The Problem with Recognizing Problems as Problems

Pharmacard:  A Prescription Drug Monitoring System Designed to Record Drug Histories and Reduce the Incidence of “Drug Misadventuring.”
 
As a medical student in 1990 I saw a 79 year old woman in the emergency room with intractable nausea and vomiting.   Earlier that week she had seen her primary care physician for nausea and a mild cough.   Diagnosed with bronchitis,  she was given a prescription for erythromycin.  Her husband brought in her medications including digoxin which can cause nausea
when blood levels are too high.  A  markedly high level came back on the blood draw indicating  digitalis toxicity.  I spoke to her primary care physician who was unaware of her digoxin prescription; completely clueless that she was prescribed the foxglove plant extract by a cardiologist for an irregular heart beat.images-22
Digitalis was first described by William Withering in 1785 for heart conditions and this is considered the beginning of modern therapeutics.  Sometime after erythromycin became available in 1952 it was discovered that taking the two drugs together increased digoxin levels. This simplest  type of drug interaction is called interference and occurs when one drug either accelerates of slows down the metabolism or excretion of the other.
Based on the progression of symptoms her husband reported and the elevated levels on admission this woman undoubtedly had elevated digitalis levels when she was seen by her doctor earlier in the week.   Unaware of the digitalis he inadvertently worsened her condition by giving her a medication that elevated her levels even further. She was lucky.
introduction-to-adverse-drug-reactions-14-638The Boston Collaborative Drug Surveillance Program found digoxin to be the second most commonly implicated drug in causing death in hospitalized patients and the most commonly implicated drug implicated in hospital admissions (N Engl J Med 291:824–828, 1974).
Digitalis toxicity in those who die outside of the hospital often goes unrecognized as most are elderly and assumed to have died from age related causes.
Seeing several more cases of drug related problems caused by ignorance of current medications and lack of communication prompted an  interest in drug misadventures.  I also became interested in developing a computerized up to date and accurate record accessible by all health care providers in real time , a closed loop system of “portable” information easily transferred among all health care providers be they primary doctors, pharmacists or emergency room personnel.
Research pharmacologist Dr. Edward Gallaher and I brainstormed over ideas and eventually came up with a computer program using  WORM (write-once-read-many) optical technology used in compact disc systems. much like a CD-R but without the spinning disc.  The credit-card sized disk could store up to two megabytes of data on an optical layer that could be written once and never changed. An optical card-reader interfaced with any IBM compatible PC.   The plan was to place card readers at pharmacies, medical offices and emergency rooms.  We called it Pharmacard.
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Pharmacard System Developed. ASTI Connections. Vol 4. Eugene, OR: Advanced Science and Technology Institute; 1992.

