A Small Opening to a Big Problem

“Doctora, Melissa left some FMLA paperwork on your desk, please fill it out soon.” Knowing that I am tardy at paperwork, my medical assistant reminded me before she left for lunch.

“Melissa who?” I couldn’t think of any Melissa on the top of my head who would need Family and Medical Leave Act application right now. Mostly, I fill out FMLA papers for new parents after I deliver their babies. And none of my recent delivers were to a Melissa.

“Melissa Ruth".”

“What? Why?” Melissa Ruth is a young, previously healthy patient of mine. We recently discovered that she had anal fissures, which are painful cuts in the rectum that make defecation extremely painful. They are usually caused by constipation or really persistent diarrhea, resulting in cuts in the lining of the rectum that are non-healing. These fissures can bleed. Sometimes even light touch or sitting is uncomfortable. They can really disrupt one’s life if untreated.

But Melissa and I have been trying many different treatment modalities, taking a step-wise approach. One of these treatments would have worked by now, she should be well on her way to healing!

Puzzled, I picked up the phone and called her.

“Hi Melissa, this is Dr.Zha. I received your FMLA paperwork. Did the cream I send you not work?”

The cream I was referring to was called Rectiv, the brand name for 0.4% topical nitroglycerin, which works by relaxing the blood vessels in the rectum, and in turn takes pressure away from the anal fissures. By doing this, the medication reduces symptoms of pain, and allows healing of the cuts. I sent the cream over two weeks ago, it should have worked by now. If not, usually I would have heard from the patient.

Melissa started to cry on the phone.

As it turned out, her insurance didn’t cover the medication. So she couldn’t afford it.

How expensive can a rectal cream be, you ask?

According to GoodRx.com, Rectiv is over $700 without insurance, and with a coupon, the price is brought down to “generous” $650 a tube.

Could I afford it? I asked myself. Even with a doctor’s salary, I would think twice about it. However, I’ve always learned that anal fissure pain is very severe. So I suppose if I was suffering immensely and anally like Melissa, I would clench my teeth and pay for it.

But she couldn’t. Many can’t.

“My pain is so severe, each time I go to the bathroom or sit down for over an hour, I sweat and feel like I might faint. My husband has to wipe my butt. I am so embarrassed and miserable!” Mellissa cried on the phone. I felt her pain coming through the line.

“Let me call you back, Melissa.”

I called the pharmacist — otherwise known as the life line for clueless doctors. I have to admit that without pharmacists, many of us would have unintentionally harmed many patients by prescribing the wrong medications or inappropriate dosage.

“Is there another brand than Rectiv I can prescribe?” I secretly hoped that the problem was as simple as me being a young doctor, and not knowing many clinical drug pearls. The recommended topical treatment for anal fissures is 0.4% nitroglycerin in the literatures. There has to be other cheaper brands out there.

“No. Rectiv is the only FDA approved 0.4% rectal nitro in the US.” The pharmacist vetoed my fantasy immediately.

In the best case scenario, a insurance covers Rectiv, which will most likely reduce the price to just short of $100. Nitroglycerin pills, the life-saving tablets that rescue chest pain caused by coronary artery disease, on the other hand, cost less than $10, even without insurance.

“Could I prescribe her the nitro tablets and have her use it rectally?” Of course, I was not serious when I asked this. But just in case…

“No.”

“I was joking. Of course not. Do we have any other option? As you know, anal fissures are very painful!” I sounded desperate.

“Have you given her stool softeners, had her try Sitz Bath, and maybe topical steroids?” The pharmacist asked, dutifully, like how the IT guy is obligated to ask “have you tried turning off then turning on your computer”.

“Yes, we have tried all of that. And her blood pressure is always very low, I really don’t want to try a oral blood pressure medicine.” These encompass all the options to treat anal fissure without surgery or Botox (also manufactured by the same company as Rectiv, coincidentally).

“What about pain medications?” He asked. I was starting to get frustrated by all the questions.

“Well, short of narcotics, we have tried them all.” I sighed. It was true.

To be honest, at this point of the conversation, holding Melissa’s FMLA paperwork in my hand, and having heard her tearfulness on the phone, the thought of prescribing her narcotics pain medication crossed my mind. Of course, I wouldn’t do it. It’s not clinically indicated, not to mention it’s addictive properties.

But, we live in a country where opiates are cheaper than a rectal cream to treat anal fissures.

