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    Vera Hassner Sharav:
    The escalating cost of healthcare is in large measure due to
    the spiraling expenditure on drugs--many of which are misprescribed.
    The Boston Globe reports about one Medicaid patient who is prescribed
    18 medications at a cost of roughly $16,000 a year--
    "all at the expense of the financially struggling Massachusetts
    Medicaid program." 

[Fred A. Baughman Jr., MD:
there used to be a caveat in medicine that said
where drug side effects were a possibility, that the first step the
physician was to take was to stop all non-essential medications. And all
psychiatric drugs (there being no such thing as a psychiatric disease) being
non-essential, they would then be discontinued-judiciously]

    The woman (who was alcoholic) is a pharmaceutical company's
    dream consumer. Thanks to psychiatrists' poly-pharmacy prescribing
    practices she is taking multiple costly drugs of the same class.
    Such prescribing practices are more likely to generate drug-induced
    new pathologies 

[Fred A. Baughman Jr., MD:
in psychiatry, every drug, single or multiple is sure
to generate more pathology than the "disease"/"chemical imbalance" for which
it is prescribed, because there is no such thing as a psychiatric

than to cure the condition for which they are prescribed.
    What some would call malpractice, is an incredibly lucrative marketing
    According to Massachusetts Medicaid 

[Fred A. Baughman Jr., MD:
it is a disgrace for Medicaid in
any state to accept as legitimate, psychiatry's claims of "diseases" as
things to prescribe for. ADHD is the biggest fraud of all, and a violation
of the Controlled Substances Act with every prescribed Schedule II

, the 10 most prescribed drugs under
    the Medicaid program are:
    1. Zyprexa (antipsychotic) costs Massachusetts taxpayers $4.2 million,
    2. Protonix (heartburn) costs $3.6 million
    3. Risperdal (antipsychotic) costs $3.1 million
    4. Lipitor (anti-cholesterol) costs $2.8 million
    5. Seroquel (antipsychotic) costs $2.8 million
    6. Neurontin (neuropathic pain...) $2 mill
    7. Depakote (antidepressant) $1.7 million
    8. OxyContin (narcotic) $1.6 million
    9. Zoloft (antidepressant)$1.5 million
    10. Paxil (antidepressant) $1.2 million
    7 of the 10 drugs are expensive psychiatric drugs that are eating up
    the Medicaid budget. The Boston Globe reports that about 40,000 patients
    in the Massachusetts Medicaid program take eight or more medications.
    "Thousands of other patients take five or more psychiatric drugs,
    more than one newer antidepressant, or more than one newer antipsychotic."
    Furthermore, "For patients on eight or more drugs or five or more
    psychiatric drugs, Medicaid officials will try to
    educate doctors about why this could be a health problem."
    One must wonder about the professional competence of State licensed
    psychiatrists who prescribe powerful, mind altering drugs, yet
    are ignorant about these drugs' potential to cause patients harm.

[Fred A. Baughman Jr., MD:
there is virtually never justification for an antipsychotic in a
child, and surely never for the fraudulent diagnosis of pre-schizophrenic


    Cost and consequence
    Medicaid aims to curb 'poly-pharmacy' approach, but drug limits may
    undermine patients' health
    By Liz Kowalczyk, Globe Staff, 6/22/2003
    Seven years ago, Cheryl Desio was homeless and addicted to alcohol,
    sometimes sleeping on a gym mat in a friend's basement, other times staying
    briefly in a shelter or with one of her children. One night, drunk and
    angry, she remembers showing up at Massachusetts General Hospital looking
    for psychiatric help and began a long climb up, to treatment programs at the
    Salvation Army in Brockton, Father Bill's Place in Quincy, Boston's Lemuel
    Shattuck Hospital, and the Edwina Martin House in Brockton. Finally she
    moved into a low-income apartment in Dorchester, which she shares with a
    roommate, and onto Medicaid, the government's health insurance program for
    the poor.
    "Cheryl is a real survivor," said Dr. Michael Folino, her primary care
    physician. "It's amazing to me she's still living and doing well."
    Desio, 50, is amazed, too, especially at her children's generosity and
    respect since she became sober. One daughter pays her monthly phone bill
    while a son bought her reading glasses. "We're so proud of her," said her
    daughter Stacy Konopka, 27. "Growing up with her drinking was really hard.
    Her life was spiraling down. This year she called me on Mother's Day,
    because I have a new daughter. To have her do that, was amazing."
    But keeping her fragile life and health together is not easy. Desio takes 18
    medications, for diabetes 

