Before You Pop That Pill

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Haig is an Assistant Clinical Professor of Orthopedic Surgery at Columbia University College of Physicians and Surgeons. He has a private practice in the New York City area.

For most Americans, the world of medicine is about pills. Although we live longer, healthier lives because of our pills, not all of us are happy to take them. I have a good number of anti-medicine patients — some who won't take any medicines at all. Others want more pills than they should. I spend lots of time straightening out people's thinking about medicines.

Dr. Scott Haig is an Assistant Clinical Professor of Orthopedic Surgery at Columbia University College of Physicians and Surgeons. He has a private practice in the New York City area

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"I'm not a pill person" is what Ellie says. She is an attractive tennis-playing 65-year-old woman who has been with me through a broken wrist and a shoulder operation. She took only Tylenol for the pain in both instances. She is (for many other reasons) a great woman — upbeat and interested in everything, outgoing, concerned and very into her sports; I hope I'm at least a little like her when I hit 65. It's because of Ellie and others like her that I harbor a mild aversion to taking medicines myself. I haven't yet started swallowing the daily statin they say I should be taking now, the daily aspirin, the lycopene for my prostate. Although I prescribe pills every day — mostly for pain relief — my usual advice as I hand over the prescription is "try to get off these as soon as you can." So with this confession off my chest here are a few things you should know about pills.

Allergies: Go into any medical establishment at all these days and there's one question you will be asked again and again: "are you allergic to any medications?" Drug allergy is very different from drug sensitivity. In our current computerized medi-bureaucracy, you must be careful about telling hospital personnel that you are allergic to things you're really not. Those who your enter your medical information into the big hospital computer programs don't often ask if it's a true allergy — causing hives, itchiness, rashes, heart rate and blood pressure changes or breathing difficulties. Drug sensitivities, on the other hand, include the constipation, queasiness, wooziness and confusion we see with narcotics; the dry mouth from cold and allergy medicines; the mood swings with steroids and other hormones; even the yeast infections some women get with antibiotics.

Once a drug you name gets listed in the computer as "allergy" though, the pharmacy computer kicks out any order a doctor makes for it; they won't send your nurses the drug. Then when you really need the drug, you might not be able to describe your reaction to it. Few practitioners take the time to go over your list, carefully asking, "now what really happens when you take X?"; they just won't prescribe it. We use first-line drugs first for a reason — they generally work the best with the least bad side effects. So you could end up on more dangerous, less effective medications than you would otherwise. It might be, for example, better to give you that antibiotic and treat the yeast infection later than to give another drug and burn out your kidneys. Medicine is full of delicate choices between imperfect alternatives. Bottom line: go over your allergy list carefully with any nurse or doctor who takes it. Ask to see it when you check into the hospital and correct it if it's wrong.

Product inserts: These are another thorn in our sides. Although distributed to millions of people, they seem to be written for only 12 — the ladies and gentlemen of the jury. The huge foldouts with the tiny writing are primarily there to cover the drug company's legal backside, but patients are reading them more and more. We then have to deal with indignant, or even angry patients coming back to us with steam shooting out of their ears. "Look what these pills do to you — it says it right here! Are you trying to kill me?"

Although hard to read, product inserts include some terms with which everyone is familiar, specifically, nausea, vomiting, diarrhea, insomnia, malaise and muscle aches as well as the ever-popular "unknown dangers to nursing mothers." Yes, these can actually be the side effects of the drug your doc has prescribed but remember: the drug company lists every symptom the people in their test groups report — and it doesn't "blank" the reports against placebo. People are very suggestible, (Do you feel nausea? — "well come to think of it..."). Some of them may happen to have a hangover or gastrointestinal bug on the day they participate in the drug trial. Its easy to get a long list of these for any drug. Even placebo (a sugar pill) produces nausea, vomiting, etc., in test groups. So ask your doc what the usual side-effects are and don't be freaked out by the insert.

Generics: A good number of patients still ask for "the good stuff" — the actual brand name drug — not the generic forms. By law the pharmacy has to give you the far cheaper generic pill unless the doc writes "DAW" (Dispense As Written) in the little box on the script. It's easy for the doctor to do this — it takes less time and effort to write the three letters than to convince you you're wasting money. I've never seen any significant difference between the generic and branded versions of the drugs I prescribe. Neither have the colleagues I've asked. Save your money.

