The Intricacies of Antidepressant Interactions

Once upon a time there were jokes circulating about putting Prozac (fluoxetine) in the drinking water.

The idea was that the modern antidepressants were indicated for most people living in today’s society, and that these drugs were completely safe to use.

Now, these same drugs have so many warnings that they have become increasingly difficult to use in treating the common maladies of depression and anxiety.

The earliest scuttlebutt about Prozac causing suicidal thinking never did go away completely. We were assured that the suicide rate itself did not go up, only thinking about it. Some of that was explained by powerful antidepressants potentially unmasking bipolar illness and causing manic episodes. But a few years later, Paxil (paroxetine) was reported to cause suicidality in adolescents.

Just in the past few months, I was reminded several times about the intricacies of prescribing SSRIs.

A middle aged man on the blood thinner warfarin suddenly developed nosebleeds when his INR shot above the therapeutic range. His psychiatrist had doubled his Prozac two weeks earlier.

An anxious and depressed elderly woman wanted to try an antidepressant, and I gave her a low dose of Lexapro (escitalopram). She told me the following week that she felt tired and listless. I ordered some routine blood taste and her sodium level came back precipitously low. We stopped her Lexapro and she felt better again within a week.

A tall, thin elderly man with Parkinson’s disease and depression wanted to try something for his mood. I searched the literature and prescribed the SSRI with the most data on use in his condition. The following week he felt lightheaded. His blood pressure and pulse were both lower than his baseline, and I ended up cutting his beta blocker in half twice before his vital signs normalized; I had never heard or seen this interaction before.

A middle aged woman with a history of pulmonary emboli had been difficult to regulate on warfarin, and during a recent hospitalization, the doctors had changed her over to the novel anticoagulant Eliquis (apixaban), which doesn’t require any monitoring. When it was time to refill her Zoloft (sertraline), my computer flagged me with a bold, red warning that apixaban and sertraline are a dangerous combination resulting in increased risk for bleeding.

The list of warnings for this class of drug goes on, including effects on pregnancy, heart arrhythmias, seizures, glaucoma, liver disease and diabetes.

Given that their effectiveness is reported to be only marginally better than placebo, I have become increasingly more cautious about prescribing them.

Just this year, though, in Molecular Psychiatry, a new analysis of old data suggests that previous studies had used an ineffective rating system for depression, and that SSRIs are more powerful than we thought.

I remain skeptical. Once bitten, twice shy.

A Fifteen Minute Man

“I should be home well before nine o’clock”, I said to my wife on the phone as I steered my eight cylinder SUV quietly down the highway at 75 mph (121 km/h) with more than 100 miles left to go.

“More like eight fifty-five”, I added.

“That’s well before nine?” She sounded both weary and incredulous. I knew what she meant. I am not as obsessive about time as I used to be, but even outside the clinic, I have an awareness of time that is possibly not entirely normal or healthy.

As a physician in America today, I work within a schedule of fifteen minute blocks. Some visits, like physicals or hospital follow-ups are scheduled for thirty minutes, but the bulk of what I do has to average out to fit a fifteen minute slot, or sometimes, when we double-book, half of that.

It takes constant awareness of time to function in that manner, and I work very consciously not to relay that awareness too plainly to my patients.

Whenever I work with new scheduling staff, I have to help them learn how long things take. They don’t usually know much about medicine, but it is essential to have a sense of which things take a lot of time and which don’t.

For example, a person with acute chest pain and shortness of breath, although this may sound serious, only takes a few minutes, because it involves a triage decision – if it’s bad enough we ship them out to the hospital. If it’s not, we order a basic set of tests with relatively few possible outcomes.

On the other hand, an older person with fatigue, depression, nausea, weakness, weight loss or any kind of gynecological or bowel related problem takes a lot more time. Just getting an older person undressed and on the exam table can take half of a fifteen minute slot, let alone taking a good history from someone whose memory, conversation style or medical savvy isn’t in tune with the pace of today’s society.

In the past I remember making lists. An earache takes five minutes, severe headaches up to fifteen, and so on.

I also often say, “if you can’t figure out what they need or if you can’t get off the phone with them, I probably can’t solve their problem in a double booked, seven and a half minute slot.”

Compared to ten or fifteen years ago, I am less emotionally affected by my gains or losses in my daily race against the clock. I tend to make more automatic, subconscious corrections in my pace, depending on how my day is going. And, more importantly, I seldom get frustrated about time.

