You've had your flu shot, what about your booze shot?

I heard on the radio this morning that there are animal trials underway for a new injectable drug they referred to as a "shot against alcoholism." What it actually is (and I haven't looked into the actual study) is not like a vaccination, but probably more similar to a "depot" drug, akin to something like DepoProvera for birth control: a drug you can take orally every day or get an injection (this new drug is 6 months, from what I understand) which maintains its effect for an extended period of time. It sounds like what they're working on (in Chilean mice, so far) is similar to Antabuse (disulfiram) which is a pill you take every day as a deterrent to drinking. If you drink while it's in your system, it produces horrible sickness (think "worst hangover you can imagine") including significant nausea and vomiting.

So why would something like that work? You don't have to take it if you don't want, then you'd be able to drink without consequence. It's a form of aversion therapy (akin to Schick-Shadel) which has a couple common uses. First is people who are self-motivated enough to quit but for whom other attempts have failed. They may realize, most of the time, that they shouldn't drink, but they do at times of stress, in the evening after a hard day, etc. They can reliably take their pill every morning, knowing that they shouldn't drink, then when an urge comes about they have a physical barrier to overcome the thoughts like "one drink will be okay" that lead to relapse. It doesn't always work, though; they interviewed one of these patients on the radio who actually planned to stop taking it a few days before an event (e.g. Super Bowl party) but always The other subset would be people who have legal factors involved such as DUI, probation, etc. and who can't be depended upon to stay compliant. They will be more closely followed by health care providers or probation officers, sometimes visiting daily to observe their dose.

Either of these types of people can be lost to follow up or fail to take their pill every day so they can have a drink. This new idea for a 6-month injection eliminates that day-to-day variability in compliance. You can't think "I'll just not take it today so I can drink tomorrow" because the drug is in your system for way longer than that. It also provides a solution to the huge costs and personnel requirements with daily check-ups in the cases of probation and the like. So it seems like a perfect solution! Though, as now with Antabuse, it would probably still be reserved for refractory cases of alcoholism, that is, those people who have tried and failed the more traditional treatments.

I can see one potential problem, though. It isn't unique to a long-acting version, but as with any addiction treatment, there is more than the physical-chemical process. I could easily see how courts might just mandate this drug's use as part of sentencing for certain cases (DUI, repeat intoxication offenders) and leave it at that. However, you aren't truly treating an addiction if you stop the physical behavior but don't address the psychological, emotional, and mental changes involved in any drug or alcohol addiction. You shouldn't give someone this shot and send then out the door the same way that you shouldn't give methadone treatment (substitute/replacement for heroin/opiate addiction recovery) without providing counseling, support groups, 12-step programs, and other resources. That said, though, as long as a holistic approach to alcoholism treatment isn't lost in the presence of a novel, convenient drug/delivery method, this could promise to be a beneficial solution, both financially (with no need for daily monitoring and fewer repeat offenses) and in terms of treatment success (resulting in fewer losses/injuries/deaths), for people who can't make those last steps to completely cutting out alcohol. It may also be a feasible alternative to repeat offenses or incarceration for those with DUI history as a contingency of driver's license reinstatement in certain cases. It isn't into human clinical trials yet, so it's at least 4-5 years down the road, but it will be interesting to see if this drug is successful and how it could potentially improve alcoholism treatment.

The worst day of their life, an average day for us.

As I mentioned in my previous blog, there are a lot of differences between what you do and see as a clinical pharmacist vs. a retail pharmacist. A lot of it just has to do with the nature of drugs and therapy used in inpatient vs. outpatient settings, but clinical pharmacists also participate in more "real" or tangible aspects of patient care. After spending only seven weeks in hospital settings, especially the last three in ICU and Emergency settings, I've seen more patients at the end of their life than any retail pharmacist ever would. It was an interesting experience to see and participate in my first few life-or-death "code" situations. When you see such situations depicted on TV, it's a very solemn and often hectic serious of events, but that's not usually how things go in real life.

There isn't this scrambling and shouting of orders that you see when they get the paddles and shock someone on TV. People work fast, but since these events are an everyday occurrence, especially at hospitals that treat more critically-ill patients, everyone is more used to what might happen and can act in a prompt but calm manner. Rushing around and yelling may make for good primetime drama, but it only adds more confusion and potential for error in real life. Doctors will urgently ask for drugs, shock, procedures, etc. but they do so in a methodical and calm way to ensure clarity and understanding for those administering treatment and the person recording what is done. Sometimes it even seems like they're teaching a class while treating a patient.

It's also not uncommon, except in the most difficult and complicated codes, for people to be smiling or even cracking jokes sometimes. That's not to say that they don't care about the patient; I have never seen a patient treated with less than the highest level of care and concern. But when you see these things every day, you quickly forget about the raw morbidity of the situation in the moment. This is a good thing, though. It's hard to stay focused on treatment and doing your job when emotion stands in the way, as it can be a very powerful factor. Critical conditions, terrible medical events, and death are just part of the job and some level of objectivity is important to keep focused on that one patient and all the patients after her.

