When exploring urgent treatment options for your patients, be sure to look at the bigger picture before you push the panic button.
PSYCHIATRISTS ARE PHYSICIANS FIRST
It was the kind of voice message that I hate to hear: “He needs Xanax. He is having panic attacks.”
I recognized the voice of the social worker who left the message. She was a nice person, kind and caring—which is why I referred my patient to her in the first place. She was not the kind of MSW who treats psychiatrists like short-order chefs who take orders from therapists who themselves act like harried servers as they shout orders at kitchen cooks hidden behind tall metal shelves that separate the counter seating from their sizzling-hot oven surfaces.
That other kind of therapist evokes images of old-time diners—the Landmark Coffee Shop, in particular—which I passed en route to my Soho office, before my office closed for the pandemic. Always overcrowded and understaffed, Landmark was indeed a landmark, for it miraculously survived the changing landscape of New York City’s Soho District and persisted even after the pandemic emptied out nearby New York City offices.
Even if I hated to hear voice messages with demands for Xanax, I enjoyed recollecting Landmark, where strangers shared tables with other strangers, in scenes remotely reminiscent of Edward Hopper’s Nighthawks painting. Fortunately, Landmark’s strangers could connect with one another over coffee, unlike the alienated individuals who populate Hopper’s Nighthawks.
My fingers immediately started typing an email to the patient in question (“Kenny”). I was already certain that Kenny needed an appointment, even if it was unlikely that he needed a Xanax prescription. The urgency of the therapist’s message told me that we needed to schedule something STAT—especially since Kenny was not known to have panic attacks.
On the other hand, Kenny had a history of substance use, which he overcame through hard work and determination, and by making a “geographical” to New York City, away from the sunny streets of South Beach, which was known for its Art Deco hotels, as well as its over-the-top party scenes.
He repeatedly reminded me of his love for Miami’s Art Deco and how much he hated to leave such architecture—but how much he realized that his hotel concierge job, coupled with Florida’s non-stop party scenes, made it impossible to stay sober there.
It surprised me that someone would suggest a Xanax prescription for such a person—if they knew his history. It was possible that Kenny omitted this salient part of his past and focused only on the ex-boyfriend he had left behind—the one who had been an albatross on his journey to an alcohol- and drug-free life.
Then again, I wondered if Kenny had relapsed and convinced his new therapist to recommend his old favorite, which would be unfortunate, but not entirely unexpected, given the high rates of recidivism. Alternatively, it was entirely possible that this so-called “panic attack” resulted from resumed cocaine use, which is often described as palpitations or a “panic,” but which carries more medical risk.
While awaiting a response from Kenny, I was reminded of a case from years ago when a very different sort of social worker contacted me and demanded that I change a patient’s antidepressant because the patient’s sertraline was making her vomit.
Yet the patient had been on the same medication and the same dose for many months, making the MSW’s “diagnosis” unlikely, since SSRI-induced nausea almost always remits within a week and almost never appears many months later (unless the patient forgets to take it with food).
That therapist worked in clinics in which psychiatrists have limited control over clinical activity and therapists often forget—or perhaps never knew—that psychiatrists are physicians first who must assess a patient and do a differential diagnosis before making clinical decisions or prescribing medications.
That latter call came along before the days when telepsychiatry had become standard, yet I was able to get a basic history from the patient over the phone. The patient was vomiting. She stated that she was doubled over with abdominal pain and was not merely nauseated. This was clearly a medical problem, not a medication complication, and it demanded an emergency room (ER) evaluation.
The ER doctor diagnosed an acute abdomen, ordered imaging studies, and subsequently sent the patient off to surgery. It turned out that the patient’s gastrointestinal discomfort resulted from torsion of an ovarian tumor.
That experience further confirmed the need to follow medical protocols, even when confronted with reasonable requests from other mental health professionals. In that case, the request was unreasonable, given what we know about SSRIs and gastrointestinal symptoms. It was also apparent that the patient would have died if she not immediately been transferred to surgery.
In Kenny’s case, I knew both the patient in question and the therapist well. The therapist admitted that she had not had time to get a full history and had focused only on the source of immediate distress, which revolved around ending a relationship. She did not know about Kenny’s history of substance misuse or his long history of binge eating. As it turned out, the history of substance use was only 1 of several chess pieces in play.
Kenny had started treatment because of his binge eating, which had worsened whenever he attempted to stop drinking alcohol. His binges revolved around ice cream cravings, which are often reported by individuals who are newly alcohol-free.
To Kenny’s chagrin, he had gained considerable weight since moving to New York City, where he did not have immediate access to swimming that was behind his back-door in Florida, and where he had more tempting restaurants to choose from than ever before.