Managing time is a little like driving, more automatic after more years of practice.

I remember how I completely failed to notice two pedestrians trying to cross the street in one of my early driving lessons. I was stopped at a red light on a hill and getting ready to turn left. I was completely focused on my left foot on the clutch, the ball of my right foot on the brake pedal and my heel on the accelerator, hoping the baby blue Volvo wouldn’t stall on me.

Now, even though I don’t drive a standard very often, I can still do those kind of maneuvers without engaging my conscious mind.

In the clinic, even though I am always aware of where I am, time-wise, I almost always carefully control how I express that awareness. My years of experience often help me get to the heart of things quicker than I did in my youth, and my years of relationship building with my patients give me the credibility to sometimes declare priorities when there is more going on than I can reasonably address in one visit.

At the same time, some of the things I have seen over the years have helped me recognize those times when I have to stop everything and do what needs to be done, no matter how long it takes.

Handling time, like so many other things we do in medicine, is a necessary part of our work, but it isn’t the essence of our work. Time can be a distraction, just like our technology can be too visible.

People who don’t treat patients themselves don’t usually understand the nature of our work. Instead, they focus their attention on things they know: Is the doctor running on time, is the documentation complete, are the billing codes correct, or does the doctor have “huddle” with the scheduler and medical assistant every morning?

Focusing too consciously on any one of such housekeeping issues detracts from the real work that we do, at least when we are new in our careers. For a brand new driver, how you drive is at first more important than where you are going, because of all the components that necessarily go into driving a car safely. For a new healthcare provider, the form of our work tends to dictate the function, especially in today’s hyper-regulated corporate environment.

When we deal with patients, we need to keep the external considerations as invisible as possible. We need to inspire the confidence that we are really paying attention and we need to create an atmosphere that is conducive to healing.

When I talked to my wife from the car the other night, I should have dropped my instinctive thoughts of that five minute margin, just like I didn’t give her a blow by blow account of which way I was turning the steering wheel, whether I was using cruise control or not, or whether I had switched on my high beams.

I should have just said, “I’ll see you at nine”.

EMRs, PCMH and OCD are Limiting Access to Care

We have a problem in our clinic.

Between our EMR implementation a few years ago and our PCMH recognition shortly after that, our office visit documentation has become bloated and our cycle time has almost doubled.

There are no brief visits anymore, since every visit entails screening for multiple psychosocial conditions and consideration of various immunization and health maintenance reminders.

Nobody sees over thirty patients a day anymore; we’re lucky to exceed twenty.

That means patients today are actually more likely to go to walk-in clinics or emergency rooms than they were a few decades ago. We’re still okay with PCMH as long as we have a single open access slot at the beginning of every day, and we don’t actually get any credit for squeezing in, or double booking, acutes.

It also means patients with chronic illnesses get seen a little less often than they used to. Sure, we have RN case managers who can stay in touch with them, but the communication between them and the medical providers is hampered by the new busyness of checking our electronic inboxes, which takes seconds longer for each item than the old paper reports used to take, and which is done “in between patients” in our already tight schedules or after hours, staying late at the clinic or logging in from home.

It wasn’t supposed to be this way.

Here is what we hoped and were led to believe would happen:

1) EMRs were supposed to make documentation lightning fast.
2) EMRs were supposed to make data review and retrieval faster than paper systems.
3) PCMH would have us transform into physician driven, super-efficient, yet warm-and-fuzzy places filled with patient friendly personal touches.

Instead, medical practices have evolved into bigger bureaucracies with OCD afflicted doctors who don’t lead practice transformation, but who feel personally responsible to compensate for all the shortcomings of their hastily implemented, immature technology.

OCD may be the most significant and destructive acronym in today’s healthcare environment. And we have all been cultivating it, medical practices and providers alike.

The old school expression of OCD, in Marcus Welby’s era, was extremely high physician productivity and unwavering personal commitment to patients.

The new manifestation of OCD is trying to follow overly ambitious, often conflicting Federal edicts and mind-melding ourselves with our computers to the point of losing touch with our patients’ real needs.

Why else did we end up with a working environment where we allow ourselves to be distracted by health maintenance discussions when somebody comes into see us for what should be a ten minute visit for a simple sore throat, or when they are in pain from an injury?

