Lying naked on the bed

A few weeks ago, my husband went in to have a vasectomy.  I am proud of him-- for being brave (only about 10% of US men get vasectomies); for announcing his reason for missing work to his all-male engineering team (imagine the uncomfortable squirms when he brought up the topic at their weekly debrief); and for taking ultimate responsibility for our family's family planning.

And so ends a two-decades long birth control chapter in this woman's life. Woohoo!

In his defense, he did way less milking of the situation than I had anticipated. I had envisioned him reclining dramatically on the couch with an ice pack on his crotch avoiding normal household duties and requesting room service and an endless supply of cereal and Game of Thrones episodes.  Instead, he came home with a smile on his face, exclaimed, "It wasn't really much more pain than a shot of Novocaine at the dentist", and went about helping out with the day-to-day madness that is having three young children. For the next few days, he took it a little easy, occasionally winced in discomfort, and his only recurring complaint was the itchiness.

All in all, it was a success. And a relief-- for both of us.

All said, I cannot help but ruminate on the one remark he made that I find particularly fascinating and somehow shocking: the totally new and "strange feeling of lying naked in the room waiting for the procedure to begin." He repeated a few times, "I've never been in that position. . . just lying there naked."

Lying naked on the bed.
Waiting for a procedure to begin.
Lying naked on the bed.
Wondering.
Lying naked on the bed.
Scared.
Lying naked on the bed.
Vulnerable.
Lying naked on the bed.
Cold.

How long have I been lying naked on a bed waiting for someone to come in?
Cold.
Vulnerable.
Scared.

Twenty-two years.

Since age 18, upon deciding I was going to have sex for the first time, and I dutifully made an appointment for my very first pack of birth control pills and my very my first pap smear. We don't do this, by the way, anymore. We don't pap 18-year-olds. Pap smears in the US start now at age 21, and in some countries in Europe cervical cancer screening doesn't start until age 30. We also don't tie birth control to the requirement you get a pap smear. Turns out that was a dumb idea. In fact, the only thing that birth control and pap smears have in common is that they kind of sort of both involve your private parts.

Again a year later, when I had another pap.

And again, when I had my first vaginal infection.

And again at age 21, when the Peace Corps required I have a rectal exam in addition to a bimanual  exam to be "cleared for service" (WTF?!?). The bimanual exam-- by the way-- is the "two hand" exam-- you know the one-- one hand inside your vagina, one hand outside on your belly, the one that doesn't feel very good and yet somehow seems important. It turns out that physicians don't really know what they are looking for when they do a screening bimanual exam-- our ability to detect cancers or other badness with our two hands is about the same as flipping a coin. In one study of women with known ovarian tumors, physicians were only able to "find" the tumor by examining with their hands 50% of the time. So this type of exam should only be done with forethought-- when your provider suspects you may have a uterine infection or some lesion that could be helped by examining you. 

And again, when I finished my Peace Corps service.
And again, and again and again.
When I got pregnant. And delivered. And got pregnant. And miscarried. And couldn't get pregnant. And had a test. And then another. And then another.
When I had surgery. And then intrauterine insemination. And then IVF.
When I got pregnant again. And delivered.
When the doctor yelled at me for not being undressed and "ready for him" at my postpartum visit with my fussy 6 week old baby who didn't want to be put down.

And again when I was pregnant with my third child and went in for my intake appointment. I was asked to undress completely, as the physician needed to examine my breasts and do a bimanual exam. The funny thing is-- I let her do it-- despite the fact that I know better. That there was no particular reason she should do such an exam at all. Her time (and mine) would have been better spent probing the safety of my relationship, my fears about my advanced maternal age, or heck, just getting to know me.

And yet, there I was, lying naked on the table.

This post is for you, women. For all of you who have laid naked on the table, wrapped in a generic cloth gown that gapes open no matter how you tie it-- or worse, a paper gown that literally rips into shreds as you attempt to preserve your modesty. And then wait for 3 or 5 or 25 minutes for that fateful knock on the door.  To have your very most private parts examined.

Being naked is scary. It's vulnerable. It's raw.  And, unfortunately, it's part of being a woman-- a woman who has sex, a woman whose parts are tucked up inside of her, a woman whose body is both capable and vulnerable-- to being pregnant, to contract disease, to have all the crazy shit that can happen to our amazing parts (everything from vaginal discharge to pelvic discomfort to herpes to a saggy post menopausal bladder).

This is also a post for you, doctors. The scariest part of being a doctor is being vulnerable to forgetting-- forgetting that every single body we have the privilege to see and touch and examine is that one person's only body. It is their most precious and private part. And they are entrusting me and you to acknowledge the power, recognize the specialness, and do what we need to do to care for them with utmost love and respect.

