Saturday, April 22, 2017

Madge Pontius - 1927-2017

On April 20, 2017, an embodiment of tenacious, loving humility entered into the collective memories of those who knew Madge Pontius, 89, of Coral, Michigan.

Madge's neonatal cries were first heard June 7, 1927 in Sheridan, Michigan, as the daughter of Aden and Goldy Verda (Case) Springsteen.  She was raised on the family farm in Sheridan and graduated from the Sheridan Community Schools Class of 1945.

She got to know her lifetime sweetheart, Dude (Durward) Pontius, through an 18 month correspondence during World War II, encouraged by her brother Ed.  When she and Dude finally met at the train station, her eyes “twinkled, her eyelashes fluttered” and they couldn’t keep apart after their first kiss.  They married three weeks later, with the warning from her mother that such whirlwind romances never last -- before Dude’s passage in 2010, they shared 65 wedding anniversaries.

While Madge was employed briefly at Gibson’s and Ore-Ida, her real work was with and for her family.  Her daughters fondly recall the marathon shopping expeditions that were a hallmark of every Christmas holiday, and she let everybody in her family and circle know her love, even when called “medieval” in her discipline, and always with her secret recipe for pot roast at the ready.

Her music was an extension of this love, with hands that could find a keyboard in nearly any room of the house, and her artistic temperament expanding to painting, dancing, and quilting.  Wednesdays were frequently set aside for duets on keyboards and strings with her son David, who shared her musical muse.

Madge and Dude were both long time members of the Cowden Lake Christian Church and the Hough-Pontius VFW, where she was part of the Ladies Auxiliary.

Her passage was peaceful, having heard the loving appreciation and devotional words of friends and family, in the home that she had built with her husband, Dude.  Her embrace of that location was an extension of her love of those 65 years together.

Madge will be remembered by many, but most deeply by her three children:   Carol Hale of Greenville, Dave (Vickie) Pontius of Stanton, Anne (Jim) Middleton of Battle Creek.  Her surviving extended family includes nine grandchildren, nine great-grandchildren, and great-great-grandchildren, one brother Harold “Hud” (Dorothy) Springsteen of Sheridan; two sisters-in-law - Helen Springsteen of Stanton, and Lois Springsteen of Sheridan; many nieces, nephews, friends, and her church family.

Madge was preceded in death by parents Aden and Verda Springsteen; her husband Durward Pontius in 2010; one son, Mark Durward Pontius; and two grandchildren, Andrew Joseph Hale and Nicola Marie Hale; siblings John Springsteen, Loretta Potter, Lorna Wolf, Edwin Springsteen, and Donavan “Mick” Springsteen.

A Celebration of Madge Pontius will be Tuesday, April 25, 2017 at 11:00 am at the Cowden Lake Christian Church, with Pastors Cris Hammer and Julie Drews officiating. Memorials to Madge may be directed to the Cowden Lake Christian Church.  Electronic condolences to the family may be made utilizing the guestbook at, but Madge always preferred her displays of affection to be face-to-face, a tangible artifact, a wisp of happiness - a fleeting moment of joy.

Saturday, April 08, 2017

Scanning and Merging Some Sketches, ca 1978-1980

Scanned in using Photoshop, no real corrections needed, at 300dpi.  Then entered into Sony Vegas, 6 frames per image, merged with a 0.2 overlap for each sketch, exported as mp4, reimported and reversed in mp4, then with a stretched slide whistle effect both in and out, and again exported as mp4. Then to be fancy, added a border sketched in 1978, based on the Red Seal opening title from "Paris Qui Dort" by Rene Clair.   Far too much for this 3 second clip, but it's one more thing off the list!


Saturday, March 04, 2017

Notes from The Cornered Druggist: Xerese, another useless FDA-approved drug

(While listening to public radio this morning, I was struck by its discourse on language and its various paths of evolution.   The combination of the letters “GM,” for example, can mean "genetically modified," "General Motors," or my first name when spoken in Alabama. But I digress...)

