Angry Doctor

Monday, July 31, 2006

Use and Abuse 3

This newspaper report today gives an idea of the scale of the Subutex problem (emphasis mine):

Govt to tackle the abuse of drug Subutex

WITHIN two weeks, the Government will unveil a strategy to tackle the rising trend of Subutex abuse, which is the only approved drug prescribed to help heroin addicts cope with withdrawal symptoms.

Health Minister Khaw Boon Wan said he was worried by the "Singaporean" problem, with 40 per cent of the estimated 4,000 abusers from the Malay community, and another 40 per cent from the Chinese community. The trend is especially alarming in Dr Khaw's Sembawang constituency, where the issue of Subutex abuse crops up at every residents' meeting.

"The addicts … cause a social nuisance, leaving behind needles after they use them in the toilets and corridors, frightening the neighbours," he said.

Subutex abusers get a "high" by injecting themselves with the dissolved drug. When used correctly, the pill treats heroin withdrawal symptoms such as nausea.

Between 2002 and 2004, the number of Subutex pills prescribed here is estimated to have shot up from 78,764 to 619,472.

Dr Khaw said his office and the Ministry of Home Affairs would come up with a solution that is "complete" rather than "symptomatic".

There has recently been talk about making Subutex a controlled drug so that doctors selling it would be held even more accountable. Anyone caught with the drug without a prescription could face a fine and/or imprisonment.

Last October, the Government sought to tighten supply by making it mandatory that doctors submit details on patients using Subutex. — CHRISTIE LOH

angry doc likes numbers - they fuel his imagination.

The demand for Subutex increased nearly seven times over the course of two years. Now even if all the Subutex prescribed were to heroin addicts using them as prescribed, the sheer increase in the number of heroin addicts would have been a cause for concern. And that's not even counting Subutex that had been brought into the country illegally.

So did the people who knew of the number of Subutex tablets prescribed in the country conclude that the heroin addiction problem must have improved dramatically over those years, judging from the number of addictis who must have been on therapy? If that was indeed their conclusion, did they check with the Central Narcotics Bureau to see if this was consistent with their surveillance of the drug abuse situation in Singapore?

Or did they not know that the drug was being abused at all?

Well, perhaps all that are not important now. What angry doc is more interested in now is the Ministry's "complete" solution to the problem.

Stay tuned. I know I will.

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Thursday, July 27, 2006

Hair for Hope 3

Blinkymummy has a close encounter with the Hair for Hope project.

Watch the video.

Make the pledge.

Tuesday, July 25, 2006

Use and Abuse 2

I did not expect the Central Narcotics Bureau (CNB) to respond the the letter by Dr Soo which we discussed in this post two weeks ago, but they did so in a letter to Today today.

Providing substitute drugs will only prolong addiction

Letter from Dawn Sim
Public Affairs, For Director
Central Narcotics Bureau

WE REFER to the letter "Drug for heroin dependence can turn lives around" by Dr Soo Inn Choong (July 10).

Abusing drugs such as heroin is a deliberate act of taking a psychoactive substance against the law.

Drug addicts must account for their actions and take personal responsibility to stop their undesirable habits which have serious repercussions on their lives, careers and families.

Providing addicts, who are unwilling to take personal responsibility, with a substitute drug merely encourages them to prolong their addiction from one drug to another.

In our experience, rehabilitating drug addicts can only be achieved through a comprehensive programme of treatment through rehabilitation and aftercare. Unless they are compelled to stop and supported to take responsibility for their actions as part of a holistic rehabilitation programme, many will continue to dither and languish in the embrace of one drug or another.

For every case cited by Dr Soo, we know of many others who have thoroughly cleaned themselves from their addictions and lead healthy and productive lives without the need to be under the bondage of any drugs.

It is with this approach that we have managed to keep Singaporeans relatively drug-free. The Central Narcotics Bureau and the Ministry of Health have been monitoring the Subutex situation closely.

The two agencies are also working together to assess if additional measures are needed.

