xenobiotica

Quotables from the OSHP Annual Seminar 2010

2010-07-17T09:52:00.000-07:00

A couple months ago I attended the Oregon Society of Health-System Pharmacists (OSHP) Annual Seminar at the Oregon Coast. I came away with many ideas about pharmacotherapy, leadership and the practice of pharmacy. I'd like to share some of my favorite quotes from the Saturday sessions.

From Sara White MS FASHP talk on leadership:
"Every pharmacist is a little 'l' leader."
"Management is about ensuring right things are done correctly."
"If there were no rules what would you do, how would you contribute?"
"Sometimes, it's easier to get forgiveness than permission."
"It doesn't matter how many research articles you can spout off in defense of an action... if you piss someone off they'll never listen to you."
"Learn to influence up."
"Make it easy for those in charge to say yes."

Anonymous on Health Care reform:
"Change is a freight train; either you get on-board or your grit in the wheel."
"Stay tuned and be engaged."

Ali Olyaei PharmD BCPS:
"Good drugs are like UFOs; it sounds good but you've never seen one!"

The mind of a pharmacy student (recent notes in preparation of NAPLEX board exam)

2010-06-04T11:58:00.000-07:00

HAART for HIV

Guideline for ART Initiation

Preferred therapy should include the following → 2 NRTIs + one more of the following:
- Protease inhibitor

- Non-nucleotide Reverse Transcriptase Inhibitor (NNRTI)

- Integrase Strand Transfer Inhibitor

Nucleotide Reverse Transcriptase Inhibitor (NRTI)s
1. Preferred: Tenofovir + Emtricitabine (Truvada)
2. Alternative:
  1. Abacavir + Lamivudine (w/negative HLA-B*5701 test)
  2. Zidovudine + Lamivudine (DOC pregnancy)
  3. Didanosine + Lamivudine
Protease inhibitors
1. Preferred:
  1. Atazanavir + Ritonavir
  2. Darunavir + Ritonavir
2. Alternative:
  1. Lopinavir + Ritonavir (DOC pregnancy)
  2. Fosamprinivir + Ritonavir
  3. Saquinavir + Ritonavir
Non-nucleotide Reverse Transcriptase Inhibitors (NNRTIs)
1. Preferred: Efavirenz (Sustiva)
2. Alternative: Nevirapine (DOC pregnancy)
Integrase Strand Transfer Inhibitor: Raltegravir

ART Drug Specifics

NRTIs: terminate reverse transcription of viral DNA
1. ADEs: Lactic acidosis, hepatic stenosis, pancreatitis, lipoatrophy, lipodystrophy, peripheral neuropathy, N/D, flatulence
2. Do not give stavudine + zidovudine (antagonistic)
3. Stavudine → hyperlipidemia
4. ABC → HLA-B*5701 testing
5. Emtricitabine → hyperpigmentation
6. Zidovudine → bone marrow suppression
NNRTIs: inhibit reverse transcriptase
1. ADEs: rash (SJS, TENs, etc. ~14 days), ↑LFTs, hepatitis
2. Induce CYP3A4 (except delavirdine)
3. EFV → QHS, empty stomach, false positive cannabinoid test, vertigo, vivid dreams, anxiety, euphoria
4. Etravirine → active in K103N mutation, take with food (↑ bioavailability)
PIs: inhibit protease cleaving gag and gag-pol proteins
1. ADEs: hyperlipidemia, ↑blood glucose, ↑LFTs, fat maldistribution, bad GIT (take with food)
2. Inhibitor/substrate CYP3A4
  1. except boosted tipranavir
  2. Don't use Atorvastatin, Simvastatin or Lovastatin (3A4)
3. Atazanavir → hyperbilirubinemia, 'lipid sparing', always boost w/ritonavir
4. Indinavir → nephrolithiasis (1.5L H₂O/day), blurred vision, metallic taste
5. Caution in sulfa allergy: F DAT
  1. Fosamprenavir
  2. Darunavir
  3. Amprenavir
  4. Tipranavir

Other Importances

Renal Dosing: ST ZELD
1. Stavudine
2. Tenofovir
3. Zidovudine
4. Emtricitabine
5. Lamivudine
6. Didanosine
Hepatic Dosing: FIAA
1. Fosamprenavir
2. Indinavir
3. Abacavir
4. Atazanavir
Preferred in Pregnancy: AZT + 3TC + (NVP or LPV/r)
1. Zidovudine
2. Lamivudine
3. Nevirapine
4. Lopinavir/Ritonavir
Avoid in Pregnancy: TED → 2 forms birth control
1. Tenofovir: changes bone growth
2. Efavirenz: teratogenic
3. Didanosine: birth defects

Drug Disposal

2010-02-25T21:01:00.000-08:00

One of the most frequent questions I get as an intern pharmacist is how to dispose of unused medications. Frustratingly the suggestions for proper disposal seems to change frequently. Several years ago the common recommendation was to flush them down the toilet. More recently the guidance was to crush them up in a desiccant, like kitty-litter, and throw it away. And now there are even programs that recycle unused prescription medications for use in uninsured populations and foreign relief. The question remains: what are you supposed to do with unused or expired medication?

