Most people
associate the use of leeches as a medical treatment with the Dark Ages, bloodletting
and witchcraft. They believe that the medical profession stopped using leeches
over three centuries ago. And yet, in 2004, the FDA approved the commercial marketing
of leeches for limited medical purposes, mainly to help heal wounds and restore
circulation in blocked blood veins. Leeches apparently may be
effective on a very limited basis … but are used in very few instances and
have been largely replaced by more effective methods.
Today, this same thought process must be utilized regarding the use of pharmaceutical drugs, particularly benzodiazepines in the treatment of eating disorders. If not, the consequences could be deadly.
Medications and Eating Disorders
The United States Food and Drug Administration has approved only
two drugs to treat eating disorders. Lisdexamfetamine dimesylate (Vyvanse) is the first FDA-approved drug to treat
binge eating disorder in adults. It's also used to treat ADHD. It is not clear
how the drug works in binge eating, but it is thought to control the impulsive
behavior that can lead to bingeing. In studies, patients who took the medicine
had fewer episodes of binge eating.
The FDA also approved the use
of Prozac (Fluoxetine) for Bulimia Nervosa.
However, guidelines issued by the Royal
Australian and New Zealand College of Psychiatrists’ (RANZCP) warn there
is no evidence supporting the use of psychotropic medications for adult
anorexia. In fact, a recent meta-analysis found there is absolutely zero
evidence supporting the use of antipsychotics to treat anorexia. This is bolstered
by Stephanie Zerwas, clinical director of the UNC Chapel Hill Center of
Excellence for Eating Disorders who stated, “Antidepressants and even
antipsychotics are really much more ineffective when people are in a
malnourished state.”
In a fasting or malnutrition state, the individual is not
producing neurotransmitters (i.e. serotonin, norepinephrine, dopamine) at a
level where there can be maximum therapeutic benefit. Medications are less
effective until re-feeding has taken place.
No medication has been FDA-approved for the treatment of Anorexia
Nervosa. Studies show that antidepressants are no more effective for weight
gain than placebo. Three trials studied tricyclic antidepressants, while the
fourth studied the selective serotonin reuptake inhibitor, Prozac (2,3,4,5).
Pharmacotherapy (medication treatment) is not an initial or primary treatment
for anorexia nervosa. Various psychotherapy modalities, i.e. Cognitive
Behavioral Therapy and Family Based Therapy have far more supportive evidence.
Despite these studies, doctors have been known to prescribe an aggressive
medication regiment to treat eating disorders. Remeron (mirtazapine), which has
not even been studied in trials with Anorexia Nervosa, is nonetheless often
used in patients with Anorexia Nervosa (especially if there is co-occurring
depression or anxiety) due to its ability to help with sleep and increase
appetite, thereby potentially increasing weight gain.
In order to treat the symptoms of eating
disorders and the co-current conditions, doctors often prescribe a plethora of
drugs not specifically approved to treat the disease. This is called
"off-label" prescribing. Since those classes of drugs are not
specifically approved to treat eating disorders, one is left to speculate
whether doctors are prescribing medications for symptomology alone based upon
their own “Confirmation bias” and not based upon peer-to-peer scientific
research.
In psychology and cognitive
science, “Confirmation bias” is a tendency to search for or interpret
information in a way that confirms one's preconceptions, leading to statistical
errors. Confirmation bias is a type of cognitive bias and represents an
error of inductive inference toward confirmation of the hypothesis under study.
Confirmation bias is a
phenomenon wherein decision makers have been shown to actively seek out and
assign more weight to evidence that confirms their hypothesis, and ignore or
under weigh evidence that disconfirms their hypothesis. As a result, a
prescription drug regiment which is designed more to address various symptoms
of co-occurring conditions is becoming commonplace and is based more upon that
practitioners intuition, observations, personalities and colleagues’
endorsements rather than peer-to-peer reviewed scientific research. This is particularly
true with regard to the use of benzodiazepines.
Benzodiazepines
Benzodiazepines are becoming one of the more
readily prescribed medications in treating symptoms of eating disorders. When
benzos first came to the market in the 1950s, they were prescribed for a range
of neurological disorders such as epilepsy as well as anxiety related disorders
such as insomnia. But over time, using the loophole in federal drug control
laws known as the “practice of medicine exception,” doctors began to prescribe
the drug for any perceived disorder.
Klonopin seems to be becoming the benzo drug of
choice being prescribed for persons with eating disorders. Some doctors
indicate that benzos have been shown to increase the palatability of food and
result in increased consumption of food.
However, the manufacturer of Klonopin indicates
that it is for short term use only, between 7 – 10 days. In part, that is
because Klonopin is a highly addictive substance and its side effects are many.
These include seizures, accidental falls, hallucinations, unusual heartbeat,
insomnia, drowsiness, blurred vision and slurred speech.