Scrubs has been called the most accurate medical show on TV and I wholeheartedly agree. A lot of that is because of the more serious (non-comedic) situations like what Dr. Cox told Turk when he took a patient's death too hard: "You see Dr. Wen in there? He's explaining to that family that something went wrong and that the patient died. He's gonna tell them what happened, he's gonna say he's sorry, then he's gonna go back to work. Do you think anybody else in that room is going back to work today? That is why we distance ourselves, that is why we make jokes. We don't do it because it's fun, we do it so we can get by and sometimes because it's fun. But mostly it's the gettin' by thing."

Of course, that objectivity and ability to distance yourself is not always easy. Sometimes you have a "Jane Doe" patient brought in by ambulance who has so many tubes and lines in place that it's hard to see what she looks like. That's not as hard. But when it's someone who you recently saw up and talking who is now critically ill, or someone whose spouse is brought in crying to hold their hand, it's a lot harder to distance yourself. Or if it's a person who was otherwise healthy and suffered an unexpected sudden event, there's more emotion involved than in the case of someone who, through a long series of poor choices, put themselves into their condition (a "this could happen to me/someone I care about" factor).

I am always very vigilant for the presence of family. Usually the family is not present in the most serious/unstable part of code situations but are brought in once the patient has been somewhat stabilized. Those family members are usually not familiar with how situations like this are handled in a hospital and things you do or say that are common from a medical perspective and matter-of-fact can be taken as insensitive by someone who is experiencing a personal tragedy and one of the worst days of their life. Though I'm not religious myself, I really value the spiritual staff of a hospital because they don't have to worry about the patient's treatment at all but are there to provide a link between the family and the medical personnel. They do things like explain the condition of the patient in accurate but sensitive terms and explain why certain interventions have been taken in a way that someone with no medical training can understand. It is a better way to treat both the patient, medically, and their family, emotionally, to have separate people responsible for those very different but also very important things.

As I said in my last blog, clinical pharmacy is what I want to do. From reading all that I just wrote, you might be asking why I would want to be around death and illness every day. It's not about that, though, as much as it's about the rewarding things I would do to help people recover from illness or injury. People who are in a hospital, as either patients or visitors, are not happy to be there. Because of that, it's easy to think of reasons not to want to work there, but I believe that the rewards I can find in improving someone's care, either through direct interventions or indirect recommendations or support services would easily outweigh the surrounding sadness and tragedy.

I don't expect it to become any less heart-wrenching to see kids coming into an ICU to see their grandparent for the last time (and I could never see myself having a job where I was directly involved in breaking that news), and I hope I don't ever become numb to those situations, but it is an unfortunate reality of working in that setting. Sure, there will be more difficult situations to deal with throughout a career in a hospital vs. a retail store, but they won't overshadow the sense of accomplishment of improving patient care, as long as they are looked upon with just the right balance of objectivity in treatment and compassion for patients and their families.

My Career Revelation

If you asked me where I saw myself working after graduation any time throughout pharmacy school, I wouldn't hesitate in saying that a community/family/retail store was the place I wanted to be. Since I did my first hospital rotation last month, though, I see that as only a fall-back option. My only hospital exposure before last month was the introductory experience at UWMC a couple years ago. While I was there, I really only saw the factory-like dispensing/order entry pharmacist duties. Sure, there were questions from doctors and a couple times they would talk to a patient, but it seemed like the part of retail I'm not as fond of, just in a basement with almost no outside contact. After a month at a rural hospital and a couple weeks into a critical care rotation at a larger hospital, though, I have been exposed to and given the opportunity to do some of the many clinical things that pharmacists do in a hospital setting.

A clinical pharmacist plays an integral role in the healthcare team. Doctors have a lot of things to think about when treating a patient and it's simply not feasible to expect them to do or know everything; thus, the total care of the patient depends on people from many different healthcare disciplines. A few examples of things pharmacists do as part of this team are daily monitoring of end-organ function and re-dosing of drugs accordingly, management of drugs (antibiotics and anticoagulants mostly) that require very individualized dosing and need frequent monitoring, recommendation of anticoagulants to prevent clots while in the hospital, and regular evaluation of antibiotic choice for indications, susceptibility results from cultures, cost, toxicity, etc. Pharmacists are also heavily relied upon for drug dosing, recommendation, and preparation in situations like cardiac/respiratory arrest, blood pressure support, and intubation.