Maybe we should look at the root cause of the drug disposal problem by asking, why is there medication to dispose of in the first place? From what I've seen medications are rarely, no longer needed, but are left over from incomplete regimens. The problem may be two fold; health professionals may on occasion be over prescribing or unnecessarily changing therapies and patients may not be 100% adherent to the treatment schedules? All that aside, the problem remains that there are millions of unused pills that are in need of disposal.

Here in Oregon there is a statewide drug return day scheduled for March 13th: Prescription Drug Turn-In Day March 13 Here you will be able to bring any prescription or OTC drug to be appropriately destroyed, no questions asked. Check with your pharmacist for a program in your neighborhood.

Of course there are environmental concerns with the disposal of medications. If we flush them they may contaminate the watershed and if we throw them away the drugs have the potential of leaching into the soil from the land fills. Dr. DeGraw who taught me Human Anatomy and Physiology always said, "The solution to pollution is dilution" and there may be something to that. The FDA actually recommends that many drugs still be flushed due to their solubility, which yield mostly inert products when exposed to excessive water. Here is the FDA's flush-able med list: Disposal by Flushing of Certain Unused Medicines: What You Should Know.

If there is no medication removal program in your area and the drug you need to dispose of isn't on the FDA's flush-able list, The Office of National Drug Policy (http://www.whitehousedrugpolicy.gov/) suggests you follow these steps:

Take your prescription drugs out of their original containers.
Mix drugs with an undesirable substance, such as cat litter or used coffee grounds.
Put the mixture into a disposable container with a lid, such as an empty margarine tub, or into a sealable bag.
Conceal or remove any personal information, including Rx number, on the empty containers by covering it with black permanent marker or duct tape, or by scratching it off.
Place the sealed container with the mixture, and the empty drug containers, in the trash.

Recycling Prescription Medications:
A new and exciting way to 'dispose' of extra or unneeded medications is to recycle them by giving them to the uninsured or foreign relief. These programs claim to keep medical costs down, there is an estimated $1 billion dollars of pills that are thrown away each year! They also save health care money by treating patients that frequently visit the hospitals by preventing ER admissions. "A study by the Commonwealth Fund in 2006 found 59 percent of uninsured people with chronic conditions either skipped a dose of their medicine or went without it because it was too expensive. One-third of that group visited an emergency room or stayed in a hospital overnight or did both, compared to 15 percent of their insured counterparts."

The first place to look for drug recycling is the manufacturer of the medication that you are trying to dispose of. This is usually listed on the prescription drug label, and if not your pharmacist will have access to this information. Many pharmaceutical companies either directly or by way of a 3rd party arrange for the repurposing of their products. If they won't take it back check to see if your state has a drug recycling or reuse program here, a state-by-state list of drug recycling legislation.

Drug recycling resources:

In conclusion, we need to minimize waste in health care and that requires the proper use and disposal or recycling of medications. To prescribers, ensure the necessity and quantity of the prescriptions you write, and to patients, be adherent to the drug regimen that you've been prescribed. If after this there are still unused drugs that need disposal look for a recycling program in your area and if none exist follow the recommendations for proper disposal.

Altitude Sickness

2010-02-17T18:02:00.000-08:00

I recently had a friend who asked an interesting question about the pathophysiology of altitude sickness and why the drug acetazolamide or Diamox is used for it. Here is the FDA drug information sheet (package insert) for acetazolamide for those intrepid chemists or pharmacists out there!

The exact cause of altitude sickness is not well understood, and as a result, the role of acetazolamide is foggy as well. Here are a few ideas -

Some of the signs and symptoms of altitude sickness:
- Headache
- Nausea
- Loss of appetite
- Shortness of Breath
- Dizziness
- Drowsiness
- Fatigue
- Changes in consciousness or gait
- Pink/frothy sputum (from small vessel hemorrhage in the lungs)
- Difficulty sleeping

Pathophysiology of Altitude Sickness:
The current theory is that most of these symptoms are a result of cerebral edema in the splenium of the corpus callosum, a reservoir in the brain that connects the left and right hemispheres. This region must maintain a very specific pressure and concentration of cerebral spinal fluid (CSF) for appropriate brain function. The more serious symptoms of altitude sickness may be a result of the lack of oxygen reaching this area in the brain causing the small vessels to increase their delivery of blood, increasing the volume (and pressure) of the fluid which may, in very severe cases, cause neuronal cell rupture. At altitude there is less oxygen available, but your muscles still need to work so you can function and move; so instead of burning oxygen your tissues switch to anaerobic metabolism to produce energy. This form of metabolism has a waste product, lactic acid, which after a time throws off your pH homeostasis. Your body compensates for this metabolic acidosis by hyperventilating to blow off the acid in the form of carbon dioxide, giving respiratory alkalosis. The hope is that your cardiovascular system can blow off enough acid (CO2) to restore pH to a healthy 7.4 and life will carry on as normal. In a rapid ascent to altitude your body can't ever achieve this balance and it reacts by producing the symptoms of altitude sickness.

