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It’s worth taking a look at the Mediterranean Diet – not just for its health benefits, but for the economic advantages as well. A recent report in BMJ (that’s what they call themselves. They used to be the British Medical Journal, but they got modern) seems to confirm that this type of diet, heavy on fruits, vegetables, fish and with lots of olive oil, beans and whole grain cereals, reduces the risk of heart disease, Parkinsons and Alezheimer’s Diseases and cancer, certainly as compared with the American diet of red meat and saturated fat.

What seems important is that the Mediterranean Diet not only keep you healthy, which reduces drug costs, but it’s relatively inexpensive, so that it reduces food costs as well. Lots of people, when they try to economize, opt for low cost foods, which means more starch and saturated fats. Yes, fish can cost more than beef, but that’s a matter of shopping – and there are plenty of low cost fish available. Vegetables and beans are relatively inexpensive, and cheap olive oil has the same health benefits as the expensive stuff. Meanwhile, the Mediterranean Diet can reduce cholesterol and blood sugars, and may lead to weight loss, which is also very beneficial for type 2 diabetes. One of the best ways to cut back on drug costs is simply to stay healthy, and the proper diet can do that. But – keep in mind that in this context “diet” doesn’t mean “lose a size by Christmas” – it’s a lifelong commitment. It might be a good idea to check some cookbooks out of the library.
http://www.bmj.com/cgi/content/abstract/337/sep11_2/a1344?fmr

Sometimes, when medical costs get too high, people turn to complimentary and alternative medicine (CAM). The trouble is, it’s not always easy to tell the difference between CAM and quackery, and lots of quacks do hide themselves behind the mantle of a traditional form of care. Finding a reliable source of information can be difficult. For those people who are interested in herbalism, the American Botanical Council has an English Language edition of The Cimplete German Commission E Monographs and a companion volume entitled Herbal Medicine. Commission E is the German equivalent of the United States Food and Drug Administration, and they’ve done a thorough review of a lot of herbal remedies in common use. The reports are objective – some work, others don’t. The monographs also report on appropriate doses and dosage forms. What’s important is that the Commission wasn’t carrying an ax for either side. Some natural product advocates reject anything that’s made by a pharmaceutical manufacturer, and some physicians reject anything that isn’t from a company traded in one of thr major stock exchanges.

If your library doesn’t have a copy, ask your librarian if it’s possible to get one on interlibrary loan. This is one source you can trust.

There’s more reason to talk to your pharmacist. Back in 2006, the Journal of the American College of Physicians published a study on how well people understand prescription labels. It turns out that a lot of people don’t – at least not well enough to take their medication properly. Predictably, people with the lowest literacy had the most trouble, but even people who seemed to understand the proper way to take medication, people with high literacy levels, didn’t really understand. As many as 27% of college graduates didn’t understand how to take their medications, and how you take your medication can make a difference in how well it works, or if it works at all.

Whatever pharmacy you go to, you’re going to get the same drug, That’s why it pays to shop around. Go to two different restaurants and there can be big differences between two dishes with the same name, but drugs are going to be the same regardless of whether you go to a chain store or an independent, a high or low volume store. But, if you do choose to use several pharmacies to fill your prescriptions, be sure you speak to the pharmacist at every single one of them, and let them know all the drugs you’re taking – all of them. That includes over-the-counter drugs and herbal supplements. It includes stuff you’re buying at the pharmacy, the discount store, supermarket, and on-line.

The reason for having pharmacists and not just technicians counting and pouring pills is because drug therapy has become increasingly complicated, and as people take more and more drugs, it’s more important to keep track of doses and interactions. Physicians usually know a lot about a small number of drugs, but don’t know all that much about the drugs they don’t routinely prescribe – that’s why pharmacists are essential. But, if they only see one prescription, they can’t do a proper evaluation.

And don’t be embarrassed to let them know you’re shopping for the best price. It may not be the best way to make friends, but the pharmacist is providing a professional service that’s included in the price of the drug. Feel free to ask.

The State of Michigan has a web site devoted to drug price comparisons, and here’s how they put it:

A Word To Safety
It is wise for consumers to keep track of the medications they are taking in order to avoid potentially harmful drug interactions, prevent possible drug duplication, and allergic reactions. If you do decide to shop at more than one pharmacy, make sure that you inform all of your pharmacists of all of the drugs you are taking.

If anybody asks, you don’t want fried with that. Have an apple instead.

It’s never a good idea to jump to conclusions from a single study, no matter how well designed it was. Still, a study from the Universidad de Oviedo in Spain, published in the journal Gerontology in May 2008 had interesting results. The researchers looked at the diet habits of 288 people between the ages of 60 and 85 to see if any patterns of food intake could be associated with long life. They adjusted for age, gender, energy intake, chewing ability, hyperglycemia, hypercholesterolemia, physical activity, smoking habit, self-perceived health, education level and the institution from which participants were recruited. When they got done, they found that long life was directly associated with higher fruit intake, while people who ate more potatoes died earlier.

The authors of the paper aren’t convinced that eating potatoes is bad for your health – this type of result sometimes turns up by chance, and that’s why studies should be repeated a few times until there’s an obvious pattern, but if your goal in life is to make it to 100, you may want to take a look at your shopping list.

