American College of Physicians: Internal Medicine — Doctors for Adults ®

Thursday, February 25, 2016

Of drugs and rectal pain

I had a patient who was a real pain in the ass. Wait. No. He was actually a really nice guy. He wasn't a pain in the ass, he had a real pain in the ass. Literally.

I was initially concerned about a pilonidal cyst, given the unfortunate fact that he was previously afflicted with this condition (which I consider to be incontrovertible proof of Satan). But, fortunately to him, his pain was literally “in the ass,” and that rules out the evil diagnosis, moving my thoughts to a condition called proctalgia fugax (which is a Latin person's way of saying: “butt pain that comes and goes”).

I realize this doesn't sound much like good news on my patient's part, but, as opposed to the lousy surgery necessary for treatment of a pilonidal cyst, an effective treatment for this is fairly simple (and surprising): nitroglycerin ointment applied to the rectum. Nitroglycerin, it turns out, relaxes smooth muscles and dilates blood vessels, both of which somehow can improve the distressing symptoms of this strange condition (as well as pain from other related proctological demonic attacks). I'm not sure who had the idea to first try this, or what their inspiration was. Perhaps they misheard the term Angina Pectoris as Angina Rectalis.

I did my usual search at (a website everyone should use as often as possible) to see where the drug is cheapest. It turns out that Kroger won the contest, but the price was $479. According to the literature, the appropriate strength of nitroglycerin for rectal use (cleverly called “Rectiv”) is 0.4%. This seemed a pretty high price for a medication which has long been generic, so I searched for generic nitroglycerin ointment (used for pain due to heart disease) and found it for $35 at Walmart. The only difference between the 2 that I can tell is that that preparation (called NitroBid) is 2%.

There are several possible explanations for this huge price discrepancy:
1. The dilution of nitroglycerin is a dangerous and expensive process, as it is quite explosive.
2. The cost of coming up with the name “Rectiv” by the marketing department was extremely high. It is far more clever than NitroBid, to be sure.
3. There is a secret ingredient in Rectiv that raises the cost. Perhaps they have to get anal secretions from unicorns.

While these seem reasonable, I suspect a different reason: the company which makes Rectiv, Allergan (which also makes Botox), has cornered the market on 0.4% nitroglycerin, and so can charge exorbitant amounts for a medication with no other discernible reason to be expensive (it certainly took little R & D cost, and doesn't regularly get advertised during the evening news).

I'm sure my anally distressed patient would have paid $1,000 for relief, but this wasn't my first ride at the proctalgia rodeo (which has recently been nominated as an Olympic event), and I knew he could use the more potent cheaper version with the boring name (and has nothing to do with unicorns) without problems. He did, and he got immediate relief. Now, like Androcles, I have someone who owes me a great debt for my kindness and wisdom.

This incident is just 1 example of the terrible gaming that routinely occurs with the prices of drugs. There are plenty of others. Why, for example, do brand name medications continue having such high prices after the medication has gone generic (often 10-20times higher)? The reason is, if the generic no longer available, they get a cash windfall.

For example, Carafate (a medication for stomach ulcers) went generic a many years ago and so you can get 120 tablets of the generic for $33.

But recently the suspension form (which I've used for mouth ulcers and esophageal problems) became unavailable as a generic and so now is only available as the brand name drug. The result is that the once inexpensive suspension now comes with a premium price tag of more than $150. Note that this price is for 420 ml, which is the equivalent of 42 tablets, so the mark-up is more than 10-fold.

Pharmacies join in on the price gaming by pricing 1 drug much lower than competitors, while going way higher than the market on others. Generic Topamax (a drug used for seizures and migraine prevention), for example, costs $11 at Publix and $68 at Rite Aid.

So should you go to Publix for all of your medications? Unfortunately, if you get your Topamax with a Lipitor chaser, the generic cholesterol drug costs more than $90 at Publix, where it's much cheaper at other pharmacies.

All pharmacies do this, in my experience, so you can't count on any 1 pharmacy to have cheap prices. To get inexpensive medications, you must shop around and be willing to go to multiple pharmacies for multiple medications. It's a game they play that usually works, as most folks either don't know about this, or they just don't want to bother going to multiple pharmacies.

These games come at a great cost, dramatically raising the cost of care for millions of Americans. It is legal. It is done all the time. And it is gouging. And this gouging isn't unique to the pharmaceutical industry, as labs and radiology providers have their tricks to make enormous profit margins on the services they provide.

Fortunately for this my patient, I was not only able to reunite him with the joys of sitting, but I was able, with a little research, to find him his proctological savior at a low cost. Unfortunately, most patients don't have docs who are economically incentivized to save them money, and most people don't realize all of the games played by pharmaceutical companies and pharmacies to routinely perform wallet biopsies, nor do they know how to find the cheapest prices for their medications.

I don't know what can be done about this kind of thing aside from increasing awareness. I'm not real confident in any government solution. People just need to be smarter shoppers when it comes to their care. It's just a shame that people who are dealing with health problems (even if it is just trouble sitting) have to outsmart the gaming done by those supposedly trying to help them.

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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