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Although computerized medical records existed in 1992 they were predominantly stand alone with many just replicating the paper record without word search capability.  Moreover these programs did not communicate with one another so no information portability existed between the entities involved.  Communication of information from pharmacy to doctors to emergency room was not an option.  The system was fragmented and the search for information long.
But drug mishaps were a real problem.  As with digoxin they could be fatal.  Multiple reports of drug induced morbidity and mortality were found in literature searches.  An obvious problem existed. . Many were drug interactions such as that with digitalis and erythromycin.  From my viewpoint the need for addressing the problems caused by inadequate and and incomplete records was not only self-evident but a priority.   Solutions however were few.  “Brown-bag” sessions in which patients bring in a paper bag containing all of their meds were held periodically.  Little booklets titled “patient medication records” were given to patients to update and record their new and current prescriptions.
PHARMACARD4In addition to an up to date medication list we decided to put in the bare but essential elements of the medical record that would be needed in an emergency; these consisted of demographics, emergency contacts, a basic problem list, allergies and a baseline EKG.
An available baseline EKG was decided based on its presence making it much easier to detect a problem by looking for differences.  A baseline EKG would conceivably facilitate the timing and accuracy of diagnosis.  In addition it would save money because without a comparison the default is admission.
We then applied for multiple research grants for funding to do a pilot study.  All were rejected and contained comments suggesting we pitch our wares to the computer people not the medical people-this is computer science not medical science.
We received very little interest at an AMA poster presentation in Washington D.C.  Few people would even read the poster with most taking a quick glance and redirecting straight ahead as if they were avoiding a street-corner pollster.   Those who did read it were either non-plussed, perplexed or cynical.
A research psychopharmacologist M.D.,PhD from France  asked permission to give me some advice.   He then told me it would not work.   He said the idea was great, it would work as intended and probably help prevent drug related problems.  But that did not matter because no one
gets it yet.”
   Aside from a handful of people intimately involved in the research most everyone else finds this useless as do most people at the  conference.  This means nothing to them.
PHARMACARD5 They don’t see the problem and they don’t see a need for a solution. Many believe it is the patient’s responsibility to keep track of their medications and that any problem associated with not providing their medication list up to date were self-inflicted.”  He said it will be a different story in five or ten years when the problem is acknowledged and accepted by the rank and file.
In 1999 the Institute of Medicine published To Err is Human: Building a Safer Health Care System placing  patient safety high on the nation’s health care agenda.  Medical errors, adverse drug reactions and interactions were deemed a big problem. Identifying ways to keep track of medications became a priority and multiple business ventures popped up and got their hats in the ring.    Suddenly everyone not only recognized the problem but imparted the sense they knew it all along.  Seven years had gone by and our project had then fallen by the wayside. In addition our optical platform was obsolete.
As with firefighter arson this illustrates the most crucial step in addressing a problem is admitting the problem exists.  Firefighter arson had been documented for over a century but not properly addressed.  The  extent of the problem was not publicly recognized until  a  Special Report: Firefighter Arson was done by the Department of Homeland Security, the United States Fire Administration and the National Fire Data Center in 2003.   The most crucial step was admitting the problem exists.  The second was defining the problem. The third was having zero tolerance for those engaged in the problem.  States that have taken this approach have found a marked reduction in firefighter arson.
PHARMACARD1The  problem of not recognizing  problems as problems can also be applied to individuals;  Bill Cosby comes to mind.  So too does FSPHP self-appointed drug-testing expert Dr. Gregory Skipper whose irresponsible introduction of junk-science drug testing into the marketplace through a loophole  has undoubtedly caused many more deaths than Dr. Harold Shipman who killed more than 250 patients in the U.K. by injecting them with morphine.
Skipper’s introduction of junk science drug and alcohol testing and use of cutoff points he pulls out of a hat and then moves upward as the problems are exposed is shameful.     The fact that he unleashed this on other doctors knowing full well what would happen in a zero tolerance program needs to be revealed.
My survey is revealing many suicides as a direct result of these tests, including those of medical students and residents.  And most of those who have died were not  even remotely addicts or alcoholics.  They were reported anonymously,  given one of these tests and asked to be evaluated at a “PHP-approved” assessment center  where a diagnosis was confirmed followed by  3-4 months of inpatient treatment.   I am finding out most of the doctors referred to PHPs do not have any problems but the PHPs and their affiliates are giving false diagnoses, false drug testing and using threats to control them and there is little they can do about it.    Skipper’s complete lack of empathy for his victims as he continues to put  coins in his purse is abhorrent.       Meanwhile the death  count continues to rise.Slide39Screen Shot 2015-03-12 at 11.17.53 PM

Junk Science and the Need for Regulatory Oversight of Forensic Laboratory Developed Tests

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Laboratory Developed Tests

Questions about the accuracy and marketing of Laboratory Developed Tests (LDTs) have led to the current debate whether the U.S. Food and Drug Administration (FDA) should regulate a subset of diagnostic tests currently exempted from oversight. Designed to bring clinical tests to market that the costly FDA process would otherwise preclude, such as those for rare diseases, the LDT pathway bypasses Federal regulation and accountability.  Questions about the validity of these tests have raised concerns over patient safety and a call for oversight.  Among those asking for regulation are Massachusetts Senators Edward J. Markey and Elizabeth Warren.

Opponents of regulation argue the LDT  pathway enables new and pioneering tests to be developed quickly and improve patient care.  A recent viewpoint piece published in JAMA opposing regulation noted such advances have occurred “in large part because of the nimbleness of relatively small clinical and academic laboratories that can quickly respond to new medical findings and patient needs by rapidly and safely developing and improving laboratory-developed tests.”

But the LDT pathway does not require proof of test validity, that the test is actually testing for what it claims to be testing, and with no FDA oversight a lab can claim any validity it wants in marketing the test.  There is no accountability.    Proponents of  regulation argue that this lack of oversight is a direct threat to patient safety and, as an opposing viewpoint piece in JAMA notes, a “patient’s life or death could hinge on whether a single, unregulated diagnostic test result is meaningful.”

