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

Our Apologies

Unfortunately, we will not be holding our Parent's Workshop on February 24, 2007. It was to have taken place at Walker Elementary School, Crestview, FL. We hope to plan another in a few months. We would love to hear your ideas on seminars you would be interested in attending.

Treatment Options for Opioid Dependence

Opioid dependence is increasingly a problem in many communities. Furthermore, an estimated 20% or more of individuals interested in getting help for their dependence avoid seeking treatment because of the stigma attached to the condition and limited treatment availability.

A new law has been enacted which allows for office-based treatment of opioid dependence.

For this reason, Okaloosa NeuroPsychiatric Center has because trained in office-based treatment of opioid dependence and has begun offering this service to patients. Opioid-dependent patients often prefer office-based treatment because it allows for greater privacy than more traditional forms of care. In addition, because the medication used (buprenorphine) is available by prescription, office-based treatment is often more flexible and convenient than other treatments.

Our office is available for consultation and referrals. Please feel free to contact us if you would like to discuss treatment services offered.

First Ever Parent's Workshop

Okaloosa NeuroPsychiatric Center will be holding its first ever Parents Workshop, Saturday, February 24, 2007 from 9am to 1pm at Walker Elementary in Crestview, FL. Led by Licensed Mental Health Counselor, Angela Trawick and Behavioral Management Specialist, Lisa Lagrone, this workshop will address children's mental health disorders, behavioral problems, parenting skills, and family dynamics. The cost is $30 for individuals, $45 for couples and must be received by Tuesday, February 20, 2007. For more information, email Michaela at okaloosacenter@earthlink.net.

PRN, Pro Re Nata

Is it "Help When Needed Most" or "The trap door to confusion and the passport to misuse and addiction..."?

According to the US Department of Health and Human Services, some 42 million Americans, roughly 20% of the population have used prescription drugs for non-medical purposes. Opiates, hypnotics, anxiolytics, sedatives, CNS stimulants, and depressants are the most frequently misused agents. The National Center for Health Statististics reports that over 50% of an estimated 400,000 accident-related injuries are prescription drug related. Misuse and addiction to prescription drugs is at an epidemic proportion and an alarming public health concern. An internet search for "prescription drug misuse, abuse, and addiction" locates an estimated 500,000 pieces of information. Misprescribing and over prescribing are the 2nd most common cause of disciplinary actions against physicians and the 3rd most common cause of professional liability claims. Similar to other public health threats when left unattended by the medical community, this phenomenon has resulted in the development of self-help organizations, such as AddictionByPrescription.com, by individuals and groups who have lost hope and confidence in medicine. The problem of prescription drug abuse, misuse, and addiction is rather multifaceted, complex, and multi-stakeholder, including the drug, the manufacturer, the patient and their unrecognized and untreated addictive psychopathology, the doctor, the nurse, the health care administrator, the pharmacist, and not least, the socioeconomic interest groups involved in drug acquisition, distribution, and employment of individuals feeding off this destructive industry.

The nonverbal communication of PRN instructions generally suggests that the physician is aware of a particular symptom in the patient and has knowledge about a possible remedy. He or she, however, conveys to the patient that they will not be there nor do they know when the symptom might strike and be severe enough to warrant suppression. As a result, the physician gives a PRN instruction suggesting, "I know this medication may relieve your symptoms... you take it when you think you need it... " This is the passport to misuse and addiction to medications of abuse.

Availability, accessibility, and lack of structure and schedule for "using" are among the cardinal and necessary elements for addiction to alcohol and drugs. Prescription fraud, walkie talkie doctor shoppers, and lack of concise medical instructions, along with casual accountability for left over or unused CNS-acting prescription drugs at institutions, hospitals, pharmacies, and nursing homes, are among the primary reasons for prescription drug abuse and addiction among health care professionals and diversion of prescription drugs into the communities. PRN instruction and access to CNS-acting medications is the gateway to abuse, misuse, and addiction.

Physicians provide countless medical instructions to the patients who most follow them word for word and step by step based on the confidence and trust they place in their physician. These instructions, be they procedural in nature or actionable are invariably backed by the hard science behind them, as it pertains to instructions for medications: time of onset, duration of action, half life and bioavailability, pharmacodynamics and pharmacokinetics of medications guide the physician to render the appropriate instructions. It is unlikely that a physician would order a PRN antiobiotic or for that matter a PRN antiviral medication. Even in the case of insulin dependent diabetics, the PRN usage and administration of insulin is preceded by measurements of blood and urine glucose. Similarly, in the case of intractable pain and fever, we employ measurable objectives and limiting parameters for PRN administration of analgesics and antipyretics. Manufacturers of medications with abuse and addictive potentials advise against prolonged use of these medications and warn of the potential of misuse and addiction. Except for scheduled maintenance usage of legend medications for pain and other symptoms in progressive malignant conditions where maintenance therapy might be appropriate, the customary standard for usage of these medications calls for short term, i.e., only a few weeks, and sufficient scheduled dosages to suppress the target symptom until a more permanent and safer alternative is established. PRN instruction of legend medications in a hospital setting is usually left to the discretion of an educated and skilled nurse who in collaboration with the physician is supposed to use objective measures to evaluate the necessity for a single PRN administration. Maybe we should use the same reasoning for judicious use of the medications of abuse. The only PRN instruction I give to my patients is an emergency room visit or phone calls for Unscheduled Follow Up Visits.

K. Shams, MD
Executive Medical Director
Okaloosa NeuroPsychiatric Center