Treatment:

This is where acetazolamide comes in. It is a carbonic anhydrase inhibitor, that means it prevents an enzyme in the body from eliminating acidic products. This feature also helps rid excess fluid throughout the body. Historically it has been used to treat high blood pressure caused by too much blood volume by producing more urine and eliminating the excess fluid from the cardiovascular system; hence acetazolamide's diuretic properties. It has also been used to treat glaucoma lowering the intra-ocular pressure by preventing the ciliary body from producing aqueous humor. Now what's weird is that acetazolamide is used in altitude sickness since it perpetuates a state of metabolic acidosis. Apparently this drug has been used to treat neurological disorders like epilepsy (also: familial periodic paralysis) because it slows the excretion of excess fluid in the brain that cause seizures. Surprisingly when acetazolamide is used to treat altitude sickness, especially when used in prevention (before ascent), it slows the over-secretion of fluid in the corpus callosum assisting in the mitigation of the headache, nausea, loss of appetite, shortness of breath, dizziness, drowsiness, fatigue and changes in consciousness or gait. Additionally, studies have shown that those who take acetazolamide to treat altitude sickness had improved lung function and less difficulty sleeping after rapid ascent to altitude. Unfortunately, almost anytime you introduce a xenobiotic into your system there are side effects; and acetazolamide is no exception. Increased urination and formation of crystals in the urine are a couple of note since being at altitude leaves you at an increased risk for these as well. As a result above normal hydration is important to avoid dehydration and kidney stones.

Representative Case:

The image above is a Tesla(2) MRI scan of the brain of a patient with high-altitude cerebral edema (HACE) showing marked swelling in the splenium of the corpus callosum (area with dense opacity). The patient, a climber, went on to climb Mount Everest about 9 months after this episode of HACE.

Solid Organ Transplant

2010-01-07T19:31:00.001-08:00

I’ve never had to deal with a chronic ailment and as a result I feel I’ve taken my health for granted. Roll playing the part of a recent transplant patient in class this week helped me realize challenges that the newly diagnosed may face and to appreciate the fear associated with the lack of understanding of medications and procedures related to their disease. These issues assisted me in visualizing and establishing counseling points that I will be sure to cover with patients of new and chronic illnesses.

Of the many challenges that the newly diagnosed face; appreciating the effect drug regimens have on the activities of daily life was paramount. I found it surprising that the administration times and procedures became an obsession constantly on my mind. I perpetually worried about taking the right drug at the right time and continually fretted over following the written instructions to the letter, as I had received them. I felt the weight of the responsibility of the new liver that I received and protecting it at all cost. I have a better understanding now after this short roll playing activity how complicated regimens can affect a patient’s quality of life and the organization (or lack there-) of it. I can also see how some patients may become apathetic in their adherence when it takes such an emotional and temporal toll on their lives.

Going in to this activity I knew next to nothing about solid organ transplants or the medications used post-transplant. I found myself feeling slightly upset that I was literally handed a bag of drugs and told don’t miss a dose or your new liver will fail and we’ll have to do this all over again. I felt discouraged that I didn’t know what pills I was taking or how it was going to help me and my new organ. I grew to resent the medication because I spent so much of my day preparing, dosing, and thinking about them when I had no idea what they were doing inside of me. I specifically remember early on, a desire to throw them all away in an effort to prove that I was still running my life, not some doctor and his bag of pills; a feeling which was quickly allayed in the fear of losing my new tissue and disappointing those that worked on my behalf to get it.

The pearl of most importance that I gained from walking a mile in the moccasins of a recent transplant patient this week, was the way it will change my practice as a doctor of pharmacy. Now that I understand the fear, stress, and apathy that can ensue with a life-threatening new or chronic disease I can address these issues at the initiation of therapy and check up several times throughout. Truly, the best weapons to combat these negative feelings regarding treatment are knowledge and encouragement. If someone had only sat me down in post-op to explain what had been prescribed, provided a simple explanation of what each drug will do inside my body, and what I should expect to see while taking them; I would not have had the feelings of discouragement, fear or stress as much as I did. I will attempt, as I continue in my role as an intern pharmacist, to incorporate a simple metaphor or analogy that anyone can understand about how a drug works and what to expect from its use, in all of my patient counseling endeavors. Additionally, I believe that the stress of the daily regimen and a developing apathy towards it, that I experienced, might have been avoided with the encouragement of a health advocate. After this exercise I am determined to truly advocate for the health of my patients. No one is perfect, but sometimes a simple, “you’re doing a great job”; or, “keep up the good work”, is sufficient to sally someone in being more adherent to the stringent schedule of a complicated dosing regimen.

