Drugs are Cheap

Getting a syringe from my supply closet, I noticed that only a dozen remain. I’d better order more. A hundred syringes costs $12.

I buy from an internet medical supply company. For orders under $200 it charges a fat “handling fee,” so I try to order enough to exceed it. Most of my purchases are drugs, but that presents a problem because they’re so cheap.

I notice other hotel doctors charging $50 to $150 for an injection. I carry seven injectables. The content of a single shot of all seven rarely cost more than a dollar.  

What do I need?..... I stock B12 not because it’s necessary but because guests ask for it. This doesn’t happen often, so my bottle is almost out of date. The price has gone up, but it’s still $31 for a 30cc vial. That’s thirty injections.

I’m down to a few dozen Ondansetron tablets, the best nausea remedy. Ten bottles of thirty will set me back $37.

It never hurts to stock up on loperamide (Imodium is the brand), my favorite diarrhea treatment, but I was surprised to discover the price has jumped to ten times what I paid a few years ago: $104 for five hundred. Many old but important drugs such as penicillin that once cost pennies a pill have skyrocketed to dazzling levels. The weird thing about loperamide: it’s sold over-the-counter. Walmart charges $5.00 for a bottle of 72. That works out to $35 per five hundred. I’ll buy loperamide from Walmart.

I’m not short of many drugs, and buying too many is dangerous. At over ten dollars a bottle, my most expensive is antibiotic drops for swimmer’s ear. Swimmer’s ear has been unexpectedly rare, and I recently discarded five bottles that expired in January. My remaining three expire in May. Should I buy more?  Doctors have to make tough decisions…

Amazing Medical Maxims

What many laymen believe are serious signs are not.  Here are examples.

1. Local pain is worrisome; widespread pain is reassuring.

When a guest suffers abdominal pain, I ask to see where it hurts. When he or she indicates the entire abdomen, I relax a little. The common stomach virus produces widespread pain. When the patient’s finger rests on a small area, I worry about conditions like gallstones, appendicitis, or diverticulitis whose pain is usually localized.

2. One allergy can be serious; many allergies: not so much.

An allergy is a specific immunological reaction that can be fatal, but most drug reactions are not allergies. If a medicine upsets your stomach or gives you a headache that’s usually what we call “drug intolerance.” If you’re willing, it’s OK to continue it, something we never do with an allergy. However, doctors use “allergy” indiscriminately, and laymen add their own diagnoses, so many patients confront us with a long list of forbidden drugs, foods, and environment stuff. The major consequence is not illness but expense. If you say you’re allergic to penicillin (90 percent of those who say so are wrong), for example, an alternative costs fifty times more.

3. Things don’t turn into other things.

Mostly this comes up with viral upper respiratory infection (cough, congestion, sore throat, fever).  Everyone knows that antibiotics are useless for viruses, but if a doctor diagnoses a virus, many patients believe they’ve wasted the trip. This is where the maxim comes into play.

“If I don’t get something it turns into… “bronchitis…strep…pneumonia…a bacterial infection….”  It doesn’t. In otherwise healthy people, illnesses don’t change into other illnesses, and experts persistently warn doctors that giving antibiotics to prevent complications is positively harmful. They wouldn’t keep warning us if we didn’t keep doing it.

The Free Market Strikes Again!

I spend less than $1,000 a year for supplies, so giving them out gratis is no sacrifice. Two or three times a year, I place an order at a pharmaceutical web site. It’s easy, but sometimes I get a jolt.  

I hand out doxycycline, an old antibiotic and the recommended treatment for the most common pneumonia and the most common sexually transmitted disease. In 2012 I paid $50 for a bottle of five hundred. That’s twenty-five treatments which works out to $2.00 for each. When I ran low in 2014 I decided to reorder. Checking the web revealed that five hundred seemed to cost $1,655. That couldn’t be right, so I looked around, but it wasn’t a typo. So I ordered azithromycin, effective and about $4.00 per treatment.

This happens regularly. Remember penicillin? You may think it’s obsolete, but it remains a superb antibiotic and the best treatment for common infections from strep throat to syphilis. Twenty years ago it was as cheap as aspirin. I could buy a thousand for $30. Now the price is $130 and rising.

Here’s what happens. As a drug gets older and older, it gets cheaper and cheaper. But doctors like newer drugs. Everyone (you included) believes they are immune to advertising, but you’re not, and doctors are no different.

It’s a good rule that any drug in an ad is wildly expensive and not superior. Look at the ad: if it doesn’t say the drug is the best, it isn’t. A few years ago Avelox or Levoquin would cure your pneumonia as well as doxycycline at forty times the cost. Doxycycline at $1655 a bottle still costs less but not by as much.

