Near-Death Experiences Delivered to Your Home by Your Friends on the Internet
2004; Elsevier BV; Volume: 79; Issue: 8 Linguagem: Inglês
10.4065/79.8.979
ISSN1942-5546
Autores Tópico(s)Pain Management and Placebo Effect
ResumoWith the engines of modern industry and the medical community constantly promising or producing one miracle treatment after another, it is ironic that many of the greatest impediments to improved medical care and health, in both industrialized and developing nations, evolve around issues of access, education, distribution, compliance, and cost. At one extreme, those who have absolute financial or access obstruction to health care can expect to reap the downstream consequences of malnutrition, hypertension, diabetes, infections, and other conditions. At the more affluent end of the spectrum, competition for health care funds, inadequate education, and balancing the desire for timely access with the demands of busy schedules also hinder health care delivery. Traditional medicine, with a long history of paternalistic physician-patient relationships, is having some difficulty dealing with these issues. Physicians, who have long considered themselves at the hub of health care delivery and have viewed exhaustive demands for their input and long work hours as major challenges to improving patient outcomes, must increasingly consider whether they will indeed be the primary source of a patient's care and whether the treatments they have recommended will or will not be accepted and implemented as a result of financial, logistical, social, or cultural influences. This has resulted in a new focus of medical investigation: With the assumption that physicians are capable of providing access to and navigation through the best health care available to humankind, how can these same physicians and the systems in which they function perform more effectively to affect patient access, compliance, and (ultimately) outcomes. If it is true that, as Henry David Thoreau remarked, nature abhors a vacuum, it is also true that capitalism abhors a missed opportunity. In the absence of satisfactory physician-patient interactions, those in need of health care are increasingly seeking solutions from nontraditional sources. This change in practice is fueled in many instances by patients’ (ie, consumers’) desire to have better access, rapid response, and more control over their lives coupled with suppliers’ desire to generate profits. Although the serious consequences of this change will be addressed subsequently, one would be remiss in not acknowledging the irony and humor created by the new ways. It would be the rare reader who has not been amused and confused by the recent plethora of direct-to-consumer drug advertisements. I can envision a conversation, based on an amalgam of personal experiences, of people laughing at a social gathering in which it is remarked, “Did you see the latest ad for the new drug ‘Liveverlastium’? I'm not sure what it is supposed to do, but it causes headaches, nausea, and impotence, and I'm supposed to ask my physician about getting a prescription.” Physicians later see the results of direct-to-consumer and other modern forms of communication. Some years ago, focus-group research conducted by Mayo Clinic Proceedings in major US metropolitan areas asked physicians, “What motivates you to read an article in a medical journal?” The most common response (“the article is of general interest; anyone would want to read it”) and the third most common response (“direct relevance of the information to my practice”) were understandable. The second most common response was a surprise: “To protect myself from the reams of information patients bring from the Internet and other sources of supplier-to-consumer material.” Physicians further stated that—given the slick presentations on Internet sites—they had extreme difficulty distinguishing between material that was legitimate (and hopefully evidence-based) vs material that had no scientific basis. If highly trained physicians have this problem, how can the average patient sort through seemingly endless supplies of information, and promises of benefit, to obtain advice and solutions relevant to their conditions? The Internet is capable of not only providing advice of questionable value but also bringing patients into contact with the use and misuse of “treatments.”1Fung CH Woo HE Asch SM Controversies and legal issues of prescribing and dispensing medications using the Internet.Mayo Clin Proc. 2004; 79: 188-194Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar The implications of bypassing a traditional physician-patient relationship in these instances can be profound. Missing is the ability of the physician to apply evidence-based concepts to the care of a patient or—absent the direct availability of such evidence—to begin the