Spray Your Valentine With Liquid Trust!

2009-02-14T12:00:00.000-08:00

Hurry there's still time to get your liquid "trust-spray" for Valentines Day! The world's first OTC oxytocin product, formulated to enhance people's trust in you for only $29.95! From their web site we read, "Liquid Trust Enhanced has been specially designed to give a boost to the dating and relationship area of your life. This upgraded formula still contains the same great Oxytocin formula, but now includes the powerful pheromones Androstenone and Androsterone. For the first time, you can create a TRUSTING and PASSIONATE atmosphere...It all starts with Trust." Check it out @: www.VeroLabs.com.

Yeah I didn't believe it when I first saw it either. As per Dr. Buhler's Physiology of Female Hormones lecture; Oxytocin is an endogenous neurohypophysial hormone released from the posterior pituitary of both men and women and acts to contract the smooth muscles in the uterus and pelvic floor region during coitus and child birth.

Oxytocin comes from the Greek; okytokos, meaning swift birth. (Martini, 2006). Before the modern understanding of oxytocin, it was common practice to let a first born twin; suckle at the mother’s breast; speeding the birth of the second child, assisting the expulsion of the placenta (after birth), and promoting the pre-pregnancy uterine size and tone. (Tortora, 2003). We now know that this is due to the hormone oxytocin. A synthetic oxytocin (Pitocin) is used exogenously and is indicated for use in producing rhythmic uterine contractions in full-term labor, control of postpartum bleeding, and induction of postpartum milk let down.

Apparently it has the added (alternate) effect of bonding and increasing the trust in people near its release. It is thought to play a role in augmenting the pair bonding between mates and therefore helps determine long-term monogamy. Quote taken from a study of neuron transmission in prairie voles, "Other neurotransmitters are known to support social affiliation, including the neuropeptides oxytocin and vasopressin, and monogamous prairie voles have a higher density of oxytocin receptors in the nucleus accumbens compared to more promiscuous vole species." (Edwards, 2006) This study concluded that there was a significant correlation between the prairie voles that had more oxytocin receptors and those which lived monogamous lives!

And so what about that Vero Labs claim of 'liquid trust' in a bottle, could there be something to it? Though the FDA approved an over the counter nasal oxytocin spray (that has since been removed) available to assist new mothers in stimulating the milk let down reflex; they only approved a 0.5 mg strength, one that their own literature states was a sub-physiological dose. The possibility that a perfume, like the one sold by Vero Labs, being substantially less than the concentration of this OTC nasal spray, could provide the behavior modifying results of making people trust in others as they are claiming, is rather slim. Happy Valentine's Day!

References:

1. Martini, F. (2006). Fundamentals of Anatomy & Physiology Seventh Edition. Pearson Education Inc. San Francisco, CA.

2. Kosfeld, M; et al. (2005). Oxytocin Increases Trust in Humans. Nature. vol. 435, pp. 673-676.

3. Uvnäs-Moberg, et al. (1999). Oxytocin as a possible mediator of SSRI-induced antidepressant effects. Psychopharmacology. vol. 142, pp. 95 – 101

4. http://arbl.cvmbs.colostate.edu/hbooks/pathphys/endocrine/hypopit/oxytocin.html

5. Tortora, G., Grabowski, S. (2003). Principles of Anatomy and Physiology Tenth Edition. John Wiley & Sons, Inc. New York, NY.

Prescribing Pharmacists

2009-01-31T09:00:00.000-08:00

The next time you go to the hospital or clinic it might be a pharmacist that writes you a prescription for your medication. Ever since the clinical pharmacy movement started in the 1970s, the role of pharmacists has slowly taken on new roles and more responsibilities in addition to filling and dispensing drug orders, that in some cases includes prescribing. Many times it is the pharmacist who is consulted by nurses and doctors to choose an appropriate agent for complicated inpatient (or outpatient) issues. Pharmacists have been prescribing in Australia and Great Britain for many years now under the supervision of an already established prescriber, a practice which they call secondary prescribing. The Department of Health in the UK stated that as of the end of 2004, the first year that legislation allowed it, there were around

1000 pharmacist prescribers. The Royal Pharmaceutical Society of Great Britain states, "Regulations to allow independent prescribing (without the supervision of a doctor/ mentor) by pharmacists came into effect in May 2006. Pharmacist independent prescribers can prescribe for any clinical condition but they must only prescribe within their professional and clinical competence." (see #1. below) Of the numerous studies examining the proficiency of, and need for pharmacist prescribers, the consensus has been that allowing this responsibility to pharmacists; improves patient care, frees physicians for more pressing cases, and saves a great amount of money for the healthcare industry and its patients.

