Of Drugs and Rectal Pain

I had a patient last week who was a real pain in the ass.  Wait.  No.  He was actually a really nice guy.  He wasn\’t a pain in the ass, he had a real pain in the ass.  Literally.

I was initially concerned about a pilonidal cyst, given the unfortunate fact that he was previously afflicted with this condition (which I consider to be incontrovertible proof of Satan).  But, fortunately to him, his pain was literally \”in the ass,\” and that rules out the evil diagnosis, moving my thoughts to a condition called proctalgia fugax (which is a Latin person\’s way of saying: \”butt pain that comes and goes\”).


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What my patient looked like

I realize this doesn\’t sound much like good news on my patient\’s part, but, as opposed to the lousy surgery necessary for treatment of a pilonidal cyst, an effective treatment for this is fairly simple (and surprising): nitroglycerin ointment applied to the rectum.  Nitroglycerin, it turns out, relaxes smooth muscles and dilates blood vessels, both of which somehow can improve the distressing symptoms of this strange condition (as well as pain from other related proctological demonic attacks).  I\’m not sure who had the idea to first try this, or what their inspiration was.  Perhaps they misheard the term Angina Pectoris as Angina Rectalis. 

I did my usual search at GoodRx.com (a website everyone should use as often as possible) to see where the drug is cheapest.  It turns out that Kroger won the contest, but the price was $479.  According to the literature, the appropriate strength of nitroglycerin for rectal use (cleverly called \”Rectiv\”) is 0.4%.  This seemed a pretty high price for a medication which has long been generic, so I searched for generic nitroglycerin ointment (used for pain due to heart disease) and found it for $35 at Walmart.  The only difference between the two that I can tell is that that preparation (called NitroBid) is 2%.


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 There are several possible explanations for this huge price discrepancy:

  1. The dilution of nitroglycerin is a dangerous and expensive process, as it is quite explosive.
  2. The cost of coming up with the name \”Rectiv\” by the marketing department was extremely high.  It is far more clever than NitroBid, to be sure.
  3. There is a secret ingredient in Rectiv that raises the cost.  Perhaps they have to get anal secretions from unicorns.

While these seem reasonable, I suspect a different reason: the company which makes Rectiv, Allergan (which also makes Botox), has cornered the market on 0.4% nitroglycerin, and so can charge exorbitant amounts for a medication with no other discernible reason to be expensive (it certainly took little R & D cost, and doesn\’t regularly get advertised during the evening news).

I\’m sure my anally distressed patient would have paid $1000 for relief, but this wasn\’t my first ride at the proctalgia rodeo (which has recently been nominated as an Olympic event), and I knew he could use the more potent cheaper version with the boring name (and has nothing to do with unicorns) without problems.  He did, and he got immediate relief.  Now, like Androcles, I have someone who owes me a great debt for my kindness and wisdom.

This incident is just one example of the terrible gaming that routinely occurs with the prices of drugs.  There are plenty of others. Why, for example, do brand name medications continue having such high prices after the medication has gone generic (often 10-20x higher)?  The reason is, if the generic no longer available, they get a cash windfall. 

For example, Carafate (a medication for stomach ulcers) went generic a many years ago and so you can get 120 tablets of the generic for $33.


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But recently the suspension form (which I\’ve used for mouth ulcers and esophageal problems) became unavailable as a generic and so now is only available as the brand name drug.  The result is that the once inexpensive suspension now comes with a premium price tag:


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Note that this price is for 420 ml, which is the equivalent of 42 tablets, so the mark-up is more than 10-fold.

Pharmacies join in on the price gaming by pricing one drug much lower than competitors, while going way higher than the market on others.  Generic Topamax (a drug used for seizures and migraine prevention), for example, costs $11 at Publix and $68 at Rite Aid.


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So should you go to Publix for all of your medications?  Unfortunately, if you get your Topamax with a Lipitor Chaser, the generic cholesterol drug costs more than $90 at Publix, where it\’s much cheaper at other pharmacies.


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All pharmacies do this, in my experience, so you can\’t count on any one pharmacy to have cheap prices.  To get inexpensive medications, you must shop around and be willing to go to multiple pharmacies for multiple medications.  It\’s a game they play that usually works, as most folks either don\’t know about this, or they just don\’t want to bother going to multiple pharmacies.

These games come at a great cost, dramatically raising the cost of care for millions of Americans.  It is legal.  It is done all the time.  And it is gouging.  And this gouging isn\’t unique to the pharmaceutical industry, as labs and radiology providers have their tricks to make enormous profit margins on the services they provide.

Fortunately for this my patient, I was not only able to reunite him with the joys of sitting, but I was able, with a little research, to find him his proctological savior at a low cost.  Unfortunately, most patients don\’t have docs who are economically incentivized to save them money, and most people don\’t realize all of the games played by pharmaceutical companies and pharmacies to routinely perform wallet biopsies, nor do they know how to find the cheapest prices for their medications.

I don\’t know what can be done about this kind of thing aside from increasing awareness. I\’m not real confident in any government solution.  People just need to be smarter shoppers when it comes to their care.  It\’s just a shame that people who are dealing with health problems (even if it is just trouble sitting) have to outsmart the gaming done by those supposedly trying to help them.

6 thoughts on “Of Drugs and Rectal Pain”

  1. One thing than can be done would be to change drug re-importation laws. Other quite modern and comfortable countries don’t have the same problems we do in the US because they don’t stand for it. Even allowing Americans to buy a year supply in those countries and bring it home would make a difference.

    Many people can take a vacation in Vancouver, Cancun, or Paris and more than pay for it with drug savings. The US subsidizes (and beyond) pharmaceutical research costs for much of the world.

    Who wants to visit the Taj Mahal?
    http://www.bloomberg.com/news/articles/2015-12-29/the-price-keeps-falling-for-a-superstar-gilead-drug-in-india

  2. I think you are discounting the stranglehold that manufacturers have over the pharmaceutical industry in your assignment of blame regarding cost solely to the retail pharmacy. That,and the draconically low-balled contracts pharmacies are forced to accept if they want to have any customers. When the sole manufacturer of medication calls "allocation" and the wholesale cost to pharmacies jumps by a factor of 10 overnight, but the reimbursement to the pharmacy from the 3rd party payor doesn’t increase to match…how can a pharmacy operate and survive? Then, mercurial forces decree that only X brand will be reimbursed at a net positive rate. If you use Y brand,even if it’s less expensive for the pharmacy,and thus, to the 3rd party payor….they don’t. Pay,that is. The ins and outs of manufacture, distribution, and pricing are so much more complex than your story makes it seem. Don’t paint the pharmacists who are out there trying to save lives while helping patients afford food and electricity with the tarred brush of price gouging, we’re all theoretically on the same team!

  3. So well written. I am a sufferer of prolactia fugex.. Actually I just got my first tube of nitroglycerin. I’m sitting here a bit nervous of using it for the first time. I know I will when the pain comes tonight. This is just what I needed to read. Thank you so much for the words of wisdom. OMG that face has been me everynight. I wanted to tear something off the wall or beat my face against the door, luckily I just squeal. I hope it works.. I was thinking about that whole pain in the ass pun, but I didn’t say it to my doctor today, I totally shoulda lol.

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