investigation of a patient's condition based on intuition (ie, a part of the “art of medicine”) from years of medical practice. When patients take their care into their own hands, typically absent are knowledge of the interdependence of anatomical, physiologic, pharmacological, and other interactions and the ability to provide a trained observer to monitor progress. Disastrous or lesser consequences are more than a possibility; they are inevitable, as outlined in 3 articles in this issue of Mayo Clinic Proceedings.2Lineberry TW Bostwick JM Taking the physician out of “physician shopping”: a case series of clinical problems associated with Internet purchases of medication.Mayo Clin Proc. 2004; 79: 1031-1034Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar, 3Dalal AK Harding JD Verdino RJ Acquired long QT syndrome and monomorphic ventricular tachycardia after alternative treatment with cesium chloride for brain cancer.Mayo Clin Proc. 2004; 79: 1065-1069Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar, 4Nasir JM Durning SJ Ferguson M Barold HS Haigney MC Exercise-induced syncope associated with QT prolongation and ephedra-free Xenadrine.Mayo Clin Proc. 2004; 79: 1059-1062Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar Lineberry and Bostwick2Lineberry TW Bostwick JM Taking the physician out of “physician shopping”: a case series of clinical problems associated with Internet purchases of medication.Mayo Clin Proc. 2004; 79: 1031-1034Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar describe 4 patients who used the Internet to obtain psychoactive “prescription” medications. A 35-year-old man (case 1) obtained large doses of amitriptyline, which he used subsequently in a suicide attempt. The Internet site used by this patient provided consultation by a “cyber physician” who helped identify a list of antidepressant medications but otherwise had no input into the patient's selection or procurement of amitriptyline. Three other patients—a 37-year-old man (case 2), a 42-year-old man (case 3), and a 29-year-old woman (case 4) received “opiates,” tramadol, and hydrocodone, respectively, from the Internet without a prescription or appropriate physician input. All 4 patients, not surprisingly, experienced life-threatening consequences, including drug addiction, depression, suicide attempts, seizures, cardiac conduction disturbances, and rhabdomyolysis. In all instances, no local physician was aware of the patient's drug consumption before hospital admission for the treatment of complications. In a separate report, Dalal et al3Dalal AK Harding JD Verdino RJ Acquired long QT syndrome and monomorphic ventricular tachycardia after alternative treatment with cesium chloride for brain cancer.Mayo Clin Proc. 2004; 79: 1065-1069Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar describe a 43-year-old woman who had resection of a right temporal lobe glioblastoma multiforme brain tumor. After hospital discharge, she researched alternative/adjunctive treatments of cancer on the Internet and self-initiated a 10-day course of cesium chloride. The day after completing the drug course (and 3 weeks after surgery), she presented to the hospital emergency department with seizures and ventricular tachycardia, requiring repeated episodes of transthoracic electroshock treatment. Further work-up during hospitalization revealed that the patient had acquired long QT syndrome that correlated with elevated serum cesium concentrations. These authors identified other published reports of cesium chloride–associated cardiac tachyarrhythmias in patients seeking alternative/adjunctive treatment of cancer. In all cases, the patients researched and obtained the drug through the Internet. Of note, using the Google search engine (July 12, 2004), I discovered that the Internet is replete with sites touting the antineoplastic properties of cesium chloride for a large number of unrelated tumors and also identifying pricing competition among vendors. Oddly enough, the same searches that link to proponents and vendors of cesium chloride also link to the American Cancer Society Internet site in which it is stated that “there is no scientific evidence that non-radioactive cesium chloride supplements have any effect on tumors, and there have been some side effects reported.”5American Cancer Society Making treatment decisions: cesium chloride.Available at: www.cancer.org/docroot/ETO/content/ETO_5_3X_Cesium_Chloride.asp?sitearea=ETOGoogle Scholar Recently, ephedra was removed from the over-the-counter drug market, in large part because of evidence from the Food and Drug Administration (FDA) of an association with debilitating or fatal cardiovascular events, including myocardial infarction and stroke. These adverse events and the compound's withdrawal from the over-the-counter market have been duly published in