An anesthesiologist friend of mine is fond of quipping: "the opposite of good is better."
His aphorism means that when you try to improve something that’s already working well, the results are often worse rather than better. Examples of this truth are some recent drug recalls by the Food and Drug Administration that have resulted in hardships for many of my patients. Although I appreciate the FDA’s unstinting efforts to advance my second career as a medical humorist, I doubt that the patients I’m writing about see anything funny about their situations.
The 89-year-old woman that came in with her daughter to see me this afternoon was not laughing about her experience. She said that she hoped I wasn’t offended, but she didn’t really want to come see me! I’ve heard this sentiment thousands of times, so I wasn’t the least bit insulted. People don’t like being sick. Left to her own devices, she wouldn’t have come, but her family physician and her daughter ganged up on her and forced her to visit me. She resembled a very frail, hard of hearing bird in a loud checkered jacket.
By Dr. Larry Greenbaum
Her tale of woe began in late November, when she was admitted to the hospital with severe pain and swelling of her arms and hands. Arthrocentesis confirmed a diagnosis of pseudogout. She insisted that her problems were precipitated by stopping Darvocet (acetaminophen and propoxyphene). This didn’t make much sense to me since Darvocet isn’t an anti-inflammatory drug, but I just write down the history as I’m told it. It’s generally a good idea to try and see things from the patient’s point of view. Don’t shoot me, I’m just the scribe.
"You mean you never had problems with pseudogout before you went off Darvocet?!"
"Oh I had arthritis, but nothing like this!" She went on to describe prodigious soft-tissue swelling of her arms that was so bad that one of her bracelets was swallowed up by the swelling! She had been heavily medicated for pain, and as a result she didn’t remember too much about her hospital stay.
Alas poor Darvocet, I remember him fondly! I had taken to heart the numerous warnings that I had read over the years concerning the use of this medication for geriatric patients. The drug’s active metabolite norpropoxyphene was said to cause arrhythmias, while other literature suggested that propoxyphene just didn’t work well as an analgesic. Because of these warnings, I had greatly decreased the number of prescriptions that I was writing for Darvocet over the last 5 to 10 years. I had completely stopped writing new prescriptions for the medication for older patients.
I also asked many of my older patients that were on Darvocet chronically to switch to other analgesics. This was a time-consuming process. Some of my patients tried several different pain medications before coming to the conclusion that they had their best results with Darvocet. A few older patients begged to be put back on their Darvocet. I didn’t think the medication needed to be removed from the market. I think a "black box warning" for the package insert would have been sufficient.
My patient was released from the hospital on Colcrys (colchicine) twice a day, but she found that she needed three pills a day to control her arthritis and her family physician was worried about her taking such a high dose of the medication. In addition, she was paying about $360 for 60 tablets at the pharmacy, which turned out to be a bitter pill to swallow. Maybe Mary Poppins singing, "Just a spoonful of sugar helps the medicine go down ..." would have helped, but I doubt it. She suffered a classic double whammy. She lost her faithful Darvocet, and she had to pay about $6 for every Colcrys tablet.
Another patient in my practice, an 82-years-old woman with gout, had been stable on allopurinol and colchicine. After Colcrys came out and the old cheap colchicine went bye-bye, she tried going with allopurinol alone because of the shocking price of Colcrys. This didn’t go well. She is normally ambulatory, but she came to my office in a wheelchair with a colossal flare-up of polyarticular gout. To get her out of her awful flare-up of gout, I had to put her on prednisone. I instructed her daughter to go to the Colcrys website, check out the patient-assistance link and hope that pharmaceutical largesse would be available for the elderly and the poor.
I also saw a 34-year-old nurse with Behçet’s disease whose orogenital disease had been very well controlled on colchicine twice a day. Since switching to Colcrys, she started having more sores in her mouth. She had originally presented with colonic ulcers. When I saw her recently, she was complaining of constant burning pain in her upper abdomen. My clinical hunch was that her Behçet’s was acting up. I increased her Colcrys to three times a day and told her that if the increase in dose frequency didn’t help her, she would need a gastrointestinal endoscopy. This may be purely overactive imagination on my part, but sometimes I get the impression that the old colchicine worked better than the expensive doppelganger replacement drug.