(A ten minute oil change for your car is not the same as a 100,000 mile service, is it? Why is health care any different?)

Why else do we think that it is appropriate to do depression, alcohol, smoking, domestic and drug abuse screenings on new patients the minute they walk through the door to size us up as their chosen new health care provider?

(How did it become patient centered not to spend the first visit, or even the first few minutes of a new therapeutic relationship, listening to the concerns of a new patient?)

Why else, if not because of our personal and organizational OCD, are we sending our own patients to the walk-in clinic instead of fitting them into our own schedules? Isn’t it because of our obsessive fear that we might document such a quick visit without the required Federal accoutrements and end up scoring poorly on some arbitrary quality scale?

(Do we really think the walk-in clinic will do a better medication reconciliation than we do if we squeeze a 45 year old hypertensive diabetic in for quick look at an ankle sprain?)

Pardon my comparison to veterinary medicine, but in my veterinarian’s cash practice, they manage their health maintenance reminders by simply printing them automatically on the receipt. If I bring a pet in for something simple, they don’t bloat the visit up by talking about things I didn’t come in for; they stay on schedule and I can read the printed reminders at my leisure.

Somehow, in the new vision of primary care, we went from taking care of our patients over a continuum of time to doing everything all at once, as if there were never going to be other visits. That kind of OCD is anathema to real primary care.

And somewhere along the path to more patient-centeredness, we got sidetracked by the paternalistic ambitions of our biggest payer, Medicare, into hammering our customers with Federally imposed public health agendas that have little to do which their personal vision of why they need a doctor.

To quote a new patient who came in to size me up a few years ago:

“I need a doctor when I’m sick.”

Access, in other words.

Role Play

Physicians play many roles in patients’ health care and lives in general.

In one encounter we may be the only one encouraging a hesitant or discouraged person to look inside and outside themselves for the strength to move forward with a difficult decision.

In the very next appointment we may be taking charge as a patient develops chest pain and shortness of breath in front of our eyes.

We sometimes find ourselves in a position where we are uniquely able to challenge our patients by saying things they wouldn’t even let their own families tell them, just because we are their doctors, because of the authority they consciously or subconsciously are willing to give us.

Again and again I find myself in situations where I, the person, might hesitate about what to say or do, but I, the doctor, sense what my archetypal role is for that patient in that moment.

I regularly find myself filled with a sense of peaceful warmth, a sense of quiet certainty that changes my demeanor, posture, voice and words, as if I am carried by a greater force. I don’t have enough religious conviction to state for sure that I am at that moment under any kind of divine influence, but I certainly know that I, the doctor, handle all kinds of difficult situations better than I, the graying and nearsighted Swede.

I believe very firmly that I am carrying on the legacy of millennia of healers, the masters of modern medicine and the mentors of my own education. I am aware of my split second reflections about what my old eye doctor, my family practice residency director or the specialists I have observed and tried to emulate would have done in a given situation.

The role I play is bigger than the person I am. It gives me the ability to rise above my own shortcomings, to enlist whatever the source of my abilities is as I move through my daily list of patient encounters.

In this era of social media, lack of privacy and challenging of authorities, doctors sometimes sabotage themselves by revealing too much of themselves. This can detract from the important roles they are called to play.

Sir William Osler once said “look wise, say nothing and grunt”. I am sure it was tongue-in-cheek and for effect, but it was a warning not to speak mindlessly. He also spoke and wrote a great deal about pursuing equanimity, defined as mental calmness, composure, and evenness of temper, especially in a difficult situation.

Both pieces of advice encourage physicians to remain a little bit removed or apart, in order to effectively carry out the roles we are called to play in ministering to the sick. They also serve to enhance our abilities of observation and listening, the foundation of medical diagnosis.

Playing the different roles of a physician is not a frivolous game or charade. It is more like being a musician in a well tuned orchestra. Our demeanor, our voice and our words are our instruments. We use them, not to shine or stand out for ourselves, but to express and deliver our measured parts in a great symphony that touches both listener and player profoundly, albeit each one of us differently.

A Country Doctor, Duped

A woman in her mid thirties with a terrible limp and a past surgical history in the dozens became my patient two years ago. Her prosthetic left leg served her well, but her right leg was moving awkwardly because of advanced hip arthritis and a formerly shattered ankle.

She was on long acting morphine and short acting oxycodone. Her Social Security disability insurance didn’t cover the long acting form of oxycodone.

