Dude, I need a WTF stamp
I could stamp all the ridiculous prescriptions and fax 'em back to the douchenuggets who wrote them.
Lucky for me, I can have one made… I wonder if my company will pay for such a worthwhile piece of office equipment?
Knowing me, I'd probably go around stamping people, too.
On panic disorder and benzodiazepine use
I'm taking a class just for fun right now — psychopharmacology — and the discussions that crop up are quite excellent. Many of the students are prescribers in my area, and I fill their scripts on a regular basis. It makes for an interesting, voyeuristic look into their thought processes given some of the case studies. That is, I know who they are, but they don't know who I am…
This week's topic is panic disorder and relapse in patients with and without a history of substance abuse. Fun topic, really, and one close to my heart.
Case study:
[You are] working with a 32 year old man who comes to you for an evaluation of panic in August in Lowell. He meets the diagnostic criteria for panic disorder and has been experiencing untriggered episodes for the last 2 months. Name three factors that would guide your selection of medication and then discuss your pharmacologic plan for this unfortunate man.
One of the responses — by a prescriber in my area — was to encourage deep breathing, progressive relaxation, identifying triggers and avoiding the situation, CBT, and starting an SSRI. If panic continues, start a benzo.
This strikes me as fairly typical approach for a primary care provider in dealing with someone who presents during an acute panic attack, but I think that it's doing the patient a disservice. Perhaps it's also a typical response for a psychiatrist who is afraid to use benzodiazepines.
I'll post my response here, verbatim, because I think there's a deep (and common) misunderstanding of what panic is, and what having a panic attack is like.
It seems like you're thinking of panic as something that can be gotten out of, as though it's a normal fight-or-flight type response where removal from a stressful stimulus means no more panic.
This is dangerous thinking, and forgive me if I've read you wrong.
It can be harder than perhaps some practitioners think to identify a trigger. While triggers can often be identified, I think it's important to note that when a patient first presents, and you make a diagnosis of panic disorder, discovering these triggers will be more complex than simply avoiding a stressful situation, or simplifying and eliminating stressors from one's life. (Which is a very time-consuming process.)
You can't turn the ship on a dime.
Please don't fall victim to the idea that because you've been scared out of your wits a few times and your heartrate went up and your BP went through the roof that that is a panic attack. It's not. Panic attacks usually appear in a completely idiopathic manner, particularly the first time they hit. It's not an "Oh Gee, you scared me," type of thing, it's more of a "DEAR GOD I'M DYING, SOMEONE PLEASE DIAL 911" type of thing.* (The caps are appropriate there.
)
Panic attacks can, and do hit without any warning in an otherwise comfortable, relaxed setting. Watching a movie in your living room, for example.
It's not like [situation] -> panic attack a few minutes or an hour later with a clear antagonist. It can come days after the stressors. It can also take a few weeks and lots of practice to build up an arsenal of effective coping mechanisms to return oneself to a calming state in the middle of an active attack.
Re: Deep breathing. This can also be problematic as at the point where one's lungs are fully inflated one can experience a PVC or PAC, which is VERY disconcerting to someone who's already acutely aware of what their heart is doing. I can actually trigger PVCs in myself by doing this.
–
I don't mean to lecture. I'm not the professor, and perhaps I've read too much between the lines of what you've written. As someone who didn't get out of bed for 3 weeks the first time I had a panic attack, I feel very strongly about the issue, and combatting it aggressively rather than taking a more laid back, it'll-fix-itself approach. Particularly this: "deep breathing, progressive relaxation, identifying triggers and avoiding the situation, CBT, [etc.]"
Those are all great long-term approaches, but the short-term is what someone with panic disorder in an active phase cares about most. Long term stuff can come after, just get me through right now.
And I am keenly aware that my personal experience should never cloud my clinical judgement inasmuch as that is humanly possible.
* I tried to dial 911 my first time, in the middle of a biochemistry lecture, no less. But I couldn't see well enough to dial the number. In retrospect, knowing what I know now, I'm glad I couldn't because that would have been a misuse of medical resources. :p
Early in panic, people are usually not capable of accessing the skills to use behavioral coping mechanisms. You usually need to halt the panic quickly and this is where BZDs are needed. Panic is such an uncomfortable and painful experience, the BZD's are in a way like pain medications in the early stages of treatment.
The more you talk, the less I believe you
Something I've noticed for years: the more a patient talks at you, the more likely they are to be lying. They talk and talk and talk, and nothing of substance comes out. It's a smokescreen for something else they want. They tell you their life story, and then ask for an early fill on their Vicodin as though the two are somehow related.
Do they think I'm stupid? I can't count the number of times I've put the phone down with the person still talking at me (without having said more than "May I help you?") done something, and then come back with them still blowing hot air.