In today's hospitals, the pharmacist is part of the "team," not just a voice on the phone coming from the basement pharmacy. We can make recommendations to doctors about possible changes when we see something that can be changed or adjusted, and for many things there are protocols that allow pharmacists to make the changes themselves (e.g. changing an antibiotic dose when renal function changes). Most doctors are glad to have someone focused on the drugs specifically and we often get asked for input on decisions about drug choice or dosing. (Of course, there are pharmacists that take this too far and assume the position of telling the doctor what needs to happen or what was done wrong. They're shut down pretty quickly, though, and that's a whole different topic…)

What a lot of the difference between retail and hospital comes down to, from my perspective, is the need for professional/clinical judgment and decision-making. There are some aspects of retail where the pharmacist has to make these types of decisions, but unless a prescriber calls for advice or something is so out-of-whack that you call them to clarify, there often isn't enough information to form an opinion. All you have is the list of things they've had filled at your pharmacy, the prescription in front of you, and sometimes the patient's word (which can be variable, especially in elderly patients who didn't understand what their doctor told them). Sure, you catch big issues sometimes, but the little intricacies of drug therapy that a pharmacist is trained to evaluate usually slip by because you don't have the patient's history or lab results and you aren't physically there with the prescriber (and face-to-face interaction with doctors really does make a difference).

Don't get me wrong, I really do enjoy the "heart" of retail pharmacy. Talking to customers that have been coming in to your store for years, being a trusted person to come to with ailments that don't warrant a trip to the doctor, teaching people about their glucose meters and compression hose, and many other things are what drew me to pharmacy in the first place. However, with the amount of time you have to spend dealing with insurance companies, steadily declining reimbursement rates, and ever-expanding big box stores are crushing the small pharmacies, the only ones that provide these services. Sure, I could find a job at one of the few independent stores and be very happy for a while, but who know how long before that totally dies out and either factory/production-line or mail-order pharmacies take over completely. I think the monotony of filling and checking prescriptions would quickly take over the attractive aspects of customer service, too, especially with the need to process more prescriptions just to remain profitable. Being a clinical pharmacist will have its monotonous tasks too (entering orders, going through reports), but it is a growing field that I find much more mentally stimulating. And every pharmacist I've talked to so far has said that you can easily switch from hospital to retail at any point in your life, but it's rare and much more difficult to do the opposite. So if I want to have a clinical position, the time to act is now.

So how do I go about this? Unfortunately, it's not as easy as just applying to a hospital instead of a store. Inpatient pharmacy managers are looking, almost exclusively, for candidates with post-graduate training. Since I had this revelation within the last couple months and not a year ago, I've missed the whole application process for residencies starting after graduation. The plus side of that is I won't be starting a residency during the summer and can work at Camp Parsons. But that also means that I'll have to figure out some sort of plan for the upcoming year that I hadn't ever thought to consider until now. To be continued…

A Few Words on Guns

It's been quite a while since I've written one of these things.  It was a busy summer and it's been a busy year doing my last year rotations for pharmacy school.  I have thought of numerous blog topics, but haven't really ever sat down to write one of them.  The thing that prompted me to write this one was the three very heated conversations I've been around in the last 5 days on the topic and the fact that I am not one to interrupt such "discussions" so never really got to explain my take.  So here goes…

I could write for days about gun control and the different opinions of people all across the spectrum from complete pacifists to anarchists (and we're seeing all kinds come out of the woodwork right now).  I don't want to do that, though, I just want to address what I think the problem actually is and some reasonable solutions for improving our system and hopefully preventing some of the violence and tragedies we have seen.

MENTAL HEALTH

The first solution I think of every time I hear one of these stories on the news is not related to gun control, but to mental health.  Society has moved a long way from putting all of the people with mental disabilities in asylums, but there is still a stigma.  That and the fact that mental illness can't be visually seen and isn't as easily measured makes it difficult for people to get help.  It is just as important to evaluate our mental health options for children (especially those with broken homes or living in lower-income households) and for adults who can't afford it or don't have the support of family and friends that is often taken for granted.  I don't have any idea what a specific improvement would be, as I have little experience with or knowledge of  that system, but it needs attention and it is a shame that gun control pushes this very important medical factor out of the public's eye every time there's a similar tragedy.