The debate has focused on the reliability and validity of a number of clinical tests currently marketed with unverified claims of accuracy such as those used for prenatal screening and Lyme disease.  Notably absent from the discussions are the vast number of  Laboratory Developed Tests tests being used for “forensic” drug and alcohol testing with the current FDA draft guidance stating simply:

  • At this time, FDA will continue to defer oversight of the use of these tests in the forensics (law enforcement) setting to the existing system of legal controls, such as the rules of evidence in judicial proceedings and other protections afforded through the judicial process.”


The Birth of EtG:  The Introduction and Marketing of Laboratory Developed Tests for “Forensic” Drug Testing  Via a Lucrative Loophole

Numerous “forensic” tests of unknown validity using urine, blood, hair, fingernails breath and saliva have been developed and brought to market as LDTs since the first one was introduced in 2003 when ASAM physician Dr. Gregory Skipper,  then Medical Director of the Alabama Physicians Health Program,  “convinced the initial lab in the USA, NMS near Philadelphia to start performing EtG testing.”1   With essentially no evidence base Skipper then claimed the alcohol biomarker “appeared to be 100 percent specific” in detecting covert use of alcohol for several days after ingestion based on a study he coauthored that involved a mere 35 forensic psychiatric inpatients in Germany, all male2  

Screen Shot 2014-02-24 at 10.08.19 PMUsing an arbitrary cutoff level of 100 ug/L the EtG was marketed as a valid and reliable test and blindly tested on those being monitored by programs not beholden to the strict protocol and procedure dictated by the Mandatory Guidelines for Federal Workplace Drug Testing that most Employee Assistance Programs (EAPs) adopted.  In other words, the test was used on those who possessed little power or had their power removed.

The test was  subsequently found to be so sensitive that it could measure incidental exposure to alcohol in foods, over the counter cold medications, mouthwash3,4, hand sanitizer gel5, and nonalcoholic wine.6 Sauerkraut and bananas have even been shown to cause positive levels.7

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Shortly after the EtG debuted, complaints began to accumulate from individuals testing positive who adamantly proclaimed they did not drink.  Steadfast in their trust of expert opinion and the claimed accuracy of  EtG, the complaints of the accused were largely disregarded by those doing the monitoring.   People lost their licenses, jobs, careers, and reputations. Others lost their freedom or had their children taken away. It is unknown how many died by suicide.

There have been multiple  lawsuits filed since the introduction of the EtG including a class-action suit, but these were inevitably met with a well-funded and deep legal defense and their “experts.” The labs have taken a  “stand your ground” position yielding either dismissals or in favor of the defense.   As a new to the market  lab with no prior evidence-based research in forensic testing prior to its implementation and use for forensic testing, the proponents of EtG testing had no meaningful opposition in terms of a scientific body of facts and evidence and no credible voice to present it.  With the only “experts”  in EtG validity being those  who introduced and promoted its use there were no counter-forces.  Those suffering the consequences of a false-positive test had no recourse.  But as the toll of mayhem increased  it eventually reached a tipping-point where others began to take notice.

Page from the Talbott Recovery Center  list of products containing alcohol that doctors are required to avoid due to interference with EtG testing

Page from the Talbott Recovery Center list of products containing alcohol that doctors are required to avoid due to interference with EtG testing

In 2006 the Wall Street Journal reported the problems with the EtG to the general public,8 and SAMHSA issued an advisory stating that “legal or disciplinary action based solely on a positive EtG…. is inappropriate and scientifically unsupportable at this time. These tests should currently be considered as potential valuable clinical tools, but their use in forensic settings is premature.”9

Since that time Skipper has served as expert witness in close to 46 administrative hearings 22 criminal  14 custody and 1 Federal class action suit.

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But this did not stop the Federation of State Physician Health Programs  from using the EtG on physicians being monitored. Instead they instructed doctors to avoid anything potentially containing alcohol including hand sanitizer which a 2011 study found could result in EtG concentrations of almost 2000 ug/L. 10 To continue to justify the use of EtG they added other LDTs as confirmation tests of LDTs such as EtS and PEth– Junk Science to confirm  junk science. Nonsensical smoke-and-mirrors antithetical to science and evidence-based medicine.

Since the birth of the EtG a variety of tests have been introduced and marketed as LDTs utilizing nails, blood, hair, breath and urine—all with unknown validity but marketed without constraint.  No regulation, oversight or accountability exists.