[Fred A. Baughman Jr., MD:
a real disease]

, depression 

[Fred A. Baughman Jr., MD:
a symptom, not a disease]

, anxiety, 

[Fred A. Baughman Jr., MD:
a symptom, not a


[Fred A. Baughman Jr., MD:
a symptom, not a disease]

, and emphysema

[Fred A. Baughman Jr., MD:
a real disease]

, all at
    the expense of the financially struggling Massachusetts Medicaid program.
    The cost for her medicines alone: roughly $16,000 a year.
    On July 1, Medicaid officials will start reviewing Desio and other
    "poly-pharmacy" patients -- those using many medications or several
    medications in the same class -- for its newest cost-cutting initiative
    aimed at controlling the state's skyrocketing prescription drug costs.
    Medicaid officials believe that pushing doctors to reduce the number of
    medications individuals take will not only save the state as much as $20
    million annually 

[Fred A. Baughman Jr., MD:

 but will reduce dangerous side
    effects and drug interactions for patients 

[Fred A. Baughman Jr., MD:
far more important]

    Many doctors fear the initiative will have unintended consequences for
    seriously ill Medicaid recipients like Desio, whose complex conditions often
    require an equally complicated drug cocktail. "The question is what happens
    when you take one brick out of the foundation?" said Folino, medical
    director of Harbor Health Services Inc., a group of three community health
    centers in Boston.
    Desio's doctors don't know whether Medicaid officials will push them to
    reduce or change her medications, or whether the reviewers who monitor drugs
    for the agency will find them all medically necessary. But Desio is anxious.
    "I am scared of this," she said

[Fred A. Baughman Jr., MD:
having been lead to believe all
are necessary]

. "I'm doing the best I can to keep myself well."
    Medicaid officials have been struggling to control the program's growing
    $1.1 billion pharmacy budget by switching many patients from expensive brand
    name drugs to cheaper generics 

[Fred A. Baughman Jr., MD:
the aim should be to stop all
non-essential medications]

. When generics don't exist, most patients now
    can take only the cheapest brand name drug for a particular condition.
    When Desio tried to renew her prescriptions for the antidepressant Lexapro

[Fred A. Baughman Jr., MD:
non-essential, since depression is not a disease]

    and the migraine 

[Fred A. Baughman Jr., MD:
it must be determined if she has real migraine
headaches or the much more common, frequent, psychogenic, "tension"

medication Maxalt two weeks ago, her pharmacist said
    Medicaid would no longer pay for these expensive drugs -- unless her doctors
    get special permission 

[Fred A. Baughman Jr., MD:
even if true migraine, older, less expensive
medications will likely suffice, leaving precious funds to pay for real
disease care within Medicaid]

    But these measures, Medicaid officials say, have done nothing to address a
    pressing cost problem that also may be hurting patients' health. About
    40,000 patients take eight or more medications. Thousands of other patients
    take five or more psychiatric drugs, more than one newer antidepressant, or
    more than one newer antipsychotic. Officials don't know precisely how much
    these members' medicines cost the program, which insures 950,000 poor and
    disabled residents, but still think some of it is wasteful spending.
    Starting July 1, Medicaid officials will use a computer program to identify
    these patients and call their physicians to ask them to reduce their
    medications. Patients will not be allowed to take more than one newer

[Fred A. Baughman Jr., MD:
always a justifiable move as 2 or more
antidepressants can never be proved to be superior to one ]

or more
    than one newer antipsychotic 

[Fred A. Baughman Jr., MD:
always a justifiable move, as 2 or more
antipsychotics can never be proved to be superior to one ]

--unless a doctor
    proves with medical records that the combination works better for the
    patient than a single drug.
    For patients on eight or more drugs or five or more psychiatric drugs

[Fred A. Baughman Jr., MD:
never justifiable, always enhances risk of side effects including

    , Medicaid officials will try to educate doctors about why this could be a
    health problem. Massachusetts is one of the first states to target

[Fred A. Baughman Jr., MD:
every state should since psychiatric polypharmacy is
never justifiable]

, said Mike Fitzpatrick, director of policy
    research for the
    National Alliance for the Mentally Ill, a nonprofit advocacy group based
    near Washington, D.C. But he said many states now are following suit. Texas
    plans to limit patients to four brand name drugs per month, and Eli Lilly &
    Co., maker of a number of psychiatric drugs, gave Missouri several hundred
    thousand dollars in part to educate doctors who are prescribing patients too
    many psychiatric drugs.
    "There is increasing evidence that members are getting many drugs that
    aren't appropriate or are excessive," said Douglas Brown, Massachusetts
    acting Medicaid director. "If we focus on the relatively small number of
    people on high numbers of drugs, we can improve their health care and save
    But Dr. George Sigel, Desio's psychiatrist 

