Also in this week’s column: the dangers of amitriptyline and the opioid crisis.
Q. I am a retired emergency-room physician. I have fought a battle for 20 years to stop pill-splitting. This is often what managed-care organizations like Kaiser and Veterans Affairs use as a cost-containing strategy. If “dose” means anything, this practice should be abandoned: The pieces are not even close to exact halves. This variation in dose can harm patients.
A. Pill-splitting often has been recommended as a way to save money. That’s because the higher dose is frequently priced about the same as the lower dose. For example, the cholesterol-lowering drug pitavastatin (Livalo) costs about $300 a month whether you get it as a 2 mg tablet or a 4 mg tablet.
One study of pill-splitting found that volunteers who cut hydrochlorothiazide tablets in two pieces ended up with almost half of the pieces of this diuretic the wrong size (Pharmacotherapy, January-February 1998).
Researchers in Switzerland concluded that scored tablets are not always designed to be split (Swiss Medical Weekly, Feb. 27, 2010). In some cases, the scoring appears to be decorative. A Food and Drug Administration study found that the thyroid drug levothyroxine should not be cut even when tablets are scored (AAPS PharmSciTech, September 2010).
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Surprisingly, a Dutch study found that hand-breaking tablets was more accurate than using a pill splitter (International Journal of Pharmaceutics, May 15, 2014).
Q. My wife, 76, has been taking amitriptyline since 2013. Just last week, the results of a PET scan confirmed she has dementia. Her neurologist said the amitriptyline should not have been much of a factor, but I wonder.
A. Amitriptyline is an old-fashioned antidepressant. It is included on the Beers List of drugs that should be avoided or used with extra caution for people over 65 (Pharmacist’s Letter, November 2015).
Anticholinergic drugs like amitriptyline can contribute to confusion, memory problems and cognitive impairment. So that you can learn more about this problem and other drugs that may be inappropriate for senior citizens, we are sending you our Guide to Drugs and Older People. Anyone who would like a copy, please send $3 in check or money order with a long (No. 10), stamped (70 cents), self-addressed envelope to: Graedons’ People’s Pharmacy, No. O-85, P.O. Box 52027, Durham, NC 27717-2027. It also can be downloaded for $2 from our website: peoplespharmacy.com.
Q. What are people in chronic pain going to do now that the pendulum has swung toward not prescribing opiates for chronic pain?
As a hospice nurse, I frequently see patients suffering from terminal-cancer pain. I myself am a chronic-pain patient and am scared to death that I will no longer be able to get adequate relief from severe pain.
Is anyone with compassion overseeing agencies such as the Drug Enforcement Administration, insurance companies or government policymakers?
A. Regulators are caught on the horns of a terrible dilemma. On the one hand, they are dealing with an opioid epidemic. There are scary headlines about abuse of drugs like oxycodone (OxyContin) and fentanyl. Overdose deaths are reported almost every day. As a result, policymakers have cracked down on opioids. The DEA has made it harder for physicians to prescribe such medications for people dealing with chronic pain.
Many patients suffering long-term severe pain are having a hard time getting relief. We have heard from hundreds of such people who never abused opioids or increased their dose. Sadly, there are no simple solutions to this challenging dilemma.