There is no dispute that benzos are highly
addictive. Stevie Nicks of Fleetwood Mac fame, with regard to klonopin,
stated" “This drug was more deadly than the coke.” (when asked which drug
had the most significant impact on her). "The
overwhelming feeling of wellness and calm equals blah, nothing. My creativity
went away. The fabulous Stevie everyone knew just disappeared. I became what I
call the 'whatever' person. I didn't care about anything anymore. I got very
heavy. One day I looked in the mirror and said, 'I don't know you.' And I went
straight to the hospital for 47 days."
When an RTC does not engage in aggressive
discharge planning, does not properly educate parents and does not coordinate
with a patient’s treatment team at home, the results can be an overdependence,
abuse and addiction on drugs with a deadly outcome.
Hypothetical and speculation turns into reality.
During one of my daughter’s many residential
treatment stops, after being in a certain treatment center (“The Program”) for
six (6) weeks, United Behavioral Healthcare (“UBH”), our then
insurance provider, made the determination that it was stopping payment for all
treatment for eating disorders and trauma and mandated that it would only pay
for a detox program for Morgan. Naturally, this determination was
quite mysterious since Morgan had been under the exclusive care of this
residential treatment program for six (6) straight weeks and had come to this
facility from another hospital.
The Program appealed this determination and the following day, UBH
approved an additional six (6) day stay, ostensibly to allow The Program to
begin a detox and titration program off of klonopin.
The doctor at the Program overseeing her treatment protocol had
actual knowledge that UBH was terminating all payment for Morgan’s eating
disorder treatment, that Morgan was being overmedicated and had become dependent
on medication and was going to be discharged. The doctor knew that Morgan needed to be titrated off klonopin
and have its administration overseen by a trained medical professional.
Nonetheless, not only did this doctor not start a titration protocol, but continued
to subject Morgan to 6 mg of klonopin per day. When Morgan was discharged to
our care, the Program had not even begun a detox program. It also did not make any
recommendations or advice about a detox program. And, it discharged
Morgan unsupervised, on a Super Shuttle van for transport to the airport with a large, gallon size baggie filled with prescription drugs,
including at least 36 doses of klonopin. This conduct was tantamount to an
alcohol rehab facility giving its patient a case of beer as a parting
gift.
However, the Program did start a process of covering their own
conduct. In Morgan’s Transition/Discharge Summary, Morgan’s treatment team, stated:
“PT did not initially disclose a hx of substance abuse, but OP team informed
treatment team of pt’s severe alcohol and substance abuse
issues. Therapist presented pt with this information who stated that
she was not “ready to give that up” at this time. Pt would
periodically seek more benzodiazepines from psychiatrist.
The logical conclusion one can draw from these notes is that the
treatment team was woefully unprepared, there was a lack of communication
between the intake team and treatment providers and the Program was already
pointing fingers elsewhere for its own incompetence.
After Morgan came home, the predicted catastrophe happened. Three
days later, she was in an emergency room at Presbyterian Hospital in Plano,
Texas because of an overdose of klonopin. Her vital signs were
erratic, she was lethargic and was generally not responsive to
stimuli. She was placed in the Intensive Care Unit. She survived that time. But, the incredibly difficult road to recovery was made that much more rocky because of her addiction to klonopin.
Morgan Claire Dunn died on
October 30, 2016. We discovered that she had been prescribed the following
drugs by doctors and RTCs who were attempting to treat her eating disorders:
1. Fluvoxamine;
2. Ambien;
3. Lithium;
4. Potassium;
5. Vayarin;
6. Fluoxetine HCL;
7. Buspirone HCL;
8. Gabapentin;
9. Mirtazapine;
10. Latuda;
11.
Metronidazole;
12. Vitamin B-1;
13. Divalproex;
14. Doxepin;
15. Zolpidem;
16. Mag Oxide;
17. Cymbalta;
18. Hydroxyzine Pamoate;
19. Trazadone;
20. Mynocycline;
21. Baclofen;
22. Topiramate;
23. Thiamine HCL;
24. Ondansetron ODT;
25. Prazosin;
26. Sulfamethoxazole;
27. Citracal Plus D3;
28. Omeprazole;
29. Spironolactone;
30. Ferrous Gluc;
31. Venlafaxine;
32. Lamotrigine;
33. Ranitidine;
34. Trifluoperazine;
35. Olanzapine;
36. Vancomycin;
37. Oxcarbazepin;
38. Risperidone;
39. Naltrexone;
40. Neurontin;
41. Vistaril;
42. Trileptal;
43. Klonopin
Again, the FDA has approved two drugs to treat
eating disorders.
Morgan Dunn was prescribed at least forty-three
(43) different medications.
Forty-Three (43).
Wow! This is unconscionable!
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