leading medical journals,6Haller CA Benowitz NL Adverse cardiovascular and central nervous system events associated with dietary supplements containing ephedra alkaloids.N Engl J Med. 2000; 343: 1833-1838Crossref PubMed Scopus (809) Google Scholar, 7Samenuk D Link MS Homoud MK et al.Adverse cardiovascular events temporally associated with ma huang, an herbal source of ephedrine.Mayo Clin Proc. 2002; 77: 12-16Abstract Full Text Full Text PDF PubMed Scopus (218) Google Scholar, 8Ashar BH Miller RG Getz KJ Pichard CP A critical evaluation of Internet marketing of products that contain ephedra.Mayo Clin Proc. 2003; 78: 944-946PubMed Scopus (31) Google Scholar on the FDA Internet site,9US Food and Drug Administration FDA issues regulation prohibiting sale of dietary supplements containing ephedrine alkaloids and reiterates its advice that consumers stop using these products.Available at: www.fda.gov/bbs/topics/NEWS/2004/NEW01021.htmlGoogle Scholar on medicine and health Internet sites,10Warner J FDA issues final ban on ephedra [WebMDHealth Web site].Available at: http://my.webmd.com/content/article/81/97056.htmGoogle Scholar and in the lay press.11CNN FDA finalizes ephedra ban.Available at: www.cnn.com/2004/HEALTH/diet.fitness/02/06/ephedra.ban.ap/Date: February 6, 2004Google Scholar, 12CBS News Court green-lights ephedra ban.Available at: www.cbsnews.com/stories/2004/02/06/health/main598394.shtmlDate: April 12, 2004Google Scholar Manufacturers of dietary supplements, which were a common source of ephedra, have been quick to respond to the FDA ruling and now extensively advertise and sell “ephedra-free” replacement products, often using the Internet as a tool. Because these products are considered herbally derived dietary supplements, they are not regulated as prescription medications.11CNN FDA finalizes ephedra ban.Available at: www.cnn.com/2004/HEALTH/diet.fitness/02/06/ephedra.ban.ap/Date: February 6, 2004Google Scholar Not surprisingly, the stimulant and antiobesity properties formerly provided by ephedra are now mimicked by a variety of other well-characterized, and not so well-characterized, sympathomimetic agents.4Nasir JM Durning SJ Ferguson M Barold HS Haigney MC Exercise-induced syncope associated with QT prolongation and ephedra-free Xenadrine.Mayo Clin Proc. 2004; 79: 1059-1062Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar The association of ephedra-like adverse effects with ephedra-free sympathomimetic products would be expected, as reported by Nasir et al.4Nasir JM Durning SJ Ferguson M Barold HS Haigney MC Exercise-induced syncope associated with QT prolongation and ephedra-free Xenadrine.Mayo Clin Proc. 2004; 79: 1059-1062Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar They describe a previously healthy 22-year-old woman who experienced a syncopal episode while running. On hospital admission, she was diagnosed as having hyperglycemia, ketoacidosis, and sinus tachycardia with QT prolongation. The patient had taken a sympathomimetic-containing, yet ephedra-free, dietary supplement the evening before and again 45 minutes before a 3.5-mile run. The physiologic aberrations disappeared with discontinuation of the dietary supplement. Although the source of the patient's procurement of this product and background information concerning it are not provided in the report, the Internet provides exhaustive marketing and readily identifiable suppliers for ephedrafree dietary supplements, without adequate mention that their pharmacological effects may differ little from those of the ephedra-containing products (July 12, 2004, search). In these collective reports,2Lineberry TW Bostwick JM Taking the physician out of “physician shopping”: a case series of clinical problems associated with Internet purchases of medication.Mayo Clin Proc. 2004; 79: 1031-1034Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar, 3Dalal AK Harding JD Verdino RJ Acquired long QT syndrome and monomorphic ventricular tachycardia after alternative treatment with cesium chloride for brain cancer.Mayo Clin Proc. 2004; 79: 1065-1069Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar, 4Nasir JM Durning SJ Ferguson M Barold HS Haigney MC Exercise-induced syncope associated with QT prolongation and ephedra-free Xenadrine.Mayo Clin Proc. 2004; 79: 1059-1062Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar self-administration of pharmacologically active substances, independent of physician consultation or oversight, caused or could likely have caused near-death experiences in all 6 patients. An association between Internet-related procurement of information and treatment was apparent in 5 of the 6 patients and could well have played a role in the remaining patient. Clearly, these practices and consequences have implications for modern health care providers, who must deal with adverse treatment