This is also a post for you, men, who may have less opportunity to lie naked on a table at the doctor's office. But your time, too, will come. You will get a hernia or a weird lump in your testicle, or maybe you will be one of the 10% of US men to sign yourself up for a vasectomy.  (It's not so bad, after all). In the meantime, please do us all a favor, and treat every body you come across (particularly those who are lying naked in front of you) with love and respect.

And some day, when you are scared or sick-- may your body be treated the same.

Maggie will not die without her Xanax

I am often a little behind on television. This is due, in large part, to the fact that we don't actually own a television. I share this to clarify why my husband and I are currently watching the very beginning of Season 1 of HBO's acclaimed drama The Newsroom, while the rest of you are watching the end of Season 2.

Back here in Season 1, during a very sweet scene, my attention was drawn to an awkward piece of dialogue--it first caught my ear because the writing was oddly stilted and then held me because the content was downright infuriating.

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It went something like this:
The smart young protagonist runs outside to the back patio in the midst of a full-blown panic attack. Her unrequited love bends down to comfort her. In between a series of witty and tender words in which he skillfully calms her anxiety, he manages to say, "Maggie, where's your Xanax?" She tells him she forgot it at home, and he responds with a furrowed brow, "You must always have your Xanax with you for moments like this. You need it. Don't ever leave home without your Xanax."

Uh oh. Red flag. Big red flag. GIANT red flag.

First, Xanax (and its generic equal alprazolam) is one of the most addictive and, frankly, troublesome medicines I prescribe. Sure it has its place, but it is not the equivalent-- as implied in this scene--to an epinephrine pen, which would be essential in the case of an allergic reaction. Maggie might very well feel like she may die, she might even call 9-1-1, but a panic attack, though frightening, is not actually life-threatening. I assure you, Maggie will not die without her Xanax.

Second, Xanax is a brand name drug that is actually now available in generic form. There is no reason for the screenwriters to use the brand name unless they are advertising the brand.  Hmmm. . .is drug-brand name-dropping on TV legal? Should it be? Is it ethical?

Third, are you agitated? Because I am. I think I need a Xanax.

Xanax for president?
Xanax (pronounced ZAN-ax) is the number one prescribed psychiatric medication in our country and has been in the number one position since 1988. In 2012, there were more than 47 million Xanax prescriptions written in the US. Forty-seven million! Most experts believe it to be the most successful anti-anxiety medicine on the market because of aggressive marketing by its maker, Upjohn. Upjohn has convinced patients and physicians alike that Xanax is the most effective treatment for panic attacks and panic disorder. That's why Maggie is taking it.

Xanax is a member of the benzodiazepine family (affectionately called "benzos" in the medical world). The benzos are a class of medicines used to treat anxiety that also includes lorazepam (aka Ativan, ranked #4 on the list of top psychiatric medications), diazepam (aka Valium, #9 on the list) and clonazepam (aka Klonipin). All of the benzos work on the brain's GABA receptors, which essentially are our "downer" or "quieting" neurons. Xanax activates our "downer" neurons, thereby turning down and quieting our anxious selves. Got that?

Even though you and I are supposed to believe Xanax is better than the other benzos for panic, a 2011 review of studies comparing Xanax to the other benzodiazepines found that Xanax was not, in fact, superior to any of the other benzos for panic disorder (see this link, if you are interested in the actual analysis). Xanax has also been shown to be notably inferior to two better treatment choices for panic: Cognitive Behavioral Therapy (CBT) and antidepressants (specifically, selective serotonin reuptake inhibitors, like Prozac and Zoloft, as well as tricyclic antidepressants, like Elavil).

CBT is a specific type of therapy that has been shown to be particularly effective in panic disorder--73% of patients are panic free after three to four months of CBT (I'll write about CBT in a future post). Studies of anti-depressants also show them to be effective (61% of patients are panic-attack free after 12 weeks of one of these medications). Okay, so admittedly neither of these treatment choices are foolproof (I, too, would like to see the results closer to 100%), but they do help a lot of people.

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The reason people like Xanax for panic is similar to the reason my husband likes his albuterol inhaler for his asthma: it works fast. Unfortunately, however, both Xanax and albuterol do little, if anything to prevent the next attacks. And Xanax does worse than doing nothing; in fact, Xanax leads to a triple whammy of benzo-badness: 1) It is addictive, 2) It causes rebound anxiety, and 3) It turns your brain into mush.
Sound enticing?

Just to be clear, my issue with Xanax is not specific to Xanax, it's just that Xanax is the incumbent benzodiazepine and has held that office for much longer than two presidential terms-- Xanax has been top dog since George Bush Senior was elected President.