This bingeing and weight gain were especially unwelcome at a time when Kenny was seeking out new romantic relationships. He also feared a return of the depression that had accelerated his alcohol use in the past.
At that time, there were anecdotal reports that glutides (glucagon-like peptide agonists, or GLP-1 agonists for short), which were already approved for diabetes treatment, could deter alcohol cravings. It was known that they decreased appetite and caused weight loss—when prescribed at doses that are higher than doses used to control diabetes, although some individuals noted appetite decreases early on, at doses lower than expected.
It seemed like a solution was at hand. When Kenny’s insurance agreed to pay the high price, it was an extra and unexpected bonus. Their decision may have been influenced by Kenny’s attempted but harmful trials of other less expensive medications. He had previously developed a kidney stone while on topiramate, so I could not represcribe this medication that curbs both food and alcohol cravings and decreases impulsivity.
Kenny’s past misuse of stimulants made Vyvanse an equally undesirable choice, albeit for different reasons. Adding bupropion to naltrexone (to create a cheap generic version of expensive Contrave) was a possibility, but there were risks to that approach, given Kenny’s past overuse of alcohol and the chance that some individuals “forget” to take the naltrexone that curbs alcohol use and “forget” that the seizures can follow alcohol binges in individuals on bupropion.
When the insurance approval came through for one of the glutides, Kenny’s primary care physician prescribed the injectables almost immediately. All went well for a while, and Kenny lost weight even before he reached target doses typically needed for obesity control. He was thrilled with the result but stressed, as he hoped for even faster progress because he had many more pounds to go.
Now Kenny had a new bout of attacks. At his appointment, he insisted that he had not returned to drinking, which was an important variable, since the panicky feelings often follow stopping alcohol use. He flatly denied the use of cocaine or stimulants, either licit or illicit, that could mimic panic attacks. He said no new stressors had arisen in his life. The only change since our last appointment was a higher dose of glutides and a change in his eating patterns.
Digging deeper into the details, I learned that Kenny barely ate at all during the day. He said that he was so encouraged by his initial response to the glutides that he wanted to push further and faster. Noting that his appetite completely disappeared on his new injectables, Kenny confessed that he went without food whenever he could. Without food, but with a potent antidiabetic agent on board, Kenny was likely becoming hypoglycemic, and hypoglycemia manifests itself with the exact same symptoms as panic attacks—at the start.
At that point, another flashback from many years past surfaced. The horrific image of a diabetic patient had been etched into my memory, indelibly, decades earlier, while doing an elective in endocrinology. The image was impossible to erase in spite of the passage of time.
This “screen memory” (to use Freud’s words, in one of the rare instances in which Freud referenced film, a medium he otherwise disdained) appeared in my mind’s eye. It dated to medical school when I was trailing along with the entourage on morning rounds. We stopped at an unresponsive patient, whose limbs were distorted by contractions that he had acquired while residing in an understaffed nursing home that did not do physical therapy for bedbound patients. How did he get that way? The endocrinology fellow was eager to share salient “teaching points.”
That poor fellow was an “insulin-dependent diabetic,” as type 1 diabetes was known in those years. He also had an alcohol use disorder (as implied by empty alcohol bottles found at his bedside and noted on his chart).
It was surmised that he had passed out from alcohol after injecting himself with his insulin, and so did perceive the symptoms of hypoglycemic (such as tachycardia and diaphoresis) and was unable to down the requisite orange juice with sugar cubes (which were standard emergency treatment for hypoglycemia in those years). As a result, he sank into a coma and suffered irreversible brain damage—or so the story was reconstructed.
I surely did not want Kenny to suffer such a fate, so I told him this story. I found that telling patients stories (especially “old time” stories) often helped them understand the impact of their choices more easily than straightforward messages that sound like moralizing.
Then I told Kenny another story about the vast vat of peanut butter kept in the anteroom to the labor room, where doctors and nurses scooped a tablespoon of peanut butter as they scurried to emergency deliveries. That way, they ensured that their blood sugars did not drop and interfere with their concentration during such critical procedures.
I informed Kenny that peanut butter’s high protein and high fat concentration protected against blood sugar dips that typically followed pure carbohydrate consumption. Plus, peanut butter had far fewer calories than most individuals assumed (only 35 calories per teaspoon), making it an excellent choice, provided that one was not allergic to peanuts. Assuring me that he had no such allergies, Kenny agreed to this simple “peanut butter prescription” to avoid the dangers of low blood sugar.