The newest gadget they are using on doctors is the Cellular Digital Photo Breathalyze which he is promoting in the same manner as the EtG after a study he co-authored with Robert Dupont on just 12 subjects.


Expanding Laboratory Developed Tests to Test Everyone:   The ASAM White Paper on Drug-Testing and the  “New Paradigm” 

Although the current use of these tests is limited to the criminal justice system and professional monitoring programs this may soon change as the American Society of Addiction Medicine is proposing a “new paradigm” of zero-tolerance random widespread drug and alcohol testing. This is outlined  in the ASAM White Paper on Drug Testing and described by Robert Dupont in his keynote speech  before the Drug and Alcohol Testing Industry Association (DATIA) annual conference in 2012.

The ASAM White paper states drug testing is “vastly underutilized” throughout healthcare and describes the use of drug testing “within the practice of medicine and, beyond that, broadly within American Society.”

As the consequences of a single unregulated “forensic” test result can be grave, far-reaching and even permanent it is critical that these tests be included in the debate on regulation of LDTs.

Evidence based medicine is not restricted to randomized trials and meta-analyses. It involves tracking down the best external evidence with which to answer our clinical questions.11

Expert opinion is the lowest level of evidence available in the EBM paradigm.12,13   Fortunately, the scientific method and Cochrane type critical analysis of the available evidence is  a tool to help people progress toward the truth despite their susceptibilities to unconscious confirmatory bias or conscious confirmatory distortion .14  Unfortunately, no one has used these tools address they panoply of tests of unknown validity that have already entered the market ; poised to be used on virtually everyone.

  1. Skipper G. Exploring the Reliability, Frequency, and Methods of Drug Testing: What is Enough to Ensure Compliance?:   Alcohol Markers and Devices. 2013; http://www.fsphp.org/Skipper, Exploring the Reliability Frequency and Methods 2 Presentation.pdf.
  2. Wurst FM, Vogel R, Jachau K, et al. Ethyl glucuronide discloses recent covert alcohol use not detected by standard testing in forensic psychiatric inpatients. Alcohol Clin Exp Res. Mar 2003;27(3):471-476.
  3. Costantino A, Digregorio EJ, Korn W, Spayd S, Rieders F. The effect of the use of mouthwash on ethylglucuronide concentrations in urine. Journal of analytical toxicology. Nov-Dec 2006;30(9):659-662.
  4. Reisfield GM, Goldberger BA, Pesce AJ, et al. Ethyl glucuronide, ethyl sulfate, and ethanol in urine after intensive exposure to high ethanol content mouthwash. Journal of analytical toxicology. Jun 2011;35(5):264-268.
  5. Rosano TG, Lin J. Ethyl glucuronide excretion in humans following oral administration of and dermal exposure to ethanol. Journal of analytical toxicology. Oct 2008;32(8):594-600.
  6. Hoiseth G, Yttredal B, Karinen R, Gjerde H, Christophersen A. Levels of ethyl glucuronide and ethyl sulfate in oral fluid, blood, and urine after use of mouthwash and ingestion of nonalcoholic wine. J Anal Toxicol. Mar 2010;34(2):84-88.
  7. Musshoff F, Albermann E, Madea B. Ethyl glucuronide and ethyl sulfate in urine after consumption of various beverages and foods–misleading results? Int J Legal Med. Nov 2010;124(6):623-630.
  8. Helliker K. A test for alcohol–and its flaws. The Wall Street Journal2006.
  9. Administration SAaMHS. The role of biomarkers in the treatment of alcohol use disorders. In: Advisory SAT, ed2006:1-7.
  10. Reisfield GM, Goldberger BA, Crews BO, et al. Ethyl glucuronide, ethyl sulfate, and ethanol in urine after sustained exposure to an ethanol-based hand sanitizer. Journal of analytical toxicology. Mar 2011;35(2):85-91.
  11. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ. Jan 13 1996;312(7023):71-72.
  12. Shaneyfelt TM, Centor RM. Reassessment of clinical practice guidelines: go gently into that good night. JAMA. Feb 25 2009;301(8):868-869.
  13. Straus SE, Green ML, Bell DS, et al. Evaluating the teaching of evidence based medicine: conceptual framework. BMJ. Oct 30 2004;329(7473):1029-1032.
  14. Haack S. Defending Science–Within Reason: Between Scientism and Cynicism. Amherst, N.Y.: Prometheus Books; 2003.

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