She told me several times how much she hated being on narcotics, but they kept her functioning. She was able to do her own housework and she was taking classes in medical coding and billing.

Her pill counts were always correct and her urine drug screens always showed morphine and oxycodone – never anything else.

A year ago, an anonymous caller told Autumn that my patient was injecting her morphine. I saw a couple of scratches on her arms, and she told me she had this nervous habit of picking at her skin. I said that habit could keep her from receiving future prescriptions for pain medications, and I never again saw any marks on her arms or legs.

Last summer, we got an emergency room report from Massachusetts that documented how my patient had presented with symptoms of opiate withdrawal. The story she had told there was that she had lost all her pain medication when her car was broken into at a highway rest area several days earlier. She was dehydrated and needed intravenous fluids.

When I saw her back, she was still shaky, and she asked me not to represcribe her long acting morphine. She said, tearfully, that she was determined to get off her narcotics. Just some oxycodone to take the edge off her pain, but she didn’t want to have these drugs in her system all the time, she told me.

Her next drug screen only showed oxycodone and its metabolite, oxymorphone, just as expected.

A few months later, she ended up missing her followup appointment because her mother fell ill and needed emergency surgery. “I stretched my oxycodones”, she said, “and I did all right”.

“Let me do another drug screen, to prove that you didn’t take anything else”, I said.

She tensed up, but didn’t say anything, except “will the results go up on the new patient portal?”

“As soon as I’ve signed off on them, yes.”

A few days later, the opiate confirmation test came in. Her oxycodone level was medium high, but there was no oxymorphone, suggesting only recent oxycodone intake, but not proving continuous use. That was reasonable as she had been taking her prescription less regularly. But, confusing at first, her morphine level was higher than the assay could measure. There was also a high level of codeine.

I had in front of me a test result that suggested probable heroin use.

I had to check my facts, but needed some extra time to do my research. Meanwhile, she called to inquire about her results. Autumn told her that they probably hadn’t come in yet, if they weren’t on the portal.

Heroin, also called diacetylmorphine, is rapidly metabolized to 6-monoacetylmorphine (6-MAM), which is six times more potent. Within a few hours, 6-MAM is transformed to morphine and no longer detectable in urine or other body fluids. Street heroin often has some acetylcodeine in it, which is metabolized into codeine.

I checked with the reference lab. They could run a test for 6-MAM, but because it is present only for a few hours, it might still be negative even if my patient was using heroin. The turnaround time for the analysis could be up to a week.

I picked up the phone.

“I’ve got your opiate confirmation test”, I started.

She was silent.

“It shows your oxycodone, but also more morphine than I’ve ever seen, and some codeine.”

She said nothing.

“That is the pattern we see with heroin use. And, in any case, you wouldn’t be expected to have that much morphine in your system when you are no longer prescribed morphine, and I never prescribed codeine for you. I have a confirmation test pending for 6-MAM, which is a breakdown product that we see in the body before heroin becomes morphine. But this disappears quickly from the system, so we don’t always see it in heroin users”, I explained, based on my recent homework.

She still said nothing, except “can you put the result up on the portal so I can look at it?”

That was it. She hung up. I never heard from her again.

A few days later, her 6-MAM report came back. It was positive. I signed off on it, and it went up on the portal.

A Transformative Visit

Dustin Ouellete grew up a bit the other day.

I had known Dustin as an infant, and his mother before that. Several years ago, the Ouellete family moved away to the big city, but last summer they came back.

Dustin came in a few times with his father, and his main concern was migraines. Dustin’s father, a quiet man who seldom smiles, was concerned that the headaches were keeping his son from excelling in sports, and Dustin seemed overwhelmed with the idea of taking daily medication.

It seemed clear that physical exertion beyond a certain intensity was a trigger for Dustin’s s migraines, and at first, he thought he might be able to treat them as they came along and just be careful about learning his limits. Ibuprofen, taken early during a migraine, seemed to work three quarters of the time. The sumatriptan I had prescribed worked once and seemed ineffective another time, his father reported on the phone a few weeks after Dustin’s first visit.

I saw them in followup, and he agreed to try topiramate. During the titration period, he still had a few migraines, so I got a phone call that they were stopping it.

A short while ago. Dustin came in with his mother, an exuberant woman who used to have migraines as a teenager.

