Thursday, August 17, 2006

Virgin Bone

Hail all,
And apologies for the protracted absence. Will reply to comments soonish.

What's been happening? Well, the mood is improving, in fact, has improved so much I don't feel the need to bang on for hours about myself and my feelings. From the biochemical point of view, things, I suspect, are on the way up.

To mark this, Sarah and I abandoned our ethics, tore off our priciples and went to not one, but two drug company dinners. The last one of these was a while back, and since I spend the intervening months ranting about the corrupting influence that drug companies have on medicine, I felt the pull of conflicting desires as soon as I walked into the room.

On the good side was a a host of colleagues in a high-ceilinged room, smoked salmon and caviar, nubile waitresses and vivacious sales reps, and fine wines (a light shiraz to accompany the samples of zolpidem sedative tablets, a fuller merlot to complement the fentanyl pain patches).

On the bad side was the guilt (about admiring the high-ceilinged room, indulging myself in the smoked salmon and caviar, glancing at the nubile waitresses and vivacious sales reps, and quaffing the fine wines), and the fear that any of my fellow ragers against the machine would see me here.

But by God, it was worth it. Tuesday's talk was full of woe, in particular the woe experienced by people who suffered from insomnia, and the paradise that awaited them if they popped a zolpidem tablet. I think it was the first time I have listened to an eminent, highly successful physician's presentation in his area of expertise and been utterly unconvinced by what he said.

Because it was mostly crap. Not the parts about this new version of zolpidem helping you sleep - that was obvious (although it was interesting that sixty percent of people reckoned placebos, or sugar pills, worked pretty damn fine, too). It was the succession of slightly dubious graphs, the series of studies that examined how well people slept on this medication but didn't look at what happened when they stopped, and the way he skimmed past any evidence that zolpidem had any potential for abuse or addiction.

This on the same day that I admitted a patient for zolpidem withdrawal (taking ten times the usual amount, getting the shakes when she stopped), and read about a man who developed seizures after ceasing his "forty tablet a day" habit.

Interestingly, he began taking the tablet because of his insomnia due to his "conjugal problems". And how did he get forty tablets a day? From his wife (a pharmacist). Published recently in "The American Journal of Health System Pharmacy", and presumably soon on CSI.

Anyway, enough about Doctor Shill's Travelling Show. The thing is, this man had started out having some kind of medical training, and that must have included critiqueing things like what he was saying. So he must know at some level that he's talking crap, that he's slanting some facts and ignoring others, that he's subtly shifted his stance from helping people to helping Sanofi Aventis Pty Ltd. He must know somewhere that he's sold out.

Doubtless these ethical and austere thoughts comforted me as I slurped at my smoked salmon and shiraz and leered at the waitresses.

And stockholders, after all, are people too.

There was also a brief movie about new software for total knee replacement, so we all watched someone scraping, chiselling and hammering at the bones and gristle in a large man's knee, while we munched contentedly on our steak. The surgeon explained all this using phrases like "drilling into the virgin bone", in a manner suggesting an oil magnate gazing over an untouched snowfield.

The second talk was on fentanyl patches. These are, unsurprisingly, patches with fentanyl in them, and fentanyl is a potent opioid. Again, the potential for "things going wrong" is significant.

A man in an ED in the US attemtped sucide by shoving a large number of them up his bottom.
Two men in Norway died after boiling up the patches and injecting the liquid obtained.

A report in a forensics journal warns against leaving fentanyl patches on dead bodies because the patches "provide a source of fentanyl for drug abusers".

And then a report in an Anaesthesiology journal. This describes a man (previously beleived to be dependent on fentanyl) who arrived in hospital for a "standard urological procedure".

He was intubated, i.e.: given various muscle relaxants, sedatives, pain killers and so forth, and the operation went ahead. Suddenly, at the end of the operation the man sat up, extubated himself i.e.: pulled that tube thing out of his throat that we put in to help you breathe) and asked if he could leave. He was persuaded to lie down and a dressing was applied.

During this time the count was commenced and it was discovered that some of the fentanyl (a 5ml vial) was unaccounted for.

Eventually, during applying the dressing, "the missing, unopened 5 ml vial of fentanyl emerged from the patient’s rectum".

Anyay, sorry about the lower gastro-intestinal tract humour. Normal transmission will commence shortly.

Thanks for listening,


Blogger Niamh Sage said...

Whatever lingering guilt you may be feeling after the sumptuous dinner (and waitresses), I think you just redeemed yourself with that write-up!

You are the Kerry O'Brien of the medical world :D

Glad to see you back again, and feeling better. I've been thinking of you!


ps long-arse wedding write-up and link to photos is on my LJ and Blogger thingy, if you're interested.

pps Blogger has seen fit to give me a wonderful verification word today: "almizm" :D I'll leave it to my esteemed medical friends to make up a good meaning for that one!

8:47 PM  
Blogger Benedict 16th said...

Bugger me backward with a blunt market vegetable*

I went to the same talk but a different host, Mr Potty gave the talk, he is the one you met at the Queen's head!
I pointed out that the new Zolpidem sustained release seemed to have very similar pharmokinetics to
standard Zopiclone (which is already off patent). I don't think they are going to invite me out again!?
Also the immediate release zolpidem recently went up in price from about retail AUD $26 per 20 to
$32 per 20. The new longer acting is about $26 for 21!!!!!!!! and you get 12.5 mg for the price of 10mg!.

I suppose it is a coincidence that Zolpidem goes off patent in Oz in about November?

* Foilest - Zolpidem might be something immediately of interest to you, have a look at some of your meds
and look at the little tiny 4 point font on one of them that says Zolpidem

*aparently the only time the BBC objected to anything from the script of a black adder episode

9:55 PM  
Blogger Benedict 16th said...

... and your post reminded me of my old post-doc boss, prof of dept, and general bigwig, getting pissed on Saki in oak boxes...
singing something about the Virgin Sturgeon need no urgin'"

PS we gotta catch up and bruise our livers...

PPS Neeve Rosemary
I think it was meant to be Almizan - a very topical choice at the moment

10:05 PM  
Blogger Bronze John said...

Hail All,
Thanks for the comments. I did write that one with you two in mind, oddly enough. I will go hence and look at the wedding writeup, enviously. Ben', we have to arrange to go to the same one of these at the same time - give us a ring next time something interesting looking comes up and we will do likewise.


10:29 PM  

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