We are presented with two different views of the same 'problem', which likely stems from the fact that the CNB and Dr Soo probably see two rather different groups of addicts in the course of their work - the one with addicts who did not voluntarily seek help, and the other with those who came forward willingly, after the decision to quit.

Dr Soo sees addiction to heroin as 'a disease that should be treated like every other'.

The CNB sees addiction to heroin as 'a deliberate act... against the law'.

Of course, there is no reason why it can't be both.

But Dr Soo also sees Subutex as a medication, and he believes that '(i)n the same way that people with other mental disorders such as schizophrenia or depression need medication, so do those with heroin dependence.'

Whereas the CNB believes the use of Subutex 'merely encourages (addicts) to prolong their addiction from one drug to another'.

Well, these two positions are a little harder to reconcile, but there is no reason why it cannot be the case of the former in some people, and the case of the latter in others. In fact, that is almost certainly the reality, since we know some people quit their heroin addiction with Subutex, and some people abuse Subutex.

Addiction is a complex phenomenon involving many aspects of a person, including genetics, biology and psychology. Add to that the social implications or stigma of the term 'addiction', and the picture gets even more complex. There probably isn't a one-size-fits-all solution to heroin or Subutex addiction, not to mention other forms of addiction. The 'best' solution depends on which spectrum of the 'problem' you have to deal with.

As politically-incorrect as it seems, angry doc tends to agree with the idea that taking personal responsibility is an important step in quitting any addiction (or controlling many chronic medical conditions, for that matter). While we may argue over individual susceptibility to addiction and what the best method of quitting is, I believe one thing all successful 'quitters' must have had in common was the personal decision to quit, and the continued decision to see the rehabilitation process through, be it cold-turkey, or drug-assissted.

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Thursday, July 20, 2006

Hair for Hope 2

A follow-up on the Hair for Hope project:

"An amazing number of over 599 volunteers will be parting their hair for a good cause. Among them are 99 ladies! Make a pledge through one of them to support the cause and their head shaving act! "

If you click on the link you can see the pictures of some of the people who have pledged to shave their heads for the cause. The first round of shaving takes place this Sunday at Suntec City Mall.

Wednesday, July 19, 2006

Being Happy

Apologies for not posting over the past few days, but sometimes diagnoses are made accurately, patients are compliant and have good outcomes, and normally-obstructionist jerks co-operate fully, and there really isn't anything to make angry doc angry.

And I'm not the only one feeling a little more placid this week - Dr Crippen, Dr tscd, and Dr Barbados Butterfly all seem to be enjoying a little respite from the usual aggravations too.

Not much on the media front to ruffle my feathers either. In fact, this article from Today today even managed to put a smile on my face:


"What about healthcare policies aimed at making people happier? If people are happier, they are less likely to fall ill, thus, saving money for the taxpayer and themselves. What about educating Singaporeans on depression being a common illness? And negotiating with makers of Prozac and other anti-depressants that have limited side effects to supply Singaporeans with cheap pills?"

Yes, we should just put it in the tap water and make everyone happy.


Friday, July 14, 2006

Big Pharma 2, angry doc 1

Readers who visit Dr Crippen's blog will realise that angry doc is a fan and an occasional 'commenter' (what do you call someone who comments on a blog entry?).

Here's an article on the subject of objectivity of medical journals (by a former editor of the BMJ) recommended by a fellow reader/'commenter' there.


"... the editors are likely to favour randomised trials. Many journals publish few such trials and would like to publish more: they are, as I've said, a superior form of evidence. The trials are also likely to be clinically interesting. Other reasons for publishing are less worthy. Publishers know that pharmaceutical companies will often purchase thousands of dollars' worth of reprints, and the profit margin on reprints is likely to be 70%. Editors, too, know that publishing such studies is highly profitable, and editors are increasingly responsible for the budgets of their journals and for producing a profit for the owners. Many owners—including academic societies—depend on profits from their journals. An editor may thus face a frighteningly stark conflict of interest: publish a trial that will bring US$100 000 of profit or meet the end-of-year budget by firing an editor."

