If you do a Google search for "Tylenol #3", the second hit on the page is this link. Looking closely at the page, you’ll note that we’re talking about "Tylenol #3" specifically. Why then, is the Common Name listed as "acetaminophen – codeine – caffeine"?

There is no caffeine in Tylenol #3. There’s just acetaminophen and codeine.

What form(s) does this medication come in?

Tylenol NO. 3 with Codeine®: Each round, hard, white, flat-faced tablet, bevelled-edged, engraved with "3" on one side and "McNEIL" on the other, contains acetaminophen 300 mg and caffeine 15 mg, in combination with codeine phosphate 30 mg. Nonmedicinal ingredients: cellulose, cornstarch, and magnesium stearate. This medication does not contain gluten, lactose, sodium metabisulfite, or tartrazine.

Who should NOT take this medication?

Anyone allergic to acetaminophen, caffeine, or codeine should not take this medication.

In the United States, when a doctor writes "T3" or "Tylenol #3" you’re getting 300mg of acetaminophen and 30mg of codeine. No caffeine.

However if you go to the Janssen-Ortho website and hit up their product information PDF for their Tylenol products, it indicates there’s caffeine in T2 and T3, but not T4. But the Ortho-McNeil website’s prescribing information (PDF), for T3 indicates that it’s 300mg APAP and 30mg of codeine. No caffeine.

So WTF is going on here? I called Ortho-McNeil (US makers of T3) and I also called Janssen-Ortho (Canadian counterpart). The US office told me what their website did: no caffeine. I have yet to hear back from the Canadians — they say they’ll return your call in one business day. I’m wondering if there’s a difference between Canadian T3s and US T3s? Maybe in Canada, they have 15mg of caffeine, whereas in the US, they don’t? If this is indeed the case, talk about a nightmare trying to track down accurate consumer information. Yikes.

Update: I just got off the phone with Janssen-Ortho of Canada, and Tylenol #3 in Canada has caffeine in it, which means that it is different than the US formulation of Tylenol #3. If I had trouble figuring this out, how much moreso would your average consumer struggle?

[tags]Medicine, pharmacy, drug information, T3, Tylenol #3[/tags]

According to a Reuter’s report, CVS plans to open 300 new Minute Clinics in 2007.

Is this going to change the way doctor’s offices fundamentally do business? In the long-term, I think so, because right now they can’t compete with retail convenience. In multi-doc office, I expect to see doctor/NP/PA scheduling altering to have a more or less constant presence in the office. This will be particularly true with NPs and PAs who can handle more immediate issues — the things that will be diagnosed at Minute Clinics.

There’s been lots of talk in the medical blogging community about how Minute Clinics are “bad” in the sense that a patient’s medical history will be spread out over multiple locations. That the treatment prescribed by the NP at the Minute Clinic will be sub-par, or not what one’s PCP would have chosen. These are valid complaints, so I expect to see doctors respond in the areas where Minute Clinic density is higher.

You don’t need a large medical practice to cover a lot of hours. Lots of hours = lots of availability. Sure it’s not as nice as a 7-7 medical practice, but it IS more convenient for the patients/customers. And it has unexpected benefits as well — 3 days weekends once a month and the like are not uncommon for pharmacists.

Realistically, a moderately-sized medical practice (3 docs, say) could easily cover 72 hours of availability per week. 8am-8pm Monday through Friday, and 9am-3pm on Saturday and Sunday. Start with one doctor in the morning, have the second come in later in the day, say around 11am or noon, and doctor #1 goes home around 4-5pm while his/her colleague stays until late. This is what retail pharmacists do, and I expect you’ll see variations on this theme for doctors once they start feeling the pressure from retail clinician availability. Get an NP or a PA to see the urgent cases, and I think you could probably cut down on ER overuse in your area.

Are there problems? Yes. Are the insurmountable? No. Will it happen in the next five years? Probably. Think about it. 300 Minute Clinics in 2007 alone. If they become big hits, expect to see that number grow yearly. That’s a lot of Minute Clinics. That’s a lot of lost, easy revenue.*

*I think it was Flea(?) who said that these types of visits are the bread and butter of pediatricians because they’re fast and easy. These are the types of visitors the Minute Clinics are catering to.