In the September-October 2008 issue of Mother Jones magazine, there’s an article by James Ridgeway about Medicare part D, the prescription drug benefit. Mr. Ridgeway is a respected journalist and author, with book and movie credits. Although his article has no new information, it does describe his own tribulations both in selecting the best plan for himself, and the way in which part D was devised, which led him into the dreaded “donut hole” where the benefit stopped offering any benefits.
While the article doesn’t offer much in the way of useful advice, it’s wonderfully reassuring. If Mr. Ridgeway could have these problems, then anybody can.

On August 25th, CBS News’ show 60 Minutes did a report on a serious drug overdose given to two newborn infants. The infants survived, but similar problems have occurred in other hospitals with tragic outcomes. The reporters kept asking “how could this happen?” and made the point that three people had responsibility for checking the dose. The report didn’t go into enough detail to answer some of the obvious questions about responsibility, but several thoughts came to mind, not about this specific incident, but about drug therapy in hospitals in general.

1) How rushed was the staff? There are serious staff shortages in just about every health care profession, even while the need increases. There’s an estimate that by the year 2020 there will be 157,000 unfilled pharmacist jobs. By 2025, there may be a shortage of 500,000 nurses – in 2007 the immediate shortage of nurses was estimated at 116,000. So far, the answer to the problem has been to increase work-load, increasing productivity. It also increases the risk of error.

2) Was the computer system set to prevent errors? A well designed computer program would stop an adult dose being ordered for an infant – it’s not a major bit of programming. Was it?

3) Was there a pediatric pharmacy, preferably with a pediatric pharmacist on duty? If there’s an overall staff shortage, it may be hard to recruit suitable specialists, but it’s a lot simpler to set aside a space on the unit and only stock it with appropriate drugs. That isn’t an infallible system, because older children may requite adult doses, but it helps.

There’s no way to completely avoid human errors; there will always be tragedies like this one. As we become more reliant on drugs therapy, and as the aging population means that more people will require drugs, we’ll need more professionals and better systems, and we should address the problem as soon as possible. Right now there’s a shortage of over 700 faculty positions in nursing schools, which means that we’re losing the ability to train nurses to make up the shortage. Pharmacy schools report 417 vacant faculty slots, and dental schools need about 400 more professors. That’s going to be a problem, very soon.

Byetta – there are two important reports about Byetta, the generic name is exenatide, an injectable drug used in treatment of diabetes. On one side the Food & Drug Administration is giving sterner warnings about the risks of exensatide, that in rare cases, it can cause inflammation of the pancreas, and this has occasionally been fatal. At the same time, a study presented at a meeting of the American Diabetes Association reported that patients treated with exenatide actually had longer survival than patients using other anti-diabetic drugs. The results of this study will need more examination, since there doesn’t seem to be a cause and effect relationship, and sometimes this type of thing shows up in a study result simply by chance. It will take additional examination, both of the results of this study, and probably additional large studies, before any conclusions can be drawn. In view of the known risks of pancreatitis, patients shouldn’t be switched from other drugs to exenatide unless there’s a compelling reason to do so.

In the New York Times health blog, Tara Parker-Pope draws attention to a blog by Dr. Robert Lamberts, an Augusta, Georgia primary care physician. The blog (http://www.musings.org) is usually informative, often funny, and occasionally infuriating. Dr. Lamberts has created lists of rules for physicians and for patients (how to be a better patient.) In his honor, here are some rules for physicians dealing with pharmacists:

1) Write either legibly or illegibly, not in-between: http://www.musing.org,legible prescriptions are best, but if it’s completely illegible, then I’ll call. Too many prescriptions are semi-legible, look like one thing, but were supposed to be another. That’s how mistakes get made. The extra few saved by scribbling aren’t worth it.

2) Come to the telephone: telephone communications are supposed to be between physician and pharmacist, but too often, the physicians assign these calls to their office staff. In many states, telephone prescriptions dictated by anyone but a licensed prescriber are illegal. What’s particularly annoying is when we call to alert the physician to a prescribing error, and they still won’t speak to us directly.

3) Don’t say “I’ll take responsibility”: The pharmacist is an independent professional, and filling a prescription is effectively a collaboration between two colleagues. Our responsibility is to the patient, not to the prescriber. If we feel that a drug or a dose is unsafe, we can’t fob off responsibility and liability if something goes wrong. Part of the problem is that we can refuse to fill a prescription if there’s enough evidence to convince us that it’s dangerous, but we can’t counterprescribe. So, if the physician orders penicillin for a patient with a penicillin allergy, the pharmacist has an obligation not to dispense the drug, but that leaves the patient with an infection that’s not being treated.

4) Talk to your patients: This is a serious problem, and it’s built into the system. Physicians and pharmacists are both pressed for time, and what gets cut out may be the most important part – the counseling. Maybe physicians assume the pharmacist will do it, and pharmacists assume the physician will do it, and too often the patient never gets counseled. Neither one should rely on the other.
There are more rules, but these would be a good start.

A recent review in the journal Spine, evaluated the use of non-steroidal anti-inflammatory drugs for treatment of low back pain. The reviewers concluded that these drugs, which include ibuprofen, naproxene, fenoprofen, meloxicam, nabumetone and lots more, do have some benefit, but don’t expect much from them. They also looked at the studies to try to answer the question that has been asked often enough – which is best. There really doesn’t seem to be a best, they’rr all about the same once the dose is adjusted for differences in potency. The best choice is the cheapest, used in the lowest effective dose in order to minimize side effect. As the doser gets higher, the side effects, particularly the effects on the stomach, become more common and more severe.