Yesterday, I received an order from a dentist's office for a product called Xerese, something we have never stocked, and a product that was listed as available from my wholesaler for the princely sum of $1085. This certainly warranted further exploration.

It turned out that this five (5) gram tube of an ointment contains a combination of 5% acyclovir and 1% hydrocortisone.

Acyclovir, a long-generic antiviral treatment for herpes, comes in capsules of 200mg for about 10 cents each, and hydrocortisone has also been available as an ever-the-counter product and can be found at a dollar store for, well, a dollar.

Five grams of Xerese contains a total of 250mg of acyclovir (a 5% concentration means 5 grams in 100 grams, so using the cross-multiplication process in algebra -- oh heavens, this note contains math! -- 250mg is in 5 grams, after the proper conversion of grams into milligrams -- oh my head, more math).

This means Valeant, the makers of Xerese, is taking raw materials that cost at most $1.10 and is charging $1085 for the product, wholesale.

So you may wonder why I just don't make this product by scratching together the ingredients,
investing about five minutes of mix and label time, and pass it on to the patient at a huge savings.

The answer is this - I am forbidden to do so by federal law. The FDA has given the license for this combination to Valeant of Canada, and for me to create the combination is to violate the directives of the FDA, and in so doing, would be dispensing a non-FDA approved product.

You may recognize the name Valeant, by the way, one of the recent collection of gouging pharmaceutical companies.

However, I can get a prescription for 8 acyclovir capsules from that dentist, see that the patient charge is no more than $5, then instruct the patient to get a one dollar tube of hydrocortisone ointment from my shelf, and then, by demonstration, show the patient how to mix the two products, how to put the combination into a one-ounce ointment jar, and then possess not just five grams, but thirty grams of homemade "Xeresel” with a wholesale value of over six thousand dollars.

To put it in context: Xerese costs $217/gram.   Gold (as of 3 March 2017) costs $39.70/gram.

Sadly, the WMU prescription benefit actually covers this product with a $40 copay to the patient. I will be aggressively petitioning them to correct this oversight.

Monday, January 16, 2017

Breakout Discussions at the October 2016 Heroin Summit Conference, Battle Creek, Michigan

Questions, notes, and discussion from the Opiate Summit - October 2016, Firekeeper’s Casino, Battle Creek MI
Breakout session - Jim Middleton, moderator
(the session ran 90 minutes - here are some of the notes I took during the discussion, covering nine of the dozen questions posed by the moderator (me), the panelists, or the audience.)

1. Akron, Ohio had a sudden emergence of carfentanil - how do we prepare for such an emergency in this area? - increased monitoring of nalaoxone use in treating overdoses - if it takes more than a few milligrams to resurrect the patient, chances are strong that the product in question contains carfentanil.  At present, fentanyl and carfentanil are not part of routine screening; current law enforcement personnel is able to focus on marihuana possession with greater interest because the product itself is so very visible.  Carfentanil can be lethal at a dose of 1mg.

2. When can we see improvements to the current MAPS program?  - the new server is set to roll out in January 2017, with clinicians being able to review their own MAPS usage data (to check for unauthorized use of their DEA information) in April 2017.  The internal flags within the MAPS program are set pretty high - reportedly, it takes the use of many multiple unique clinicians in a 30 day period to flag a patient as being suspicious, placing a lot of the interpretive burden for abuse at the level of the pharmacist.  Clinicians are still underutilizing the MAPS program, not helped by its “voluntary” participation.  (The Lieutenant Governor, during his opening remarks, openly acknowledged the challenge of the narcotic problem in Michigan, but seemed reluctant to increase any regulatory burden by Michigan upon the clinicians.)