[tags]Medicine, pharmacy, CVS, Minute Clinic, retail medicine[/tags]

The University of Maryland School of Medicine has essentially come up with a spit test for lung cancer:

In the January 15 issue of Clinical Cancer Research, the researchers report that their fledgling test, designed to check whether two genes believed to be tumor suppressors are deleted in cells found in sputum, identified 76 percent of stage I lung cancer patients whose tumors also showed the same genetic loss. Existing sputum “cytology” tests, which look for changes in cell structure, identified only 47 percent of the patients, they say.

While no other simple sputum analysis has found such a high correlation with lung cancer, it is not yet good enough for the clinic, researchers say, and so they are now expanding their test to screen for up to eight genes.

This is pretty cool, and while it may not be good enough for the clinic, it does appear to have greater potential than say, the controversial PSA test for prostate cancer which misses 82% of tumors in men younger than 60, and 65% of cancers in men over 60. While you can’t yet make a direct comparison between the two, this spit test does seem like it will end up being more accurate than the PSA test.

The researchers are hoping to drill down to the genes that are specific only to cancer. Current cytology tests show the extend of cell damage, but this doesn’t correlate to lung cancer rates because most heavy smokers do not develop cancer. Looking for only the genes involved is a more precise approach to calculating lung cancer risk.

[tags]Medicine, cancer, lung cancer, oncology, genetics[/tags]

I saw this when it first came out, but unfortunately I didn’t give it a second thought. Details, unfortunately are scarce, but it’s good news nonetheless. The NYT has more on the fun backstory of the plant-based remedy:

In some ways, it is a wonder that the work survived at all. In 1670, at the age of 42, Rumphius went blind. In 1687, his still unpublished manuscript and all of his illustrations were destroyed in a fire that swept through the European quarter of Ambon. Undaunted, he dictated a new version and commissioned artists to draw new illustrations.

Fortunately, the second time around he kept a copy of the manuscript. The original was lost when the ship carrying it back to the Netherlands was sunk by a French naval squadron. Still unfazed, Rumphius continued his work, finishing the last volume shortly before his death in 1702.

The extract shows some efficacy against E. coli and MRSA. It was used in ancient times as a remedy for dysentery.

The seeds of the tree, Rumphius wrote, “will halt all kinds of diarrhea, but very suddenly, forcefully and powerfully, so that one should use them with care in dysentery cases, because that illness or affliction should not be halted too quickly: and some considered this medicament a great secret, and relied on it completely.”

Very cool story. I just wish researchers knew more about the active compound itself, and whether it is related to any other antibiotics on the market. I could see it being entirely new or being related to a current antibiotic: it could be from the seeds themselves, which would indicate that it’s entirely new, or it could be from a fungus growing inside the seed (think a moldy peach pit), in which case it could be related to current antibiotics. I guess we’ll have to wait and see — I don’t have access to the BMJ, so any details about the extract itself are hidden from me, if they are even known. Alas.

Geographic isolation can make for some very interesting evolutionary developments. It would be really cool if this was completely new.

[tags]Medicine, MRSA, pharmacy, antibiotics, MDROs, drug discovery, botany[/tags]

There is a small body of research out there that indicates that thiazolidinediones (TZDs) — specifically rosiglitazone (Avandia) — may inhibit angiogenesis. Without new blood vessels to feed fuel tissue growth, there is no tumor growth. There aren’t many researchers out there experimenting with these drugs, unfortunately, but new findings published in the International Journal of Radiation Oncology – Biology –Physics indicate that pioglitazone (Actos) may prevent brain damage in mice undergoing radiation treatment for tumors, which could mean more studies looking at the effects of TZDs on cancer and its management.

The study involved young adult rats that received either radiation treatment equal to levels received by humans or a “sham” treatment involving no radiation. Animals in both groups received either a normal diet or a diet containing the diabetes drug.

Cognitive function was assessed a year after the completion of radiation therapy using an object recognition test. Rats receiving radiation exhibited a significant decrease in cognitive function, unless they received the diabetes drug for either four or 54 weeks after radiation.

The researchers are hopeful that the findings may allow clinicians to give higher doses of radiation. There is a strong correlation between higher doses of radiation and longer lifespans, but there has always been some reluctance to prescribe these higher doses for fear of damaging healthy, surrounding tissues.

[tags]Medicine, pharmacy, Actos, cancer, radiation, oncology, pioglitazone[/tags]

Kevin asks “How to get more medical students interested in geriatrics?” and suggests tuition loan forgiveness. Or rather, the article he links to, does.

My question is, do you *really* need more geriatric doctors?