Addiction
Okay, so there is a lot of tiptoeing around in the world of addiction medicine around semantics. Care is often taken to distinguish "dependence" from "addiction". "Dependence" is a term used to describe "physical dependence"-- that is, bodily adaptations that result in withdrawal when drugs are discontinued (e.g. If you stop drinking your two cups of coffee cold turkey, you'll probably get a really bad headache). "Addiction" is a term used to refer to "the loss of control over the intense urges to take the drug even at the expense of adverse consequences" (e.g. You lost your home and got divorced as a direct consequence of your gambling addiction).

Scientists all agree that Xanax leads to physical dependence. It changes the brain, at least during the time you take it, and perhaps forever. In fact, withdrawal  from any benzodiazepine can kill (unlike withdrawing from Prozac or morphine, both of which can make people miserable but won't actually kill them). Almost everyone who takes a daily or twice daily dose of Xanax develops dependence; not everyone gets addicted. There is a certain subset of people who can take Xanax on a regular basis without it having adverse consequences on their lives, but the risk of physical dependence leading to addiction is high.

Xanax is also a known drug of abuse. National rates of hospitalizations due to all benzodiazepines actually tripled between 1998 and 2008 (see national data). Benzodiazepines are often abused in combination with alcohol or other drugs (like opiates). In fact, benzos were recorded as contributing causes in 30% of prescription painkiller overdose deaths in 2011. Large numbers of high school students admit to having tried a benzodiazepine, most commonly Xanax. Some clinic systems have even stopped prescribing Xanax altogether because of drug-seeking behaviors (see story in NY Times from 2011).

Please remember that benzodiazepine withdrawal can be deadly. If you have been taking regular benzos for any length of time and you decide you want to stop taking them, you should work closely with your physician to do so. Don't stop them on a whim.

Rebound Anxiety and Rebound Insomnia
We have known since the benzodiazepines came on the market that they cause what we call "rebound anxiety" and "rebound insomnia". This basically means the more benzos you take, the more anxiety you have. Bummer. And not exactly what you were hoping for.

Brain Mush
Known effects of the benzodiazepines include sedation, decreased attention, and anterograde amnesia. In simpler terms, benzos make you sleepy (which is why they are used by anesthesiologists to put you  to sleep for surgery); they make you a little less "tuned in" (which is excellent for panic, not so excellent for driving your kiddos to school); and they make you lose your ability to create new memories during the time the medication is working (looking to forget what is just about to happen to you?).  Another bummer.

It's also pretty clear that some combination of those effects lead you to be a little less cognitively sharp. Brain mush is a very technical term for the dulling effects of benzodiazepine use; there is convincing evidence that long-term use of benzodiazepines causes people to score lower on neuropsychological tests. The longer you are on them, the worse you score (see here for study). Same is true in elderly people (here is that study).

Is there an appropriate time for benzos?

Yes, I think there is a time and a place for benzos, but they must be both prescribed and taken with care. You should work closely with your provider to discuss the risks and benefits and really take benzos only when absolutely needed. And, please, don't share them with your neighbors-- this is not a neighborly good deed.

Examples, in my opinion, of appropriate uses of benzos:

• I had a patient recently flying back East to her 50th high school reunion. She is terrified of flying and even more terrified of seeing her former classmates. I gave her a few tablets for the flight, both ways. I'm stingy, I think I gave her 6 pills.
• I have a patient with advanced dementia who gets super anxious before coming to any dentist or doctor's appointments. Her son gives her a baby dose of lorazepam before the visits, and we avert hours of drama for her and him.
• I had a patient recently assaulted at the transit center. He is having some flashbacks and panic when getting on the bus in the evening to go home. He is working closely with a therapist and considering starting an antidepressant, but he really needs to keep riding the bus to work in spite of his current symptoms. This is a temporary and urgent fix.

What about Maggie?
Well, let's be clear here. I am not Maggie's doctor. I don't have a relationship with her, nor do I know her well enough to know why she is taking Xanax and whether or not it is an appropriate choice. I have not probed her psychiatric history, I don't know her substance abuse history, and I don't know what other prescription or recreational drugs she uses. I can make an educated guess, from this scene, that she experiences panic attacks. In this context, it's hard for me to make a therapeutic decision for her.

I would say, if she has simple panic attacks that are random and infrequent, then yes, Xanax (or any of its equivalents) is probably an okay medicine for her. For very occasional use and only in combination with an adequate trial of cognitive behavioral therapy. I would also like to know what she is doing for her own self care (she has a super stressful job) and how she intends to manage stress going forward. I'd be worried she may have some underlying anxiety disorder that isn't be addressed. If she gets panic attacks any more often than infrequently, she should probably consider a trial of an anti-depressant.