The more words someone uses, the greater the chances are that they're full of shit.
This is in contrast to someone with a legitimate issue who will tell you their story in as few words as possible, and then ask what they need to do. Even people who typically blow smoke talk less when they're actually telling the truth and they have, for instance, a police report to back it up.
Every retail pharmacist in the world knows exactly what I'm talking about, and I'm sure most ED types do too. Remarkable that the bottom-feeders on the planet haven't figured out that if they just kept their mouths shut, I'd be 2-3x more likely to believe them. I would have thought such a skill would be accidentally uncovered and remembered. But perhaps idle chatter is the verbal form of a nervous twitch, and many of these folks are halfway decent candidates for the Darwin Awards anyway, so I shouldn't be surprised that they haven't learned from past successes.
In any event, they'd all be shitty poker players.
Oops
Absolutely perfect timing with Dr Dino's Oops Meter.
Got a phonecall from an FP's office across the street from the pharmacy. Medicaid patient had brought in his Risperdal Consta injection for his bi-weekly shot. The nurse dropped the injection in the office, which broke it, resulting in some non-emergent, but non-trivial lacerations to herself in the process.
Could we get another one? Of course, it's 4pm on a Friday, and MassHealth doesn't do lost/damaged precription overrides — if they did, their budget would probably double (TAP doesn't make this shit up, you know) — but could we pleeeeeeease try. And they would, of course, call MassHealth themselves.
Risperdal Consta is about $650 per dose.
Of course the answer was no, but with both of us on the phone, MassHealth said they could do it tomorrow (that would be today, I guess) as a once-in-a-lifetime early-fill don't-ever-ask-again override.
I'm so glad it worked out, and I feel terrible for this nurse. She's probably wishing she had dropped some cyanocobalamin instead. We'd have just given it to them for nothing had it been something like that.
Based on Dino's examples on the oops meter, I'd give this a solid 8. Right next to breaking wind in front of your boss. On the elevator.
Nerd alert!
Spotted in the wild:
:ninja:
Evolution of thought processes
Phone rings. "Hello, may I help you?"
"Hi, I was wondering if I can take an Aleve for my shoulder ache? I also take lisinopril."
7 years ago:
WTF is lisinopril?
Time: instantaneous
6 years ago:
I know how to spell lisinopril!
Time: ~0.5 seconds
5 years ago:
Lisinopril is for blood pressure!
Time: ~1-2 seconds
4 years ago:
Have I seen this before? Yes… I have because Aleve is naproxen sodium, and I've seen people take Naprosyn with lisinopril.
Time: ~2-3 seconds
3 years ago:
Lisinopril is an ACE inhibitor, and I see this combination every day.
"Sure, that's fine."
Time: ~0.75 seconds
2 years ago:
*Visual, mental review of systems, picturing the RAAS pathway and envisioning how naproxen is metabolized to see where and how the two intersect.*
"Sure, that's fine."
Time: ~0.5 seconds or so
Most recently:
How old is she? What's her creatinine clearance? Might she be better off with diclofenac or celecoxib? Eh, it's probably okay on a short-term basis, and it's not a terrible choice, but it's probably not the best choice, either.
"Sure, that's fine."
Time: ~1-2 seconds
What's the next step, I wonder? Quicker processing? Maybe. Deeper comprehension? Hopefully.
This development of thought processes is the difference between these two residents. The ability to take in a situation in its entirety, process it efficiently, while remaining calm and friendly takes time and exposure, and has very little to do with intelligence or any other innate quality.
* Naproxen is considered an unacceptable agent in geriatric patients even though it is used in the elderly pretty regularly. (My grandmother, for instance.) Probably because most internists, orthopods, and others are often not terribly familiar with geropharmacology, which is why geriatrics is its own specialty both in Medicine and Pharmacy.
How-To: Find the best Medicare Part D prescription drug plan
So we're in the open enrollment period for Medicare Part D. It started on November 15, and it ends on December 31. I've been doing consulting twice a week, and the scramble is in full effect. While I do quite a bit more than plunk in drugs and quantities for my consulting, there is one tool that is the backbone of what I do when running various scenarios. It's the Medicare.gov plan finder.
This guide does not apply if you have a hybrid medicaid-medicare plan through your state. Those folks know who they are, and if you have no idea what I'm talking about, you don't need to worry about it.
Before you begin you'll need three things:
- A complete drug list of the person you're doing the research for. This means you'll need drug names, strengths, and quantities. Calculations are done for a 30-day supply, so if you take something 3 times a day, the quantity for 30 days will be 90.
- About five minutes
- An Internet connection (har har)
Here's a walk-through, so you'll want to open the link in a new window or tab…