One Irish study made some interesting discoveries after interviewing a number of new prescribing pharmacists and the doctor/ mentors that helped them during their first two years. The article was called: Pharmacists' and mentors' views on the introduction of pharmacist supplementary prescribing: a qualitative evaluation of views and context, and was published in the International Journal of Pharmacy Practice, 2007. They found that, "all participants [pharmacists & doctors] saw it [prescribing rights for pharmacists] as the next step, a natural progression for pharmacy and something that would formalize current practice." They make the claim that prior to this official legislation pharmacists had been effectively performing this type of prescribing only without receiving the due recognition for their input into patient care. One pharmacist was quoted saying, "I would like the ability to change that of my own accord without having to go to a junior doctor who knows absolutely nothing, just tell him to sign off something I've told him to do, which to my mind is ridiculous." Moving in this direction will require pharmacists to be more proactive than reactive. Pharmacists have always been seen as the 'safety net' with regard to correcting or 'catching' prescribing issues, but expanding the role to envelop prescribing within a professional and clinical area of competence or specialty, will bring pharmacists to the forefront of patient care and responsibility. It will save time and money to involve a pharmacist at the beginning of a patients' care rather than only to come behind to fix or catch mistakes that were out of his control. Its the difference between, "offering advice and making decisions," one pharmacist reported.

Surprisingly, pharmacists have even been prescribing here in the US for some time now too. March, 1995 the Veterans Affairs Medical Centers (VAMC) received the go ahead from the FDA to issue a directive that allowed for an expanded scope of practice, including independent prescribing privileges for Clinical Pharmacy Specialists (CPSs). In addition to the normal activities of a registered pharmacist, this new directive allows CPSs to prescribe new medications; including, initiation, continuation, termination or alteration of drug therapies, and the authority to perform, order, or review physical exams and lab tests. CPSs can now assist in emergency procedures, adverse drug reactions, patients with chronic and acute diseases, and administer medications. (See: Prescribing privileges among pharmacists in Veteran Affairs medical centers, American Journal of Health-System Pharmacists, 2001.)

Dare I say that there is not a more exciting time to be a pharmacist since Alexander Flemming discovered the antibiotic properties of penicillin in 1928! Independent prescribing rights for pharmacists is a major advancement for the career. It will necessitate current pharmacists to embrace a changing job description with increasing roles and responsibilities and it will require students of pharmacy to be engaged and alter their goals and outlook for their career. I believe that in a decade's time we will look back and realize that prescribing rights for pharmacists was a logical advancement and we won't be able to imaging what it was like before they could.

References

1. http://www.rpsgb.org.uk/worldofpharmacy/currentdevelopmentsinpharmacy/pharmacistprescribing/index.html

2. http://www.ashp.org/import/news/NewsCapsules/article.aspx?id=227

3. http://www.ashp.org/import/news/HealthSystemPharmacyNews/newsarticle.aspx?id=985

4. http://www.ashp.org/import/news/HealthSystemPharmacyNews/newsarticle.aspx?id=1604

5. http://www.ualberta.ca/~csps/JPPS8(2)/L.Emmerton/pharmacists.pdf

6. http://www.shpa.org.au/pdf/positionstatement/prescribing_jun05.pdf

Clinical Pharmacy

2009-01-10T11:49:00.000-08:00

I've recently been posed the question: "What exactly do pharmacists do in a hospital?" Clinical pharmacists have assisted hospitalists in areas of service, research and education. Here's a summary of what I've seen/read as the importance of a pharmacist-doctor team in the clinic or hospital:

SERVICE

Hospitalist-Pharmacist collaboration can improve direct patient care in the following areas:

· Medication Reconciliation

· CMS Core measures – including antibiotic selection, vaccination, and smoking cessation

· Monitoring drug therapy – including warfarin, insulin, and other drugs with a narrow therapeutic index

· Innovations in transitions of care – especially at admit and discharge to improve continuity of care

· Ensure access to needed medications after discharge

· Patient education

RESEARCH

Hospitalists and pharmacists have collaborated:

· To reduce length of stay

· To improve the discharge process

· To reduce costs (patient and hospital)

· To improve interdisciplinary training

· To improve hospital quality and patient safety

EDUCATION

Pharmacists and hospitalists have collaborated:

· To provide training in palliative care

· To improve interdisciplinary education, as above

· To write and improve textbooks

Illinois and its Governor

2008-12-10T18:27:00.000-08:00

I find it awfully interesting that the day after I question Rod Blagojevich's use of authority he's arrested!? (I even tried so hard to leave his name out of the case!) 'The Economist' said of him that he took office in 2002, "vowing to bring ethics reform to Illinois." What a joke that turned out to be. (see http://www.economist.com/world/unitedstates/displayStory.cfm?story_id=12757603&source=features_box2.)