I'd also say that Maggie shouldn't be advertising her Xanax to you. Decisions about your diagnosis and which medications are appropriate for you should be a matter of discussion with your primary care provider, not some pharmaceutical advertisement. Or some cute smart girl you see on TV.

Now let's talk about product placement (aka 'name dropping') of pharmaceuticals
I am not that media savvy. I'm forever missing references to pop culture, and I can never confirm or deny a particular star's presence in a film. So maybe it is not shocking that I had no idea that pharmaceutical product placement was "a thing" until I watched the Xanax scene. When I started researching material for this post, I found that others have been talking about the topic for years; the earliest policy research dates back to 2005. Have you ever noticed a drug-name being dropped on your favorite show?

I could take this opportunity to launch into a diatribe about direct-to-consumer advertising to patients (Cut to commercial: music plays, previously incontinent grandma cured by the magic medicine runs through an open field and hoists her grandchild above her head, huge smile on both faces, music fades.). But direct-to-consumer advertising is a big topic for another day. For today, I want to consider specifically the issue of pharmaceutical product placement in TV and movies. Should it be allowed?

According to Nielson Media, product placement is defined as "any verbal or visual integration of a brand into a plot line". Examples of common products intentionally placed in the way of TV and movie cameras include Mercedes-Benz vehicles (the 2012 winner for making the most big screen appearances), Apple computers (a close #2), Budweiser beer, and the classic example of E.T.'s Reeses Pieces.

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Turns out one of the first pharmaceutical product placements was in 2005 by the pharmaceutical company, Organon, which placed posters for Nuvaring, a birth control method, in the background of episodes of Scrubs and King of Queens. Soon after, analysts started noting Zoloft (an antidepressant) and Lap-Band (a patented procedure for gastric bypass surgery) being dropped into certain daytime soap operas. Even though I love birth control, I want people to know about anti-depressants and gastric bypass surgery, this still seems wrong.

Marketers are banking on our emotional relationships to some fictional character in some fantasy world to subtly persuade us that the medication our favorite character is taking is what we need too. This doesn't seem like a good way to get educated. 

In contrast to the examples mentioned above, some viewers might assume that the inclusion of medication brand-names in screenwriting is unavoidable. Some might argue that using brand names captures "how doctor's speak" or literally "how patients talk about their medications." What do you think?  If a scene is going to realistically cover a health issue, must the writer specifically mention a medication by name? Does it make the dialogue more real? Does it lend credibility? Or is it merely advertising?

I can share with you that, as a physician who cares about the undo influence of pharmaceutical companies on my practice, I very consciously try not to use brand names when speaking with patients or other providers about medications. In fact, writing "Xanax" over and over for this story is killing me. I do firmly believe that the more I see, write, read, and say a name, the more likely I am to prescribe and use that drug (rather than generic or equivalents that may be less expensive and just as good). I also know that I am human, my patients are human, and marketing works on humans.

There is no way to confirm that the name dropping is actually funded by the pharmaceutical companies because transactions between private companies and the media outlets are not privy to public information. So we won't really know. But we can guess. And my guess is that the makers of Xanax paid for Maggie's scene.


The practice of pharmaceutical product placement is also questionable from a legal perspective. The FDA has strict guidelines about what information needs to be included in pharmaceutical advertising (that's why we always hear that raspy voice at the end of the TV commercial reminding us that, "in rare circumstances we could die or lose our fourth digit on our left foot by taking such-and-such medication"). But, does the FDA consider this advertising? As far as I can uncover, the FDA, FCC and FTC currently do not have specific guidelines to address the use of prescription drug references in fictional entertainment. This gap clearly leaves some space for abuse-- and puts us at risk for some serious manipulation.

After all, if the cute smart girl is taking Xanax, why wouldn't I want it too?
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Additional  references on benzodiazepines:
http://www.psychologytoday.com/blog/how-everyone-became-depressed/201306/benzo-hysteria
http://psychcentral.com/lib/top-25-psychiatric-medication-prescriptions-for-2011/00012586

Additional references on product placement
http://www.pharmalive.com/sites/default/files/blogs/attachments/product-placement.pdf
http://www.marketingpower.com/AboutAMA/Pages/AMA%20Publications/AMA%20Journals/Journal%20of%20Public%20Policy%20Marketing/TOCS/summary%20spring%2008/Pharmaceuticaljppmmay08.aspx
http://www.rxentertainmentinc.com/what-we-do/product-placement/