I’ve opined extensively on pharmacists as prescribers, and I’ve basically concluded that it’s not a bad idea, so long as they’re not making the diagnosis. (Because that’s not part of one’s curriculum in pharmacy school.) With things like the CCGP certification, do you really need doctors who specialize in old people?

I’m inclined to think yes… and no. Surely you need some, but probably not the numbers that have traditionally done so. In fact, most of the CCGPs I know can, and do, run therapeutic circles around the doctors when it comes to managing drug regimens for the elderly. And that’s not meant as an insult to the MDs, it’s simply a fact.

Let the pharmacist deal with adjusting dosages and fixing interactions and managing polypharmacy; let the MD stick to making diagnoses. Clinical pharmacists are generally more interested in the management of drug regimens anyway.

I have a feeling this is the way geriatric medicine is going to mostly go in the near future. I wouldn’t be surprised to see other, select fields do the same thing. Pharmacists are, after all, cheaper than doctors. ;)

[tags]Geriatrics, medicine, aging[/tags]

I had a physical last week that lasted an hour(!). My doctor (who I just started seeing) did two extra things that I’ve never had done before during the course of a routine physical: an EKG and a hearing test. Both of them made me scratch my head inwardly, and they were performed at the end of the physical by a nurse.

I’m a healthy male, in my mid-to-early twenties, with no history of heart problems, and I’ve not complained about anything hearing-related, save twice-a-year ear infections. I’m convinced the hearing test is part of what he does at every physical, because I mentioned my ear infection as an afterthought, after he’d already told me about the hearing test…

Is this normal for physical exams now? Or is it just so he can bill for a bit more from my insurance company?

Back in July, CVS bought MinuteClinic, thinking to get a jump on the coming retail health clinic boom. If you’re like me, and you oppose the fast-food medicine phenomenon, you’re probably against the whole idea.

What I can’t argue against is the convenience, and that’s what’s going to be the big thing. People aren’t going to utilize them for the management of chronic illness, they’re going to use it for the one-off things: Hey I’ve got an ear infection. Hey I’ve been hacking my lungs out for the last 3 days. Hey my sinuses are about to explode and I’m ready to go postal on anyone who f’n looks at me. That sort of thing. (“Zpak, next!” “Zpak, next!” “Amoxicillin, next!…” etc. etc. ad inifinitum) Anyways, what’s better than stopping by CVS, seeing the PA (or NP), doing some shopping, then stopping by the pharmacy to pick up your Zpak? One-stop shopping at it’s finest.

Anyway I spoke at some length with a CVS district manager two weeks ago about the MinuteClinic thing, asking for some details on how they’re run. Who are they staffed by? (An MD? Probably not.) He didn’t know, which sort of irritated me. He was thinking in terms of revenue, and I’m thinking in terms of what’s best for the patient. I guess my main question is how you’re going to have someone diagnosing and prescribing without an MD on staff. PAs and NPs, of course are able to prescribe, so long as they have a supervising physician. (In the two states I’m familiar with, anyway.) So where’s the incentive for the MD to “supervise” a clinician at a retail-based health clinic that’s taking revenue away from their own practice, regardless of whether they own their own shop, or are part of a bigger whole? From a pure business perspective, it doesn’t make sense to me, unless CVS plans to share part of the revenue from their health clinics with these practices. (Which I don’t see CVS doing.)

Maybe they’ll higher one supervising MD per district and have all their NPs or PAs report to him? That’s really the only way I could see a system like that working, but it would seem like a terribly kludgy system. Does anyone know?

In any event, retail health clinics will not be coming to New Hampshire or Massachusetts in 2007, according to aforementioned DM. There hasn’t been any money allocated to open clinics. They will be popping up in Maine, particularly in the uniquely urban-rural areas like Bangor. Apparently there’s more money to be made there than in southern NH and Massachusetts, which really isn’t terribly surprising given the relative density of clinicians to the general populace.

[tags]Medicine, pharmacy, CVS[/tags]

Disclaimer: none of the stores I’ve worked in have ever been held up. I’ve never had anyone shove any weapons into my face and demand XYZ controlled substance. Those of you who have experienced this may think differently.

All of the pharmacies I work in, save my home store, have mandatory 24 hour OxyContin waiting periods. I used to be envious of these stores, but the more I learn think about it, and about pain management in general, the more I think maybe it’s a stupid rule. Why was I envious of those other stores at first?

