As a Pharmacist I really didn't like the way that the Hive Learners post came out today.
WHEN TOLERANCE BECOMES A THREAT
And then it mentioned that (and I'll paraphrase).
...When you take a drug for an extended period of time, your body becomes tolerant to it.... some illnesses that now resist simple treatmentsAgain as a Pharmacist I had to think. What are they really asking me to answer? I say that because it could actually be more than one type of question. I'll highlight three different scenarios and then target the one that I think was really being asked.
Scenario #1 -- Sulfonylureas for diabetes (ie. Glyburide).
Ever wonder how you make a horse run faster? A rider will often whip it, flog it or otherwise give it an incentive to run faster. However, that only works so long. Eventually the horse just thinks forget it, I'm not running any more.
Guess what? Something similar to that happens with Glyburide. Now this medication is used to help the body secrete more insulin and can be helpful in the initial stages of Type 2 diabetes. Take the medication, prompt the body to release more insulin and blood sugar goes down helping diabetes. Unfortunately, it doesn't last. Eventually the body becomes tolerant to the higher insulin levels and the medication is no longer effective. It fits the post prompt but I don't think that is what the moderator was looking for.
As a side note this can actually be a way for some medications to work. Capsaicin is actually used for pain relief. However, initially it causes the body to release more pain producing mediators as it is a spicy pepper extract. Given continuously though the body just kind of gives up responding and the natural pain mediators either run out or are less effective and as a result pain goes away. But I digress and I'll get back on track.
Scenario #2 -- Diminishing effects (ie. Dimenhydrinate / Morphine)
Some medications the body just becomes tolerant to over time. Gravol (Dimenhydrinate) is something that is supposed to be used to treat nausea. Many people use it for insomnia. For occasional use it can be effective and I often take it on vacation with me for jet lag. However, with continual use it becomes less and less effective so people often take more and more. Unfortunately as the dose goes up the amount that causes serious problems stays roughly the same and people work there way continuously towards overdose. Bad scenario.
Morphine and all its alternative forms the body downregulates to over time. Downregulation basically means that over time the body becomes less susceptible to the medications effects. More and more medication is required to get the same effect. Indeed that happened to my father when he was dying of bone cancer. At first he was on 30mg of Morphine...near the end of his life he was at over 3000mg. Perhaps some of that was the progression of the disease but a large part was simply that the medication was less effective. End result: people need to keep taking higher and higher doses.
Now in the case of morphine (and other opioids) some people chase the same initial "high" or euphoria they got on the first dose and that is never going to happen. There is the term "Chasing the Dragon" which usually ends up again very badly. Other times they are chasing pain relief but often morphine can't make people pain free so they just take more and more and never get complete control and often get hyperalgesia (worse pain). Another less than ideal solution.
However, I also things this isn't what the moderator was looking for as Morphine and its related medications is rarely considered a "simple treatment".
Scenario #3 -- Bacteria resistance (Quinine and other antibiotics).
The poster child for medication losing effectiveness would be Quinine. If you haven't heard of Quinine it is used to treat Malaria. Well, it formerly was used to treat malaria. I would guess that there is widespread resistance of the protozoa that causes malaria and Quinine is rarely if ever the first choice ... although in some instances it may be used as backup.
The same can be said for Penicillin for skin infections. Maybe it would work I would be surprised if any physician wrote it as their first choice for the majority of infections.
In fact a great many bacteria are now resistant to one or many different antibiotics and things that used to be treated with a simple prescription for :
Amoxicillin 500mg
i TID x 10d
m: 30Would now require a more complex treatment. Perhaps a culture and sensitivity test to verify what antibiotic the infection is susceptible to. In some cases even more invasive therapy.
I have a feeling this is what the moderator was asking about so I'll continue using that as my premise.
A world after antibiotics It is hard for most modern people to think of a world without antibiotics. However, years of misuse has made a problem that is unlikely to be avoidable. Likely it is not a matter of if there will be a problem but rather when the problem will be insurmountable by current techniques.