“Well…there is a compounding pharmacy about 45 minutes away from here. You could call them and see what they offer.” Finally, he gave me some possibility. As much as he sounded like he was pointing me toward a drug dealer, I was happy I could do something.

“Great! Thank you!” I took down the information, and called as soon as I hung up with the pharmacist.

A compounding pharmacy is a magical place where medications are made for those patients whose needs can't be met by commercially available drugs. This process takes a prescription from a doctor. For instance, if you are allergic to a component in a brand name drug, your doctor can prescribe you the active ingredients of this medication minus the one you are allergic to, and have it put together into a drug by the compounding pharmacy. I have never personally used such pharmacies, as a primary care physician, who is conservative in prescribing medications. And in family medicine, most medications used are widely available and well tolerated.

“Yes, we are able to make a similar cream with three different medications in them for anal fissures.” The pharmacist who picked up my call said.

Music to my ears! She reported the three different medications, two are for soothing the pain, and one is nitroglycerin.

“Perfect! How much is it?” I braced myself for the answer. Compounding pharmacies usually don’t take insurance.

“$92.”

Expensive, but it was not $700 a pop.

“Great! I will let the patient know and call you back to give you a verbal order.”

I was so excited to call Melissa. She won’t believe it! It’s like I just bargained successfully in the market and scored a 85% off! And I’m about to brag about my accomplishment!

“I am not sure we can afford that, either, Dr.Zha. But if you think it would help me, I will ask my parents to see if they can lend me some money to buy it!” Melissa’s answer was filled with mixed emotions: gratitude, relief, disappointment, and a little hopefulness.

After hainging up the phone, I looked at the time: 45 minutes of my lunch hour was gone! All I did was being on the phone to try to get a small tube of an anal cream paid for.

When I called the compound pharmacy back, I was also filled with mixed emotions: frustration about wasting time chasing after a prescription, sympathy toward my patient, and anger about the whole situation.

Would we rather take a capable person off the workforce than making medications for a small cut in the butt affordable?

This felt like a ridiculous question.

“Ok doctor, please let the patient know her cream should be ready for pick up tomorrow. Make sure you tell her we don’t take insurance.” Said the compounding pharmacist.

“Um, actually, can I please just pay for it?” I whispered, afraid someone around me would hear me. It’s generally not encouraged to pay for a patient’s medications. Because “once you start, and the word get out, you will never stop”.

I knew Melissa very well. I took care of her whole family. They would never take advantage of me. In fact, if they knew I paid for it, they probably wouldn’t even pick it up.

“And, please don’t tell the patient I paid for it. Thank you.”

“What can I help you with? An anal fissure?” I remember my very humorous attending joking like this. I found it hilarious at the time, too. But today, it stopped being funny. Anal fissures aren’t a laughing matter. No medical condition is.

And what is even more serious, sometimes deadly (think insulin) is the drug price problem in our country. In fact, in 2020, according to Bloomberg, Americans spend the most money in the world on prescription medications, and by a substantial amount (about $1,200 per person per year).

The unaffordable anal fissure rips a small opening to a big problem.

A recent study showed that for a new drug, big pharma earn 10x in profit than what it costs to develop the drug. And if a new drug is patented, the FDA can grant exclusivity of this drug to a company for a very long time, during which the drug can’t be made generic. Of course, the longer this exclusivity is, the more money a pharmaceutical company makes. As a result, the US market makes more than half of the world’s drug revenues for a typical branded medication, while only possessing 4% of the global population.

“I buy my insulin from Canada”, “I had to ship my baby’s formula from Europe”, and “I go to Mexico for my yearly checkups, they do CT scans and labs for much cheaper” are just some of the things I have heard my patients say in even my short career so far. When my parents were stuck in the US with me due to international travel restrictions during the pandemic for a year and half, I was terrified that they would somehow fall ill. I did everything short of keeping them in a plastic bubble, because we couldn’t afford paying out of pocket for an ER visit for my uninsured parents. But sometimes, even with insurance, the cost of simply stepping into a medical facility is astronomical for the patient.

As a primary care provider, I’d like to draw people to me, and keep them healthy. But often, the cost of care and cost of drugs push patients away. We need to lower drug prices before it’s too late for an individual like Melissa, and our nation as a whole.

*The story of the above patient was based on a true story, but the details and names were significantly altered to protect confidentiality.*