PHARMACEUTICAL PUSH ME PULL YOU-A STAPLE WITHIN THE CSCS
Next we cover another glaring mistake that the professors of polypharmacy often make when they get carried away with their prescribing habits. I’ve seen it so often that I had to give it a name. Let’s call it pharmaceutical push me pull you. Like those mythical beasts of Dr Dolittle’s world the pushmi-pullyu’s sutured together facing in opposite directions. In this particular case let’s look at Jimmy’s predicament.
Jimmy has ADD supposedly which is utter nonsense. Jimmy is so damn smart he could (before the meds) read a book in one sitting and remember it all. Not nursery rhymes either, Chaucer or Shakespeare were more his level. He had a dual major in English literature and history. It’s a matter of fact that you cannot have ADD and get a degree in those two subjects sorry. It just doesn’t work that way, not when you have to read two books a week for your professors. I actually think this disease is all hype and BS to sell medications but anyway he got the diagnosis of ADD. As a consequence he was given a prescription for amphetamine. Already we have a huge problem and the first push me pull you scenario.
Amphetamine now has a black box warning-the most serious warning the FDA gives-that misuse of amphetamines may cause sudden death and serious cardiovascular adverse events. It is also known that speed can cause strokes, high blood pressure and brain atrophy. Not to mention a host of other side effects not listed on the black box label.
Let’s see now…(dreadful music in the background)… Jimmy had a previous heart attack which left him pulseless on admission to the ED-basically he arrived dead. That means Jimmy has a bad heart-he has coronary artery disease (CAD). Technically he had an episode of SUDDEN DEATH. Isn’t there a black box warning regarding using amphetamine and sudden death? In fact, how the hell do we know that his prescription speed didn’t cause his sudden death? Either way you DO NOT keep prescribing this drug to someone with this history.
Yes sir, you most certainly do not keep prescribing speed under these dangerous conditions but apparently his family practice Doc in the Box (FP-DIB) and psychiatrist (P-DIB) are not overly concerned. (DUH-DIB). (Remember this tid-bit of truth when I get to how his FP-DIB reacted when I suggested he receive a prescription for the ‘dangerous anabolic’ testosterone). Said FP-DIB takes no umbrage with his peer who prescribes a dangerous amphetamine.
I am concerned about Jimmie being on speed and I believe that to be malpractice. He has severe refractory hypertension which makes his CAD worse, eventually causing kidney injury, and a host of other problems such as increased risk for stroke. Yet here we are giving him speed three times a day poisoning his endothelium thus increasing his blood pressure, accelerating his heart disease and stroke potential, while actively depleting his central (brain) catecholamines: dopamine and serotonin-which may worsen depression. This single drug is not only promoting depression and psychiatric disease but it is making his blood pressure impossible to control and accelerating CAD. Furthermore, he has a history of anxiety-speed fuels anxiety. It mimics the fight or flight response hello? And of course, the said black box warning regarding sudden death is there for all to see.
This is just one example of a push me pull you that you see in virtually any patient on a handful or more meds. I have one question. If his antihypertensive medications, all three of them, are countermanded by the use of speed, and he already has a bad heart, what fool continues to give him speed knowing this history? Speed can and probably will give him a stroke or another heart attack sometime in the future. If that happens I will sue his doctors. This is not community standard even in the fatally flawed CSCS. But it is so common that I occasionally have to put a pillow over my face and wail like lost cow (sorry that’s what it would sound like).
I have seen prescribing nightmares like this over and over. I think one of the reasons is because most DIB’s don’t know pharmacology in the depths that are truly needed to be a safe prescriber-to know pharmacology at the receptor level. Plus you actually have to care about what your patient is being given and the consequences of that decision. Furthermore, the CSCS and the DIB’s are under the false assumption that all meds (except for the major interactions that Walgreen’s will catch)-behave as solid non-interactive billiard balls. Really, I kid you not.
Here’s a push me pull you (just skip it if it’s too technical): remember the ad for Abilify: if your SSRI isn’t working add Abilify (an AAP essentially). OK, SSRI’s increase 5HT (fancy term for serotonin) in the brain, Abilify or any other AAP blocks it. Push me pull you right there and virtual proof that they have no idea what’s really happening in a depressed persons brain. Which of course they don’t since there is no “theory” that has held up to scrutiny. In other words how does blocking serotonin improve depressive symptoms when the first drug increases serotonin to improve depressive symptoms? You can’t have both. Yet, this is commonly done now when the first SSRI doesn’t work. How about if we just stopped the first one? Wouldn’t that amount to the same thing? Duh.
Here’s more: speed increases norepinephrine (NE), dopamine (DA) and serotonin (5HT) in the brain yet the AAP’s block both 5HT and DA in the brain, then the SSRI’s increase 5HT in the brain. The SSNRI’s will also increase NE & 5HT in the brain. It’s not uncommon to be on three of these at a time-all antagonizing each other. Up and down and up and down. Get it? Jimmy is on three of the above classes: an AAP (Seroquel), an SSRI and speed. Brain Salad Surgery as EL&P called it. This, by the way, is what modern psychiatry has evolved into. Do you or anyone you love really want to be part of this scam?
