PNN, Primum Non Nocere

First do no harm...
Pitfalls of Co-Management and Concurrent Care

The Mind and Body:
The reductionism approach that evolved out of the expansion of medical knowledge and certain socioeconomic concerns resulted in highly specialized medical experts, medical technologies, and medical settings well-endowed to care for the organs and systems at the cost of disregard for the person.

The Glamour of the Part at the Cost of the Whole:
As a result of this divisionism and reductionism, physicians were highly educated and trained in the heart, for example. Countless medications and medication instruments for the study and management of the heart were developed, and a unit, an entire hospital, or medical institution was devoted to the form and function of the heart. The finishing touch on this school of thinking is in place when a journal and a nonprofit association are devoted to the research of a specific organ or system. After this fanfare, the clinical care for that particular organ or system becomes such a monument that entrance and exit to its realm becomes the virtue of a few on the giving and receiving ends of the service spectrum. This illusion is usually reinforced by a sanctioning judicial system that would not show mercy on any physician departing from this format as a standard of medical care and management, through huge malpractice law suits.

Failure of the Logic:
Practice parameters of organ and system-oriented procedural medicine such as neurosurgery and gynecology do not overlap and consequently, the limitation of knowledge of a gynecologist about neurosurgery or for that matter what he or she would do to or for the patient was not so concerning. This model, however, was rather successful for procedural medication as long as one was able to afford it. The organ and system-oriented model, however, has not been so successful and, in fact, inadequate for non procedural medical care and management, such as internal medicine, family practice, psychiatry, oncology, or neurology. Inadequacy of this model in evaluation and treatment of degenerative disorders of our time involving multiple organs and systems, and development of dual or multiple indication pharmaceutical agents is self-evident.

Old Ways and New Concepts:
The inadequacy of the organ and system and mind versus body model of medicine in meeting the demands of degenerative and multiple organ system disorders affecting mind and body, is the result of many evolving factors including:
1. The changing nature of health concerns from an organ and system orientation which depends predominately on variables such as prevalence, novelty, cost of care, virulence of the disease, moral values, age, and gender. The political and socioeconomic climate has resulted in a noticeable shift from organ and system orientation to situation, age, gender, and condition orientation. Development of emergency medicine, geriatric, child and adolescent, military, and even traffic and pain specialties are the product of this recent trend and recognition of the limitation of the organ and system-oriented model of thinking.
2. Discovery of the new and re-validation of multiple indications of the old pharmaceutical agents covering more than one target symptom.
3. Recent cultural awareness of the undeniable role of the mind in health and disease and recent socioeconomic movements for parity in mental and physical care.
4. Celebrity and significant personality exposure and admission of mental ailments such as Ronald Reagan's admission of his affliction of Alzheimer's, Mike Wallace's admission of depression, and Betty Ford's admission to alcoholism.

To Do No Harm:
The main and single most important tool of management in non procedural medicine is the utilization of pharmaceutical agents. Target-specific pharmaceutical agents without collateral properties and free of side effects are nonexistent.

Pharmaceutical agents do not remain confined nor follow the boundaries of the specialty of the specialist who prescribed them. Interaction between drugs, their cumulative effects and their compounding and additive side effects are unavoidable. This is particularly true for all CNS-acting pharmaceutical agents.

It is under this critical climate that concern about the most damaging effects of co-management of patients should heighten. For example, the lorazepam prescribed by one physician will not contain itself to management of a presumed anxiety without interacting with effects and side effects of cholinesterase inhibitors for memory enhancement and hydroconon for pain, prescribed by another physician, or for that matter the selective serotonin reuptake inhibitor prescribed by a third physician.

The blanket administration of these agents without consideration for their overall effect and their collective and additive actions and side effects is far less beneficial than the presumed single effect anticipated by each prescriber. This is particularly true about concurrent usage of all CNS-acting agents including opiates, hypnotics, sedatives, anxiolytics, and CNS stimulants and depressants.

Divisionism and Reductionism at Work:
It is no wonder that the most frequent nursing home calls for management of the agitation of an elderly patient most frequently leads one to the management of runaway polypharmacy. This is particularly true for a patient placed on one of these cholinesterase inhibitors, so called memory enhancing drugs, in combination with benzodiazepines. Despite the illusion of panacea created about cholinesterase inhibitors manufactured by pharmaceutical companies, cholinesterase inhibitors have nothing but side effects, such as agitation, weight loss, and somnolence on elderly patients in Stage III and over on GDS.

Utility of these medications for memory dysfunction in Stage II - IV on GDS is a rather tasking proposition. Stage II - IV dementia overlap with depression in more than 50% of elderly patients. Stage II - IV dementia in a fair number of elderly patients is usually associated with CNS-acting medications prescribed for other reasons, including opiates and benzodiazepines for pain and sleep, respectively. Further, the potential anticipated favorable effects of these agents should be evaluated against their hepatocellular side effects particularly in hepatobilliary compromised elderly patients.

These agents do not improve the memory and recollections in patients who have lost their problem-solving and executive abilities and/or are incontinent for bowel and bladder, which includes a majority of nursing home patients. Improvement in memory is the least concern to the caretaker of these individuals, who have to feed, manage, and watch after the safety of these patients.

Testimonial:
One needs only to observe an elderly agitated patient on cholinesterase inhibitors prescribed by a well-meaning physician who has subsequently prescribed an IM dose of lorazepam to control the agitation generated by the cholinesterase inhibitor to believe in the unintentional harm done. This tragedy in the making is compounded when this unholy procedure has been initiated by two different prescribers who may not share the same knowledge and orientation.

So What?:
Most likely, it will be Primum Non Nocere, if physicians involved in concurrent care and management of the same patient share mutual awareness and knowledge of these dilemmas or can negotiate delegation of the management of CNS-acting medication to one prescriber who has gained full knowledge of the indications, contraindications, side effects, pharmacodynamics, pharmacokinetics, drug-drug interaction of the medications, and is sympathetic to the overall effects of these agents on the patient, and the social and environmental system that they live, in advance...

K. Shams, MD
Executive Medical Director
Okaloosa NeuroPsychiatric Center