effects and hopefully will participate in proactive methods of prevention. Solutions for modern health care delivery woes are complex, particularly because, as it relates to the provision of health care from nontraditional sources, the Internet has let the genie out of the bottle. Problems associated with alternative treatments and sources of care are often unknown to patient-consumers. “Natural” products are often assumed to be safer, without knowledge that many controlled substances, such as digitalis, narcotics, antibiotics, hallucinogens, and muscle-paralyzing agents, had “natural” origins. Furthermore, consumers often incorrectly assume that Internet-available drugs and food supplements, emanating from diverse suppliers, ascribe to the same quality and safety standards expected in US FDA–approved products. There is insufficient appreciation that the extensively discussed, lower-cost medications available to Americans through “Canadian Internet pharmacies” may involve suppliers with few or no connections to Canada; additionally, those suppliers may not function as true pharmacies (with implied legal and quality control) but instead as warehouses.1Fung CH Woo HE Asch SM Controversies and legal issues of prescribing and dispensing medications using the Internet.Mayo Clin Proc. 2004; 79: 188-194Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar, 13Hubbard WK High prescription drug prices and the influence of the Food and Drug Administration [reply].Mayo Clin Proc. 2004; 79: 569-570Abstract Full Text Full Text PDF PubMed Google Scholar, 14FOX News Channel Black-market pharmacies on Web pose risks.Available at: www.foxnews.com/story/0,2933,120471,00.htmlDate: May 20, 2004Google Scholar If Internet suppliers will misrepresent their function and geography, what would stop them from lying about the safety and efficacy of their products? What would prevent individual privateers from filling any gaps in service resulting from the pressure of regulatory agencies on organized industries? Absolutely nothing, as this “message board” exchange on the Internet,15Ephedra—purchase some goods ECA.Available at: www.nutritionalsupplements.com/supplements/viewtopic.php?p=49774Google Scholar accessed on July 12, 2004, identifies: Party 1: Can someone help me find a place that still sells original [name of ephedra-containing product deleted] or something like that on-line. I have been trying to lose weight for the past 2 months, and I am out of stuff. Please help.Party 2: It's illegal to sell since April 12th…but what are you looking for, any particular product, maybe I can help you out.Party 3: Yea it's a bit harder to find now, but you can still get it if you ask the right people. This example shows that, if the correspondents are indeed capable of delivering on their promises, the Internet is being used to facilitate the trafficking of known banned substances, widely appreciated to have serious adverse effects. An analysis of Internet trafficking of substances harmful to humans is not intended to distract from the limitations of modern medicine in distributing legitimate prescription medications and ensuring optimum patient safety. As described by the Institute of Medicine in its landmark 1999 report “To Err is Human: Building a Safer Health System,”16Kohn LT Corrigan JM Donaldson MS Committee on Quality of Health Care in America, Institute of Medicine To Err is Human: Building a Safer Health System. National Academy Press, Washington, DC1999Google Scholar preventable medical errors, including medication errors, meaningfully contribute to morbidity, mortality, and costs in the US health care system. However, what is missing with the direct-to-consumer delivery of pharmacologically active substances, outside of traditional means, is the monitoring, reporting, and management that the physician-patient relationship should provide. Ironically, as seen in the examples from this issue of Mayo Clinic Proceedings, when serious adverse effects occur after patients procure and use medications by nontraditional means, physicians and traditional medicine must handle the consequences, often while confronted with inadequate information and a patient who is unable to communicate.2Lineberry TW Bostwick JM Taking the physician out of “physician shopping”: a case series of clinical problems associated with Internet purchases of medication.Mayo Clin Proc. 2004; 79: 1031-1034Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar, 3Dalal AK Harding JD Verdino RJ Acquired long QT syndrome and monomorphic ventricular tachycardia after alternative treatment with cesium chloride for brain cancer.Mayo Clin Proc. 2004; 79: 1065-1069Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar, 4Nasir JM Durning SJ Ferguson M Barold HS Haigney MC Exercise-induced syncope associated with QT prolongation and ephedra-free Xenadrine.Mayo