Today I found another discrepancy between the way we want to see the world, and the way it is.
I have breathing problems I believe were caused by exposure to my parents’ cigarette smoke when I was young. When I talked to a doctor in Ann Arbor, Michigan, around 1980 he told me I didn’t have asthma, but asthma-like symptoms and gave me a booklet to read. It said asthma was a condition of the lungs that only could be identified with an autopsy.
The Ann Arbor doctor told me my condition would be exacerbated by exercise, cold temperatures, and exposure to water. That was certainly proved true when I moved to Chicago and had to walk by the lake to get to the commuter train station in winter.
Fast forward to today. Our concept of asthma has changed, partly because there are fewer doctors per patient, partly because of the discipline imposed by malpractice insurance, and partly by pharmaceutical companies offerings medicines based on symptoms, not diagnosis.
A while back I asked someone in my doctor’s office about that definition of asthma. Oh no, I was told, you have asthma is you have trouble breathing.
My most recent doctor was appalled I was using albuterol sulfate, because it was not a control medication, but an emergency treatment. He cut back my prescription and told me to take one of the inhaled steroids.
I wasn’t convinced, because when I had tried one years before it seemed to have no affect. But with the one medication cut back I had no choice. Within six months I was in his office with uncontrollable coughing, my first serious asthma attack in years.
I went back to using the albuterol but continued the steroid, until last winter when I saw an article that said the steroid ws only effective in about 50% of the cases. The reason: there are different kinds of asthma, and the steroid treats only one type. Albuterol is what works in the other cases. [1]
It noted that no one did the diagnosis required to determine the type of asthma. There lies the gap between medical research, with its sophisticated laboratory tools, and what’s available from commercial companies and covered by medical insurance.
When coronavirus hit and Trump started making noises about cutting off our trade with China, I tried to get all my prescriptions renewed one last time. I was sure one had Chinese ingredients. I wasn’t sure about the others.
I wasn’t the only one. Apparently many people started stock piling their medications at the time albuterol inhalers were being used to treat respiratory problems of people with COVID-19. A scarcity developed, although one publication glibly said it wasn’t a supply problem, just an increase in demand. [2] Try that answer on an economics exam.
This is where the reality based on television takes over. In the typical medical drama like Marcus Welby or Doctor Kildare, a problem is identified before the first commercial, a desperate search is made, and, just before the final advertisement, a solution is found.
The one I remember most clearly was a M.A.S.H episode that was rerun about the time hantavirus was infecting Native American athletes. In the beginning, the medics are treating some patients with hantavirus and Klinger says he has the same symptoms. The medics assume he is playing another role to be dismissed from the army, and ignore him. Then when he gets really sick, they discover it also can affect Lebanese like him. They gave him the necessary treatment, and he was back in full drag in the next episode.
In the case of albuterol, the Federal Drug Adminstration reported the shortage, probably in April. [3] Medical websites warned people with asthma to use their steroids and other maintenance drugs, and not rely on albuterol. One even said a canister should last several months. [4] The medical research reported in December had not percolated through the establishment.
Then, the government took action. The FDA approved "the first generic version of an albuterol sulfate inhaler" to increase supply. [5] After that appeared, the stories of shortages disappeared.
I couldn’t get my refill in April because the prescription had expired, and I had postponed by annual physical until New Mexico began to allow some offices to reopen. Then, I got the one with Chinese ingredients first.
Next, and now it was August, I needed to refill something that was running out. This was when it was becoming obvious the Post Master was slowing down the mail. It took three weeks, instead of two to get the refill. I ended up taking the medicine every third day, instead of daily, to get by.
Now it was time to reorder the albuterol. I thought I was safe, but then my next to the last canister failed. This happens every couple years, and now I was down to one that was half gone, if I trusted the meter on it.
The post office has improved since its actions were publicized. I mailed the prescription on Monday, and on Thursday got an acknowledgment that it had been received. Then Saturday, I received an "urgent" message to call them.
Saturday was the first day of a three-day holiday. I called and was told my prescribed version of albuterol was out-of-stock, and to call back Monday. It was after that that I went on-line and searched for keywords "albuterol" and "shortages."
It’s been a difficult summer when smoke almost constant from fires in Mexico, Colorado, Arizona, California, and local ones like Rio Medio. Saturday the California and Medio fires were sending smoke that accumulated in front of the Jémez and even began to obsure the badlands.
I started worrying because I didn’t know the nature of the shortage. I didn’t dare take the remaining medicine, lest the canister fail. I put on my cotton beard mask in the house. I tried inhaling oxygen from an oxygen bar, a device used by gym rats to give themselves an edge. It only helped a little. I used a little of my precious cough medicine to treat the nasal drainage caused by the smoke. (Precious because it also became unavailable for reorder in April).
Instead of taking medicine in the middle of the night, I got up and spent half an hour on the oxygen bar. Then, and only then, did I take a puff of albuterol. Note, I said a puff. The prescribed amount is two.
I called Monday, but of course only the answer line people were working. I did ask when the other people would be available Tuesday, and was told 5 am. I asked the man his time zone, and calculated someone would be available at 6 am.
The smoke was worse yesterday, and I was still just as cautious.
Today, I was told the generic form I used was out of stock, [6] but that the name brand was available. The difference would be $100 co-pay instead of zero.
This is where having some savings or other financial resources matter, and why the poor suffer most in pandemics. I authorized the increased payment, and asked when I should have it. He was a bit hesitant, because so much depended on the post office, but he hazarded by the end of the week.
I got off the phone, and took some medicine.
When I get the prescription package I’ll discover the real cost. When I last had the medicine refilled it cost $105 for three months, and that was six canisters. It’s never been zero.
Over the weekend I was considering asking my doctor’s office for another copy of the prescription to take to a local drug store to see if they had it. That chain would be experiencing similar problems, but there was a chance the New Mexico warehouse might have more than the national one preferred by my Medicare Part D insurer.
The daily reports on Wikipedia, which have been less regular, indicates the number of new cases of Coronavirus since September 1 has come down from 31 to 22. The number of deaths in two weeks remains at three. [7]
Another holiday may change all that, and new storms can ignite new fires.
Sources:
1. "Inhaled steroids may not work for half of asthma patients." PulmCCM website. 12 December 2019. Its source was the New England Journal of Medicine.
Suzanne Leigh. "Gold Standard Asthma Treatment May Not Be Effective for Most Patients with Mild Asthma." University of California San Francisco website. 19 May 2019. Its source was the New England Journal of Medicine.
2. American College of Allergy, Asthma and Immunology. "A message to asthma sufferers about a shortage of albuterol metered dose inhalers." 9 April 2020. It had the sentences: "it is not a production problem. The shortage is occurring because of the increased use of albuterol inhalers in hospitals."
3. United States Federal Drug Administration. "Drug Shortages" website. It still had the announcement of the albuterol shortage when I looked yesterday, 7 September 2020.
4. American College of Allergy, Asthma and Immunology. "It is important that you not overuse your albuterol inhaler, as one canister should last for months."
5. Kristin J. Kelley. "FDA Approves Generic Asthma Inhaler, Acknowledges Shortage Due to COVID-19." Jwatch website. 9 April 2020. Its source was the New England Journal of Medicine.
6. I had thought when my doctor (another one from the ones so far mentioned) changed my prescription, it was to a generic, but perhaps it was just to a cheaper alternative that insurance companies would accept.
7. Wikipedia. "2020 Coronavirus Pandemic in New Mexico." Updated daily.