Dustin had tried out for another sport and had started to have migraines again. He had restarted the topiramate, but at 50 mg twice a day it wasn’t holding him. He was considering dropping that sport and choosing something less strenuous. His mother said “it’s up to you, Dustin”. He looked glum and overwhelmed.

I thought for a minute, then leaned back and started:

“Well, Dustin, you have a choice here. You can spend the rest of your life tiptoeing around the triggers you have for these migraines and turn away from this sport or that, or you can invest some more time and effort in finding the right dose of the medication we have started, or another one, and figure out once and for all what it’s going to take to beat this problem so you can do anything you want, maybe not this season but for the future.”

I could see his mind working.

I continued, “it’s like my right shoulder. I have dislocated it many times, but now I know exactly what I have to avoid in order for that not to happen – I can’t put my jacket on while sitting down, I can’t reach for something in the back seat while I’m driving, and so on. I decided not to have surgery, so I have to live by my limitations. That was the right decision for me, but someone with a different job might have made the opposite decision.”

Dustin sat motionless for what felt like two full minutes. Suddenly his posture changed, from a semi-slouch to bolt upright, and his eyes came alive.

“I think I’ll drop out off track this year, work my way up on the topiramate dose, see how the beginning of the summer goes just doing some informal stuff, and then be ready for soccer season.”

“You claimed it!” I made a “yes” gesture with my hand. “You stopped being a victim, you are taking charge, and not letting your migraines run your life”, I said.

Dustin almost squirmed with enthusiasm in his seat, and his mother beamed in her corner of the room.

I continued, “you can up it by 25 mg every week, I’ll send a new prescription for some 50’s, take sumatriptan if you get a migraine, and you call me when you get to 100 mg twice a day, oaky?”

“You got it!”

Dustin stood up, and his mother followed. He was taking charge.

Don’t Squeeze, Tie, Slap or Bite the Hand that Feeds You

Dear Health Care Business Leader,

I am writing to you in a spirit of cooperation, because the way health care works today, it is too complex a business to manage “on the side” while also taking care of patients. And I hope you don’t have any illusions about medicine being so simple that non-physicians like yourself can manage patients’ health care without trained professionals who understand medical science and can adapt the science and “guidelines” of medicine to individual patients with multiple interwoven problems with disease presentations that seldom match their textbook descriptions.

We need each other, at least under the current “system”. So I ask you to view us as allies, because we actually do the work that ultimately pays your wage or your profit, and is the basis for your own performance metrics. We are in this together, like it or not, so let me ask that you don’t do some of the things that several of your colleagues are doing:

Don’t squeeze us too hard.

When you do, the quality of our work, the health of those we serve, is in jeopardy. Instead of just imposing productivity targets, quality thresholds or pay-for performance schemes, listen to what we need in order to keep our patients healthy. Invite us to the table; we actually know a lot about how to work smarter, faster and better, so don’t be afraid of our participation. If we feel squeezed and abused, you will get perfunctory performance, but if you partner with us, we can, together, make patient care much better.

Don’t tie our hands.

I know you mean well, but when you pick or design tools and workflows for us to use, you often make it harder for us to do the work that patients need us to do well.

Don’t give us EMRs that cut our productivity in half, when computers have streamlined work in other sectors; don’t make assumptions about how doctors think and how we process information. For example, let me read CT scan reports and other test results, without scrolling, right when I see my patient in follow-up, import them into today’s office note, and “sign off” on them right then and there, not after my office hours when I should be spending time with my family. And, also, when I am in today’s patient note, let me see all recent results, consultations, calls and refills WITHOUT clicking on several “tabs” that may not have any results under them. Data is meaningless without context, and a good computer system should enhance the context behind the data.

Don’t slap our hands.

Doctors are highly motivated individuals, who generally work harder than anyone asks them to. If we don’t seem to do what you want us to do, it is either because we think you are asking us to do the wrong thing or because you haven’t given us the tools to do the right thing. We don’t need to be prodded along like cattle, and we don’t respond to being slapped.

Don’t bite.

Don’t inflict pain and don’t threaten us with it. Our first inclination will likely be to take care of our patients and ignore you, but we will ultimately respond if threatened or attacked enough. You may think of health care entrepreneurs from the business community as introducers of disruptive change, but consider the possibility that physicians, if pushed too far, could be the ultimate disruptive force in health care.

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