Confessions of an Rx Drug Pusher

by Gwen Olsen

  Once, I encountered a twelve-year-old boy in the emergency room who had taken his grandmother’s medication. His eyes had rolled into the back of his head and locked there. This is known as an oculogyric crisis. However, where my heart really went out was to the poor, little elderly patients in the Veterans Administration (VA) hospital, the nursing homes, and the psychiatric wards. They seemed to suffer the most on Haldol. I heard constant reports about excessive dry mouth, blurry vision, painful constipation, and urinary retention. (Nurses even complained about fecal impacts associated with chronic neuroleptic use.) These side effects are known as anticholinergic effects, and my training had actually consisted of a little rhyme to assist me in learning them. It went, “Patients on Haldol can’t see, can’t spit, can’t pee, and can’t shit.”

  Reps were instructed to minimize these side effects by encouraging the doctor to simply administer an anticholinergic drug simultaneously with Haldol. Still, the most dreaded side effect by patients and doctors alike remained akathisia. A patient with agitated akathisia could not only be self-injurious, but was also a danger to other patients and staff.

  These observations led me to question the medical prudence and moral ethics behind giving a long-acting, irreversible neuroleptic like Haldol decanoate, especially because Haldol was documented to have a huge potential to cause negative side effects. Once this drug was on board and a patient reacted to it, there was absolutely nothing doctors could do except give additional drugs to manage the side effects while the patient rode out the three weeks the injection was intended to last. Of course, three weeks was only the half-life of the drug. There would be remaining drug residual for some time after that.

  The company’s position was that the untreated schizophrenic patient is a threat to society and himself. Traditional oral medications could not ensure patient compliance in the absence of an institutional setting. With larger numbers of mental health patients being forced into outpatient settings such as MHMR facilities, there seemed to be a real, perceived need for this extended- release form of Haldol. Hence, the product managers argued the benefits outweighed the risks, particularly when you considered one of the benefits was that Haldol decanoate would enjoy an exclusive patent whereas the old haloperidol was available generically and sold at a significant cost reduction. Not only did Haldol decanoate ensure patient compliance, it ensured corporate longevity as well. Back then, at an average wholesale cost of $165 per injection, Haldol decanoate was a much more profitable dosage form than the tablet counterpart that sold for pennies on the dollar. The marketing strategy revealed at launch was to acquire the stabilized patient, emphasizing the reduced chance of relapse and overall reduced drug exposure. (Why? Were they admitting drug exposure was harmful to the patient?) That meant getting the long-term refill business. Never mind that the long-acting neuroleptics were already known to cause even worse side effects than their shorter-acting versions. For the company, this was considered a small price to pay for the trade-off.

  Being the ambitious, determined person I was, I set out to convert as much of my Haldol tablet business to Haldol decanoate business as I could. In spite of my reservations, I justified the activity because I figured it wasn’t my place to question the treatment choices made by a patient’s doctor. That’s not what I was paid to do. I was only there to provide the information to help him or her make the best choices, right? So true! But, even then, only two years into the game, I was already beginning to question: The best choices for whom?

  6

  Anxiolytics: Prescription for Addiction

  “Addiction [is] a preoccupation and compulsive use of an experience or substance despite the recurrence of adverse consequences…some people may have a biological or genetic predisposition to addiction.”

  —The ASAP Dictionary of Anxiety and Panic Disorders

  My first basic sales training class with McNeil found me roommates with a former Upjohn rep. We got along well, and her previous experience was a comfort to a novice rep like me. Under the pressure of the long hours and lack of sleep, I started getting anxious. After all, I wasn’t able to take pot on my business trips, my usual way of winding down for the evening in order to relax and sleep. My roommate, on the other hand, had the perfect solution. Upjohn had a new anxiolytic called Xanax (alprazolam). It was being touted as the nonaddicting Valium. They were also marketing a new sleep aid in the same drug category called Halcion (triazolam). (The industry had coined the term anxiolytic because of the negative publicity benzodiazepines were receiving about their addiction potential.) My roommate had samples of both and offered me some.

  I remembered my mother giving me her Valium (diazepam) once before a beauty pageant I was in. I was fourteen. It felt wonderful. The total calm. The jitteriness that often consumed me was completely relieved as I confidently glided across stage. I loved it! I popped the Xanax without a second thought. Sure enough, I loved it too! As for the Halcion, I would sleep the sleep of the dead that night. I don’t think I have ever slept that well since. I would refrain from taking Halcion too much after overhearing a conversation between two residents that had pulled long shifts the day and night before. One would confide to the other that he had found notes in one of the patient’s charts that he had written the previous night, but he had no memory of having been called back to the hospital. The other resident had kind of laughed and shrugged it off, but I could tell the doctor involved was really disturbed by his memory malfunction. I decided to limit my Halcion use to rare occasions as needed.

  These drugs would be my mainstay, off and on, for the next ten years. Somehow, I felt less guilty and more dignified about using these drugs over marijuana. They were the perfect solution for me. They were not illegal. I didn’t have to worry about the random drug testing I underwent in the industry. They didn’t make me have glassy, red eyes. There was no stigma attached to taking them, and they didn’t impair my mental functioning (or so I thought) the way marijuana did. I could take these things all day long if needed whereas I could only smoke pot at the end of the evening or after I had completed my day’s work.