Clin Proc. 2004; 79: 1059-1062Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar Although many of the dilemmas created by the modern health care environment, including those related to the Internet, are disturbing, there is promise that the same technology that helped create problems can also be used to solve these problems. Integration of medical information and information sharing among physicians, pharmacists, and other providers can help lessen problems with “physician shopping” by patients, drug incompatibilities, and other issues. However, such sharing of information has implications for privacy and confidentiality of patient information. Furthermore, as discussed astutely by Lineberry and Bostwick,2Lineberry TW Bostwick JM Taking the physician out of “physician shopping”: a case series of clinical problems associated with Internet purchases of medication.Mayo Clin Proc. 2004; 79: 1031-1034Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar physicians (particularly those in environments with extensive integration of health care information) may assume erroneously that the system is protecting them from errors, when in fact the patients they are caring for may be going outside the system for the procurement of additional, potentially injurious treatments. Hence, physicians may fail to ask critical questions because they assume that technology has provided a safety net when in fact it has provided a screen of camouflage. To quote the enigmatic baseball legend Yogi Berra, “The future ain't what it used to be.” Providing the best care for patients tomorrow may depend fractionally less on laboratory-based researchers, trialists, and other investigators working diligently to provide the most efficacious and safest treatments possible and more on logisticians, ethicists, sociologists, economists, and others dealing with challenges of access, cost, and communication. The patient and society are ill served if the prescription for a miracle treatment is unfilled or, if filled, the treatment sits idly on the shelf. Alternatively, all are ill served if patient quests for alternative treatments result in ineffective or dangerous substitutions for best medical care. These are perplexing issues that will demand the best minds that medical practitioners and investigators can provide. Solution initiatives will need to be sophisticated and widespread if we are to effect outcomes in the manner expected by physicians and patients alike. It is a daunting task but one that will intrigue and revivify the creative minds of the numerous professionals who consider the provision of medical care a “calling.” Taking the Physician Out of “Physician Shopping”: A Case Series of Clinical Problems Associated With Internet Purchases of MedicationMayo Clinic ProceedingsVol. 79Issue 8PreviewIn the United States, psychoactive prescription medications rank second only to marijuana as drugs of abuse (if tobacco and alcohol are discounted). Physician shopping—visiting multiple physicians simply to procure prescriptions—has been a traditional method for acquiring drugs illicitly. As community-based efforts to curtail physician shopping have expanded, drug abusers have turned increasingly to the Internet. Illegal Internet pharmacies, increasing rapidly in number during the past decade and requiring neither prescription nor physician oversight, offer minimal interference to obtaining drugs. Full-Text PDF Exercise-Induced Syncope Associated With QT Prolongation and Ephedra-Free XenadrineMayo Clinic ProceedingsVol. 79Issue 8PreviewThe Food and Drug Administration recently banned the sale of ephedra alkaloids because of their association with arrhythmic sudden death, myocardial infarction, and stroke. This has resulted in the emergence of formulations marketed for weight loss and performance enhancement that are “ephedra free” but contain other sympathomimetic substances, the safety of which has not been established. We report a case of exercise-induced syncope in a healthy 22-year-old woman that occurred 1 hour after she took the second dose of Xenadrine EFX, an ephedra-free weight-loss supplement. Full-Text PDF Acquired Long QT Syndrome and Monomorphic Ventricular Tachycardia After Alternative Treatment With Cesium Chloride for Brain CancerMayo Clinic ProceedingsVol. 79Issue 8PreviewIndividuals searching for symptomatic relief or a potential cure are increasingly seeking and using nontraditional therapies for their various diseases. Little is known about the potential adverse effects that patients may encounter while undergoing these alternative treatments. Cesium chloride is an unregulated agent that has been reported to have antineoplastic properties. Cesium chloride is advertised as an alternative agent for many different types of cancers and can be purchased easily on the Internet. Full-Text PDF
Referência(s)