Let me just tell you how weird this guy is. In an interview in 2006 after the incident I mentioned in my post yesterday (see: Opinions in the Wind) he was quoted as saying, “Rather than try to get the legislature to pass something—because we attempted to and they didn’t do it—on my own, through executive order action, I forced these guys to fill prescriptions for birth control for women who come in with prescriptions from their doctors.” (see from the right http://www.lifesitenews.com/ldn/2008/dec/08120903.html & from the left http://www.windycitymediagroup.com/gay/lesbian/news/ARTICLE.php?AID=13039. Just in case anyone accused me of being imbalanced!) Last time I checked, forcing a bill into law by 'executive order action' that takes away the rights of one person (a pharmacist) to choose how they will express their ethical and religious freedom was expressly forbidden in the Constitution of the United States. Well let's see what he can do from behind bars? I hope pharmacists in Illinois unite, stand up for their right to refuse, and reverse that unconstitutional law that this power hungry Governor mandated!

Here's the official public record of the criminal complaint that lead to his arrest: http://dig.abclocal.go.com/wls/documents/blago_complaint.pdf.

Opinions in the Wind

2008-12-09T22:00:00.000-08:00

Pharmacy school has challenged many of the the ideas and opinions I had previously justified. If nothing else it has shown me that there is much more gray area in most issues than one might presume by looking at the surface. During an ethics case study the other day we pursued a lengthy debate about the degrees of death and the differences between euthanasia and assisted suicide. For those outside of Oregon, our state is one of the few as I understand, that allow physician assisted suicide. You can check out interesting statistics and information on our "Death With Dignity Act", at http://www.oregon.gov/DHS/ph/pas/. This act was passed by voters in October 1997 and allows for terminally ill patients to voluntarily end their lives by taking a lethal dose of medication prescribed by a physician and often filled and dispensed by a pharmacist. Last year (2007) 45 physicians prescribed 85 killer scripts, 49 of which were used to end the life of a patient.

Here's what I think I've sorted out from our deadly debate: manslaughter > euthanasia > assisted suicide > the 'Principle of Double Effect'. The keys for understanding the differences in these is in the semantics of their definitions. The National Institutes of Health has an online medical dictionary that's really great; http://www.nlm.nih.gov/medlineplus/mplusdictionary.html. They define euthanasia as: the act of killing hopelessly sick or injured individuals in a relatively painless way for reasons of mercy. The assisted suicide entry reads: suicide by an individual facilitated by means or information provided by someone else aware of the individuals' intent. Now although the 'Principle of Double Effect' wasn't listed in this - or any other medical dictionary I checked - it is understood in the health community to be in this context, the inadvertent overdose of pain medication leading to respiratory failure and death of a patient. This 'second' or double effect of death is not considered harm to the patient when correctly administered in the proper setting, i.e. hospice or palliative care.

Let me say, right off the bat, that I do not condone Kevorkian ethics surrounding euthanasia, especially since its illegal in all 50 states; but, this issue does present a couple of interesting ethical dilemmas for me with respect to assisted suicide and double effect, which are legal. First of all, how do I feel about taking part in the conscious death of another individual? Secondly, do I or any other health care provider, have the right to refuse care if they disagree with the ethics of what they're being asked to do?

As for the first question, if you had asked me 4 months ago, I would have said unequivocally that there is no way I would participate in the death of another person no matter the circumstance, but that was before I understood the tole (pain) that cancer, ALS and other terminal illnesses take on a person; so now, I'm not sure yet where I stand. I would condone the use of the principle of double effect but I'm going to have to ponder how I would handle being asked to fill or dispense a suicidal medication. I don't know if assisted suicide fulfills the fundamental ethical principle of beneficence or my vow to 'do no harm'.

As for the second question; there was an interesting case a while ago of a pharmacist in Illinois that refused to fill a prescription siting his right to refuse care based on a religious ethical stance that he maintained. He later found that the patient was the daughter of the State's Governor who wasn't very happy about the pharmacist causing an unnecessary emergency of finding another pharmacist to fill the prescription in the middle of the night. The Governor lobbied the state legislator and the voting block and eventually was successful in writing a bill into law that obligated every pharmacist in the state to fill every script that they receive from any licensed physician. This needless to say is a major setback for the career relegating the pharmacist to nothing more than a technician that fills an order. Personally I 'prescribe' to the libertarian model, where each provider has the right to choose his or her mode of practice and ethical justification within the limits of the board that carries their license.

Here's another ethical quandary I've been asked to consider. If you asked me 4 months ago how I felt about addiction, I'd probably tell you that it was wrong to be addicted to a drug and we, as doctors, need to help prevent and treat (wean) patients that struggle with this problem. Well I've found more gray area here to be weighed. We were talking in class just today about Parkinson's Disease (PD), the debilitating degenerative neurological disease that cripples its sufferers with uncontrollable tremors, rigidity, bradykinesia and a shuffling gait. One of the side effects of several of the drugs used to treat the symptoms of PD is an elevation in mood by stimulating the medial fore-brain bundle, which holds the pleasure and reward center of the brain responsible for addiction. Herein lies the question, is it necessarily bad to be 'addicted' to a drug that helps control a disease state, especially one who's side effect actually makes you feel (emotionally) better? I say no, in this context, being addicted is not a harmful thing, and I would probably be happy to see a patient use his or her prescription with good compliance especially if they felt better doing it!