  One time, my dentist, my dermatologist, my family practitioner, and my ob- gyn all prescribed Xanax for various things. My dentist gave me a script before a dental procedure he thought might cause anxiety. My dermatologist did the same before sclera therapy, a procedure to repair spider veins. My ob-gyn wrote one for PMS symptoms, and my family practitioner prescribed it for sleep disturbance. I remember I didn’t even fill all of the scripts because I had so much Xanax.

  Upjohn heavily promoted both Halcion and Xanax for years. Samples of Xanax would literally fall off of shelves because they were so crammed into sample closets! However, that soon changed as other reps caught wind of the drugs’ wonders and became addicted. Samples began falling into open detail bags instead of patient’s hands, making them more and more difficult to find. Some doctors would readily give samples to reps for anything we complained about, including work stressors, back pain, sleep problems, and so forth. Of course, with time, it would be discovered short-acting benzodiazepines are even more addicting than long-acting ones like Valium.

  Additionally, controversy that surfaced surrounding Halcion and drug- induced psychosis resulted in the drug being banned in the United Kingdom in 1993. Thirteen other countries followed this action. Partially, this occurred for reasons that emerged in the 1988 trial of Ilo Grundberg, a fifty-seven-year-old Utah woman who killed her elderly mother by shooting her eight times in the head. Grundberg was judged to have been “involuntarily intoxicated” by Halcion, and Upjohn settled out of court in 1991. However, documentation uncovered in the discovery process of the trial disclosed a clinical study submitted for Halcion’s approval that had “underreported the number of patients who had paranoid reactions to the drug and overstated the number who had similar reactions to a placebo.” In spite of the paperwork discrepancies, the FDA still considered Halcion safe and effective following its investigation (Fried 239).

 
; Believe it or not, I still didn’t know I was addicted to Xanax for several years. When I discovered I was pregnant in 1988 with my son, out of concern for the fetus, I stopped taking it cold turkey. Boy, that would turn out to be a mistake! The panic attacks started almost immediately. I had been on Xanax for nearly three years. I thought I was going to die! My heart raced, and my hands shook. I thought I would suffocate. I was short of breath and dizzy. I had a total loss of spatial perception. I had no idea what was happening! I started getting seriously anxious and mildly depressed. I couldn’t sleep. I was under a tremendous amount of pressure at work at the time, in addition to the pregnancy, so I attributed it to that. I sought out a psychologist to talk to. She diagnosed me with an adjustment disorder. With her assistance, I managed to get through the next several weeks of withdrawal hell. Talk about morning sickness! I would vomit, and I was nauseous from daylight to dark that first three months. In fact, the doctors were concerned I was losing, not gaining, weight with the pregnancy. Nobody had even thought to consider I might be experiencing drug withdrawal, even though, at some point, I had informed all of my caretakers I had been taking Xanax. Because these drug-induced symptoms resembled the same ones associated with the problems for which I had been prescribed Xanax, I remained clueless as well. I would discover much later that any psychiatric symptom or disorder can also be caused by the drugs used to treat them (Breggin and Cohen 50).

  It should be noted that dependence on anxiolytics/benzodiazepines can develop rapidly, often within days or weeks. All long-term users are addicted. Benzodiazepine withdrawals are considered far worse and last much longer than those associated with alcohol or barbiturates. They can sometimes last weeks or months, depending on the length of time the drug has been used. Other commonly prescribed benzodiazepines include Serax (oxazepam), Valium (diazepam), Klonopin (clonazepam), Ativan (lorazepam), Dalmane (flurazepam), Restoril (temazepam), Tranxene (clorazepate), ProSom (estazolam), Librium (chlordiaze- poxide),and Versed (midazolam) (Kotulak).

  Addiction and Mental Illness

  Mental illness seems to occur more frequently in substance users. Once again, it is the age-old “chicken or the egg” dilemma. Did the drugs cause the condition, or did the condition predispose the individual to drug use? The fact is that it can be extremely difficult to discern which came first. However, many substance abusers describe being driven to drug or alcohol use in order to manage their mood swings or deal with feelings of inadequacy. This process of self-medicating contributes to substance abuse and addiction in many people with mood disorders.

  Addiction is not a moral weakness of character or lack of self-control. If you have a brain, you have the potential to become an addict. Addiction, as we have seen, is also not limited to illicit drugs. Many of the prescription psychoactive drugs and hypnotic pain killers are highly addicting. Our drug rehabilitation and psychiatric treatment facilities can attest to that. It is no secret in the medical community that drug addiction among professionals is highest among their own, including doctors, nurses, drug reps, and pharmacists, who all have easy access to controlled prescription medications (Kuhn et al 254-255).