[Fred A. Baughman Jr., MD:
make their living
diagnosing invented "diseases" prescribing drugs, treating the side effects
of the drugs]

, objects to government
    interference in his medical judgments, and worries these initiatives will
    shake patients' confidence in their doctors. "They won't know if the doctor
    is thinking about what's best for them, or about how time-consuming it's
    going to be for him to get permission from Medicaid," he said. The state's
    "prior approval" forms are two-pages long and require a detailed
    description of the patient's medical history. "There's no way deleting any
    of Cheryl's medications on the basis of cost is going to be good for her,"
    he said.
    Other physicians are not so sure. Medicaid officials -- and some doctors --
    say that for various reasons, including health insurers' reluctance to pay
    for long hospital stays and intensive outpatient psychotherapy since the
    advent of managed care, poly-prescribing or poly-pharmacy has gotten out of
    hand. Dr. Marie Hobart, a Worcester psychiatrist who serves on the Medicaid
    committee that developed the new poly-pharmacy rules, said the agency
    primarily wants to cut costs but deserves credit for taking a clinical
    approach. The committee reviewed studies on poly-prescribing and interviewed
    Widespread poly-pharmacy came about, she said, partly because doctors in
    clinics are struggling to see huge numbers of complicated patients.
    "Sometimes these multiple medicines have been arrived at in a painstaking
    way," she said. "Other times we have patients who are very difficult to
    treat and very little time to spend with them, and it becomes more difficult
    to make changes in their medicines."
    Dr. James Ellison, a psychiatrist on the committee and president of the
    Massachusetts Psychiatric Society, said patients tapering off one medication
    and starting another sometimes feel better and believe it's the combination
    rather than the new drug taking effect. And sometimes, he said, doctors
    resort to poly-pharmacy in desperation on difficult patients for whom no
    drug seems to work. Out of 200 patients he's treating for depression, one
    man takes two newer antidepressants known as Selective Serotonin Re-uptake
    Inhibitors -- even though no proof exists for this combination.
    "I don't think that's why the patient is doing well, but he strongly
    believes this is useful," Ellison said. "My worry is that we're exposing
    him to increased side effects, and for society, we're drawing resources away
    from other problems."
    Folino, Desio's doctor, said he is not a fan of poly-pharmacy but that it
    will be difficult to comply with the state's directive in complicated cases
    like hers. Desio has hepatitis C, diabetes, and chronic obstructive
    pulmonary disease from years of smoking and not taking care of herself. She
    also has cervical stenosis, a narrowing of the spinal canal that pinches the
    nerves, and migraines that cause her severe pain.
    Desio, who has huge light blue eyes and a worn look, takes medicines four
    times daily. The regimen is so complicated a nurse has written it on a big
    sheet of paper. A good day is when she can walk around the Harborpoint
    housing development in Dorchester or sit on a bench near the ocean. Less
    often recently is a bad day -- or two or three together -- when she can't
    get out of bed.
    Folino said Desio's drugs interact in such a way that she needs more than
    one medication for each problem. For example, she requires a steroid,
    Advair, to help her breathe. But that elevates her blood sugar, so Folino
    has had to put her on three diabetes medications. Steroids also can
    destabilize her anxiety and depression 

[Fred A. Baughman Jr., MD:
it is essential to remember
these are not essential medications since anxiety and depression are not
diseases. In that her real medical diseases are worsened by her
psychotropic medications, they should be discontinued.]

; she's on
    four medications to control
    those conditions. But she has to be careful about which antidepressants she
    takes because they can cause weight gain, and in turn aggravate her diabetes.
    Even so, Desio is having symptoms Folino said could be the result of
    multiple drug interactions. Her roommate has called an ambulance many times
    because Desio has gotten dizzy, fallen, and been unable to stand up. Folino
    referred her to yet another doctor, a neurologist 

[Fred A. Baughman Jr., MD:
think of all the
true medical complications of her non-essential psychiatric drugs]

    "Obviously it's a delicate balance," Folino said. "This could have to do
    with poly-pharmacy. But on the other hand, with the combination she's on
    she's functioning as well as she ever has."
    Liz Kowalczyk can be reached at
    This story ran on page E1 of the Boston Globe on 6/22/2003.
    © Copyright 2003 Globe Newspaper Company.

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