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"What's wrong with this study?"

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Here's a "mock" medical transcription/case report.

Y'all can probably guess who it's about. ;)

Submitted Tuesday, August 8th, 2006

Patient was a 23 year old American male of Asian-Indian descent, with primary complaint of maintenance insomnia. Patient arrived as hyperverbal, and very proactive with regards to his own treatment. Patient discussed the possibility of Lunesta (eszopiclone) to aid in his sleep maintenance; however, this drug was decided against due to the unlikelihood of insurance coverage. Benzodiazepines were considered in lieu of eszopiclone.

Due to the widespread use in insomnia, known safety, and cost efficiency of triazolam (Halcion), patient was prescribed (not by his own request) this medication 0.25mg PRN at night. Patient was told to call back ASAP if this medication did not help; from there we would explore other options, including eszopiclone.

IMPRESSION: Patient with maintenance insomnia.

Signed,

Dr. [name omitted to protect the not-so-innocent]

August 8th, 2006

Now here's some facts.

Halcion (triazolam) has a half-life of less than 2 hours (as little as 30 minutes in some studies). This correlates to about a 1-3 hour duration of effectiveness. Another common use for triazolam (besides INITIATION insomnia) is an adjunct/second drug to help knock patients out for short but semi-invasive outpatient procedures (such as endoscopy and spinal tap).

I took the plunge with the med, though, and the first night I was up by 2 AM, unable to sleep again. Essentially, the same as if I took no med. The next night, though, was absolute hell. I'd wake up almost every hour, drenched in sweat, WITH SLEEP PARALYSIS.

I called Dr. Doofus and bitched his practice out the wazoo to give me Lunesta. They finally did, 2 days ago. And FWIW, 15 days of Lunesta/mo. is covered by my Rx insurance at a co-pay of $15, and the other 15 days are covered at 60% (meaning another $25). So not SO bad, $40/mo. Worth it for my sleep anyways.

Needless to say, any doctor who attempts prescribing me ANYTHING that I don't know for sure plays nice with me is going to get a pain in the ass. :)

Edited by herrfous

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Heya herrfous,

1. Fine, switch drugs. Hope the Lunesta works for you!!

2. Why, when [MD] asked you about your coverage, did you say you had none? Or why *didn't* you ask how much it would be for [clone] if you pay cash? (MDs wouldn't usually know that but you/s/he could find out from the pharmacist in a hurry.)

Seems avoidable to me. Zzz drugs (zolpidem, zaleplon, zopiclone) beat 'azepams anyday. Most of us'll Rx a zzz if the patient can *remotely* afford it.

(also -- halflife doesn't correspond to duration of action so directly -- but that's Glen, not me)

3. Did your MD talk to you much about sleep hygeine?

--ncc--

Edited by ncc1701

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ncc---

doc never asked me about coverage, just assumed. I guessed it's just assumed in the US that an insurer won't cover whatever drug is necessary for you. ;)

and as for sleep hygeine, I'd brought it up before he had a chance to (note that the above isn't an actual hx report :) ). I have pronounced delayed phase sleep disorder, i.e., when your sleep schedule is incompatible with that of greater society's. If it were up to my body, I'd go to bed at 4 AM and wake up at noon. But that's not how society functions, so I need to be knocked out at midnight and knocked awake at 8 AM. I think I had a post about this somewhere

.....

[and yes I know half-life doesn't always correspond to duration of action... but 45 minutes vs. 60 hours... I mean REALLY!!!]

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Heya herrfous,

In most FP offices I've worked in, there's a spot on the Patient Profile for whether they have coverage or not.

Silly not to ask you. Very silly. ;)

(I might have picked clonazepam if I picked an azepam. Intermediate is usually useful.)

(Glad your MD at least considered sleep hygeine. Kind of like, our job, you know.)

--ncc--

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ncc--

I hope more practices use this "patient profile" thingy, since this has always been a concern, "oh insurance won't cover that". Knee-jerk reaction Patellar tendon reflex to a pricey name-brand medication.

And indeed I did leave the suggestion of clonazepam/klonopin with him, though for some reason he went and pursued Lunesta instead (I think I was bitching more in that direction, so yeah). Klonopin worked wonders for me in Baltimore, and I was able to quit cold turkey off of 1mg qhs. But I'm weird that way. ;)

Edited by herrfous

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