Maybe angry doc should stop asking drug reps for free copies of trial reprints too?

I swear, the more I learn about the healthcare business, the harder it is for me to sleep at night...


Wednesday, July 12, 2006

"Reward us for taking care of ourselves"

A rather insightful article from Jeremy in Today yesterday:

Reward us for taking care of ourselves

A FEW days ago, while brushing my teeth, it struck me that it was within my power to control, if not reduce, the dental costs for my parents.

I could do that if I continue to eat healthy food, clean my teeth as often as necessary and visit my dentist regularly.

Considering that it is much, much cheaper to go for regular check-ups than to repair or replace bad teeth or treat a gum problem, it makes sense for us not to neglect our oral hygiene. But if we do so, we have only ourselves to blame for that big hole in our pocket when the bill comes.

Using the same logic, we can arrest the rising medical costs if we take responsibility for our health. If we do not take care of our body, we must be prepared to pay the price.

It may not be easy to maintain a healthy body, but it is simple: Adopt a healthy lifestyle, go for regular medical checkups and take our medication when we are not well.

The other option is to face the prohibitive medical cost. Then we are free to abuse our body and indulge in unwholesome food.

Never mind the lifestyle diseases like high blood pressure or hypertension, we can take care of them when it gets worse. If that is our choice, we should not complain about rising medical costs — we should accept the consequences with equanimity.

Many people do not realise or admit that they are responsible for themselves. They cannot change the rates of medical fees, but they can change themselves.

I am aware that there is no guarantee that you will not be sick if you do all the right things for your health.

You can't do much to prevent inherited diseases like cancer and diabetes from striking you. But regular checkups can mean that when it does, it can be detected earlier, and by taking one's medication consistently, one can treat it.

In short, it will cost less if you take control and more if you let it fester.

Notwithstanding this, I am sure there would be fewer sick people if everyone took responsibility for their own well-being. With fewer people requiring medical care, might the Government be able to afford to give more subsidies?

Might insurance premiums be lower? In other words, everyone can contribute to the lowering of medical costs.

I would like to suggest that the Government come up with a system to give more help to patients who take care of their own health.

For example, points can be given to those who go for regular checkups, attend health talks and adopt a healthy lifestyle. These points can be converted into discounts when they see a doctor.

More help should be given to those who deserve it because their medical problems are not of their own doing.

For those who choose to abuse their body, however, the Government should increase the medical fees, to hopefully serve as a deterrent to other like-minded people.

(The writer is a student, aged 16.)

OK, the issue is more complex than that, and even if the idea has merit, implementation is going to be politically-difficult.

Nevertheless, even if you take into account the fact that Jeremy has osteogenesis imperfecta (scroll down this page to see an article and picture of him), is wheelchair-bound, and has probably spent more time in hospital than most people his age, that is still a rather more mature attitude than is held by many people several times his age.

I think I shall make an appointment with my dentist tomorrow...


Big Pharma 1, angry doc 1

I wonder why but Big Pharma seems to be out in full force this week. Is performance review at the end of the month?

Drug-pusher: Good morning, angry doc. Here's some breakfast for you compliments of STD.

what I want to say: Yikes! I'm really hungry and that looks really delicious, but...

what I say: No thanks, I buy my own breakfast.

Drug-pusher: OK... have some free pens and notepads then.

what I want to say: Ooh! Colourful!

what I say: No thanks, I buy my own pens and notepads too. How can I help you today?

Drug-pusher: Oh, I am here to remind you of our product. As you can see from this colourful poster, it's been shown to be better than our closest competitor in the COPY-CAT and ME-TOO studies.

what I want to say: Isn't COPY-CAT the one where your company omitted important information, or is that ME-TOO?

what I say: OK. Do you have copies of the trial papers for me then?

Drug-pusher: Er... sorry, I don't them with me right now...

what I want to say: Remind me again: are you here to give out breakfast, pens, notepads, or product information?

what I say: ...