Well people that bring in scripts for CIIs — especially OxyContin — seem to bring in 2 or 3 at a time. And they usually come in packs of 2-3 people at a time. Almost like they’re all friends or something. (“Hey guys let’s hang out and take some Oxies tonight!” “Yeah, OK!”) I have no idea why. Maybe it’s just my area. Anyway, that means you’ve got anywhere between 6 and 9 OxyContin scripts to fill. These people often choose to wait. Filling 9 prescriptions for CIIs really gums up the works. Most retail pharmacies keep their CIIs in a safe, and only a pharmacist has access to them for theft reasons. This means that the pharmacist is tied up for about 15-20 minutes doing nothing but working on these prescriptions. That’s a royal pain in the ass for everyone else. Those of you familiar with retail pharmacy understand that ours is an interrupt-driven business. You just don’t have time to concentrate exclusively on one task for 15 or 20 minutes to the exlusion of all else. The rest of the place falls apart because the pharmacist is the bottleneck through which all prescriptions must pass.

It’s easier if there are two pharmacists on, because one can pick up the slack, but at most smaller retail pharmacies, there is no pharmacist overlap.

Anyway, as I said, my attitudes have changed. While I don’t think it’s often necessary for these people who wait for their Oxy scripts to do so, I do think retail pharmacies should re-think the “mandatory” 24 hour wait period so that (ostensibly) we can order OxyContin for the next day.

Random aside: Ordering OxyContin for the next day is complete and utter BS anyway, as you pharmacists will know. It takes at least two days for the requisite 222 form to make it to the supplier. In fact, there’s just one pharmacist per pharmacy allowed to sign off on a CII order, and s/he doesn’t work 7 days a week, usually. So next-day ordering is out most of the time. The idea is that this policy will trick people into thinking that your retail store doesn’t actually have any OxyContin on the premises for safety reasons.

Back on topic: people who are on maintenance doses of OxyContin don’t usually need to wait. In stores where there’s a 24-hour wait policy, these people happily drop off their prescriptions and pick them up the next day.

Last night we had a person who had been in a serious accident involving a tractor trailer get released from the hospital. She had 3 prescriptions, one of which was for OxyContin. I had to turn her away — which made me mad because we had it in stock, and I sent her up the street to my home store where we don’t have any waiting rules — for what amounted to no reason. I guess this “rule” is in place for “safety” reasons. Though any criminal is going to know — not guess — that this rule is complete BS, which isn’t going to prevent him from holding you up in the first place.

If you’re at one of these 24-hour wait stores, are you really going to try to convince some dude sticking a .44 magnum in your face that you really don’t have any OxyContin in the safe? Somehow I doubt it. It’s just not worth the risk.

So we’ve created a rule that merely offers the illusion of protection. It keeps the honest opioid users honest, won’t deter those bent on breaking the law, and prevents those who may legitimately need a prescription for OxyContin today (first-time fillers) from getting their medication.

What a wonderful, pointless system we’ve created. I think it would be more effective if we simply advertised the fact that we keep less than 100 tablets of OxyContin in the store at all times. That, at least, sounds somewhat believable.

While this post was more introspective and rant-ish, I have lots more to say about the clinical aspects of pain management in the near future, especially about the castigation of opioid users by pharmacy staff, and the backwards attitudes of (usually older) pharmacists when it comes to pain management.

[tags]Medicine, pharmacy, OxyContin[/tags]

So it looks like at the end of next week, we’re going to run out of generic Plavix. I’ve not followed the business drama of Big Pharma in a little while because I find it dull, so I have no commentary on the outcome of the lawsuit, which I presume has been settled in S-A and BMS’s favor. Apotex had a good run while it lasted. I mentioned in September that we were warned that this might happen.

In any event, it looks like it’s for real. As far as I know, this is the only time in recent history where a generic has been withdrawn. I think I recall similar things happening for Lanoxin (digoxin) and Synthroid (levothyroxine), but generics for those drugs were withdrawn because of problems with bioequivalence rather than as a result of litigation.

It’s going to suck explaining the reasons why clopidogrel is temporarily going the way of the Dodo. People don’t take too kindly to the idea of their copayments doubling (or more). I’m thinking I should write a little handout for people explaining what happened so we don’t have to have the same conversation 500 times. After telling something a dozen or so times, you’ve heard all the wisecracks and complaints that such a topic engenders, and it just gets redundant and tiresome.

I also think the idea of jerking patients/consumers around like this is ethically wrong, patents and the justice system be damned. But then morality is entirely dependent on one’s point of view, now isn’t it?

[tags]Medicine, pharmacy, big pharma, plavix, clopidogrel, ethics[/tags]