I'm certain there will be interesting cases to come that will challenge my preconceived opinions and stances as I continue my investigation into the world of pharmacy. This will be a continual forum to open some of these gray areas of pharmacy practice for the discussion and consideration of all.

Intro to Pain

2008-11-18T09:35:00.001-08:00

So we started a class the other day called Intro to Pain. It's taught by Dr. Jackson the pain specialist... really! I didn't believe it at first either, there really is such thing as a doctor of pain!

Flu Season 2008

2008-11-14T00:13:00.000-08:00

Doctor Carlson, the preceptor at my Safeway Pharmacy rotation site this fall, requested that I make a public service announcement about the flu that patients could read while waiting for their shots. With his assistance as editor I came up with this poster:

How do you spell that?...or, its all greek to me!

2008-11-12T11:39:00.000-08:00

I remember asking my mom when I was learning to spell how to spell the letters so I could remember the word better! Like how do you spell the letter 'C' or 'S' or 'M', etc. I recall her telling me, "there is no way to spell a letter son". This memory was sparked during Dr. Pokala's description of the reason for neuronal plaque development in Alzheimer's Disease being a result of the cellular cytoskeleton breakdown due to the loss of integrity of the τ-protein. I thought to my self, "I don't remember what this Greek letter looks like, how am I going to write it in my notes? Maybe if I knew how it was spelled I could transliterate this Greek symbol into the roman alphabet." Yeah, I know I'm a little slow. I eventually came to and realized that Greek is one of the few languages I know of that gives you the option of using the symbol or spelling it out! This one's for you Mom, (τ) is spelled: tau! Oh, and if anyone else was wondering I looked them all up, here's the rest of the Greek alphabet...

alpha, beta, gamma, delta, epsilon, zeta, eta, theta, iota, kappa, lambda, mu, nu, xi, omicron, pi, rho, sigma, tau, upsilon, phi, chi, psi, omega

- The image above is a photomicrograph from: pharmalicensing.com/.../1117210578_429747d2adcec showing a tangle of τ-protein (large dark triangular structure) that may be a cause of Alzheimer's Disease!

Food Diaries

2008-11-10T09:38:00.000-08:00

Our academic extention groups threw this newsletter PSA together in a half an hour today!

I need a Latin pseudonym...

2008-10-09T21:12:00.000-07:00

So Paracelsus is my new hero. Dr. Harrelson (PhD. Medicinal Chemistry) lectured today about drug discovery, its history and practical use. Anyway, he mentioned that this guy Paracelsus, kind of stood up to the establishment headed by the Galen doctrine of polytherapy (throw as many herbs as you think necessary at the patient and the body will "take what it needs" to heal) by suggesting that each herb given as a remedy has what he called a 'vital spirit' or 'quintessence' that was responsible for its pharmacological benefit. He postulated that this quintessence from herbs and minerals were contaminated with impurities that inhibited their 'natural' benefit. So off he went purifying natural products by isolating their active ingredients. The now purified compounds were given to patients suffering from certain ailments and the effect or drug action was observed and recorded. This lead Paracelsus to the theory of monotherapy; or a drug intervention where only one drug is used to treat one disease state. It sounds like pretty standard stuff for our 21st century ears, but in his day this was an exciting and revolutionary theory.

All that history aside, that isn't the purpose for my posting. I'm in love with the romanticism of taking a Latin pseudonym as did so many scientists, philosophers and writers of the romantic and classical eras. It was a right of passage so to speak for the educated, no matter their native language, to understand Latin grammar and even take on a Latin pseudonym or to Latinize their given name in order to publish during the scientific revolution. Take this guy Paracelsus; his real name was, Theophrastus Philippus Aureolus Bombast Honenheim, pretty amazing in its own right but not very practical in conversation. What about Carl von Linne, known to most by Carolus Linnaeus, the Swedish botanist/ zoologist that started the whole binomial nomenclature thing! Sometimes the pseudonym would not be a Latinization of their own name but would take on an attribute or characteristic of that person. Take the Polish born renascence man, Mikolaj Kopernik who had many names, the best known of which was Nicolaus Copernicus which literally means 'one who works copper'. The famous Frenchman, Rene Descartes was known as Renatus Cartesius among academic circles. Galileo Galilei was... wait he was Italian?! (seen above right).

So I guess I feel like I want to join this uber-cool club of scientists by finding a Latinized pseudonym of my own! For those of you who know me, please suggest some original and relevant Latin names to consider. If you don't know me all that well, suggest some Latinized forms of my given name, or check out my profile and try something more character based. I'm excited to see what you all come up with!