  Becoming a Mother in the Eye of a Hurricane

  I was about eight-and-a-half months pregnant when my husband’s daughters from his first marriage were taken from his ex-wife in Wisconsin. She had a cocaine addiction and was neglecting her children. Her two sons by her second husband had already been sent to live with their father. The youngest daughter, Connie, came to live with us in Corpus Christi while the older daughter, Tina, went to live with my husband’s parents near Milwaukee.

  It was a difficult transition for Connie at the age of twelve. Not only was she a long distance from her home in Wisconsin, but it was the first time she had been separated from her sister, Tina, who was very close to her in age. Connie was also very attached to her younger brothers. As it were, she had been their caretaker, and now they were also gone. It was heartbreaking when she arrived with all of her worldly belongings in one small brown box. Most of it, odds and ends of clothing and junk jewelry, was not even worth keeping. I bought her a new wardrobe and got her hair cut stylishly. I set about trying to make her over. Poor thing, now that I look back, I had no idea how that must have made her feel. I meant well, and the little girl in me so wanted her acceptance. However, I am pretty sure she interpreted it as though she was not good enough for me the way she was.

  Connie was a good little helper. I could tell she had been given responsibility for her siblings and housework because she assisted with little complaint. She understandably felt a loyalty toward her mother, even though I had not been party to the separation between Connie’s parents. She resented my relationship with her father, partly because I think she felt abandoned by him. Rod had joined the navy to support the children shortly after the divorce. They were very young, only four and five years old, when he was stationed in Hawaii. The girls had endured unspeakable neglect and abuse when they were left in their mother’s sole custody. My husband and I were shocked at the information Connie shared with us. He really had not known the extent of her mother’s dysfunction and addiction since their divorce. So, it was also understandable that Connie had grown a thick skin at an early age to protect herself. All of my attempts to break through to her were thwarted.

  Nevertheless, I enjoyed having Connie around and getting a head start on parenting, although it would be quite different trying to mentor a twelve-year-old girl that resented me from caring for a totally dependent infant boy that was soon to arrive. It was a blessing to have Connie as a part of our family at that time. I hope she will someday see it that way. She was there for the birth of her halfbrother, but, unfortunately, she was also there for my postpartum depression.

  I guess everything in my life was intended to be high drama because I didn’t even manage to have my son under normal circumstances. On September 11, 1988, (notice the poor kid’s birthday) when our son, Austin, entered the world, Corpus Christi was being evacuated in anticipation of the arrival of Hurricane Gilbert. It was predicted we would be in the eye of the storm any day. I was in the hospital hooked up to an intravenous Pitocin-drip in an attempt to induce labor. Because I had gestational diabetes, the doctor was concerned. I was overdue, and the baby might get too large, further complicating the delivery.

  Several hours later, eighteen to be exact, they disconnected the IV and told me to go home. It was obvious the baby was not coming. I had not even dilated one centimeter after eighteen hours of killer contractions produced by the Pitocin. Maybe the drop in barometric pressure would induce labor. I was told to go home and wait.

  We had no sooner gotten home before, lo and behold, my water broke. So, it was back to the hospital for labor and delivery. The only problem was that I still wasn’t dilating. The pain was so excruciating. I guess I was controlling it. Finally, the doctor on call arrived and sent for the anesthesiologist.

  I remember curling up into a ball as I waited in anticipation, attempting not to move while the spinal block was started. Sweet relief! I was so relieved that I started to dilate instantly. One…two…three…four centimeters.

  The doctor was alarmed. “Somebody put an IV in her!” he barked. “This baby’s coming!”

  The nurses scrambled to get the IV in, but, because I was so dehydrated, they had to make several attempts until they finally settled for a vein in the top of my hand. The coaches were telling me to push—push with all my might! The baby was just starting to crown.

  Suddenly, the doctor looked startled as he watched the monitor of the baby’s heartbeat.

  “Something’s happening.something’s wrong.I can feel it,” I thought.

  “The baby’s in distress,” he said. “We can’t wait…Forceps!”

  I thought I would faint. Then, all at once, the baby was out. His umbilical cord was wrapped around his neck, and the doctor quickly untied it. I saw the medical personnel shoving my husband out the door into the foyer as he objected. The baby was immediately
swept away by the nurses and was not placed on my stomach as I had seen in my prenatal films. That was when my ears started to fill with fluid, as though I was being submerged under water. I tried verbalizing this to the doctor.

  “Damn it, Gwen, stay with me!” he demanded. “We’re losing her,” I heard him say to the anesthesiologist as his voice faded with everything else and the room went black.

  I didn’t see any tunnels or lights, nor did I have any deceased relatives come to greet me. However, at that instant, I was consumed with an utter feeling of peace I have only had once since. That would be the night I talked with God. I experienced the dissolution of my individual boundaries and felt a complete oneness with everything around me. I no longer felt separated physically from anyone or anything in the room. I had no fear and no apprehension. It was just a wonderful, blissful feeling of peace. I would never again be afraid to die.

  When I came to, all of these ashen-white faces were hovering above me with frightened, concerned looks on them. Apparently, I had lost a considerable amount of blood. My uterus had been seriously torn by the forceps. I was also having an allergic reaction to the Duramorph (morphine sulfate), the anesthesia in my spinal block.