Not long after this event occurred (and fortunately did not recur), reports about Ozempic overdoses and poisonings appeared in mainstream media. Reports poured in from the Los Angeles Times,1 the New York Times, the New York Post,2 as well as CNN and ABC and probably many more sources. On December 18, 2023, Brenda Goodman’s broadcast on CNN Health’s Live TV noted that “poison centers see nearly 1500% increase in calls related to injected weight-loss drugs as people accidentally overdose.”3
A few days earlier, on December 15, reporters Youri Benadjaoud, Katie Kindelan, and Lindsey Krill likewise informed ABC News viewers that “poison control centers report increase in calls related to drugs used for weight loss.”4
Even earlier, on December 13, the New York Post wrote that poison control centers were hearing more and more about “severe nausea, vomiting, and stomach pain,” which usually resolved with IV fluids, but sometimes required hospitalization.2
Even though the Post’s headlines “named names”—and specific brand names at that—the text of the article implicated “compounded versions of semaglutide drugs [that] often come in glass vials that contain multiple doses, [so that] patients draw their own doses into syringes [which] makes it easy for patients to get confused and take a much larger dose than they should.”2,5
Those less expensive “compounded” versions of semaglutide (which are manufactured by unauthorized sources and supplied by “medical spas” or online sources that operate on the fringes of FDA jurisdiction) became popular because they were so much more affordable than cost-prohibitive branded versions of similar pharmaceuticals.
Then the New York Times rang an even more ominous warning bell the first week of the new year. On January 7, 2024, the Times alerted readers about even easier ways to obtain these coveted weight-loss medications. In an article entitled, “As Eli Lilly Wades into Telehealth for Weight Loss, Doctors Are Wary,”6 the Times detailed new distribution channels for medications that went into short supply soon after Hollywood stars bragged about their miraculous powers.
According to the Times, LillyDirect teamed with an independent telehealth company that prescribed medications.6 Pro and con debates about this tactic followed the headlines. Speculation about competitors who might enter this evolving market ensued. It was already well-known that some well-established previously “non-medical diet programs” had started hiring their own professional staff to prescribe these injectable medications via online consultations only.
Shades of Cerebral and Done came to mind. Those headline-making online startups took advantage of loosened oversight of stimulant prescriptions during the pandemic—but were subsequently stymied when an alphabet soup of acronym-named government agencies swooped down on them.
The DEA, the FDA, and even the DOJ would temper overly zealous prescribing patterns that followed underscrutinized clinical evaluations performed by overworked nurse practitioners, some of whom contacted those regulatory agencies, as well as various news outlets.
Fortunately, Kenny did not fall into this quagmire, and harm was averted simply by applying standard differential diagnostic tools and recalling that psychiatrists are physicians first. We are not mere prescription providers who function like ‘50s-era Pez dispensers. Luckily, in Kenny’s case, we did not push the “panic button” before exploring the bigger picture.
Dr Packer is an assistant clinical professor of psychiatry and behavioral sciences at Icahn School of Medicine at Mount Sinai in New York, New York.
1. Childs J. Ozempic overdose? poison control experts explain why thousands OD’d this year. Los Angeles Times. December 20, 2023. Accessed January 15, 2024. https://www.latimes.com/science/story/2023-12-20/semaglutide-ozempic-wegovy-overdoses
2. Lallanilla M. Poison control got 3,000 calls due to Ozempic overdoses this year. New York Post. December 13, 2023. Accessed January 15, 2024. https://nypost.com/2023/12/13/lifestyle/poison-control-calls-jump-1500-due-to-ozempic-overdoses/
3. Goodman B. Poison centers see nearly 1,500% increase in calls related to injected weight-loss drugs as people accidentally overdose. CNN. Updated December 19, 2023. Accessed January 15, 2024. https://www.cnn.com/2023/12/13/health/semaglutide-overdoses-wellness/index.html
4. Benadjaoud Y, Kindelan K, Krill L. Poison control centers report increase in calls related to drugs used for weight loss. ABC News. December 15, 2023. Accessed January 15, 2024. https://abcnews.go.com/GMA/Wellness/poison-control-centers-report-increase-calls-related-drugs/story?id=105685860#:~:text=As%20the%20popularity%20of%20drugs,3%2C000%20calls%20related%20to%20semaglutide
5. Lallanilla M. Fake Ozempic is putting desperate users at risk—how to spot knockoffs. New York Post. November 7, 2023. Accessed January 15, 2024. https://nypost.com/2023/11/07/lifestyle/fake-ozempic-putting-users-at-risk-how-to-spot-knockoffs/
6. Blum D. As Eli Lilly wades into telehealth for weight loss, doctors are wary. New York Times. January 5, 2024. Accessed January 15, 2024. https://www.nytimes.com/2024/01/05/well/weight-loss-tirzepatide-lilly-telehealth.html?smid=nytcore-ios-share&referringSource=articleShare