Just Say No to (Free) Drugs!

I recently signed a pledge at NoFreeLunch.org that I will no longer dispense sample drugs. It wasn't an easy decision as I have many uninsured patients that would benefit from free medicine. But I often see patients come in who are no longer taking a much needed medicine because they cannot afford it. They were first prescribed the medicine as a sample. Sample drugs are almost exclusively new drugs that are still on patent and therefore expensive. Patients may not know that there are often cheaper and/or generic options to these medicines.

One example of this that I see frequently is Advair, a medication used to control asthma symptoms. Asthma care is broken down into a series of steps. The first step is to treat mild intermittent symptoms with albuterol only. If you have moderate persistent symptoms, you advance to Step Two and are prescribed an inhaled steroid. Patients who still need more control of symptoms go to Step Three where a third drug, a long acting beta agonist (LABA), is added.

Advair is a combination of the inhaled steroid fluticasone and the LABA salmeterol so it is a Step 3 medicine. However, it is also a new medicine that is on patent so samples are given to providers. Patients with and without insurance are given this medicine as a sample and later, when they run out of medicine, lose their insurance, and/or change providers, they find that it can cost around $180 per month. So folks now have to decide between spending money they may not have or deciding not to treat their or their child's asthma.

My experience has been that many of these people are probably at Step Two in the asthma treatment guideline and only need an inhaled steroid. These are also somewhat expensive, but at $75 per month, significantly cheaper than Advair.

There are times when the newer drug is the better drug but often these drugs are "me too" drugs.

Most of my patients understand why I am doing this. For patients that do need expensive medications, there are patient assistance programs where the pharmaceutical companies will provide with free medications.

A bike pump nebulizer adapter (and how about a bike powered nebulizer?)

Problem: Providing nebulized asthma medications when there is no electricity available. MDI or HFA inhalers are definitely an option but some people need more medicine than these can provide.

Summary: John D. Klich has a patent on nebulizer bike pump adapter which filters the air through a device that fits between the pump and the nebulizer.

Two posted discussions both suggest and discourage the use of a bike pump to operate a nebulizer.

But the bike technology best suited for nebulizer function may be the bike itself, which could be used to power the nebulizer's own compressor. This would help circumvent the problem of oil and other foreign matter from the bike pump entering the nebulizer. I hope to work on this idea at some point. I'm sure it's been done already, but I haven't found any documentation on it yet.

Safety Net Antibiotic Prescriptions (SNAP)

This is a simple way to offer patients and parents the option of either treating an infection or waiting to see if the infection will resolve on its own.

A patient may be seen with an infection when it is too early to determine if it is a viral infection that will resolve on its own or develop into a bacterial infection that requires antibiotic treatment. A prescription for an antibiotic is written with the instructions to not fill it unless the infection persists or worsens.

This process often creates an opportunity discuss appropriate antibiotic use. Parents and patients like the option of treating without having to come in (and pay for) another visit.

References
Treatment of Otitis Media With Observation and a
Safety-Net Antibiotic Prescription. Pediatrics 2003; Siegel et al. 112 (3): 527.

An evidence based approach to reducing antibiotic use in children with acute otitis media: controlled before and after study. BMJ 1999;318:715-716 (13 March)