Drug-pusher: Er, I can send you the papers another day.

what I say: Thank you.

Drug-pusher: Thanks for your time. Remember our product!

what I want to say: Only if you remember what your job should be about!


Hair for Hope

If you've seen that picture on posters at bus stops and have been wondering what it's all about, you can find out at the Hair for Hope site here.

Registration closes on 12th July. You may sign up here.

(I've post-dated this entry to keep it on top of the page until 12th July.)

Monday, July 10, 2006

Use and Abuse

There is almost always two sides to a story, and this letter from Dr Soo published in Today today tells 'the other side' of the Subutex story:

Drug for heroin dependence can turn lives around
Letter from Dr Soo Ing Choong

I am a general practitioner and have worked to improve the health of my patients for more than 18 years.

Heroin addiction is a national problem. In the same way that people with other mental disorders such as schizophrenia or depression need medication, so do those with heroin dependence.

The health authorities recognised the usefulness of Subutex in treating heroin dependent patients, and approved its use in 2002. Since then, several Ministry of Health guidelines have trained doctors like myself in the proper use of this medication, and effectively stopped doctor-hopping by registering patients under the Cards system (Central Addictions Registry for Drugs Singapore).

Over the year, there have been many reports of people abusing Subutex — the only approved and effective medication for the treatment of heroin dependence. And with every negative media article, dozens of success stories go untold.

For every case of abuse of this medication, there are numerous patients who can return to work and contribute to society, re-establish family relationships and raise their children with love, as they try to break free from their dependence.

I have treated a large number of patients who have turned their loves around to become contributing members of society with the help of this medication. The public needs to understand that heroin dependence is a disease that should be treated like every other.

We've discussed this problem previously, and the subject continues to make the news and medical literature (click here to see the scale of the problem, here to find out about an alternative to Subutex, and here to look at some gross pictures of limbs turned gangrenous from Subutex abuse).

My own suspicion is that even with tighter regulation or even total banning, Subutex-abuse will continue to be a problem as long as it is manufactured, whether legitimately or illegally, if it indeed gives 'even more high' than heroin.

The genie is, as it were, already out of the bottle.

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Saturday, July 08, 2006

Interpreter of Maladies 5

"Results. Thirteen encounters yielded 474 pages of transcripts. Professional hospital interpreters were present for 6 encounters; ad hoc interpreters included nurses, social workers, and an 11-year-old sibling. Three hundred ninety-six interpreter errors were noted, with a mean of 31 per encounter. The most common error type was omission (52%), followed by false fluency (16%), substitution (13%), editorialization (10%), and addition (8%). Sixty-three percent of all errors had potential clinical consequences, with a mean of 19 per encounter. Errors committed by ad hoc interpreters were significantly more likely to be errors of potential clinical consequence than those committed by hospital interpreters (77% vs 53%). Errors of clinical consequence included: 1) omitting questions about drug allergies; 2) omitting instructions on the dose, frequency, and duration of antibiotics and rehydration fluids; 3) adding that hydrocortisone cream must be applied to the entire body, instead of only to facial rash; 4) instructing a mother not to answer personal questions; 5) omitting that a child was already swabbed for a stool culture; and 6) instructing a mother to put amoxicillin in both ears for treatment of otitis media."

- from Errors in Medical Interpretation and Their Potential Clinical Consequences in Pediatric Encounters, PEDIATRICS Vol. 111 No. 1 January 2003, pp. 6-14

Friday, July 07, 2006

Interpreter of Maladies 4

"This job wasn't always easy -- and maybe I wasn't always qualified -- but it was an important part of family life in my immigrant family. Banning this interaction between child and parent -- especially when the family has no other choice -- seems wrong to me. When I was interpreting for my family, I felt I was fulfilling my filial duty. I was contributing to the family.

I hope that the state could get to a point where every non-English speaking person can have access to a professional translator when they need one as they seek health care. If that happened, children like me wouldn't have to learn a third language -- medical talk -- that they may or may not fully understand."