3. How do you perceive the 25% reduction in opioid production affecting the current heroin crisis?  - the lack of access to legally prescribed and manufactured opioids will result in an increase in illicit use.  While the DEA is taking steps to reduce the total amount of opioid products available for use, with the tools they have at their disposal, the overall impact of this restriction is being regarded as misguided: pharmacies with the wherewithal will begin stockpiling product in anticipation of the shortage by year’s end, which will only further contribute to the shortage.

4. What responsibility do drug companies have in this opioid abuse problem?  - the concensus in the group was that it laid a lot of blame on the drug manufacturers, both for creating the problem and for apparent price gouging for the treatment - naloxone prices have escalated 400% in just the past few years.  LARA (Michigan’s Licensing and Regulatory Affairs) was also taken to task for their perceived lack of oversight, giving Michigan the reputation of being the “new Florida” (one peninsula switched to another) for “bad prescribers.”

5. Family medical providers are the most common over-prescribers.  Any studies on the causes of this or the actions being taken to reign in this practice?  - It takes 30 seconds to say yes, 30 minutes to say no.  Independent physicians have been placed in group practices in order to maintain reimbursement through their insurance contracts.  Blue Cross began cutting reimbursement by 25% to independent clinicians while linking reimbursement to community health improvement.  In January 2017, Blue Cross, through its pharmacy benefits provider (PBM) Express Scripts,  is also restricting controlled substance analgesics to a 30 day supply, along with a maximum daily “morphine equivalent” for pain therapy before triggering a prior authorization process.   Caremark, the nation’s other primary PBM is implementing similar restrictions in 2017.  Both PBMs are implementing these new controls in a rapid manner, often with only a few weeks’ (or days) notice.

6. What is “Pink”?  An Upjohn test drug with about 7 and ½ times the potency of morphine, it was not considered useful enough to go beyond initial studies, but was assigned an ID of U-47700.  The patent has apparently expired, and its manufacturing information has been circulating.  Pink, carfentanil, “bath salts” all seem to be originating from labs in China and are being distributed to the United States by way of Mexico.

7. What can hospital administrators do to help or support providers/clinicians?  Hospital emergency departments in Grand Rapids have created a network to identify and move opioid “frequent fliers” into rehabilitation programs, while strictly limiting outpatient prescriptions for controlled substance analgesics.  Cross-platform EMR databases also help to identify patients with similar health-risk behaviors.

8. Heroin addicts - criminals or victims?  - The original view that the overdosed heroin user was a victim was embraced by law enforcement in March of 2016.  However, by year’s end, the repeated revisits to overdosing are taking their toll on law enforcement attitudes.  One weekend, police rescued the same patient 6 times in a 48 hour period, and the patient refused further treatment.  Such rescues are becoming a challenge with pressures to work staffing more “efficiently” and with other police services still requiring attention.

8. What is the status of naloxone and pharmacy distribution in Michigan?  - still adrift in the Michigan legislature (October 2016), Kent and Kalamazoo counties have proactively partnered with Spartan-Nash stores and Dr. Sandra Dettman of Grand Rapids to provide naloxone kits with a prescription umbrella from Dr. Dettman.  The kits are 2-packs of naloxone in nasal spray format, with 4mg naloxone per dose.   The public is still completely misinformed about the effects of naloxone being a “cure” for the overdose - it is only effective for minutes before requiring re-administration, and carfentanil requires a substantial increase in dose for effectiveness (and is effective for an even-briefer period of time).

9. Has Adderall been a problem? - Adderall and other ADHD stimulants in the DEA C-II category are routinely abused or sold by students, prescribed with very brief physician interactions, and are coming under increased DEA scrutiny once it feels adequate processes are in place for opioid review.  “Helicopter” parents are pressing clinicians to prescribe stimulants, not for ADHD, but for performance enhancement in academics and athletics.  Stimulants used in such a manner may increase attentiveness and short-term memory retention, but may actually diminish long-term retention of information.

(cc) Jim Middleton, The Animating Apothecary