GUN SAFETY AT HOME AND WITH YOUR KIDS

Now for gun control itself.  Before we go so far as to ban everything or start taking away guns from people who would never use them in a crime, there are numerous things that could be done to control gun violence and injuries.  The first is safety at home.  Gun owners have a HUGE responsibility with security.  Owning a gun means that you are responsible for where it is and whose hands it gets into.  For someone who lives alone, that may be as easy as keeping guns out of sight from outside, keeping your house locked,  and keeping reasonable measures in place to deter theft.  However, in homes with other people, especially children, there are more steps that need to be taken.  Gun locks and safes come in a huge variety of options.  You can get a big climate-controlled, Fort-Knox-like gun safe, but you can also get a sturdy lock for less than ten dollars.  There is no reason why someone in your house should be able to get to your gun if you don't intend them to.  Many of the tragic shootings are not committed by gun owners themselves, but by people who live in a house where guns have been left unsecured and/or accessible.  Another thing that should be done in households with guns is the education of kids at a young age.  What you let your child do at what age all depends on your comfort level, beliefs, and their maturity.  At minimum, though, you can't just keep guns hidden and not discuss safety.  Kids are curious and will find anything you try to hide.  So a better option is to teach them what a gun is, how they can be used for their intended purposes, but also dangerous and fatal if used improperly.  For older children, safe gun handling is vital.  The three basic rules, if followed, can prevent almost any accident: always keep the gun pointed in a safe direction, always keep the gun unloaded until ready to use, and always keep your finger off the trigger until ready to use.   In addition to those: don't ever touch a gun at home or at someone else's house without asking permission from your parents.  If you don't want to teach a kid to shoot or use the gun, fine.  But at least teach them how to be safe when there's a gun in the house.

GUN LICENSING?

Ok now here's my fix for the gun control issue that we're facing as a country.  Licensing.  When you turn 16 and wish to drive, you can get your driver's license.  When you turn an appropriate age and would like to buy, own, or use a gun, there should be a license for that.  Just like there are requirements for classes and exams (both written/knowledge and practical exams) for driving, there should be training and exam requirements for gun ownership.  When you get that license, they would do a criminal background check as well as a check for history of mental illness (which, if present, would be evaluated by a physician for relevance to gun safety concerns).  Just like you have to renew your driver's license, you would have to renew your gun license.  Those checks would be repeated upon each renewal.  When I buy a gun, I have absolutely no problem with background checks, and wouldn't even if they were required periodically after the initial purchase.  Neither should anyone else who owns a gun for non-criminal purposes.  Yes, it would be even more of a hassle than the process is now, but when it comes to the safety and security of schools and society, you should be willing to step through a couple of hoops for an elective purchase of something that has the potential to easily be lethal in the wrong hands.

OUR RIGHTS AND BETTER MANAGEMENT THAN OUTRIGHT BANS

With all I said about licensing, you'll notice I didn't say anything about the government telling you what you can and can't have.  Sure, high-capacity magazines aren't NECESSARY.  And there are a lot of situations where semi-automatic actions are more than you need.  But restrictions on those things shouldn't be made on a global level, they should be made for specific situations.  Pistols have the potential to be more dangerous and tricky to handle than long guns.  So don't ban them for everyone, implement an age requirement (which we have: 18 to buy a long gun, 21 for a pistol).  Having a gun where alcohol is consumed opens up more room for problems.  So don’t ban the gun, just restrict what you can have with you at various locations (bars, stadiums, schools, etc.).  I personally don't think there's any reason a regular citizen would  need an "assault rifle," but as Americans, we have rights to own what we choose to own, even if there are requirements to doing so. The answer isn't tightening down what you can and can't have, it's in ensuring that people who own guns are adequately knowledgeable in safety and have been background-checked and that special locations or circumstances are evaluated and mitigated individually.  (One exception is that I don't think there's any reason for anyone to have an automatic gun, but I'm not going to delve into detail there.)

IN CONCLUSION

So in summary (whew, that was a long blog), the answer to gun control shouldn't be to ban guns altogether but rather to enhance our current system in a way that better reviews criminal and mental history as well as evaluates a buyer's knowledge, skills, and attitude in regards to gun safety.  Gun-owning parents need to educate their children on firearm safety and all gun owners need to put sufficient measures in place to prevent unauthorized access to their guns.  I found a quotation from Thomas Jefferson (said to George Washington): "One loves to possess arms, though they hope never to have occasion for them."  That statement describes me pretty well.  I got interested in guns after running a rifle range and teaching various courses, and I enjoy the sport of target shooting, plinking, and trap/skeet.  I don't hunt, but only because I don't want to deal with the associated mess.  And having guns for home/personal defense gives some piece of mind, but I hope I'm never in a situation that they'd be necessary for that.  If we do ban guns, the criminals will still get them one way or another.  That ban would affect the law-abiding citizen and probably wouldn't reduce crime in the way gun-ban-advocates would hope.  I'll close with an interesting comparison and another quote from Jefferson.

Chicago has some of the most stringent gun control laws, yet is on the very high end of crime rates.  In contrast, a small city in Montana required  every adult to carry a gun for a certain period of time and the crime rate went down to zero.  (Just some food for thought).

"Laws that forbid the carrying of arms . . . disarm only those who are neither inclined nor determined to commit crimes . . . Such laws make things worse for the assaulted and better for the assailants; they serve rather to encourage than to prevent homicides, for an unarmed man may be attacked with greater confidence than an armed man." 
--Thomas Jefferson, quoting Cesare Beccaria in On Crimes and Punishment (1764).