- from Translation Trouble - Children May Be Barred From Interpreting for Their Parents, New America Media

Thursday, July 06, 2006

Interpreter of Maladies 3

"The Fresno County Health Department provided only Hmong speakers to interpret for her, though Souvannarath doesn't speak the language. According to Souvannarath, one Hmong interpreter somehow communicated that she shouldn't take the medications because they were killing her. Another Hmong interpreter misunderstood Souvannarath and told authorities that she was suicidal when she was not, which resulted in a two-day incarceration in a dark, cold jail basement cell. For 11 months, her daughters, who were as confused as Souvannarath, were her only real interpreters."

- from From Sickbed to Jail, for Lack of Medical Interpreting, New America Media

Wednesday, July 05, 2006

Interpreter of Maladies 2

"Trying to communicate through an untrained interpreter is like playing the children’s game of telephone: Start with a sentence, pass it along a chain of people, and laugh when it emerges altered and garbled at the end of the chain. Except in a clinic situation with an untrained interpreter, you are left wondering whether what you asked was what the patient heard. And that’s not funny.

Study after study has shown that untrained interpreters in medical settings—such as husbands, friends, secretaries, and janitors who have some bilingual skills and happen to be available—are reliably unreliable. They typically lack fluency in English, the linguistic skills to convert from one language into the other, and knowledge of the medical terminology that’s needed to provide an accurate and complete interpretation. They might have their own agendas or opinions and, in the worst cases, might intentionally cover up their own abuse of the patient."

- from Doctoring Across The Language Divide, Health Affairs

Tuesday, July 04, 2006

Interpreter of Maladies

“I work in a doctor’s office.”

“You’re a doctor?”

“I am not a doctor. I work with one. As an interpreter.”

“Tell us more about your job, Mr. Kapasi,” Mrs. Das said.

“What would you like to know, madame?”

“I don’t know,” she shrugged, munching on some puffed rice and licking the mustard oil from the corners of her mouth. “Tell us a typical situation.” She settled back in her seat, her head tilted in a patch of sun, and closed her eyes. “I want to picture what happens.”

“Very well. The other day a man came in with a pain in his throat.”

“Did he smoke cigarettes?”

“No. It was very curious. He complained that he felt as if there were long pieces of straw stuck in his throat. When I told the doctor he was able to prescribe the proper medication.”

“That’s so neat.”

“Yes,” Mr. Kapasi agreed after some hesitation.

“So these patients are totally dependent on you,” Mrs. Das said. She spoke slowly, as if she was thinking aloud. “In a way, more dependent on you than the doctor.”

“How do you mean? How could it be?”

“Well, for example, you could tell the doctor that the pain felt like a burning, not straw. The patient would never know what you had told the doctor, and the doctor wouldn’t know that you had told the wrong thing. It’s a big responsibility.”

“Yes, a big responsibility you have there, Mr. Kapasi,” Mr. Das agreed.

Mr. Kapasi had never thought of his job in such complimentary terms. To him it was a thankless occupation. He found nothing noble in interpreting other people’s maladies, assiduously translating the symptoms of so many swollen bones, countless cramps of bellies and bowels, spots on people’s palms that changed color, shape, or size.

- from Interpreter of Maladies, Jhumpa Lahiri

Saturday, July 01, 2006

You got pressure, I also got pressure

Here's an interesting article which Dr Crippen linked to in his blog; perfect for angry doc's weekend reading.

It's pretty long (you can skip the first section, which really is just an anecdote - an allergy can occur with any medicine, new or old, cheap or expensive), but comes with lots of colourful tables and charts.

The article presents one side of the story (and as usual I would advise readers to read more on the topic rather than to make a conclusion based on this one article alone) but I included the link because I think it gives an idea of the kind of moving targets doctors have to deal with in this day and age of Evidence-Based Medicine, as well as who might be moving these targets.

Under the latest guidelines, most of us would have pre-hypertension.

I wonder how long before we all need treatment for pre-mortality.