Taking Mama’s Pills

He was in his mid-fifties and seemed pretty clueless.  What’s more, he had more abnormal movements than any 20 people and looked like he was dancing with an invisible partner.

It's Dangerous To Take Drugs Prescribed For Someone Else

He sat at home all day trying to get himself involved in things like doing laundry and watching television so that he could get himself tired enough to sleep, focused enough to avoid the voices. He was safe — no forced hospitalization was necessary or even possible here. He promised that he would not harm himself no matter what the voices said, but it became clear that he lived in a world where devils and demons gave him a continuous commentary on everything from why Obamacare would never help him to — the size of his wife’s behind. There may have been some exhortations to harm self or others in the distant past, but they were indeed distant.

He said he had no medicine for the past ten years.  I asked how he lived and he said his family was no help, but his woman was. He was married to someone else but this woman was the only person who knew his day-to-day life and she had brought him to the clinic, so I got a release signed and got her in there. I told her he said he had no medicines in say, the past ten years or so.  She started laughing.

“He ought to be telling you the truth.  He gets his Mama’s old Seroquel whenever he can. Makes the voices shut up so he can sleep a little. “

My first thought was that this man had gone and taken someone else’s prescription, maybe even had a bottle with Mama’s name in his possession.  I had heard of people getting into all kinds of trouble about this in California, and I have certainly done my bit telling people to keep meds in their original bottles, but I have no direct experience with this particular problem, and that seemed to be the least of our worries.

Lots of problems with drug labelling.  I figure I am lucky if I can get the patient to get a label in the right language.  This IS California, ya know. So we drop all this and look at the problem.

The movements were tardive dyskinesia, from haloperidol most likely or some other drug in that family.  I recommended an inexpensive but decent brand of B vitamins, some amino acids, whatever this loving woman could afford for this man.  Of course, no known insurance could pay for them.

The question was how to treat this man.  Let the loving woman pay for the B vitamins.  I could get him samples, compassionate care medications, free stuff, and it could be Seroquel (quetiapine) but it would have to be the extended release and not the “old” seroquel he liked.  Of course they wanted to know why. First question was, how likely was Seroquel to work completely at a higher dose?  I suddenly remembered that in the days of the tricyclic antidepressants I had actually read that if a drug had worked (and been tolerated) on a first degree relative of a patient, then it would probably work on the patient.  Pretty good.

I started to wonder about new or “novel ” antipsychotics.  How close was his DNA to that of his mom?  50% of it had to come from her. She was housebound and there was no way I could talk to her.  His dad was dead.

Now, we are down to the question he wanted plain old Seroquel and I had the new one — Seroquel XR.

But leave it to our friends at Wikipedia to do a pretty good review of the literature.  I made the magistral decision our schizophrenic was not elderly; he did not seem demented, maintained a relationship with a longtime girlfriend. I had used the plain Seroquel for years with patients without problems, slowly ramping up the dose from the lower ones that provided sedation to the higher ones that stopped nighttime doses cold and done just fine.  Now, an extended release — why?

Astra-Zeneca seems to have done what other companies do. In order to maintain profit they had marketed a spiffy new and “more effective” form.

OK fine.  They give free samples of their new product, of which they are proud, but I am now old enough to have seen LOTS of drugs go into spiffy new formulations to maximize the profits.

Like Paxil (paroxsetine) from our friends at Glaxo Smith Kline .

Now here I used to love that paroxetine had a sort of help-them-get-up-in-the morning effect, while its liver metabolite helped people relax and sleep in the evening.  Of course, that effect is all gone with the “new, improved” Paxil CR.

I do think these silly-pudding drug companies think I am too dumb to know what they are doing.  But I digress.

Here was an older schizophrenic whose arm was being stroked by his longtime girlfriend while I was trying to explain to him why I could not get him for free the same Seroquel his Mama took, but this was a souped up one he had to take earlier, maybe an hour before going to bed, and not do anything afterward.  It should help the voices during the day, maybe a little better than Mama’s stuff, but he should not drive — which luckily he did not do anyway.

Now he and his girlfriend would fill out some papers.  Maybe we could get “MediCal.”  Maybe “compassionate care” (free medicine from the manufacturer, with his name on the label, shipped to the clinic and stored especially for him).

Then I had to come clean on one big problem.  Nobody, but nobody, knew the milligram-equivalents between the two kinds of Seroquel.  I mean, starting when it first came out, I pretty much wore out the toll free phone line to Astra -Zeneca.  Nobody could tell me exactly how many mg. of one kind someone needed when you transferred from one to the other. Anecdotes from other practitioners (whom I tend not to trust) had told me that they were pretty much milligram-equivalent. So if the type had to be switched midstream, we could guess and watch. They weren’t happy when I told them this, but I must speak truth.

Three weeks later I not only got him a medical doctor who had started him on antihypertensives, but I got him on the free samples of the newfangled stuff, and he told me that the demons and devils had a “blue planet” of their own now and it was moving away from the earth, so things were in pretty good shape.

The B vitamins had helped his tardive dyskinesia, which was now minimal; you could not find it unless you were looking for it. Screening bloods were good; no major illness, and we moved foreword.

There is no precision pharmacology in this field.  Although there are blood tests available to tell how people will respond to an antipsychotic, I know personally of no group that pays for them. There is some emerging information on antipsychotic response, but nothing I know about that can be applied clinically.  This case was solved by commonsense genetics (If it was good for Mama …) and seat-of-my-pants drug equivalency. But there is a happy ending —

At the three week follow-up, the patient insisted on kneeling and kissing my hand. I blushed mightily.