Here's a cool list of Latinized names: http://en.wikipedia.org/wiki/List_of_Latinised_names

or: http://freereg.rootsweb.com/howto/latinnames.htm

Pharmacy - The Noble & The Ancient

2008-09-29T21:50:00.000-07:00

Pharmacy is one of the oldest professions, older even than banking (believed to have begun around the 3rd millennium B.C. in Greece) with ties to Mesopotamia; the first record of apothecary is registered in 2600 B.C. Babylon. Shen Nung the legendary emperor of China (depicted at the left testing the medicinal quality of an herb) is considered the father of ancient herbal remedies and was celebrated in his ability to prepare medicines for many illnesses. The Eber Papyrus of Egypt (1552 B.C.) was the first pharmacopoeia with a collection of 700 drug preparations which listed prescriptions for ailments as common as headache and constipation and as complex as asthma & even references cancer!

Apparently there wasn't a separation between pharmacy and medicine anciently, as our society historically believes. These ancient practitioners, apothecaries and 'medicine men' simply diagnosed, prescribed, prepared and dispensed their remedies to those who sought them out. One of the greatest practitioners of medicine were the Arabian twins (and Christian martyrs which helped them achieve patron saint status) Damian and Cosmas. They traveled on their own accord and provided health and medical care pro bonno publico to those in need through the ancient region of Aegea.

In 1240 AD the German Emperor Stauferkaiser Frederick the II gave the Edict of Salerno, what later became known as the Magna Carta of Pharmacy. Therein he proclaimed that the profession of pharmacy would be practiced separately from that of medicine, that there would be official supervision of pharmaceutical practice, and that each pharmacist would be obliged to swear an oath, to prepare drugs reliably and with high quality. I suppose in hindsight that this was a necessary evil, as it fixed the price of pharmaceuticals and herbs, making them accessible for the common German citizen. Unfortunately it hurt the profession because it relegated the role of the pharmacist to little more than that of merchant shopkeeper, dispenser, or manufacturer, and prevented him from performing the more specialized roles of clinician, herbalist and healer that he was accustomed to performing.

But the profession advanced and yielded wise and capable pharmacists. Dante Alighieri famous author of the "Divine Comedy" was a noted pharmacist. Self proclaimed prophetic, Nostradamus made many contributions to the field of apothecary. Other pharmacists of note include; Nicholas Culpeper, author of timely works such as, "The English Physician" and the "Complete Herbal" & the brilliant Revolutionary War General (and traitor at right) Benedict Arnold, were respected apothecaries during the 17th and end of the 18th centuries respectively. American favorites: Coca-Cola, Root Beer & Dr. Pepper were invented by pharmacists, John Pemberton, Charles Hires & Charles Alderton respectively. The contribution of all these, and so many other pharmacists, apothecaries and herbalists to our quality of life and modern society is truly staggering... like standing on the shoulders of giants!

Here I find myself, a student of pharmacy (class of 2011), on the threshold of past wisdom and staring down a corridor of future possibility. I feel honored and eager to contribute to this noble and ancient profession. There are maybe a handful of moments that I will never forget where I was and how I was feeling. One such moment was the white coat ceremony for Pacific University of Oregon's entering class of 2011, where I donned the vestment of professional and compassionate healer. I agree with the School of Pharmacy that, "the white coat is a symbolic, non-verbal communication used to express a fundamental belief system that society observes." It provides reassurance and confidence to those that will seek me out, that they will be dealt with competently, seriously and compassionately.

Which one of these isn't like the others?

2008-09-25T11:40:00.000-07:00

Can you tell which one of these doesn't belong, or which one is natural and which one is synthetic?... Neither can your body!

So many people it seems these days think (incorrectly) that there is something special about natural or herbal remedies, or that there is something inherently 'bad' about pharmaceuticals and manufactured chemicals. Your body's CYPs and transmembrane receptors metabolize or bind all of these substrates in the same way because they can't tell the difference between them. Compound (A) is norepinephrine an endogenous (naturally produced) neurotransmitter hormone. Substance (B) is Ma Huang or ephedrine; a.k.a. mormon tea, this is an herbal drug that releases endogenous norepinephrine. Finally, species (C) is pseudoephedrine a synthetic xenobiotic that performs the same function as ephedrine; causing the release of endogenous norepinephrine.

If the body can't tell the difference and there is no toxic effect why should it matter if the xenobiotic that you introduce into your body is 'natural', i.e. herbal or synthetic?

Some wisdom from the past

2008-09-23T11:48:00.001-07:00

Paracelsus (1493-1541) has said, "What is a poison? All substances are poisons; there is none that is not a poison. The right dose differentiates a poison from a drug." Everything we ingest, manufacture, consume, etc. are in essence xenobiotics. They're all made up of carbon and oxygen and hydrogen and nitrogen. (This list might include very little sulfur, sodium and other trace elements). All the food we eat, all of the pharmaceuticals we ingest and all of the pesticides, herbicides and fertilizers we use are just chemicals made up of a variety of the aforementioned elements. They are in essence foreign compounds waiting to poison us as Paracelsus warned. All of them are good and have they're place in modern society, but need to be used prudently and with understanding of the mechanisms of kinetics within the body.