Speed increases NE and epinephrine (E) in the periphery (blood vessels, bronchioles & heart) causing hypertension and tachycardia, his blood pressure meds counteract this effect through several mechanisms which try to block these events. Push me pull you. Get the picture? Jimmy is diabetic, speed increases blood sugar through stimulation of beta receptors in the liver as part of the fight or flight response. Aren’t we trying to lower his blood sugar? Duh. It’s not that uncommon to see patients on a combination of these drugs blocking each others effects which is considered community standard medical care. This helps to explain why there are so many deaths by medicine. Yet once again I’m the kook for questioning the use of these dangerous drugs and apparently one of the few that even recognizes these interactions. Often times in the end nobody knows what the hell is going on in that poor tormented body and they don’t care.
In fact, for years I used a patient of one of the family practice docs out in the East Bay that I worked with who subsequently became a patient of mine. I used her as a case study of push me pull you’s for the students at Five Branches medical pharmacology class. It was an exercise in how NOT to prescribe drugs. This poor woman had so many interactions that you could rename it to Coming and Going at the same time. The good news is that I had her all cleaned up within a year. If memory serves me there were a half dozen central (in the brain) push me pull you’s.
Now back to Jimmy. The worst thing of all is that the dangerous scenario above using speed does not require an in depth, receptor level, knowledge of the pharmacology of amphetamine. Regardless of any deeper knowledge of receptors, any egg-toothed, bed-wetting sprat with a high school education should know that hypertension, heart disease and speed do not go together. Hell, Dr Leary said as much 48 years ago when he made the now famous statement “speed kills.” When did that change? Even if you never knew this fundamental aspect of speed it’s written in bold black letters for you to read as a Black Box Warning precisely so that even an imbecile won’t write a prescription to high-risk patients! Alright I’m getting a migraine I have to go home.
MAKING FAT PATIENTS FATTER SEEMS IRRELEVANT
Insulin and AAP’s make you very fat. Getting fat is something society dreads yet 2/3 are already jet-puffed. Jimmy was no exception. Until I suggested that he try to change to metformin Jimmy’s DIB had him on insulin-which was ridiculous. Patients do not need insulin injection in type II DM. They already have a sea of insulin in their blood. In Jimmie’s case we know with virtual certainty that his DM II is from decreased insulin receptor sensitivity because that’s what happens with metabolic syndrome which he has. The problem is with the receptors not the insulin. In fact, if you do put them on insulin they will get fatter and sicker as Jimmy has done. Insulin as you recall is necessary for the transfer of fat into fat cells. It makes you fat. As an anabolic hormone it takes little molecules (sugar and fatty acids) and makes bigger ones (adipose tissue).
As you gain weight your resistance to insulin rises and you actually make matters much worse by taking exogenous insulin. If you continue to do this you will eventually cause your patient much harm by never addressing the actual causes of his decreased insulin receptor sensitivity and because high levels of insulin cause inflammation and disease over time. As I explain in great detail in my chapter on diet, Welcome to the Industrial Diner, a high fasting insulin level is one of the main causes of the diseases of the first world because it causes endothelial dysfunction which leads to heart disease and hypertension among other things.
Therefore, if this continues it directly worsens hypertension, heart disease and kidney disease. He could easily have another heart attack, end up on dialysis, develop blindness, accelerate his peripheral neuropathy or any one of a number of deadly complications from DM. His AAP Seroquel has also fattened him up like a feedlot animal. Do you see how mismanagement through drugs alone, the apathy, the ignorance of them ends in disaster?
I would approach it differently through diet: by eliminating non-fibrous carbs like bread and other cereal grains, sugar and adding in some form of exercise. Simply stopping grains and sugars will reverse this condition. That’s it. Instead of countless drugs simply changing the diet-in a real and meaningful way-is more powerful than any prescription.
It is well known that exercise can markedly increase insulin receptor sensitivity and changing to a drug like metformin would be better since it will not make you fat. Furthermore, once the glycemic loads of his foods are reduced his need for insulin plummets; getting off insulin is not as difficult as you might think especially while exercising. This is vital anyway since you cannot heal your endothelium without some form of dietary change and working out. Here is where many things have to be done simultaneously for a successful intervention. So far in Jimmy’s case every year he keeps getting sicker and sicker and I could not stand idly by and witness the devastation. Which by-the-way is happening to millions of people just like him. The only difference is that they do not have a guardian or protector like me to scrutinize the caretaking.
Next week we’ll talk about how his statin accelerates some of his diabetic conditions and how the antipsychotics are a cause of chronic disease, disability and death and the legal proceedings against the makers of Seroquel. Yes, AstraZeneca is involved in a huge class action suit. You see it’s not just the kook saying these drugs are bad! It’s times like these that I actually like lawyers.