Here is the problem in a nutshell. Assume that a person has a billion bacteria causing an infection. That person takes an antibiotic and kills off all but a thousand of the bacteria. The person feels better because there is no bacterial load to speak of. Unfortunately guess which bacteria are left? The ones that were the least susceptible to the antibiotic. Guess which ones start growing again? The ones that were left. To make matters worse bacteria "talk" to each other and spread defensive techniques.
When the well runs dry
Right now there is a lot of antibiotic resistance but there is typically something that still works. I'm far more likely now to see someone start on amoxicillin, move to clarithromycin and then try again with clindamycin than I would have seen when I started as a Pharmacist. I'm more likely to hear about someone being sent to the hospital for IV antibiotics than when I started also. But what happens when antibiotics stop working?
Elective surgeries stop
Here is the thing. When you cut open the body there is always the risk of infection. If the infection is easy to treat? Do the surgery and treat infection if it occurs. Or do preventative antibiotics and no issue. *But if antibiotics are ineffective?
- Dental surgery could lead to very serious complications
- Cataract removal becomes far more risky
- Hip replacement surgery or knee replacement...scary
- Open heart surgery, coronary artery bypass grafts, etc.
Common surgeries becomes far higher risk if people do it at all
A return to the bad old days.
Increasingly diseases that were previously thought treatable may very well become untreatable. A quick look at Tuberculosis. A horrible disease that progressively destroys you lungs until you can no longer breathe. Used to be easily treatable. Now treatable with combination therapy which causes far more side effects and for longer duration. However if those medications become ineffective? We go back to the bad old days where people had lungs deflated.
However, there are a lot of things that were common that don't happen now. Imagine a simple scrape turning into the loss of the arm. Amputations could be far more common if antibiotics don't work. A dog bite? A cat scratch? Step on a nail? Now they could very easily become life threatening.
Old remedies become far more important
But just because antibiotics stop working doesn't mean that we don't have things that kill bacteria. Simple soap and water? Hydrogen peroxide? Rubbing alcohol? They become far far more important to keep people alive! Due to how they work bacterial resistance to these items is highly unlikely. Still...they are no substitute for a good antibiotic once an infection takes hold.
The antibiotic substitute.
Not to be all doom and gloom there is a replacement possibility after antibiotics. Phage treatment. Phages are natural viruses which kill bacteria. They are highly effective in their job. Unfortunately they are also highly specific. Instead of being able to just give a cephalosporin antibiotic for a cut or scrape. Now you have to find the exact bacteria causing the infection and culture for each individual. That means there is no quick treatment available. It also means a very expensive treatment for an individual. For those without resources? Availability becomes a serious issue.
Survival of the fittest
For those people who can't get the dedicated individual treatment? Well, supportive care. You have an infection and if your body is strong and able to fight it off...you live. If your system is weak and cannot fight it off? You die. Nursing care just give you the best chance to fight it off.
Closing Thoughts
When people come into the pharmacy they often ask why "simple" medications are behind the counter. I usually say that with every medication there is a risk and reward. Simple medications like amoxicillin have a dark side that not everyone sees. Other drugs can also become ineffective if used improperly. I mentioned morphine, glyburide, and dimenhydrinate. I could have easily added cancer treatments which the cancer calls can adapt to over time. I could have added biologics for autoimmune disorders where the body makes antibodies to the treatment over time. I could have even added vinyl gloves or adhesives where the treatment becomes toxic over time (after 32 years my hands now reject the labels I need to attach to medication). However, I think antibiotics worked the best to fit the prompt and fit the best to make many sick people better. Unfortunately without changes in how they are used there will be some big changes that need to happen in the future.And that's my take on the current Hive Learner prompt. I don't think it was the best worded prompt but I hope I answered the question. Of course I love responses so feel free to write ... I love feedback.
And hope that I never see a post antibiotic world in my lifetime