As doctors incline toward a new drug, they prescribe the older one less. Pharmacies buy less. Pharmaceutical companies stop making it. Eventually the remaining companies notice the absence of competition, and the free market works its magic.   

I Have Syphilis

Those were the first words from a young flight attendant as soon as we had exchanged greetings.

Earlier, he had told his supervisor of a groin rash. I had popped a tube of antifungal cream into my bag and driven off, expecting an uncomplicated visit.

I asked how he knew this, confident that he had searched the internet and received the usual terrifying and incorrect information.

“My boy friend has the same sore. He went to a clinic. They did a test and said he had syphilis and gave him a shot of penicillin.”

I couldn’t argue with that. He would need the same test and injection. Since he was flying back the next day, he could take care of it then.

“I can’t!” he pleaded. “I don’t go to Australia for two weeks.”

His destination was Cairo because he worked for an Egyptian airline. On sexual matters Arabs are less easy-going than Australians, and he was frightened of the consequences if his employer found out.

I encounter this now and then. Even in the US where discrimination is illegal, employees worry. I never encounter syphilis, so I don’t carry injectable penicillin, but I handed over an approved alternative treatment, and he promised to follow up with his doctor in Australia. Later, writing my medical report for the employer, I worked hard to write an accurate if ambiguous description of a bacterial groin infection. 

Too Many Cooks

As I was preparing for bed, a call arrived from one of my favorite hotels, the Palomar. It’s large and upscale but mostly I like it because it’s only a short drive. The caller explained that his nine year-old son had been coughing for three days.

“I started him on phenoxymethy penicillin,” he added.

 “Does he have a bad sore throat?” I asked. Penicillin treats strep throat and no other common childhood illness, but the presence of coughing makes strep unlikely.

“No. I thought it might help… My brother is a pediatric consultant in London. He gave me a Ventolin inhaler.”

“Did that help?”

“A little.”  That means 'no,' but it was a good idea. Asthma inhalers often relieve a cough even in patients without asthma.

“I’m a doctor who comes to hotels. Would you like me to see him?” I asked.

“My wife wonders if I should take him to a clinic for a chest x-ray and blood tests.”

“Unless he’s very sick, that’s not necessary.”

“Maybe you should come. Can you give him cortisone?”

“I carry cortisone….”

“So you could give him an injection?”

“I’d have to examine him first.”

After consulting with his wife, he said “We will wait for you.”

I exchanged my pajamas for a suit, filled out my encounter form, and was about to leave when the phone rang. It was the Palomar, and I knew what that meant. Guests don’t like to cancel in person, so a hotel employee delivered the message.

“The gentleman says he’s decided to take the child to an urgent care clinic.”

“There’s none in this area open so late. He’ll have to go to the UCLA emergency room.”

“Thanks for the information. I’ll tell him.”

I reverted to my pajamas and went to bed where I passed an uneventful night. The Palomar guest probably passed it in the emergency room.

Doctors Should Keep Their Mouths Shut

A teenager at a downtown hotel had strep throat. Unlike most other bacteria, strep remains as sensitive to penicillin as it was seventy years ago. This is good news because penicillin is a terrific drug. It doesn’t upset your stomach, it has few side effects, it’s cheap….

“He’s allergic to penicillin,” said the mother.

“How do you know?” I asked.

She thought for a while. “The doctor told us. I think he had a rash…”

Once you’re branded as allergic to penicillin, no doctor in his right mind will prescribe it. This was bad news because I carry amoxicillin, a form of penicillin, and hand it out gratis. I don’t carry a substitute, so the mother had to find an open pharmacy and pay about twenty times amoxicillin’s price.

Ten percent of the population believes they’re allergic to penicillin and almost all are wrong. Ninety percent wrong is the usual figure, but some studies find almost zero genuine penicillin allergies.

What happened in this case? Chances are, years earlier the doctor prescribed a penicillin either to treat an infection or as a placebo, and the patient’s mother noticed a rash a few days later. Everyone knows that chicken pox and measles and rubella produce a rash, but any viral infection, including the common cold, can produce a pink, spotty eruption. To make matters worse, five or ten percent of everyone who takes amoxicillin or Augmentin (which contains amoxicillin) develops a similar rash. It’s harmless and disappears in a few days. Stopping the antibiotic doesn’t speed this up.

Experts agree that none of these are allergies.  

But why take a chance? Laymen worry. It’s 100 percent safe (and much quicker) to diagnose an allergy.

If a doctor had told you to flush $1000 down the toilet, you’d object, but that’s the equivalent if you go through life with a nonexistent penicillin allergy. If you’re lucky!... Rarely, you could be in serious trouble.

Skin tests are accurate, so you might want to see an allergist. It costs a few hundred dollars which insurance might not cover.