Shark Cartilage: The next topic is a very sensitive one: glucosamine-chondroitin pills for arthritis. Patients ask me about these literally everyday. They're not cheap but they are not dangerous and, according to a well-done, recent study with 18,000 people — (half gets the stuff, the other the placebo and neither knows what they got until they report how the pills worked) — they are not effective. They are "natural" though, and many patients love them. The say their pain is "relieved" and they are sure the stuff works because of something about never having seen a shark with low back pain. Educated, rational people — even my favorite rheumatologist — still swallow the stuff. Go figure.

Natural remedies: They are not uniformly benign. Renal failure, seizures and bleeding disorders are a few of the known side effects of pills you can buy in health food stores. Socrates, we recall, was killed by an all-natural drink.

Naturopathy is an interesting belief system based on the premise that the myriad ingredients in whole plant parts cancel out the side effects of the "drug" in the plant. And many drugs do come from plants. The classic example is digitalis leaf. The foxglove plant contains a chemical, digitalis, that can regulate an irregular heartbeat. Digitalis, the purified chemical, has many well-known side effects, while whole foxglove leaf, say the naturopaths, does not produce these side effects because the other ingredients in the leaf "cancel" them out. Is this really true? I've got my doubts; I have treated a few patients on "dig leaf" — they seemed healthy. I have treated far more on regular digitalis and who were healthy too. Very few of the heart guys have gone over to natural meds despite patient requests and marketing trends. I'm happily spared the issue; there being little that can be done "naturally" about the broken bones and torn tissues I treat.

Naturopathy says that sick animals have an instinctual knowledge of what plants to eat to make them better. Is this true? I have seen dogs eat grass and vomit. There was no package insert to warn them!) Perhaps it was only the bunnies and deer with irregular heartbeats that ate all that foxglove in my wife's garden but again, I doubt it. It's confusing, but this I know: when they're really sick, the naturopaths, the homeopaths, the osteopaths, chiropractors and acupuncturists — they all come to us. Even my dog slouches over and puts his head on my lap.

We all linger in the natural remedy aisle; it's...natural. Even this pill-averse orthopedist will take an echinacea or two if I feel a sore throat coming on. But there is no uniform governmental or academic scrutiny of these things so don't believe everything you read or hear about them — most of it is coming from the folks who are selling it.

Drugs most likely to give you trouble: The common drugs to be most concerned about are two — coumadin and narcotics.

Coumadin is the "blood thinner" we use when you've had a stroke, heart valve replacement or blood clot. It works by poisoning an enzyme in your liver that helps produce clotting factors. Its blood thinning (anticoagulating) effect comes on slowly but can quickly become (dangerously) greater than we want when you take different drugs or even different foods. The anticoagulation we want can easily overshoot — with dire consequences. It also can render ineffective or too effective, other drugs that are processed in the liver. Getting you on just the right dose of coumadin takes about a week, then you show up and get your blood drawn every week to make sure the level of anticoagulation is staying where you want it. There are more bad drug reactions and problems with coumadin than with all the other drugs put together. It is, however, the only thing we've got in pill form that controls clotting. If you're on it don't bang your body around — you will bruise and bleed internally. And make sure you get your levels checked.

Narcotics are the "hot button" for every orthopedist. People call us at all hours asking for them. They plead, cajole and lie to get them. Every few months an article appears saying we give too many, then another month and an article says we don't give enough. Narcotics make good people do things they never would. In the medical setting they say "I just wanted the pain to go away — its about the pain, not the drug. "In the street setting they say" the drug took control over me — it robbed me of my free will." Remember, it's the same stuff.

The human interaction with narcotics is powerful and complex, truly fascinating and the topic of a future column. Here I'm just giving the bottom line and its straight from my heart: if you break a bone, have an operation, wrench your back and get a few tablets for short term use — fine. You will be off them in a few days and probably never feel the grip. But if you have a chronically painful condition of any sort, do everything in your power to stay off narcotic pain medicines. These drugs affect not just your brain, but your mind. Lives, families, whole communities have been destroyed by people using them. Narcotics are what you're thinking of when someone says the word "drugs." So real their promise of happiness — but it's a lie. Misery and death are the true gifts of this 'angel of light' in our world of pills.