more rural hospitals at rates in the same league as larger tertiary hospitals.

More than 70 percent of the bacteria that cause hospital-acquired infections are resistant to at least one of the antibiotics most commonly used to treat them

I’m not aware of a any significant safety problem (*g)) for drugs manufactured in Canada.

Not just drugs manufactured there but those which pass through their system. I forget but Ireland has become a country that exports drugs manufactured there to us and the Canadians. The Canadians get it for one price and we get it at a much higher one.

DHS is saying that they WILL be requiring passports for anyone returning to the US …. so I figure that a whole bunch of needy people are going to run out of their meds in a few months…

But other than my usual maintenance appointments and the surgery i had last year for the condition that causes the pain? I don’t go in for petty things. I’m actually glad i got dirty and got sick a lot as a kidlet. It’s helped me in the long run. *grin* Even with all this new stuff bugging me.

maybe we will repeat 1929-~1942.

Unfortunately the windows in modern sky scrapers don’t open.